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SUMMARY:
How to Treat Arthritis with Niacinamide (Vitamin B-3) |
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Arthritis Treatment |
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THE
COMMON FORM OF JOINT DYSFUNCTION METHOD OF TREATMENT OF
JOINT DYSFUNCTION (pages 20-29) After completion of his
physical examination, the patient was apprised of the normal and abnormal
findings revealed by the clinical study. Where problems other than joint
dysfunction existed, these were discussed, and appropriate therapeutic
recommendations were made. The subject of joint dysfunction was then
presented. The meaning of the numerical value of the patient's Joint Range
Index was explained to him in terms of the Clinical Classification of Joint
Function (see page 21), and the dynamic nature of joint dysfunction was
described. The patient was told that joint dysfunction was reversible in time
when appropriate therapy was taken. All patients with joint
dysfunction who elected to accept treatment were given niacinamide in
suitable doses, either alone or in combination with other vitamins. When
indicated the appropriate vitamins were prescribed in addition to
niacinamide. The water-soluble vitamins used were never prescribed in aqueous
solution, but as tablets or as dry powders in capsule form. When vitamin A
was used, it was usually given in conjunction with vitamin D. Vitamin D was
always given in conjunction with vitamin A; when vitamin D was administered
in this study, the daily dosage rarely exceeded 6,000 U.S.P.units per 24
hours (14) (10) (38) (56) (59) (95). Participation in the
therapeutic program was entirely voluntary on the part of the patient. Some
patients at the outset declined to accept treatment for their joint
dysfunction. When a patient accepted therapy for his joint dysfunction, with
each succeeding visit after the initial one, improvement or lack of
improvement in his joint dysfunction was frankly discussed with him. No
patient was chided because he was unwilling or unable to carry out the
program of therapy as it was originally scheduled. Thus, because there was no
“loss of face," most patients cooperated well and gave an accurate
account of their deviations, if any, from the suggested therapeutic program.
Some patients at the end of the first or second month of treatment, or at a
later time, felt so much improved physically that they discontinued therapy
for their joint dysfunction, mistakenly believing, in spite of advice to the
contrary, that they were "cured," and required no further therapy
or medical supervision. Some of these persons, who experienced a recurrence
of their original pattern of symptoms upon premature cessation of therapy,
returned subsequently for re-evaluation of their therapeutic needs. Other
patients, who felt that they had not benefited from therapy for their joint
dysfunction, did not continue with treatment though objectively they
responded satisfactorily to adequate therapy, as shown by increasing values
of the Joint Range Index on serial re-measurements. Therapy was always
individualized. In the therapeutic program introduced for the treatment of
joint dysfunction, each patient served as his test object in the bio-assay of
the dosage of niacinamide necessary to reverse his joint dysfunction. Therapy
with niacinamide (used 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
No joint
dysfunction
96-100 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 the therapeutic
results achieved; e.g., 300 mg niacinamide given three times daily (900 mg/24
hours) is inferior in its therapeutic action to 150 mg niacinamide
administered every 3 hours for 6 daily doses (900 mg/24 hours). Therefore, to define the type of
therapy used, the writer routinely records the following data: (a) the number
of milligrams or units administered per dose, and (b) the total number of
milligrams or units administered per 24 hours. No untoward effects or
clinical signs of toxicity were noted when niacinamide (alone or in
combination with other vitamins) was administered on the above dosage
schedules to individuals for short or long periods of observation. Before
1943, mild hypoglycemia had been noted clinically in a few persons when
niacinamide exceeded certain dosage levels (97) (135) (51) (62), but this
phenomenon has not been observed since that time. "ADEQUATE" AND
"OPTIMAL” DOSAGE LEVELS OF NIACINAMIDE IN THE TREATMENT OF JOINT
DYSFUNCTION "Adequate"
dosage of niacinamide is defined as that clinically safe dosage of
niacinamide which, when ingested in divided doses throughout the day by a
person with joint dysfunction whose ordinary diet is not inadequate in
protein or calories, and whose joints are not subjected to excessive
mechanical joint injury, will effect in time what the writer has considered
to be a satisfactory pattern of increasing values of the Joint Range Index.
