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CHAPTER I
To read Chapter
2, click this link: http://www.doctoryourself.com/kaufman7.html
THE COMMON FORM OF JOINT
DYSFUNCTION
by William Kaufman, M.D.,
Ph.D. (1949)
Copyright C 2001 Charlotte
Kaufman. Reprinted with permission.
Edited by Andrew W. Saul
(This chapter presents
Dr. Kaufman’s protocol for the treatment of arthritis with niacinamide,
vitamin B-3. He also used ascorbic acid (vitamin C), thiamine (B-1),
riboflavin (B-2), all in large doses. His rationale and his measurement
methods begin the chapter, but you might wish to scroll down to the section
on dosage (“Methods of Treatment”) and read that first. The
chapter closes with case histories and an insightful, practical discussion of
patient management. Graphs and other original illustrations are not
provided here, but may be seen in the original text, available through this
website. For ordering information, please either click here or scroll down to the very bottom of this
webpage.)
The author’s
preface, and all references cited, are posted at http://www.doctoryourself.com/kaufman11.html
INTRODUCTION
The relationship between
the continuous administration of adequate amounts of
niacinamide and improvement
in both hypertrophic arthritis and rheumatoid arthritis was
originally reported in 1943
as part of a clinical study on niacinamide deficiency disease,
aniacinamidosis, observed in
a group of 150 private patients studied during the years
1941 and 1942 (97). (The
term aniacinamidosis was employed by the writer in 1943 to
define a syndrome which was
thought to be the consequence of a niacinamide tissue
deficiency disease. The term
aniacinamidosis would be redefined today (1949) without
reference to its possible
etiology, as the syndrome which is ameliorated or corrected
when a person ingests
certain nontoxic amounts of niacinamide (far in excess of those
obtainable from his usual
diet), and recurs in time when such niacinamide
supplementation is
discontinued.)
The form of
aniacinamidosis which was seen by the writer prior to 1943 included, in
varying degrees of severity,
changes in skin texture and pigmentation; subcutaneous
swellings; tenderness of
periosteum, cartilage and voluntary muscle to pressure or
squeezing; tenderness and
enlargement of the liver; gastrointestinal symptoms;
changes in the morphology of
the lingual mucous membrane; and limitation in ranges of
joint movement. This
clinical syndrome of aniacinamidosis was characterized (a) by its
prompt recession when
niacinamide was exhibited orally for a sufficient period of time in
adequate doses, and (b) by
its recurrence, often in the original degree of severity, upon
premature cessation of
therapy with niacinamide. Most persons who were treated
required maintenance doses
of niacinamide continuously to prevent relapse (97).
It was observed in the
course of the above study that persons who had clinically both
aniacinamidosis and obvious
arthritis experienced, in response to adequate oral therapy
with niacinamide over a
sufficiently long period of time, clinical improvement in both the
aniacinamidosis and the
arthritis. On the other hand, premature cessation of therapy
with niacinamide caused a
worsening of both the aniacinamidosis and the arthritis.
Furthermore, when the total
dosage of niacinamide per day was reduced from
apparently adequate to
inadequate levels in such persons, there was a more gradual
recurrence of the severer
aspects of aniacinamidosis and a slower worsening of their
arthritis than occurred with
complete cessation of therapy with niacinamide. It was
noticed that individuals who
suffered from both aniacinamidosis and clinically obvious
arthritis required larger
daily doses of niacinamide for recovery from niacinamide tissue
deficiency disease than
those who had no clinically obvious arthritis (97).
With the compulsory
enrichment of cereal products in 1943 (25), the niacin content of
the average American diet
was increased from 11 to 17 mg per 2500 calories (30).
Since 1943, the clinical
syndrome of aniacinamidosis as originally described has not
been seen regularly, but has
been supplanted by a syndrome in which most of the
manifestations of
aniacinamidosis as originally described are milder, and many of the
symptoms and signs of the
aniacinamidosis of 1941 and 1942 are absent. However,
limitation in the ranges of
joint movement has continued to be an objective, measurable
attribute of the metabolic
disorder corrected by adequate niacinamide therapy. In 1944,
in an effort to secure
quantitative data concerning the relationship between treatment
with niacinamide and
recovery in arthritic joints, the writer introduced goniometric
examination of joint ranges
of all persons who had at the time of the initial physical
examination clinically
obvious arthritis. In 1945, it was decided to broaden the base of
this study by routinely
measuring the joint ranges of all patients presenting themselves
for physical examination.
For this purpose, there was introduced as part of every
physical examination an
abbreviated goniometric examination of the movement of 20
joints or joint groups in
easily measured, specified ranges. Within five minutes, this
abbreviated goniometric
examination of joint ranges could be performed and recorded
by the examiner on a special
form devised for this purpose. By this method, a suffi-
ciently large number of
joints or joint groups were measured in defined ranges to afford
an adequate and
representative sampling of the mobility of the moveable joints of the
body.
With the introduction of
routine measurement of the joint ranges of all new patients who
presented themselves for
examination, it soon became apparent that limitation of joint
movement in the 20 measured
ranges was exceedingly prevalent in many individuals
without joint complaints or
clinically obvious arthritis. Moreover, limitation of joint
movement in persons without
complaints referable to joints was often of the same order
as that observed in patients
(with and without clinically obvious arthritis) who did have
complaints referable to
their joints.
It was decided to
simplify the approach to the study of limitation of joint movement by
combining the numerical
values obtained for each of the 20 measurements of joint
range movement into a single
numerical value which was the "weighted" average of all
these measurements. This
"weighted" average was called the JOINT RANGE INDEX.
As will be shown later, the
Joint Range Index is used by the physician in the objective
appraisal of joint function (joint
mobility) in numerical terms, in the clinical classification
of the various grades of
severity of joint dysfunction, in the selection of the initial level of
niacinamide therapy, in the
regulation of subsequent levels of niacinamide therapy, and
in the observation of the
response of joint dysfunction to adequate and inadequate
niacinamide therapy. In
addition, the use of the Joint Range Index enables the patient to
understand the objective
basis for the diagnosis of joint dysfunction in his case, and the
objective basis for the
evaluation of the response of his joint dysfunction to adequate
and inadequate therapy.
A WORKING HYPOTHESIS:
THE DEGENERATIVE PROCESS AND
THE REPARATIVE PROCESS IN JOINTS
Certain inductions have
been made from factual data acquired during the clinical study
of patients with joint
dysfunction (with and without clinically obvious arthritis) whose joint
ranges were measured for the
determination of the Joint Range Index at various time
intervals under various
conditions of niacinamide therapy: before niacinamide therapy
was instituted, during
premature cessation of adequate or inadequate niacinamide
therapy, during the
substitution of adequate for inadequate niacinamide therapy, and
during continuously adequate
niacinamide therapy. These inductions have been
synthesized into a working
hypothesis which explains the status of a patient's joints in
terms of two oppositely
directed, coexisting articular processes: the deteriorative
process, and 'the reparative
process.
