Hering’s three legged stool: acute pain management of osteoarthritis of knee joint- a case study

Dr Raghila KP
ABSTRACT
Homoeopathy claims to be “The Science of Therapeutics”. The assumption of therapeutics is the science which has developed after Homoeopathy.  ^[1] The physicians high and only mission is to restore the sick to health, to cure, as it is termed^{[.2],[ 3]} Osteoarthritis can be defined as the degeneration of the hyaline cartilage covering the articular surfaces with pathological evident of synovial joint disease characterized by focal loss of articular cartilage with proliferation of new bone and remodeling of joint contour.^[1] The more stricking, singular, uncommon and peculiar signs and symptoms of the case are chiefly and most solely to be kept in view in a case. These indications are unusual, distinct and unique for each person. Homoeopathic treatment methodology is based on such called PQRS symptom of the patient which can individualize the patient as a person.

KEYWORD:  Characteristic symptom, Osteoarthritis, Kali Bich.

INTRODUCTION: 

^[2],[3] Osteoarthritis (OA), is also called as Osteoarthrosis or degenerative joint disease, is the most common form of chronic disorder of synovial joints. To diagnose it as OA, clinical manifestations are joint stiffness, diminished mobility, discomfort and pain. Disease progression is usually slow but can ultimately lead to joint failure with pain and disability. The joints which commonly involve are knee, hip, hands and shoulder rarely.^[10] They are classified as primary which occurs due to wear and tear with repeated minor trauma, heredity, obesity, aging and secondary due to fall or injury which occurs at any age.^[4] In 2005, it was estimated that over 26 million people in the USA had some form of OA^[5].There is a steady rise in prevalence from age 30 such that by 65, 80% of people have radiological evidence of OA though only 25-30% are symptomatic. The number of people affected with symptomatic knee OA is likely to increase because of the aging of the population and the obesity epidemic^[6].A study was conducted to find out if there was any correlation between osteoarthritis and osteoporosis and the  study shows that there is a slight negative correlation between osteoarthritis and osteoporosis and they are inversely proportion to each other^.[5] A study was conducted to Evaluate the Efficacy of Homoeopathic Medicine In Management of Osteoarthritis of Knee and  was observed that Rhus tox was prescribed   highest among all 6 medicine found to be prescribed in Osteoarthritis of knee joint with 88.64% improvement in pain, 85.71% improvement in Symptoms, 88.09% improvement in Activity of Daily living, 80% improvement in Sports and recreational activity and 75% improvement in Knee related activity. Bryonia precedes Rhux tox, then Calc flour then Causticum then Calc. carb and least was Kali Carb. OA is a chronic disease but there can be acute exacerbations of pain which can be treated well with similimum.

^[7][12][13] Dr Hering, years before the “keynote system” was ever heard of, said: “Every stool must have at least three legs, if it is to stand alone.” He advised selecting at least three characteristic symptoms as the basis of prescribing.  A characteristic or keynote symptom is a generalization drawn from the particular symptoms by logical deduction^[1]  In Organon of Medicine §153 Dr. Hahnemann writes, “In this search for a homoeopathic specific remedy, that is to say, in this comparison of the collective symptoms of the natural disease with the list of symptoms of known medicines, in order to find among these an artificial morbific agent corresponding by similarity to the disease to be cured, the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case of disease are chiefly and most solely to be kept in view; for it is more particularly these that very similar ones in the list of symptoms of the selected medicine must correspond to, in order to constitute it the most suitable for effecting the cure. The more general and undefined symptoms: loss of appetite, headache, debility, restless sleep, discomfort, and so forth, demand but little attention when of that vague and indefinite character, if they cannot be more accurately described as symptoms of such a general nature are observed in almost every disease and from almost every drug^{.[ 7],[8]}According to Dr Guernsey’s, There is usually something peculiar in case, some prominent feature or striking combination of symptoms that directs the attention to a certain drug. Guernsey simply invented a new name for the old Hahnemannian idea. Guernsey’s “keynotes” and Hahnemann’s “characteristics” as synonymous terms, which they are, and making legitimate use of Guernsey’s method, it has value. .^[8] It was Dr Guernsey highlighted the importance of these symptoms in homoeopathic practice. Many other great prescribers like Dr Lippe, P.P.Wells, H.C Allen, etc. gave importance to key note prescribing.