The pattern of recovery from joint dysfunction in response to niacinamide
therapy, and the numerical limits of increments in the value of the Joint
Range Index which are considered to be satisfactory for the first month of
therapy and for succeeding months, are described on page 24. “Optimal” dosage of
niacinamide is defined as that clinically safe dosage niacinamide which, when
ingested in divided doses during the day by a person with joint dysfunction,
would permit the most rapid recovery in joint function, as demonstrated by
the largest possible increments in the values of the Joint Range Index in the
shortest possible period of time. At present, the optimal dosage of
niacinamide for the treatment of joint dysfunction has not been determined
clinically, although it is hoped to approximate such a dosage level
eventually. Since adequate dosages of niacinamide have given clinically
satisfactory results without producing any untoward symptoms or signs of acute
or chronic toxicity, no attempt has been made in this study to determine
the optimal level of niacinamide therapy in the treatment of the various
clinical grades of joint dysfunction. However, as
the higher dosage levels of niacinamide have been cautiously explored in the
past 22 months, it has been found in severe and extremely severe joint
dysfunction that divided doses of niacinamide totaling 4 or 5 grams
(4,000-5,000 mg) per 24 hours are therapeutically superior to the lower
dosage schedules which previously had been considered adequate. Even
these higher dosage levels of niacinamide may not be optimal for the
treatment of joint dysfunction. The optimal dosage of
niacinamide for the treatment of joint dysfunction, as well as the limit of
human tolerance for niacinamide, can be established only in those medical
centers equipped to provide careful clinical supervision, and to conduct such
chemical, metabolic and clinical laboratory studies as would reveal the
earliest signs of toxicity, should these occur with the administration of
progressively higher dosage levels of niacinamide. DESCRIPTION OF JOINT
DYSFUNCTION AND ITS TREATMENT FOR THE PATIENT Since the
cooperation of the patient is a prerequisite for the successful therapy of
joint dysfunction, it was found desirable and necessary before treatment of
joint dysfunction was instituted to discuss with the patient his various
clinical problems (including the dynamic nature of joint dysfunction, and its
response to niacinamide treatment, and the dynamic nature of certain
complicating syndromes, and their appropriate treatment), and the therapeutic
goals. During the course of therapy, it may become necessary to review and
amplify this discussion for the benefit of the patient as various clinical
problems arise. Joint dysfunction
is the articular aspect of a generalized, usually slowly progressive
metabolic disorder which is corrected in time by adequate niacinamide
therapy. Since the retrograde changes in tissue structure and function which
characterize this disorder occur insidiously over a period of years, many of
its symptoms and signs are incorrectly attributed by laymen and physicians
alike to the so-called "normal" aging process. But 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 niacinamide
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 toadequate
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 niacinamide 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 aniacinamidosis. 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
prescribed until such time as the supervising physician may decide, on the
basis of objective clinical evidence, that it is necessary to increase the
level of niacinamide therapy in order to produce continuously satisfactory
improvement in the Joint Range Index. However,
certain factors other than the ingestion of inadequate amounts of niacinamide
may tend to depress the Joint Range Index. These include (a) transient or
persistent mechanical joint injury resulting from unusual or physical
exertion (see page 79) or from psychogenically sustained hypertonia of
somatic muscle (see page 115), (b) rapid and excessive gain in weight to
obesity levels, (c) excessive ingestion of alcohol, (d) inadequate dietary
protein. When any of these factors is operative, it is of limited value to
increase the amounts of niacinamide taken by the patient in an effort to
effect satisfactory improvement in the Joint Range Index. Instead,
treatment should be directed toward lessening the degree of mechanical joint
injury, reducing the patient's weight to the normal range, interdicting
alcohol, and increasing the protein intake to adequate levels, respectively. When
indicated, the physician describes for the patient four complicating
syndromes frequently coexisting with joint dysfunction, and their treatment
(see page 76). Most of the articular and non-articular symptoms of a patient
with joint dysfunction which are not corrected by niacininide therapy usually
originate as part of these four complicating syndromes. When the patient
understands the etiologic basis of his symptoms, he will not have anxiety concerning
the meaning of symptoms which would otherwise seem mysterious and alarming.