The deteriorative process
consists chiefly of two operational factors tending to cause
retrograde changes in joint
structure and function, (a) "wear and tear in joint structures,
which results from ordinary
or unusual joint uses, and (b) a slowly, moderately or rapidly
progressive metabolic
disorder which is corrected in time by adequate niacinamide
therapy. This metabolic
disorder occurs even in persons subsisting on what is
considered to be the average
"good" or "adequate" diet of today (172) (118) (193).
The reparative process
tends to overcome the retrograde articular changes caused by
the deteriorative process.
Even persons subsisting on "good" or "adequate" diets
of
today lack sufficiently
potent reparative mechanisms to offset for any prolonged period
of time the retrograde
influences of the deteriorative process in joints. However, with
supplementation of the
average good" or "adequate" diet of today with adequate
amounts of niacinamide, the
articular reparative process becomes sufficiently powerful
to overcome the retrograde
changes in articular tissues produced by the deteriorative
process, and in time permits
improvement in the functional status of joints, as
objectively demonstrated in
the individual patient by serially increasing values of the
Joint Range Index.
For purposes of this
study, it has been postulated (a) that clinically perfect articular
structures have the fullest
ranges of articular movement, (b) that clinically imperfect
articular structures have
less than full ranges of articular movement, and (c) that the
range of joint movement in
moveable joints is a practical measure of the degree of
clinical perfection of these
articular structures. At any given moment, the patient's Joint
Range Index is an indirect
measure of the balance between deteriorative and reparative
articular processes in the
joints whose ranges of movement are determined
goniometrically.
In an untreated
population, the deteriorative process seems to preponderate over the
reparative process, as is
shown by the average tendency of the Joint Range Indices of
this group to decrease with
increasing age (see Graph 1G, page 153).
When the ranges of
movement of a given joint are re-measured at any given time
interval (e.g., one month),
there may be no change, an increase, or a decrease in joint
movement when the second
measurement is compared with the first. When there has
been no change in the range
of joint movement, it is postulated that the effects of the
deteriorative process have
been balanced by the effects of the reparative process for
this time interval, and that
no significant change in the functional status of the joint has
occurred. However, when the
range of joint movement has decreased, it is assumed
that the deteriorative
process in articular tissues has been more powerful than the
reparative process for a
sufficient period during this time interval to permit deteriorative
effects to preponderate over
reparative effects, with the result that deterioration has
occurred in the functional
status of the joint. On the other hand, when the range of joint
movement has increased, it
is assumed that the reparative process in articular tissues
has been more powerful than
the deteriorative process for a sufficient period during this
time interval to permit
reparative effects to preponderate over deteriorative effects, with
the result that there has
been improvement in the functional status of the joint.
It may be that some
arthritic joints are damaged by a deteriorative process of such
intensity and duration that
joint recovery is not possible, even with prolonged adequate
niacinamide therapy. Even
though initial clinical examination may indicate that eventual
recovery of these joints is
unlikely, only a prolonged trial of adequate niacinamide
therapy will disclose
whether or not such joints actually have been damaged beyond
repair. It has been observed
that deformed arthritic joints which seemed on the initial
clinical examination to have
been irreparably damaged by the deteriorative process
have shown recovery of the
full ranges of joint movement, and a progressive decrease
in severity of the obvious
arthritic deformities with adequate niacinamide therapy over a
prolonged period of time.
METHOD OF STUDY
The observations recorded
in this volume were derived chiefly from the clinical study of
455 persons of both sexes,
ranging in age from 4 to 78 years, who consulted the writer
from March 1945 to February
1947 in the course of his private practice of internal
medicine. (In Section IV the
frequency distribution by five-year age groups of all patients
studied is shown in Table
1A; that of all male patients, in Table 1B; that of all female pa-
tients, in Table 1C.) All
patients studied were ambulatory. Their occupations were
varied. Although no attempt
has been made to classify the economic status of these
patients, the majority of
these patients would be considered to belong to the moderate
income groups, and
relatively few would be considered to belong to the low income
groups. They came chiefly
from New England. Many had no complaints
referable to
health, but desired a
routine physical examination; others had minor or major health
problems.
For purposes of this
study, a detailed enumeration of the incidence of various diseases
in the population group
examined would be of no significance, since it was found that no
matter what associated
diseases the patient had, his joint dysfunction responded in a
predictable way to adequate
therapy with niacinamide, to premature cessation of such
therapy, or to the
substitution of inadequate for adequate therapy. A partial listing of
various diseases other than
joint dysfunction seen in this group of patients may,
however, be of some
interest: gall-bladder disease (with and without stones), chronic
hypertrophic gastritis,
duodenal ulcer, diverticulosis of the colon, cardiospasm, multiple
intestinal polypi, irritable
colon, Paget's disease of bone, post-menopausal osteoporosis,
multiple sclerosis,
syringomyelia, spastic paralysis, chronic and acute anxiety states,
anginal syndrome,
arteriosclerotic heart disease, rheumatic heart disease, anemias,
myeloge nous leukemias, allergic
diseases, fibroid tumors of the uterus, hypothyroidism,
hyperthyroidism, diabetes,
gout and arrested lues (48).
All persons included in
this study presented themselves as new private patients. Only in
this sense was there
selection of the population group studied. All patients were
subjected to an initial
examination, which consisted of a detailed history, physical
examination and certain
laboratory studies. These findings were recorded on a special
form, together with the
physician's impressions and therapeutic recommendations.
Kodachrome transparencies
were taken of the tongue, gums and eyes of each patient
to serve as a point of
reference in the objective study of the response of tissues to
vitamin therapy (105) (106)
(107) (37) (39) (183) (191) (114) (35) (174) (8) (109). In
addition, monochrome
photographs were taken of selected patients to document
clinically obvious arthritic
deformities.
During the initial visit,
in the course of the general physical examination, certain ranges
of joint movement were
measured in a standard way (149), and the numerical values
obtained were used in
computing the Joint Range Index. The sound-proofed room in
which the examination was
performed was kept at a temperature comfortable for the
patient, who was completely
disrobed save for the covering sheet. Care was taken to
have the patient adequately
draped at all times. The examiner informed the patient
before each measurement of
joint ranges as to what would be done next, indicating that
maximal joint ranges were to
be measured. The ranges of knee and hip movement were
measured with the patient
recumbent. All other joint ranges were measured in the sitting
position. In addition to
measurements of joint ranges, the following data were recorded if
they were elicited on
physical examination of the joints: pain, crepitus (cracking or other
sound), muscle spasm,
redness, unusual warmth, swelling, engorgement or
accentuation of the
periarticular venous pattern, and deformity.
Instruments used in
measuring joint ranges were made of metal according to the writer's
specifications:
A gravity-type
goniometer, fashioned after the one described by Cooper (34), was found
to be a highly versatile
instrument (see Figures 1, 2, 3 and 12).
(Figure 1. Illustrates
the goniometer, a device for measuring joint movements and
angles. The calibrations are
also shown.)
