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Case Report
4 (
4
); 120-127
doi:
10.25259/JISH_31_2021

Role of homoeopathic medicine in the treatment of a case of carpal tunnel syndrome with dysthymia: A case report

Department of Organon and Homoeopathic Philosophy, Dr. M.L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India
Department of Medicine, Dr. M.L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India
Corresponding author: Manali Kirti Jain, Department of Medicine, Dr. M.L. Dhawale Memorial Homoeopathic Institute, Palghar, Maharashtra, India. jainmanali31@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Kapse AR, Jain MK, Sarvagod HS. Role of homoeopathic medicine in the treatment of a case of carpal tunnel syndrome with dysthymia: A case report. J Intgr Stand Homoeopathy 2021;4:120-7.

Abstract

This case report focuses on 50-year-old woman who was diagnosed with dysthymia and carpal tunnel syndrome (CTS). After reviewing her detailed history, she was prescribed homoeopathic medicine Natrum Carb considering the grief after death of her middle daughter, suppression of emotions since her childhood and her characteristic mental state of desiring to be alone and weeping when alone; her characteristic physical generals and dispositional qualities were also considered. After taking homoeopathic medicine, significant improvement occurred in her subjective symptoms such as paraesthesia as well as in the objective CTS-related signs such as the Tinel sign and Phalen test. Her anger, weeping spells, sleep disturbances and sadness were ameliorated as well. Homoeopathic medicine was found to be effective in relieving CTS and dysthymia in this case. Further research is needed to prove the efficacy of this treatment method in this disease.

Keywords

Carpal tunnel syndrome
Dysthymia
Homoeopathy
Case report

INTRODUCTION

Carpal tunnel syndrome (CTS) is the most common form of median nerve entrapment syndrome. Approximately one in five symptomatic individuals are expected to have CTS based on clinical examination and electrodiagnostic (ED) studies.[1] It is more common in women. Comorbidities are seen in approximately 75% of patients; hypertension is a comorbidity in approximately 25% of patients.[2]

Dysthymic disorder is the best characterised as long-standing fluctuating low-grade depression, experienced as part of the habitual self and representing an accentuation of traits observed in the depressive temperament. According to the World Health Organization, as of 2021, depression affects an estimated 3.8% of the global population, approximately 280 million people.[3] In 2017, 45.7 million people had depression in India; depression had the greatest contribution to disability-adjusted life years due to mental disorders.[4]

Clinical features and diagnostic tests of CTS

CTS has symptoms due to compression of median nerve. Clinically, it is diagnosed by Tinel sign, Phalen’s manoeuvre and flick’s sign.[5] Electrophysiologically (EP) via nerve conduction studies and electrodiagnostically (ED) via ultrasonography of the wrist joint are done which are considered gold standard for diagnosis. However, according to many studies, utility of the ED and EP testing in evaluation of CTS is also a question.[6,7]

Clinical features and diagnostic criteria of dysthymia

DSM V has laid down criteria for diagnosis of dysthymia.[8] The point H is further elaborated in Kaplan as dysthymic disorder is typically an ambulatory disorder compatible with relatively stable social functioning. However, the stability is precarious. The dedication of persons with dysthymic disorder to work has been suggested to be overcompensation and a defence against their battle with depressive disorganisation and inertia.

Treatment

Treatment options for CTS include non-surgical and surgical methods.[9] The prevalence and incidence of CTS increased from 1993 to 2013 with increased rates of surgery.[10] Hence, it is required to understand the role of homoeopathic medicines in CTS so that we can prevent unnecessary surgeries in patients.

Treatment options for dysthymia include non-pharmacological, pharmacological and a combination of both.[11] Despite significant psychopharmacological advances in the past six decades, the management of major depression and other mood disorders continues to challenge mental health providers as these drugs have considerable adverse effects. Many patients with mood disorders who are dissatisfied with conventional treatment seek other interventions, in particular complementary and alternative medicine.[12]

Few studies are available regarding the role of homoeopathic medicine in the treatment of CTS. The homoeopathic medicine Arnica Montana is widely used in cases with inflammation, swelling or bruises. Hughes-Games states that Arnica 6C was effective in post-operative swelling and bruising in CTS surgery.[13] Another double-blind randomised comparative study demonstrated a significant reduction in pain after 2 weeks of administration of homoeopathic medicine in patients with CTS compared to the placebo group.[14] A pilot study showed that Bach flower remedies cream was effective in the management of mild-to-moderate CTS, reducing symptom severity and providing pain relief.[15] A study showed that homoeopathic medicines might be comparable to antidepressants and superior to placebo in depression;[16] patients with anxiety and depressive disorder who chose to consult general practitioners prescribing homoeopathy reported less use of psychotropic drugs and were marginally more likely to experience clinical improvement.[17] The database on studies of homoeopathy and placebo in psychiatry is limited; however, studies show some benefit of homoeopathic treatment for patients with self-reported depression.[18]

A study showed significant correlation of subjective symptoms of CTS with psychological factors, rather than EP severity; prompt treatment of psychological comorbidity is an important in the management of CTS.[19] We present a case report of a patient with CTS and dysthymia who was treated with homoeopathy using individualisation.

