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CHAPTER I
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. Kaufman’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 (“Methods of Treatment”) and read that first. If you are looking for the doctor's comments relevant to ADHD, scroll to nearly the end of the page and they can be found in boldface type. 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.)
The author’s
preface, and all references cited, are posted at http://www.doctoryourself.com/kaufman11.html
INTRODUCTION
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 (c) 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
Heberden’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 “Indices.”
(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 Kaufman’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 “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 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
"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 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 (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.
It would appear from
clinical observations that, in the absence of joint trauma, there is
an orderly and sequential
pattern of recovery of joint mobility in a patient with joint
dysfunction in response to
continuous, adequate niacinamide therapy provided that the
patient's diet is not
inadequate in protein Or calories. Serial re-examinations of joint
ranges during the course of
continuous, prolonged, adequate niacinamide therapy
reveal that with the passage
of time, there are the following changes:
(a) progressive increases
in ranges of joint movement;
(b) progressive shifting
of painful zones of joint movement toward the periphery of the
most recently acquired zones
of increased ranges of joint movement, until, ultimately,
after the fullest range of
movement for the joint has been achieved, there is absence of
pain on the execution of the
fullest movement possible for the joint in the specified
range; and,
(c) progressive shifting
of zones of resistance to passive movement toward the
periphery of the most
recently acquired zones of increased ranges of joint movement
until, ultimately, after the
fullest range of movement for the joint has been achieved,
there is no resistance to
passive movement on the execution of the fullest range of
movement possible for the
joint in the specified range of movement.
These dynamic changes in
joint mobility occurring during the course of treatment
suggest that sequential
alterations in joint morphology must occur in response to
continuous, adequate
niacinamide therapy to permit the observed changes in joint
mobility described above.
With cessation of
adequate niacinamide therapy, the therapeutically-improved joint
mobilities cannot be
maintained for any prolonged period of time.
SELECTED CASE HISTORIES
ILLUSTRATING THE THERAPEUTIC RESPONSE
OF JOINT DYSFUNCTION TO
NIACINAMIDE ALONE OR IN COMBINATION WITH
OTHER VITAMINS
This section presents
selected case histories which illustrate and emphasize the
dynamic nature of joint
dysfunction, with and without clinically obvious arthritis, as
demonstrated by changing
values of the Joint Range Index over a period of time in
response to various levels
of niacinamide ingestion. Twenty case histories, abbreviated
in various degrees, are
presented, together with a figure for each case which
summarizes both the response
of the Joint Range Index to the type of vitamin therapy
employed, and the amounts of
the vitamin(s) administered per 24 hours. A few figures
summarize additionally the
changes observed in the Sedimentation Rate during
therapy.
Cases A through K have
been chosen to demonstrate the effect on joint dysfunction of
(a) adequate therapy with
niacinamide, (b) reduction of niacinamide from adequate to
inadequate levels, and (c)
premature discontinuance of niacinamide therapy.
Cases L through T show the
effects on joint dysfuntion of adequate and for the
inadequate therapy with
niacinamide administered in combination with of the
other vitamins. Whenever
adequate doses of niacinamide are given in combination with
other vitamins to persons
with joint dysfunction, improvement in joint function, as
indicated by rising values
of the Joint Range Index, is of the same order as would be
anticipated if niacinamide
in the amounts present in the vitamin mixture were the sole
therapeutic agent. It will
be demonstrated by these case histories that joint dysfunction
(with or without clinically
obvious arthritis) is ameliorated in time by adequate therapy
with niacinamide (alone or
in combination with other vitamins). This is true regardless of
age, sex, occupation,
geographic origin, economic level, or associated diseases.
Whenever adequate therapy
with niacinamide is replaced by inadequate therapy or by
premature cessation of
adequate niacinamide therapy, there is a worsening of joint
function which in time is
reflected by decreasing values of the Joint Range Index.
Whenever inadequate
therapy with niacinamide is replaced by adequate therapy with
niacinamide, joint function
again improves, as measured by increasing values of the
Joint Range Index. In
general, the expectancy is that, with adequate niacinamide
therapy for a sufficiently
long period of time, the patient's joint function will improve
continuously so that
ultimately the Joint Range Index will measure between 96 and 100
(no joint dysfunction) and
will be maintained at this level for as long as the amount of
niacinamide ingested by the
patient continues to be adequate for his bodily needs. In
the absence of severe
mechanical joint injury, when the diet of the patient is not
inadequate in protein or
calories, two stages are observed in the recovery of joint
dysfunction in response to
adequate niacinamide therapy. First, there is the initial large
increase in the Joint Range
Index of at least 12 units which occurs in a month or less.
(At the end of one week of
continuous adequate therapy with niacinamide alone or in
combination with other
vitamins, those few persons whose Joint Range Indices were
determined at this interval
had an increase in the Joint Range Index which was of the
same order as that usually
observed at the end of one month of therapy.)
This rapid initial
improvement in the Joint Range Index is, in all probability, largely
the
result of the resolution of
tissue edema in response to adequate niacinamide therapy
(97) (189). Associated with
this rise in the Joint Range Index, the patient often has
marked subjective
improvement in feeling tone. The next stage of recovery from joint
dysfunction is slow, with a
gradual increase in the Joint Range Index of at least 0.5 to
1.0 unit per month. Recovery
from joint dysfunction in response to treatment with
niacinamide is considered to
be clinically satisfactory, and the dosage of niacinamide is
considered to be adequate,
when the Joint Range Index increases at the end of the first
month and thereafter within
the limits of recovery for these time intervals as defined
above. A lesser rate of
recovery in joint dysfunction in response to niacinamide therapy
is judged to be
unsatisfactory, and the niacinamide dosage schedule is then increased
to a level which will permit
recovery from joint dysfunction at a satisfactory rate
(provided that the patient
is not subsisting on a low-protein diet).
Since there are wide
individual variations in the need for niacinamide, the physician
must determine empirically
for each patient that level of niacinamide therapy which will
produce satisfactory
improvement in joint dysfunction. On the whole, the suggested
dosage schedules (see page
22) will cause satisfactory improvement in joint
dysfunction. However, on any
of these dosage schedules, at any time there may be
stabilization of the Joint
Range Index until the dosage level of niacinamide is suitably in-
creased, whereupon the Joint
Range Index will rise again in a satisfactory manner. In
order for the patient to
make the best possible progress in recovery from joint
dysfunction, periodic
re-examinations must be performed by the physician so that the
niacinamide dosage schedule
may be adjusted as necessary to ensure serially rising
values of the Joint Range
Index until the level of 96-100 (no joint dysfunction) is
reached, and subsequently,
to maintain the patient at this level.
In recovering from joint
dysfunction, especially of a severe grade, a patient is likely to be
less impressed by the
physician's Opinion that satisfactory improvement has been
made in response to adequate
niacinamide therapy, than by his own sudden realization
that he is again able to use
his body in ways that were impossible for a long time before
the institution of
niacinamide therapy; e.g., he is able to turn his head enough to enable
him to park his car without
difficulty; he can go up and down stairs with ease; after
sitting in a movie theatre
for hours, he does not experience prolonged stiffness and
discomfort upon arising from
his seat; he can trim his toenails without difficulty.
The selected case
histories presented below demonstrate the usefulness of the routine
determination of the Joint
Range Index in evaluating the severity of the patient's joint
dysfunction, in following
his response to niacinamide therapy, and in regulating dosage
levels of niacinamide during
the course of treatment. However, in most instances, if the
patient who is recovering
from joint dysfunction is to feel well, it is also necessary to
evaluate whatever additional
coexisting clinical problems he may have, and to institute
whatever therapeutic measures
may be indicated. In subsequent sections, certain
complicating syndromes will
be described, which may cause arthralgia as well as other
articular and non-articular
symptoms, often complicating the treatment of joint
dysfunction.
CASE A. No.309, female,
age 26, housewife, married.
This case history
illustrates, in a woman with clinically obvious rheumatoid arthritis,
(a)
improvement in joint
function as measured by increasing values of the Joint Range
Index in response to
adequate niacinamide therapy, (b) impairment in joint function as
measured by a lowered Joint
Range Index as a result of substitution of inadequate for
adequate therapy, and brief
cessation of therapy, and (c) subsequent improvement in
joint function as measured
by an increased Joint Range Index in response to the re-
introduction of more
adequate niacinamide therapy. (These results are summarized in
Figure 15.)
When she was 16 years
old, she was hospitalized for special study of her joint disorder,
and was informed upon
completion of this clinical investigation that she had arthritis.
Her bone and joint symptoms
were not ameliorated by the therapeutic program which
was then recommended, and,
indeed, became progressively worse, especially since her
marriage at the age of 20,
when she first started to do housework. The amount of her
housework was considerably
increased in volume after her two children were born.
Her presenting complaints
include marked limitation of motion and pain (both at rest and
on the initiation of joint
movement) in the hip joints, knees, low back, neck, and fingers.
She states that these joint
symptoms are becoming progressively more severe, and are
worsened by changes in
weather and by any form of physical activity, including her
housework. Although she has
worn many different types of shoes, her feet have never
been comfortable. She is
irritable and tired, and frequently awakens during the night
because of joint discomfort
and muscular aching. Often she awakens in the morning
feeling more tired than she
did when she went to bed the night before.
Physical Examination:
B.P. 130/80. P. 84. R. 18. T. 99.4 degrees. Wt. 135 lbs. Ht. 65 ½
inches. She seems tired, and
looks older than her stated age. She moves slowly, as if
guarding against rapid
movements of her joints which might give her increased pain.
