Abstract
Juvenile fibromyalgia syndrome (JFMS) could be a chronic condition characterized by symptoms of chronic diffuse contractile organ pain and multiple painful tender points on palpation. it’s typically in the midst of fatigue, disorders of sleep, chronic headaches, irritable gut syndrome, and subjective soft tissue swelling. The quality of the presenting clinical image in JPFS has not been sufficiently outlined within the literature. Similarities to adult fibromyalgia syndrome in JFMS are typically tough to compare, as a result of several of the symptoms are “medically unexplained” and sometimes overlap oft with
other medical conditions. However, a legitimate designation of JFMS typically decreases parents’ anxiety, reduces inessential additional investigations, and provides a rational framework for a management plan. The diagnostic criteria planned by Yunus and Masi in 1985 to outline JFMS were ne’er valid or critically analyzed. In most cases, the clinical designation is predicated on the history, the physical examination that demonstrates general tenderness (muscle, joints, tendons), the absence of different pathological conditions that would make a case for pain and fatigue, and also the traditional basic laboratory tests.
Analysis and clinical observations outlined that JFMS could have a chronic course that impacts the functional standing and also the psychosocial development of youngsters and adolescents.
This paper shortly reviews the prevailing information on JFMS specializing in the diagnosis, clinical and also the epidemiologic characteristics in youngsters and adolescents for higher understanding of this disorder.
Keywords: juvenile fibromyalgia syndrome, epidemiology, clinical characteristics, diagnosis
Introduction
Chronic pain (defined as persistent and repeated pain) may be a vital downside within the pediatric population, cautiously calculable to have an effect on from 20% to 35% of children, particularly adolescents, round the world (1). In general, pain may be classified into three varieties that generally overlap: nociceptive or peripheral pain(related to wreck of tissue by trauma or inflammation); neuropathic pain(associated with injury of peripheral or central nerves); and centralized pain ( has no specifiable nerve or tissue injury and is believed to result from persistent neuronal dysregulation, active ascending pain pathways, and a deficiency of descending restrictive pain pathways) (2).
Fibromyalgia syndrome (FM) is associate upset condition, of a nonetheless unidentified aetiology, characterized by chronic widespread contractor pain, fatigue and sleep disorders. The pain isn’t caused by native inflammation however is also because of abnormal operate of pain receptors within the brain (3, 4)
Patients with FM ordinarily expertise symptoms for many years before diagnosis. Repeated and infrequently dearly-won laboratory investigations, frequent care visits, and referral to a large vary of specialists contribute to goodish discomfort and price to patients.
Recent guidelines are in agreement that the diagnosing remains clinical, and also the purpose of a definite physical examination and restricted laboratory investigations is to exclude alternative corporal diseases that have similar symptoms (3, 4). This has fostered a way of insecurity in health care professionals resulting in unnecessary investigations, excessive medicalization of patients (5, 6), and referral to varied paediatric specialists (e.g., neurologists, rheumatologists, pain medicine) before the identification of the syndrome.
Although children and adolescents will meet the factors of FM for adults (3), no general accord has been achieved for the diagnosing and management of children and adolescents with chronic widespread pain (7).
This paper reviews concisely the prevailing information concerning the diagnosing further because the clinical and epidemiologic characteristics of FM for higher understanding of the juvenile fibromyalgia syndrome (JFMS) and homoeopathic approach .
Brief history of fibromyalgia
In 1592, withinside the book “Liber de rheumatismo”, Guillaume deBaillou defined a few of muscular pains much like FM. This might be the first actual medical description of FM. An crucial step become made through William Balfour (8), a general practitioner in Edinburgh who become the first, in 1815, to explain “A unique ache, typically pushed through an inflammatory action, concerning fibrous and white tissues, belonging to muscular tissues and joints, like tendons, aponevroses”. He referred to as this big ache “fibrosistitis.”
In 1880, an U.S. psychologist named Beard wrote approximately a group of symptoms along with fatigue, big ache, and mental disturbances. He referred to as it ‘neurasthenia’ and attributed the troubles to the pressure of modern life (9). For many years, loss of a unifying aetiology and a normal terminology hindered the expertise and popularity of FM.
