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Joint Dysfunction, Part 2
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CHAPTER 2
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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
(Dr. Kaufman now
discusses physical and psychological stresses, allergy, posture, obesity and
other factors that may interact or interfere with niacinamide megavitamin
therapy for arthritis. This chapter’s three original photographs are not
provided here, but may be seen in the original text, available through this
website. For ordering information, you may either click here or scroll
to the very bottom of this webpage.)
References cited in
this chapter are posted at http://www.doctoryourself.com/kaufman11.html
Four Complicating
Syndromes Frequently Coexisting with Joint Dysfunction
It might appear to the
reader that the niacinamide treatment of a patient with joint
dysfunction is a more or
less mechanical and uninteresting procedure. However, in
practice, the treatment of a
patient with joint dysfunction is never a mechanical or dull
routine, since therapy of
joint dysfunction and commonly occurring complicating
syndromes must always be
adapted to the special needs of the individual patient. For
the most part, the treatment
of a patient with joint dysfunction is a constantly interesting
and instructive discipline
both for the patient and physician.
Commonly occurring
complicating syndromes coexisting with joint dysfunction must
often be corrected if the
patient is to be able and willing to take niacinamide therapy as
prescribed, and if he is to
feel well ultimately. Even though joint dysfunction improves to
the level of 96-100 (no
joint dysfunction) in response to adequate niacinamide therapy,
the patient may have
continuing articular and non-articular symptoms, of one or more of
these complicating
syndromes, and he may erroneously conclude that the niacinamide
treatment of his joint
dysfunction has failed. On the other hand, whether or not a patient
is taking niacinamide
treatment, when these complicating syndromes are corrected, he
may have an improved sense
of well-being and freedom from articular and non-articular
symptoms, but it does not
follow necessarily that his joint dysfunction is improving, since
serial re-measurements of
his Joint Range Index may indicate that his joint dysfunction
may be unimproved or
worsened.
In the treatment of a
patient with joint dysfunction who has one or more of four
complicating syndromes
frequently coexisting with joint dysfunction, the physician must
correctly identify the basis
of the patient's articular and non-articular symptoms, and
must institute concurrently
the appropriate specific therapy required for the successful
management of joint
dysfunction and any of these four syndromes which the patient
may have:
(a) the delayed post-traumatic
articular syndrome (see page 79);
(b) the chronic allergic
syndromes (page 96);
(c) the sodium retention
syndrome (page 114);
(d) the syndrome of
psychogenically induced, sustained hypertonia of somatic muscle
(page 115).
The articular symptoms of
any one or any combination of these four syndromes may be
present in a patient without
joint dysfunction, or may be absent in a patient with joint
dysfunction (with or without
clinically obvious arthritis); and may occur in a patient with
joint dysfunction before
niacinamide therapy is instituted, during the course of adequate
niacinamide therapy, when
adequate niacinamide therapy is replaced by inadequate
niacinamide therapy or upon
premature cessation of niacinamide therapy. The articular
and non-articular symptoms
of bodily discomfort of these four syndromes may vary in
intensity, duration and
extensiveness. With each of these syndromes a patient may
have a steady state of
discomfort which persists until the syndrome is successfully
treated.
The four complicating
syndromes frequently coexisting with joint dysfunction will be
described as if each were an
independent clinical entity. Often, the successful
management of any one of these
syndromes will not materially influence the clinical
course of the other
untreated coexisting syndromes. At times, however, these
complicating syndromes may
be interrelated, in the sense that when one of the
untreated complicating
syndromes becomes more severe, the other coexisting
untreated complicating
syndromes also become more severe; and in the sense that the
successful treatment of one
of the complicating syndromes may simultaneously amel-
iorate or lessen the
intensity of symptoms of the other untreated coexisting complicating
syndromes. Clinically, it
may be very easy, or it may be extremely difficult, to ascertain
the etiologic basis of the
patient's articular and non-articular symptoms. The most
helpful clues to the
etiology of the patient's symptoms are obtained from careful clinical
study, including a detailed
history of the onset and development of symptoms, re-
examination of the patient,
an analysis of the food-symptom diary kept by the patient
(see page 103), and an
evaluation of the patient's response to a trial of therapy directed
toward the amelioration of
the symptoms of a given complicating syndrome.
Although from the
physician's point of view, the patient's symptoms are subjective
phenomena, to the patient
his symptoms are real and have objective existence. By
giving verbal expression to
his symptoms, the patient is exteriorizing the fact that he
does not feel well, and
implying that if his symptoms could be made to disappear, he
would feel well.
The physician must give
careful consideration to the possible meaning of all the
patient's symptoms, whether
or not they seem to be trivial, atypical or bizarre at the time
of their recital. The
physician should regard the patient's symptoms as direct or indirect
clues to the nature of the
patient's ill health, even if the clinical meaning of these
symptoms continues to be
inapparent. Once the etiology of the patient's symptoms is
recognized by the physician,
it often becomes possible to institute appropriate treatment
which, in time, ameliorates
these symptoms. While the etiologic basis of some
symptoms may be readily
perceived by the physician, the clinical significance of other
symptoms may remain obscure
for a long time or may never be ascertained. Even
some symptoms which at first
hearing appear fantastic to the physician may prove, in
time, to have a definite
clinical basis which can be identified. When the nature of the
patient's disorder becomes
manifest, it is often found that most patients with puzzling
symptoms were entirely
accurate and honest in their reporting of symptoms. It is the
rare patient who
deliberately distorts facts and invents complaints and illnesses, and
even such a patient by so
doing gives valuable clues to the nature of his illness.
In evaluating the
clinical significance of articular and non-articular symptoms, it is
necessary to remember that
the patient's prevailing emotional state influences the
nature of his complaints
(29) (182) (242). A patient who is mildly depressed may
complain at great length
about his various symptoms, and may express considerable
doubt that he will ever get
well. On the other hand, a patient who is euphoric will
complain little or not at
all of articular and non-articular symptoms, and his general atti-
tude toward all of his life
situations will be optimistic. A patient who has feelings of
anxiety, guilt, hostility or
frustration may find substitute satisfaction in complaining
bitterly about articular and
non-articular symptoms. A patient whose attention is fixed on
his symptoms will have many
complaints excepting when his attention is distracted by
more interesting matters. A
patient with a rigid conception of his own perfection seldom
will complain of symptoms.
Occasionally, a patient unconsciously attempts to gain the
approval of the physician by
exaggerating his favorable response to therapy. On the
other hand, a patient may
use his complaints about poor health to "punish" the
physician (authoritarian
figure) by insisting with evident satisfaction that his health has
been unimproved or worsened
by treatment, when it is obvious from physical
examination and from the
remainder of the patient's story that he has in fact improved
physically. At times, when a
patient has secondary gains from his illness, he seems
impelled to complain about
his symptoms, and even when he has improved as a result
of treatment and has fewer
symptoms, he continues to complain more and more about
less and less.