Her posture is poor. Slight
dorsal kyphosis and slight pelvic tilt are evident upon
inspection. Her proximal
interphalangeal joints of the fingers of both hands are
thickened and swollen. Her
skin is yellow, dry, slightly inelastic, and has a prominent
reticular pattern. She has
severe tenderness on moderate digital pressure over the
maxillary and frontal
sinuses, over the chondral ribs, the lower third of the sternum and
chondrosternal junctions,
the right trochanter, the lowermost third of the tibias bilaterally,
the third, fourth and fifth
cervical vertebrae and the lumbar vertebrae.
The liver edge is at the
level of the costal margin in the right mid-clavicular line at the
end of deep inspiration, and
is tender to palpation. Her tongue shows hyperemia of the
anterior third and atrophy
of papillae. Her teeth are in good repair, although the gums
are slightly retracted,
infiltrated and swollen. Her conjunctivae are slightly thickened,
and show some increased
vascularity. Tickle sense is absent everywhere. She has
hypopallesthesia. Her
initial Joint Range Index (65.6) indicates severe joint dysfunction.
She was given 100 mg of
niacinamide to take every 3 hours for 6 daily doses (600
mg/24 hours) and in one
month there was improvement in her Joint Range Index and in
her general health. She
appeared less tired. She stated that she had experienced less
pain, stiffness and
limitation of movement since treatment with niacinamide had been
instituted. Her color had
improved, and her skin appeared less yellow. Her liver was not
tender to palpation. The
tenderness on digital pressure over the bony prominences,
which was so marked on the
previous examination, had practically disappeared. Tickle
sense was present. She had
recovered normal vibratory sensation. However, since the
rate of recovery of her
lingual mucous membrane in response to therapy with
niacinamide was considered
to be somewhat slow, the dosage of niacinamide was
increased to 100 mg. every 1
½ hours for 9 daily doses (900 mg/24 hours). She took
this amount of niacinamide
daily for about 300 days, and showed subjectively and ob-
jectively continuous and
progressive improvement. The numerical value of her Joint
Range Index rose
from 65.6 to 90.2 in 300 days. Thus, according to the Clinical
Classification of Joint
Function, she had progressed from severe joint dysfunction to
slight joint dysfunction.
Since she had shown an
excellent response to therapy, she was asked to return for her
next re-examination in six
months, at which time her Joint Range Index had fallen to
78.2, with a concomitant return
of many of her presenting symptoms. Upon inquiry, the
following facts were
elicited:
Shortly after her last
visit, she knew that she was feeling better than she had ever felt in
her life and thought,
therefore, that she was "cured." She gradually decreased her
niacinamide intake, and
finally, for three weeks before her examination, took none.
As a result of her
self-prescribed change in the therapeutic program, she had regressed
clinically in all respects.
Clinically, her joint dysfunction regressed from slight (90.2) to
moderate (78.2). A new
dosage schedule of niacinamide was prescribed (150 mg every
3 hours for 6 daily doses,
or 900 mg/24 hours), which she took faithfully.
When therapy with
niacinamide was thus re-introduced, her Joint Range Index was
78.2. In 84 days it rose to
86.4, and in 184 days to 91.2. Thus, she had again
progressed from moderate to
slight joint dysfunction. Her symptoms referable to bones
and joints disappeared, and
there has been progressive resolution of her abnormal
physical signs.
Since she has gained some
insight into the dynamic nature of her joint dysfunction, it
appears likely that this
patient will continue with her therapy as directed. It is anticipated
that with continuously
adequate niacinamide therapy she will in time achieve a Joint
Range Index of 96-100 (no
joint dysfunction).
CASE B. No.147, female,
age 61, housewife, married.
This case history
illustrates, in a woman with severe hypertrophic arthritis, (a)
improvement in joint
function, as measured by an increased Joint Range Index in
response to a given dosage
of niacinamide, (b) slight impairment in joint function as
measured by a lowered Joint
Range Index resulting from a small decrease in the
niacinamide dosage from the
previous level, and (c) an accelerated improvement in the
Joint Range Index as a
result of two successive increases in the niacinamide level (see
Figure 16).
She has had joint
discomfort for many years, and moderate deformities of the fingers for
at least 10 years. Six to
seven years ago she first noticed severe pain in her hip joints.
Her knees are very stiff.
All her life she has had curvature of the spine, and has had a
good deal of pain in the
back. Recently she has had increased fatigability and insomnia.
Physical Examination: She
looks older than her stated age. B.P. 140/80. Wt. 159 ½ lbs.
Ht. 65 inches. She has
tenderness on digital pressure over the sternum, medial
epicondyles, iliac crest,
trochanter, styloid process of the radius, sacroiliac joints.
Marked kyphoscoliosis is
noted. Her tongue shows evidences of infiltration and atrophy
of papillae. The edge of the
liver, which is one finger's breadth below the rib margin in
the right mid-clavicular
line on deep inspiration, is tender to palpation. Bony
prominences of the lower
extremities are hyperpallesthetic to the tuning fork. Tickle
sense is absent. Plantar
dysesthesia is present.
This patient had severe
joint dysfunction, as measured by her Joint Range Index of
68.2. She was asked to take
100 mg. of niacinamide every 1½ hours. In a month, she
had experienced marked
improvement in her Joint Range Index, and considerable
subjective relief from joint
discomfort. The plantar dysesthesia was no longer present.
Liver enlargement had
diminished markedly (liver tenderness and enlargement
disappeared after a longer
period of therapy). Hyperpallesthesia of the lower extremities
was replaced by a normal
vibratory sensation. Tongue showed the improvement
expected with one month of
niacinamide therapy. She looked younger than on her initial
visit. She had no further
difficulty with fatigability or insomnia.
She continued to make
good progress clinically for over 300 days, when she reduced
her niacinamide intake from
1200 mg/24 hours as originally prescribed, to 1000 mg./24
hours in divided doses of
100 mg. per dose. With this self-administered reduction in
niacinamide dosage, her
Joint Range Index decreased from 85.5 to 84.9.
The level of niacinamide
was increased to 150 mg. every 1 ½ hours (1500 mg/24
hours) with an increase in
her Joint Range Index from 84.9 to 90.1 in 267 days. The
niacinamide dosage was then
increased to 200 mg. every 1½ hours (2000 mg./24
hours) with an increase in
the Joint Range Index from 90.1 to 92.8 in 58 days.
Thus, in a period of
almost two years, this patient's Joint Range Index rose from 68.2
(severe joint dysfunction)
to 92.8 (slight joint dysfunction). It is anticipated that with
continuously adequate
niacinamide therapy, she will in time achieve a Joint Range
Index of 96-100 (no joint
dysfunction).
CASE C. No.325, female,
age 63, housewife, married.
This case history
illustrates, in a woman with moderate hypertrophic arthritis,
continuous
improvement in joint
function, as measured by increasing values of the Joint Range
Index in response to
adequate niacinamide therapy (Figure 17 summarizes this case).
For more than 10 years,
she has had "chronic rheumatism," as well as many episodes
of "acute
rheumatism" characterized by painful transient swellings of her hands,
wrists,
knees and ankles. Her
present complaints include generalized stiffness of joints (severe
for an hour after she
awakens in the morning) and accentuation of muscular, periosteal
and articular discomfort
with weather changes. While her wrists, shoulders and fingers
have been painful and
swollen "off and on," her knees have given her the greatest,
most
persistent discomfort. In
the past year her knees have become so painful that she has
had many sleepless nights.
Physical Examination:
B.P. 170/80. Wt. 180 lbs. Ht. 61 ¾ inches. She is moderately
obese, tired-looking,
hyperkinetic. Her skin is relatively inelastic, has increased
brownish pigmentation, and
the normal reticular pattern is accentuated. The
conjunctivae show thickening
and increased vascularity. She has some circumcorneal
injection. Her teeth are in
good repair. The gingival membrane is thickened and
retracted, but there is no
evidence of gingival infection. Her tongue shows marked
atrophy and infiltration of
lingual papillae. Her Joint Range Index of 65.8 indicates
severe joint dysfunction.
She has a moderate upper dorsal kyphosis. Her wrists, fingers
and knees are swollen. No
objective signs of impaired nerve function are elicited. Her
Sedimentation Rate Index is
0.4 mm/min. (Wintrobe-normal range 0.1 - 0.3 mm/min.).
Hemoglobin 11.8 g./100 cc.
(acid hematin photo-electric colorimeter). An x-ray of her
knees taken immediately before
therapy was instituted showed evidence of a
hypertrophic type of
osteoarthritis.
Niacinamide (150 mg every
3 hours for 6 daily doses, which is 900 mg/24 hours) was
prescribed. After one month
of therapy, she reported subjective improvement in her
general feeling tone.
Objectively her skin and tongue showed improvement. The
prominent swellings had
disappeared from the sites enumerated above. Her kyphosis
seemed less prominent. She
appeared younger and more vigorous than when first
seen.
She stated on her fourth
visit that she felt almost entirely free from all joint discomfort at
the end of about 100 days of
continuous therapy with niacinamide. She was particularly
pleased that she was no
longer awakened at night by knee pain. Objectively, her tongue
and skin continued to show
resolution of the abnormalities noted at the initial
examination.
During five months of
treatment, she has made objective improvement in joint function,
as indicated by an increase
in the Joint Range Index from 65.8 (severe joint
dysfunction) to 83.2
(moderate joint dysfunction).
CASE D. No.461, female,
age 68, widow, invalid.
This case history
illustrates, in a woman with severe chronic rheumatoid arthritis,
improved joint function as measured
by increasing values of the Joint Range Index and
by decreasing values of the
Sedimentation Rate Index in response to therapy with
niacinamide in the early
months of such therapy (see Figure 18).