In 1904, a pathologist, Ralph Stockman, mentioned proof of inflammatory changes taking place withinside the fibrous, intramuscular septa of biopsies from afflicted sufferers (10). That locating led Gowers W. (11) to introduce the term “fibrositis” to explain the infection of fibrous tissue in his description of low again ache. In next years, the terms fibrositis, fibromyositis, psychogenic, psychosomatic, or muscular rheumatism have all been used as descriptors for this syndrome.
The term “fibromyalgia” become first utilized by the Nobel Prize winner, Hench in 1976 (12). Smythe and Moldofsky (13), and Yunus et al. (14) formulated diagnostic standards for FM, at the same time as Müller and Lautenschläger (1990) formulated diagnostic standards for generalized tenomyopathy (15). The foremost manifestations have been described as ache in a couple of components of the body, in addition to constitutional and vegetative manifestations, and local hyperalgesia at muscle and tendon insertions (“soft points”).
Between the Seventies and the 90s, the popularity of the disorder become an crucial step each for sufferers and physicians. The disorder acquired a name, diagnostic standards, and evaluation tools.
In 1990 the American College of Rheumatology (ACR) first installed standards for the category and analysis of the disorder (16). New ACR classifications got here into impact in 2010 (17), 2011(18) and 2016 (19) to validate the scientific analysis of FM.
Prevalence of fibromyalgia in children and adolescents
The prevalence of FM in adults is about 2% (95% CI, 1.4-2.7). It is higher among women (3.4%) than men (0.5%). The average age of diagnosis in adults is around 40-50 years, and 13-15 years for children and adolescents (3, 6, 20).
The reported prevalence of JFMS varies widely probably reflecting differences in ethnicity, socio-cultural background, psychological traits of the population and diverse methodologies that have been used in the published studies (21, 22).
Pathophysiology
Current proof indicates that FM is that the results of the combination of a genetic predisposition and varied inessential stressors that result in a method called central sensitization of the central system (CNS) (23–26). Central sensitization may be a advanced development during which there’s hyperexcitability of central sensitive circuits brought on by activity dependent changes in junction transmission. This increased sensitization involves changes in receptors, neurotransmitters, particle channels and signalling pathways within the central system to such associate extent that even innocuous non-nociceptive stimuli are perceived as painful and also the perception of toxic stimuli is exaggerated, prolonged and widespread.
Adolescents with FM were found to be additional sensitive to pressure pain than their healthy peers; this implies a bent for sensitization of peripheral and/or central sensitive data usually rumored in adults with FM (27). In addition, abnormalities related to FM embody associate inability to sustain deep stage four sleep, neurochemical abnormalities (especially serotonin, dopamine, and norepinephrine), hypothalamic-pituitary-adrenal axis dysfunction, and peripheral sensitization.
Recent studies in patients with FM checked out useful activity in the brain. they need projected that, within these patients, acute pain appears to activate somatosensory, insular and cingulate animal tissue areas, whereas chronic pain preferentially activates anterior and structure animal tissue areas. In addition, anatomical changes reminiscent of regional decrease in grey substance density, volume or thickness in varied regions of the brain, not restricted to sensitive areas, are delineated in patients with completely different chronic pain conditions. These anatomical and useful property changes are possible to be secondary to chronic pain (28–31). In support of this view, treating chronic pain effectively will reverse these structural and useful abnormalities and restore traditional brain function in humans (32).
Familial studies known the chance of genetic predisposition, with up to one-quarter of relatives of FM patients reportage chronic widespread pain (33). A genetic predisposition to fibromyalgia has been incontestable linking sure genes to fibromyalgia, reminiscent of the SS genotype polymorphism in the promoter region of the monoamine neurotransmitter transporter cistron (5-HTT) (34), and also the LL and gonadotrophin genotype polymorphisms within the gene cryptography the COMT (catechol-O-methyltransferase) catalyst (35).
Moreover, inflammatory processes may play a major role in the pathological process of FM (36).
There may be a set of individuals with FM who check positive for antinuclear protein (ANA) and have constitutional symptoms that tally those of patients with early lupus (37). Therefore, in individual cases, FM could also be associate early sign of an autoimmune disease (38).
Some studies have wanted to demonstrate the prevalence of secretion abnormalities in people with FM, however not specifically in young patients.
In summary, the pathophysiology of FM remains unclear, though some information indicate that a major central sensitization element is at the root of the syndrome. It seems that the system system, neuroendocrine system, and central system play a major role in the pathological process of this disorder (39,40).