DELAYED POST-TRAUMATIC
ARTICULAR SYNDROME
(In this section, there is
excluded from discussion such severe accidental injuries as
lacerations of the
supporting structures of joints, bone fractures involving joint
structures, torn articular
cartilages causing internal derangement of joints, and
penetrating joint wounds.)
Without knowledge of the
clinical patterns of the delayed post-traumatic articular
syndrome, the cause of many
articular symptoms and signs often remains obscure.
With knowledge of such
patterns, and with knowledge of the patient's physical activities,
occupation, and emotional
tensions, the physician can often identify the basis for the
patient's troublesome
articular symptoms and signs, and can advise the patient how to
modify his way of living so
that in the future he will be less likely to experience such
symptoms and signs.
The delayed
post-traumatic articular syndrome is the consequence of certain types
of
mechanical joint
injury:
(a) articular trauma
which is likely to occur in the course of more or less ordinary
physical activity;
(b) alterations in the
alignment of joints due to certain acquired habits of posture, or
indirectly due to
niacinamide-induced improvement in joint mobility;
(c) psychogenically
induced, sustained hypertonia of somatic muscle.
In general, the severity
of the patient's delayed post-traumatic articular symptoms
seems to depend on the
following factors: the clinical grade of severity of his joint
dysfunction; the severity,
repetitiveness and duration of the inciting mechanical joint
injury; the patient's
prevailing moods; and his attitudes toward his symptoms and life
situations.
Mechanical joint injury
may be well tolerated by persons with the milder grades of joint
dysfunction, who will have
either no clinically discernible articular sequelae or will
develop relatively mild
symptoms and signs of the delayed post-traumatic articular
syndrome for relatively
short periods of time; but mechanical joint injury usually is poorly
tolerated by persons with
the more severe clinical grades of joint dysfunction, who tend
to develop severe symptoms
and signs of the delayed post-traumatic articular syndrome
which last for relatively
long periods of time (97). In general, immediate and delayed
post-traumatic articular
symptoms and signs tend to be more severe in untreated
persons with joint
dysfunction than in persons with joint dysfunction who are receiving
adequate amounts of
niacinamide. A patient with joint dysfunction who is receiving
inadequate niacinamide
therapy is more likely to suffer from the delayed post-traumatic
articular syndrome than if
he were receiving adequate niacinamide therapy. If his
niacinamide intake is
increased from inadequate to adequate levels, even though
mechanical joint injury
continues at the same level as previously, the niacinamide-
induced reparative process
will often preponderate over the trauma-induced
deteriorative process, and
the delayed articular post-traumatic syndrome will be
ameliorated.
The immediate effects of
a single episode of extremely severe joint injury are well
understood because of the
close temporal relationship between the articular injury and
the ensuing articular
symptoms of discomfort, pain and disability, which may be
associated with one or more
of the following physical signs in the mechanically injured
joint region: tenderness to
palpation, swelling, heat, redness, congestion of the
superficial circumarticular
veins, spasm of somatic muscles operating the injured joint,
and painful or painless
limitation of active and passive articular movement. The delayed
effects of such severe
mechanical joint injury may include a continuance of articular
discomfort, pain and
disability lasting for months or years, and clinically well-defined
arthritic changes in the
injured joints (33) (121) (19) (131).
The immediate effects of
a single episode of a less severe grade of mechanical joint
injury are also well
understood, but the delayed effects of such an injury to the joints
have not been given the
clinical attention they deserve. Because there is often an
asymptomatic period of two
to four days between the subsidence of the immediate post-
traumatic articular symptoms
and the appearance of the delayed post-traumatic articular
syndrome, the physician and
patient may be unable to perceive the causal relationship
between the inciting
mechanical joint injury and the delayed post-traumatic articular
symptoms. When the delayed
post-traumatic symptoms of joint discomfort, pain and
disability occur three or
four days after the inciting joint injury, there may be one or more
of the following objective
findings in the injured articular regions: tenderness to
palpation, swelling, heat,
redness, congestion of the superficial circumarticular veins,
spasm of the somatic muscles
operating the injured joint, and painful or painless
limitation of active and
passive articular movement. These delayed post-traumatic
articular symptoms and signs
may be more severe and more persistent than those
occurring immediately after
joint injury, and gradually decrease in severity, usually
disappearing by the tenth to
fourteenth day following the inciting injury to the joint.
Occasionally, the delayed
post-traumatic articular syndrome may persist for a month or
more after a single joint
injury, particularly when the patient's joint dysfunction is
extremely severe, or when
the inciting trauma is unusually great. At times, there may be
no articular symptoms and
signs immediately following mechanical joint injury, or such
immediate articular symptoms
as may appear immediately after the injury may seem so
insignificant to the patient
that he disregards them. Sometimes, the only sign of the
delayed post-traumatic
articular syndrome may be increased painless limitation in the
ranges of movement of the
injured joint. Even relatively slight injury, when sufficiently
repetitive, may lead, in
time, to a steady state of articular discomfort, pain and disability,
and to the appearance of
clinically obvious arthritic deformities in the injured joint region
(96).
Sometimes, the cause of
delayed post-traumatic articular symptoms may be identified
only with difficulty after a
prolonged period of clinical study. When a patient with joint
dysfunction suddenly
experiences a single isolated episode of joint pain and disability,
or gradually develops a
persistent state of articular discomfort (with or without periodic
exacerbations) or merely an
asymptomatic lowering of the ranges of joint motion,
careful clinical study may
disclose the fact that in the performance of a particular
physical act either once or
repetitively, the patient inadvertently or unknowingly injured
the affected joints, or may
disclose the fact that the patient has developed
psychogenically induced,
sustained hypertonia of somatic muscle of sufficient severity
to injure his joints. Joints
used statically or dynamically in the performance of everyday
activities may incur
mechanical trauma sufficiently severe to cause a single episode of
articular discomfort, pain
and disability, or may incur mechanical trauma sufficiently
severe and repetitive to
cause a steady state of articular discomfort, pain and disability.
When a patient has joint
dysfunction of a high clinical grade of severity, his articular
structures are particularly
vulnerable to lesser grades of joint trauma, which may give
rise to the more severe and
persistent symptoms and signs of the delayed post-
traumatic articular
syndrome. When a patient is recovering satisfactorily from joint
dysfunction in response to
continuously adequate niacinamide therapy, and a specific
joint is subjected to a
single episode of moderate injury, usually there is temporarily a
delayed post-traumatic
decrease in the range of movement of this joint -with or without
accompanying symptoms of the
delayed post-traumatic articular syndrome - although
his uninjured joints
continue to improve at a satisfactory rate. If the articular injury is
more or less continuous, the
range of movement of the injured joint decreases, and, in
time, tends to stabilize for
as long as the niacinamide-induced reparative process bal-
ances the trauma-induced
deteriorative process in the injured joint. At this time, an
increase in the patient's
niacinamide intake does not materially improve the range of
movement of the continuously
injured joint, except in some instances where previous
levels of niacinamide
treatment have been inadequate. However, a decrease in
niacinamide intake causes
the range of movement of the continuously injured joint to
decrease at a more rapid
rate than if adequate amounts of niacinamide were taken con-
tinuously.