Much of the initial
history had to be elicited with the patient reclining on a couch
because she was too tired to
sit up. She states that she had her first attack of "acute
rheumatism" more than
40 years ago. These attacks of "rheumatism" recurred
irregularly at frequent
intervals until 2 years ago, when they apparently ceased. They
were characterized by
abruptly increased swelling, stiffness, pain and limitation in the
range of joint movement. The
joints were hot to the touch, but not red. In the course of
these various attacks, not a
single joint or joint group the body was "missed." However,
not all of the joints were
involved at any one time. The acute episodes usually lasted 2
or 3 days and were followed
by her ordinary chronic joint discomfort, which was
somewhat more endurable than
the severe exacerbations of her difficulty. However, in
the past 5 years, her
chronic discomfort and disability have increased so much that she
doesn't think "it's
worth going on living this way.
For more than 25 years,
she has had severe deformities which have become
progressively worse, so that
now her hands are of little use to her. In addition, her
wrists, elbows, shoulders,
knees, ankles, feet (including the toes) are deformed, swollen
and painful. For many years
she has not been able to move her right wrist actively or
passively, presumably
because of complete ankylosis of the wrist joint; the range of
movement of the left wrist
is negligible. The ulnar deviation of her fingers prevents her
from doing very much with
her hands. She cannot raise her arms in abduction high
enough to comb her hair nor
can she fully extend her elbow joints. She is unable to flex
or extend her ankles
appreciably. Her toes are fixed in abnormal positions by joint
deformities. Her knees, the
most painful joints in her body, are hot and swollen. She
thinks her knees have become
markedly worse in the past year. Even with assistance
she can scarcely get out of
a chair because the pain in her knees is so severe that she
thinks her legs might suddenly
“let go." She is unable to walk upstairs and for years has
lived on the first floor of
her house. For more than 5 years, she has been unable to turn
her head. If she wants to
see someone behind her or to the side, she has to turn her
whole body. For the past 5
years when she wakes at night and wants to turn her head,
she has to turn her whole
body in bed since her neck won't turn. Since her knee
deformities do not permit
full extension of these joints, when she is recumbent in bed
she has to have two large
pillows under her knees to support them in the least un-
comfortable position. When
she arises in the morning she is "terribly stiff" for about
an
hour. This severe stiffness
recurs late in the afternoon.
During the past 5 years,
she has had severe wasting of the muscles everywhere, but
most markedly in her
forearms and hands. She has suffered for the past 10 years from
paresthesias of certain
fingers of her hands.
She has an allergic
colitis which is subject to exacerbations when she eats certain
offending foods, such as
milk, onions and chocolate. In the past 5 years, she has slowly
and progressively lost more
than 40 pounds in weight. She is so tired that for the past 5
years she has been unable to
be up for longer than half an hour at a time.
Her arthritis had not
been helped by any form of treatment which she had received to
date.
Physical Examination: She
is an extremely tired, crippled, chronically ill woman who is
emaciated and has practically
no subcutaneous fat. Extreme wasting of somatic
musculature is noted. Wt. 90
¾ lbs. Ht. 67 ¾ inches. B.P. 124/82. P.80. R. 18. Grips: R.
24, L. 20 (normal range for
women 60-80). The skin is inelastic and thickened
everywhere. There is a pervading
color of light brown that is not sunburn. The reticular
pattern of the skin is
moderately accentuated. Severe callusing of the feet is noted.
There is marked swelling
noticeable in her face, around her elbows, wrists, fingers,
knees, ankles, feet. Digital
pressure over the bony eminences causes no pain, although
severe pain can be elicited
from every moveable joint upon maximal passive or active
movement. Examination of the
eyes reveals circumeorneal injection and conjunctival
thickening. The optic disc
out-lines are not distinct. Arteries are slightly tortuous, being
narrowed from 0 to 2-plus;
the veins and arteries are 2-plus infiltrated. No nicking or en-
gorgement is seen. The
vermilion borders of the lips are thickened and magenta-
colored. No cheilosis is
noted. The gums show slight pitting and moderate infiltration
and retraction. The tongue
is magenta-colored, and its substance is swollen. The lateral
lingual margins show
complete atrophy of all papillae. Elsewhere, fungiform papillae are
extinguished and filiform
papillae are atrophic. There are many transverse fissures in
the lingual mucous membrane.
Her thyroid gland is 1-plus enlarged in the isthmus, but
the lobes are not enlarged.
Trachea in the midline. Chest is negative to auscultation and
percussion excepting for
emphysema. Heart is enlarged by percussion, the point of
maximal impulse being 8 ½
cms in the 6th intercostal space. She has a soft, 1-plus non-
transmitted mitral systolic
murmur. Apical sounds are distant and of fair quality. No liver
tenderness. No organs or
masses are felt in the abdomen. Her temporal, branchial and
radial arteries are slightly
thickened. Her abdominal arteries, aorta, right and left internal
iliac vessels are thickened and
tender. Right and left posterior tibials pulsate 3-plus and
are firm. The dorsalis pedis
arteries are not palpable. She has moderately severe dorsal
kyphosis and swollen ankles,
knees, wrists and fingers. The fingers, held in marked
ulnar deviation, are
markedly deformed, as are her toes. The wrists are apparently
ankylosed. Crepitus is
elicited from the neck joints and from all moveable extremity
joints. Vibratory sensation
in the right lower extremity (toes, malleolus and tibia) is more
marked than in the left.
Vibratory sensation in the upper extremities within normal limits.
No plantar dysesthesia.
Tickle sense 2-plus on forehead, absent elsewhere. Sense of
light touch and sense of
motion and position are intact.
Urinalysis negative.
Hemoglobin 9.0 g/100 cc (acid hematin photoelectric colorimeter).
Sedimentation Rate Index
1.65 mm/min. (Wintrobe-normal 0.1-0.3 mm/min.).
Her Joint Range Index was
45.0, indicating extremely severe joint dysfunction. (In order
to obtain an initial value
for her Joint Range Index, measurement of hip and knee
ranges used in computing the
Joint Range Index was made in the usual way, save for
the fact that the marked
flexion deformities of the knees caused some pelvic tilt with the
patient recumbent. However,
on the 139th day, the flexion deformity of the knees could
no longer be demonstrated.
Also, since the fixation of the fingers of the deformed hands
did not permit extension of
all of her fingers to the zero, or neutral level - i.e., the level
where the finger would be
neither flexed nor extended - a new convention was
introduced in this instance.
When the fingers on maximal extension did not reach the
zero line, the percentage of
the quadrant between the dorsura of the finger being
measured and the zero line
was noted with a minus sign, and tile finger index was
derived in the usual way,
adding algebraically the various measured values obtained for
each hand.)
She was asked to take 150
mg of niacinamide hourly during the day (2400 mg/24
hours). After 34 days of
such therapy, she stated that she had been feeling stronger,
and that she tired somewhat
less readily than formerly. She stated emphatically that her
shoulders were almost entirely
comfortable, and moved much more freely. She could
comb her hair for the first
time in 5 years. Her knees were still painful, and she was not
as "spry getting out of
a chair" as she would like to be, but she was able to get out of a
chair without assistance.
Her color, she thought, had improved.
When she walked, she held
herself more erectly and moved with better balance than
she had when first seen. She
seemed mentally alert and responsive. She was able to
get up from her chair without
assistance, although she had some difficulty in doing so,
and some pain in her knees.
Her skin had become a little more elastic and was lighter in
color. The reticular pattern
of the skin was less prominent. Her lingual mucous
membrane showed some signs
of improvement. The tissue swellings previously noted
had almost disappeared. She
had gained 1 ¼ lbs in weight. Her Joint Range Index had
increased from 45.0 to 58.5.
The venous pattern around the knee joints was much less
prominent than it had been
when she was first seen. She could extend her knees
almost completely, and was
able to lie flat on the examining table without a pillow under
her head, and required only
a small pillow under her knees for comfort. The ulnar
deviation of the fingers was
less marked than when she was first seen. The
Sedimentation Rate Index had
improved slightly, having declined from 1.65 to 1.50
mm/min. In 76 days of
treatment with niacinamide, her Joint Range Index had stabilized
at 58.2. There was no
discernible tissue edema. She had had further improvement in
her feeling tone. She was
very much more comfortable physically, and was troubled
hardly at all by pain and
discomfort in her joints. Her stiffness was markedly decreased.
Since her Joint Range Index
had apparently stabilized, the dosage of niacinamide was
increased so that she took
on alternate hours 150 mg and 200 mg of niacinamide (2800
mg/24 hours).
In 139 days she had a
Joint Range Index of 61.5. She thought that her was improved
considerably. She weighed 5
lbs. more than when first seen. She was generally more
cheerful and seemed to be
more youth-in appearance and behavior. She could now be
up for several hours at a
time without requiring a nap. She was able for the first time in
many years to go upstairs
without assistance, although she still had moderate pain in
her knee joints on doing so.
She could get out of a chair easily without assistance and
with very little discomfort.
She was able to lie flat on the examining table without pillows
under her head or knees, and
without pain or subjective discomfort. Her Sedimentation
Rate Index had decreased
from 1.50 mm/min. (34th day) to 0.44 mm/min. (139th day).
Her niacinamide schedule was
increased from the previous level to 250 mg per hour
(4000 mg/24 hours), since it
was felt at this time that the severity of her joint dysfunction
warranted such a therapeutic
trial at that time.
About 3 weeks before her
next scheduled visit, she was feeling so well that she took
liberties with her diet,
eating foods (milk, onions, chocolate) to which she knew she was
extremely allergic. The
ingestion of these offending foods activated her allergic colitis,
as a result of which she
lost 4 lbs. in 10 days. She had resumed her usual diet (avoiding
milk, onions and chocolate)
about 10 days before her visit, and was again feeling better,
although her colon was still
somewhat irritable and hyperactive. Save for this interlude
of allergic colitis, which
she considered to be an unimportant incident, she felt very well
physically.
