Thursday, March 24, 2011


 OSTEOARTHRITIS -HOMOEOPATHIY MANAGEMENT

DEFINITION
        Osteoarthritis" is derived from the Greek word "osteo", meaning "of the bone", "arthro", meaning "joint", and "itis", meaning inflammation, although the "itis" of osteo arthritis is somewhat of a misnomer inflammation is not a conspicuous feature of the disease.
       Osteoarthritis is defined as the non-inflammatory condition of synovial joints characterized by focal loss of articular hyaline cartilage with proliferation of new bone and remodeling of joint contour.

Causes
1.  Genetic predisposition
2.  Age (women above 45yrs)
3.  Major trauma
4.  Repetitive joint use
5.  Female sex
6.  Race
7.  Obesity
8.  Congenital or developmental defects
9.  Prior inflammatory joint diseases

JOINT INVOLVEMENT
1.  OA is more common in weight bearing joints.
2.  Pattern of joint involvement in OA is also influenced by prior vocational or a vocational overload.

CLASSIFICATION OF OA

I.           Idiopathic OA

A.  Localized OA
1)  Hands
2)  Feet
3)  Knee – a. Medial compartment
   b. Lateral compartment
   c. Patellofemoral compartment
4)  Hip –   a. Eccentric
                  b. Concentric
             c. Diffuse
5)  Spine – a. Apophyseal joints
                   b. Intervertebral joints
              c. Spondylosis
              d. Ligamentous
6)  Other singular sites – a. Glenohumeral
                          b. Acromio clavicular
                            c. Tibiotalar
                            d. Sacroiliac
                            e. Temporomandibular

II.         Secondary OA

A.  Trauma
1)  Acute
2)  Chronic (sports, occupation)
B.  Congenital or developmental disorders
1)  Localized diseases.
a.   Legg – Calve – Perthes disease
b.  Congenital hip dislocation
c.   Slipped epiphysis
2)  Mechanical factors
a.   Unequal lower extremity length
b.  Valgus or varus deformity
c.   Hyper mobility syndromes
3)  Bone dysplasia’s
a.   Epiphyseal dysplasia
b.  Spondyloepiphyseal dysplasia
c.   Osteonychon dystrophy.

C) Metabolic disorders
        1. Ochronosis
        2. Hemochromatosis
        3. Wilson’s disease
        4. Gaucher’s disease

D) Calcium deposition diseases

1.  Calcium pyrophosphate dihydrate deposition
2.  Apatite arthropathy.

E) Other bone and joint diseases

1.  Localized  – Fracture
- A vascular necrosis
- Infection
- Gout
2.  Diffuse      – Rheumatoid arthritis
- Paget’s disease
- Osteopetrosis
- Osteochondritis

F. Neuropathic

G. Endemic

1.  Kashin – Beck
2.  Mseleni


H. Miscellaneous

1.  Frost bite
2.  Caisson’s disease
3.  Hemoglobinopathies

PATHOLOGY
        Proliferation of chondrocytes to form clones in early stages. Biochemical changes – Water content of matrix increase and the concentration of proteoglycans decreases Vertical and horizontal fibrillation and cracking of the matrix as the superficial layers of cartilage are degraded.
        Granular articular surface becomes softer then normal. Full thickness portions of the cartilage are sloughed and the exposed sub chondral bone plate becomes the new articular surface. Friction smoothes and burnishes the exposed bone giving polished ivory appearance.

        Rebuttressing and sclerosis of underlying cancellous bone. Small fractures and dislodged pieces of cartilage and subchondral bone tumble into joint forming loose bodies, Fracture gaps allow synovial fluid to be forced into the subchondral regions in a one-way ball-value mechanism.

        The loculated fluid collection increases in size forming fibrous walled cysts. Mushroom shaped osteophytes  develop at the margins of the articular surface and are capped by fibro cartilage and hyaline cartilage that gradually ossify.
        Minimal synovial alterations. In severe disease, fibrous synovial pannus covers the peripheral portion of articular surface.

CLINICAL FEATURES

Joint pain
Deep ache localized to the involved joint. 
Aggravated by joint use and relieved by rest
Later becomes persistant.
Nocturnal pain interfering with sleep in advanced hipOA.
Stiffness     
After rising in morning or after a period of inactivity.
Lasts less than 20 min
No systemic manifestations.


PHYSICAL EXAMINATION:
Localized tenderness
Bony or soft tissue swelling
Bony crepitus
Synovial effusion
Warmth in early stages
 Periarticular muscle atrophy due to joint disuse.

IN ADVANCED STAGES
Bony hypertrophy
Subluxation
Marked loss of joint motion.

