Hi- I have been looking for more info for joint pain. This article\website is really interesting if anyone has it. It is the most logical thing I have read on the subject. I have some relief from yucca root, beets juiced, etc. but have been looking for something better.The website is doctoryourself.com
Megavitamin Arthritis Treatment: William Kaufman, M.D., Ph.D.
Joint Dysfunction, Part 1 Home
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. Kaufmanâ€™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 (â€œMethods of Treatmentâ€) 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 authorâ€™s preface, and all references cited, are posted at http://www.doctoryourself.com/kaufman11.html
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© 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 Heberdenâ€™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 â€œIndices.â€ (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 Kaufmanâ€™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 â€œloss 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 “OPTIMALâ€ 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.
â€œOptimalâ€ 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© 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©.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 incr