In 202 days of
niacinamide therapy, she was almost completely free from joint
symptoms, including pain.
Her Joint Range Index had risen from 61.5 (139th day) to
62.9 (202th day). Her elbows,
which could not be fully extended initially, were now
easily extended. Her right
wrist, which had been clinically completely ankylosed, now
moved 10% in extension and
0% in flexion. The left wrist, which on the initial
examination had moved 0% in
extension and 10% in flexion, now moved 15% and 50%,
respectively. She was able
to lie on the examining table without any pillows under her
head or knees. She was able
to get out of a chair as any normal person would. Her
knees, which had been originally
markedly swollen, were markedly decreased in size.
Since the initial visit,
there had been a decrease in the transverse diameter of the knees
of 0.44 inch across the
right knee and 1.38 inches across the left knee (measured
across the broadest part of
the knees).
Summary: This case
history illustrates the effects of niacinamide therapy in the early
months of such therapy in a
person with extremely severe joint dysfunction (severe
chronic rheumatoid arthritis
of long duration). A summary of certain clinical and
laboratory data obtained
during the various office visits is listed in Table 0A.
Subjectively, as a result
of treatment with niacinamide, in the early months of therapy
this patient experienced a
sense of well-being, including greater strength, less
fatigability and freedom
from joint pain and stiffness. She had less limitation in the
ranges of joint motion. She
had an increased appetite and enjoyment of food. She had a
new zest for living.
Her weight loss between
the 139th day and 202nd day was attributed to her allergic
colitis, which she induced
by eating foods to which she knew was hypersensitive.
Her severe hand
deformities showed some signs of resolution, so that the fingers which
were formerly fixed in ulnar
deviation could now be passively brought into the normal
position without pain. The
wrist joints which were clinically ankylosed showed some
tendency toward renewed
movement, although objectively the right wrist was not
considered to have shown
significant improvement thus far. The left wrist showed
marked improvement, and it
is anticipated that in time, with continuously adequate
niacinamide therapy, there
will be further movement of this joint both in flexion and
extension.
During the above period
of clinical observation the increased Joint Range Index,
decreased Sedimentation Rate
Index, increased weight, decrease in joint swelling and
in generalized tissue edema,
increased hemoglobin, red blood count and hematocrit, all
indicate the arrest and
partial reversal of her severe chronic rheumatoid arthritis, as a
direct result of therapy
with niacinamide as the sole therapeutic agent. Further observa-
tion of this patient is
necessary in order to determine the maximal degree of clinical
recovery possible for her in
response to continuously adequate niacinamide therapy
over a much longer period of
time.
CASE E. No.339, female,
age 78, spinster.
This case history
illustrates, in an elderly woman with severe acute rheumatoid arthritis
(probably superimposed on
mild chronic hypertrophic arthritis), improvement in joint
function as evidenced by
rising values of the Joint Range Index in response to adequate
therapy with niacinamide
(see Figure 19).
This woman considered
that for her age she had enjoyed excellent health until 6 months
ago, when her younger
sister, aged 75, had a stroke. Before her sister's illness, the
patient had never done much
physical work. However, since the sister did not wish to
be hospitalized, or to be taken
care of by strangers, the patient undertook to give
nursing care to her sister
at their home. The bedrooms were on the second floor, and
the patient made many extra
trips up and down the rather steep flight of stairs, usually
carrying her sister's meals
to her. She was so busy with her sister's care that she
neglected to eat her usual
abundant diet, substituting starchy foods for high-protein
foods.
After a month of such
increased physical activity and change in her dietary habits, she
was aware of pain, stiffness
and swelling of her joints. She took 8-10 aspirin tablets (0.3
g) a day with only slightly
increased comfort. Although prior to her sister's illness she
had been able to go up and
down stairs without difficulty, now she could not climb the
stairs without gripping the
banister with her left hand and pulling herself upward step by
step in this way.
Her sister improved
gradually over a period of several months, so that at the time of her
initial visit she had much
less to do physically, although she continued to have a high-
carbohydrate diet. Her
joints continued to give her trouble, so that she had constantly
severe pain in the neck,
severe low back pain, and painful swelling of the knees, ankles,
wrists, hands, elbows and
shoulder joints. She had persistent numbness and tingling of
her hands, which were so
swollen that she could not "make a fist." She noticed that
many of her joints were
extremely hot to the touch, and that she had considerable
crepitus in most of her
joints. Every morning for several hours she felt stiff, until the
aspirin "took
hold." Her stiffness recurred toward evening, when it was not relieved
by
aspirin. With changes in
weather, she had increased joint discomfort. Her sleep was
disturbed and restless
because of her joint discomfort. She had lost 16 lbs. in the past 3
months. She felt that she
was becoming progressively weaker, and felt exhausted most
of the time.
Physical Examination: T.
99.2 degrees. P.74. R. 18. B.P. 150/90. Wt. 156 lbs. Ht. 62 ¼
inches. Grips: R. 20, L. 12
(normal range for women 60-80). She is a sick old lady who
is apparently in great pain
during the interview and physical examination. She seems
dulled mentally. Her voice
is quavery and quernious. She walks with extreme slowness
and some dysequilibrium.
Her Joint Range Index is
62.9, indicating severe joint dysfunction. The joints of the left
side of her body are
somewhat more involved by the arthritic process than those of the
right. She has marked dorsal
kyphosis. Her knees, ankles, wrists, hands, elbows and
shoulder joints show the
marked swelling seen in classic rheumatoid arthritis. Prominent
venous engorgement around
the knees is noted. Her extremity joints are hot to the
touch. A few subcutaneous
periosteal nodules are felt on the ulna and tibia.
Her skin is yellow-brown
and somewhat atrophic. The reticular pattern of the skin is
accentuated. She has a few
ecchymoses. Many hyperkeratotic hair follicles are
observed on the extensor
surfaces of her extremities. She has Bit6t spots. Her
edentulous gums are swollen
and reddened. Her tongue shows hyperemia of the tip
and lateral margins, and
marked atrophy of papillae. Her heart is enlarged by
percussion, the point of
maximal impulse being felt 10 cm. to the left of the mid-sternal
line in the 5th intercostal
space. Throughout systole there is heard a 8-plus, moderately
high-pitched, rough,
non-transmitted aortic systolic murmur. The lungs are
emphysematous but otherwise
negative to physical examination. The liver margin is felt
3 fingers' breadth below the
costal margin in the right midclavicular line at the end of
deep inspiration, and is
8-plus tender. No other organs or masses are felt. Reflexes are
within the range of normal.
Her dorsalis pedis arteries are firm, pulsate 8-plus and are
equal; her posterior tibial
arteries are firm, pulsate 1-plus and are equal. Tickle sense is
absent, but vibratory sense,
sense of light touch and sense of motion and position are
intact. Her Sedimentation
Rate Index is extremely elevated, being 1.80 mm/min
(Wintrobe-normal 0.14).3
mm./min.). Hemoglobin 11.4 /100 cc (acid hematin
photoelectric colorimeter).
Niacinamide was prescribed,
to be taken 150 mg. every 3 hours for 6 doses daily (900
mg/24 hours). After 22 days
of this therapy, much of her joint swelling had resolved,
although she still
complained of pain and stiffness. She walked and sat more erectly
than on her first visit. She
walked with better balance, and more rapidly than she had
originally. Her liver margin
was palpated 2 fingers' breadth below the right costal margin
in the right mid-clavicular
line on deep inspiration, and was 2-plus tender. Her Joint
Range Index had risen from
62.9 (severe joint dysfunction) to 73.2 (moderate joint
dysfunction).
In 84 days of therapy,
her Joint Range Index had apparently stabilized at 72.8. Although
slight ankle edema still
persisted, edema around other joints was no longer evident. Her
Sedimentation Rate Index had
decreased from 1.80 mm/min to 1.00 mm/min. In order
to be completely free from
bone and joint symptoms she required only one aspirin tablet
a day. Her voice had lost
its quaver. She seemed to be more alert mentally and more
vigorous physically. There
had been considerable improvement in her lingual mucous
membrane.
In 172 days of treatment,
her Sedimentation Rate Index had improved further, so that it
was 0.85 mm/min and her
Joint Range Index had risen to 76.2. She stated emphatically
that she felt better than
she had in many years, and was almost entirely free from joint
discomfort and pain. She was
delighted to report that she no longer required the help of
aspirin to be comfortable.
Her liver was no longer enlarged or tender to palpation. Wt.
158 lbs.
At the end of 280 days of
treatment, her Sedimentation Rate Index had fallen to 0.65
mm/min and her Joint Range
Index had risen to 80.7. She was able for the first time in
almost a year to go upstairs
without either pulling herself up by the banister or climbing
up the steps hand over hand,
foot over foot, as an animal would. Her skin had become
more elastic and less
atrophic. Her color was improved, and the yellow-brown color had
been disappearing. No
evidences of joint swelling could be made out. The ulnar and
tibial subcutaneous nodules
originally present could no longer be identified. She had no
evidence of liver
enlargement or swelling of the liver on palpation.
However, since the rate
of recovery of her lingual mucous membrane in response to
therapy with niacinamide was
considered to be somewhat slow, it was decided to
increase her dosage schedule
from 150 to 180 mg. of niacinamide per capsule, to be
taken one every 3 hours for
6 daily doses (an increase from 900 to 1080 mg. of
niacinamide per 24 hours).
For one month she adhered
faithfully to the revised program of therapy, and felt in such
excellent health and spirits
that she became careless, reducing her niacinamide intake
to approximately one capsule
every 3 1/2 hours for 5 daily doses (900 mg niacinamide
per 24 hours).
