Copyright C 2001 Charlotte Kaufman. Reprinted with permission.
Edited by Andrew W. Saul
(Dr. Kaufman’s practical recommendations for case management is summarized in this short chapter. References cited in this chapter are posted at http://www.doctoryourself.com/kaufman11.html )
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Coordination of Treatment of Joint Dysfunction and the Four Complicating Syndromes
In previous sections, joint dysfunction and the four complicating syndromes were
described as if they occurred separately. Although joint dysfunction may occur alone, it frequently occurs in association with one or more of the four complicating syndromes.
Even though a patient’s Joint Range Index has been therapeutically elevated to 96-100 (no joint dysfunction), he may still have one or more of the complicating syndromes, which require successful treatment if he is to feel well.
The treatment of joint dysfunction and the four complicating syndromes is time-
consuming by ordinary standards. The initial clinical study of the patient, which is
performed in one session, may require as long as six hours. After the initial visit, the
patient and physician meet at monthly intervals, and when the patient’s problems
appear to be resolving satisfactorily in response to therapy, the office visits are
scheduled at two-, three- and four-month intervals; each visit may require as long as
one and a half hours, depending on the patient’s clinical problems. Within this schedule of office visits, it is possible to work out the various problems of the patient with joint dysfunction and the four complicating syndromes without causing the patient to become excessively dependent on the physician. It is necessary to keep accurate and detailed clinical records.
The differential diagnosis of the four commonly occurring complicating syndromes may be relatively easy, or extremely difficult. In some patients, when the four syndromes exist as apparently independent clinical entities, the successful treatment of any one syndrome does not influence the remaining syndromes, and all four syndromes must be treated successfully if the patient is to feel well. In other patients, the four complicating syndromes may appear to be interrelated as primary and collateral conditions, and the successful treatment of the primary syndrome also affords relief from the collateral syndromes. Thus, it may be necessary for the physician to recognize which of the patient’s complicating syndromes are primary and which are secondary, and to treat the primary syndrome(s) first. For example, a patient with the chronic allergic pain syndrome may have collateral anxiety about the meaning of his symptoms, which generates psychogenically induced, sustained hypertonia of somatic muscle; this in turn causes the delayed post-traumatic articular syndrome; additionally, the chronic food allergy may cause some degree of excessive sodium retention. The elimination of the offending food from the patient’s diet will correct his allergic pain syndrome, and will also relieve his anxiety and collateral complicating syndromes (psychogenically induced, sustained hypertonia of somatic muscle, delayed post-traumatic articular syndrome, and sodium retention syndrome). Treatment in this instance of any or all of the collateral syndromes will give the patient little or no benefit if the chronic allergic pain syndrome remains uncorrected.
Even though the patient’s initial complicating syndromes are corrected, he may have at any time a recurrence of these syndromes, or he may develop for the first time any other complicating syndromes or diseases. Such changes in the patient’s clinical status require appropriate study and treatment.
The presence or absence of joint dysfunction can be ascertained from the determination of the Joint Range Index. The presence or absence of the four complicating syndromes may be apparent at once to the physician upon completion of the initial clinical study, or the diagnosis must be tentative, pending further study, including observation of the patient’s response to a trial of therapy. The diagnostic conclusions derived from studying a patient by the methods outlined in previous sections may be conveniently summarized in the form suggested below, and must be revised from time to time to describe the patient’s current clinical status.
I. Joint Dysfunction:
No joint dysfunction 96-100 Joint Range Index
Slight joint dysfunction 86-95
Moderate joint dysfunction 71-85
Severe joint dysfunction 56-70
Extremely severe joint dysfunction 55 or less
With or without clinically obvious arthritis: Regional or generalized; Hypertrophic,
