Chapter 8 Musculoskeletal system
Rheumatoid arthritis
Case history
Penny tells you she and her partner, Dianne, have been talking about whether or not to have a child together. Both their families are supportive, but they have experienced negative attitudes and behaviour from some people about their relationship, particularly regarding them having a child together. Penny tells you she sometimes feels angry and resentful about the difficulties involved with having a child, particularly when she thinks of some of the family situations she has seen as a child protection officer. She knows she and Dianne could provide a loving and supportive environment for a child and it seems unfair that it should be so much harder for them.
| Analogy: Skin of the apple |
Does the pain radiate out from that spot?
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Family health | |
| Has anyone else in your family experienced similar symptoms? | Yes. My mum and grandmother both have arthritis. Gran’s arthritis is really quite bad now. |
| Trauma and pre-existing illness | |
| Have you had any trauma to your hands in the past six months? | No. |
| Recreational drug use | |
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Emotional health | |
| Do you ever feel sad, anxious or depressed? | Yes. Di, my partner, and I are thinking about starting a family. Some people are really negative about us as a couple and about us being parents. That really gets me down sometimes. When I think of the situations I see in my job, it is really unfair that people don’t think Di and I would be good parents. |
| Daily activities | |
| Tell me about your daily routine. | I’m up around 6.30 and get to work usually by 8 or 8.30. Home again by about 6. Bedtime is usually around 10.30. On the weekends we spend time at the markets on Saturday morning and do things around the house in the afternoon. Sunday is usually spent catching up with family and friends. |
| Stress release | |
| How do you manage your stress? | |
| Occupation | |
| Do you enjoy your work? | I used to, not so much anymore. I’m thinking about going back to uni to do something else. |
| Action needed to heal | |
| If you could snap your fingers and have anything you need to help your symptoms improve, what would be your wish list? | Tell me what’s going on with my hands. Give me some supplements or herbs to help. |
| Long-term goals | |
| Where do you see yourself in five years? | I’d like to be a parent, maybe also doing another job. |
TABLE 8.4 PENNY’S SIGNS AND SYMPTOMS [2, 6–8]
| Pulse | 92 bpm |
| Blood pressure | 127/81 |
| Temperature | 36.9°C |
| Respiratory rate | 15 resp/min |
| Body mass index | 22 |
| Waist circumference | 75.7 cm |
| Face | Pale and tired looking, pale conjunctiva, pale palmar creases; tenderness over proximal interphalangeal joints on both hands |
| Urinalysis | No abnormality detected (NAD) |
Results of medical investigations
No medical investigations have yet been carried out.
TABLE 8.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 6–8, 10, 11, 13, 65]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Causal factor: Trauma/ruptured tendons: can cause pain in finger joints | Need to determine if Penny has experienced an injury to her hands recently; onset of pain would correlate with an injury and be aggravated by movement; joints would appear very red and swollen |
| INFECTION AND INFLAMMATION | |
| Dupuytren’s contracture: tenosynovitis of flexors of fingers; fixed flexion contraction on the hand; tender fingers and can occur gradually on both hands | Pain felt in her palm at the base of the third and fourth digits; no visible contracture seen on the palms where the fingers bend towards the hand and cannot be flexed |
Presents more commonly in young and middle-aged women with arthritis in small joints of the hand, low appetite and fatigue
Case analysis
| Not ruled out by tests/investigations already done [2, 6–11, 64–68] | ||
| CONDITION AnD CAUSES | WHY POSSIBLE | WHY UNLIKELY |
| CANCER AND HEART DISEASE | ||
| Primary or metastatic tumour | Pain in fingers; pain will be worse at rest | Usually deep boring pain |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Causal factor: Postviral arthritis: glandular fever, rheumatic fever, reactive arthritis | Fatigue and pain in fingers, Most often presents as polyarthritis involving more than 5 joints | Mild fever present; will have joint pain that moves to different areas over a period of days |
| FUNCTIONAL DISEASE | ||
| Carpal tunnel syndrome: pain often in wrist, thumb, index and middle fingers; weakness in abduction of thumb and hypalgesia in the index finger [64, 67] | Pain and stiffness in hand; can occur in later stages of rheumatoid arthritis (RA); common in women; symptoms can occur at night; common to have nocturnal pain, will be felt in wrist and sometimes forearm | Hands will often look normal with no joint swelling; should be no pain experienced on palm of the hand |
| Raynaud’s phenomenon/disease: when this condition appears as an underlying cause of another disease it is called ‘phenomenon’, otherwise this condition is known as Raynaud’s disease | Discolouration of the fingertips due to sluggish blood flow | Extremely painful |
| Thoracic outlet syndrome | Hand pain worse on waking; numbness in hands | Usually only left hand and after arms are hyperabducted on waking; hands will feel weak |
| Fibromyalgia | Hands feel cold, stiff and condition is exacerbated by stress; sleep disorders | Will have widespread tender joints on pressure; usually diagnosed if has been present for more than 3 months |
| Causal factor: Physiologic fatigue: caused by depression, caffeine, alcohol, excess sleep, poor sleep due to uncomfortable mattress or pillow, being too hot or cold when trying to sleep, hunger during the night, excess exercise and intense emotions | Common to have delay in falling asleep | Symptoms may present for less than 14 days duration and not usually associated with changes in self-esteem, social difficulties or overall mood; diagnostic studies are within normal limits (this needs to be investigated further) |
| DEGENERATIVE AND DEFICIENCY | ||
| Anaemia/anaemia of chronic disease: where the inflammatory cytokines seem to mediate a decreased release of iron from the bone marrow to developing red blood cells, causing decreased red cell survival; can be common in RA | Symptoms of anaemia include fatigue, insomnia and depression | |
| AUTOIMMUNE DISEASE | ||
| Rheumatoid arthritis (RA) | Stiffness in the small joints of the hand, symmetrical presentation, improves with activity; symptoms of hand stiffness present for more than 6 weeks, stiffness is worse in the morning; fatigue and anaemia associated with symptoms; proximal interphalangeal joints tender; joints in hands can be warm and red; stiffness can be migratory and involve several joints; persistent pain; not usual for joints to appear red; symptoms are symmetrical | |
| Systemic lupus erythematosus (SLE) | Pain in hands not usual for joints to appear red; fatigue; symptoms are symmetrical | Intermittent painful episodes; hands will appear normal, no fever |
| Causal factor: Overlap syndrome | Symptoms of RA and SLE and Raynaud’s | |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Causal factor: Nerve compression of the brachial plexus or cervical nerve and ulnar nerve [68] | Pain in hand and fingers | Tingling sensation that is localised to nerve distribution on the ulnar border; will often feel sharp shooting pain |
| Peripheral neuropathy | Can occur in RA | Weakness in fingers; numbness in fingers |