The Joint Range Index may
or may not be significantly depressed by the post-
traumatically decreased
range of movement of a single joint. It is, therefore, necessary
to analyze the component
joint ranges which are measured for the computation of the
Joint Range Index in order
to observe which joints show post-traumatically decreased
ranges of joint movement and
which joints simultaneously have made satisfactory
improvement in the ranges of
joint movement for the period of observation during which
the patient was ingesting
continuously adequate amounts of niacinamide.
It is often possible to
identify the type of behavior which caused mechanical injury of
certain joints from an
analysis of the distribution of joints with decreased ranges of
movement and those with
increased ranges of movement, and from knowledge of the
patient and his physical
activities and hobbies at various seasons of the year, and of his
emotional tensions. For
example, when the fingers of the right hand, right wrist and right
shoulder
show decreased movement, and
the patient has recently returned from a train trip, one
can establish that the most
likely cause of the decreased ranges of movement was the
carrying of a suitcase. When
mechanical articular injury is sufficiently generalized, there
is a delayed post-traumatic
decrease in the ranges of movement of the injured joints
and in the Joint Range Index
even though the patient with joint dysfunction is ingesting
continuously adequate
amounts of niacinamide; however, with cessation of joint injury
there is usually a
satisfactory rise in the Joint Range Index in response to adequate
niacinamide therapy.
Certain physical
activities have been identified as causes of the delayed post-traumatic
articular syndrome in some
patients at various times during this study, and include:
sawing, planing, hammering,
house-painting, weeding, spading, hoeing, spraying,
hedge-clipping, lawn-mowing,
bowling, sailing, rowing, paddling a canoe, fly-fishing,
driving a car, knitting,
crocheting, tatting, wringing of clothes, house-cleaning, cleaning,
scrubbing floors, waxing
floors. In some persons the repetitive performance of a
physically awkward act may
cause joint injury; e.g., the frequent daily use of a desk
telephone with a short cord,
which requires the user to twist his body into an awkward
position each time he uses
the telephone. In some patients, holding the joints in a fixed
position and carrying
moderate weights for relatively short or long periods of time may
give rise to a delayed
post-traumatic cycle of joint discomfort and disability; e.g.,
maintaining one knee and
ankle fixed in an awkward position by sitting on the medial
aspect of the ipsilateral
heel, or sitting in a chair with the dorsum of the ipsilateral foot
twisted behind one leg of
the chair; hanging onto an overhead strap in a subway or bus;
holding a knitting bag,
handbag, shopping bag, brief-case, suitcase, or even holding a
strong dog in leash.
Similarly, certain jerky movements requiring the sudden exertion of
extra muscular force will
also give rise to a post-traumatic cycle of joint discomfort and
disability; e.g., opening a
window or drawer that "sticks," or loosening a stubborn jar
cover with a strong steady
twisting movement, or opening and closing a "tight" water
faucet. Joint trauma may
occur during the night when the patient maintains awkward
sleeping postures for
relatively long periods of time, particularly if he simultaneously has
during sleep psychogenically
induced, sustained hypertonia of somatic muscle. Certain
recently acquired or old
methods of walking which the patient habitually uses will cause
injury to the knee and hip
joints and will cause a steady state of symptoms of articular
discomfort, pain and
disability, and signs of impaired mobility of hip and knee joints.
Joint trauma may occur
also when a patient with joint dysfunction (with or without
clinicallv obvious arthritic
deformities) has mental tensions which are exteriorized
through psychogenically
induced, sustained hypertonia of somatic muscle. Although
such a patient may
erroneously believe that he is completely relaxed, the coapting
pressures exerted
continuously against articular surfaces, and the accompanying
tensions on periarticular
structures often cause continuous joint trauma for as long as
this sustained somatic
muscle hypertonia persists. When psychogenically induced, sus-
tained hypertonia of somatic
muscle is present and the patient uses his joints in
everyday activities, there
is joint trauma in excess of what would have occurred in the
performance of these
activities in the absence of sustained hypertonia of somatic
muscle. Psychogenically induced,
sustained hypertonia of somatic muscle in persons
with the more severe grades
of joint dysfunction may cause articular swelling, redness,
increased congestion of the
superficial circumarticular veins, increased heat, spasm of
the somatic muscles
operating the joints, stiffness, and limitation in the ranges of active
and passive joint movement.
In time, repetitive joint trauma from this source will favor
the appearance of clinically
obvious arthritic deformities. Ordinarily, the patient is
unaware of his mental
tensions and his psychogenically induced, sustained hypertonia
of somatic muscle, although
he is very aware of his symptoms due to the delayed post-
traumatic articular
syndrome.
Many persons with joint
dysfunction (with or without clinical or radiographic evidence of
arthritic changes in joints)
may be unaware of any articular discomfort or disorder until
joint trauma gives rise to
the delayed post-traumatic articular syndrome. The anxiety
and mental tension developed
by such patients as a result of this articular discomfort,
pain and disability
(particularly when a steady state of articular discomfort is reached)
often create secondary
psychogenically induced, sustained hypertonia of somatic
muscle which is sufficiently
severe to perpetuate joint injury and its sequelae.
TREATMENT OF THE DELAYED
POST-TRAUMATIC ARTICULAR SYNDROME
Treatment of the delayed
post-traumatic articular syndrome should be directed toward
preventing the joint
traumata which produce this syndrome and toward giving the patient
relief from whatever delayed
post-traumatic articular symptoms he may have. Since
joint injury may be caused
by ordinary or unusual, essential or non-essential daily
activities, it is not always
possible to prevent articular trauma, even when the physical
act producing joint injury
is known. However, once the causation of mechanical joint
injury is recognized, the
patient should be advised how to keep joint injuries to a
minimum in the performance
of his essential everyday physical activities. A patient who
understands the temporal and
causal relationship between the mechanical joint injuries
of everyday activities and
the symptoms of the delayed post-traumatic articular syn-
drome is likely to modify
his activities so that mechanical injury to his joints will be
minimal and, when possible,
to avoid those unessential physical activities which may
actuate the delayed
post-traumatic articular syndrome.
Many patients erroneously
believe that "exercise loosens the joints." It is often
necessary to demonstrate to
a patient that after exercise his Joint Range Index and the
ranges of movement of his
exercised joints are depressed, sometimes for days or
weeks. In patients who have
the lesser clinical grades of joint dysfunction, such delayed
post-traumatic depression of
joint ranges may not be sufficiently severe or prolonged to
warrant the interdiction by
the physician of all unessential physical exercise. However,
in patients who have the
more severe clinical grades of joint dysfunction, such delayed
post-traumatic depression of
the joint ranges may be sufficiently marked and prolonged
to impede satisfactory joint
recovery in response to niacinamide therapy. For each
patient, where possible,
physical exercise should be adjusted so that the resultant joint
injury will not materially
impede satisfactory niacinamide-induced recovery from joint
dysfunction.