A graduated collar was
devised which permitted the measurement of neck rotation (see
Figures 4 and 5).
One tool consisted of an
angle device with provision for the maintenance of any angle
by tightening a set screw,
and a graduated plate on which the angle device was fitted in
order to read the angle
therefrom (see Figure 7).
A graduated plate was
used to measure flexion and extension of the wrist (see Figure 8)
and, rarely, in markedly
deformed hands to measure extension of the
metacarpophalangeal
(knuckle) joints of the fingers (see Figure 11).
A special device was
constructed for the measurement of extension of the
metacarpophalangeal joints
of the fingers (see Figures 9 and 10).
MEASUREMENT OF THE RANGES
OF JOINT MOVEMENT USED IN COMPUTING
THE JOINT RANGE
Knees. The patient is
adequately draped, lying flat on his back with his body weight
evenly distributed. He is
asked not to contract his lower extremity muscles actively
during this measurement,
since such contraction lessens the range of movement of the
knee joint. His right thigh
is flexed passively by the examiner so that it is at right angles
to his trunk. The examiner
then extends the patient's right leg maximally, taking care not
to displace the ipsilateral
thigh even slightly, and taking care that the patient does not
flex his contralateral thigh
even slightly, as this would cause pelvic tilt. The angle which
the leg makes with a
hypothetical plane passing through the knee joint at right angles to
the thigh is measured by
reading the indicator dial of the gravity-type goniometer, which
is held with its long axis
parallel to the long axis of the right leg. The range of movement
of the left knee joint is
measured in a symmetrical manner (see Figure 2).
(Figure 2. Illustrates
the measurement of knee-joint extension, showing a) Knee joint at
beginning of measurement; b)
Knee extended 50%; c) Knee extended 100%.
Hips. The patient is
asked not to contract his lower extremity muscles (particularly the
adductor muscles of his
homolateral thigh) since such active muscular contraction
lessens the range of
movement of the hip joint. With the patient lying symmetrically on
his back, the right thigh is
flexed by the examiner so that it remains perpendicular to the
trunk, care being taken that
the right foot is not rotated from a neutral position of rest.
The right thigh is then
abducted maximally by the examiner, care being taken not to
displace the contralateral
buttock from the table. If the contralateral buttock is levered
off the examining table by
the examiner's abduction of the ipsilateral thigh, then
abduction of the right thigh
is maintained, but the patient is permitted to rotate so that
both buttocks are on the
table again and bear weight symmetrically. The gravity-type
goniometer is then applied
so that its long axis parallels the long axis of the right thigh,
and the appropriate reading
of the degree of hip abduction is made and recorded (see
Figure 3). The range of
movement of the left hip joint is measured in a symmetrical
manner.
Figure 3. Illustrates
measurement of hip abduction, showing a) Thigh at beginning of
measurement; b) Thigh
abducted 50%; c) Thigh abducted 100%)
NOTE: For purposes of
clarity in illustration, the examiner is pictured as standing be-
hind the thigh that is
abducted. In practice, he stands in front of the thigh that is being
abducted, so that he can
easily read without parallax the scale of the gravity-type
goniometer.
Lateral Rotation of the
Neck. The patient is asked to sit symmetrically, and to make
himself as "tall"
as possible. He is asked to hold his neck so that it is neither flexed
nor
extended, nor laterally bent
to the right or left. A specially constructed graduated metal
collar (see Figure 4) is
fitted symmetrically at the level of the base of the neck so that
the 100% graduation always
rests on the anteriormost portion of the trapezius ridge,
and the patient is asked to
rotate his head maximally to the right. Since the examiner
wishes to measure and record
maximal values, when the patient reaches his initial
maximal joint of lateral
rotation, he is always urged to do better, to prevent his
restraining full neck
rotation because of subjective discomfort. During measurement of
lateral neck rotation, the
patient is at no time permitted to raise his shoulders, or to flex,
extend or laterally bend his
neck (see Figure 5). When the patient signifies that he has
achieved maximal rotation of
his neck to the right, the measurement of neck rotation is
made. The range of neck
rotation is read directly from the graduations on the neck
gauge by the examiner, who
sights along the plane perpendicular to the center of the
patient's chin to avoid
parallax, ascertaining the graduation on the neck gauge which
would pass, if extended,
through the center of the chin. The measurement of rotation of
the neck to the left is made
in a symmetrical way.
(Figure 4. Illustrates
the graduated collar (with degree markings similar to those of a
protractor) used in the
measurement of neck rotation)
(Figure 5. Illustrates the
measurement of lateral neck rotation using the graduated
collar, and shows the
position of head at beginning of measurement, the head rotated to
the right of left 50% and
100%)
Shoulders. The range of circumduction
of the shoulder joint is measured by careful
inspection and estimation
rather than by the use of a particular device. In order to be
certain that maximal ranges
are elicited and estimated, the maneuver of circumduction
of the shoulder is performed
several times for each shoulder. The patient is asked not to
contract his shoulder girdle
or upper extremity muscles, since such active muscular
contraction lessens the
range of movement of the shoulder joint. In measuring the range
of circumduction of the
right shoulder, the physician stands to the right of the patient,
who faces forward, sitting
as "tall" as he can, with his shoulders maintained
horizontally.
The physician places his
left hand on the patient's right shoulder to prevent its
displacement from the
horizontal position when the patient's right arm is subsequently
circumducted for
measurement. The physician's right hand holds the patient's right
elbow lightly, slightly
flexing the patient's right forearm on the right arm, but not holding
the right elbow so rigidly
as to interfere with subsequent free movement of the shoulder
joint during circumduction.
In this position, the physician circumducts the shoulder joint
of the right arm in a
clockwise direction so that the patient's right elbow describes the
largest possible
"circle" during circumduction (see Figure 6).
(Figure 6 illustrates the
method for estimating of the range of shoulder circumduction
(range of motion in a
circling motion). a) The figure drawn in unbroken lines shows the
position of the patient, as
well as the position of his right upper extremity (marked 0) at
the beginning and end of the
maneuver of shoulder circumduction. The physician's left
hand maintains the patient's
right shoulder horizontally throughout the maneuver of
shoulder circumduction. The
broken lines show three successive positions (50,100,50)
of the right upper extremity
during clockwise circumduction. Estimates of the range of
shoulder circumduction are
made with 0, 50, 100 as positions of reference.
b) Frontal view of
the patient's position and the examiner's hands at the begin-fling and
end of the maneuver of
shoulder circumduction, corresponding to the 0 position in (a).
The movement of shoulder
circumduction is graded as 50% when the right arm swept
upward in maximum
circumduction reaches, at the highest point of the arc, the plane
perpendicular to the
sagittal plane of the body at the level of the shoulders. The
movement of shoulder
circumduction is graded as 100% when the arm swept upward in
maximum circumduction
reaches at the highest point of the arc of circumduction the
plane parallel to the
sagittal plane of the body and perpendicular to a horizontal plane
passing through the level of
the shoulders. With some practice, bearing in mind these
two reference axes, the
physician can make estimates of the fractional ranges of
shoulder circumduction with
sufficient accuracy to be included in the computation of the
Joint Range Index. Circumduction
of the left shoulder is measured in a symmetrical
manner.