Clinical symptoms of fibromyalgia syndrome
Chronic great ache, the pivotal and maximum crucial symptom, isn’t always localized to any unique frame tissue and tends to transport from web website online to web website online. Symptoms of fatigue, sleep disturbances, cognitive changes, mood disturbances and diverse somatic signs might also additionally arise to an extra or lesser extent.
Pain is defined as being diffuse, deep, and non-stop often with durations of exacerbation, and signs can be modulated with the aid of using diverse factors which include mental stress, immoderate bodily activity, viral infections, and fatigue. Therefore, the scientific presentation of FM may be pretty diverse with a few regions of the frame greater pain than others, fluctuations in depth of ache, and variable depth of different related signs. Patients also fluctuate notably in phrases of the severity of practical impairment (7, 25, 41).
Although JFMS has been much less nicely studied than grownup fibromyalgia, it’s far obvious that the scientific functions are essentially similar, with minor differences (41), e.g., joint hypermobility is a greater, not unusual place in JFMS (42), whilst mental comorbidities are not unusual to place however much less severe; altered sleep sample appears to be a not unusual place amongst sufferers with JFMS (21,43, 44).
Patients with JFMS can be especially prone to school absenteeism due to their unremitting great ache disrupted sleep, and continual fatigue (45).
Physical examination
Many musculoskeletal illnesses appear able to triggering the system of central sensitization with an related boom in sleep disturbance, fatigue, huge ache, and different signs and symptoms not unusualplace in FM (46–49). Therefore, bodily examination (irrespective of whether or not gentle factors are counted) remains the important thing withinside the assessment of sufferers to evaluate the tenderness (allodynia and hyperalgesia) related to FM in addition to to useful resource withinside the differential diagnosis (50).
The clinical traits of FM amongst guys are much like the ones in women, besides that guys have fewer signs and symptoms, ache webweb sites and gentle factors, and much less common fatigue and irritable bowel syndrome, (51)
Physical examination
Many musculoskeletal diseases appear capable of triggering the method of central
sensitization with associate degree associated increase in sleep disturbance, fatigue,
widespread pain, and different symptoms common in FM (46-49). Therefore,
physical examination (regardless of whether or not tender points are counted) remains
the key within the analysis of patients to assess the tenderness (allodynia and
hyperalgesia) related to FM still on aid within the differential
diagnosis (50).
The clinical characteristics of FM among men are like those in women, except that men
have fewer symptoms, pain sites and tender points, and fewer frequent fatigue
and irritable internal organ syndrome, (51)
Yunus and Masi diagnostic criteria for juvenile primary fibromyalgia syndrome
(Adapted from: inflammatory disease Rheum 1985; 28: 138-145)
|
Major
Criteria
Generalized musculoskeletal
pain at three or more sites for three or more months
No underlying medical
condition
Normal laboratory tests
Five or more typical tender
points
Minor Criteria Presence of three of the following features: Chronic anxiety or tension Fatigue Poor sleep Chronic headache Irritable bowel syndrome Subjective soft tissue swelling Numbness Pain modulation by physical activities Pain modulation by weather factors 10. Pain modulation by anxiety or stress |
Differential diagnosis of fibromyalgia in children and adolescents
Because the foremost prominent criticism of patients with FM is body pain, the differential diagnosis ought to take into account a large kind of alternative painful conditions. Similar to FM in adults, JFMS is usually troublesome to classify, as a result of several of the symptoms are scientifically “medically unexplained” and sometimes overlap with other medical conditions adore chronic fatigue syndrome (63), irritable gut syndrome, and head ache headache.
Practically, the differential diagnosis of FM includes disorders that have symptoms of widespread pain and fatigue. These disorders embrace hypothyroidism, inflammatory and alternative myopathies, polymyalgia rheumatica, other rheumatic diseases, infectious agent infections, and severe D deficiency (5–7, 41).
Laboratory testing
There are no particular assessments to affirm the analysis, however some of the differential diagnoses sicknesses may be excluded through an in depth medical exam and particular laboratory testing. Although now no longer required to set up the analysis of FM, recurring laboratory testing (if now no longer already completed in the beyond 6-12 months) is often obtained. These assessments consist of measurements: of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, complete blood mobileular count, complete metabolic panel, and thyroid feature assessments.
