Effect of Homoeopathic remedy Rhus Tox on the Musculoskeletal disorder

 Dr Puneet Kumar Misra

Abstract – The stiffness at rest and relief after movement are the leading prescribing to Rhus tox in musculoskeletal disorder. The  stiffness is an indication of the non inflammatory / inflammatory Musculoskeletal disorder  and  Rhus tox also have the  leading indication of its  prescribing   in all condition , during study it is found that the prescribing of same are cover the  stiffness of all non inflammatory/ inflammatory Musculoskeletal disorder and independent from  onset of  origin or mode  of the   disorder . Majority of homoeopath use this indication during prescribing of the Rhus tox in the joint disorder treatment, and rank of this indication is consider in the highest level and use of this remedy improve the quality of life of the effected person.This drug are highly specific and general indicated for the stiffness disorder.

Introduction – commonly middle age person start to feels stiffness in all or few joint as a very non specific and mild  trouble joint complaint. At the beginning of it  most of the people are not taken it seriously ,but when the  disorder reduced the quality of life i.e. difficult in start to standing or  upstairs  move after short or  prolong sitting then he start focus on the disorder, and this disorder also change own presentation after  change in the weather, most commonly in the wet and winter season  are increase the difficulty while summer provide some relief but user of summer gadgets for cooling i.e. air cooler, AC also a source of the aggravating disorder. The musculoskeletal disorder present in the various manner with different mode of the origin all are described  in the details one by one  further.

Joint disease

A combination of pain and stiffness, leading to loss of function, is a classic feature of joint disease. Usually one component predominates, as with stiffness in inflammation and pain in mechanical joint problems. Therefore, specific questions will establish whether symptoms are non-inflammatory (e.g. osteoarthritis) or inflammatory (e.g. rheumatoid arthritis). As with any condition, the good clinician will also draw out the consequences of the disorder in terms of the impact on the patient’s day-to-day function and quality of life. The effect on relationships, work and social activities will help the clinician to gauge the severity of the problem and possibly elicit issues of stress and psychosocial pressure. 1

 Non-inflammatory joint disease

Pain of a non-inflammatory origin is more directly related to function and use and usually improves with rest. This is in contrast to inflammatory joint pain which is often present at rest as well as on use and tends to vary from day to day and from week to week. Stiffness, particularly in the morning or after a period of inactivity, is often reported in a patient’s history and typically lasts no more than 30 minutes. However, in severe cases the duration may be much longer. Subjective joint swelling may be described and indeed patients with knee osteoarthritis may present with a significant effusion. Joint swelling in this context tends to be more intermittent than the persistent joint swelling and warmth seen in inflammatory conditions. Locking of a joint may occur. In the knee, this means that the knee becomes locked in such a way that it will not extend fully, although it may flex. In other joints, locking is less well defined and simply means that at some point through its range of motion the joint becomes stuck, usually associated with pain and often followed by swelling. Locking is due to material within the joint interfering with movement at the articular surfaces. In the knee, this is usually part of one of the menisci or a cartilaginous loose body. 1

Inflammatory joint disease

Early morning stiffness Early morning joint stiffness that persists for more than 30 minutes is an important symptom of active inflammatory joint disease. Ask about redness (rubor), warmth (calor), tenderness/pain (dolor) and swelling (tumour), the classic features of inflammation. 1

Acute monoarthritis –The most important causes of acute arthritis in a single joint are crystal arthritis, sepsis, SpA and oligoarticular juvenile idiopathic arthritis . Other potential Common causes are – Gout • Pseudo gout • Trauma • Haemarthrosis • Spondyloarthritis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis  and Less common causes are – Rheumatoid arthritis • Juvenile idiopathic arthritis • Pigmented villonodular synovitis • Foreign body reaction • Tuberculosis • Leukaemia* • Gonococcal infection • Osteomyelitis*. 2

