Musculoskeletal system

Chapter 8 Musculoskeletal system

Rheumatoid arthritis

Case history

Penny Chua, 29, has come to the clinic for help with pain and stiffness in her hands. Over the past 10 weeks Penny has noticed her hands have started to feel stiff, especially in the mornings. She tells you her hands are not sore or swollen, but some of her finger joints are warm to touch and tender when she presses them. The stiffness is there until mid-morning when her hands feel normal again. The stiffness affects both hands and the joint tenderness is not always in the same fingers. Penny also tells you her hands always feel cold.

Penny is a child protection officer and has been finding she is not really enjoying her work as much as she used to. She is wondering whether it is time for a career change but isn’t sure what else she would like to do and whether she is willing to go back to study to retrain for another career.

Penny is more tired than she used to be and has lost some weight. She isn’t sure why she has lost weight but thinks maybe it has something to do with how she is feeling about work. She thinks this may also be the reason she has been having problems falling asleep.

Penny tells you she feels she eats quite well but concedes her appetite is not what it was. She eats plenty of vegetables with her evening meal and eats chicken two or three times a week, fish once a week and red meat a couple of times a week. Once or twice a week she will have a vegetarian stir-fry or pasta dish. She enjoys fresh fruit and muesli for breakfast with yoghurt and milk and usually has a sandwich with egg, cheese or meat and salad for lunch unless she is out of the office when she will eat whatever is available. Penny loves her morning coffee when she gets to work, and has been drinking more coffee and tea during the day to help with her energy and motivation. She drinks about 500 mL of water each day and has a glass or two of wine with dinner three or four times per week.

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.

When you ask Penny about her family medical history, she tells you both her mother and her grandmother have arthritis and her grandmother’s arthritis has worsened considerably as she has aged.

TABLE 8.1 COMPLAINT [1–11]

Analogy: Skin of the apple	Complaint: Define the presenting complaint and symptoms; understand the complaint Hand pain and stiffness
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Onset
When did you first notice the problem in your hands?	About 2½ months ago.
Timing
Can you feel the pain in your hands all or just some of the time?	I feel it pretty well most of the time. They’re quite bad in the morning, but get better throughout the day. My hands always feel cold these days.
Exacerbating factors
Is there anything that makes the pain worse?	First thing in the morning.
Relieving factors
Is there anything that makes the pain better?	The pain improves by the middle of the morning.
Location and radiation
Where do you feel the pain and stiffness? Does the pain radiate out from that spot?	In my finger joints, but it isn’t always the same finger. It seems to stay in the same place until it eases off.
Examination and inspection	Penny looks pale, and has pale palmar creases. There is tenderness of the proximal interphalangeal joints of both hands.

TABLE 8.2 CONTEXT

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
How much alcohol do you drink each week? Do you smoke? Do you ever take recreational drugs?	Not very much, maybe one or two glasses of wine with dinner 3–4 times a week. No. No.
Functional disease
When your hand pain is worse in the mornings do you know if you slept with your arms raised? (thoracic outlet syndrome)	I’m not sure, I will have to ask my partner if I do that.
Infection and inflammation
Do you have difficulty pinching or grasping bigger objects, opening jar tops or turning door knobs? (osteoarthritis at base of thumb, rheumatoid arthritis)	When I get a bad flare up, it is hard to do things with my hands without causing pain.
Supplements and side effects of medication
Are you taking any supplements or medicines?	Not at the moment.
Autoimmune disease
Have you noticed any skin rashes develop when you have your swollen hands? (systemic lupus erythematosus – SLE)	No, my skin seems to be OK.
Stress and neurological disease
Do you experience nocturnal pain in your hands associated with numbness or pain in wrist, hand or forearm? (carpal tunnel syndrome) Have you experienced a sore neck or shoulder with weakness and limitation of movement when you have sore hands and fingers? (nerve compression)	When my hands are swollen they can hurt during the night but I do not get numbness in my hands. I have been told a massage could be good for my back and neck because I’m really stiff, but my hands can be sore when my back feels OK.
Eating habits and energy
Tell me about your diet.	Penny’s diet consists of 2–3 chicken meals per week, 2 red meat meals, 1 fish meal and 1 vegetarian or pasta meal per week. She eats vegetables with each meal. Breakfast is usually muesli, fresh fruit, yoghurt and milk and lunch is usually a sandwich with some form of protein with salad. Her tea and coffee intake has increased recently and she has about 500 mL water daily.

