1DDX: LECTURE 38 – MARCH 7th, 2007

CONDITIONS OF THE MUSCULOSKELELTAL SYSTEM

For exam purposes: be able to differentiate between the different types of arthritis. Focus on differences, what would be
necessary to make diagnosis.

Energetics of health will be incorporated in this lecture.

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Inflammatory arthritides: swelling, inflammation is part of the pathology. Reaction is creating local inflammation.
Other types (with osteoarthritis): inflammation is involved, but it is a result of the pathology.

RHEUMATOID ARTHRITIS
• Don’t know why people get it, not one specific thing that causes it.
• “systemic”: has the ability to affect more organs in the body.
• Often a lot of pain with this condition, this brings patients in, but there is much more going on.
• Bilateral: this is key. Other types of arthritis can present unilaterally.
• Occurs in a lot of different joint at the same time`
• RA: can affect axial joints, but it is primarily peripheral joints: hands
• Deviation of hands due to RA.
• Knees are a big area for RA, but hands are “always” affected.
• More synovium is produced than normal (synovial fluid). Causes inflammation within the synovial capsule which
wears on the tissue.
• With swelling, the synovium because thickened, granulation tissue (pannus). With needle biopsy of joint, can see
pannus. Synovium is solidified from inflammation.
• (OA is abnormal wear and tear on normal tissue, or normal wear and tear on abnormal tissue. This wear and tear
causes inflammation, not the condition itself.)

Etiology
• “Autoimmune”: we start attacking healthy tissue. Others AI conditions: MS, Sjoren’s syndrome. It is when our body
stops recognizing self, and we start breaking down our own body.
• Germ theory: you get persistent infection then inflammation, and then get immune response to self and components
of the joint.
• Cross-reactivity due to molecular mimicry. Get inflammation; bring in antibodies etc., AA structure on bugs looks like
the collagen structures in body (especially joints). Create memory of our own tissue, get reaction.
• Can also get cross-reactivity due to food sensitivity: undigested proteins are going into blood and we are reacting to it:
leaky gut syndrome, low HCl. We are reacting to something that we are taking in on a regular basis.
• RA tends to be progressive: gets worse as you go along.
• Most bugs come and go, don’t get progressively worse. With cross-reactivity, it may be more likely that food is the
cause, not bugs. Something that is coming in and continuously irritating.

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Super antigen theory
• Super-antigen theory: rare T-cells are activated by unusual cross-reaction of Ag to T-cell and APC
• Starts to short-circuit immune system, get uncontrolled reaction, massive attack. Reaction of T-cells to specific joint
tissue (this theory applies to all AI diseases)
• Why do some people get it and others not? Genetic differences, lifestyle differences?
• These antigens may not look exactly like “self” molecules, but close enough to cause reaction.

Etiology
• Genetic component: HLA-DR (Histocompatibility antigen): puts you in favour of having RA. Not everyone with RA
has it, but many do.
• 4X increased chance of getting it if it is in your family. (We can work with patients preventatively)
• Abnormal bowel permeability: we get to work with this a lot
• Correlation with Celiac’s disease: 37% of RA patients have high IgA antibodies to gliadin. Not all Celiac’s have RA, or
vice versa, but there may be a common allergen.
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• Dr. Loken had friend who was diagnosed with RA at 13, told she would be on anti-inflammatories for the rest of her
life. Had to be carried by father. Went to see allergist (skin prick), found she was sensitive to wheat, dairy,
solanaceous foods. Got acute arthritis symptoms whenever she ate these foods, and after a few months of
elimination, symptoms disappeared. (When she went back to her MD and reported this, he said he didn’t want to see
her anymore if she was going to see the allergist…)
• Can avoid foods, but it is best to heal the gut as well so that you can go back to eating these foods again
• Many people will see changes with the elimination diet. Very often have acute, rapid, reactions if they re-introduce
foods.
• Class discussion: Not everyone wants to go on the elimination diet: all NDs put patients on them! Is this the best
treatment? Dr. Loken: Great if we can just change one simple thing to make them better.
• Allergy testing: skin prick just tests IgE. Many food sensitivities are IgG or IgA, and won’t show up with skin-prick
testing. If you test IgE and IgG (this can be done in the clinic. Cost=$200 US), you will get a relatively good picture,
but still not complete. Can see the highest ones with a skin prick, but you still can’t rule out food allergies.
• Do this test at the beginning of your treatment before you start changing anything.
• Another option: muscle testing, Vega testing… practitioner bias? Is this an accurate measure? Often get HUGE lists of
things to eliminate. Elimination diet looks at severity of reaction, and just focuses on these foods.
• Can’t expect to see good results from treatment if they are highly sensitive to something that they are ingesting every
day.

