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					                             RHEUMATOID ARTHRITIS



TEMPERAMENT OF ILLNESS AND ORGANS INVOLVED

Hot and moist to moist and hot imbalance – Abnormal sanguinous / phlegmatic humour,
pathway 2 (chronic). The temperament of muscle is dry and hot whilst bones, joints,
tendons and ligaments are cold and dry.


DEFINITION OF RHEUMATOID ARTHIRITIS (R.A)

Allopathic definition – R.A is the second most common form of arthritis after osteo-
arthritis. It is a chronic autoimmune disease which results in joint damage mediated by
cytokines, chemokines and metalloproteases but the precise cause is unknown.
Peripheral joints like the wrists, metacarpophalangeal joints are symmetrically inflamed.
Often resulting in progressive destruction of articular structures. R.A affects 1% of the
population, women are 2 - 3 times more affected than men. The onset can occur at any
age but most often between 35 -50 yrs. Children and the elderly can also be affected (The
Merck Manual, 2006).

Tibb definition – R.A is a hot and moist to moist and hot condition brought about due to
abnormal sanguinous / phlegmatic humour accumulation overtime. This is a chronic
condition (pathway 2).It affects women more than men due to their high level of innate
moisture. Individuals of the sanguinous and phlegmatic temperaments are predisposed to
R.A due to their high levels of moisture. This indicates that hereditary factors play a huge
role in the development of this disorder. This disorder is in the hot and moist frame due to
the nature of the inflammation which involves heat, redness, pain, swelling, stiffness and
loss of function. A high level of heat and moisture is needed to facilitate the
inflammatory process.


SIGNS AND SYMPTOMS

Usually the onset is insidious, beginning with systemic symptoms which progress to joint
symptoms but these can occur simultaneously. Systemic symptoms include early
morning joint stiffness, generalized afternoon fatigue and malaise, anorexia, generalized
weakness and low-grade fever. Joint symptoms include stiffness lasting for more than 1
hour on rising in the morning or occurring after prolonged inactivity. Joint involvement is
typically symmetrical, tender, with erythema, warmth, swelling and limited motion
affecting the wrists, index and middle metacarpophalangeal joints more often .Other
joints affected are the proximal interphalangeal (P.I.P ), metatarsophalangeal, elbows and
ankles but any joint can be involved. The axial skeleton is rarely involved with exception
of the upper cervical spine.




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Synovial thickening can be detected. Fixed deformities like flexion contractures
develops rapidly. These presents as ulnar deviation of the fingers, swan-neck and
boutoniere deformities.

Subcutaneous nodules usually develops later in 30% of patients, affecting sites of chronic
irritation and pressure like the extensors of the elbow. Visceral nodules are asymptomatic
and commonly seen in severe R.A .Extra-articular signs include vasculitis causing leg
ulcers, pleural/ pericardial effusions, pulmonary fibrosis, pulmonary nodules,
lymphadenopathy, pericarditis and myocarditis. Cervical spine involvement causes spinal
cord compression which may worsen extension of the neck.

The course of R.A is unpredictable however rapid progression is seen in the first 6 years
with year 1 being the worst. Within 10 years permanent joint abnormalities develops in
80% of patients (The Merck Manual, 2006).


DIAGNOSIS

R.A. should be suspected in patients presenting with polyarticular, systemic arthritis.
Based on the American Rheumatism Association any 4 of the following criteria must be
present for diagnosis of R.A :-

Morning stiffness for 1 hour or longer
Arthritis in 3 or more joints.
Arthritis of the hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes ( hand x-ray : erosions, calcification of bone)

X- ray only shows soft-tissue swelling within the first few months followed by
periarticular osteoporosis, joint space narrowing and marginal erosion which becomes
visible. M.R.I can detect early articular inflammations and erosions. Synovial fluid
examination is useful in ruling out other inflammatory conditions ( The Merck Manual,
2006).


TREATMENT AND MANAGEMENT

Allopathic treatment – A balance of rest and exercise, adequate nutrition ( with limited
emphasis of food associated exacerbations), physical measures, drugs ( first - line
treatment eg. NSAID’s, disease-modifiying drugs ,antirheumatic drugs, corticosteroids,
cytotoxic / immunosuppressive drugs) and sometimes surgery.




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Tibb treatment frames include: cold and moist, cold and dry and dry and hot.