When she was next seen on
the 355th day of niacinamide treatment, her Joint Range
Index had risen from 80.7 to
84.1, although the Sedimentation Rate Index had risen
slightly from 0.65 to 0.75
mm./min. When she was informed that the Sedimentation Rate
Index was less good than
previously, she agreed to take her medication faithfully.
On the 417th day, her
Joint Range Index had risen from 84.1 to 86.0, and her
Sedimentation Rate Index had
fallen from 0.75 to 0.56 mm/min. At this time she was
euphoric, and did not
remember when she had felt so well. She was physically and
mentally vigorous. Her voice
was clear, resonant and decisive. With considerable
satisfaction, she reported a
renewed interest in being with people, and in entertaining
guests. She looked younger
than when first seen, appearing to be closer to 60 than 80
years of age. She had been entirely
free from bone and joint symptoms, and had not
taken any aspirin for about
8 months. She could walk up and down stairs without
difficulty and without any
sense of physical impairment or exhaustion.
Her carriage was erect,
although she still had a dorsal kyphosis which would be graded
as moderate. Her skin was
smoother, softer, less atrophic and more elastic than it was
on her first examination;
the reticular pattern was less marked than it had been, but still
accentuated. She had no discernible
joint swellings or deformities. There was no
hepatic tenderness or
enlargement. The lingual mucous membrane showed a more
satisfactory rate of
recovery than it had to date in response to niacinamide therapy. Her
muscular strength as
measured by the dynamometer had improved (Grips: R. 50, L.
46). Hemoglobin 12.0 g/100
cc (acid hematin photoelectric colorimeter).
Summary: This elderly
lady with severe joint dysfunction (acute severe rheumatoid
arthritis probably
superimposed on a mild chronic hypertrophic arthritis) showed in 417
days in response to
treatment with niacinamide as the sole therapeutic agent, an
improvement in the Joint
Range Index from 62.9 (severe joint dysfunction) to 86.0
(slight joint dysfunction).
Her Sedimentation Rate Index improved from the exceedingly
high rate of 1.80 mm/min to
0.56 mm/min. (Wintrobe-normal 0.1 - 0.3 mm/min). Her
muscular strength (grips) as
measured with a dynamometer in pounds per square inch
rose from the initial
measurement of R. 20, L. 12 to R. 50, L. 46 (normal range for
women 60-80). In addition to
the objective improvement in all of her joints and in her
general health, there was a
striking decrease in her apparent age. It is anticipated that
with continuously adequate
niacinamide therapy she will in time achieve a Joint Range
Index of 96-100 (no joint
dysfunction).
CASE F. No.85, female,
age 69, housewife, married.
This case history
illustrates, in a woman with severe joint dysfunction and severe,
chronic hypertrophic arthritis,
(a) improved joint function, as measured by an increased
Joint Range Index in
response to adequate therapy with niacinamide for one month, (b)
impaired joint function, as
measured by a lowered Joint Range Index, as a result of
substitution of inadequate
for adequate niacinamide therapy, and (c) improved joint
function, as measured by
subsequent increases in the Joint Range Index in response to
the re-introduction of more
adequate therapy with niacinamide (see Figure20).
She has had arthritis for
a long time. For at least 10 years, she has had marked
deformities of the hands.
Her arthritic symptoms have become more severe in the past
6 months, during which time
she has been increasingly tired, more forgetful and more
irritable.
Physical Examination:
B.P. 168/78. Wt. 118 lbs. Ht. 62 ½ inches. Her skin has a
yellowish cast and is
inelastic, with a markedly accentuated reticular pattern. She has
no periosteal tenderness on
digital pressure, and no liver tenderness or enlargement.
The lingual papillae are
atrophic. Sedimentation Rate Index 0.75 mm/min. (Wintrobe-
normal 0.1-0.3 mm/min).
Hemoglobin 9.9g/100 cc (acid hematin photoelectric
colorimeter). White blood
count 8,000. Her Joint Range Index was 59.6, indicating that
her joint dysfunction fell
within the lower range of the severe grade of joint dysfunction.
Hypertrophic deformities of
the joints of the fingers were noted.
She had severe joint
dysfunction (severe hypertrophic arthritis). She was given
niacinamide, 150 mg every 3
hours for 6 doses daily (900 mg/24 hours). For one month
she took the medication as
prescribed, making the expected improvement in her Joint
Range Index, which rose to
78.3. During the next two months she gradually reduced her
dosage of niacinamide, with
a concomitant fall in the Joint Range Index. She then
resumed taking the
niacinamide as originally directed, with subsequent improvement in
the Joint Range Index.
Since her Joint Range Index
appeared to have stabilized (80.2 and 80.7), her
niacinamide intake was
increased to 250 mg every 3 hours for 6 doses daily, with a
resultant improvement in the
Joint Range Index. In 349 days her Sedimentation Rate
Index decreased from 0.75 to
0.35 mm/min (Wintrobe-normal 0.1-0.3 mm/min). In 735
days her Joint Range Index
had risen from 59.6 to 88.7, a shift from the lower range of
severe joint dysfunction to
slight joint dysfunction. This patient subsequently discon-
tinued treatment because she
mistakenly thought she was cured, since she felt so well.
CASE C. No.336, female,
age 29, private secretary, single.
This case history
illustrates, in a woman with moderate joint dysfunction, without
clinically obvious
arthritis, (a) improvement in joint function as measured by increasing
values of the Joint Range
Index in response to adequate niacinamide therapy, (b)
impairment in joint function
as measured by a lowered Joint Range Index in response to
premature cessation of
niacinamide therapy, and (c) subsequent improvement in joint
function as measured by an
increased Joint Range Index in response to the re-
introduction of adequate
niacinamide therapy (see Figure 21).
Her presenting symptoms
are increasing fatigue and irritability. She has no symptoms
referable to bones and
joints.
Physical Examination: She
looks and acts tired. Her skin has a yellowish cast, and is
generally coarse. She has
marked atrophy and infiltration of the lingual papillae. Her
liver on deep inspiration is
felt at the costal margin in the right mid clavicular line and is
1-plus tender. She shows no
clinical evidence of arthritis, although her Joint Range
Index of 73.7 indicates
moderate joint dysfunction.
In response to 150 mg of
niacinamide every 3 hours for 6 daily doses (900 mg/24
hours) she displayed
progressive improvement in her joint dysfunction, as shown by
increasing values of the
Joint Range Index (a value of 90.4 was 6btained after 207 days
of continuous niacinamide
therapy). This patient experienced also improvement in her
general health, with
complete resolution of excessive fatigue and irritability, and con-
comitant improvement in the
lingual mucous membrane.
She lost interest in
continuing with therapy, and for four months took no medication.
There was a gradual
recurrence of her presenting symptoms, and she returned for
study and treatment. Her
Joint Range Index had dropped from 90.4 on the 207th day to
79.5 on the 442nd day. With
resumption of therapy, her Joint Range Index rose from
79.5 on the 442nd day to
92.7 on the 470th day, and to 96.5 on the 725th day.
CASE H. No.208, male, age
10, schoolboy.
This case history
illustrates, in a boy with moderate joint dysfunction, without
clinically
obvious arthritis, improvement
in joint function as measured by an increasing Joint
Range Index in response to
adequate therapy with niacinamide (see Figure 22).
He has experienced
ill-health, including many severe infections. He is jittery, nervous
and apparently unable to fix
his attention on anything for even short periods of time. He
has paresthesias in the legs
if he sits for more than half an hour. He is irritable and
easily tired.
Physical Examination:
B.P. 110/70. Wt. 67 lbs. Ht. 55 ¼ inches. His skin is yellow-brown
everywhere, and roughened
and discolored, particularly over the knees, ankles, elbows
and hands. The reticular
pattern is slight. He has many ecchymoses, particularly on the
right leg. There is
tenderness on pressure over the sternum, sternoclavicular junction
and chondrosternal junction.
He has mild atrophic changes in the lingual papillae. The
conjunctivae lack lustre,
but are not otherwise abnormal. Teeth are in good repair.
Gums are swollen, slightly hyperemic,
slightly retracted. No infection of the gums was
noted. The liver edge is
2-plus tender and 2 fingers' breadth below the costal margin in
the right middavicular line.
He has plantar dysesthesia lasting 35 seconds. He has
hyperpallesthesia in the
lower extremities. Tickle sense is absent on the legs, but
present elsewhere. Standing,
he is unable to touch his fingers to the floor with knees
unbent, the distance from
fingers to floor with maximal bending being well over 12
inches. The Joint Range
Index of 78.0 indicated moderate joint dysfunction.
After one month of
treatment with niacinamide (100 mg three times a day after meals
and at bedtime; 400 mg/24
hours), his Joint Range Index showed improvement.
Tenderness and enlargement
of the liver had disappeared, as had his abnormal
neurologic signs. There was
a marked improvement in his personality.
In 1,003 days of
continuous niacinamide therapy, this boy's Joint Range Index has
improved from 78.0 (moderate
joint dysfunction) to 98.2 (no joint dysfunction). He is
now able to bend over as
described above and touch the floor with his fingers. His color
is no longer yellow. He is
cheerful, cooperative and alert, and has stopped being a
"problem child."
He does not suffer from irritability or excessive fatigability
CASE I. No.431, female,
age 87, interior decorator, divorced.
Figure 23 illustrates, in
a woman with moderate joint dysfunction and moderate
hypertrophic arthritis,
improvement in joint dysfunction, as measured by a continuously
rising Joint Range Index.
CASE J. No.808, female,
age 39, commercial artist, widow.