(Figure 7 illustrates
measurement of the degree of the wrist to bend. Captions follow
below.)
a) Angle device set at 90
degrees, or 100% of a trigonometric quadrant. Its arms may
be rotated around its
central axis and fixed by a set screw at any desired angle.
b) Measurement of wrist
flexion by the angle device. With the wrist held at maximum
flexion, the arms of this
device are brought into apposition with the surface of the
dorsum of the hand and
forearm. The set screw holding the arms of the angle device is
tightened in this measured
position, the angle device is fitted into the graduated plate
(c), and a reading of the
angle of flexion is made.
c) Graduated plate with angle
device fitted to make reading of the range of wrist flexion
obtained in (b).
Wrists. The maximum
degree of flexion and extension of the wrist is measured either
with the angle device (Figure
7) or the plate device (Figure 8), using the dorsum of the
forearm and hand as the
surfaces between which all angles are measured.
The plate device is more
convenient for this measurement, being used so that the
central axis of its
graduations corresponds to a projection of the center of the right
wrist
joint. The 0 line is held
parallel to the long axis of the right forearm, and the 100 line is
held perpendicular to the
projection of the central axis of the right wrist joint. The patient
is asked not to contract his
forearm or hand muscles during this measurement, since
such active contraction
lessens the range of movement of the wrist. Care is taken to
measure maximal passive
flexion and extension, and to sight along the dorsum of the
hand in such a way that
parallax is avoided. The patient is not permitted to flex or
extend the fingers during
the measurement of maximal flexion or maximal extension of
the wrist. Measurement of
flexion and extension of the left wrist is made in a
symmetrical manner.
(Figure 8 illustrates the
measurement of flexion and extension of the wrist with the
graduated wrist plate,
another protractor-like scale to fit the hand. 50% and 100%
flexing is shown.
For clarity in
illustration, (d) and (e) picture the examiner's fingers as exerting
pressure
on the subject's fingertips
to induce maximal passive extension. In practice, this
pressure is exerted on the
palm of the hand, just proximal to the metacarpophalangeal
joints.)
Metacarpophalangeal
(Knuckle) Joints. The right hand is inserted into the special device
(see Figures 9 and 10) with
the palm resting on the baseplate. The 100 line of the
graduated plate is
perpendicular to the projection of the central axis of the
metacarpophalangeal joint to
be measured. The patient is asked not to contract his
forearm or hand muscles
during this measurement, since such active muscular
contraction lessens the
range of extension of the metacarpophalangeal joints. Only the
finger that is being extended
by the examiner is permitted to leave the baseplate. The
index finger is extended
maximally by the examiner. This may be done in the face of
objections from the patient,
who may experience pain from this maneuver. The angle of
extension between the dorsum
of the hand and the dorsum of the finger is measured in
such a way that parallax is
avoided. Extension of the second, third, fourth and fifth
fingers of the right hand is
measured successively. The metacarpophalangeal joints of
the left hand are measured
in symmetrical fashion.
(Figure 9.
Illustrates the device for the measurement of extension of the
metacarpophalangeal
(knuckle) joints. This also resembles a custom-fit protractor,
with
angle measurements in scaled
in degrees.)
In some persons, for whom
the special device cannot be used because of severe
deformities of the
interphalangeal joints of the hands, the wrist plate with the central cut-
out (see Figure 11) is
adapted to the measurement of metacarpophalangeal extension.
The plate is fitted between
the fingers so that the 0 line is perpendicular to the projection
of the central axis of the
metacarpophalangeal joints, with the 100 line parallel to the
dorsum of the hand and
perpendicular to the central axis of the metacarpophalangeal
joints. In this use of the
wrist plate, 100 minus the plate reading measures the
movement of finger extension
at the metacarpophalangeal joints. The patient is asked
not to contract his forearm
or hand muscles during this measurement, since such active
muscular contraction lessens
the range of extension of the metacarpophalangeal joints.
Extension of the
metacarpophalangeal joints is measured, holding the plate as
described above, for the second,
third, fourth and fifth fingers of the right hand. The
corresponding joints of the
left hand are measured in a symmetrical way.
(Figure 10 illustrates
the technique for measuring extension of the metacarpophalangeal
(knuckle) joints. Details shown:
Hand in the special device (Fig. 10) at the beginning of
measurement; (a) lateral
view, (d) looking from above downward, (g) frontal view. The
metacarpophalangeal joint of
left forefinger extended 50%: (b) lateral view, (e) looking
from above downward, (h)
frontal view. The metacarpophalangeal joint of left forefinger
extended 100%: (c) lateral
view, (f) looking from above downward, (i) frontal view.
(Figure 11. Illustrates
the measurement of extension of metacarpophalangeal joints in
severely deformed hands,
using the wrist plate. Shown: a) Position of hand at beginning
of measurement. b)
Metacarpophalangeal joint of left forefinger extended 50%.
c) Metacarpophalangeal joint
of left forefinger extended 100%.
Neck Bending. This
measurement is not used in the computation of the Joint Range
Index, since it has not been
made routinely. In some persons, it cannot be measured
accurately because of their
persistent tendency to angulate the shoulders.
The patient sits
symmetrically as erectly as he can, with his shoulders held level. His
neck is neither flexed nor
extended, nor rotated to the right or left. The neck is bent
maximally to the right, and
the angle of bending is measured by reading the dial of the
gravity-type goniometer, applied
so that its long axis parallels the long axis of the nose
(see Figure 12). Left
lateral bending of the neck is measured in a symmetrical manner.
(Figure 12 illustrates
the measurement of lateral neck bending with the gravity-type
goniometer. Shown: Position
of head at beginning of measurement; Right lateral neck
bending of 50%; Left lateral
neck bending of 50%.)
CERTAIN CONVENTIONS
ADOPTED IN MEASURING VARIOUS JOINT
RANGES
Save for the range of
shoulder joint circumduction, the maximum range of each joint
movement, when elicited as
described previously, approximates one trigonometric
quadrant of 90 degrees. This
is true for (a) extension of the knee joint; (b) abduction of
the hip joint; (c) right
lateral rotation of the neck; (d) left lateral rotation of the neck;
(e)
flexion of the wrist; (f)
extension of the wrist; (g) extension of the metacarpophalangeal
joint. Because the angle of
maximal movement of these joint ranges approximates one
quadrant, it is convenient
to measure these ranges in terms of percentages of a
quadrant rather than in
degrees.
This convention was
adopted chiefly because patients visualize percentages of a range
of movement more easily than
equivalent measurements expressed in degrees. For all
measurements except
circumduction of the shoulder joint, simple arithmetic
computation permits, when
desired, the conversion from percentages to degrees, since
10% of a quadrant is equal
to 9 degrees.