DIET

Avoid hot and moist and moist and hot foods, these includes sweet and salty foods.
These foods increase heat and moisture therefore avoidance is important especially
during inflammatory stages. Examples of hot and moist foods are - mutton, lamb, liver,
turkey and goat ( red meats are discouraged due to the pro-inflammatory properties),
bananas, paw paw, bread, macaroni, mangoes, dates, salt. Avoid animal fats, alcohol,
caffeine containing products like tea, coffee and chocolates. Avoid highly acidic foods
like pickles.

Eat more cold and moist (bland) foods like rice, cranberries, litchis, carrots, cucumbers,
pineapples. Cold and moist foods should only take up 10 -20 % of this diet. This will help
to decrease the excess heat.

Increase consumption of cold and dry (sour) foods like tomatoes, peanut butter, fish
(especially those rich in omega 3 like sardines, mackerel and salmon – proven to benefit
joint mobility) 30-40% of the diet. This will counteract the heat and moisture
accumulation.

Increase consumption of hot and dry ( spicy) foods like chicken, garlic, peppers, cashews,
eggs, 30 -40 % of the diet. This will provide dryness that overcomes the excess moisture
associated with R.A.


MOVEMENT AND REST

A balance between exercise and rest is essential to the treatment plan. The patient should
undertake regular light to moderate exercise but avoid over-exertion (as this will increase
unnecessary heat) particularly in hot or humid weather. It is important to maintain the
ideal B.M.I as excess weight places strain on the already compromised joints.

Physiotherapy and occupational therapy is important to the initial therapy to maintain
joint function, for recommended energy consideration strategies, for range-of-motion and
strengthening exercises.Conditioning exercises programs specific for the particular joints
involvement with improve joints mobility, muscle strength, aerobic fitness and
psychological well-being without increasing fatigue or joint symptoms. Physical activity
involving aerobic exercise and strength training combats rheumatoid cachexia which is
the loss of body cell mass of skeletal muscle, viscera and the immune system.




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SLEEP AND WAKEFULNESS

Adequate sleep is essential along side the exercise program. An afternoon nap would be
beneficial, 6 -7 hrs sleep daily is encouraged.


ELLIMINATION

This is crucial to eliminate the excess sanguinuous humour which is readily concocted for
elimination. Therefore the patient should maintain daily bowel movements by consuming
a high fiber diet. E.g. oat bran and grains together with a high water intake ( 6-8 glasses
daily)


ENVIRONMENTAL AIR AND BREATHING

The patient should refrain from tobacco usage and exposure to secondary smoke. The
Tibb slow breathing exercise is encouraged to decrease the excess heat in the system.


EMOTIONS

Since R.A is a debilitating chronic disorder affecting lifestyle with psychological
implications, the family of the patient should be part of the management strategy. Family
members should be educated and advised on forming a support structure. This will allow
family members to be more empathetic which will directly provide emotional support to
the patients. Family education will also act as a screening strategy to detect R.A early in
susceptible individuals (sanguinous/ phlegmatic).


REGIMENTAL THERAPY

Cupping is highly effective in treating inflammation and promoting healing and
restoration. Dry cupping points include UE 1,2,3 and LE 7,8,9,15 depending on joint
involvement. This is preceded by a relaxing massage with citronella oil which is cold and
dry. The oils used depends on the stage of R.A, if in the inflammatory stage then
citronella is indicated, if R.A progresses to the cold and dry stage then a heating,
moisturizing oil like olive oil is appropriate. NB: Massage is contra-indicated over areas
of inflammation, pain and rheumatoid nodules. Massage in the surrounding areas.

Breathing exercises, meditation, the traditional Indian head massage and visualization are
effective relaxation techniques to treat fatigue, and emotional distress associated with
R.A.




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MEDICATION

Tibb Antiflam tabs – The hot and dry quality is suitable for musculoskeletal disorders
associated with hot and moist imbalance. Indicated in RA and gout . NB: Contraindicated
in hypertensive patients.

Ingredients – Colchicum luteum and Withania somnifera are all known for their analgesic
and anti-inflammatory effects. Commiphora mukul – analgesic with bone healing
qualities

Tibb Rumaflam tabs – indicated in arthritis and muscle pain, the dry and hot quality is
suitable in musculoskeletal disorders associated with hot and moist imbalance.

Ingredients – Shanku bhasma – highly enriched with calcium, phosphorus and
magnesium (maintains mineral balance needed for healthy joints). Sida cordifolia and
Maharasnadi quath – analgesic qualities effective in R.A.