CASE REPORT

Preliminary data

Mrs. N.B. 50/F, shopkeeper, came for consultation on 3 October 2019.

Chief complaints

Chief complaint is written in the LSMC format[20] for better clarity [Table 1].

Table 1:: Chief complaint in the LSMC format
Location Sensation Modality Acc
Musculoskeletal system
Since 1–2 months
B/L forearm extending to hand occasionally
Mostly extending from wrist (volar aspect) to hand, L>R
H/O similar complaints 5–6 months back, variable
4 years back
Neck extending till upper arm
Paraesthesia and numbness
Tenderness: Subscapular and mid scapular region
Stitching and pricking pain all over the body
Underwent treatment for cervical spondylosis
Symptoms were pain and radiculopathy
Radiographsuggested cervical spondylosis. The film is unavailable
<Holding object for a long time
Circulatory system for 2 years
F: Variable
D: Variable
Occasional
Hypertension detected
Alternate heat and cold flushes with perspiration
Heaviness of chest with difficulty in breathing
A/F: Shock, grief death of middle daughter<warmth>draft of air++
Mind:
Emotion
for 2 years
Low depressive mood
Decreased sleep
Constant thoughts
Purposefully, occupies herself with work to avoid thoughts ending in fatigue
Weeping spells
Socialises but now desire to be alone
App: Not altered
A/F: Shock, grief death of middle daughter<alone

Patient as a person

  • Appearance and behaviour: Melasma

  • Appetite: Hunger <, craving: Sweets+2, aversion: Sour+2 and milk+3

  • Menses: Staining and menopausal for 1 year

  • Coldness: Palms and soles (tips of fingers > palms)

  • Thermals: Chilly, sun <3 headache. Joint pains in winter, desires open air.

Life space

The patient had cordial relations with family. She refused to speak about her childhood apart from that she had an irritable and excitable temperament. The family’s financial condition was weak as father died when she was young, so she worked to help them.

After marriage, she had daily arguments with husband, as he was censorious, alcoholic and never did what she asked. He did not handle the financial and other responsibilities well, which irritated her. The husband has hit her several times under the influence of alcohol. Her father-in-law (FIL) would protect her. During bouts of anger, she contemplated suicide by hanging from the fan but never attempted it. For 8–10 years, her impulsivity and anger have reduced after attending religious assemblies; she started listening 90% and spoke 10%. At present, the husband is unemployed due to his illness. She did not allow him to work, as he would squander money. She also felt that if he injured himself, it would create consequences for them. She opened a small shop 12 years prior using her savings and with her brother’s support; she manages it by herself. Her younger daughter earns; the elder daughter, who is married, provides some financial help, which patient mostly refuses. The FIL passed away 3 years prior; since then, patient’s husband has developed chronic kidney disease. Due to this, her savings fall short, which creates future anxiety. The care provided by patient has improved her relations with her husband.

The patient was most attached to her middle daughter, and she was the most pampered child. The daughter would get angry on petty issues. She would share her feelings with the patient who would console her saying that Shravan (God’s disciple) has told them not to get angry easily and she would also take her to religious assemblies to resolve her anger issues. Two years prior, the daughter committed suicide without any apparent reason. When the patient came to know this, she was in a state of shock. She felt sad and still feels the grief deep within. The patient continuously thinks about the daughter and weeps when alone. She wonders why her daughter took such a step the patient feels that she raised her daughter with love despite the numerous difficulties; the daughter should have considered the mother’s feelings before taking such a step. Since then, the patient has developed above complaints.

The patient wants things done according to her specifications or else does not like it. She gets angry, which lasts for 5–10 min; she screams in anger then calms down. The patient is quite obstinate.

Examination findings

General

T: Afebrile, P: 80/min, RR: 20/min and BP: 160/98 mmHg.

Systemic

RS: AEBE, clear, CVS: S1S2 heard, P/A: NAD and CNS: Conscious and oriented.

Local

Tenderness: Subscapular and mid-scapular region, cervical ROM: Free, cervical impingement test: Negative, Tinel sign: Positive and Phalen sign: 30 s. No sensory and motor deficit.

Mental status examination

Appearance

50/F wearing spectacles, partially groomed, restless and fidgety hands.

Behaviour

Calm, cooperative most of time, not maintaining eye contact and weeping.