In a few individuals, the
range of maximal wrist flexion is in excess of one quadrant.
Also, in very few persons,
either neck rotation to the right or neck rotation to the left, or
both, are in excess of one
quadrant. In these instances, for purposes of calculating the
Joint Range Index, movement
beyond one quadrant is considered as 100%, or the full
range.
The conventions used in
the measurement of shoulder circumduction have already
been described (see page
10).
As a convention, the
various graduated scales used in the measurement of joint ranges
were read to the nearest 5%
(4.5 degrees). A few readings were made with the angle
device to 1 % (0.9 degree),
but this was found to be an unnecessary refinement for
purposes of this study.
COMPUTATION OF THE JOINT
RANGE INDEX
It will be helpful in understanding
the steps used in the computation of the Joint Range
Index to refer to the form
used for recording the measured values of the 20 specified
joint ranges, and for
computing the Joint Range Index (see Figure 13). The numerical
values obtained upon
measurement of the 20 specified joint ranges are entered
separately into the
appropriate space and column of the form at the time of the physical
examination.
(Figure 13 illustrates
the worksheet Dr Kaufman designed and used to record degrees
of joint dysfunction with
his patients. In addition to angular measurements, he also
noted clinical data such as
intensity of pain, crepitus, muscle spasm, redness, unusual
warmth, swelling, prominent
or engorged venous pattern, deformity, or the presence of
Heberden’s nodes.)
The Joint Range Index is
the arbitrarily weighted mean of the numerical values obtained
upon the measurement of 20
specified joint ranges. Measurements of the neck, wrists
and fingers are weighted so
that these joints will not unduly affect the numerical value of
the Joint Range Index, since
they show increased ranges of movement more rapidly
than the larger joints
(hips, knees, shoulders) in response to adequate niacinamide
therapy.
The following steps are
employed in computing the Joint Range Index from the
measurements of 20 specified
joint ranges:
The neck rotation index
is computed by adding the measured values for the maximal
ranges of right and left
neck rotation and dividing by two. (In computing the various
indices entering into the
final computation of the Joint Range Index, the figures are
rounded off to the nearest
whole number; e.g., 0.5 or over is listed as the next highest
digit, and less than 0.5 is
dropped.)
The resulting quotient is
entered into the appropriate space under the heading “Indices.”
(Neck bending is similarly
averaged, although it is not used in calculating the Joint
Range Index.) Readings for the maximal
range of circumduction of the right and left.
shoulders are entered
separately in the proper spaces. Readings
for the maximal
ranges of extension and
flexion of the right wrist are added and divided by two, the
quotient being entered in
the appropriate space. A similar computation is made for the
left wrist, and similarly
recorded. Readings
for extension of the four
metacarpophalangeal joints
of the right hand are added, divided by four, and the
quotient entered in the
appropriate space. A similar computation is made for extension
of the four metacarpophalangeal
joints of the left hand. Readings
obtained for
measurement of maximal
abduction of the right and left hips and for maximal extension
of the right and left knees
are separately recorded in appropriate spaces. The above 11
values are then added, the
sum obtained divided by 11, and the resulting quotient is
termed the Joint Range
Index. This computation is carried to one decimal place. (In
about 2% of the patients
seen from March 1945 to February 1947 the Joint Range Index
could not be computed
because one or more of the component ranges of joint motion
could not be measured; e.g.,
in persons who could not flex the thigh to make a right
angle with the trunk because
of severe arthritis of the hip joint, or in persons with one or
more limbs amputated.)
Thus, the Joint Range
Index is precisely defined in terms of the "weighted" average
of
the 20 ranges of joint
movement chosen for measurement. A Joint Range Index of less
than 96.0 is taken to
indicate the presence of joint dysfunction.
METHOD OF TREATMENT OF
JOINT DYSFUNCTION (This section, consisting of
pages 20-29, is the heart of
Dr Kaufman’s work.)
After completion of his
physical examination, the patient was apprised of the normal and
abnormal findings revealed by
the clinical study. Where problems other than joint
dysfunction existed, these
were discussed, and appropriate therapeutic
recommendations were made.
The subject of joint dysfunction was then presented. The
meaning of the numerical
value of the patient's Joint Range Index was explained to him
in terms of the Clinical
Classification of Joint Function (see page 21), and the dynamic
nature of joint dysfunction
was described. The patient was told that joint dysfunction
was reversible in time when
appropriate therapy was taken.
All patients with joint
dysfunction who elected to accept treatment were given
niacinamide in suitable
doses, either alone or in combination with other vitamins.
When indicated the
appropriate vitamins were prescribed in addition to
niacinamide. The
water-soluble vitamins used were never prescribed in aqueous
solution, but as tablets or
as dry powders in capsule form. When vitamin A was used, it
was usually given in
conjunction with vitamin D. Vitamin D was always given in
conjunction with vitamin A;
when vitamin D was administered in this study, the daily
dosage rarely exceeded 6,000
U.S.P.units per 24 hours (14) (10) (38) (56) (59) (95).
Participation in the
therapeutic program was entirely voluntary on the part of the patient.
Some patients at the outset
declined to accept treatment for their joint dysfunction.
When a patient accepted
therapy for his joint dysfunction, with each succeeding visit
after the initial one,
improvement or lack of improvement in his joint dysfunction was
frankly discussed with him.
No patient was chided because he was unwilling or unable
to carry out the program of
therapy as it was originally scheduled. Thus, because there
was no “loss of face,"
most patients cooperated well and gave an accurate account of
their deviations, if any,
from the suggested therapeutic program. Some patients at the
end of the first or second
month of treatment, or at a later time, felt so much improved
physically that they
discontinued therapy for their joint dysfunction, mistakenly believing,
in spite of advice to the
contrary, that they were "cured," and required no further
therapy
or medical supervision. Some
of these persons, who experienced a recurrence of their
original pattern of symptoms
upon premature cessation of therapy, returned
subsequently for
re-evaluation of their therapeutic needs. Other patients, who felt that
they had not benefited from
therapy for their joint dysfunction, did not continue with
treatment though objectively
they responded satisfactorily to adequate therapy, as
shown by increasing values
of the Joint Range Index on serial re-measurements.
Therapy was always
individualized. In the therapeutic program introduced for the
treatment of joint dysfunction,
each patient served as his test object in the bio-assay
of the dosage of niacinamide
necessary to reverse his joint dysfunction. Therapy
with niacinamide (used alone
or in combination with other vitamins) was not
deemed successful unless
there continuous, objective improvement, as judged by
continuously increasing
values of the Joint Range Index on consecutive reexaminations.
(When a patient subsists on
a low-protein diet, amounts of niacinamide that would
ordinarily be adequate for
the treatment of his joint dysfunction prove to be inadequate
for satisfactory
improvement. In this case, the dosage of niacinamide is continued at
the
same level, but the protein
level of the diet is increased to adequate levels, with
subsequent satisfactory
improvement in the joint dysfunction.) (118) (120) (172).