Depending on symptoms (e.g., period of ache and acute vs. continual), clinical history, and physical exam findings, different assessments can be indicated (e.g. antinuclear antibodies, rheumatoid factor, viral infections, diet D levels, imaging, electroencephalog-raphy, electrocardiography, genetic studies, biopsy) if there is a medical suspicion for an alterna-tive purpose of the ache (3–5, 64–66).
Psychological problems/issues must be taken into consideration due to the fact they’re even extra common, e.g., depression (subtypes in line with DSM-V), tension issues (subtypes according to DSM-V), post-worrying pressure issues and dissociative issues with or with out self-injurious behaviour. There is likewise the possi-bility of mental contamination of parents, as visible in Munchhausen through proxy syndrome (64).
Debated is the viable function of hyperparathyroidism in FM, pronounced best in adults. A excessive frequency of hyperparathyroidism, in ladies with FM as opposed to the overall population, turned into pronounced through Costa et al. (65). By contrast, Ferrari and Russell discovered that the prevalence of number one hyperparathyroidism in FM sufferers turned into now no longer one-of-a-kind than that visible in different sufferers with widespread or localized ache (66).
Ciregia et al. (67) investigated the presence of capacity diagnostic and/or prognostic biomarkers in saliva which will be beneficial for the control of FM sufferers. Specifically, the salivary profile of FM sufferers turned into in comparison with the ones of wholesome subjects, subjects struggling migraine (version of non-inflammatory continual ache), and sufferers suffering from rheumatoid arthritis (version of inflammatory continual ache). Two-dimensional gel electrophoresis (2-DE) 2-DE serotransferrin and alpha-enolase have been discovered differentially expressed in FM sufferers. The authors concluded that the identity of ailment salivary biomarkers will be beneficial in detecting FM clusters and centered treatment.
Practical considerations
There are currently no instrumental checks or precise diagnostic markers for FM.and JFM. It is hoped that, withinside the close to future, a few checks consisting of salivary signs can provide a clue for losing mild upon complicated illnesses like FM. The issue in diagnosing this condition, specifically in kids and adolescents, can purpose a extraordinary deal of frustration amongst sufferers and dad and mom, while no definitive clinical purpose and/or reason behind the child’s signs is provided. Therefore, dad and mom might also additionally search for more than one consultations withinside the conviction that a severe underlying disorder goes to be missed.
Prognosis of fibromyalgia in children and adolescents
Initial studies indicated a positive long prognosis for JFMS (44, 68). By contrast, studies in subjects with JFMS recruited from hospital settings have shown a chronic and unsteady course, with symptoms continuous in ~70% of young people (43, 69, 70).
One controlled study printed in 2010 of patients with JFMS and matched healthy controls (mean age, fifteen years) showed that regarding 50% of patients with JFM met the complete ACR criteria for fibromyalgia at ~4 years follow-up (mean age, nineteen years), and >70% had continuing symptoms of pain, fatigue or sleep problem (70).
Several authors report totally different prognoses between adults and youths with FM. (43, 45, 71). They recommended that the first detection of JFMS is a sign of a higher prognosis (69), with significant gains in quality of life (73), and functionality for people who receive adequate treatment, whereas those with widespread pain that aren’t treated adequately have a bigger likelihood of developing fibromyalgia (74). On the opposite hand, during a massive prospective longitudinal study of JFMS patients, Kashikar-Zuck et al. (75) found that the majority of adolescent patients (~80%) with JFMS seen during a paediatric specialty care setting continuing to report persistent pain and different FM symptoms as they transitioned into young adulthood
Conclusions
JFMS is characterised through chronic extensive musculoskeletal ache, sleep disturbances, fatigue, and the presence of a couple of discrete soft factors on bodily exam. Its pathogenesis isn’t totally understood, even though it is presently believed to be the end result of a significant frightened system (CNS) malfunction that will increase ache transmission and perception. To date, there is no “gold standard” for diagnosing FM due to the fact signs and symptoms can be a part of or overlap with different illnesses or syndromes. Therefore, till a higher scientific definition is achieved, all diagnostic standards must be interpreted with warning and problem to modification. Recent hints agree that the prognosis remains scientific, and the motive of the bodily exam and constrained laboratory investigations is to rule out a few different somatic disorder that may sufficiently provide an explanation for the signs and symptoms.