| General anxiety disorder (GAD) | Has been present for at least 6 months; anxiety disorder is often associated with loss or potential of a loss; weight loss, lack of sleep; feelings of irritation; person often complains of physical symptoms without thinking there may be a mental disorder; difficulties or delay in falling asleep is common | Ascertain whether Penny has experienced significant weight loss; if tension and stress have been overwhelming for at least 6 months; often associated with diarrhoea, tight chest, difficulty breathing; less common to experience frequent waking and early morning wakefulness as in depression |
| Mixed anxiety and depressive disorder | Depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy, or intense sadness, insomnia; not enjoying work as much as she used to; angry and resentful about difficulties having a child | Can be associated with numerous physical complaints associated with depression such as restlessness, headaches, shortness of breath, gut or skin disorders; need to define if significant incapacity to continue daily activities for work |
| Causal factor: Insomnia: primary | Difficulty falling asleep, frequent waking during the night | Usually associated with no physical or emotional triggers |
| Causal factor: Insomnia: secondary | Due to chronic pain, anxiety or depression | |
TABLE 8.7 DECISION TABLE FOR REFERRAL [2, 7–11, 13]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
TABLE 8.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6, 8–11, 13, 65, 66]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE MEDICAL INVESTIGATIONS: | |
| Musculoskeletal physical examination | Assess bone, muscle or nerve pain, inflammatory or non-inflammatory arthritis |
| Tinel sign (tapping on medial nerve) and phalen test (flexing the wrist) | Carpal tunnel syndrome |
| Adson tests | Brachial plexus neuralgia |
| Cold response test | Raynaud’s phenomenon |
| Nail fold capillary test | Raynaud’s phenomenon |
| Full blood count |
Haemoglobin: low; main function for red cell is carrying oxygen to tissues and returning CO2 from tissues to lungs Platelets: high; the number of platelets (thrombocytes) gives information about efficiency of blood clotting Red cell indices: |
| Film comments |
Film comments: microcytic hypochromic RBC Microcytic means the red blood cell is a small weight and generally these cells have less haemoglobin Hypochromic means the red blood cell has a deficiency in haemoglobin; the presence of anaemia with microcytosis and hypochromia does not necessarily indicate iron deficiency, although this is the most common cause; the commonest other causes are thalassaemia, sideroblastic anaemia and anaemia of chronic disease |
| Serum ferritin | |
| Serum iron levels | |
| Total iron binding capacity | |
| ESR/CRP | |
| Rheumatoid factor | |
| Antinuclear antibodies (ANA) | |
| X-ray on left and right hands | Check if there are any fractures, joint or bone abnormalities, arthritis |
| Liver function test | Hepatitis |
| IF NECESSARY: | |
| MRI of the hands and cervical spine | Arthritis, tumour, bone abnormality, nerve entrapment |
| Electromyogram (EMG) and nerve conduction velocity test (NCV) | Carpal tunnel syndrome |
Confirmed diagnosis
Prescribed medication
TABLE 8.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
• Dietary recommendations to identify and eliminate dietary antigens or aggravating foods
• Dietary recommendations to increase intake of antioxidants and essential nutrients
• Herbal tonic and tablets with immunomodulatory and antimicrobial action to address potential underlying infection
• Herbal tea, tonic and tablets with digestive, silagogue, choleretic and cholagogue action to improve digestive function
• Supplemental nutrients to modulate immunity, reduce allergic response, support gastrointestinal mucosa and normalise gastrointestinal permeability
• Recommendation for Penny to deal with her psychological and emotional issues through therapy
• Recommendation for Penny to exercise regularly to improve her psychological health and stress response
• Herbal tea, tonic and tablets with nervine and adrenal tonic action to support Penny’s nervous system and stress response
Treatment aims
• Reduce joint pain, stiffness and inflammation [14, 15, 31, 61].
• Prevent disease progression and joint degeneration [14–16, 61].
• Support joint health and enhance proteoglycan and cartilage synthesis [15, 16, 63].
• Modulate Penny’s immune response [14–16, 61].
• Enhance intestinal integrity and support optimal digestive health and function [14–16, 62].
• Identify and manage allergies or sensitivities [14–16].
• Identify and correct nutritional deficiencies [14–16].
• Enhance efficacy of conventional medications, reduce dosage and frequency required and minimise adverse drug side effects [14–16].
• Reduce oxidative stress [14–16, 61].
• Help Penny deal with psychological and emotional issues [15, 17] and support her stress response [17].
Lifestyle alterations/considerations
• Encourage Penny to work through her issues surrounding work and parenthood [15, 17]. A tailored cognitive behavioural therapy program may be beneficial [18].
• Penny will benefit from regular exercise to help improve her psychological health and stress response [20, 21]. Exercise is also likely to improve symptoms and maintain joint functionality [19, 22].
Dietary suggestions
• Identify and remove dietary triggers [14, 15, 31]. Commonly implicated foods are wheat and other gluten-containing grains, corn, dairy and food additives [14, 15, 31]. There is a correlation between food sensitivities and RA [14, 17, 28, 29, 31] and Penny may find particular benefit in avoiding allergenic foods [31].
• Encourage Penny to avoid foods from the solanaceae (nightshade) family: eggplant, capsicum, tomato, capsicum (peppers) and potato [14, 15]. They are implicated in promoting inflammation and pain in rheumatic diseases [30].
• Encourage Penny to increase consumption of foods containing omega-3 fatty acids [14, 15, 32, 33] and monounsaturated fats [32] while reducing consumption of omega-6 fatty acids [32] and saturated fats [14, 15, 16]. Reducing linoleic acid and arachidonic acid while increasing omega-3 and monounsaturated fats [32, 34] can enhance the anti-inflammatory action of omega-3 fatty acids [32, 33].
• Encourage Penny to avoid or reduce consumption of refined carbohydrates, sugar, red meat and animal fats [15, 31].
• Penny may find an uncooked vegan diet containing berries, fruit, vegetables, nuts, sprouts and germinated seeds is beneficial [14, 29]. If she feels a raw vegan diet will be difficult to maintain she should consume a mostly vegetarian antioxidant-rich whole-food diet that is high in fibre, whole grains (avoiding grains to which she is sensitive), legumes, vegetables, fruit, flavanoid-rich berries and cold-water fish [15, 29, 31, 34].
• Encourage Penny to eliminate coffee, tea and alcohol [14, 31, 35] and increase her water intake.
• Encourage Penny to drink fresh vegetable juices once or twice daily [31].
Physical treatment suggestions
• Hydrotherapy: moist heat packs to relieve stiffness and tenderness [15].
• Ice massage/cold packs for five minutes around joint to alleviate pain if Penny experiences an acute flare-up, followed by five-minute massage and repeat cycle for 20 minutes [15].
• For hands, a hot Epsom salt hand bath for 20 minutes will help ease the pain [54]. A heat compress on the hand with a plastic pad on top for 20 minutes is beneficial in cold weather [54, 55].
• Alternating hot (three minutes) and cold (30 seconds) hand bath locally to inflamed or painful joints for four rounds [54].
• Constitutional hydrotherapy [55–58].
• Full-body water-based exercise when the symptoms radiate to other joints in the body [59, 60].
• Penny is likely to benefit from exercises to strengthen muscles, increase range of movement and preserve joint function [15, 19]. High-intensity exercise therapy can improve functionality [15, 22].
• Penny may find massage therapy is beneficial to reduce symptoms and improve her stress response [23–25].