The clinical
classification of joint function in terms of the numerical values of the Joint
Range Index is
listed below:
Clinical Classification
of Joint Function
Degree of Joint Dysfunction
Joint Range index
No joint dysfunction 96-100
Slight joint dysfunction
86-95
Moderate joint
dysfunction 71-85
Severe joint dysfunction 56
-70
Extremely severe dysfunction
55 or less
For each clinical grade of
joint dysfunction, the initial dosage schedule of niacinamide
suggested below effects in
time such improvement in joint dysfunction as the writer has
considered to be clinically
satisfactory. (However, since April 1947, it was found that
dosage schedules 50-100%
greater than those recommended below (particularly
in the moderate, severe and
extremely severe grades of joint dysfunction) are
therapeutically superior, as
judged by the patient's clinical response.)
While the initial dosage
may be increased as necessary during treatment, it is not
decreased, even though the
Joint Range Index increases in response to adequate
therapy.
The vitamins were
administered orally, usually in equal doses at equal intervals during
the day, and, in severe and
extremely severe joint dysfunction, during the night when
the patient would
spontaneously awaken from sleep. In slight grades of joint
dysfunction, the daily
continuous ingestion of 100 mg of niacinamide after meals
and at bedtime sufficed for
treatment (400 mg/24 hours). Usually adequate in
moderate joint dysfunction
was the continuous ingestion of 150 mg niacinamide
administered every 3 hours
for 6 daily doses (900 mg/24 hours). In extremely
severe and severe grades of
joint dysfunction, 100-150 mg niacinamide were
prescribed every hour
(1500-2250 mg/24 hours), every hour and a half (1110-1650
mg./24 hours), or every two
hours (800-1200 mg/24 hours), depending on the
severity of the joint
dysfunction, the more frequent schedule being used in more
severe cases (97) (51).
It has been found in the
treatment of joint dysfunction that the manner in which
the daily dosage of
niacinamide is divided has an important bearing on the
therapeutic results
achieved; e.g., 300 mg niacinamide given three times daily (900
mg/24 hours) is inferior in
its therapeutic action to 150 mg niacinamide administered
every 3 hours for 6 daily
doses (900 mg/24 hours). Therefore, to define the type of
therapy used, the writer
routinely records the following data: (a) the number of
milligrams or units
administered per dose, and (b) the total number of milligrams or units
administered per 24 hours.
No untoward effects or
clinical signs of toxicity were noted when niacinamide
(alone or in combination
with other vitamins) was administered on the above
dosage schedules to
individuals for short or long periods of observation. Before
1943, mild hypoglycemia had
been noted clinically in a few persons when niacinamide
exceeded certain dosage
levels (97) (135) (51) (62), but this phenomenon has not been
observed since that time.
"ADEQUATE" AND
"OPTIMAL” DOSAGE LEVELS OF NIACINAMIDE IN THE
TREATMENT OF JOINT
DYSFUNCTION
"Adequate"
dosage of niacinamide is defined as that clinically safe dosage of
niacinamide which, when
ingested in divided doses throughout the day by a person with
joint dysfunction whose
ordinary diet is not inadequate in protein or calories, and whose
joints are not subjected to
excessive mechanical joint injury, will effect in time what the
writer has considered to be
a satisfactory pattern of increasing values of the Joint
Range Index. The pattern of
recovery from joint dysfunction in response to niacinamide
therapy, and the numerical
limits of increments in the value of the Joint Range Index
which are considered to be
satisfactory for the first month of therapy and for succeeding
months, are described on
page 24.
“Optimal” dosage of
niacinamide is defined as that clinically safe dosage niacinamide
which, when ingested in
divided doses during the day by a person with joint dysfunction,
would permit the most rapid
recovery in joint function, as demonstrated by the largest
possible increments in the
values of the Joint Range Index in the shortest possible
period of time. At present,
the optimal dosage of niacinamide for the treatment of joint
dysfunction has not been
determined clinically, although it is hoped to approximate such
a dosage level eventually.
Since adequate dosages of niacinamide have given clinically
satisfactory results without
producing any untoward symptoms or signs of acute or
chronic toxicity, no attempt
has been made in this study to determine the optimal level
of niacinamide therapy in
the treatment of the various clinical grades of joint
dysfunction.
However, as the higher
dosage levels of niacinamide have been cautiously explored in
the past 22 months, it has
been found in severe and extremely severe joint
dysfunction that divided
doses of niacinamide totaling 4 or 5 grams (4,000-5,000
mg) per 24 hours are
therapeutically superior to the lower dosage schedules -
which previously had been
considered adequate. Even these higher dosage
levels of niacinamide may
not be optimal for the treatment of joint dysfunction.
The optimal dosage of
niacinamide for the treatment of joint dysfunction, as well as the
limit of human tolerance for
niacinamide, can be established only in those medical
centers equipped to provide
careful clinical supervision, and to conduct such chemical,
metabolic and clinical
laboratory studies as would reveal the earliest signs of toxicity,
should these occur with the
administration of progressively higher dosage levels of
niacinamide.
DESCRIPTION OF JOINT
DYSFUNCTION AND ITS TREATMENT FOR THE PATIENT
Since the cooperation of
the patient is a prerequisite for the successful therapy of joint
dysfunction, it was found
desirable and necessary before treatment of joint dysfunction
was instituted to discuss
with the patient his various clinical problems (including the
dynamic nature of joint
dysfunction, and its response to niacinamide treatment, and the
dynamic nature of certain
complicating syndromes, and their appropriate treatment),
and the therapeutic goals.
During the course of therapy, it may become necessary to
review and amplify this
discussion for the benefit of the patient as various clinical
problems arise.
Joint dysfunction is the
articular aspect of a generalized, usually slowly
progressive metabolic disorder
which is corrected in time by adequate
niacinamide therapy. Since
the retrograde changes in tissue structure and
function which characterize
this disorder occur insidiously over a period of years,
many of its symptoms and
signs are incorrectly attributed by laymen and
physicians alike to the
so-called "normal" aging process. But these retrograde
changes in morphology and
function of bodily tissues are usually reversible in
time when adequate levels of
niacinamide are supplied continuously to bodily
tissues. The patient who
takes continuously adequate amounts of niacinamide
experiences, in addition to
improvement in joint function, an improvement in his
general health.
Theoretically, optimal
nutrition must be continuously available to bodily tissues to
ensure the best possible
structure and function of tissues (104) (108). While we do not
know what constitutes
optimal nutrition, it has been demonstrated empirically that even
persons eating a good or excellent
diet according to present-day standards
exhibit measurable
impairment in ranges of joint movement which tends to be
more severe with increasing
age (see page 153). It has also been demonstrated that
when such persons supplement
their good or excellent diets with adequate
amounts of niacinamide,
there is, in time, measurable improvement in ranges of
joint movement, regardless
of the patients' ages. In general, the extent of recovery
from joint dysfunction of
any given degree of severity depends largely on the duration of
adequate niacinamide therapy
(see pages 187 and 188).
