Osteoarthritis and homoeopathic therapeutics

Dr Annapoorna H

OSTEOARTHRITIS is a non-inflammatory degenerative joint disease characterised by focal loss of cartilage with accompanying peri-articular bone response in the form of sub-chondral bone sclerosis and attempted new bone formation in the form of bony over growths called osteophytes.

• Commonly seen in weight bearing joints such as hip and knee.
• Also seen in spine and hands.
• Both males and females are affected.
• More common in elderly women i.e., above 50 years, particularly in postmenopausal age.

 RISK FACTORS

• Obesity especially OA knee.
• Abnormal mechanical loading eg. meniscectomy, instability.
• Inherited type II collagen defects in premature polyarticular OA.
• Inheritance in nodal OA.
• Occupation ex. farmers.
• Infection: non-gonococcal septic arthritis.
• Heriditary.
• Ageing process in joint cartilage.
• Defective lubricating mechanism.
• Incompletely treated congenital dislocation of hip.

PRIMARY OA

• More common than secondary OA
• CAUSE – unknown
• Common in elders where there is no previous pathology.
• It is mainly due to wear and tear changes occuring in old ages mainly in weight bearing joints.

SECONDARY  OA

It is due to predisposing cause such as –

• Injury to the joint
• Previous infection
• Rheumatoid arthritis
• Congenital dislocation of hip
• Deformity
• Obesity
• Hyperthyroidism

TYPES OF OA

• Nodal generalised OA
• Crystal associated OA
• OA of premature onset

NODAL GENERALISED OA

• Herbeden’s nodes are seen 
• Bouchard’s nodes are seen
• Carpometacarpal  joints of thumb
• Hallux variety
• Valgus/rigidus
• Mostly affects Knees and hips
• Type of joint affected Apophyseal joints

CRYSTAL ASSOCIATED OA

• Deposition of calcium pyrophosphate dihydrate 
• Mainly seen in elderly age group
• Women are mainly affected
• Joint affected mainly are knees

OA OF PREMATURE ONSET

Mainly seen In previous mescectomy cases and haemochromatosis.

PATHOLOGY

OA affects the following :

• Articular cartilage
• Bone
• Synovial membrane
• Capsule
• Ligament
• Muscle

1. Articular cartilages

• Osteoarthritis primarily affects the articular cartilage.
• Increase in water content and depletion of the proteoglycans from the cartilaginous matrix.
• Repeated weight bearing on such cartilages leads to its fibrillation.
• The cartilage gets abraded by the grinding mechanism at work at the points of contacts between the opposing articular surfaces.

2. Bone (Eburnation)

• With further rubbing the subchondral bone becomes hard and glossy.
• Meanwhile, the bone at the margins of the joint hypertrophies to form a rim of projecting spurs known as osteophytes.
• Formation of subchondral cysts and sclerosis.

3. Synovial membrane and capsule

• Synovial membrane undergoes hypertrophy and becomes oedematous.
• Reduction of synovial fluid secretion results in loss of nutrition and lubricating action of articular cartilage.
• The loose flakes of cartilage incite synovial inflammation and thickening of the capsule, leading to deformity and stiffness of the joint.

4. Ligaments and muscles

• Ligament Undergoes fibrinous degeneration
• There is low grade chronic inflammatory changes due to which joint becomes contracted or elongated.
• Muscles undergo atrophy which results in limited movements and functions of joint.

SIGNS AND SYMPTOMS

• Disease usually occurs in elderly people, mostly bilaterally in the major joints of lower limbs.
• Knee is involved more commonly in a population with asian living habits i.e., the habit of squatting and sitting crossed legged.
• Pain is the earliest symptom.
• Coarse crepitus.
• Swelling of the joint is the late feature and is due to the effusion caused by inflammation of the synovial tissues.
• Stiffness is due to pain and muscle spasm.
• Restricted movement and deformity
• Muscle weakness or wasting
• Capsular contracture and incongruity of the joint surface contribute to it.

ON EXAMINATION

• TENDERNESS on the joint line.
• CREPITUS on moving the joint.
• IRREGULAR ENLARGED looking joint due to formation of peripheral osteophytes.
• DEFORMITY – VARUS of the knee, flexion-adduction-external rotation of the hip.
• Effusion rare.
• STIFFNESS of joint movement. 
• SUBLUXATION detected on ligament testing.

INVESTIGATIONS

There are no pathognomonic laboratory findings for OA

 Laboratory analysis is performed for differential diagnosis

RADIOLOGIC FINDINGS OF OA

• Narrowing of joint space 
• (due to loss of cartilage)
• Osteophytes
• Subchondral (paraarticular) sclerosis
• Bone cysts

RADIOLOGIC GRADE OF OA

• G1     Normal
• G2     Mild
• G3     Moderate
• G4     Severe
• Kellgren Lawrence Classification

PRIMARY PREVENTION

• Regular exercises
• Weight control
• Prevention of trauma

TREATMENT OF OA

• Symptomatic treatment
• Structure modifying treatment
• Surgical treatment

SYMPTOMATIC TREATMENT

• Decrease of joint loading

        – Weight control

        – Splinting

        – Walking sticks

• Exercises

         – Swimming

         – Walking

         – Strengthening

• Patient education

HOMOEOPATHIC MANAGEMENT

MAJOR REMEDIES INDICATED ARE

• BRYONIA ALBA
• RHUS TOX
• KALI CARBONICUM
• ARNICA
• RUTA
• KALMIA LATIFOLIA
• COLCHICUM
• LEDUM PALUSTRE
• APIS MELIFICA
• CALCAREA CARBONICUM
• STICTA PULMONALE
• PULSATILLA NIGRICANS
• RHODODENDRON
• LITHIUM CARBONICUM
• MEDORRHINUM

BRYONIA ALBA
Knees stiff and painful. Hot swelling of feet. Joints red, swollen, hot, with stitches and tearing; worse on least movement. Every spot is painful on pressure. Constant motion of left arm and leg.