Although physically
strenuous exercise may give some patients with the more severe
grades of joint dysfunction
temporary benefit through transient release of
psychogenically induced,
sustained hypertonia of somatic muscle, the joints are not
benefited by such exercise.
It may be desirable to permit a patient with unresolved
mental tensions to continue
to enjoy his strenuous physical exercise, since the
advantages of obtaining
transitory relief from sustained hypertonia of somatic muscle
may outweigh the
disadvantages of actuating the post-traumatic articular syndrome.
However, in time, with
satisfactory psychotherapeutic resolution of his emotional
tensions, the patient
usually is relieved of his psychogenically induced, sustained
hypertonia of somatic
muscle, and consequently does not have the urgent need for
seeking emotional release
through excessive physical activity.
The more
niacinamide-induced recovery a patient has had from his initial clinical
grade
of joint dysfunction, the
better he will be able to tolerate the articular trauma of his
everyday activities. The
substitution of inadequate for adequate niacinamide therapy, or
the premature cessation of
adequate niacinamide therapy, tends to make the delayed
post-traumatic syndrome more
severe. Continuously adequate niacinamide therapy
helps to minimize the
symptoms and signs of the delayed post-traumatic articular
syndrome but does not
prevent their occurrence.
The use of plain or
enteric coated aspirin (0.3 to 0.6 g per dose) or enteric coated
sodium salicylate (0.6 g per
dose) distributed as needed during the day - in a person
having no intolerance for
these drugs - often gives the patient relief from his localized or
generalized post-traumatic
articular symptoms. Rarely, for the relief of articular pain, it is
necessary to give additionally
codeine (0.030 to 0.060 g per dose) or demerol (0.100 to
0.150 g per dose), as
required. Procaine hydrochloride infiltration of an injured joint
region has not been used
(33) (211), nor were intravenous procaine hydrochloride
injections used (63).
Relative rest of the
injured joints tends to hasten recovery from the delayed post-
traumatic articular
syndrome, provided that there is daily movement of the joint, without
weight-bearing, through the fullest
possible ranges of active and passive movement.
When the delayed
posttraumatic articular syndrome occurs in a given joint region, it is
often helpful to apply
massive hot, wet, Epsom salt dressings (for 30 minutes 3 or 4
times daily) to a large
region, including and surrounding the injured joint. Moist heat
seems to be more efficacious
than dry heat, although it is often more convenient to use
dry heat (heating pad, or
heat from an electric incandescent bulb). With the use of moist
or dry heat special care
must be taken not to burn the patient. Certain types of massage
administered to injured
articular regions may be helpful in giving some patients
subjective relief from
localized post-traumatic articular symptoms. A patient who injures
his joints and develops
generalized delayed post-traumatic articular symptoms may
have temporary relief from
these symptoms by soaking in a tepid bath for 20 or 30
minutes. In selected
instances, a suitable type of body massage following the bath may
give additional benefit.
MISCELLANEOUS TYPES OF
MECHANICAL JOINT INJURY AND THEIR
TREATMENT
Posture. Certain types of
posture in sitting, standing; walking and working cause
mechanical joint injury,
regardless of the patient's clinical grade of joint dysfunction,
whether or not he is
receiving adequate niacinamide treatment. Often there is a
correlation between the
patient's posture and his symptoms of bodily fatigue and joint
discomfort, pain and
disability, and therefore the physician must constantly analyze the
patient's static and dynamic
postures and make appropriate suggestions for the
correction of faulty
posture. A few commonly occurring types of static and dynamic
postural abnormalities are
described below, together with suggestions for their
treatment. No general
discussion of posture is included, since a number of excellent
descriptions of what
constitutes good posture are available in the literature (33) (84)
(73).
It was observed that many
patients who were making satisfactory recovery from severe
or extremely severe joint
dysfunction in response to adequate niacinamide therapy
(even those who had reached
the level of slight joint dysfunction or no joint dysfunction)
had continuance or worsening
of symptoms referable to hip and knee joints and to the
muscles of their lower
extremities, and that objectively, recovery of movement in hip and
knee joints lagged behind
recovery of movement in other moveable joints. When it was
recognized that these
patients were continuing to use habitually the abnormal posture
described below, even though
therapeutically increased ranges of joint movement
permitted more efficient
walking posture, appropriate suggestions were made for the
correction of improper
postures. When the patient taking adequate niacinamide therapy
adopted these suggested
changes in walking posture, he experienced some immediate
relief from his symptoms
and, in time, when the recommended posture became
habitual, he usually became
entirely free from symptoms referable to his hip and knee
joints and to his lower
extremity muscles, and the rate of recovery in the ranges of hip
and knee joint movement was
accelerated. Now that patients are routinely advised, as
described below, to modify
improper walking posture at the outset of niacinamide
therapy, the continuance or
accentuation of this pattern of articular and muscular
symptoms of the lower
extremities is seldom seen, and recovery of movement in hip
and knee joints parallels
that of other joints in response to adequate niacinamide
therapy.
This commonly occurring
postural abnormality of standing and walking results chiefly
from sustained hypertonia of
the quadriceps muscles, associated with various degrees
of cocontraction (sustained
hypertonia) of the flexor and adductor muscles of the thighs.
At first this postural
abnormality may occur only as an unconsciously adopted
accompaniment of unresolved
emotional problems, which initiate psychogenically in-
duced, sustained hypertonia
of somatic muscle. In time, such postures and the
sustained hypertonia of
somatic muscle may become habitual, whether or not the
patient continues to have
unresolved emotional problems. In the standing position, the
patient's muscles contract
more forcefully than necessary to maintain his stance
efficiently. In addition,
the patient usually has increased pelvic tilt and increased lumbar
lordosis, and holds his head
in a forward position which accentuates the
thoracicocervical curve. Any
dorsal kyphosis the patient may have seems to become
more prominent as a result
of this abnormal posture. Often in this posture the patient's
abdominal muscles become so
lax that his abdomen becomes pendulous (6). In
walking, the person with
sustained muscular hypertonia tends to maintain the poor
standing posture described
above. In forward progression, he tends to inhibit the natural
swinging movement of the
arms. With each consecutive step, the ipsilateral trunk-thigh
muscles elevate the thigh
sufficiently to permit pendulum-like swinging of the entire
ipsilateral lower extremity
as a more or less rigid unit, with little or no associated knee
movement. Upon simultaneous
palpation of the anterior and posterior thigh muscles of
the patient as he walks, it
is possible for the physician to detect a high degree of
cocontraction of antagonists
and protagonists of the hip and knee joint movement
without palpable relaxation
of these thigh muscles during walking. It is tiring for the
patient to stand and walk in
the manner described above. He also experiences a sense
of resistance to walking
which he describes as dragginess, heaviness, weakness,
unsteadiness and stiffness
of the lower extremities. He may have pain, discomfort and
stiffness in the muscles of
his thighs, back and neck; there are often associated
symptoms of discomfort, pain
and disability in the hip and knee joints. In addition, the
patient may have pain and
discomfort in the joints of his lumbosacral region, in his
upper thoracic spine, and in
the cervical spine. He may have noticed that over a period
of time he has become
"round-shouldered," that it is hard for him to straighten up,
and
that his "stomach"
has become more prominent. When such a posture is habitual for
many years, the patient with
joint dysfunction suffers from the steady state of the post-
traumatic articular
syndrome, and is likely to develop arthritic changes in the various
joint regions subjected to
excessive mechanical trauma, resulting in part from improper
alignment of joints, and in
part from continuously sustained hypertonia of somatic
muscle.