TABLE 8.3 CORE

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?	Sometimes work can get quite stressful and also thinking about whether or not to have a child is making me a bit stressed. I try to talk through what is bothering me and then think about other things to reduce 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
Bacterial infection – staphylococci, TB, Borrelia Fungal infection Viral infection: rubella, mumps, hepatitis B All types of infection can cause fatigue and pain in fingers	Can present as mono-, oligo- and polyarthritis; self-limiting and resolves quickly; mild fever present
Septic arthritis: may not present with clear symptoms initially; Staphylococcus aureus most common cause	No fever; joint pain will develop over a couple of days; joints will appear very red and swollen
Palindromic rheumatism	Rare and short-lived form of arthritis in joints that become acutely painful, swollen and red and then resolves completely
Osteoarthritis: symptoms may be asymmetrical or symmetrical	Pain eases with rest due to the mechanical nature of the disease; distal interphalangeal joints are usually tender; hands will have a square appearance and there is crepitus on movement of the joint; often occurs in older age groups; stiffness can occur after resting but only for a few minutes and there will be pain on movement
Gout: crystal formation; pain in finger	Usually only affects a single joint; will develop quickly; the joint will appear very swollen and red
Causal factor: Referred arthritis/bursitis of shoulder: pain in hand and fingers	No shoulder pain reported
ENDOCRINE/REPRODUCTIVE
Diabetes: peripheral neuropathy and hand stiffness, lack of circulation, cold hands	Urinalysis NAD
AUTOIMMUNE DISEASE
Autoimmune chronic hepatitis: Presents more commonly in young and middle-aged women with arthritis in small joints of the hand, low appetite and fatigue	No fever present; no jaundice or yellow sclera of the eyes

Case analysis

TABLE 8.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

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
• Stiffness in hands that is persistent • Family history of arthritis • Common age group for women to develop RA	• Weight loss • Finger joints tender • Delayed sleep	• Anger/resentful over difficulties having a child
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Fatigue • Loss of appetite • Limited water intake • Excess coffee and tea intake	• Wanting a career change • Not sure if she wants to study for a new qualification • Employment as a child protection officer exposes Penny to cases of extreme child risk or abuse leading to the risk of burnout and depression/anxiety
REFERRAL DECISION	REFERRAL DECISION	REFERRAL DECISION
• Referral for medical investigation for cause of hand stiffness	• Assess diet and test for anaemia and nutritional imbalance	• Counselling about issues surrounding having a child • Career advisor

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:* MCV: slightly low (indicates size of red blood cell) MCH: slightly low (indicates weight of red blood cell) MCHC: slightly low (indicates haemoglobin concentration in red blood cell)
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	Raised Can be raised in anaemia of chronic disease and sideroblastic anaemia; normal in thalassaemia
Serum iron levels	Low Low in anaemia of chronic disease
Total iron binding capacity	Low Low in anaemia of chronic disease, raised in iron deficiency anaemia; normal in sideroblastic anaemia and thalassaemia
ESR/CRP	Raised Indicates inflammation and possible infection
Rheumatoid factor	Positive Circulating autoantibodies, in inflammatory diseases such as RA and SLE, which have a portion of IgG as their antigen and self-aggregates into immune complexes that cause inflammation and joint damage; the most common reactive IgM molecule is rheumatoid factor
Antinuclear antibodies (ANA)	Negative An antibody that reacts against cellular nuclear material and is indicative of an autoimmune abnormality; this is very sensitive in detecting SLE, but not specific to this disease as it can be present in other inflammatory and autoimmune diseases
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