With the ingestion of
adequate amounts of niacinamide continuously for a sufficient
period of time, a patient
whose ordinary diet is not inadequate in protein or calories,
whose joints are not
subjected to excessive mechanical trauma, will recover from joint
dysfunction at the
satisfactory rate of 6.0 to 12.0 Joint Range Index units, or better, in
the first month of therapy,
and 0.5 to 1.0 Joint Range Index unit, or better, for each
month of therapy thereafter,
until a Joint Range Index of 96-100 is reached. (Rarely,
when a patient has one or
more ankylosed joints, he may have no appreciable active or
passive movement of these
ankylosed joints, even after two years of adequate niacin-
amide therapy, although his
other joints recover the full ranges of movement in
response to such therapy. In
such cases, the Joint Range Index cannot reach 96-100;
e.g., when one wrist is
ankylosed and has not shown increased movement in response
to niacinamide therapy, the
maximum Joint Range Index attainable is 90.9; and when
both wrists are ankylosed,
the maximal Joint Range Index attainable is 81.8.)
In general, the more
severe and more chronic the patient's joint dysfunction, the slower
is the rate of recovery in
response to adequate niacinamide therapy, and the slower his
subjective appreciation of
improvement. The rate of recovery for each patient must be
established empirically from
serial determinations of the Joint Range Index. In order to
ensure a continuously
satisfactory rate of recovery from joint dysfunction, the physician
must re-examine the patient
at intervals during the course of niacinamide therapy.
Whenever a patient taking
the amounts of niacinamide prescribed by the physician, and
eating a good or excellent
diet, fails to make satisfactory improvement in his Joint
Range Index, in the absence
of excessive mechanical joint injury the niacinamide
schedule must be revised
upward to that level which permits satisfactory improvement.
Failure of the patient to
take niacinamide as directed will result in failure to improve at a
satisfactory rate.
When a patient has joint
dysfunction associated with obvious arthritic deformities, he is
told that the physician
cannot predict whether or not in his case articular deformities will
resolve with adequate
niacinamide therapy. However, in response to adequate
niacinamide therapy for a
sufficient period of time, other patients have shown partial or
complete resolution of their
arthritic joint deformities. Some patients with arthritic
deformities show resolution
of some of their joint deformities, but not of others. Only
careful observation of the
patient's deformities on serial re-examinations will indicate
whether or not his
deformities are resolving in response to adequate niacinamide
therapy. In most instances,
the rate of resolution of the deformities will be slow, if it
occurs at all.
It cannot be predicted
whether or not a given joint that appears to be completely
ankylosed clinically will
recover any degree of movement. It has been observed many
times that joints appearing
to be clinically ankylosed prior to therapy tend to have partial
or complete recovery of movement
in response to adequate niacinamide therapy,
although some ankylosed
joints have not shown any degree of movement as a result of
therapy during an
observation period of several years. In response to adequate nia-
cinamide therapy over a sufficient
period of time some patients have partial or complete
recovery of movement in some
of their ankylosed joints, but not in others. Only careful
observation of the ranges of
joint movement on serial re-examinations will demonstrate
whether or not a given
ankylosed joint can recover any degree of movement in
response to adequate
niacinamide therapy.
In general, in the
absence of complicating factors, the higher the patient's Joint Range
Index rises in response to
adequate niacinamide therapy, the fewer articular symptoms
he will have; and the better
he will feel. However, even though the Joint Range Index
increases satisfactorily in
response to adequate niacinamide therapy, the patient may
not feel well because of
complicating syndromes which are not on the basis of aniacin-
amidosis. Careful clinical
study is necessary in order to establish the etiology of
whatever complicating
syndromes may be present and, with appropriate therapy, the
patient is likely to become
free from articular symptoms and to feel well. However, at
any time symptoms of bodily
discomfort may recur which must be studied and given
appropriate treatment as
promptly as possible, if the patient is to feel well again. While
the patient may obtain
temporary relief from articular and other symptoms through the
use of analgesics,
narcotics, sedatives, antihistaminics and local anesthetics, only
adequate treatment of joint
dysfunction and the complicating syndromes is likely to give
more lasting benefits.
In order to assess the
effects of niacinamide therapy on joint dysfunction and on the
patient's general status,
the patient is usually re-studied one month after continuous
niacinamide therapy has been
instituted. If good progress in recovery from joint
dysfunction is noted at that
time, he is reexamined in two months, and thereafter every
three to six months. For the
most part, this schedule of re-examination is found to be
satisfactory for the
supervision of the therapeutic program of patients presenting the
chronic problems of joint
dysfunction, although when the individual's problems are of
unusual complexity, or when
intercurrent problems arise, the time interval between visits
is shortened.
When a patient with joint
dysfunction fails to make the anticipated progress in response
to niacinamide therapy, he
is asked if he has taken the medication as prescribed; if not,
he is urged to do so. (When
a patient has taken multiple vitamin capsules as prescribed
and has not made satisfactory
improvement in his Joint Range Index in response to
such therapy, the druggist
is asked how the vitamin powders were compounded. The
clinical effectiveness of
niacinamide seems to be lessened when niacinamide is mixed
with ascorbic acid by
vigorous trituration, since this favors inter-molecular reactions
between niacinamide and
ascorbic acid in the dry powder state. The occurrence of such
inter-molecular reactions
between niacinamide and ascorbic acid is hindered by the
preliminary admixture of
each dry powder separately with a small amount of calcium
stearate (0.2%) before the
final admixture by sieving.)
It is always emphasized
that the patient must take his medication continuously as pre-
scribed until such time as
the supervising physician may decide, on the basis of
objective clinical evidence,
that it is necessary to increase the level of niacinamide
therapy in order to produce
continuously satisfactory improvement in the Joint Range
Index.
However, certain factors
other than the ingestion of inadequate amounts of niacinamide
may tend to depress the
Joint Range Index. These include (a) transient or persistent
mechanical joint injury
resulting from unusual or physical exertion (see page 79) or from
psychogenically sustained hypertonia
of somatic muscle (see page 115), (b) rapid and
excessive gain in weight to
obesity levels, (c) excessive ingestion of alcohol, (d)
inadequate dietary protein.
When any of these factors is operative, it is of limited value
to increase the amounts of
niacinamide taken by the patient in an effort to effect
satisfactory improvement in
the Joint Range Index. Instead, treatment should be
directed toward lessening
the degree of mechanical joint injury, reducing the patient's
weight to the normal range,
interdicting alcohol, and increasing the protein intake to
adequate levels,
respectively.
When indicated, the
physician describes for the patient four complicating syndromes
frequently coexisting with joint
dysfunction, and their treatment (see page 76). Most of
the articular and
non-articular symptoms of a patient with joint dysfunction which are not
corrected by niacininide
therapy usually originate as part of these four complicating
syndromes. When the patient
understands the etiologic basis of his symptoms, he will
not have anxiety concerning
the meaning of symptoms which would otherwise seem
mysterious and alarming. The
patient with joint dysfunction who has one or more of
these complicating syndromes
is told that he will not feel well unless joint dysfunction
and these coexisting
syndromes are correctly identified and successfully treated, and
that in order to accomplish
this, his active participation in the clinical investigation and
therapeutic program is
required.