Such a patient is shown
how to modify 'his gait so that he consciously lifts his feet,
raising and flexing each
knee alternately with each successive step, instead of walking
stiff-kneed. He may notice
at once that walking in this way is relatively effortless and
comfortable as compared with
his usual gait, which caused his lower extremities to feel
draggy, heavy, weak,
unsteady and stiff, and his thigh muscles to feel painful and
uncomfortable. With this
correction in gait, simultaneous palpation of anterior and poste-
rior thigh muscles will
indicate that there is alternately well-coordinated contraction and
relaxation of the opposing
thigh muscles. When, in addition, the patient learns to hold
himself as tall as possible
in standing, walking and sitting, he may lose his pelvic tilt,
lumbar lordosis and anterior
neck flexion. The patient must practice the therapeutically
suggested alterations in
posture so that ultimately he habitually uses those static and
dynamic postures which cause
the least injury to his joints, and as a result he will no
longer be troubled with symptoms
from this type of improper p05ture. When a patient
has marked limitation in
ranges of movement of hip and knee joints before niacinamide
therapy is instituted, he is
unable to correct his gait in the manner suggested. When
niacinamide-induced recovery
permits sufficient increase in hip and knee movement,
this correction of gait is
possible. Occasionally, irreversible arthritic joint changes are
present which make this
improvement in posture mechanically impossible.
Sacro-iliac Joint Strains.
A patient with a history of recurrent sacro-iliac strains is given
certain suggestions
concerning posture which are often helpful in preventing
recurrences of such strains:
he should avoid twisting his trunk in the performance of any
physical act while standing
with his trunk bent at an angle of 35 to 55 degrees with his
thighs, since this maneuver
is frequently the cause of sacro-iliac strain. He should not
"cross his knees"
when sitting. He should not stand asymmetrically with most of his
body weight resting on one
foot. He should sleep on a non-sagging bed.
High Heels. Women who
wear high-heeled shoes are likely to have postural back
strains caused by
compensatory lumbar lordosis, pelvic tilt, flexion of the neck and
slight
bending of the knees - all
of which are necessary to maintain balance in the erect
posture when high heels are
worn. Some women wearing high-heeled shoes may have
a steady state of back
fatigue, discomfort and pain from such postural strains, while
others may have these
symptoms only when they are on their feet a great deal, or when
they carry unaccustomed
weights. Symptoms from postural strain are accentuated by
the alternate wearing of
high-heeled and low-heeled shoes. Women are advised to wear
slippers and shoes having
heels of uniform height, preferably low or medium heels.
Lifts. Often patients who
were obliged to wear lifts continuously on their shoes to
alleviate hip and knee
discomfort prior to adequate niacinamide therapy found during
niacinamide-induced recovery
of joint mobility that discomfort of hip and knee joints
increased in severity.
However, when the lifts were removed, this discomfort
disappeared.
Obesity. The excess
weight of the moderately overweight patient increases mechanical
injury of the weight-bearing
joints (hips, knees, ankles, small joints of the feet). The
excess weight of the
markedly overweight patient causes more severe mechanical
injury of these joints and,
in addition, during standing and walking the patient has
postural strain from
balancing his heavy, often pendulous abdomen, and develops
associated articular
symptoms of fatigue, discomfort and pain in various portions of his
back. Adequate weight
reduction is part of the treatment of such patients with joint
dysfunction, and a
prerequisite for this is often the successful resolution of the
patient's
emotional problems (23)
(138).
Painful Feet. A patient
with painful feet may adopt awkward bodily postures which
subject many joints of the
body to excessive mechanical injury.
It is not uncommon to
find that considerable foot pain is caused by the wearing of shoes
which have unevenly worn
heels or projecting irregularities of the insoles. A patient who
habitually dorsifiexes his
toes while wearing shoes, often develops considerable
discomfort of the feet and
legs. When such a patient is made aware that he habitually
dorsiflexes his toes, he can
eventually break himself of this habit, and he will be free
from discomfort from this
source.
During the course of
adequate niacinamide therapy, a patient with joint tilt,
dysfunction may develop
considerable pain and discomfort in the ball of the foot and in
one or more of the four
small toes of the feet even though he has continued to wear
footgear (shoes, slippers,
socks or stockings) which was comfortable previously. When
one foot is significantly
longer than the other, the foot pain experienced during
niacinamide therapy may be more
severe in the longer foot, or present only in the
longer foot.
As part of the
progressive retrograde changes of untreated joint dysfunction, over a
period of years many
patients develop in the four small toes mild, moderate or marked
deformities, consisting of
partial flexion of the interphalangeal joints, and partial
extension of the
corresponding metatarsophalangeal joints; thus, one or more of the
four small toes of each foot
are "curled" to various degrees. Where there is a significant
disparity in the length of
the two feet, the "curling" of the toes of the longer foot is
the
more pronounced than that of
the shorter foot. Such "curled" toe deformities are much
more common in women than in
men, presumably because the higher heels and
narrower toe caps of women's
shoes are additional factors which mechanically favor the
formation of
"curled" toes. With niacinamide-induced articular improvement,
there is a
gradual
"uncurling" of the deformed toes, with virtual lengthening of the feet
which is
particularly prominent on
weight-bearing. Consequently, footgear of a size entirely
comfortable prior to
niacinamide-induced joint reconstitution becomes painfully short,
with resultant injury to the
feet. When such an injury has taken place, the patient often
complains of pain, burning,
throbbing and swelling in the ball of the foot. These
symptoms usually are most
severe on the plantar surfaces of the second, third and
fourth metatarsophalangeal
joints. Examination reveals redness, swelling, heat and
exquisite tenderness to
digital pressure on the ball of the foot. There may be swelling,
pain and redness of the
interphalangeal joints of the four small toes. The skin of the
dorsolateral surfaces of the
fourth and fifth toes near the interphalangeal joints may be
irritated, swollen, painful
and reddened from rubbing against the lining of the shoes, and
at times there may be, in
addition, secondary infection. Callusing of the skin of the ball
of the foot, and corns in
the rubbed areas on the toes are commonly found.
