Clinical Herbalism Journal
"A Case Study in Auto-Immune Arthritis"
by Clinical Herbalist, Sarah Ritter
Overview
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A 66 year-old woman, a professional with a somewhat stressful job and mother to grown children, came to the Acorn Clinic in December 2021, suffering from systemic inflammation that affected her joints. She had recently attended a seminar of Paul Bergner’s on Systemic Inflammation, Food Intolerances, and Autoimmunity and sought out an appointment with one of Paul’s students. She weighed 113 lbs at intake and was 5’7”. She was pale and very thin, with dark circles under her eyes and said she suffered from dry skin, especially on the bottom of her feet which were scaly and itchy. She said she had always had cold hands and ankles, always wore a scarf (even in summer) to protect her neck from cold breezes, and slept under many layers of blankets.
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She was diagnosed with Rheumatoid Arthritis in March 2020, right around the onset of the pandemic. She was gardening and twisted her ankle. The next morning it was bruised and swollen. 2 weeks later she had a severe inflammatory episode. Every joint in her body was swollen and painful. She couldn’t open her mouth, lift or carry anything. The pain exhausted her and she laid down at 6pm for bed because she couldn’t handle the discomfort. Her joints were extremely swollen and large, with fingers like sausages, stiff and immovable. She had sacks of fluid on top of her hand, which she later had drained.
She saw her acupuncturist 3 times a week, until he told her the issue was systemic and referred her to a rheumatologist. The rheumatologist put her on prednisone, 5mg. She didn’t get better and saw another rheumatologist who upped her prednisone to 15mg. It worked. She titrated back down to 5mg but had not been successful titrating any lower than that without her symptoms returning. She came to see us with this one goal in mind - to get off of steroids without rebound inflammation. I asked her what else was going on at the time of onset and she said she had coached a good friend who was dying of cancer through the death process. She had also started taking a class on how to refinish her basement around the same time. It’s possible that mold from her basement plus emotional upheaval could have sparked the health crisis. She had tested positive for Lyme, although she never remembered being bitten or ill from a tick bite. She also had Mononucleosis (EBV) years prior.
"She was likely deficient in protein, vitamins, and minerals from a recent raw vegan diet, which she followed for more than 6 months."
She was likely deficient in protein, vitamins, and minerals from a recent raw vegan diet, which she followed for more than 6 months. She admitted it was supposed to be a 28 day cleanse per the Medical Medium book, but that she extended it hoping for relief from inflammation. She later added small amounts of meat and fish as well as grains because she felt like she wasn’t getting everything she needed, and said she very occasionally ate eggs and cheese. She was underweight after losing 10 pounds from the diet and said she no longer had any fat on her body at all.
As for secondary complaints, she said she had suffered from chronic nasal congestion and drainage since she was a child, and suspected allergies to Roses and Locust trees. She complained of no digestive issues except not feeling satisfied after meals and occasional flatulence but I assumed she had leaky gut syndrome from more than a year of steroid use and because her systemic inflammation and seasonal allergies suggested a food intolerance. She had also recently been diagnosed with Osteopenia and put on Fosamax for declining bone density. Finally, she mentioned that she experienced neuropathy in her arms with the onset of her RA.
She got adequate sleep, usually 9 hours, and did biofeedback if she ever had any problems getting to sleep, which worked well for her.
Therapeutic Strategy
Since my client was very likely protein deficient, I suggested 65g per day, with a minimum of 25g of protein for breakfast - preferably warm, cooked food to warm up her very cold constitution and spark her digestive fire. But she didn’t like eating eggs or breakfast meat in the morning and added 20g of collagen powder to morning oatmeal instead. I informed her that protein was absolutely essential for musculoskeletal healing and that recent evidence indicated higher protein diets appear to be protective against bone loss, increasing bone mineral density. Also, adequate protein builds muscle mass, and acts as an immune tonic by helping regulate many components of our immune system.