There are several Homoeopathic medicines which has their affinity on the joints. ^[11] Kali bich is one such remedy having affinities on the bones and fibrous tissue.

CASE PROFILE:
An 83 year old male, Christian reported in the OPD on 12-11-19 with the complaint of pain in bilateral knee joint since 10yrs and increased pain since 15 days.

HISTORY OF CHIEF COMPLAINT:
Patient gradually developed with the complaint of bilateral knee joint pain past 10years.It was gradual in onset and progression and the severity of pain varies according to his physical exertion. The pain started initially in the right, then within 2 weeks it started with left with same presentation.  Presently the pain is marked in the popliteal region for the last 15 days. The pain is of Aching² type which get aggravated in the morning2+ with stiffness which lasts less than 3 minutes. The pain occupied particularly in one point always especially in medial aspect of the popliteus. The complaints are aggravated on walking^2+, rising from sitting position⁺, standing for long, bending his knees^2+, squatting²⁺ and Night ²⁺. Patient also complaints of weakness of knee joint bilaterally. The pain was slightly better when he takes rest ⁺. There is no radiation of pain, numbness of joints and history of fall in the patient.

ON EXAMINATION: 

BP: 140\80mmhg, Right arm supine position

Pulse: 73 beats/min, Regular rhythm, moderate Volume, Vessel wall not palpable 

KNEEJOINT:

• No edema and Swelling, No redness
• Crepitus: +ve bilaterally
• Movements: Flexion and extension possible

PERSONAL HISTORY:

• Appetite: Good, mixed.
• Thirst: Good, 2 L per day, thirst less.
• Craving:  sweets2+
• Aversion: Milk+
• Bladder habit: Good, 4-5 times per day.
• Bowel habit: 1 time per day, regular.
• Sleep: Good, 11 to 6 am, 7 hours per day refreshing.
• Dreams: Nil
• Thermally: Hot patient

PAST HISTORY: 

Treatment History: Taken Allopathic medicine for the same

FAMILY HISTORY: Father HTN since I year.

PROVISIONAL DIAGNOSIS: OSTEOARTHRITIS OF KNEE JOINT

TOTALITY OF SYMPTOMS:
^{[8][9][12][13]}The symptoms which are peculiar in a case help to find small group of remedies is called keynote Symptoms. There should be at least three keynote symptoms in order to make correct homoeopathic prescription. In this case, with exacerbation, the three important uncommon, peculiar symptoms are taken.

1. Aching pain in the popliteal region
2. Aching pain in small spot
3. Aching pain <Night²⁺

^[8] Hahnemann has mentioned in Organon in aph 153 the importance of characteristic symptoms and suggested in the footnote that the characteristic symptoms should be referred to the ^[14] repertories for finding out an appropriate remedy for the case.

 REPERTORIZATION:

JUSTIFICATION OF REMEDY SELECTION:
A minimum symptom of maximum importance is taken into consideration. According to Dr Hering, three important uncommon peculiar, keynote so called characteristic symptom is taken into consideration. The selected symptom was mainly the characteristic pain, Pain in small spot. ^[16] According to Dr E.B Nash, Pain of Kali Bich are migratory which appears and disappears suddenly. Pain appear in small spots, which can be covered by point of the finger. Rheumatism alternating with dysentery. The action of Kali bich will be better in low trituration. According to ^[11] William Boericke, there will be tearing pain in tibia, and syphilitic rheumatism where there is an exacerbating pain at night. Joints are very weak with swelling and stiffness with marked pain behind knee joint. Cracking of all joints with wandering pain. ^[17] According to J.D Patil, Kali bich acts on fibrous tissues producing irritation and tearing pain which can bears frequent repetition. It acts on periosteum producing inflammation, disorganizations, and destruction. Kali bich is useful in syphilitic Rheumatism. Joints are affected considerably and there is more pain about the fingers and wrist, than in any other part of the body. During repertorization, pain in the popliteus was taken as pain in hollow of the knee. With considered three main keynote symptoms and after repertorization kali bich came as indicated remedy and further referring to Materiamedica, same was prescribed.