The patient is advised to
stay off his feet for several days, to immerse his lower
extremities in hot Epsom
salt solution up to the mid-calf region for 30 minutes three or
four times a day, and to
obtain footgear correctly fitted to his "new" foot size,
measured
to his foot size when he is
in a standing, weight-bearing. position. At any time the
wearing of footgear that is
too small will cause a recurrence of this type of foot
discomfort.
SOME EXAMPLES OF
MECHANICAL JOINT INJURY
CASE U, No.178, female,
age 43, housewife, married.
This patient, who had
slight dysfunction (Joint Range Index 88.1) without arthritis,
complained when first seen
that she had had daily, for a number of years, pain, swelling
and stiffness in the joints
of her hands, more marked at all times in the right hand than
in the left hand. She was
unable to attribute her discomfort and disability to any specific
act which might have injured
her joints. Her articular symptoms were always much
worse on Wednesdays and
Thursdays, and by the following Monday were noticeably
better, although she was
never completely free from joint discomfort.
Upon questioning, it was
found that for many years she ironed every Monday for about
five hours continuously.
When she was asked to demonstrate her method of ironing, it
was observed that she
exerted strong and persistent pressure in gripping the handle of
the iron tightly with the
fingers of her right hand, and exerted a strong downward
pressure with her right
wrist as she moved the iron back and forth. The left hand
grasped the edge of the
garment tightly between thumb and forefinger as she stretched
the cloth in the course of
her ironing. She stated that three or four days after ironing, her
chief discomfort in the
right hand was in the wrist and in all of the joints of the thumb
and fingers. In her left
hand, pain was limited to the wrist and the joints of the thumb and
forefinger.
Since there seemed to be a
causal relationship between the method of ironing and the
patient's joint symptoms,
she was advised to distribute her ironing through the week so
that she would do no more
than one hour of ironing on any one day. She was also
instructed to use no more
than the minimal muscular force necessary to perform her
ironing.
After a month of such a
program, she was free from articular pain, swelling and stiffness
for the first time in many
years. For three years she has had no difficulty referable to the
joints of her hands and
wrists, even though she continues to do the same amount of
housework and ironing.
This patient had a
post-traumatic pattern of persistent articular pain and disability
resulting from repetitive
episodes of mild joint trauma occurring every 7 days, with cyclic
exacerbations of articular
difficulties for 3 or 4 days after joint trauma was sustained.
CASE V, No.452, female,
age 61, invalid, married.
When first seen, this
patient had extremely severe joint dysfunction (Joint Range Index
52.2) and severe rheumatoid
arthritis, as well as a post-traumatic pattern of immediate
and delayed articular pain,
discomfort and disability resulting from a single episode of
mild joint trauma.
She had performed what
was for her the unusually difficult task of addressing 20
envelopes for Christmas
cards, holding the pen in her right hand. Ordinarily, her
husband would have performed
this service for her, but he was away on a business trip,
and she did not wish to ask
anyone else to relieve her of this obligation. When she
completed her writing, she
experienced uncomfortable cramps, fatigue and unusual
stiffness in her right hand,
which lasted for about 30 minutes. She was free from further
unusual discomfort in her
right hand until four days later, when she suddenly
experienced severe,
persistent articular pain and increased stiffness in the joints of her
right thumb, first and
second fingers, and, to a slightly lesser extent, in the joints of the
fourth and fifth fingers.
Her pain, articular swelling and stiffness persisted at a severe
level for four days, with
gradual subsidence of the delayed post-traumatic articular
syndrome over a period of
one month, which corresponded to her first month of
niacinamide therapy. At the
time of her second office visit, there was no evidence of the
delayed post-traumatic
articular syndrome.
CASE W. This 65-year-old
woman accidentally cut the digitorum profundus tendon of
her right forefinger 16
years before the photographs of Figure 35 were taken. At the
time of the initial
examination her Joint Range Index was 71.5, indicating moderate joint
dysfunction.
Since the accident, the
right forefinger could be flexed to a limited extent, and was
moved during the course of
her daily work, but not to a sufficient degree to be useful in
the performance of household
tasks. Thus, the right forefinger was not exposed to the
more severe mechanical joint
in-juries of housework and psychogenically induced,
sustained hypertonia of
somatic muscle. This patient was extremely right-handed, and
grasped her various
household implements with great force, probably because she did
not have full use of her
right forefinger.
There was no clinical
evidence of impairment of innervation or circulation to the right
forefinger. Sensations of
heat, cold, pain, light touch, vibration, motion and position
were normal in all the
digits of the right hand. All the digits of the right hand were equally
warm, and of the same color
(210).
Because the
interphalangeal joints of the right forefinger had been subjected to
little
mechanical injury, they had
no articular deformities. However, the joints of other digits of
the right hand were markedly
deformed, presumably because of repetitive mechanical
joint injury incurred by the
tight grasping of household utensils, and by psychogenically
induced, sustained
hypertonia of somatic muscle. There was marked limitation of
movement of the
interphalangeal joints of the deformed digits, but not of the
interphalangeal joints of
the right forefinger.
CHRONIC ALLERGIC
SYNDRONIES
Certain food-induced
articular and non-articular allergic symptoms which are described
below may obscure partially
or completely a patient's subjective appreciation of
improvement in response to
adequate niacinamide therapy, even though objectively
satisfactory improvement in
joint function is demonstrated by continuously rising values
of the Joint Range Index on
serial re-measurements of joint ranges. While these allergic
reactions usually do not
include any significant degree of limitation in ranges of joint
movement, they may be
responsible for considerable articular pain and discomfort, in
addition to other symptoms
of bodily discomfort. It is, therefore, of considerable
importance in the medical
management of a patient with joint dysfunction to distinguish
between the symptoms of
aniacinamidosis, which are ameliorated in time by adequate
niacinamide therapy, and
allergic syndromes which are ameliorated in time only by
elimination of the offending
allergen, or by hyposensitization to the offending allergen.
Although many diverse
clinical manifestations of food allergy may occur in persons with
joint dysfunction, three
syndromes occur frequently in response to the ingestion of an
offending food or foods: (a)
Allergic Pain Syndrome (223) (167) (221), (b) Allergic
Fatigue Syndrome (223) (167)
(152) (153), (c) Allergic Mental Syndrome (223) (167)
(151) (152) (153) (220) (40)
(166) (213) (31) (165). These syndromes are described
below. (Rarely, the allergic
pain syndrome occurred when there was an active dental or
tonsillar focus of
infection, and was alleviated when the source of infection was
eradicated. Only three
examples of such benefit were observed in this series of 455
cases.)
These syndromes may occur
separately in various degrees of severity and chronicity, or
in any combination, and may
be associated with a number of allergic symptoms not
specifically included in the
description of these syndromes. Clinical manifestations of
these allergic syndromes may
appear almost immediately after the ingestion of an
offending food material and
may continue for a few hours or a few days; or they may
appear after a latent period
of 12-76 hours following the ingestion of the allergen, and
continue for as long as two
weeks, gradually decreasing in severity during this interval.