Clinical assessment

The clinical history, pattern of joint involvement, speed of onset, and age and gender of the patient all give clues to the most likely diagnosis. Gout classically affects the first metatarsophalangeal (MTP) joint, whereas pseudo gout, which can be a presenting feature of calcium pyrophosphate dihydrate (CPPD) disease, can affect the hand/wrist, ankle, knee or hip. A very rapid onset (6–12 hours) is suggestive of crystal arthritis; joint sepsis develops more slowly and continues to progress until treated Haemarthrosis typically causes a large effusion, in the absence of periarticular swelling or skin change, in a patient who has suffered an injury. Pigmented villonodular synovitis  also presents with synovial swelling and a large effusion, although the onset is gradual. A previous diarrhoeal illness or genital infection suggests reactive arthritis, whereas intercurrent illness, dehydration or surgery may act as a trigger for crystal-induced arthritis. Rheumatoid arthritis seldom presents with monoarthritis but psoriatic arthritis (PsA) can typically present this way. Osteoarthritis can present with pain and stiffness affecting a single joint, but the onset is gradual and there is usually no evidence of significant joint swelling unless it is complicated by crystal-induced inflammation.2

Investigations –Aspiration of the affected joint is mandatory. If sepsis is suspected in a large joint, arthroscopic washout is advisable. The fluid should be sent for culture and Gram stain to seek the presence of organisms and should be checked by polarised light microscopy for crystals. Blood cultures should also be taken in patients suspected of having septic arthritis. CRP levels and ESR are raised in sepsis, crystal arthritis and reactive arthritis, and this can be useful in assessing the response to treatment. Serum uric acid measurements may be raised in gout but a normal level does not exclude the diagnosis. Ruling out primary hyperparathyroidism is essential if there is pseudo gout.2

Management –If there is any suspicion of sepsis, intravenous antibiotics should be given promptly, pending the results of cultures. Unless atypical infections/tuberculosis (requiring prolonged or special culture) are suspected, intra-articular glucocorticoid injection may be considered after 48 hours of negative synovial fluid culture. Otherwise, management should be directed towards the underlying cause.2

Polyarthritis –This term is used to describe pain and swelling affecting five or more joints or joint groups. The possible causes are.

• Rheumatoid arthritis Symmetrical, small and large joints, upper and lower limbs,
• Viral arthritis Symmetrical, small joints; may be associated with rash and prodromal illness; self-limiting,
• Osteoarthritis Symmetrical, targets PIP, DIP and first CMC joints in hands, knees, hips, back and neck; associated with Heberden’s and Bouchard’s nodes ,
• Psoriatic arthritis Asymmetrical, targets all joints and entheses; associated with nail pitting/ onycholysis, dactylitis,
• Axial spondyloarthritis and enteropathic arthritis Tends to affect midsize and large joints and entheses, lower more than upper limbs; history of inflammatory back pain,
• Systemic lupus erythematosus Symmetrical, typically affecting small joints; clinical evidence of synovitis unusual
• Juvenile idiopathic arthritis Various patterns : polyarticular, oligoarticular and systemic but also enthesitis-predominant ,
• Chronic gout Affects distal more than proximal joints; history of acute attacks,
• Chronic sarcoidosis Varies: small and large joints, often involves ankles,
• Calcium pyrophosphate arthritis Chronic polyarthritis with involvement of wrists, ankles, knees and oligoarticular small hand joints
• (CMC = carpometacarpal; DIP = distal interphalangeal; PIP = proximal interphalangeal) 2

Clinical assessment

The hallmarks of inflammatory arthritis are early-morning stiffness and worsening of symptoms with inactivity, along with synovial swelling and tenderness on examination. The most important diagnoses to consider are PsA, RA and inflammatory small joint OA. RA is characterised by symmetrical involvement of the small joints of the hands and feet, wrists, ankles and knees. PsA is strongly associated with enthesitis. Viral arthritis , Poncet’s disease (in regions where tuberculosis is highly prevalent;  polyarticular JIA (in children) and post-streptococcal arthritis should also be considered. The pattern of involvement can be helpful in reaching a diagnosis . Asymmetry, lower limb predominance, enthesitis and greater involvement of large joints are characteristic of the SpAs. In PsA there may be involvement of the proximal and distal interphalangeal (PIP and DIP) joints, as opposed to the metacarpophalangeal (MCP) and PIP joints in RA. Inflammatory OA can appear similar to small-joint PsA in the pattern of joint involvement. In PsA there may be nail pitting or early onycholysis. Psoriasis may not be present. SLE can be associated with polyarthritis but more usually causes polyarthralgia and tenosynovitis, mainly of distal limb joints/ tendons .2

Investigations –Blood samples should be taken for routine haematology, biochemistry, ESR, CRP, viral serology and an immunological screen, including ANA, RF and ACPA. Ultrasound examination or MRI may be required to confirm the presence of synovitis, if this is not obvious clinically.2