At our second monthly appointment, I recommended an elimination diet, which she was reluctant to try as the raw vegan diet hadn’t worked (although she noted that she had felt better on it than she ever had). I explained that in our Vitalist practice it’s usually the key to alleviating chronic ailments – especially systemic inflammation and autoimmunity, and that she probably felt better on the diet because she had eliminated food allergens like dairy and/or eggs but couldn’t heal because she was so deficient in nutrients, didn’t work on healing her gut, and didn’t titrate the Prednisone to allow her adrenals to start working on their own again. She also continued to eat gluten on the diet, which is a common culprit of inflammation in RA, and nuts, which she said she craved (specifically peanut butter). What we crave is often the food allergen we shouldn’t be eating, but I now suspect she was craving the bread that she ate the peanut butter on or protein in general. She wasn’t ready to give up gluten so we chose nuts and seeds, which she hadn’t tried eliminating on her raw vegan diet. She cut them out completely for 4 weeks. I also suggested she include healthy fats in her diet, unrefined coconut, avocado, and olive oils daily, and asked her to try to eat 8 servings of fruits and vegetables a day, including leafy greens. Finally, I told her to limit sweets and processed foods as much as possible.
I also recommended the following supplements to build up her nutrient reserves, which were severely depleted by her diet. She was reluctant to try any more supplements because she’d spent so much money on a host of expensive supplements that were recommended by the Medical Medium that didn’t work, but agreed to try one round of them.
I recommended she start on 400 mg of magnesium glycinate a day, divided, as it’s integral for bone and muscle health, sleep, and so many functions. It’s the most common mineral deficiency in the US due to declining soil quality (almost all of us are deficient without supplementation).
Vitamin D3 strengthens the immune system and regulates autoimmunity, and is impossible to get from the sun during the winter months where she’s located. I suggested 5,000 IU per day as a D/K combo to further help with bone health.
"Vitamin D strengthens the immune system and regulates autoimmunity"
Omega 3 promotes sufficient levels of prostaglandins, lessen inflammation, and helps dryness. I suggested 2000 mg per day of EPA/DHA until we built up her reserves, then 1000 mg per day as a maintenance dose. She later found this to be indispensable in managing her inflammation. I recommended a good multivitamin to restore her B vitamins and zinc and 2500 mg of vitamin C to help with regulating immunity, leaky gut, and inflammation.
She did Pilates regularly, and I asked her to continue to do some light movement daily, such as a 30 minute walk to move her lymph and increase vitality and immunity.
With the elimination diet I added a gut healing powder composed of Marshmallow root, Calendula flower, Plantain leaf, Cinnamon bark, and Fennel seeds to heal the gut. She didn’t like this initially but loved it later and took ½ teaspoon twice a day mixed in a banana, nut butters, or just as a tea.
"A month after she started making all these changes, she seemed much happier, and looked more vital - relaxed yet energetic. She told me her neuropathy had completely gone away for the first time in two years, and that her feet were no longer scaly yet still dry."
She reported that she didn’t like taking her fish oil because she had to take so many capsules to get what she needed so we found her a different brand that required only 2 per day. She successfully and without issue re-introduced nuts - one new kind every 3 days. Nuts were not an issue for her. She was still taking collagen protein every morning, but did not further increase protein in her diet and asked if she could somehow just eat plant proteins. I explained that lectins in beans were likely to further damage her gut, and impair digestion, and that soy proteins were usually highly processed and posed health issues as well. We talked about meats she might be open to eating - meatloaf, hamburgers, beef stew, and she agreed to try to incorporate more meat into her diet, as well as garlic for warmth.