The daily ingestion of an
offending food or food material produces a more or less steady
state of allergic symptoms,
with some exacerbation of these symptoms soon after the
ingestion of this food.
Clinical proof that a
suspected food is responsible for a patient's allergic symptoms is
obtained (a) when such
symptoms disappear when the offending food material is
completely excluded from his
diet for a sufficient period of time (2-3 weeks), and (b)
when there is a recurrence
of the initial pattern of allergic symptoms upon ingestion of
the offending food material
soon after he has become symptom-free as a result of
abstinence from the
allergenic food for a sufficient period of time; i.e., before
abstinence
from the food has been
sufficiently prolonged for hyposensitization to have occurred.
(In addition to these
three syndromes of allergic food reaction, offending foods have
caused in patients with
joint dysfunction the following types of allergic symptoms, which
could be produced by the
ingestion of the offending food, and could be eliminated by
complete avoidance of the
offending food:
Skin: Hives,
angioneurotic edema, chronic pruritus, chronic skin lesions
Mucous membranes:
Angioneurotic edema, canker sores.
Eyes: Chronic
conjunctivitis.
Head: Cephalgia, including
migraine.
Respiratory tract: Sneezing,
postnasal drip, vasomotor rhinitis, recurrent sore throats,
recurrent colds, sinusitis,
asthma.
Gastro-intestinal: Nausea,
vomiting, abdominal pain and cramps, heartburn, water
brash, diarrhea, bilious
attacks.)
While the ingestion of
any food material can produce allergic symptoms in allergic
persons, certain foods
(chocolate, citrus fruits, tomato, pineapple, whole wheat, corn,
milk, eggs and nuts) seem to
be the most frequent offenders in the production of the
allergic syndromes described
below.
An oral threshold dose of
an offending food is defined as the smallest quantity of that
food which, when ingested
not oftener than once every two weeks, will produce allergic
symptoms in a person
sensitive to this food. An oral sub-threshold dose of an offending
food is defined as that
amount ingested not oftener than once every two weeks which
will produce no clinically
discernible allergic reactions in a person sensitive to this food.
However, if sub-threshold
doses of a single offending food are eaten daily by a person
who is sensitive to this
allergenic food in threshold doses, in a few days or weeks there
may be precipitated a
clinically obvious allergic reaction, which probably represents the
summation of clinically
inapparent allergic reactions which have reached an intensity
exceeding the threshold for
the production of allergic symptoms.
If sub-threshold amounts
of several offending foods are eaten on the same day, an
allergic reaction to these
may occur, even though such foods when eaten separately on
different days do not give
rise to a clinically apparent allergic reaction. It has been noted
that single sub-threshold
doses of different offending foods ingested on consecutive
days may precipitate a
clinically obvious allergic reaction.
In many persons with
severe food allergies, the amount of the offending food which
precipitates clinically
significant allergic reactions is so small that every trace of this
food
must be eliminated from the
patient's diet if he is to have relief from his allergic
symptoms.
When an offending food is
eliminated from the diet for a sufficiently long period of time,
the tolerance gained with
clinical hyposensitization may be excellent and apparently
unlimited; or it may be
moderate and easily broken down, either by too frequent
ingestion of the food in
small or moderate amounts, or by the single ingestion of an
excessive quantity of this
food; or, the tolerance may be so slight that it may be easily
broken down by the single
ingestion of a very small amount of the offending food
material.
Whether or not the
patient has a personal or family history of allergy, at any time he
may become sensitized to any
food and have any pattern of food-induced allergic
symptoms, which may vary in
severity, chronicity and extensiveness from time to time
(158) (159) (160).
Transient sensitization
to certain foods has been observed in many patients with upper
respiratory infections
("colds") who have a continuance of their acute coryza,
malaise
and lymphadenopathy as a
result of a practice widely used in the treatment of "colds,"
particularly, during the
early days of the "cold," namely, the ingestion daily of a quart
or
more of such liquids as
citrus fruit juices, pineapple juice, tomato juice, milk and choco-
late milk. When a person
with a limited tolerance for these food materials takes these
liquids in larger quantities
than usual for him, his oral threshold dose is exceeded, and
an allergic tissue reaction
is produced which resembles that of "infectious colds."
Often,
this food-induced allergic
reaction prolongs "cold-like" symptoms for several weeks.
However, when the patient
eats his usual diet and takes 8 to 10 glasses of water daily
instead of large quantities
of the above fluids, this food-induced allergic reaction is
avoided and the patient
recovers much more rapidly from his "cold."
Cyclic food
resensitization is likely to occur when certain foods in season are eaten
daily
in ordinary or excessive
amounts; e.g., tomatoes, citrus fruits, pineapple, strawberries,
peaches, melon, corn; and
hyposensitization is likely to occur when these foods are not
in season, and the patient
excludes them from his diet, or limits the amounts ingested.
To avoid cyclic
resensitization, an allergic patient is advised to vary his diet as much
as
possible throughout the
year, and not to have too frequent or excessive ingestion of any
one food (158) (159) (160).
Sometimes a patient with
pollinosis will observe during his hay fever season that his
reactions to known
allergenic foods tend to be more severe, and that certain foods,
which he could ingest with
impunity at other seasons, give rise to allergic food reactions.
Conversely, the ingestion of
certain foods during his hay fever season may worsen his
symptoms of pollinosis.
Extremes of environmental
temperature occasionally increase the severity of the
patient's reaction to the
ingestion of an allergenic food.
A given food may cause
allergic symptoms only when the patient is emotionally
disturbed; or, a person who
reacts to the ingestion of an allergenic food may react more
violently if this food is
ingested at a time when he is emotionally disturbed. Many
patients suffering from
severe allergic symptoms have considerable secondary anxiety
concerning their allergic
ailment, and often associated psychosomatic symptoms are so
severe that they dominate
the clinical picture, and the patient is considered to be
psychoneurotic.
Excessive ingestion or
excessive retention of dietary sodium tends to make the allergic
reaction to allergenic foods
more severe (99).
In women, a cyclic
variation in the allergic pattern has been noted, so that clinical
evidence of food allergy may
occur only during the two weeks before, but not during the
two weeks after, the
menstrual period; or, food-induced allergic symptoms may be
present throughout the
month, but accentuated during the two weeks before the period
(223) (167).
Allergic Pain Syndrome.