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Devil’s claw Harpagophytum procumbens |
80 mL | Anti-inflammatory [36, 37]; analgesic [36, 37]; antirheumatic [37]; chondroprotective [36]; digestive bitter [37]; beneficial for degenerative musculoskeletal disorders [36] |
| Rehmannia Rehmannia glutinosa |
70 mL | Anti-inflammatory [37, 41]; adrenal trophorestorative [37, 41]; beneficial to reduce inflammation in autoimmune disorders [37, 41]; may help protect against suppressive effects of corticosteroid and chemotherapy [37, 41] |
| St John’s wort Hypericum perforatum |
50 mL | Anti-inflammatory [36]; antidepressant [36, 37]; anxiolytic [36, 37]; analgesic [36]; antiretroviral [36, 37]; antimicrobial [36, 37] |
| Supply: | 200 mL | Dose: 10 mL twice daily |
TABLE 8.11 HERBAL TABLET ALTERNATIVE
| Anti-inflammatory herbal tablet to be taken in conjunction with herbal tonic if extra anti-inflammatory support is required; alternative to NSAIDs | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Boswellia Boswellia serrata |
1.9 g | Anti-inflammatory [40, 45]; anti-arthritic [40, 45]; beneficial for RA in combination with turmeric, ginger and withania [46] |
| Turmeric Curcuma longa |
2.0 g | Anti-inflammatory [36, 37, 44]; antimicrobial [36, 37]; antioxidant [36, 37]; choleretic [36, 37]; immunomodulator [36]; improves morning stiffness and joint swelling in RA [44]; prevents joint inflammation in RA when taken prior to the onset of joint inflammation [45] |
| Celery seed Apium graveolens |
1.0 g | Anti-inflammatory [36, 40]; cholagogue [36]; antirheumatic [36, 40, 43]; sedative [43] |
| Ginger Zingiber officinale |
300 mg | Circulatory stimulant [40, 43]; antirheumatic [40, 43]; silagogue [40] |
Dose: 1–2 tablets 3 times daily
| Alternative to tea and coffee | ||
| HERB | FORMULA | RATIONALE |
| Passionflower Passiflora incarnata |
1 part | Anxiolytic [36, 40]; sedative [36, 40]; traditionally used for insomnia [36]; beneficial for anxiety and nervous restlessness [36] |
| Willowbark Salix alba |
2 parts | Anti-inflammatory [36, 38, 40]; analgesic [36, 38, 40]; antirheumatic [38, 40] |
| Prickly ash Zanthoxylum americanum |
1 part | Circulatory stimulant [38, 40, 43]; antirheumatic [38, 40, 43]; silagogue [38, 40] |
| Peppermint Mentha × piperita |
½ part | Mild sedative [36, 37]; antioxidant [36, 37]; enhances cognitive performance [36]; included to improve taste of the tea |
Decoction: 1 tsp per cup – 1 cup 3 times daily
TABLE 8.13 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Omega-3 fish oil 10,000 mg daily in divided doses [14, 36] |
Anti-inflammatory [14, 15, 36, 39]; omega-3 supplementation improves clinical status in RA [42, 47] and can reduce the need for antirheumatic medication [47]; omega-3 supplementation reduces tender joints and morning stiffness in RA [32, 33, 42]; benefits of fish oil supplementation in RA are enhanced when an anti-inflammatory diet is followed [33] |
| 1,200 mg quercetin and 750 mg bromelain daily in divided doses [14, 36] | Quercetin is anti-inflammatory [36, 39]; antioxidant [36, 39]; immunomodulator [36]; quercetin inhibits inflammatory enzymes, prostaglandins and leukotrienes [36], stabilises mast cells [36] and inhibits mast cell release of histamine [39]; Bromelain is an anti-inflammatory [15, 31, 39]; beneficial in auto-immune disease [39]; bromelain reduces inflammation and improves RA symptoms [15, 31, 48] |
| Glucosamine sulphate 1500 mg daily in divided doses [36] |
Anti-inflammatory [36, 52]; chondroprotective [36, 50, 52]; stimulates proteoglycan synthesis and therefore cartilage repair [53]; can provide symptom relief [51] and may suppress progression of joint pathology in RA [52]; enhances health of gastrointestinal mucosa [49] |
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[68] Ferry S., Silman A., Pritchard T., et al. The association between different patterns of hand symptoms and objective evidence of median nerve compression. Arthritis Rheum. 1998;41:720–724.
Fibromyalgia
Case history
| Analogy: Skin of the apple |
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Recreational drug use | |
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Support systems | |
| Do you get much support when you’re on your own? | If I really need help I can ask my sister or friends, but I prefer not to. |
| Emotional health | |
| Do you ever feel anxious or depressed? | Sometimes, particularly when my husband is away. |
| Stress release | |
| How do you deal with your stress? | If I have the energy and I’m not in too much pain I go to the gym. Otherwise I use chocolate therapy! |
| Home life | |
| What are things like for you at home? | Up and down. Things can get a little strained with the boys now they’re in their teens. It’s much harder when my husband is away and I have to deal with them on my own. |
| Action needed to heal | |
| What do you feel you need to heal? | I’m not sure. Maybe there are some herbs or vitamins that can help. |
| Long-term goals | |
| Tell me about your long-term goals. | I’m looking forward to getting back into nursing. I think it would be good to be out of the house and be able to focus on something other than my family. |
TABLE 8.17 CORRINE’S SIGNS AND SYMPTOMS
| Pulse | 86 bpm |
| Blood pressure | 130/75 |
| Temperature | 36.7°C |
| Respiratory rate | 17 resp/min |
| Body mass index | 23 |
| Waist circumference | 78 cm |
| Face | Strained look and pale |
| Urinalysis | No abnormality detected (NAD) |
TABLE 8.18 RESULTS OF MEDICAL INVESTIGATIONS [4, 7–10]
| TEST/INVESTIGATION | RESULT |
|---|---|
| Rheumatoid factor (RH factor): in inflammatory diseases such as rheumatoid arthritis; IgG antibodies produced by lymphocytes in membranes act as antigens, which then react with IgG and IgM antibodies to produce immune complexes that cause inflammation and joint damage; the reactive IgM molecule is RH factor | NAD |
| ESR (erythrocyte sedimentation rate): indicates inflammation in general | NAD |
| CRP (C-reactive protein): if raised it could be because of infection or inflammation, look to the full blood count to confirm this | NAD |
| Full blood count Anaemia, infection, inflammation | NAD |
| Thyroid function test | NAD |
| Calcium and alkaline phosphatase | NAD |
| Creatine kinase | NAD |
TABLE 8.19 UNLIKELY DIAGNOSTIC CONSIDERATIONS [4, 6–10, 17, 73]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| FUNCTIONAL DISEASE | |
| Myopathy: disease of the voluntary muscles | Creatine kinase not raised |
| Osteomalacia/hypercalcaemia: metabolic bone disease causing generalised aches and pains | Calcium not raised and alkaline phosphatase not raised |
| DEGENERATIVE AND DEFICIENCY | |
| Anaemia | Full blood count NAD |
| INFECTION AND INFLAMMATION | |
| Bacterial infection: e.g. Yersinia enterocolitica, Escherichia coli, Shigella, Staphylococcal enterocolitis, ileocaecal TB; diarrhoea is the main symptom; may cause ulceration and inflammation | Full blood count NAD; usually self-limiting and acute in duration between 1 and 10 days depending on bacterial toxin; violent vomiting can be associated; no bloody diarrhoea reported |
| Viral infection: retrovirus, hepatitis; diarrhoea, tired, nausea, fatigue, weight loss; generalised aches and pains | Full blood count NAD, no fever present; no history or signs of jaundice; check if stools are pale; no fever |
| Polymyositis: skeletal muscle inflammation that is more often in women, causing weak proximal muscles, widespread muscle weakness and muscle wasting | Rare disease; creatine kinase and ESR not elevated; full blood count revealed no anaemia, which can be associated with polymyositis |
| Polymyalgia rheumatica: common to present as stiffness in shoulder and pelvic areas | ESR not raised |
| Inflammatory bowel syndrome: diarrhoea, often associated with arthritic symptoms of generalised aches and pains | ESR and CRP not raised |