Speech

Low tone, pitch low, taking time to answer.

Content of speech

I do not have anything, I just work all day, try to keep myself occupied because of thoughts, stress of house.

Thoughts

Constant thoughts of death of daughter, she was already irritable and she committed suicide at her in-law’s place.

Perception

No illusions or hallucinations.

Orientation

Oriented to time/place and person.

Insight/judgement

Grade III/fair.

Understanding the clinical entity

Dysthymia

As mentioned in the introduction, we can clearly see the patient seems to fulfil all the DSM-V criteria for diagnosis of dysthymia. From criteria B, insomnia and low energy are found in this case.

Essential hypertension

No pathological cause for hypertension could be identified and a significant temporal relation with stress can be seen. No investigations were done to exclude secondary causes of hypertension.

CTS

Considering the positive Phalen sign and Tinel sign with paraesthesia extending from the volar aspect of the wrist to the hand, CTS was confirmed despite the presence of subscapular and mid-scapular tenderness and a history of cervical spondylosis.

Final diagnosis

Dysthymia with essential hypertension and CTS.

Understanding of patient

The patient is depressed and desires to be alone due to her grief regarding the death of her middle daughter, which created a state of shock in her. She is constantly dwelling on the grief of the same and weeps when alone; to avoid the thoughts she resorts to religious means and forcefully occupies herself in work. We see that there is predominant suppression of emotions for many years when she considered ending her life. Her relationship with her husband also has not been cordial, whereby she has suppressed her emotions and anger and found solace through religion [Figure 1].

Figure 1:: Understanding of the patient.

Repertorial totality

Refer [Figure 2].

Figure 2:: Repertorial totality of the case.

Differentiation of remedies

We compared Nat Carb and Sepia. Dr. Hering writes about Nat Carb ‘an inability to think or perform any mental labour even if he tries to exert himself and at the same time in evening restlessness of body unless he exerts himself mentally. Sadness, depression of spirits, an intolerable melancholy and apprehension; she is totally occupied with sad thoughts; aversion to society and mankind; estrangement from individuals and society from her husband and family.’[21]

Sepia also has a state of indifference and becomes estranged from the family. Dr. Hering states, ‘Heavy flow of ideas, inability for mental activity. Felt all day as if he did not care what happened, no desire to work, every few minutes inclined to cry, without knowing the cause. Great sadness and frequent attacks of weeping which she can scarcely suppress. Discontented with everything. Very nervous and great excitability in company. Aversion to family and one’s occupation. Irritability alternating with indifference. Dread of being alone. Quiet, introspective, rarely speaks a word voluntarily, sits for hours knitting, her answers are intelligent but curt.’[22]

Differentiation between both the remedies is represented in a diagrammatic manner below [Figure 3].

Figure 3:: Differentiation between Nat Carb and Sepia compiled from various authors.

We see that in Sepia, the grief and indifference are associated with a lot of discontentment, excitability, vexation, answering curtly and dreads to be alone. Whereas in Nat Carb, the emotions manifest in the form of being alone, suppressing her emotions and dwelling over it as she is constantly occupied by them hampering her performing capacities. Physically, the sun aggravation, intolerance to hunger and milk aversion, worse by heat which is predominantly marked is also more covered by Nat Carb. Sepia lacks this sensitivity to warmth and sun and has in specific aggravation from boiled milk. Both remedies have an affinity for the circulatory system; however, Sepia has predominantly venous affections whereas Nat Carb has arterial affections as seen in the form of heat, redness and congestions.

Posology understanding

Tissue susceptibility

  • CTS: Chronic, reversible, absence of atrophy of muscles and sensory and motor deficit, slow, gradual onset with static progression

  • Dysthymia: Slow, gradual onset with persistent pattern. Suicidal ideations in the past but no attempts made. Functional disease

  • Essential hypertension: Chronic, gradual onset with static progression, functional disease, structural changes not assessed and no sequelae due to hypertension

  • Availability of characteristic symptoms at the mind and general levels

  • Sensitivity (at level of mind and nerves): High

  • Reactivity: Moderate

  • Remedy correspondence: High (at level of mind, mental causation and modalities, physical generals and disposition)

  • Fundamental miasm: Syco-syphilitic

  • Dominant miasm: Sycosis

  • Conclusion of posology: To start with 200 weekly repetition and may require 200 3P weekly or daily doses.

Final selection of remedy and posology

Nat Carb 200C 1P HS weekly.

Follow-up criteria

  1. General sense of well-being

  2. Low depressive mood: Forces herself to involve in work

  3. Low depressive mood: Thoughts when idle

  4. Low depressive mood: Weeping spells

  5. Anger and irritability spells

  6. Disturbed sleep when once woken up

  7. Disturbed sleep due to thoughts

  8. Appetite

  9. Heaviness of chest

  10. Paraesthesia

  11. Blood pressure in mmHg

  12. Phalen sign.

Follow-up of the case

S=SQ, Fl=Fluctuating, >=Amel, <=Agg, G=Good, D=Duration, I=Intensity, F=Frequency and + = Present [Table 2].