In certain allergic persons, the ingestion of a threshold amount
of an offending food
material causes primarily mild, moderate or severe generalized
pain in somatic muscle,
tendon, periosteum, and periarticular and articular structures. A
patient experiencing the
allergic pain syndrome avoids all unnecessary physical
exertion, since ordinary
physical activity causes him pain and discomfort. Physical
examination may disclose
tenderness to palpation of somatic muscle, tendon,
periosteum and periarticular
structures. When the blood pressure cuff is inflated during
the measurement of blood
pressure, the patient may spontaneously complain of severe
pain in the muscles of his
arm. Somatic muscle is hypotonic and feels flaccid. Active
and passive movement of
joints may cause articular pain. The pain of this syndrome is
usually not alleviated by
the ingestion of aspirin, and if the patient is allergic to aspirin,
the ingestion of this drug
may even be responsible for the initiation and continuance of
his allergic pain syndrome.
Body massage usually worsens his pain and discomfort. In
persons having the allergic
pain syndrome, relatively slight mechanical joint injury will
evoke severe and prolonged
symptoms and signs of the delayed post-traumatic
articular syndrome.
Allergic Fatigue
Syndrome. In certain allergic persons, the ingestion of a threshold
amount of an offending food
material causes primarily extreme muscular fatigue, which
is often associated with
cervical lymphadenopathy (rarely, generalized
lymphadenopathy),
lymphocytosis and hypothermia (although occasionally there is a
moderate elevation in
temperature). Physical activity intensifies this allergic fatigue, but
prolonged rest does not
relieve the patient's symptoms of fatigue.
Allergic Mental Syndrome.
In certain allergic persons, the ingestion of a threshold
amount of an offending food
material causes primarily mental symptoms, including
mental fatigue, depression
and confusion. The person may complain of disagreeable
"mental fogginess or
haziness," "a feeling of partial anesthesia," or a
"feeling of being
drugged." Thought
processes are slowed. The patient may have unwarranted irritability,
unreasonableness, temper
tantrums, loss of memory, inability to concentrate,
restlessness, sleepiness
(although occasionally insomnia is noted). The patient’s mental
inertia may be so severe
that he finds it difficult to make decisions about even
uncomplicated matters. He
vacillates, procrastinates, and has trouble in carrying out
even the simplest plans that
he has made. He may require long naps during the day
and may sleep long hours at
night without relief from such mental fatigue. He knows
that "something is
wrong" with him, and he can describe his pattern of mental
symptoms, although usually
he is reluctant to do so because such symptoms have been
made light of by his family
and friends. A patient may refuse to discuss his pattern of
allergic mental symptoms
with the physician at the time of the initial visit, fearing that
such symptoms are indicative
of mental disease (insanity). He often complains that "life
is not worth living” feeling
this way.
The allergic patient with
this mental syndrome may be secondarily disturbed because
his family and physicians
consider him to be a chronic grumbler and complainer. He
feels emotionally insecure
because he has been unable to obtain therapeutic relief from
his allergic symptoms. Often
such a person, with the tentative diagnosis of
"psychasthenia,"
"neurasthenia," "nervous exhaustion,"
"psychoneurosis," or
"psychosomatic
fatigue," is referred to a psychiatrist, who, after studying the
patient, be-
lieves that the patient's
problems are psychosomatic in origin, not realizing that food
allergy has created a
somatopsychic disorder, which can be corrected by the removal of
the offending food material
from the patient's diet, but not by psychotherapy.
A few patients with joint
dysfunction have, in addition to the allergic mental syndrome, a
primary neuropsychiatric
disturbance. In such in-stances, treatment must include
adequate niacinamide
therapy, exclusion of the offending food material from the diet
and expert psychotherapy.
TREATMENT OF CIIRONIC
ALLERGIC FOOD SYNDROMES
Skin testing was rarely
used in attempting to identify allergenic foods, since false-
negative scratch or
intracutaneous skin reactions may be obtained for a given food or
group of foods, the
ingestion of which causes the patient to experience clinically
important allergic
reactions, and falsepositive skin reactions may be obtained for food
materials, the ingestion of
which is clinically well tolerated by the patient (167) (152)
(153) (151) (158) (159)
(160) (81) (150).
Elimination diets,
especially the diets of Rowe (167) (171), were used and modified
empirically as necessary in
the attempt to rid the patient of his food-induced allergic
symptoms. At times, it may
be extremely difficult to select a basic elimination diet which
will accomplish this. When
symptoms due to food allergy are not abated in 7 to 14 days,
the patient is probably
allergic to one or more foods in the elimination diet. While an
elimination diet containing
few foods sometimes gives relief from allergic symptoms, the
too-frequent ingestion of
the small number of foods in such a diet favors sensitization of
the patient to any of the
allowed foods. When new foods are added to the patient's basic
elimination diet after he
has been free from his chronic allergic food symptoms for two
weeks, the patient should
keep an accurate food-symptom diary which permits the
physician to assess the
patient's clinical reactions to the ingestion of the newly added
food materials. If any added
food seems to be giving rise to allergic symptoms, its use is
interdicted. The patient's
elimination diet is liberalized as rapidly as possible by the
addition of those foods
which by trial he is able to ingest repeatedly without
experiencing allergic
symptoms. It is possible at any time for an allergic patient to
become sensitized to foods
that formerly he tolerated well, and when symptoms
suggestive of allergic
reaction to the ingestion of foods recur, it is necessary to resume
the search for offending
food materials.
The polypropeptan method
(223) of specific desensitization to twelve basic foods was
given a limited trial, and
good results were obtained in some patients. The food-
symptom diary was useful in
observing the clinical effects of specific desensitization,
and the patient's reaction
to the subsequent addition of new foods not included in the
basic list of twelve foods.
When the ingestion of new foods caused allergic symptoms,
and specific propeptans were
available for treatment, the patient was desensitized to
these foods; when specific
propeptans were not available, the use of these foods was
interdicted.
The method of individual
food-testing advocated by Rinkel and others (159) (155) was
not employed.
At times the
antihistaminics were employed as palliative measures in the treatment
of
hay fever symptoms and of
certain pruritic skin conditions (hives, contact dermatitis).
The chronic allergic food
syndromes described in this volume did not seem to respond
to treatment with
antihistaminic drugs.
While it is tedious and
time-consuming for the patient to keep an accurate food-
symptom diary, and for the
physician to analyze such a diary, this method of clinical
investigation has been most
helpful in the identification of specific foods causing allergic
symptoms, and in the
evaluation of the patient's response to elimination of allergenic
foods from his diet. Some
patients were unwilling or unable to cooperate in keeping a
food-symptom diary and in
restricting their diet as suggested. About 70% of persons
who had symptoms suggestive
of chronic allergic food syndromes were willing and able
to cooperate in this
exacting program.
The diary is kept in a
standard stenographer's notebook, with a central dividing line on
each page. Each notebook
page contains the record of one day only. The diet (including
all snacks, condiments and
food-tasting) and the time of ingestion of each meal are
noted in sequence in the
left-hand column of each page. The patient is instructed to be
specific in his description
of the types of food eaten and, wherever possible, to list the
ingredients of such mixtures
as soups and salads. In the right-hand column, the patient
lists his complaints,
including the time of onset, degree of severity and duration of
symptoms. A diary which is
carelessly kept or has |