| Gastroenteritis: abdominal pain, diarrhoea, nausea and vomiting | Associated with vomiting, fever; check if Corrine has experienced generalised crampy abdominal pain; no low-grade fever; acute gastritis usually self-limiting and less than a week |
| AUTOIMMUNE DISEASE | |
| Rheumatoid arthritis: autoimmune inflammatory disorder | ESR not raised; full blood count revealed no anaemia, which can be associated with RA |
| Systemic lupus erythematosus (SLE): widespread aches, inflammatory autoimmune disorder | ESR, CRP not raised indicating no inflammation; full blood count normal indicating no excess antibody reaction in the body |
| ENDOCRINE/REPRODUCTIVE | |
| Hypothyroidism: fatigue, general muscle aches and pains, depression, worse for the cold | Thyroid function test NAD |
Case analysis
| Not ruled out by tests/investigations already done [4, 6–12, 17, 62–76] | ||
| CONDITIONS AND CAUSES | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
| Causal factor: Food intolerance/allergy [70] | Fatigue, depression, possible dietary changes when husband is away contributes to feeling fatigued | Need to gain more insight into Corrine’s diet when her husband is at home and when he is away |
| Causal factor: Lactose intolerance | Diarrhoea | Corinne has not mentioned symptoms developing after eating particular foods; she has not mentioned significant episodes of abdominal pain |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Causal factor: Physiological depression: postviral infection |
Depression, fatigue | Need to determine whether Corrine has had viral symptoms in the past 6 months |
| RECREATIONAL DRUG USE | ||
| Causal factor: Drug or alcohol abuse | Digestive disorders, missing husband when he is away, strain with teenage children; not being able to be physically active due to aches and pains, fatigue and sleeping during the day | |
| FUNCTIONAL DISEASE | ||
| Fibromyalgia: pain in axial skeleton with tender points that has persisted for more than 3 months [70, 71, 74–76] | Pain begins with stiffness, then an ache all over that changes in location, fatigue, irritable bowel symptoms, difficulty sleeping; normal laboratory results rule out organic reasons for symptoms; can be worse from being in cold and with depression | |
| Chronic fatigue syndrome: fatigue for at least 6 months that has no physical cause, psychoses, bipolar affective disorder, eating disorder or organic brain disease [65–67, 72] | Severe disabling fatigue that affects both mental and physical functioning for at least 6 months; sleeping more, feelings of depression, social withdrawal, crying spells | Need to determine whether Corrine experiences muscular and mental fatigue for at least 24 hours after exertion before some level of recovery occurs; need to determine whether fatigue improves during the day; need to determine if Corrine experiences at least two neurological/cognitive manifestations of chronic fatigue syndrome such as impaired concentration and muscle weakness |
| Irritable bowel syndrome | Constipation alternating with diarrhoea; stress | Corinne does not mention abdominal pain as a predominant symptom |
| Causal factor: Insomnia | Fibromyalgia sufferers commonly experience difficulty sleeping, which is often attributed to depression | Need to determine if Corrine has difficulty falling asleep, frequent waking during the night and early morning wakefulness |
| Causal factor: Physiologic fatigue | Can be caused by depression, caffeine, alcohol, excess sleep, intense emotions; recent diagnostic studies are within normal limits | Symptoms present for less than 14 days and not usually associated with changes in self-esteem, social difficulties or overall mood |
| Causal factor: Functional diarrhoea | Common in times of stress; usually associated with ongoing fatigue | Need to check if the abdominal pain is associated with diarrhoea; bowel motions are watery and occur first thing in morning with no more passing during the day; bowel motions may only occur after eating food |
| DEGENERATIVE AND DEFICIENCY | ||
| Causal factor: Organic fatigue | Tired, sleep disturbances, no major physical abnormalities | Shorter duration than functional fatigue; need to determine if the feeling of fatigue worsens during the day |
| INFECTION AND INFLAMMATION | ||
| Osteoarthritis | Pain in many joints, ESR CRP, RH factor can be negative; more common in women | Usually develops in older age groups and shows signs of limited range of movement, bony swellings and instability of joints; not necessarily associated with severe fatigue; need to check Corrine’s family history as it can be congenital and begin at an early age |
| Candidiasis | Diarrhoea, abdominal distension or feeling significant fatigue | No reports of itchy or irritating vaginal discharge |
| Causal factor: Helicobacter pylori | Diarrhoea, bloating; can develop due to increase stress and anxiety | Does not usually have diarrhoea alternating with constipation |
| SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION | ||
| Causal factor: Supplement or food additive abuse: excess vitamin C or magnesium? | Diarrhoea | |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Type 1: major (clinical) depression – unipolar affective disorder | Can be moderate or severe depression; people often describe symptoms in physical terms; common for fibromyalgia and depression to be linked; misses husband when he is away; sleeps all day when in pain, experiences insomnia and significant fatigue; delayed sleep onset, lack of appetite, can be aggravated by certain conditions and situations that provoke depression; associated symptoms of lack of interest in daily activities, constipation and vague aches and pains are common | Need to determine if Corrine has at least five symptoms of depression for more than 2 weeks and cause considerable incapacity with daily activities; need to define if feel worse in the morning with sense of apprehension; need to determine if Corrine experiences early-morning wakefulness (common); frequent awakening during the night is less common |
| Type 2: minor depression | Can be mild or moderate depression; common for fibromyalgia and depression to be linked; misses husband when away | Need to show 2–4 symptoms of depression that have lasted at least 2 weeks |
| Dysthymia: mild depressive illness | Could be experiencing ‘double depression’ if Corinne has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life, low mood; Corrine feels better when her husband is home | Lasts intermittently for 2 years or more; need to determine if Corrine has had a tendency to have episodes of feeling low |
| Mixed anxiety and depressive disorder: depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy, or intense sadness | Corrine has mentioned significant incapacity to continue daily activities for work and family when symptoms are bad and her husband is away; numerous physical complaints associated with depression such as restlessness, headaches, insomnia, shortness of breath, gut or skin disorders | |
| Hyperventilation syndrome: functional breathing concern (causes include increased CO2, fatigue, muscle pain, digestive complaints); habitual patterns of breathing are developed to keep CO2 levels low that leads to anxiety-provoking consequences | Significant muscle pain or fatigue; shortness of breath, breathing quickly; hyperventilation syndrome can be a consequence of chronic anxiety or irritability | |
| Causal factor: Anxiety state | Family, career and lifestyle stresses; can experience chronic pain that is felt all over the body | Usually pain is widespread in anxiety states alone and not associated with specific tender trigger points; however, anxiety can be concurrently associated with fibromyalgia |
Working diagnosis
Corrine and primary fibromyalgia syndrome – myofascial pain syndrome
There are studies that suggest that fibromyalgia syndrome has a genetic predisposition associated with the condition, and the syndrome is likely to develop after a traumatic/viral/infection event [12].