This case history
illustrates, in a woman with moderate joint dysfunction (mild,
clinically
obvious hypertrophic
arthritis), (a) improved joint function, as measured by an increased
Joint Range Index in
response to adequate therapy with niacinamide for one month, (b)
impaired joint function as
measured by a lowered Joint Range Index, as a result of
substitution of inadequate
for adequate niacinamide therapy, and (c) improved joint
function as measured by
subsequent increase in the Joint Range Index in response to
the re-introduction of more
adequate therapy with niacinamide
Figure 24).
She had a "nervous
breakdown" 3 ½ years ago when her husband died, was followed
by typical menopausal
symptoms. She has had transient low back pain and right
shoulder discomfort after a
day's work at the drawing board. She has had for the past 3
years persistent stiffness
of joints.
Physical Examination: B.P.
130/90. Wt. 153 lbs. Ht. 66 inches. Hemoglobin 11.8g/100
cc (acid hematin
photoelectric colorimeter). She has generalized pallor, and moderate
accentuation of the
reticular pattern of skin. Her Joint Range Index of 79.4 indicated
moderate joint dysfunction
For the control of her
menopausal symptoms she was given 50 micrograms of ethinyl
estradiol once daily for a
week, and thereafter every other day. In addition, she was
given 150 mg of niacinamide
every 3 hours for 6 daily doses (900 mg/24 hours), which
she took for one month with
the expected improvement in her Joint Range Index to
86.6.
However, the next month,
though she continued the ethinyl estradiol at the prescribed
level, upon the advice of a
"friendly druggist" she dropped the amount of niacinamide
ingested to 600 mg/24 hours,
taking 100 mg instead of 150 mg every 3 hours for 6 daily
doses, with a resultant fall
in her Joint Range Index to 81.4. Subsequently, she resumed
taking niacinamide at the
level originally recommended, and her Joint Range Index rose
from 81.4 to 87.3.
Thus, in four months her
Joint Range Index shifted from 79.4 (moderate joint
dysfunction) to 87.3 (slight
joint dysfunction), even though for one month the patient had
reduced her niacinamide from
adequate to inadequate levels.
CASE K. No.416, male, age
60, accountant, married.
This case history
illustrates, in a male with severe joint dysfunction (mild but
clinically
obvious hypertrophic
arthritis); improvement in joint function as measured by increasing
values of the Joint Range
Index in response to adequate niacinamide therapy (see
Figure 25).
He was given 160 mg of
niacinamide every 2 hours for 8 doses daily (1200 mg/24
hours) and in 315 days of
such therapy his Joint Range Index rose from 65.5 to 91.8, a
shift from severe to slight
joint dysfunction. With this therapy, he experienced a feeling
of physical well-being and
vigor such as he had not had for many years.
CASE L. No.413, male, age
61, mechanical engineer, widower.
This case history
illustrates, in a man with severe joint dysfunction (clinically obvious
hypertrophic arthritis),
improvement in joint function as measured by increasing values
of the Joint Range Index in
response to therapy with niacinamide in combination with
other vitamins (see Figure
26).
This man suffered for
more than 6 years from severe, persistent headaches (occipital
and cervical pain) which
varied in intensity from day to day, but from which he had no
relief, in spite of a
regular, liberal intake of aspirin. In the past 2 years his headaches
had become increasingly more
severe. He has noticed crepitus in many of his joints,
especially in the neck. He
is stiff in the morning when he first awakens, and when the
weather changes. His
shoulders have been painful. At times he has noticed marked
stiffness and pain in his
finger joints.
Physical Examination: He
is a tired, listless adult male who looks older than his stated
age. B.P. 120/80. P. 70. R.
18. T. 97.2 degrees. Wt. 143 ½ lbs. Ht. 67 ¼ inches. His
pigmentation is
yellowish-brown. The skin of his neck and face has a sharkskin-like
appearance, and the
reticular pattern is markedly accentuated on his body. His
fingernails are thickened.
Callusing at pressure points is very noticeable. He has many
hyperkeratotic hair
follicles on the extensor surfaces of his arms and thighs, and on his
abdomen and buttocks. He has
marked tenderness on digital pressure over the
ensiform process and the
maxillary sinuses. His occipital bone is tender to digital
pressure. His eyes show
marked circumeorneal injection and photophobia. There is
some thickening and
increased vascularity of the conjunctivae. He is edentulous; the
gums have a purplish,
swollen appearance. His tongue is magenta-colored and showed
marked atrophy and
hypertrophy of papillae. He has cheilosis, perhaps partly the result
of ill-fitting dentures. His
liver margin is felt 3 fingers' breadth below the right costal
margin in the right
mid-clavicular line on deep inspiration. His posterior tibial and
dorsalis pedis arteries
pulsate 2-plus. He has marked plantar dysesthesia. Tickle sense
is absent, although his
sense of light touch, sense of motion and position and vibratory
sense are intact. He has
moderate dorsal kyphosis and moderate deformities of the
fingers. His Joint Range
Index was 67.5.
He was given a vitamin
dosage schedule as follows:
Per Dose Per
24 Hours
Niacinamide 162.5
mg 975 mg
Riboflavin
7
mg
42 mg
Thiamine
HCl
3 mg
18 mg
Ascorbic
Acid
225
mg
1350 mg
At the end of one month
of the above therapy, there was a marked change in his
appearance. He seemed less
listless and lethargic. He looked younger in appearance.
His color was less brown.
There was increased range of movement in his neck, and he
had much less spasm of the neck
muscles. He stated that his headaches were much
less severe than formerly,
that his spirits were much improved, and that he was less
tired generally. However,
his tongue, gums and eyes showed little resolution of their
severe deficiency signs at
this time. His Joint Range Index had risen to 77.8. He had no
evidence of liver
enlargement or tenderness.
With the passage of time
and the continuance of therapy at the prescribed level, there
has been progressive
improvement in his tissues and m his Joint Range Index. His
dorsal kyphosis is now less
apparent. He now has headaches at rare intervals, which
tend to be mild and occur
only when he has held his head in an awkward position for a
considerable period of time;
e.g., when he studies blueprints. With each successive
visit, he has appeared to be
a younger, more vigorous man.
With continuous therapy
with niacinamide in combination with other his Joint Range
Index rose in 190 days from
67.5 (severe joint dysfunction) to 87.1 (slight joint
dysfunction).
CASE No. 427, male,
age 45, attorney, married.
This chart illustrates,
in a man with severe joint dysfunction (without arthritis),
improvement in joint
function, as judged by increasing of the Joint Range Index in
response to therapy with
niacinamide in combination with other vitamins (see Figure
27).
This patient's Joint
Range Index rose from 67.7 (severe joint dysfunction) to 86.0 (slight
joint dysfunction) in 178
days of therapy.
CASE N. No. 337, female,
age 36, business woman, single.
This chart demonstrates,
in a woman with moderate joint dysfunction (without clinically
obvious arthritis),
continuous improvement in joint function, as demonstrated by
increasing values of the
Joint Range Index in response to therapy with niacinamide in
combination with other
vitamins (see Figure 28).
This patient had
hypothyroidism which was controlled with 90 mg of thyroid (U.S.P.)
daily. A 3-week lapse in the
ingestion of thyroid caused a recurrence of her hypothyroid
symptoms, and the resumption
of thyroid caused these symptoms to disappear. This
lapse in thyroid therapy did
not influence the pattern of recovery of her joint dysfunction.
Her Joint Range Index rose
from the initial value of 75.8 (moderate joint dysfunction) to
92.5.(slight joint
dysfunction) in 385 days of continuous vitamin therapy.
Case 0. No.194, female,
age 52, business woman, married.
This case history
illustrates, in a woman with moderate joint dysfunction (without
clinically obvious
arthritis), (a) improvement in joint function in response to a given
level
of vitamin therapy which
proved to be inadequate, as demonstrated by stabilization over
a period of time the Joint
Range Index below the 96-100 level, and (b) subsequent
improvement in joint function,
as indicated by rising values of the Joint range Index in
response to a small increase
in the level of vitamin therapy
For 511 days this patient
was given the following vitamins:
Per Dose Per 24 Hours
Niacinamide 100
mg 400 mg
Ascorbic
Acid 100
mg 400 mg
With the above level of
treatment, her Joint Range Index rose from 79.0 to 83.0 in 70
days. In 295, 391 and 511
days the Joint Range Index measured 89.2, 89.8 and 89.2,
respectively.
Her dosage schedule was
changed to:
Per Dose Per
24 Hours
Niacinamide 100
mg 600 mg
Ascorbic Acid 100
mg 600 mg
Subsequently, her Joint
Range Index rose, so that on the 632nd day after the initial visit,
it was 91.7, and in 748 days
it was 93.4, indicating a shift from moderate to slight joint
dysfunction. In 910 days of
therapy her Joint Range Index rose to 96.9 (no joint
dysfunction).
CASE P. No.362, male, age
28, attorney, single
This chart illustrates
that a man with moderate joint dysfunction (without obvious
arthritis) and mild
untreated hypothyroidism (basal metabolic rate -18%) had no change
in his Joint Range Index as
a result of the daily ingestion of 60 mg of thyroid substance
(U.S.P.) for 30 days.
However, when he received in addition to his thyroid medication an
adequate dosage of
niacinamide in combination with certain other vitamins, there was
improvement in his Joint
Range Index (see Figure 30).
CASE Q. No.278, female,
age 47, housewife, married.
This case history
illustrates, in a woman with severe joint dysfunction (with clinically
obvious hypertrophic
arthritis), cyclically, (a) improved joint function as shown by an
increased Joint Range Index
in response to adequate therapy with niacinamide in
combination with other
vitamins, (b) impaired joint function as shown by a lowered Joint
Range Index as a result of
substitution of inadequate for adequate therapy, and (c)
improved joint function as
shown by increased Joint Range Index in response to re-
introduction of more
adequate therapy (see Figure 31).