rheumatoid, or mixed
With or without x-ray signs of arthritis: Regional or generalized; Hypertrophic,
rheumatoid, or mixed
II. Delayed Post-Traumatic Articular Syndrome
III. Chronic Allergic Syndromes (Pain, Fatigue, or Mental)
IV. Sodium Retention Syndrome
V. Psychogenically Induced, Sustained Hypertonia of Somatic Muscle (With or without other psychogenic syndromes.)
Note: The terms “psychogenic rheumatism” and “psychosomatic rheumatism” (15) (16) (52) (67) (68) (78) (86) (89) (91) (98) (123) (248) are not employed in this classification since it is thought that these terms, as commonly used today, indicate a clinical complex consisting of certain identifiable elements: joint dysfunction, delayed post-traumatic articular syndrome, psychogenically induced, sustained hypertonia of somatic muscle, and, often, the chronic allergic syndromes and the sodium retention syndrome.
The four complicating syndromes may be further classified according to degree of
severity (slight, moderate, severe, and extremely severe); according to duration (short, moderate, or long; with or without short, moderate, or long intervals of freedom from symptoms; with or without short, moderate or long intervals of accentuation of symptoms; with or without a steady state of symptoms).
A method for coordinating the treatment of joint dysfunction and the four commonly
occurring complicating syndromes makes it possible to study and treat these conditions concurrently. Therapeutic strategy must be flexible enough so that it can be modified as necessary in order to attain the desired therapeutic goals. Every effort is made to find and treat any correctable conditions which may coexist with joint dysfunction and the four complicating syndromes.
At the time of the initial clinical study, the patient with joint dysfunction is given that
dosage schedule of niacinamide which is likely to cause satisfactory improvement in his joint dysfunction. When he is re-examined subsequently, the dosage level of
niacinamide may be increased, if necessary, to permit further recovery from joint
dysfunction to continue at a satisfactory rate.
Psychotherapy starts when the patient and physician first meet, and continues during the course of treatment for joint dysfunction, being supportive, preparatory, or
reconstructive, according to the needs of the patient.
If a patient appears to have the delayed post-traumatic articular syndrome, the
development of this pattern of symptoms is carefully explained to him, and he is advised how to modify his physical activities to get relief from this syndrome. The development of this syndrome as a consequence of psychogenically induced, sustained hypertonia of somatic muscle is explained, and appropriate psychotherapy is administered.
The patient is asked to keep a food-symptom diary, which is examined at monthly
intervals. The diary has often been useful in giving clear-cut evidence to the patient of the effects of emotional, allergic, and traumatic conditions on his health. When this diary indicates that the patient’s protein intake is inadequate, he is advised to increase his protein intake. When he seems to have chronic allergic food reactions, the offending foods are identified, and he is asked to eliminate them from his diet. If he seems to have the sodium retention syndrome, he is asked to limit the sodium content of his diet and to increase his water intake, and if necessary enteric coated ammonium chloride tablets may be prescribed.
During the course of treatment of a patient who has joint dysfunction and the four
commonly occurring complicating syndromes, the patient is told how his illness came into being, why it persisted, and how he can recover from his illness. When he
understands the basis of his symptoms, a patient is often able to recognize the cause of symptoms as they occur, and to prevent further recurrences of symptoms. While the patient is not encouraged to deviate from the recommended program of therapy, when deviations occur they serve to instruct both the patient and physician, since they constitute a check on the correctness of the diagnosis and recommended treatment.
Thus, the patient is, in effect, testing in reality the validity of the physician’s analysis of his problems, by prematurely dropping adequate niacinamide therapy, by eating
offending foods, by regressing to a more immature emotional level, by injuring his joints in the performance of excessively strenuous physical activity, or by ingesting excessive amounts of sodium-containing materials. From such deviations from the suggested therapeutic program, the patient often learns by experience that the recommendations made by the physician are not arbitrary, but are necessitated by the nature of his illness, and thereafter the patient is much more likely to cooperate as directed.
Although the desired goal is the solution of the patient’s clinical problems through proper analysis of his illness, and application of corrective therapy, palliative remedies are used when necessary to give the patient relief from his troublesome symptoms.
The patient is always encouraged to live as active and as full a life as is possible,
without subjecting his joints to excessive mechanical injury.
(End of Chapter 3)