 Management-Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics will help. Systemic glucocorticoids can be considered if symptoms are very severe or having a great functional impact, but early immunotherapy (DMARDs) is required in RA and in some cases of PsA. An early accurate and specific diagnosis is very important.2

Approach to Articular and Musculoskeletal Disorder –Musculoskeletal complaints account for >315 million outpatient visits per year and >20% of all outpatient visits in the United States. The Centers for Disease Control and Prevention estimate that 54.4 million, or 1 in 5 adults) of the U.S. population has physician-diagnosed arthritis. While many patients will have self-limited conditions requiring minimal evaluation, reassurance, and symptomatic therapy, specific musculoskeletal presentations or their persistence may herald a more serious condition that requires further evaluation or laboratory testing to establish a diagnosis. The goal of the musculoskeletal evaluation is to formulate a differential diagnosis that leads to an accurate diagnosis and timely therapy, while avoiding excessive diagnostic testing and unnecessary treatment . There are several urgent conditions that must be diagnosed promptly to avoid significant morbid or mortal sequelae. These “red flag” diagnoses include septic arthritis, acute crystal-induced arthritis (e.g., gout), and fracture. Each may be suspected by its acute onset and monarticular or focal musculoskeletal pain. The majority of individuals with musculoskeletal complaints can be diagnosed with a thorough history and a comprehensive physical and musculoskeletal examination. The initial encounter should determine whether the musculoskeletal complaint signals a red flag condition (septic arthritis, gout, or fracture) or not. The evaluation should ascertain if the complaint is (1) articular or nonarticular in origin, (2) inflammatory or noninflammatory in nature, (3) acute or chronic in duration, and (4) localized (monarticular) or widespread (polyarticular) in distribution. With this approach, the musculoskeletal presentation can be characterized (e.g., acute inflammatory monarthritis or a chronic non inflammatory, nonarticular widespread pain) to narrow the diagnostic possibilities. However, some patients will not fit immediately into an established diagnostic category. Many musculoskeletal disorders resemble each other at the outset, and some may take weeks or months (but not years) to evolve into a recognizable diagnostic entity. This consideration should temper the desire to establish a definitive diagnosis at the first encounter 3

ARTICULAR VERSUS NONARTICULAR The musculoskeletal evaluation must discriminate the anatomic origin(s) of the patient’s complaint. For example, ankle pain can result from a variety of pathologic conditions involving disparate anatomic structures, including gouty arthritis, calcaneal fracture, Achilles tendinitis, plantar fasciitis, cellulitis, and peripheral or entrapment neuropathy. Distinguishing between articular and nonarticular conditions requires a careful and detailed examination. Articular structures include the synovium, synovial fluid, articular cartilage, intra articular ligaments, joint capsule, and juxtaarticular bone. Non articular (or periarticular) structures, such as supportive extra articular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin, may be involved in the pathologic process. Although musculoskeletal complaints are often ascribed to the joints, non articular disorders more frequently underlie such complaints. Distinguishing between these potential sources of pain may be challenging to the unskilled examiner. Articular disorders may be characterized by deep or diffuse pain, pain or limited range of motion on active and passive movement, and swelling (caused by synovial proliferation, effusion, or bony enlargement), crepitation, instability, “locking,” or deformity. By contrast, non articular disorders tend to be painful on active, but not passive (or assisted), range of motion. Peri articular conditions often demonstrate point or focal tenderness in regions adjacent to articular structures, may radiate or be elicited with a specific movement or position, and have physical findings remote from the joint capsule. Moreover, nonarticular disorders seldom demonstrate swelling, crepitus, instability, or deformity of the joint itself.3