Evolution of the Case
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We then talked about eliminating gluten from her diet; she said she knew I was going to suggest that she give it up and was now ready to do so. She agreed to cut out gluten and oats (which can be cross-contaminated with gluten and contain proteins called 'avenins' that are similar in structure to barley) completely for the next 6 weeks. She replaced her morning oatmeal with buckwheat, which is packed with nutrients. She struggled to find a bread she liked although I provided recipes, sent discounts to a grocery delivery service that carries a good gf/df (gluten-free/dairy-free) bread, and recommended specific brands I liked. She found gluten elimination particularly challenging, and disliked having to cut it out. It’s interesting that she had easily cut out so many foods on her recent raw vegan diet (meat, fish, poultry, eggs, dairy) without much issue but was emotional about cutting out gluten. This was a hint that gluten was a probable antigen for her.
"an anti-inflammatory formula of Plantain, Turmeric, Rose, and Anise in a paste of honey and lemon to balance the dryness..."
She also started titrating Prednisone at this time, under advisement of her doctor, and planned on reducing it by 1mg every 3 weeks. I suggested an anti-inflammatory formula of Plantain, Turmeric, Rose, and Anise in a paste of honey and lemon to balance the dryness but she didn’t feel this was necessary. I should have insisted she take this before titrating but didn’t push.
3 days later she called to say she was experiencing the old RA symptoms of swollen joints and stiffness. Although we had talked about irreversible tissue damage that can come with major inflammation, she thought that since the titration was such a small step down (from 5mg to 4mg of Prednisone), she wouldn’t need any additional herbs to manage. I immediately put in order for the anti-inflammatory honey paste and sent it out ASAP.
I checked on her a few days later, before she received the formula, and her inflammation had gone down considerably and was no longer concerning, more of a nuisance. Maybe her body was responding to gluten removal with a drop in inflammation? We agreed to talk in a week. The next week she told me she had accidentally taken a 5mg Prednisone instead of 4mg and so kept on with this throughout the week, when she again stepped down to 4mg. She said she noticed almost no symptoms stepping down this time, just a little stiffness in the knuckle that had always bothered her. She said she noticed the anti-inflammatory paste seemed to free up movement, but not in a grand way. She hated the taste and could only eat it in a banana. We agreed to temporarily increase her fish oil dose while she was titrating, up to 3000 mg to further manage inflammation.
She had no issues stepping down to 3mg of Prednisone 3 weeks later, and said she no longer experienced neuropathy or joint pain, but still had stiffness and swelling in her hands in the morning, and if she used them too much doing something like gardening.
She said her joints didn’t feel the way they used to, that she could bend them, had more flexibility, and that they weren’t constantly hot. She said she thought her issue wasn’t really the joints, but the ligaments and tendons that surrounded them. “You know they are getting better when they think they don’t have their actual diagnosis anymore!” Heather Luna, the clinic director, observed.
“You know they are getting better when they think they don’t have their actual diagnosis anymore!”
But she developed a new symptom - stiffness in her right wrist, which may have been an unraveling of symptoms. Although she was still adhering strictly to the gluten and oat elimination, she expressed that she didn’t believe gluten was a problem - that the root cause was EBV, as the Medical Medium suggested. I counseled that even if EBV was the root cause, all of the vital therapeutics should heal her body enough to be able to deal with it.
She ordered more gut healing powder and continued with all of the supplements, which she felt were helping. I suggested adding weight bearing exercise to help with her bone density, as well as ensuring she got enough calcium in her diet with at least 2 cups of cooked leafy greens like chard or kale and 2 handfuls of almonds, and on days she didn’t eat those, to add bone powder not to exceed 300 mg. I also recommended she add a capful of organic aloe to her drinking water every day to help with dryness. She had previously tried adding marshmallow root powder and didn’t love the taste so had stopped doing it. I again stressed the importance of protein for bone health and warming foods for overall health although I suspect she still didn’t adhere to these.