• Abnormal antibodies and immune complexes: lead to inflammation. Ag:Ab complexes that create chronic
inflammation.
• How would we get rid of these depositions? Proteolytic enzymes: take them away from food because they will act
upon the food you are ingesting.

• Gradual onset: get flu-like symptoms to start.

• Sex differences even out after age 50. Does estrogen have an effect on the development of the disease?
• Obesity: get more aromatase: convert more testosterone to estrogen.

• Does not affect the distal-interphalangeal joints!!! (DIP joints) Most often affects hands and feet.
• Note: changes to the DIP described here are the result of erosion of the PIP that impacts the tendon, and this
hyperflexes or hyperextends the DIP (without eroding it directly.)

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• 20-30% of RA population will get rheumatoid nodules. On extensor surfaces.
• May not be able to reverse damage with treatments, but can prevent progression.
• Diagnosis: know this well. Have to have 4 of 7 criteria for at least 6 weeks.

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• Rheumatoid factor: not completely diagnostic. In 80% of RA patients, but in up to 20% of patients over 65 w/o RA
• Can have mild anemia: If they have malabsorption, Iron oxidase: used in immune reaction, therefore there is not
enough available for RBC manufacturing (impaired iron metabolism). EPO levels are lowered. They may be taking
NSAIDs and may have a GI bleed  blood loss. Make sure that if they are taking NSAIDs that they don’t have a
bleed/ulcer
• ESR: really easy to do in your clinic. Can see if inflammation is present. Not very specific, but is good at telling you if
it is there. Can also be rechecked through treatment to see change, are you moving in the right direction with your tx?
• C-reactive protein, more specific.
• Joint fluid: want to see how much of a mucin clot is formed. If little clot is formed, could be due to damage within the
joint (hyaluronic acid)

Prognosis
• Once they get it, will have significant symptoms within 1-2 years.
• Start working with them early: decrease potential destruction.

Naturopathic perspective:
• Multi-factorial condition: many things may have triggered it to begin with. Work on as many on this list as possible.
What was going on for them when they started feeling different?
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• See that there is an additive effect of stressors in their life: maybe they don’t react to certain foods unless they are
under stress.
• Want to work on as many factors as we can. Permeability of gut, circulating immune complexes, free-radicals…
• Free radicals: can do an “oxy-data” test. $15. Malondialdehyde: common excretion product of many free-radicals.
Can check this in urine or in blood ($50). Patients like to see tests, especially when things change.
• Look at ratio between free radicals and anti-oxidants. Problem if person doesn’t have enough anti-oxidant agents to
deal with free radicals.
• Foods have changed over years (less anti-oxidant content), toxic load is greater.
• Sauna detox: one of the best things you can do.
• Immune dysfunction: over-response to things that we shouldn’t be reacting to. Exaggerated Ab-mediated response.
• What are some ways that we can modulate the immune system? Probiotics and botanicals.
• Moducare: did original studies on plant sterols. Used to bring down cholesterol, but away from food, they are really
good at reducing inflammation. Make reaction switch from Ab-mediated to cell-mediated.
• Reduce inflammation: fish oils (best long-term one), probiotics, proteolytic enzymes. Tumeric, ginger (so easy! Take
about 1cm of ginger for anti-inflammatory effect)

Leaky Gut cycle

• Continuous cycle, need to cut out things that irritate gut lining. Break inflammatory cycle.

Dietary treatment
• This is a western disease: we eat lots of refined foods, saturated fats. Don’t see it much outside of NA
• Shopping advice: stick to perimeter of grocery store: the refined, processed foods are in the middle aisles.
• Look at diet goals: this would improve most pathologies that are out there.
• Most people know what they need to do, just need to motivate them to stick with it.