INFLAMMATORY VERSUS NONINFLAMMATORY DISORDERS In the course of a musculoskeletal evaluation, the examiner should determine the nature of the underlying pathologic process and whether inflammatory or noninflammatory findings exist. Inflammatory disorders may be infectious (Neisseria gonorrhoeae or Mycobacterium tuberculosis), crystal-induced (gout, pseudo gout), immune-related (rheumatoid arthritis [RA], systemic lupus erythematosus [SLE]), reactive (rheumatic fever, reactive arthritis), or idiopathic. Inflammatory disorders may be identified by any of the four cardinal signs of inflammation (erythema, warmth, pain, or swelling), systemic symptoms (fatigue, fever, rash, weight loss), or laboratory evidence of inflammation (elevated erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP], thrombocytosis, anaemia of chronic disease, or hypoalbuminemia). Articular stiffness commonly accompanies chronic musculoskeletal disorders. The duration of stiffness may be prolonged (hours) with inflammatory disorders (such as RA or polymyalgia rheumatica) and improves with activity. By contrast, intermittent stiffness (also known as gel phenomenon) is typical of non inflammatory conditions (such as osteoarthritis [OA]), shorter in duration (<60) and is exacerbated by activity. Fatigue may be profound with inflammation (as seen in RA and polymyalgia rheumatica) but may also be a consequence of fibromyalgia (a non inflammatory disorder), chronic pain, poor sleep, depression, anemia, cardiac failure, endocrinopathy, or malnutrition. Non inflammatory disorders may be related to trauma (rotator cuff tear), repetitive use (bursitis, tendinitis), degeneration or ineffective repair (OA), neoplasm (pigmented villonodular synovitis), or pain amplification (fibromyalgia). Non inflammatory disorders are often characterized by pain without synovial swelling or warmth, absence of inflammatory or systemic features, daytime, intermittent gel phenomena rather than prolonged morning stiffness, and normal (for age) or negative laboratory investigations. Identification of the nature of the underlying process and the site of the complaint will enable the examiner to characterize the musculoskeletal presentation (e.g., acute inflammatory monarthritis, chronic non inflammatory, nonarticular widespread pain). By narrowing the diagnostic considerations, the examiner can assess the need for immediate diagnostic or therapeutic intervention or for continued observation.. This approach relies on clinical and historic features, rather than laboratory testing, to diagnose many common rheumatic disorders.3

CLINICAL HISTORY Historic features may reveal important clues to the diagnosis. Aspects of the patient profile, complaint chronology, extent of joint involvement, and precipitating factors can provide important information. Certain diagnoses are more frequent in different age groups. SLE and reactive arthritis occur more frequently in the young, whereas fibromyalgia and RA are frequent in middle age, and OA and polymyalgia, rheumatica are more prevalent among the elderly. Diagnostic clustering is also evident when sex and race are considered. Gout, spondyloarthritis, and ankylosing spondylitis are more common in men, whereas RA, fibromyalgia, osteoporosis and lupus are more frequent in women. Racial predilections may be evident. Thus, polymyalgia rheumatica, giant cell arteritis, and granulomatosis with polyangiitis (GPA; formerly called Wegener’s granulomatosis) commonly affect whites, whereas sarcoidosis and SLE more commonly affect African Americans. Familial aggregation is most common with ankylosing spondylitis, gout, and Heberden’s nodes of OA. The chronology of the complaint is an important diagnostic feature and can be divided into the onset, evolution, and duration. The onset of disorders such as septic arthritis or gout tends to be abrupt, whereas OA, RA, and fibromyalgia may have more indolent presentations. The patients’ complaints may evolve differently and be classified as chronic (OA), intermittent (crystal or Lyme arthritis), migratory (rheumatic fever, gonococcal or viral arthritis), or additive (RA, psoriatic arthritis). Musculoskeletal disorders are typically classified as acute or chronic based on a symptom duration that is either 6 weeks, respectively. Acute arthropathies tend to be infectious, crystal-induced, or reactive. Chronic conditions include non inflammatory or immunologic arthritides (e.g., OA, RA) and nonarticular disorders (e.g., fibromyalgia). The extent or distribution of articular involvement is often informative. Articular disorders are classified based on the number of joints involved, as either monarticular (one joint), oligoarticular or pauciarticular (two or three joints), or polyarticular (four or more joints). Although crystal and infectious arthritis are often mono- or oligoarticular, OA and RA are polyarticular disorders. Nonarticular disorders may be classified as either focal or widespread. Complaints secondary to tendinitis or carpal tunnel syndrome are typically focal, whereas weakness and myalgia, caused by polymyositis or fibromyalgia, are more widespread in their presentation. Joint involvement in RA tends to be symmetric and polyarticular. By contrast, spondyloarthritis, reactive arthritis, gout, and sarcoid are often asymmetric and oligoarticular. OA and psoriatic arthritis may be either symmetric or asymmetric and oligo- or polyarticular. The upper extremities are frequently involved in RA and OA, whereas lower extremity arthritis is characteristic of reactive arthritis and gout at their onset. Involvement of the axial skeleton is common in OA and ankylosing spondylitis but is infrequent in RA, with the notable exception of the cervical spine. The clinical history should also identify precipitating events, such as trauma (osteonecrosis, meniscal tear), drug administration , antecedent or inter current infection (rheumatic fever, reactive arthritis, hepatitis), or illnesses that may have contributed to the patient’s complaint. Certain co morbidities may have musculoskeletal consequences. This is especially so for diabetes mellitus (carpal tunnel syndrome), renal insufficiency (gout), depression or insomnia (fibromyalgia), myeloma (low back pain), cancer (myositis), and osteoporosis (fracture) or when using certain drugs such as glucocorticoids (osteonecrosis, septic arthritis), diuretics or chemotherapy (gout) . Lastly, a thorough rheumatic review of systems may disclose useful diagnostic information. A variety of musculoskeletal disorders may be associated with systemic features such as fever (SLE, infection), rash (SLE, psoriatic arthritis), nail abnormalities (psoriatic or reactive arthritis), myalgias (fibromyalgia, statin- or drug-induced myopathy), or weakness (polymyositis, neuropathy). In addition, some conditions are associated with involvement of other organ systems including the eyes (Behçet’s disease, sarcoidosis, spondyloarthritis), gastrointestinal tract (scleroderma, inflammatory bowel disease), genitourinary tract (reactive arthritis, gonococcemia), or nervous system (Lyme disease, vasculitis).3