Penny and rheumatoid arthritis and anaemia of chronic disease

Penny is a 29-year-old woman who presented to the clinic with a 10-week history of morning stiffness presenting in both her hands with tender proximal finger joints. Both her hands feel very cold and she is also experiencing symptoms of fatigue, weight loss, lack of appetite, difficulty falling asleep and she is drinking more coffee and tea to maintain daily energy. Penny is not enjoying her work and is now at a crossroads in her life, trying to decide whether she should change career and if so what she would do. During the consultation Penny expresses anger and resentment that she and her partner, Dianne, are experiencing difficulties in having a child of their own when they know what a wonderful home they could offer, especially when Penny has witnessed firsthand the terrible conditions in which some children grow up.

Because of Penny’s persistent symptoms of stiff hands and her family history of arthritis, she was referred for immediate medical assessment. Penny returned with a confirmed diagnosis of rheumatoid arthritis and anaemia of chronic disease. This diagnosis has helped Penny understand why the stiffness in the small joints of both hands has lasted for more than six weeks. RA usually begins as a progressive peripheral arthritis that slowly develops over a few months. The most commonly affected areas are the small joints of the hand, wrist, feet, elbows, shoulders, knees and ankles. The joints have limitation of movement, are warm and tender and there can be evidence of muscle wasting. Soft tissue thickening around affected joints is common. Overall, morning joint stiffness with joint tenderness and symmetrical joint swelling are common characteristics of RA. Additional symptoms that may be present include fatigue, muscle weakness, anaemia, anorexia and weight loss.

RA is a common, chronic, persistently painful systemic disease producing symmetrical inflammatory polyarthritis and progressive joint damage that can cause severe disability in young people. The cause of the disease is unknown and toxic substances produced during the inflammatory process can lead to the destruction of cartilage. RA is three times more common in women and can begin at any age between the ages of 10 and 70, but most often begins between the ages of 30 and 40. The most likely hypothesis for the chronicity of the inflammatory process is a persistent foreign antigen, perhaps bacteria or virus, which is not destroyed or removed leading to systemic inflammation. Because premenopausal women are more likely to develop the condition than men, there seems to be a hormonal link to the disease.

Family history of RA is an influencing factor to developing the disease. There are several types of RA including short monoarticular attacks lasting up to 48 hours, transient and self-limiting episodes lasting up to 12 months similar to postviral arthritis, a remitting disease over several years or a chronic and persistent presentation that can cause more damage. Occasionally RA progresses rapidly resulting in significant damage within the span of just a few years.

General references used in this diagnosis: 2, 6–11, 65, 66

Prescribed medication

Penny’s doctor has prescribed oral NSAIDs and analgesic medication initially and, if symptoms persist, will consider prescribing other medication and referring Penny to a rheumatologist for assessment. Penny wants to try natural therapies first to see how much they can help before she takes any drugs. She will go back to her doctor for regular medical check-ups.

Anaemia of chronic disease will be treated by addressing the inflammatory process of RA rather than giving iron supplementation.

TABLE 8.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Reduce requirement for anti-inflammatory medication via lifestyle, dietary, physical therapy, herbal and supplement recommendations • Dietary recommendations to reduce inflammation and prevent joint degeneration • Physical therapy suggestions to improve joint strength, flexibility and function • Recommendation for Penny to exercise regularly to maintain joint functionality • Herbal tea, tonic and tablets with anti-inflammatory, circulatory stimulant, antirheumatic and immunomodulatory action to help reduce inflammation and protect joints • Supplemental nutrients to reduce inflammation and improve symptoms, enhance cartilage synthesis and suppress progression of RA joint pathology NB: Penny’s condition should be managed in collaboration with her doctor; if she experiences no improvement within 12 weeks or her symptoms worsen she should be encouraged to consider other treatment options; if Penny chooses to take prescribed medication from her GP or rheumatologist her herbal tea, tonic and tablets should be reviewed to ensure there are no negative interactions	• 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].

• 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].

• Acupuncture may be beneficial to Penny [26, 27].

TABLE 8.10 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

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

TABLE 8.12 HERBAL TEA

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]