General references used in this diagnosis: 4, 6–12, 66, 69–71, 74, 75
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
TABLE 8.22 DECISION TABLE FOR REFERRAL [4, 7–9, 10, 13]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
| ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE |
| Nil | ||
| REFERRAL DECISION | REFERRAL DECISION | REFERRAL DECISION |
TABLE 8.23 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [4, 6, 8–11, 76]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Musculoskeletal examination of trigger points: trigger-point test in areas of localised soft-tissue tenderness in the dorsal spine, interscapular region, base of the neck, over both sacroiliac joints, over the elbows and the medial side of the knee | Fibromyalgia |
| Abdominal examination: guarding, rebound tenderness, palpation, abnormal pulsations (auscultation) | Assess abdominal distension, tenderness, hyperactive bowel sounds |
| Hydrogen breath test: to detect bacterial overgrowth; when bacteria is metabolised by lactose or glucose there is a production of hydrogen; if there is lactose in the small intestine that has not been broken down there will be an early rise in breath hydrogen | H. pylori |
| Stool test | Rule out parasitic infections and occult blood that suggests possible diagnosis of diverticulosis, ulcers, polyps, inflammatory bowel disease, GI tumour, haemorrhoids and H. pylori; if acidic stools are passed it indicates lactose intolerance |
| Counselling/psychiatry consultation: mental health assessment | Emotional assessment and support |
| Diet diary | Have a more detailed look at the foods Corrine is eating, what times she eats, how she prepares food and the amount of food ingested |
| Elimination diets | Detect food intolerance |
| Nijmegen questionnaire | Hyperventilation syndrome |
| Sleep diary: for one week | Assess patterns of sleep and activities prior to sleep; note time Corrine goes to bed, how long she takes to fall asleep, how many times she wakes during the night, the last time of waking before morning, any dreams or nightmares, need to urinate, and comments from her sleep partner; writing down thoughts before bed and when waking is also helpful |
| IF NECESSARY: | |
| Epstein-Barr/Ross River virus blood test | Check for postviral infection |
| Antinuclear antibodies: a protein antibody that reacts against cellular nuclear material and is indicative of an autoimmune abnormality; it is very sensitive in detecting systemic lupus erythematosus (SLE), but not specific to this disease as it can be present in other inflammatory and autoimmune diseases | Connective tissue disease such as SLE |
| Oral tolerance lactose test | Determine lactose metabolism |
| Capnometer/pulmonary gas exchange during orthostatic tests | Hyperventilation syndrome |
| ROUTINE TESTS DUE TO GENDER AND AGE | |
| Cervical smear | Cervical cancer, sexually transmitted diseases, Candida |
Confirmed diagnosis
Primary fibromyalgia syndrome with associated physiological depression
Prescribed medication
• Selective serotonin reuptake inhibitor (SSRI) antidepressants: Corrine would like to try natural therapies before taking prescribed antidepressant medication
TABLE 8.24 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
|
• Continue with herbal tonic, tablets or tea with anti-inflammatory, analgesic, adaptogenic and tonic actions • Continue with nutritional supplements to help reduce pain and increase energy levels NB: If Corrine takes the prescribed antidepressant medication her herbal tea/tonic will have to be reformulated to ensure there is no interaction between St John’s wort and the prescribed medication |
• Continue with dietary recommendations to improve digestive health
• Continue with dietary recommendations to increase her intake of essential nutrients and antioxidants
• Herbal tonic, tablets or tea to support neurotransmitter function and hypothalamic-pituitary-adrenal (HPA) function
• Recommendation to identify and eliminate any dietary or environmental triggers
• Nutritional supplements to improve digestive function and energy production
Treatment aims
• Reduce muscle pain and increase mitochondrial energy production in muscle cells [14, 21, 35].
• Reduce levels of inflammatory mediators [22].
• Support adrenal glands; treat apparent adrenal exhaustion and improve stress response [15, 21, 60].
• Improve quality of sleep [16, 21].
• Balance neurotransmitter production [21, 58], HPA axis [15, 21] and enhance serotonin levels [54, 58].
• Support Corrine’s nervous system and help her manage her anxiety and stress levels [15, 61].
• Support and improve digestive function [17, 35, 59, 60] and normalise bowel flora [19, 59, 60, 62].
• Support liver detoxification and reduce endotoxinaemia [18, 57, 60].
• Support normal thyroid function. Inadequate thyroid hormone regulation or cellular resistance to the thyroid hormone are postulated to be involved in the development of fibromyalgia symptoms [21, 60].
Lifestyle alterations/considerations
• Corrine will benefit from stress-management techniques such as meditation, yoga and relaxation training [21, 35, 43, 60].
• Corrine may experience benefit from cognitive behavioural therapy [41].
• Corrine should undertake regular daily exercise. It can help improve her physical symptoms [12, 39, 40, 42] and can help improve stress, anxiety [44, 45] and her sleep patterns [45, 46].
Dietary suggestions
• Whole-food, vegetarian diet. Some fibromyalgia sufferers have experienced mild to moderate improvements following a vegetarian diet [31].
• Corrine may find a low-oxalate diet helpful in controlling her symptoms [32]. If she follows a low-oxalate diet it is essential to maintain her intake of essential nutrients.
• Increase Corrine’s dietary intake of antioxidants. Elevated free-radical levels and oxidative stress are associated with fibromyalgia [33, 56].
• Eliminate excitotoxins (glutamate, aspartame, MSG) from the diet. Some fibromyalgia sufferers respond to their elimination [20, 21].
• Ensure sufficient dietary intake of omega-3 fatty acids [33, 35].
• Balance blood-sugar levels using a low GI/GL diet [21, 60]. Dysglycaemia can worsen symptoms of fibromyalgia [21].
• Increase consumption of foods that support liver function; onions, garlic, leeks, cruciferous vegetables and lecithin to assist with cellular detoxification [35, 57].
• Eliminate coffee, which may be aggravating Corrine’s digestive symptoms [34].
• Determine whether Corrine has any food allergies or intolerances and manage accordingly [55, 60].
Physical treatment suggestions
• Regular massage may reduce muscle pain, improve sleep and assist with stress management [38, 60, 63, 77].
• Prescribed exercise therapy [12, 40, 42] and exercises to increase flexibility and stretch muscles – yoga may be helpful [39].
• Acupuncture may reduce pain symptoms [41, 60].
• Hydrotherapy: full body underwater exercise and Watsu stretches underwater have been shown to be very beneficial for hydrotherapy when practised over a period of six months [55, 47–49, 60].
• Hot baths and showers [50, 60].
• Constitutional hydrotherapy [51, 60].
• Hot foot bath to raise her core temperature and ease abdominal bloating [52].
• Apply a hot apple cider and water or castor oil compress to the abdomen to ease digestive complaints [50, 52].
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Withania Withania somnifera |
50 mL | Adaptogen [25, 26]; tonic [25, 26]; immunomodulator [25, 26]; anti-inflammatory [25, 26]; anxiolytic [26]; traditionally used for people who are physically and emotionally exhausted [26] |
| St John’s wort Hypericum perforatum | 50 mL | Antiretroviral [25]; anxiolytic [25, 26]; antidepressant [25, 26]; traditionally used for muscular rheumatism [25] |
| Rehmannia Rehmannia glutinosa |
40 mL | Anti-inflammatory [27]; adrenal trophorestorative [27] |
| St Mary’s thistle Silybum marianum |
30 mL | Hepatoprotective [25, 26], hepatotrophorestorative [25], antioxidant [25]; choleretic [25]; an aid to improve digestive function and to assist in improving liver function [25] |
| Siberian ginseng Eleutherococcus senticosus |
40 mL | Adaptogen [25, 26]; immunomodulator [25, 26]; tonic [25, 26] |
| Supply: | 200 mL | Dose: 5 mL 3 times daily |
Chaste tree (Vitex agnus castus) 1000 mg daily (either as 2 mL of 1:2 liquid extract or tablet) [23]
Improves nocturnal melatonin release [28]; considered beneficial in treating insomnia associated with fibromyalgia; can help correct raised prolactin levels, which are sometimes present in fibromyalgia [23]
Willow bark (Salix alba) liquid or tablet providing equivalent of 60 mg salicin 2–4 times daily [24]; anti-inflammatory, analgesic and antirheumatic; traditionally used for muscular pain [29]
| Alternative to herbal tonic if Corrine prefers a tea | ||
| HERB | FORMULA | RATIONALE |
| St John’s wort Hypericum perforatum |
2 parts | See above |
| Willow bark Salix alba |
2 parts | See above |
| Valerian root Valeriana officinalis |
1 part | Hypnotic [29]; sedative [25, 29]; mild anodyne [29]; traditionally used as an anxiolytic and to promote sleep [25, 29]; improves sleep latency and quality [30]; traditionally used for nervous unrest, stress and neuralgia [25] |
| Ginger root Zingiber officinale |
½ part | Anti-inflammatory [25, 26]; analgesic [26]; circulatory stimulant [25, 26]; antispasmodic [25, 26]; carminative [25, 26] |
Decoction: 1 tsp per cup – 1 cup 3–4 times daily
TABLE 8.27 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Omega-3 fish oil 6000 mg daily in divided doses [26, 35, 61] |
Anti-inflammatory [26, 61]; suppresses production of proinflammatory prostaglandins and cytokines [26, 61]; beneficial to reduce inflammatory processes associated with fibromyalgia [22] |
| High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic doses of essential micronutrients and antioxidants Dosage: as directed by the manufacturer |
To reduce oxidative stress and provide essential vitamins and minerals [33, 56]; high doses of a broad range of essential nutrients and antioxidants are indicated in fibromyalgia [21] |
| Magnesium and malic acid supplement [36]: providing a daily dose of 1200 mg malic acid and 600 mg elemental magnesium [36] | Supplementation with magnesium and malic acid has been shown to improve fibromyalgia symptoms [36] |
| Coenzyme Q10 100 mg twice daily [26] |
Essential for energy metabolism [26, 61]; antioxidant [26, 61]; reduces oxidative stress [26, 37, 61]; indicated for use in fibromyalgia [37] |
| High-potency practitioner-strength probiotic supplement containing therapeutic levels of human strain Lactobacilli and Bifidobacterium organisms [33, 59] | Disordered intestinal microflora is common in fibromyalgia [17, 59, 60, 64]; supplementation may help improve digestive function, reduce digestive disturbance [17, 19, 59] and reduce neurological symptoms [62, 64] |
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Systemic lupus erythematosus
Case history
| Analogy: Skin of the apple |
There is a slight ‘butterfly’ formation redness across Amira’s cheeks and nose.