The narration of various Materia Medica

• Lameness, stiffness and pain  on  first  moving  after  rest, or on getting up  in  the morning >. by  walking  or  continued    Great  restlessness,  anxiety,   apprehension  [Acon., Ars.]; cannot remain in bed,  must  change position often  to  obtain  relief  from pain  [from   mental   anxiety,   Ars.].  Restless,  cannot stay long in one position. Back:  pain  between  the shoulders on swallowing; pain and stiffness in small of  back  <.  sitting  or lying, >. by motion or lying on  something 4
• This  strained  condition may not be confined  to  the   muscles  alone,  but may involve the tendons, ligaments and  membranes  of   the    Several  affections of the muscles of the back  and   even  the spinal membranes(myelitis)may  come  on  from   sprain,   or  by exposure, by sleeping on damp ground, or in bed with  damp  sheets,  or   getting  wet in a rain  storm,   especially   while   perspiring.  Indeed RHUS is one of our best remedies in  lumbago.  But  it makes no particular difference what muscles are  strained  or  exposed   so as to bring on the lameness  and   soreness  the  remedy  is  the  same,  and   if   the   great  characteristic— “LAMENESS and  STIFFNESS and   PAIN  ON FIRST MOVING AFTER  REST,  OR ON GETTING UP IN THE MORN.,  RELIEVED BY  CONTINUED MOTION,  ”  is present, RHUS is the first  remedy  to think of. 5
• #Back Pain between  shoulders on swallowing.  PAIN AND  STIFFNESS  IN  SMALL OF BACK; BETTER, MOTION, OR LYING ON SOMETHING HARD; worse,  while sitting.  Stiffness of the nape of the neck. #Extremities Hot,  painful  swelling of joints.  PAINS  TEARING  IN  TENDONS,  LIGAMENTS,  AND    Rheumatic pains spread  over  a  large  surface  at nape of neck, loins, and extremities; better  motion.   [AGARIC.]    Soreness  of  condyles  of  bones.    LIMBS   STIFF,  PARALYZED.   THE  COLD FRESH AIR IS NOT TOLERATED; IT  MAKES  THE  SKIN  PAINFUL.6
• #Respiratory Organs Frequent  tickling  irritability in the air-passages,  as  if  it  would provoke cough, that makes the breath short, that disappears  on  moderate exertion. Exterimitis -All  the  limbs  feel  stiff  and  paralyzed,  during  and  after walking;  with a  sensation  of  a  hundred  weight  upon  the   nape  if  the    Sensation   of stiffness on first moving the limb, after rest. The limbs upon which he lies, especially the  arm,  fall asleep. The  flesh  on  the  limbs pained as if beaten to  pieces;  she did  not dare  to  touch  it, since the pain was greatly  aggravated thereby.  Pain,  as if bruised, in those limbs and joints upon  which he does  not  lie, in the morning in bed. 7
• #Limbs -Swelling, stiffness, and paralysed sensations in  joints,  from  sprains,  over-lifting, or over-stretching. Lameness,  stiffness,  and pain on first moving after rest, or on getting up in morning,  better by constant motion. Trembling or sensation of trembling in   The limbs on which he lies, especially arms, go to  sleep.  Rheumatic  tension,  drawing,  tearing  in  limbs,  during  rest. Excessively cold hands and feet all day. #Generalities -We  are  led  to  think  of  this  remedy  where  we  find   an  irresistible  desire to move or change the position every  little  while  followed by great relief for a short time, when they  must  again move, and experience the same relief for a short time, this  condition is usually worse at night. After resting for a time, or  on  getting  up from sleep, when first moving  about,  a  painful  stiffness  is  felt, which wears off from continual  motion,  but  relief  is  experienced from continual motion .8
• #Neck and Back -Stiff neck  with  painful  tension  when  moving;  of  rheumatic    origin; from a draft.  Pain  in cervical muscles as if parts were asleep, and as if  one    had  been  lying for a long time in  an  uncomfortable  position,    toward evening