Tibb Rumaflam cream and Rumaflam oil (lightly massage into affected area) are both dry
and hot in quality and both contains ingredients with anti-inflammatory and analgesic
qualities yet providing stimulating properties which increases blood circulation to the
affected area (Tibb practitioner monograph, 2009).


                              ALTERNATIVE THERAPIES


HERBAL REMEDIES

Wild dagga (Leonolis leonurus) is a versatile indigenous plant used to treat rheumatism
and high blood pressure.

Wild dagga bath - 3 cups of chopped fresh wild dagga, simmer gently in 1 liter of water
for 30 minutes. Strain and add to a warm bath.

Celery tea can alleviate the pain of arthritis, help lower blood pressure and is known as a
aphrodisiac. Place 15g fresh chopped celery in 250ml (1cup) then bring to a boil in a
saucepan, simmer for 3 minutes and allow infusion for 5 -10 minutes, strain, sweeten
with honey and drink 2 cups daily.
NB: Contraindicated in kidney disorders.

Garlic oil relieves painful swollen joints. Blend 3-4 tablespoons of vegetables oil to 2 –
3 tablespoons of lard in a small bowl. Mash the garlic coarsely and stir into mixture.
Gently massage into painful joints ( Readers digest: Oumas home remedies, 2002).




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THERAPY

The ancient Asian technique of acupressure involves using the hand and fingers to apply
pressure on or massage certain body meridian points in order to unblock stagnant energy
that causes pain. This is considered to be the third most popular method for treating pain
due to its painless, non toxic method. This therapy redirects energy along energy
pathways, correlating and connecting body organs and function. Acupressure is said to be
effective in disease prevention and in treating chronic pain associated with R.A.

Acupuncture, a component of traditional Chinese medicine follows the same principles
used in acupressure except that needles are used to stimulate or redirect energy channels.
Recently western practitioners has given acupuncture new credibility due to studies that
suggests that the technique stimulates the release of the body’s natural opiate like
substances called endorphins which acts as painkillers. Acupuncture has proven to
provide effective results in the treatment of R.A.

Chiropractic therapy is a widely acclaimed mainstream alternative discipline which is
based on hands-on manipulations or “adjustments” of the spinal cord. This therapy is
based on the teachings of Hippocrates, that all illnesses have a connection to the spine
and nervous system. Subluxated vertebrae are believed to block the body’s innate
intelligence to heal and relief of subluxation facilitates the healing process. Various
musculoskeletal disorders like backache, sciatica, whiplash, scoliosis, peripheral joint
injuries, osteoarthritis and bursitis are effectively treated by chiropractors ( Encyclopedia
of Alternative and Complementary Medicine, 2004).


PROGNOSIS

R.A. decreases life expectancy by 3-7 years and is associated with heart disease, infection
and G.I. bleeding which accounts for most excess mortality. 10% of patients are severely
disabled despite full treatment. Whites, woman, those with subcutaneous nodules,
advanced age at disease onset, inflammation of 20 or more joints, smokers, high levels
E.S.R and rheumatoid factor are all prone to a poor prognosis.

Sanguinous and phlegmatic R.A patients will have poor prognosis if heat and moisture
continues to dominate the lifestyle factors (non-compliance). The same applies to those
elderly patients or melancholic chronic sufferers of R.A. that are not compliant in
avoiding cold and dryness concerning the lifestyle factors.




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REFERENCES



Beers, M. H et al (2006). The Merck Manual. 18th Edition New Jersey: Merck research
laboratories




Bhikha, R and Abdul Haq, M (2001). Tibb– Traditional roots of medicine in modern
routes to health. Gauteng: Mountain of Light South Africa




Bhikha, R. (2006). Four Temperaments six lifestyle factors. Roddepoort: Ibn Sina
Institute of Tibb




Navara, B (2004). The Encyclopedia of complementary and alternative medicine, New
York: Fact on file inc.




Oakes, D et al (2002). Readers Digest – Ouma’s home remedies. Readers Digest
Association: South Africa




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CONTENTS                                                       PAGE


Temperament of illness and organs involved                      1

Allopathic and Tibb definitions of R.A                          1

Signs and symptoms                                              1

Diagnosis, Treatment and Management                             2

Diet , Movement and rest                                        3

Sleep and wakefulness & Elimination                             4

Environmental air & breathing, Emotions & Regimental Therapy    4

Medication & Alternative Therapy – Herbal remedies              5

Prognosis & Therapy                                             6

References                                                      7




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Mujeeb Hoosen
2612612
Illness management 523
Presentation
August 2010
Dr. A. Fakir




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