DIFFERENTIAL DIAGNOSIS:
        Soft tissue rheumatism
        Radiculopathy
        Referral pain
        Entrapment neuropathy 
        Vascular disease
        Crystal – induced synovitis
        Septic arthritis
        Rheumatoid arthritis.
INVESTIGATIONS
        X – Ray
                    Normal in early stages
-         Narrowing of joint space
-         Subchondral bone sclerosis
-         Subchondral cysts
-         Osteophytosis
-         Change in joint contour.
 - Erythrocyte Sedimentation rate – Normal
 - Serum chemistry determination - Normal
 -  Blood counts - Normal
 - Urinalysis - Normal

 - Synovial fluid analysis – Mild leukocytosis
-         To rule out other conditions

 - Arthroscopy – Invasive procedure to diagnose OA prior to radiographic changes
       
INTERPHALANGEAL JOINTS:                                        
Heberden’s nodes – Distal inter-phalangeal joint Bouchard’s nodes – Proximal inter-phalangeal                                        joints
EROSIVE OSTEO ARTHRITIS
           More destructive
            Mostly involves interphalangeal joint
            Leads to collapse of subchondral plate and bony                     ankylosis.
           Joint deformity and functional impairment may               be severe.
            Episodic pain and tenderness.
            Synovium more extensively infiltrated with                              mononuclear cells.

GENERALIZED OSTEO ARTHRITIS
          Involvement of three or more joints or groups of joints.
          Heberden’s and bouchard’s nodes are prominent.
          Episodic “Flare Ups” with inflammation marked by soft tissue swelling, redness and warmth.
          ESR elevated.
          Serum RA factor negative

HIP OSTEO ARTHRITIS
        Due to congenital or developmental defects such as
                - Acetabular dysplasia.
                - Legg – Calve – Perthes disease
                - Slipped capital epiphysis.
-         Bilateral involvement in 20%
-         Pain in hip referred to buttock, inguinal area and proximal thigh, rarely to knee joints.
-         Various range of motion causes pain.
       - Flexion is painless, internal rotation exacerbates pain.
-         Loss of internal rotation occurs followed by loss of extension, abduction and flexion due to fibrosis and buttressing osteophytes.

KNEE OSTEO ARTHRITIS

-         Involves medial or lateral femorotibial compartments or the patellofemoral compartment.
-         Bony hypertrophy and tenderness on palpation.
-         Small effusions may be present.
-         Bony crepitus on joint movement.
-         OA in medial compartment – Varus deformity (Bow leg).
-         OA in lateral compartment – Valgus deformity (Knock knee)
-         Patellofemoral OA – positive “shrug” sign.

SPINAL OSTEO ARTHRITIS
-         Degeneration of apophyseal joints, intervertebral disc and paraspinous ligaments occur.
-         Localized pain and stiffness.
-         Nerve root compression by osteophytes, prolopse of a degenerated disc, Subluxation of apophyseal joint causes radicular pain and motor weakness.

TREATMENT:
        Aims to reduce pain maintain mobility and minimize disability.               
GENERAL MANAGEMENT
      -      Reduction of joint loading.                                    
-         Correction of poor posture.
-         Support for excessive lumbar lordosis
-         Avoid prolonged standing, kneeling and squatting. 
-         Lose weight in obese patients.
-         Take rest periods during day.
-          

PHYSICAL THERAPY

-         Application of heat
-         Application of  ice
-         Exercise programmes
ORTHOPEDIC SURGERY
-         Joint replacement surgery in advanced OA.
-         Severe pain (walking limited up to 10min, severe rest or night pain)
-         Age (Preferred in old age; life span of prosthesis is 15 yrs).
-         Fitness for surgery and anesthesia (Lung and heart diseases)
-         Exclusion of patients with an unacceptable risk of complications

 
HOMOEOPATHIC MANAGEMENT


o   Angustura Vera
o   Arnica Montana
o   Aurum metallicum
o   Benzoic acid
o   Bryonia alba
o   Calcarea carbonica
o   Calcarea phosphorica
o   Causticum
o   Cinchona officinalis
o   Cocculus indicus
o   Colchicum autumnale
o   Colocynthis
o   Granatum
o   Guaiacum
o   Kali bichromicum
o   Kali carbonicum
o   Kali  iodum
o   Kalmia latifolia
o   Lactic acidum
o   Lathyrus sativus
o   Ledum pal
o   Natrum phosphoricum
o   Pulsatilla
o   Radium
o   Rhododendron
o   Rhus toxicodendron
o   Syphilinum








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