.#Limbs in General. Great weakness in limbs; they tremble. All  the  limbs  feel  stiff  and  paralyzed  during  and   after    walking, with a sensation of a hundredweight on nape of neck. Sensation of stiffness on first moving limb, after rest.  Limbs upon which he lies, especially arms, fall asleep.  A   sensation   similar  to  a  trembling  in  arms   and   lower    extremities, even while at rest. Drawing or tearing pains in limbs during rest.  Pains as if bruised, or sprained, in joints.  Cracking of joints when stretched.  Tension,  stiffness  and  stitches in joints;  Agg.  when  rising    from a seat. Rheumatoid  pains  in limbs: with numbness and  tingling;  joints    weak,  stiff, or red; shining swelling of joints,  stitches  when    touched;  Agg. on beginning to move, after 12 P.M., and  in  wet,    damp weather or places; Amel. from continued motion.  Pain,   swelling   and   stiffness  of   joints   from   sprains,    Over lifting or overstraining.  Inflammatory  rheumatism,  from  exposure to  cold,  followed  by    paralysis  of  right side; pains almost constant in  right  side;    marked  periodicity,  coming on at 10 P.M. and  lasting  until  6    A.M.;  Agg.  in winter and before a storm, during a  storm  pains    over  whole  body;  intense  pain  on  moving  after  rest,   but    continued motion relieved.  Chronic  inflammation  of articular structures,  especially  when    resulting from blows, strains, etc. Synovitis; spurious anchylosis. Swelling of hands and feet. Phlegmonous erysipelas of limbs. Eruption  on  limbs,  with intense itching, Agg.  at  night,  and  when putting hands in hot or cold water  #Nerves Great  restlessness:  inclination  to  move  affected  parts;  at    night;  has  to  change  position frequently;  it  seemed  as  if    something  forced him out of bed; could not sit still on  account    of  internal  uneasiness,  but  was  obliged  to  turn  in  every    direction on chair and move limbs.  Weakness: with desire to lie down; over whole body; weary as   if  deprived  of  sleep;  of limbs, mostly during  rest;  in  morning    does  not  wish to rise and dress; feels as  if  sinking  through    bed;  as if bones ached; constantly desires to sit or  lie  down;    especially on walking in open air. Great  debility  with soreness and stiffness, Agg.  on  beginning    to  move;  Amel.  from  continued  motion,  but  soon   fatigued,    requiring rest again.  Numbness: in extremities, with previous twitching and    tingling  in them; in the parts of which he lies.  #Tissues Acts on fibrous and muscular tissues.  Soreness   and  stiffness  in  muscles,  pass  off   during   any    exercise.  Flesh of affected parts sore to touch.  Pain as if flesh were torn loose from bones; or as if the   bones  were being scraped.  Pains  as  if sprained in outer parts; disposition  to  sprain  a    part  by  lifting heavy weights, or stretching arms  high  up  to    reach things.  Inflammation  of  tendons  of  muscles,  from  over  exertion  or    sudden wrenching as in case of a sprain.  Affections of ligaments, tendons and membranes, connected    with  joints. Bad effects of getting wet, especially after being heated.  In inner parts sensation of fullness; or as if they were    grown  together (adhesion) or as if something in them were torn   loose.9