She has been aware of
soreness in her joints, stiffness and limitation of movement for
more than 10 years. She has
had soreness of the tongue off and on for many years.
Physical Examination: She
is a tired woman who looks older than her stated age. B.P.
110/70. Wt. 114 lbs. Ht. 63
inches. Hgb. 10.5 g/100 cc. (acid hematin photoelectric
colorimeter). Her skin is
wrinkled, dry, yellow-brown. There is accentuation of the
reticular pattern, increased
callusing and a marked tendency to freckling. Her eyes
show conjunctival thickening
and injection. She is partially edentulous. The gums are
pitted, infiltrated, swollen
and retracted. Tongue shows moderate atrophy of papillae,
with considerable redness of
the tip and lateral margins. The margin of the liver is
tender and just palpable at
the costal margin. She has hyperpallesthesia in the bony
eminences of the lower
extremities. Plantar dysesthesia is in excess of 20 seconds.
Tickle sense is present on
the forehead, but not elsewhere. She has a low Joint Range
Index of 67.9, indicative of
severe joint dysfunction.
The following vitamins
were prescribed in the manner indicated:
Per
Dose Per 24 Hours
Niacinamide 150
mg 900 mg
Riboflavin 4mg
24 mg
Thiamine HC1 2mg
12 mg
Ascorbic Acid 175 mg
1,050 mg
Vitamin A 5,000 units 15,000
units
Vitamin D 1,000 units 3,000
units
At the end of one month,
her Joint Range Index showed the expected increase in
response to therapy. Her
color was less yellow-brown than originally. Her liver was no
longer palpable or tender.
The intensity of her neuropsychiatric symptoms had
lessened. She was less
tired, less irritable, and had marked lessening in her subjective
sensations referable to
joints. Her hyperpallesthesia was replaced by normal vibratory
sensation. Plantar
dysesthesia had disappeared. Slight tickle sense was present
everywhere.
This patient had considerable
difficulty in maintaining the therapeutic program as
originally prescribed for
her because at various times during treatment she suffered
from anxiety states, fearing
that she was pregnant. During these periods of anxiety, she
invariably reduced her
vitamin intake. Her vitamin intake as she reported it is shown in
Figure 29, together with
corresponding fluctuations in the Joint Range Index.
In spite of her
difficulties in taking the medications as prescribed, she managed to
take
sufficient amounts over a
period of time so that eventually her joint dysfunction
improved from severe (Joint
Range Index 67.9) to slight (Joint Range Index 92.3) in 682
days.
CASE R. No.77, female,
age 57, nurse, unmarried.
This case history illustrates,
in a woman with severe joint dysfunction (clinically obvious
hypertrophic arthritis), (a)
initial improvement in joint function, as shown by an increased
Joint Range Index in
response to adequate therapy with niacinamide in combination
with other vitamins, and (b)
gradual decline of the Joint Range Index as a result of
progressively greater
departure from adequate therapy (see Figure 32).
She has not worked for 5
years because she has suffered from gastrointestinal
symptoms consisting mainly
of heartburn and indigestion occur-ring about an hour after
meals, relieved by
bicarbonate of soda. Repeated x-ray studies have revealed no
abnormalities of the
gastro-intestinal tract. She has mild menopausal symptoms.
During the 5 years that
she has been unemployed, she has lived without cost to herself
with her sister and
brother-in-law. Her poor health was used by her as an excuse for not
doing even minimal
housework.
Physical Examination: She
is tense, tired and impatient. Wt. 150 lbs. Ht. 63 inches. B.P.
130/84. Skin is yellow, with
the reticular pattern moderately accentuated, as is callusing.
She has moderate, early
Bitot spots. Her receded gums are hyperemic, and slightly
edematous. The anterior
third of the tongue is reddened, and there is moderate atrophy
of papillae. She has liver
tenderness graded as 2-plus, with the liver edge at the level of
the costal margin. Her Joint
Range Index showed severe joint dysfunction (61.6).
She was given a regimen
of therapy, including a bland diet, anti-spasmodic and
vitamins prescribed in the
manner indicated below:
Per Dose Per 24
Hours
Niacinamide 175 mg 1,050 mg
Riboflavin 4.5 mg 27 mg
Thiamine HC1 3.5 mg 21 mg
Ascorbic Acid 175 mg 1,050
mg
In one month she had made
the expected progress, as indicated by improvement in her
physical condition and in
the Joint Range Index of 76.1. When she realized that she was
improving physically, she
became panicky and developed many new psychosomatic
symptoms, including severe
headaches with a bizarre pattern and syncopal spells. The
psychiatrist who studied her
elicited the information that she hated to work, and when
her brother-in-law found
that she was feeling better, he would probably insist that she
work as a nurse and contribute
to her own support. As a result of the family situation,
she gradually decreased the
amount of vitamins taken so that ultimately she was taking
about one-third the amount
which had been prescribed. The approximate pattern of
reduction in dosage as she
described it is shown in Figure 32. At no time did she have
insight into her basic
emotional problems.
CASE S. No.201, male, age
52, manufacturer, unmarried.
This case history
illustrates the effect on the Joint Range Index of varying levels of
vitamin intake over a
relatively long period of time (see Figure 33).
This man did not get
along well with one of his business partners. The periods when he
was under the greatest
emotional strain at work corresponded exactly with the periods
when he failed to take his
vitamin therapy as prescribed. Conversely, when there was
greater harmony at work, he
had no difficulty in adhering strictly to the prescribed
program.
While intellectually he
appreciated the above relationship, when he was emotionally
disturbed he was unable to
keep his vitamin therapy at the recommended levels.
However, at each interview
he reported the approximate amounts of the medications
that he had been able to
take for each time interval between examinations. His initial
Joint Range Index was 72.6
(moderate joint dysfunction), and in 509 days his Joint
Range Index was 89.0 (slight
joint dysfunction). The Joint Range Indices reflected
alterations in the level of
his vitamin ingestion.
CASE T. No. 345, female,
age 41, housewife, married.
I
This case history
illustrates, in a woman with moderate joint dysfunction (without
clinically obvious
arthritis), (a) improved joint function in response to one month of
therapy with niacinamide in
combination with other vitamins, (b) impaired joint function
as measured by a lowered
Joint Range Index as a result of premature cessation of
vitamin therapy, and (c)
improved joint function as measured by subsequent increase in
the Joint Range Index in
response to re-introduction of vitamin therapy at a higher level
than originally (see Figure
34).
Her Joint Range Index was
80.7 at the time of the initial visit. For one month she took
the following vitamins:
Per Dose Per
24 Hours
Niacinamide 150 mg 600 mg
Riboflavin 5 mg 20 mg
Thiamine HCl 2.5 mg 10 mg
Pyridoxine HCl 5 mg.
20 mg
Ascorbic Acid 200 mg. 800 mg
At the end of one month
of such therapy her Joint Range Index had risen to 84.9. For 6
months she took no further
therapy, and when she returned at the end of this time for
examination, her Joint Range
Index had fallen to 79.7. Vitamins were prescribed for her
as follows:
Per Dose Per 24
Hours
Niacinamide 190 mg 1,140 mg
Riboflavin 7 mg 42 mg
Thiamine HCl 4 mg 24mg
Pyridoxine HCl 6 mg 36 mg
Ascorbic Acid 250 mg 1,500
mg
At the end of one month
of the above therapy, her Joint Range Index had risen to 92.6.
Although not indicated in
Figure 34, in 693 days this patient had a Joint Range Index of
96.4 (no joint dysfunction).
SOME REASONS WHY CERTAIN
PATIENTS WITH JOINT DYSFUNCTION
FAILTOTAKE NIACINAMIDE
THERAPY AS DIRECTED
As will be seen
subsequently, not all of the 455 patients who were studied clinically
accepted niacinamide therapy
for joint dysfunction and returned for the necessary re-
examinations. Analysis of
the data in Section IV indicates that 80.7% of the total
population studied (78.5% of
all males and 82.1% of all females) accepted niacinamide
therapy for some period of
time. It has been learned directly or indirectly that certain
patients continued with
niacinamide therapy without returning for necessary medical
supervision; the exact
number of such patients is not known. Therefore, less than 20%
of the patients with joint
dysfunction who were studied clinically did not accept
niacinamide therapy. While
it is not always possible to ascertain the reasons why a
patient fails to take
niacinamide therapy as prescribed, some of the apparent reasons
are presented below.
The patient is unwilling
to accept a method of medical treatment that is unfamiliar
to him. Sometimes, a patient
may believe that diet alone should be adequate to
supply all his nutritional
needs, and thinks that he can "get along" as his
ancestors did, without
vitamin therapy. Some patients desire only a thorough
physical examination and an
evaluation of their health status, and are uninterested in
any form of therapy.
Sometimes, a patient feels that it is a sign of weakness to take
medications unless he is
acutely ill, and will submit to treatment only for the duration of
any medical or surgical
emergency that may arise. Some patients want magical cures,
and do not wish to undertake
any treatment that requires sustained, active patient-
physician cooperation; they
feel that the treatment demands too much of them,
especially the taking of
medications at stated intervals, and the necessity for re-
examinations. Certain
patients are very impatient, and want treatment that will give
"immediate
results." They may request that instead of the niacinamide treatment
they
be given injections (gold,
sulfur, liver, bacterial vaccine, vitamin "shots"). Some
patients
who present themselves for
clinical study want only to be reassured that they are in
perfect health, even though
they may have major medical or surgical problems, and
want to be told that any
imperfections they may have are of no significance. Other
patients want only to be
told that they are ill, and should "take it easy," or take a
long
vacation, or be relieved of
responsibilities and duties. Some patients are "shopping" for
an operation. Other patients
want only to have prolonged and expensive hospitalization,
with special studies and
treatment. Some patients who consult the physician unwillingly,
at the insistence of a
friend or relative, have no intention of following any medical
advice. Some patients
present themselves for study only to satisfy their curiosity about
the physician and his
methods.