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Family health | |
| Has anyone in your family had similar symptoms? | Yes. My aunt has SLE and my mother has OA. |
| Trauma and pre-existing illness | |
| Do your fingers feel weak after using them when repeating certain movements like working on the computer? (repetitive strain injury) | Yes, I do notice that after working on the computer they are sore. |
| Functional disease | |
| Does the pain in your hands become worse with physical activity and improve with rest? (mechanical causes, OA) | It does get sore when I am using my hands, but it seems to be sore when I am resting them too. |
| Infection and inflammation | |
| Endocrine/reproductive | |
| Amira’s cycle is between 26 and 30 days, with a bleed of about 4–5 days. She experiences no significant pain or discomfort but does sometimes feel more anxious in the days before her period. | |
| Stress and neurological disease | |
| They do not feel numb, but they can feel weak sometimes. | |
| Eating habits and energy | |
|
Amira’s diet contains red meat meals 3–4 times a week, chicken usually 3 times a week and fish usually once a week. She has either cooked vegetables or salad with her main meal and has porridge or cereal and milk for breakfast. She has leftovers or sandwiches for lunch and has about 3 cups of coffee during the day. I’m quite tired a lot of the time, I think maybe it is because I’m having problems sleeping at night. |
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client. |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Emotional health | |
| You mentioned you sometimes feel sad or anxious. Can you tell me more about that? | I’m very sad. My husband divorced me 3 years ago and now my son is leaving me too. Things have been difficult between us for the past few years, I was hoping they would get better before he left home. |
| Stress release | |
| How do you deal with stress and sadness? | I don’t know. Sometimes I just cry about it. I tell my mother but I don’t think she understands how it feels for your husband to leave you. |
| Occupation | |
| Tell me about your work. | I work in an office. I like my work and the people are kind and friendly. Maybe I’ll increase my hours there since I’m not needed at home anymore. |
| Family and friends | |
| Do you spend much time with family and friends? | Not really. I see my parents and sister sometimes. Most of the time I’m at home. |
| Action needed to heal | |
| How were you hoping I could help you? | Tell me what to do, give me some herbal medicine to help with my hands and help me feel well again. |
| Long-term goals | |
| What do you think you will be doing in five or 10 years? | I think I will be working full time and living alone. Maybe I will feel happier then. |
TABLE 8.31 AMIRA’S SIGNS AND SYMPTOMS [2, 6–8]
| Pulse | 86bpm |
| Blood pressure | 122/81 |
| Temperature | 38.5°C |
| Respiratory rate | 16 resp/min |
| Body mass index | 22 |
| Waist circumference | 76.8 cm |
| Nails and fingers | Mild vascular lesions on fingertips and nail folds; discolouration of finger tips, soft tissue swelling of fingers |
| Face | Slight redness across nose and cheeks in butterfly formation |
| Urinalysis | No abnormality detected (NAD) |
Results of medical investigations
No investigations have been carried out as yet.
TABLE 8.32 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 6–11, 13, 70, 72]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Causal factor: Trauma/ruptured tendons: can cause pain in the finger joints | Need to determine if Amira has experienced an injury to her hands recently; onset of pain would correlate with an injury and be aggravated by movement; joints would appear very red and swollen |
| INFECTION AND INFLAMMATION | |
Case analysis
| Not ruled out by tests/investigations already done [2, 6–11, 69–73] | ||
| CONDITION | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
| Atopic eczema: the word ‘atopy’ means to react to common environmental factors; can be caused and aggravated by diet or genetic factors | Lesions worse for anxiety; symmetrical lesions; eating potentially allergic/intolerant foods such as wheat and dairy | Skin rash that causes itching, begins with small vesicles and then spreads to produce thickening of the skin and weeping of pus and blood if scratched too much; associated with a history of asthma; presenting in flexor folds of the knees, behind the ears, hands, scalp, elbows and face; lesions cause irritation and scratching |
| Primary irritant eczema: degreasing of skin with water loss and dryness, fissuring and cracking; can happen at work and in the home | On areas of body that have close contact with irritants and where chemicals may be applied on skin | Usually asymmetrical lesions in exposed areas and displayed in streaks; determine if there is a skin rash on the palm of her hands |
| Photosensitive eczema | Typical features of eczema and thickening of the skin; often in individuals with pre-existing eczema (diagnosis can be missed); can be distributed over areas that skin is exposed to sun such as the hands, face and neck; may also spread to areas of the body where the skin is not directly exposed to the sun | Rare type of eczema, usually develops in middle age or in elderly men; can develop photosensitivity to artificial lighting |
| CANCER AND HEART DISEASE | ||
| Primary or metastatic cancer | Pain in fingers, fatigue, frequently getting sick | Deep boring pain that would be worse at rest |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Causal factor: Repetitive strain injury | Typing at work and strains fingers, intermittent pain | |
| Haemochromotosis | Fatigue, constipation, polyarthritis, eating regular meat and high iron-containing foods | |
| FUNCTIONAL DISEASE | ||
| Thoracic outlet syndrome | Hand pain worse on waking; common in middle-aged women | Usually only affects left hand and after the arms are hyperabducted on waking; hands would feel weak and numb |
| Raynaud’s phenomenon/disease: when this condition appears as an underlying cause of another disease it is called ‘phenomenon’, otherwise this condition is known as Raynaud’s disease | Discolouration of the fingertips due to sluggish blood flow; can be a complication of SLE and RA; finger pain is worse in cold weather | Extremely painful |
| Carpal tunnel syndrome: pain often in wrist, thumb, index and middle fingers; weakness in abduction of thumb and hypalgesia in the index finger | Pain and stiffness in hand; can be in later stage of RA; common in women; hands will often look normal with no joint swelling; should be no pain felt on palm of the hand | Common to have nocturnal pain in the wrist; need to ascertain level of stiffness and weakness accompanying hand pain |
| Causal factor: Functional constipation | Stress; currently Amira is highly emotional; constipation can develop | |
| INFECTION AND INFLAMMATION | ||
| Buerger’s disease: vasculitis of the arteries | Pain and numbness in the fingers; can cause Raynaud’s phenomenon symptoms and common between the ages of 20 and 40; can be confused with autoimmune diseases such as SLE | Would also involve feet; criteria includes current or recent history of smoking, lack of circulation in the hands and feet, painful walking; usually more common in men; need to as ascertain if the numbness is a symptom experienced with pain in the fingers |
| Acne rosacea | Inflammatory disorder common on the face with pustules and papules on the nose, forehead and cheeks; more common in women; has associated symptoms of facial flushing; usually develops in adults aged over 30 rather than adolescents | |
| SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION | ||
| Causal factor: Oral contraceptive pill | SLE symptoms | Ascertain if Amira has taken the oral contraceptive pill recently |