Table 2:: Follow-up of the case.
Date: Follow-up Action
1 2 3 4 5 6 7 8 9 10 11 12
10 October 2019 > S S S S > S S S >> 130/84 30 s Nat Carb 200 1P HS weekly
17 October 2019 Fl > > > > Fl Fl G > > 140/84 45 s Nat Carb 200 1P HS weekly
31 October 2019 Fl S >> A A S A G >> S 120/80 45 s Nat Carb 200 3P HS weekly
BP measured was with regular intake of anti-HTN tablets. Tinel sign was positive.
14 November 2019 Fl S S A A S A G >> > 126/80 25 s Nat Carb 200 1P HS daily
Tinel sign: Negative. Mood symptoms>5% with heat flushes.

Summary of the follow-up

There was a significant improvement with Nat Carb 200 1P HS daily in subjective and objective symptoms of dysthymia and CTS. Melasma, paraesthesia and sleep have improved. Her mood has stabilised; there were no weeping spells during festivals or on seeing people of her daughter’s age. She was taking anti-HTN medications irregularly but her BP was maintained in the range of 110–120/80 mmHg. On 15 June 2021, there were weeping spells when alone and BP was 140/90 mm Hg post-death of her husband due to CKD. She took anti-HTN medication for 15 days then stopped on her own. However, post that, the BP was maintained in the range of 140/80–90 mmHg with sadness. Paraesthesia was absent. She was prescribed Pulsatilla 30 BD for 3 days followed by Nat Carb 200 1P HS daily which did not help, she was shifted to Nat Carb 1M 1P HS weekly.

Patient-physician interaction

The physician applied her clinical knowledge and skills to differentiate between cervical spondylosis and CTS through appropriate tests and history. It is not easy to remain an unprejudiced observer while dealing with a life space containing so many painful experiences. It is essential to have equanimity with qualities such as sound senses and fidelity in tracing the portrait of disease as described by Dr. Hahnemann to erect a totality and treat the case. This was not the case with the physician here, who had no faith in her ability to handle the patient’s state and was in a constant state of conflict regarding her duty. The physician handled this by repeatedly poking the reserved patient for the purpose of diagnosis or obtaining symptoms. The physician did not give the patient the right to be with herself in her sorrows. The physician was constantly troubled with the idea that she has diluted patient’s experience and did not take the case in a way that could free the patient from her suffering. These thoughts created restlessness and blocked the physician who could not perceive what was available to her and was finding ways to free herself. The physician finally found a release to her feelings in the form of a poem.

DISCUSSION

In this case study, we do not see a dependent relationship between the subjective symptoms of CTS and psychological factors; in fact, despite her husband’s death, her CTS symptoms continued to reduce. However, this is a single case report; a better research study design and larger sample size need to be implemented to derive conclusions at the general level.

Nat Carb, which was selected on the basis of holistic understanding of the patient (classical individualised homoeopathy), brought about improvement in the subjective symptoms such as paraesthesia and objective signs such as Phalen sign and Tinel sign. The patient has not progressed to the advanced stage of CTS, which includes muscle atrophy, muscle weakness, limitation of daily activities and requiring surgical intervention. There has been significant stabilisation of the mood; her sadness, desire to be alone and weeping spells reduced. Moreover, there was better tolerance to precipitating factors such as husband’s death and seeing someone her daughter’s age. The suicidal ideations disappeared and disturbances in sleep have improved.

Nat Carb was not able to maintain the blood pressure to the precipitating factors but has brought change at the level of hypertension despite absence and irregular use of antihypertensives. We see that homoeopathy definitely has a role in controlling the blood pressure, but to understand its long-term efficacy requires patient compliance, proper planning of treatment by physician and monitoring of the antihypertensive doses and blood pressure.

The use of an acute or phasic remedy to treat the exacerbation of dysthymia seemed to be ineffective in this case, which indicates that dysthymia requires an individualistic approach. We see that improvement should be first seen at the general level despite improvement seen at the local level; if the reverse occurs, revision of the posology is necessary. This proves the holistic concept of homoeopathy and Kent’s observations.

CONCLUSION

Homoeopathic medicines have a significant role in the treatment of CTS with dysthymia. However, further research with larger sample sizes is required to derive better outcomes.

Acknowledgments

I would like to thank Dr. Shama R. Rao, Dr. Nikunj Jani and Dr. Kamlesh P. Mehta for their valuable contribution, guidance and support.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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