Sometimes, a patient may
be discouraged from taking niacinamide therapy for
joint dysfunction by a
"friendly" and crusading nurse, druggist, or physician, who
insists that the niacinamide
therapy of joint dysfunction is unnecessary or
useless, and tells the
patient that he needs no such treatment, or that he should
try some other type of
therapy which is in more general use.
A patient usually does
not continue with niacinamide therapy of joint dysfunction when,
on the first day of therapy,
he takes niacin-containing medications dispensed mistakenly
by the druggist instead of
niacinamide, and experiences, unexpectedly, severe flushing
and other unpleasant
symptoms characteristic of niacin reactions (113). (No flushing or
other untoward reactions
have been observed in properly selected patients with joint
dysfunction who have taken
as much as four grams of niacinamide daily for a year or
more.)
A few patients have
initial difficulties in forming regular habits of taking medication
during the first months of
treatment of joint dysfunction. Unless certain patients are seen
at relatively frequent
intervals, they lose interest in continuing with niacinamide therapy.
Some patients do not take
medications as prescribed as a device for gaining the
attention of family and
physician.
Sometimes a patient will
not take niacinamide therapy for joint dysfunction because he
develops a strong negative
transference reaction to the physician. Occasionally, such
reactions may appear as
masked negative transference reactions, when at the initial
visit the patient seems
excessively cordial, agreeing with everything the physician says,
speaking confidently of how
well he expects to feel in the future under the physician's
care. Such a patient may
never return for re-examination. If he does return, he never
takes niacinamide therapy as
prescribed, stating he is "too busy to take the medicine,"
that he has "too many
pills to take," that he "forgets" to have his prescription
refilled. He
then states with apparent
pleasure that he doesn't "feel better in any way," or that
the
treatment hasn't helped at
all," even though he may continue to return for serial re-
examinations.
Some patients who have
joint dysfunction and one or more of the four complicating
syndromes are impatient and
unwilling to cooperate in the clinical investigation of their
complicating syndromes, and
they soon drop therapy.
A patient who does not
have articular symptoms or arthritic deformities often sees no
reason why he should take
any medical therapy, even though his joint dysfunction may
be severe. A patient who has
articular symptoms and arthritic deformities may believe
that his symptoms and
deformities are not sufficiently troublesome to him to warrant the
nuisance and expense of
treatment.
Some patients with
recurrent or continuous articular symptoms (with or without clinically
obvious arthritis) are often
unable to accept the fact that their joint dysfunction can be
reversed in time, and if
they begin niacinamide therapy, it is with the greatest
skepticism. These patients,
previously studied by many physicians over a period of
years, had been advised
repeatedly that there was no effective therapy for their articular
illness. Thus, unless they
feel subjectively improved within a few weeks of beginning
treatment, they usually drop
therapy.
Certain patients who
enjoy secondary gains from their articular illness may not begin
niacinamide therapy for fear
that they may be "cured"; if they do accept therapy, they
always take less than the
prescribed amount of niacinamide.
In some instances of
severe or extremely severe joint dysfunction with clinically obvious
arthritis, but not in all
instances, there may be a relatively long latent period between
objective improvement in the
Joint Range Index and subjective awareness of improved
health as a result of
therapy. Some persons who do not feel better subjectively during
this period, fail to
continue with therapy, in spite of objective evidence for clinical im-
provement. Such persons
often drop therapy prematurely.
Whenever certain patients
are exposed to an anxiety-producing situation, they reduce
their vitamin intake to
inadequate levels, and when the tensional situation has passed,
they resume vitamin
treatment as directed.
Some patients are afraid
of "powerful" medicines, and when they have made good
improvement in response to
niacinamide therapy, they reduce their niacinamide intake
for fear that the medicine
is "too strong."
Certain suspicious
patients reduce the niacinamide level below the recommended
dosages, or stop niacinamide
therapy prematurely without informing the physician of
this. If such a patient's
Joint Range Index has been maintained at a high level in
response to a sufficient
period of adequate niacinamide therapy, there may be some lag
between the reduction in
niacinamide intake and the decrease in his Joint Range Index.
Such patients use this as
proof that the physician is wrong about joint dysfunction and
its proper treatment. Some of
these patients who return for study after having
discontinued niacinamide
therapy for a year or more, show demonstrable regression of
the Joint Range Index.
A patient with joint
dysfunction who has mental symptoms which are extinguished by
adequate niacinamide therapy
may experience such marked improvement in his feeling
tone during the first month
of adequate niacinamide therapy that he may mistakenly
believe he is
"cured," even though he has made only the expected improvement in
his
joint dysfunction. He is
likely to drop niacinamide therapy prematurely, and usually
experiences a slow or rapid
recurrence of his mental symptoms.
Some patients have a response to niacinamide therapy which seems to be the clinical
equivalent of "decreased running" observed in experimental animals (226). When these
animals are deprived experimentally of certain essential nutriments, they display
"excessive running," or hyperkinesis. When these deficient animals receive the
essential nutriments in sufficient amounts for a sufficient period of time, there is
exhibited a marked "decrease in running," or hypokinesis. Thus, certain patients may
discontinue therapy because they believe they feel less well as a result of niacinamide.
They may have the impression that vitamin therapy is depriving them of their usual abundant
energy, and may state that they are being "de-pepped" by the treatment.
A patient in this group may wonder whether or not his vitamin medications
contain a sedative. He recalls
that before vitamin therapy was instituted, he had a great
deal of energy and "drive,”
and considered himself to be a "very dynamic person."
Analysis of his history
indicates that prior to niacinamide therapy, even though he often
felt tired, he did not need
to rest or relax during the day, since he found it easier td
“keep on going” than to stop
and rest, and that he suffered from a type of compulsive
impatience, starting many
projects which he left unfinished as a new interest distracted
him, returning perhaps after
a lapse of time to complete the original project. Without
realizing it, he was often
careless and inefficient in his work, but was "busy all the
time."
With vitamin therapy, such a
patient becomes unaccustomedly calm, working more
efficiently, finishing what
he starts, and he loses the feeling that he is constantly driving
himself. He has leisure time
that he does not know how to use. When he feels tired, he
is able to rest, and does
not feel impelled to carry on in spite of fatigue. All these
changes he interprets to
mean that vitamin therapy has robbed him of his vitality. If such
a patient can be persuaded
to continue with niacinamide therapy, in time he comes to
enjoy a sense of well-being,
realizing in retrospect that what he thought in the past was
a super-abundance of energy
and vitality was in reality an abnormal "wound-up" feeling,
which was an expression of
aniacinamidosis.
Some patients become
tired of taking medications for prolonged periods of time, and
stop niacinamide therapy for
joint dysfunction.
Rarely, patients are
unable to continue with niacinamide therapy for economic reasons.
LIMITATIONS OF THIS STUDY
Certain limitations were
imposed on this study by the nature of the writer's private
practice:
1. No repeated
determinations of the Joint Range Index could be performed on a large
sampling of the untreated
population over a prolonged period of time.
2. No control series
could be studied which had been treated with placebos, single
vitamins other than
niacinamide, or multiple vitamin mixtures not containing
niacinamide.
3. No large series of
determinations of the Joint Range Index could be made from two
separate sets of
measurements made in the same individual on the same day.
(However, it was found in a
trial with a small series of subjects that two Joint Range
Indices determined from two
separate sets of joint range measurements made on the
same day in the same
individual agreed within plus or minus 0.3.)
4. No routine x-ray
studies of the joints whose ranges were measured for inclusion in
the Joint Range Index could
be obtained. However, a sufficient sampling of x-rays of
measured joints was obtained
in the course of this study to indicate that it would be of
value to have such x-ray
documentation, routinely performed before treatment was
instituted, and at intervals
during the course of treatment.
5. No standard
photographic method was available for taking serial photographs which
could be used in making
accurate, detailed comparisons of gross joint morphology
before therapy and at
various intervals during the course of prolonged, adequate
niacinamide therapy. In
documenting the gross morphology of joint deformities, certain
variables must be controlled
rigidly if serial photographs are to be strictly comparable;
e.g., positioning of the
deformed joints, lighting, lens aperture, film exposure, size of film
image, film development,
type of printing paper, exposure of printing paper, size of print
image, and print
development.
6. No attempt was made
clinically to find the highest dosage level of niacinamide which
could be tolerated safely by
patients with joint dysfunction, or to explore the effects of
such doses on the rate of
recovery in joint dysfunction. Only those dosages of
niacinamide which seemed to
be clinically safe and therapeutically effective were
employed in the treatment of
joint dysfunction.
7. No gross or
histopathologic studies could be performed on the joint structures of
patients with joint
dysfunction in the course of this study.
8. No highly specialized
chemical or metabolic studies could be performed prior to
treatment with niacinamide,
or subsequently, to follow in a patient with joint dysfunction,
(a) the fate of the ingested
niacinamide and the concomitant metabolic changes in body
chemistry and metabolism
during the course of adequate treatment of joint dysfunction;
(b) changes in body
chemistry and metabolism induced by the substitution of inade-
quate for previously
adequate niacinamide therapy; (c) changes in body chemistry and
metabolism induced by the
premature cessation of adequate niacinamide therapy.
(End of Chapter 1, which
consists of pages 1-75. The author’s preface, and all references cited, are posted at http://www.doctoryourself.com/kaufman11.html )
To read Chapter 2, click
this link: http://www.doctoryourself.com/kaufman7.html
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