PRESCRIPTION:

12-11-19

              Rx,   

1. Kali Bich 30

3-3-3

2. 2grain tab

2-0-2  , For 1 week  

FOLLOW UP CRITERIA:

• Pain in knee joint
• Stiffness
• Appetite
• Thirst
• Bowel Habit
• Bladder Habit
• Sleep

FOLLOW UPS:

DATE	SYMPTOM	PRESCRIPTION
19-11-19	Pain in Knee joint 60% better Stiffness: same All other generals good No new complaint	Rx, Kali bich 30         3-3-3        2 grain tabs         3-0-3, for 2 weeks
26-11-19	Pain in knee joint 90% better Stiffness mild <morning+ Able to walk better than before All other generals good No new complaint	Rx, Kali bich 30         3-3-3        2 grain tabs         3-0-3, for 1 week

CONCLUSION:
Osteoarthritis is a degenerative joint disease found especially in old age. This article focused mainly on treating the case considering uncommon peculiar characteristic symptom. Concept of Individualization has to be taken at grass root level. The case can be treated by giving an acute remedy for exacerbating pain followed by constitutional remedy after retaking the case. ^{[8] [9][12]} For remedy selection “Keynote Prescription” is used on the basis of PQRS symptoms. In this case less symptoms but peculiar symptoms are present. Repertorization was done with such symptoms and the remedy came was Kali bich .Though reverting back of pathology is impossible, there is marked reduction in the pain to provide better quality of life is definitely possible. The potency was selected based upon the vitality, susceptibility, age, pathology where patient presented with symptoms past 10 years. Hence it was given in low potency with frequent repetition where patient improved with pain drastically within few days. The prescription sounds solid when a minimum symptom of maximum value is taken, and it will help in restoration of health.

BIBLIOGRAPHY

1. Samuel Hahnemann, Organon of medicine, 6^th Edition
2. Dennis Kasper, 2015, Harrison’s Principles of Internal Medicine, New York, McGraw-Hil  Professional Publishing.
3. Stanley Davidson, Davidson’s Principles and Practice of Medicine.
4. Litwic A, Edwards MH, Dennison EM, Cooper C. Epidemiology and burden of osteoarthritis.   British medical bulletin. 2013 Mar 1;105(1):185-99.
5. Dave P, Trivedi M, Patel G, Shah P. To Evaluate the Efficacy of Homoeopathic Medicine In Management of Osteoarthritis of Knee. National Journal of Integrated Research in Medicine. 2018 May 1;9(3)
6. Im GI, Kim MK. The relationship between osteoarthritis and osteoporosis. Journal of bone       and mineral metabolism. 2014 Mar 1;32(2):101-9
7. Close Stuart, The Genius of Homoeopathy Lectures and Essays on Homoeopathic Philosophy, 19th impression. B. Jain Publishers (P) Ltd. Noida. 2017, 157-158
8. Shashi Kant Tiwari, 2005, Essentials of repertorization, New Delhi, B. Jain.
9. H.C Allen Keynotes.
10. Harsh Mohan, Textbook of pathology; Pathology quick review
11. William Boericke, 2004, Pocket manual of homoeopathic Materia medica, New Delhi, Indian  Books & Periodicals Publishers
12. Sankaran R. From Similia to Synergy. Mumbai, India: Homoeopathic Medical Pub. 2013.    13. Sathish Kumar V, Suman Sankar AS, Deepthi F, Priyanka PS, Chandrahasan CM. Analysis and evaluation
13. Schroyens F, 1993, Synthesis, London: Homoeopathic Book Publishers
14. Rutten LA. The importance of case histories for accepting and improving homeopathy.                Complementary therapies in medicine. 2013 Dec 1;21(6):565-70
15. E.B Nash, Leaders in homoeopathic therapeutics
16. J.D Patil, GEMS, Textbook of Homoeopathic Materia Medica

RAGHILA K.P
BHMS(Intern)
Father Muller Homoeopathic Medical College and Hospital
Mangalore, Deralakatte.