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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