KALI CARB
White swelling of knee. Tearing in arms from shoulder to wrist. Lacerating in wrist-joint. Paralysis of old people, and dropsical affection. Limbs go to sleep easily. Tips of toes and fingers painful. Soles very sensitive. Itching of great toe, with pain. Pain from hip to knee. Pain in knees.

RHUS TOX
Hot, painful swelling of joints. Pains tearing in tendons, ligaments, and fascia. Rheumatic pains spread over a large surface at nape of neck, loins, and extremities; better motion. Soreness of condyles of bones. Limbs stiff paralyzed. The cold fresh air is not tolerated; it makes the skin painful.  Tearing down thighs. ; worse, cold, damp weather, at night. Numbness and formication, after overwork and exposure.; trembling after exertion. Tenderness about knee-joint. Loss of power in forearm and fingers; crawling sensation in the tips of fingers. Tingling in feet.

ARNICA MONTANA
Great fear of being touched or approached. Pain in back and limbs, as if bruised or beaten. Sprained and dislocated feeling. Soreness after overexertion. Everything on which he lies seems too hard. Deathly coldness of forearm. Cannot walk erect, on account of bruised pain in pelvic region. Rheumatism begins low down and works up.

RUTA
Spine and limbs feel bruised. Small of back and loins pain. Legs give out on rising from a chair, hips and thighs so weak. Contraction of fingers. Pain and stiffness in wrists and hands; worse, lying down at night; pain from back down hips and thighs. Hamstrings feel shortened. Tendons sore. Aching pain in tendo-Achilles. Thighs pain when stretching the limbs. Pain in bones of feet and ankles. Great restlessness.

KALMIA LATIFOLIA
Deltoid rheumatism especially right. Pains from hips to knees and feet. Pains affect a large part of a limb, or several joints, and pass through quickly. Weakness, numbness, pricking, and sense of coldness in limbs. index finger. Joints red, hot, swollen. Tingling and numbness of left arm.

COLCHICUM
Sharp pain down left arm. Tearing in limbs during warm weather, stinging during cold. Pins and needles in hands and wrists, fingertips numb. Pain in front of thigh. Right plantar reflex abolished. Limbs, lame, weak, tingling. Pain worse in evening and warm weather. Joints stiff and feverish; shifting rheumatism; pains worse at night. Inflammation of great toe, cannot bear to have it touched or moved. Tingling in the finger nails. Knees strike together, can hardly walk. oedematous swelling and coldness of legs and feet.

LEDUM PALUSTRE
Small joints. Swollen, hot, pale. Throbbing in right shoulder. Pressure in shoulder, worse motion. Cracking in joints; worse, warmth of bed. Ball of great to swollen. Rheumatism begins in lower limbs and ascends(kalmia opposite). Ankles swollen. Soles painful, can hardly step on them. Easy spraining of ankle.

APIS MELIFICA
Oedematous. Synovitis. Knee swollen, shiny, sensitive, sore, with stinging pain. Feet swollen and stiff. Feel too large. Rheumatic pain in back and limbs; Tired, bruised feeling. Numbness of hands and tips of fingers. Hives with intolerable itching. oedematous swellings.

CALCAREA CARBONICUM
Rheumatoid pains, as after exposure to wet. Sharp sticking, as if parts were wrenched or sprained. Cold, damp feet; feel as if damp stockings were worn. Cold knees cramps in calves. Sour foot-sweat. Weakness of extremities. Swelling of joints, especially knee. Burning of soles of feet. Sweat of hands. Arthritic nodosities. Soles of feet raw. Feet feel cold and dead at night. Tearing in muscles.

STICTA PULMONARIA
Rheumatic pain in right shoulder joint, deltoid, and biceps. Swelling, heat, redness of joints. Spot of inflammation and redness over affected joint. Pain severe and drawing. Chorea-like spasms; legs feel floating in air. Housemaid’s knee. Shooting pains in knees. Joints and neighbouring muscles red, swollen, painful. Rheumatic pains precede catarrhal symptoms.

PULSATILLA NIGRICANS
Drawing, tensive pain in thighs and legs, with restlessness, sleeplessness and chilliness. Pain in limbs, shifting rapidly; tensive pain, letting up with a snap. Numbness around elbow. Hip-joint painful. Knees swollen, with tearing, drawing pains. Boring pain in heels toward evening; suffering worse from letting the affected limb hang down (Vipera). Veins in forearms and hands swollen. Feet red, inflamed, swollen. Legs feel heavy and weary.

RHODODENDRON
Joints swollen. Rheumatic tearing in all limbs, especially right side; worse, at rest and in stormy weather. Stiffness of neck. Pain in shoulders, arms, wrists; worse when at rest. Pains in bones in spots, and reappear by change of weather. Cannot sleep unless legs are crossed.

LITHIUM CARB
Paralytic stiffness all over. Itching about joints. Rheumatic pains throughout shoulder-joint, arm, and fingers and small joints generally. Pain in hollow of foot, extending to knee. Swelling and tenderness of finger and toe joints; better, hot water. Nodular swellings in joints. Ankles pain when walking.

REFERENCE:

1. API textbook of medicine
2. Davidson’s principles and practice of medicine
3. Homoeopathic materia medica by Dr.William Boericke
4. Lectures on homeopathic materia medica by James Kent
5. A dictionary of practical materia medica by John Henry Clarke