The next month she titrated down to 2mg. She noticed that she had a swollen area between her fingers but said it didn’t feel like the fluid pockets she used to get. Taking her fish oil in the evening instead of morning helped with stiffness that arose from a day of heavy use. She reported that she hadn’t been using her anti-inflammatory paste because she hated the taste and felt intuitively that it wasn’t a good fit. I reformulated it with Turmeric, Frankincense, and Ginger in a honey paste and she loved it as a tea and was compliant going forward. I should have reformulated earlier. Her symptom scores of joint pain, neuropathy, and achiness were all zero at this point and since she hadn’t been complying with the anti-inflammatory paste, removing gluten antigens was likely responsible for the lack of inflammation. I recommended a nutritive blend to help with her Osteopenia and counseled her on the side effects of Fosamax, which her doctor had prescribed.
Case Results
The client stepped down to 1mg in late April, and then completely stopped taking Prednisone in early May. Hooray! This had been her main goal. She had a well-timed appointment with her rheumatologist to check on her inflammation and learned her CRP was <1 and all blood work values normal. Her doctor was impressed and asked exactly what herbs and supplements she had been taking (but not what diet and lifestyle changes she had made, typical to the Western allopathic model). She also learned that her bone density had improved, increased by 4%, even without supplemental calcium or weight bearing exercise. She reported no increase in symptoms and planned to continue the higher dose of fish oil through reintroduction of gluten. I suggested she add a probiotic to further heal her gut. She discontinued the vitamin C supplement and reported that she had run out of vitamin D and noticed the tingling in her arms had come back, and planned on buying more. I sent her a short term formula to restore her adrenals that were depleted by steroids containing Lemon Balm, Skullcap, Gotu Kola, Licorice, and Ginger and refilled her gut healing powder. This was our last appointment, but I followed up with her two months later.
She had reintroduced gluten, but not as I had instructed. I recommended she eat a large amount at every meal for 3 days to really stir up an immune response. She ate just a small amount of pasta for one day and had no issues. So she started eating it again, although not as often as she used to - mindfully, sometimes only every other week. She tried not taking the fish oil and noticed her inflammation would come right back so now takes it religiously. She said she refills the other supplements when she can. Walking every day has been a challenge in the heat of summer but she does other exercises often. She no longer eats as much protein. She reported no complaints otherwise but said her weight was up to 120, a much healthier weight for her height.
I heard from her a few weeks later after she had taken ibuprofen twice a day for a dental problem. She felt less flexibility in her fingers and more stiffness, symptoms the anti-inflammatory honey paste couldn’t get rid of. I suggested she might benefit from eliminating gluten again, maybe challenging it with ibuprofen after 6 weeks. I also suggested Zyflamend, a supplement that works much like Ibuprofen in that it contains herbs that inhibit Cox-1 and Cox-2 modulators. I haven’t heard back since.
Clinical Insights
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I think the most critical factors in this case were gluten elimination and restoring nutrient and protein reserves. The gut powder and anti-inflammatory paste were integral in helping her titrate off of the steroids. Although I fear a relapse with the reintroduction of gluten and lack of protein in her diet, I hope she finds what works for her to feel her best.
"What I have witnessed again and again at the Acorn clinic, is that simple Vitalist techniques can defeat even the scariest of disorders, including autoimmune diseases and Lyme disease. Vitalism is a truly holistic model of healing that addresses the physiological state of our bodies, as well as our diet/nutrition, lifestyle, and psychological and spiritual health. It treats the whole person, not just the symptoms one is experiencing. The vital force communicates with us through symptoms so we may correct the imbalances."
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~ Sarah Ritter, Clinical Herbalist
Vitalists principles for vibrant health
Identify and remove obstacles to cure - removal of obstacles to cure, such as a food intolerance, is essential to health
Nutrition - Well digested and assimilated food appropriate for the specific person is essential to build, sustain, and restore function
Rest/Sleep - A healthy sleep regimen is essential
Exercise - Movement is essential for the vital force to circulate
Breath - Full deep breathing, including that induced by exercise, is essential
Sense of purpose - Alignment with our calling or sense of purpose is essential
Herbal medicines - to support digestion, sleep, and tissue function are foundational in Vitalist medicine