TYPICAL IMPROVEMENT IN
MOBILITY OF A SINGIE JOINT IN RESPONSE TO
LEVELS OF NIACINAMIDE
THERAPY USED PRIOR TO APRIL 1947
In serial determinations
of the mobility of single joints in response to levels of
niacinamide therapy used
prior to April 1947, it was found that niacinamide-induced
recovery of full joint
mobility was an orderly process. (Since April 1947, when higher
dosage schedules of
niacinamide were introduced (see page 21), there has been
a marked reduction in the
incidence of articular pain and discomfort upon
maximal passive movement of
the moveable joints during various stages of
recovery from joint
dysfunction.)
There is described below
typical improvement in joint mobility, as illustrated by several
sequential stages occurring
during niacinamide-induced recovery of full mobility of the
metacarpophalangeal
(knuckle) joint.
(Figure 14 is a schematic
representation of maximal passive extension of the meta-
carpophalangeal joint at
four successive stages (a) (b) (c) (d), during the course of
niacinamide-induced recovery
of full joint mobility. The line touched by the head of the
arrow in (a) (b) (c) (d)
indicates the upper limit of painless extension. The shaded angle
in (b) and (c) indicates the
range of painful passive extension.)
Figure 14(a). On the
initial examination before niacinamide therapy was instituted, the
metacarpophalangeal joint of
the forefinger of the right hand could be extended
passively to 30% of the full
range of extension for this joint. No pain or discomfort was
experienced by the patient
during this maneuver. The examiner noted the presence of
palpatory resistance from
the initiation of the movement of passive extension of this
metacarpophalangeal joint,
and this resistance progressively increased as the joint was
extended from the range of
0% to 30% of the maximal extension; the palpatory
resistance at the end of the
movement was graded as firm. When at the 30% level of
passive extension a small
increase of force in the direction of extension caused no
further extension of this
joint, 30% of the full range of extension was taken as the upper
limit of maximum passive
extension of this metacarpophalangeal joint.
Figure 14 (b). At the end
of one month of continuous, adequate niacinamide therapy,
maximal passive extension of
this metacarpophalangeal joint increased to 60% of the
full range of extension. No
pain or discomfort was experienced by the patient when the
metacarpophalangeal joint was
extended from 0% to 40% of the full range of extension.
The patient experienced
localized joint pain, often severe, as the joint was passively
extended from 40% to 60% of
the full range of extension. The examiner's palpatory
sensation indicated that
movement of the joint in passive extension was free from 0% to
40%, and that there was
soft, yielding resistance which progressively increased as the
finger was extended at the
metacarpophalangeal joint from 40% to 60% of the full range
of movement. When a further
small increase of the extending force did not increase the
degree of extension, 60% of
the full range of extension was taken as the upper limit of
passive extension of this
metacarpophalangeal joint. The palpatory resistance at the
end of the movement of
extension was rubbery.
Figure 14 (c).After
months of continuous, adequate therapy with niacinamide, maximal
passive extension of the
metacarpophalangeal joint reached 100%; i.e., the full range of
movement. Passive extension
of the metacarpophalangeal joint from 0% to 85% was
without pain or discomfort;
passive extension from 85% to 100% was painful. The
examiner's palpatory
sensation indicated that the movement of this joint was free from
0% to 85%, and that there
was soft resistance, which increased progressively with
increasing extension of the
metacarpophalangeal joint from the level of 85% to 100%. A
small additional force in
the direction of extension when the 100% level was reached did
not cause further extension
of this joint. The palpatory resistance at the end of the full
range of movement (100%) was
rubbery.
Figure 14(d). With a
longer period of continuous, adequate niacinamide therapy, it
was possible to achieve
full, free and painless extension of this
metacarpophalangeal joint to
the level of 100%. Slight additional palpatory force in
the direction of extension
with the joint fully extended did not increase the amount of
movement beyond the full
range of extension; i.e., the 100% level. The examiner's
palpatory sensation
indicated that the movement of extension was free from 0% to
100% of full extension, that
the resistance met at the end of this movement was firm,
and that the patient
experienced no pain from this maneuver.
It would appear from
clinical observations that, in the absence of joint trauma, there is
an orderly and sequential
pattern of recovery of joint mobility in a patient with joint
dysfunction in response to
continuous, adequate niacinamide therapy provided that the
patient's diet is not
inadequate in protein Or calories. Serial re-examinations of joint
ranges during the course of
continuous, prolonged, adequate niacinamide therapy
reveal that with the passage
of time, there are the following changes:
(a) progressive increases
in ranges of joint movement;
(b) progressive shifting
of painful zones of joint movement toward the periphery of the
most recently acquired zones
of increased ranges of joint movement, until, ultimately,
after the fullest range of
movement for the joint has been achieved, there is absence of
pain on the execution of the
fullest movement possible for the joint in the specified
range; and,
(c) progressive shifting
of zones of resistance to passive movement toward the
periphery of the most
recently acquired zones of increased ranges of joint movement
until, ultimately, after the
fullest range of movement for the joint has been achieved,
there is no resistance to
passive movement on the execution of the fullest range of
movement possible for the
joint in the specified range of movement.
These dynamic changes in
joint mobility occurring during the course of treatment
suggest that sequential
alterations in joint morphology must occur in response to
continuous, adequate
niacinamide therapy to permit the observed changes in joint
mobility described above.
With cessation of
adequate niacinamide therapy, the therapeutically-improved joint
mobilities cannot be
maintained for any prolonged period of time.
SELECTED CASE HISTORIES
ILLUSTRATING THE THERAPEUTIC RESPONSE
OF JOINT DYSFUNCTION TO
NIACINAMIDE ALONE OR IN COMBINATION WITH
OTHER VITAMINS
This section presents
selected case histories which illustrate and emphasize the
dynamic nature of joint
dysfunction, with and without clinically obvious arthritis, as
demonstrated by changing
values of the Joint Range Index over a period of time in
response to various levels
of niacinamide ingestion. Twenty case histories, abbreviated
in various degrees, are
presented, together with a figure for each case which
summarizes both the response
of the Joint Range Index to the type of vitamin therapy
employed, and the amounts of
the vitamin(s) administered per 24 hours. A few figures
summarize additionally the
changes observed in the Sedimentation Rate during
therapy.
Cases A through K have
been chosen to demonstrate the effect on joint dysfunction of
(a) adequate therapy with
niacinamide, (b) reduction of niacinamide from adequate to
inadequate levels, and (c)
premature discontinuance of niacinamide therapy.
Cases L through T show the
effects on joint dysfuntion of adequate and for the
inadequate therapy with
niacinamide administered in combination with of the
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