The Common Form Of Joint Dysfunction: CHAPTER I

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Megavitamin Arthritis Treatment: William Kaufman,

M.D., Ph.D.

 

CHAPTER I

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 Saul, Ph.D.

 

(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. The chapter closes with case histories

and an insightful, practical discussion of patient

management. Graphs and other original illustrations

are not provided here, but may be seen in the original

text, available through interlibrary loan at your

public library. References cited in the chapter are

posted separately.)

 

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 © 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

©, 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%: © 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; © 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, ©

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) © (d), during the course of

niacinamide-induced recovery of full joint mobility.

The line touched by the head of the

arrow in (a) (b) © (d) indicates the upper limit of

painless extension. The shaded angle

in (b) and © indicates the range of painful passive

extension.)

 

Figure 14(a). On the initial examination before

niacinamide therapy was instituted, the

metacarpophalangeal joint of the forefinger of the

right hand could be extended

passively to 30% of the full range of extension for

this joint. No pain or discomfort was

experienced by the patient during this maneuver. The

examiner noted the presence of

palpatory resistance from the initiation of the

movement of passive extension of this

metacarpophalangeal joint, and this resistance

progressively increased as the joint was

extended from the range of 0% to 30% of the maximal

extension; the palpatory

resistance at the end of the movement was graded as

firm. When at the 30% level of

passive extension a small increase of force in the

direction of extension caused no

further extension of this joint, 30% of the full range

of extension was taken as the upper

limit of maximum passive extension of this

metacarpophalangeal joint.

 

Figure 14 (b). At the end of one month of continuous,

adequate niacinamide therapy,

maximal passive extension of this metacarpophalangeal

joint increased to 60% of the

full range of extension. No pain or discomfort was

experienced by the patient when the

metacarpophalangeal joint was extended from 0% to 40%

of the full range of extension.

The patient experienced localized joint pain, often

severe, as the joint was passively

extended from 40% to 60% of the full range of

extension. The examiner's palpatory

sensation indicated that movement of the joint in

passive extension was free from 0% to

40%, and that there was soft, yielding resistance

which progressively increased as the

finger was extended at the metacarpophalangeal joint

from 40% to 60% of the full range

of movement. When a further small increase of the

extending force did not increase the

degree of extension, 60% of the full range of

extension was taken as the upper limit of

passive extension of this metacarpophalangeal joint.

The palpatory resistance at the

end of the movement of extension was rubbery.

 

Figure 14 ©.After months of continuous, adequate

therapy with niacinamide, maximal

passive extension of the metacarpophalangeal joint

reached 100%; i.e., the full range of

movement. Passive extension of the metacarpophalangeal

joint from 0% to 85% was

without pain or discomfort; passive extension from 85%

to 100% was painful. The

examiner's palpatory sensation indicated that the

movement of this joint was free from

0% to 85%, and that there was soft resistance, which

increased progressively with

increasing extension of the metacarpophalangeal joint

from the level of 85% to 100%. A

small additional force in the direction of extension

when the 100% level was reached did

not cause further extension of this joint. The

palpatory resistance at the end of the full

range of movement (100%) was rubbery.

 

Figure 14(d). With a longer period of continuous,

adequate niacinamide therapy, it

was possible to achieve full, free and painless

extension of this

metacarpophalangeal joint to the level of 100%. Slight

additional palpatory force in

the direction of extension with the joint fully

extended did not 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,

 

© 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 © 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

© 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 © 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 © 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 ©

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 © 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 ©

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 © 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

 

therapy; 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; ©

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.)