The patient with joint dysfunction who has one or more of these complicating
syndromes is told that he will not feel well unless joint dysfunction and
these coexisting syndromes are correctly identified and successfully treated,
and that in order to accomplish this, his active participation in the
clinical investigation and therapeutic program is required. TYPICAL IMPROVEMENT IN
MOBILITY OF A SINGIE JOINT IN RESPONSE TO LEVELS OF NIACINAMIDE THERAPY USED
PRIOR TO APRIL 1947 In serial determinations
of the mobility of single joints in response to levels of niacinamide therapy
used prior to April 1947, it was found that niacinamide-induced recovery of
full joint mobility was an orderly process. (Since April 1947, when higher
dosage schedules of niacinamide were introduced (see page 21), there has been
a marked reduction in the incidence of articular pain and discomfort upon
maximal passive movement of the moveable joints during various stages of
recovery from joint dysfunction.) There is
described below typical improvement in joint mobility, as illustrated by
several sequential stages occurring during niacinamide-induced recovery of
full mobility of the metacarpophalangeal (knuckle) joint. (Figure 14 is a
schematic representation of maximal passive extension of the
meta-carpophalangeal joint at four successive stages (a) (b) (c) (d), during
the course of niacinamide-induced recovery of full joint mobility. The line
touched by the head of the arrow in (a) (b) (c) (d) indicates the upper limit
of painless extension. The shaded angle in (b) and (c) indicates the range of
painful passive extension.) Figure 14(a). On
the initial examination before niacinamide therapy was instituted, the
metacarpophalangeal joint of the forefinger of the right hand could be
extended passively to 30% of the full range of extension for this joint. No
pain or discomfort was experienced by the patient during this maneuver. The
examiner noted the presence of palpatory resistance from the initiation of
the movement of passive extension of this metacarpophalangeal joint, and this
resistance progressively increased as the joint was extended from the range
of 0% to 30% of the maximal extension; the palpatory resistance at the end of
the movement was graded as firm. When at the 30% level of passive extension a
small increase of force in the direction of extension caused no further
extension of this joint, 30% of the full range of extension was taken as the
upper limit of maximum passive extension of this metacarpophalangeal joint. Figure 14 (b). At
the end of one month of continuous, adequate niacinamide therapy, maximal
passive extension of this metacarpophalangeal joint increased to 60% of the
full range of extension. No pain or discomfort was experienced by the patient
when the metacarpophalangeal joint was extended from 0% to 40% of the full
range of extension. The patient experienced localized joint pain, often
severe, as the joint was passively extended from 40% to 60% of the full range
of extension. The examiner's palpatory sensation indicated that movement of
the joint in passive extension was free from 0% to 40%, and that there was
soft, yielding resistance which progressively increased as the finger was
extended at the metacarpophalangeal joint from 40% to 60% of the full range
of movement. When a further small increase of the extending force did not
increase the degree of extension, 60% of the full range of extension was
taken as the upper limit of passive extension of this metacarpophalangeal
joint. The palpatory resistance at the end of the movement of extension was
rubbery. Figure 14
(c).After months of continuous, adequate therapy with niacinamide, maximal
passive extension of the metacarpophalangeal joint reached 100%; i.e., the
full range of movement. Passive extension of the metacarpophalangeal joint
from 0% to 85% was without pain or discomfort; passive extension from 85% to
100% was painful. The examiner's palpatory sensation indicated that the
movement of this joint was free from 0% to 85%, and that there was soft
resistance, which increased progressively with increasing extension of the
metacarpophalangeal joint from the level of 85% to 100%. A small additional
force in the direction of extension when the 100% level was reached did not
cause further extension of this joint. The palpatory resistance at the end of
the full range of movement (100%) was rubbery. Figure 14(d). With a longer period of continuous, adequate niacinamide therapy, it was possible to achieve full, free and painless extension of this metacarpophalangeal joint to the level of 100%. Slight additional palpatory force in the direction of extension with the joint fully extended did not increase the amount of movement beyond the full range of extension; i.e., the 100% level. The examiner's palpatory sensation indicated that the movement of extension was free from 0% to 100% of full extension, that the resistance met at the end of this movement was firm, and that the patient experienced no pain from this maneuver.
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