• The complaints of this remedy come on from cold damp  weather,  from being exposed to cold damp air when perspiring. The  patient  is  sensitive to cold air and all his complaints are  made  worse  from  cold and all are better from warmth. In a general way,  the  aching  pains, the bruised feelings over the  body,  restlessness  throughout  the limbs, and amelioration from motion are  features  that  prevail  throughout  all conditions of Rhus.  While  he  is  better  from motion and better from walking, if he  continues  to  walk he becomes exhausted. Any continued exertion of the body  or  mind  exhausts  the  Rhus    He  suffers  from  rheumatic  conditions  with  pains in the bones, lameness  in  the  muscles,  lameness  in the tendons, ligaments, and joints from  suppression  of  sweat,  from becoming chilled. These occur  with  or  without  fever.  Rhus is suitable in old chronic rheumatic conditions.  He  is  stiff,  lame, and bruised on first beginning  to  move.  This  passes  off on becoming warmed up, but soon he becomes  weak  and  must rest. Then comes the restlessness and aching and  uneasiness  which drive him to move and which again make him better, but soon  he becomes weak and these continue, so that he is never perfectly  at  ease and never finds rest. 10
• these rheumatoid pains affect every part of the body ,especially the limbs and joints ,and are all aggravate by the rest ,and relieved by motion. Lower extremities “ lameness and stiffness, and pain on first moving after rest or on getting up in the morning ,relieved by continued motion “-Hg .11
• “Rhus also induces pains, apparently of a rheumatic kind, and which are felt  not only in the limbs but in the body though most especially about joints pain and stiffness in the lumbar region are often induced and to these affection is often added a sense of numbness in the lower extremities .12

The study are focused on  the stiffness of various joint i.e. neck, shoulder, back, knee, ankle with heel    with or without pain  and  Continues observation of drug action on more than four years  on the  265 case  details are given in table  .

Total case	Male and female	Age  30-40	41-50	51-60	61-70	71-80
265	126 male139 female	71	62	59	53	20

Observations found and its discussion

1. The Rhus tox are the initial choice of drug when any adult patient gives the chief discomfort as stiffness or feel of stiffness in the joint, whole year but mainly in the rainy or winter weather. The person habitual to cooling instrument are also suffering from the mild to moderate level of the stiffness.
2. The clinically neck and shoulder stiffness present in the many form i.e. neck Along with shoulder stiffness or pain, with vertigo or headache. When the only stiffness are present then the Rhus tox lonely sufficient to control it, while when along with other disorder then this drug facilitate the function of other medicine, means when vertigo then cocculus indicus , when crepitation sound in neck and shoulder then argentum met, and with pain then belladonna ,arnica, ferrum phos, hepar sulphur as need or indication of disorder.
3. Back and chest are only present mild to moderate stiffness and it ameliorate by rhus tox only
4. Stiffness in the waist or Hip joint along with or without knee joint commonly make the troubleshooting standing or upstairs movement with moderate to marked pain and always need the association of any one drug of following i.e.  belladonna ,arnica, ferrum phos, and when crepitation sound are present   then argentum met is also needed
5. Commonly Rhus tox prescribing for early amelioration  200 potencies 10-15 drops are more effective instead of 30 and 1M,  when give in the 5-10 drop or less the start of relief takes much more time and provide  short duration  relief . for the mild case  daily night dose of 200c is sufficient for resolve the discomfort but in  the moderate to marked case  minimum two time in a day up to the   four time  and 10-15 drop every  time  and it provide the option in place  of the NSAID without gastric discomfort .
6. When the patient come with complain of stiffness along with pain it is necessary to rule out the other disorder of joint mainly large joint, because during investigation it is found that hypocalcaemia and vitamin D deficiency are present in the moderate to severe level, and when the supplements of   both component are administrated orally then amelioration are  too much rapid .   it is commonly found in the knee disorder that most of the person unknown to  deficiency of calcium ion  and  element with the vitamin D  .

Conclusion
Observation shows that when any joint of body and associated muscle  i.e. small as well as large are stiffness due to non inflammatory / inflammatory Musculoskeletal disorder,  age factor or environmental change or any other cause even after injury, Rhus tox separately or association with other needed drug having marked effect on the recovery of stiffness disorders in rapid and gently manner , the disorder of the stiffness have the marked tendency of the periodicity  after alterations in the temperature . After adequate use this remedy increased the flexibility of the body and reduced the frequency and  intensity of the joints  stiffness with pain.

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Dr Puneet Kumar Misra
Lecturer(Practice of Medicine)
Govt Pt J LN H M C  Kanpur