| Causal factor: Drug-induced SLE: hydralazine and procainamide most common | Rashes, pain in fingers | Need to establish if any medication has been taken over the past two years |
| ENDOCRINE/REPRODUCTIVE | ||
| Hypothyroidism/Hashimoto’s disease | Feels the cold, constipation, fatigue, sadness and swelling in joints of the hand | No visible goitre, weight gain, skin and hair changes |
| AUTOIMMUNE DISEASE | ||
| Systemic lupus erythematosus (SLE): will present with polyarthritis affecting 5 or more joints | Fatigue, joint pain in hands, pain in the morning, Raynaud’s phenomenon, skin rash, intermittent and transient arthritis with mild fever; not usual for joints to appear red; symptoms are symmetrical; family history of SLE | |
| Systemic sclerosis | Skin rash, gastrointestinal disturbance, Raynaud’s phenomenon, swelling in joints of the hands, raised antinuclear antibodies and RH factor can be present along with a normochromic normocytic film content; less common than SLE | Skin rash can be extensive and spread all over the body; skin on the face forms a beak-like nose and small mouth; painful ulcers on the fingers can develop; heartburn, hypertension and renal involvement can present |
| Overlap syndrome | Symptoms of RA and SLE and Raynaud’s; not usual for joints to appear red; symptoms are symmetrical | |
| Causal factor: Posttraumatic stress disorder (PTSD): Symptoms often develop within 6 months of the stressful event | Symptoms developed after divorce to husband | Has not mentioned flashbacks to a particular traumatic event |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Causal factor: Mixed anxiety and depressive disorder | Depressive disorder often associated with an experience of loss; symptoms of fatigue, apathy, or intense sadness, insomnia | Can be associated with numerous physical complaints associated with depression such as restlessness, headaches, shortness of breath, gut or skin disorders; need to determine if significant incapacity to continue daily activities for work |
| Stress | Lack of sleep, constipation, skin rash | |
| Causal factor: Functional fatigue, depression | Tiredness that has lasted for several months; grief from being separated from husband and children; feeling lonely; can be moderate or severe depression; people often describe symptoms in physical terms; has insomnia, change in appetite, fatigue; delayed sleep onset, lack of appetite, can be aggravated by certain conditions and situations that provoke depression | Need to determine if the feeling of fatigue improves during the day; early morning waking is common in depression |
| Peripheral neuropathy | Numbness in fingers | Weakness in fingers |
| EATING HABITS AND ENERGY | ||
| Causal factor: Diet: excess saturated fatty acids | Increase inflammation; eating a lot of red meat | |
TABLE 8.34 DECISION TABLE FOR REFERRAL [2, 7–11, 13]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
TABLE 8.35 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6, 8–11, 13, 70, 72, 73]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE MEDICAL INVESTIGATIONS: | |
| Full blood count | |
| Film comments | Normochromic normocytic (iron deficiency detected early; normochromic means normal haemoglobin content and colour; normocytic means normal red blood cell size) |
| ESR (erythrocyte sedimentation rate): inflammation in general | Raised |
| CRP (C-reactive protein): infection, cancer, inflammation | Normal |
| Rheumatoid factor (RH factor) | Positive: circulating autoantibodies, in inflammatory diseases such as RA, which have a portion of IgG as their antigen and self-aggregates into immune complexes that cause inflammation and joint damage; the most common reactive IgM molecule is RH factor |
| Antinuclear antibodies (ANA) | Positive: high; antibody that reacts against cellular nuclear material and is indicative of an autoimmune abnormality; this is very sensitive in detecting SLE |
| Immunoglobulins | IgG and IgM raised |
| Thyroid antibody blood test: thyroid perioxidase antibody, antithyroglobulin antibody | To rule out Hashimoto’s disease |
| IF NECESSARY: | |
| X-rays on left and right hands | Check if there are any fractures, joint or bone abnormalities; systemic sclerosis shows deposits of calcium around the fingers in an x-ray |
| Skin prick testing | Response to immediate contact allergies; test for extrinsic specific allergies |
| Skin patch tests to particular allergens | Review 2–4 days later for specific delayed contact allergies |
Confirmed diagnosis
Prescribed medication
• NSAIDs for arthralgia symptoms and oral corticosteroids if symptoms persist
• Amira would like to try natural therapies first before resorting to prescribed medication
TABLE 8.36 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS CONFIRMED)
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
|
• Recommendation to exercise daily to reduce inflammatory response and improve symptoms • Dietary recommendations to identify and avoid aggravating foods and to increase consumption of foods with anti-inflammatory and immune-modulating properties • Physical therapy recommendations to reduce pain, increase range of movement and preserve joint function • Herbal tea, tonic and tablets with anti-inflammatory, analgesic, antirheumatic and immunomodulatory action NB: Due to the presence of licorice in Amira’s herbal tea, her potassium levels should be monitored if she continues to take it for an extended period of time; it is unlikely there will be any problems at this dose NB: Amira’s serum vitamin levels can be monitored while she takes supplemental nutrients to ensure they stay within normal range; it is essential for Amira’s case to be managed collaboratively with her medical practitioners to ensure effective and appropriate treatment |
• Lifestyle recommendation to exercise daily to improve health and wellbeing
• Dietary recommendations to increase consumption of essential nutrients and antioxidants to reduce oxidative stress and promote general health
• Herbal tea and tablets with antioxidant, digestive stimulant, liver tonic and laxative action; also antimicrobial action to address the potential of underlying infection
• Supplemental nutrients with anti-inflammatory, kidney-protective and antioxidant properties to reduce oxidative stress and enhance health and wellbeing
• Supplemental nutrients to support the health of her gastrointestinal mucosa
• Lifestyle suggestions to improve Amira’s physical and mental health
• Dietary and supplement recommendations to improve symptoms of depression
• Herbal tea and tonic with nervine, sedative, anxiolytic, adaptogenic and antidepressant actions to support Amira’s nervous system, psychological health and improve her sleep pattern
Treatment aims
• Reduce systemic inflammation [14–16, 67].
• Modulate Amira’s immune response [14, 16].
• Slow down or prevent progression of the disease [41].
• Alleviate pain [41] and support joint health and mobility [14, 16].
• Deal with any underlying viral or bacterial infection if present [16, 36].
• Enhance integrity of the intestinal wall and support optimal digestive health and function [14, 37, 38].
• Identify and manage food allergies or intolerances [14, 16, 23, 39, 41].
• Identify and correct nutritional deficiencies [16, 39, 40].
• Enhance efficacy of conventional medications, reduce dosage and minimise adverse drug side effects [41].
• Reduce oxidative stress [40, 41, 50].
• Support Amira’s emotional health, nervous system and stress response [44, 45].
Lifestyle alterations/considerations
• Encourage Amira to reconnect socially with friends and colleagues. She needs to make a new support network and find effective ways of dealing with her sense of loss [18].