Emerging evidence indicates that JFMS is a circumstance that often keeps into maturity with continual bodily and mental signs and symptoms, making it vital to correctly perceive and deal with this circumstance in adolescence. A multidisciplinary approach, combining pharmacological, behavioral and exercise-primarily based totally modalities is presently the same old of take care of JFMS.
HOMOEOPATHIC APPROACH :
1. Rhus Toxicodendron – For Sore Muscles Due to Weightlifting
Rhus Toxicodendron, also known as Poison Ivy is a flowering shrub whose leaves are used to make the medicine. It belongs to the family Anacardiaceae and is commonly found in parts of Asia and Eastern North America. The main actions of the remedy are on the inflammatory conditions, skin and rheumatic pains of the body. Rhus -t is a beneficial remedy for the treatment of sore muscles caused due to lifting heavy weights. Stiffness, along with sore and painful muscles is also seen. Application of something warm over the affected part may offer some relief. There is also some soreness of the condyles of the bones. The cold fresh air is not tolerated and it makes the skin painful. Tenderness is also felt in the affected muscles.
2. Arnica Montana – For Sore Muscles Due to Trauma
Arnica Montana (also known as Wolf’s Bane) is a flowering plant of the Asteraceae family, the dried flowers of which are used to prepare the remedy Arnica. It is commonly found in the European region. Arnica is a well-indicated remedy for injury to the skin or for pain and swelling associated with bruises, aches, and sprains in the muscles. Sore muscles as a result of trauma respond well to Arnica. It is also a good remedy for the sore muscles after previous injuries. There is a sore, lame and bruised feeling in the body. The patient may feel the pain in various muscles as if resulting from being beaten. Touching the affected body part worsens the pain as muscles are tender. Arnica is also used for sore muscles caused by influenza.
3. Bryonia Alba – When Slight Motion Worsens the Pain
Bryonia Alba or White Bryony is a perennial climbing herb found in parts of Europe and Northern Iran, of the family Cucurbitaceae. The dried root of this plant is used to prepare the homeopathic remedy. Bryonia has its affinity towards dryness of all mucous membranes of the body, aching in single muscle and the serous membranes of the organs. Bryonia Alba is best suited in cases of sore muscles when relief is brought about by only absolute rest. The slightest motion of the affected part worsens the pain. People requiring Bryonia feel relief when pressure is applied to the affected part. Lying down on the affected part also makes the soreness of the muscles better.
4. Cimicifuga
Cimicifuga is a beneficial remedy for sore muscles affecting the central bulge of the large muscles. In such cases, the application of something cold worsens the pain. Cimicifuga is an excellent remedy for sore muscles caused by excessive muscle exertion, like dancing or long, continuous running, etc. Pain in the muscles of the neck from overwork like typing is also treated well with this remedy.
5. Gelsemium
Gelsemium is a beneficial remedy for the sore muscles. It is used in cases of extreme weakness and fatigue accompanying muscle soreness. In such cases, the patient gets relief by lying down or resting. Gelsemium helps to relieve the pain in the muscles as well as the weakness along with it. Gelsemium also works well for sore muscles caused by influenza.
6. Sanguinaria Canadensis
Sanguinaria Canadensis is a useful remedy for soreness and pain in the deltoid muscle. Along with being painful, the deltoid muscle is also very stiff. The pain worsens on lifting the arm and usually aggravates at night time. Sanguinaria works well for deltoid pain on the right side.
7. Agaricus Muscarius.
Painful cramps in the muscles when seated.─Sensation of tearing in the limbs, principally during repose, whether seated or standing, and which disappears on movement.─Twitchings in the eyeballs, eyelids, cheeks, posteriorly in the chest, in the abdomen.─Symptoms which exhibit themselves transversely (for instance, in the r. arm and in the l. leg), > by walking slowly.─Great sensibility in the whole body; the softest pressure produces continued pains.─Pains, as from a bruise in the limbs and in all the joints, after even moderate exercise.─Soreness and sensation of rawness (nose and mouth).─Piercing pains in different parts of the body, chiefly in the head, with desire for sleep, and faintness when seated.─Tearing pains (face, legs) continuous while at rest, disappearing While moving about.─Great weakness and heaviness in all the limbs.─Trembling.─Convulsions.─Epileptic fits.─Epilepsy (with great exertions of strength).─Great sensibility to cool air.─Great sensitiveness of the body to pressure and cold air.