Botanical medicine
• Prednisone: burns out adrenals after long-term use. Cortisol is anti-inflammatory. Prednisone is a cortisol derivative.
Adrenal gland stops producing it on its own. Women on Prednisone for a long time may start to develop osteoporosis.
• May see patients that have just come off it, will feel worse than ever (pain). Increases blood sugar too: diabetics can’t
stay on it for long.
• Have to work with these patients to get their adrenals working again. Look at herbs in notes.
• Can check cortisol levels if you are concerned.
• Phytosterols

Hydrotherapy
• Balneoptherapy is bathing therapy. Peat therapy: has a lot of sulphur and wintergreen. WG contains salicylic acid.
Decreases inflammation, makes people feel better! (good when they are NOT in an acute flare-up.)
• Paraffin wax treatment: dip hands in hot wax. Deep moist heat into area.
• Get people moving within their comfort zone.

Energetics of Musculoskeletal system

• Will see people in practice that “don’t make sense medically”. Holistic approach to medicine required. Look at
mental/emotional/spiritual level as well as physical.
• Body mimics what is happening in our lives.
• Don’t see this in every patient, but if you see people not getting results, look at other possibilities. Can make
significant impacts on people. Help people to make shifts and change the way they live.
• Listen to the way that people explain their symptoms: Let them explain in their own words.
• Where in their life are they using the same words that they use to describe their symptoms? (I can’t move, I feel
stuck…)
• Not easy to get people to think like this. Need rapport, not on first visit.

• Musculoskeletal system: moving forward. Volition, movement. People feel like they are stuck, something not allowing
them to move forwards.
• Disorder of the joints that has to do with “the space to move”.
• Core: relationship with themselves, core issues, self-esteem. (OA)
• Peripheral: their relationship with the outside world. Don’t like where they are living, aren’t happy in their relationship,
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 their work, external things. (RA)

Where do the issues reside?

• Bone: represents Earth. Stability: one of the bigger one. Finances, relationships, work (ties into both finances,
relationship). Idea of a lack of control. (nothing in the Synthesis about this?)
• We always have 3 choices in life: you can leave the situation, change the situation or change their reaction to the
situations. You always have options.
• Give situation back to patient and ask them to give you the solution. Can’t fix everyone! Are they doing the work?

• Muscles: relating to Fire.

• Liver pathologies: LV exits into muscle tissue. Paired with GB; influential point of muscle and sinews: GB 34.
• Problem with the impulse to move. They may have the SPACE to move, but lack the motivation to move forward.

• Joints: represents Ether (Ayurveda)

• “I don’t have any room to move”…
• Homeopathically: many RA patients under bird remedies category. Caged in.

• We can help people find balance in their lives! Things start to improve in their life once this happens. Shifts create
change in all aspects of their life.

• RA tends to be peripheral, inflammatory.

• Hands=give and take. Pathology primarily involving hands? Problem with letting go, or giving. Some people very
good at giving, but can’t receive. Have guilt in receiving.
• PIP joints: the fingers all represent different things.
• Inflammation is more Yin. Exceptional inflammation? Yin issues are around nuturing, creativity. Yin imbalances: often
around nurturing: not nurturing other? *Not nurturing ourselves! Getting people to address this will help pathology.
• Yin deficient: water should quench inflammation, but deficient heat pattern may present.

• Questions to ask patients:

• What does it prevent you from doing? Get an idea of where they feel limited. What do they want to do?
• Other questions: tell you about Yin and Yang. Are there excess or deficiency issues?
• A lot of people haven’t stopped to think what they would LIKE to do.
• Have to look at everything: the mental/emotional may not be the only answer either. Look at the whole picture!

Disease Occur- Age Gender Other info Diagnosis: Presentation

ence
Rheumatoid 5/1000 35-45 Female Sex Need 4 of 7 criteria for Symmetric, rarely affects
arthritis adults years 3: Male 1 difference 6 weeks (min) DIP joints. Most often
less • Morning stiffness hands and feet
pronounced >1hr (peripheral). Z-deformity,
after age 50. • Arthritis in 3+joints swan-neck deformity,
w/ swelling boutonniere deformity.
• Arthritis of hand Rheumatoid nodules on
joints with swelling extensor surfaces.
• Symmetric arthritis
• Rheum. nodules
• Rheum. factor
• Changes in x-rays

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