• Encourage Amira to exercise every day. Exercise is beneficial to her psychological wellbeing [19, 20] and graded aerobic exercise programs can be beneficial in SLE [42, 43]. Moderate exercise is associated with lower levels of inflammatory mediators [46].
• Encourage Amira to seek counselling to help her find positive coping strategies as she deals with her issues of grief and rejection [17, 18].
Dietary suggestions
• Identify and remove dietary triggers [14, 39, 41]. There is a correlation between food sensitivities and some immune-related rheumatic disorders [14, 16, 23, 39, 41]; Amira may find avoiding allergenic foods is greatly beneficial [41].
• Encourage Amira to avoid foods from the solanaceae (nightshade) family: eggplant, capsicum, tomato, capsicum (peppers) and potato [14, 16]. They are implicated in promoting inflammation and pain in rheumatic diseases [24].
• Encourage Amira to increase consumption of foods containing omega-3 fatty acids [41, 46] while reducing consumption of omega-6 fatty acids [46] and trans-fatty acids [47] and saturated fats [48]. Reducing linoleic acid and arachidonic acid while increasing omega-3 can enhance anti-inflammatory action of omega-3 fatty acids [49].
• Encourage Amira to avoid or reduce consumption of refined carbohydrates, sugar and animal fats while eating an antioxidant-rich whole-food diet that is high in fibre, whole grains, legumes, vegetables, fruit and flavanoid-rich berries [16, 40, 41, 48, 50].
• Encourage Amira to increase consumption of foods rich in vitamins A, E and C [39, 41, 50, 51].
• Encourage Amira to include plenty of turmeric and ginger in her diet. Turmeric has anti-inflammatory [25, 26, 32], antioxidant [25, 26] and immunomodulatory [25] actions. Ginger has anti-inflammatory [25, 26], antioxidant [25], circulatory stimulant [25, 26], immunonodulatory [25] and digestive stimulant [14, 25, 26] actions.
• Amira should replace coffee with green tea [41, 50] or the prescribed herbal tea.
Physical treatment suggestions
• Amira may find massage therapy beneficial to help her relax and reduce stress and anxiety [21, 22]. Massage may also be helpful by relaxing muscles, improving the range of motion of her joints and increasing endorphin production [52].
• Amira may find acupuncture therapy helpful [52, 53].
• Hydrotherapy: for hands, a hot Epsom salt hand bath for 20 minutes will help ease the pain [63]. Apply a heat compress on the hand with a plastic pad on top for 20 minutes – this is beneficial in cold weather [62, 63].
• Alternating hot (three minutes) and cold (30 seconds) hand bath locally to inflamed or painful joints for four rounds [63].
• For constipation place a hot compress on the abdomen, then cover in plastic, with a hot water bottle/heating pad on top for 12 minutes. Follow with cold mitten friction for 30 seconds (repeat process three times) [63].
• Alternating hot and cold showers daily to improve her immune system [64, 66].
• Constitutional hydrotherapy [62, 65].
• Cold water shower on the face daily [67].
• Cold oat sponge on the face to clean and ease the rash [62].
• Amira may benefit from exercises to strengthen her muscles, increase range of movement and preserve joint function [15, 54]. Such exercises are beneficial in RA, a condition with many similarities to SLE.
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Rehmannia Rehmannia glutinosa |
70 mL | Anti-inflammatory [26, 30]; adrenal trophorestorative [26, 30]; beneficial to reduce inflammation in autoimmune disorders [26, 30]; may help protect against suppressive effects of corticosteroid and chemotherapy [26, 30] |
| St John’s wort Hypericum perforatum |
40 mL | Anti-inflammatory [25]; anti-depressant [25, 26]; anxiolytic [25, 26]; analgesic [25]; antiretroviral [25, 26]; antimicrobial [25, 26] |
| Bupleurum Bupleurum falcatum |
45 mL | Anti-inflammatory [29, 30]; hepatoprotective [29, 30]; adaptogenic [56]; mild sedative [56]; beneficial in autoimmune disorders involving the kidneys [30] |
| Hemidesmus Hemidesmus indicus |
45 mL | Immunusuppressant [30, 56]; therapeutic benefits in autoimmune conditions [30, 56] |
| Supply: | 200 mL | Dose: 5 mL 3 times daily |
TABLE 8.38 HERBAL TABLET ALTERNATIVE
| Anti-inflammatory herbal tablet may be taken in addition to herbal tonic if necessary to reduce pain and inflammation as an alternative to NSAIDs | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Boswellia Boswellia serrata |
1.9 g | Anti-inflammatory [29, 33]; anti-arthritic [29, 33]; beneficial for autoimmune rheumatic conditions [58, 59] |
| Turmeric Curcuma longa |
2.0 g | Anti-inflammatory [25, 26, 32]; antimicrobial [25, 26]; antioxidant [25, 26]; choleretic [25, 26]; immunomodulator [25] |
| Celery seed Apium graveolens |
1.0 g | Anti-inflammatory [25, 29]; cholagogue [25]; antirheumatic [25, 29, 31]; sedative [31] |
| Ginger Zingiber officinale |
300 mg | Anti-inflammatory [25, 26]; antioxidant [25]; circulatory stimulant [25, 26]; immunomodulator [25]; digestive stimulant [14, 25, 26] |
Dose: 1 tablet 3 times daily
| Alternative to coffee | ||
| HERB | FORMULA | RATIONALE |
| Lemon balm Melissa officinalis |
2 parts | Anxiolytic [25, 55]; sedative [25, 29, 55]; anti-inflammatory [25]; analgesic [25]; beneficial for sleeping problems [25, 29, 55] |
| Willowbark Salix alba |
2 parts | Anti-inflammatory [25, 27, 29]; analgesic [25, 27, 29]; antirheumatic [29] |
| Prickly ash
Zanthoxylum americanum |
1 part | Circulatory stimulant [27, 29, 38]; antirheumatic [27, 29, 31]; silagogue [27, 29] |
| Green tea Camellia sinensis |
1 part | Antioxidant [25, 41, 50] |
| Licorice root Glycyrrhiza glabra |
1 part | Anti-inflammatory [25, 26]; adrenal tonic [25, 26]; antioxidant [25, 26]; antimicrobial [25, 26]; immunomodulator [25]; mild laxative [26] |
Decoction: 1 tsp per cup – 1 cup 3 times daily
TABLE 8.40 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Omega-3 fish oil 10,000 mg daily in divided doses [25] |
Anti-inflammatory [14, 25, 28, 46]; omega-3 3 supplementation improves clinical status in autoimmune conditions [41, 46] and can reduce the need for antirheumatic medication [46]; omega-3 supplementation decreases inflammatory cytokine levels in autoimmune conditions [46]; EPA favours the formation of immunoinhibitory prostaglandins [39]; helps protect against renal damage in SLE [41] and delays the onset and progression of autoimmune lupus nephritis [57]; beneficial in depression [25, 60, 61] |
|
NB: Combining the above supplements in one product is likely to improve compliance by making it easier for Amira to take all the required supplements in one dose and by reducing the financial cost |
Quercetin is an anti-inflammatory [25, 28]; antioxidant [25, 28]; immunomodulator [25]; quercetin inhibits inflammatory enzymes, prostaglandins and leukotrienes [25], stabilises mast cells [25] and inhibits mast cell release of histamine [28] Bromelain is anti-inflammatory [15, 35, 28]; beneficial in autoimmune disease [28]; bromelain reduces inflammation [60]; and may be beneficial in inflammatory autoimmune conditions [34] Vitamin E supplementation can induce remission in SLE [39] Vitamin C supplementation may prevent occurrence of active SLE [51] |
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