8. Araena diadema
Neuralgic pains, most on r. side, > by hard pressure, < at menstrual period, esp. before, but still during whole cycle; < 12 at night, unbearable, driving her out of bed; < 3 to 8 p.m.; aggravations recurring like clockwork; menses every three weeks.─Great exhaustion and lassitude.─Desires to keep constantly moving when sitting.─Subsultus tendinum.─Catalepsy; periodic headache; < in damp weather.
9. Eupatorium Perfoliatum.
Aching in bones with soreness of the flesh.─Intense soreness and aching in limbs, as if bruised or beaten.─Wrists pain as if broken or dislocated.─Heat in the hands, sometimes with perspiration.─Dropsical swelling of both feet and ankles.─Heat in the soles of the feet, in the morning.
10.Gelsemium
Trembling in all the limbs.─Deep-seated, dull aching in the muscles of the limbs and in the joints.─Neuralgic and rheumatic pains in the extremities.In the shoulders pain during the night.─Arms weak, numb.─Sensation as if r. elbow were sprained.─Pain in elbow (l.) from draught of air (at night).─Cramps in forearm on attempting to write.─Pain as if sprained in the r. wrist.─Trembling of the hands when lifting them up.─Coldness of the wrists and hands.─Hot dry hands, esp. the palms of the hands.─Spasmodic contraction of fingers.─Dupuytren’s contraction.Unsteady gait.─Fatigue after slight exercise.─Loss of voluntary motion.─Violent lancinating pain in the thigh.─Obstinate sciatica; pains < at rest and particularly when beginning to walk; burning pains, < at night, compelling her to lie awake; pain in sole of foot when walking.─Deep-seated muscular pains in legs > by motion.─Anterior crural neuralgia.─Paroxysmal; shooting pains.─Violent lancinating pain in thigh.─Thighs sore to touch as a boil; pains all > when in a sweat.─Rheumatic pains during the night in the knees.─Sudden dislocation or slipping of the knee-pan (during breakfast).─The calves of the legs feel bruised, pain at night.─Cold feet.─Spasmodic contraction of the toes.
11.Heliborus Niger
Shooting and piercing pains in different parts, and esp. in the periosteum, < by fresh air, corporeal fatigue, eating and drinking.─Pullings and tearing in the limbs.─Shooting pains in the joints.─Sudden relaxation of all the muscles.─The muscles refuse to perform their office, unless sustained attention be paid to them; staggering gait; suffering objects to fall which are grasped by the hand.─Convulsive twitching of the muscles (during sleep).─Relief is found in the open air, and sensations are felt as when recovering from a long illness.─All things have a freshness about them.─Convulsions.─Cramps.─Syncope.─Dropsical swellings.─Falling off of the hair and nails.
Conclusions
JFMS is characterized by persistent widespread system pain, sleep disturbances, fatigue, and therefore the presence of multiple separate tender points on physical examination. Its pathological process isn’t entirely understood, though it is presently believed to be the results of a central system (CNS) malfunction that will increase pain transmission and perception. To date, there’s no “gold standard” for designation FM as a result of symptoms is also a part of or overlap with alternative diseases or syndromes. Therefore, till a more robust clinical definition is achieved, all diagnostic criteria ought to be taken with caution and subject to modification. Recent tips agree that the designation remains clinical, and therefore the purpose of the physical examination and restricted laboratory investigations is to rule out another physical illness which will sufficiently explain the symptoms.
Emerging proof suggests that JFMS could be a condition that regularly continues into adulthood with chronic physical and psychological symptoms, creating it vital to properly identify and treat this condition in adolescence.
A multidisciplinary homoeopathic approach, combining exercise-based modalities is currently the quality of take care of JFMS.
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About Author:
Dr. Ashok Yadav
Head Of Department Of Practice Of Medicine (Hom.)
Dr.M.P.K. Homoeopathic Medical College Hospital And Research Centre
Dr. Navneet Kaur , Dr.Mansi Mishra
Md Scholar, Department Of Practice Of Medicine (Hom.)
Dr.M.P.K.Homoeopathic Medical College Hospital And Research Centre
A Constituent College Of Homoeopathy University
