Abstract
Rheumatoid arthritis (RA) is a chronic, autoimmune disorder which affects the joints bilaterally, causing inflammation and progressive destruction. Nearly 2.1 million people are affected by rheumatoid arthritis in the United States, with the disease most commonly inflicted in women between the ages of 20 to 50 (Flaws & Sionneau, 2017). Not only does RA lead to chronic pain, it negatively affects patients’ quality of life, is linked to shortened life-span, and often leads to disability. Standard treatment includes the long-term use of NSAIDs, biological agents, and anti-rheumatic drugs; however, it is estimated that between 60-90% of RA patients seek out alternative or complementary medicine due to the risks and side-effects associated with conventional drug therapy (Chou & Chu, 2018).
Acupuncture and Chinese herbal medicine provide RA patients a complementary or integrative solution that is safe and cost-effective. Diagnosis is made by recognizing the individual patterns presenting with groups of symptoms. Treatment is aimed at addressing underlying deficiencies, strengthening and regulating the immune system, and expelling external pathogenic factors (i.e. wind, cold, damp, heat) according to specific stages of the disease. Both the acute and chronic components of RA can be managed with acupuncture and Chinese herbal medicine, and patients can be treated in all phases of the disease, from the beginning to chronic stages, as well as during acute flare-ups. Chinese medicine provides a holistic approach to treatment to help patients not only decrease their pain and inflammation, but improve their quality of life, decrease their chance of disability and improve accompanying symptoms including fatigue, anxiety and depression. It can also help patients to decrease or eliminate the need for dangerous pharmaceuticals as well as combat their side-effects. Long-term management of RA with acupuncture and Chinese herbal medicine is essential to providing patients with a safe treatment, long-lasting results, minimizing future exacerbating episodes, and delaying progression of the disease.
Current Research
Rheumatoid arthritis (RA) has been an increasingly common condition in my practice that has yielded quite impressive results utilizing a combination of acupuncture and Chinese herbal medicine. While there is still a need for ongoing research to fully understand how acupuncture treats rheumatoid arthritis, there are several studies which demonstrate various mechanisms of action. Published in 2018, a systematic review of 43 studies on acupuncture and rheumatoid arthritis summarized that acupuncture produces anti-inflammatory, immune-regulating, antioxidative, and analgesic effects in patients with RA. Acupuncture may also reduce inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and “can lower TNF-aand VEGF in peripheral blood and joint synovia to improve the internal environment which is beneficial for RA” (Chou & Chu, 2018). Immune regulation has been demonstrated by acupuncture’s effects on lowering IgG, IgA and IgM in RA patients.
Manual acupuncture can also repair damage caused by RA by “effectively [stimulating] the innate immune cytokines (IL-1α, IL-1β, IL-6, IL-7, IL-18, TNF-α) and adaptive immunity cytokines (IL-2, IL-12, IFN-γ, IL-4, IL-5, IL-10, IL-13, IL-17) as the main part of the immune response” (Xu et al., 2018). Acupuncture may also increase serum SOD and catalase, reduce oxidative stress, and improve antioxidant status. Additionally, the endorphin release associated with acupuncture triggers analgesic effects to quell RA pain (Chou & Chu, 2018). The effects of immune system modulation, lowered inflammation and pain relief in response to acupuncture make it a powerful multi-dimensional treatment capable of diminishing the need for a multitude of western drugs and their subsequent side-effects.
Chinese Medical Theory
In Chinese medicine, rheumatoid arthritis is referred to as “wang bi”, translated as “lame impediment”. RA originates from a weakness of the body’s protective forces (i.e. immune system) which, due to their vulnerability, cannot compete with the overwhelming pathogenic burden – a TCM concept known as zheng qi deficiency (Zeng et al, 2014). Zheng qi deficiency mainly affects the spleen, liver and kidney organ systems in RA patients. When the spleen organ system is deficient, patients are prone to dampness/phlegm manifesting as joint swelling and nodules. When the liver is involved, the joints, tendons and sinews become weak and the patient is prone to accumulating toxins. The kidneys (coupled with the adrenals) are weak in patients with malformation and destruction of the bones, namely the joints of the fingers.
In addition to the aforementioned underlying factors that are present in RA patients, there are four main clinical manifestations which present in the following patterns:wind-cold-damp obstruction, wind-damp-heat obstruction, cold-heat complex and blood stasis obstruction. The more acute pathogenic factors of wind, cold and damp can result from environmental exposure or climate which affects the deeper areas of the joints by way of the body’s weakened defense system. The first pattern, cold-damp obstruction, is only present in patients at the early onset of rheumatoid arthritis before it becomes a systemic disease. This pattern manifests with pain and swelling of the joints that worsens with cold weather and improves with heat. Fever and chills may be initially present. The joints may feel cool to the touch and the patient often experiences “early morning stiffness, heaviness, numbness and/or restricted movement” (Flaws & Sionneau, 2017). No joint deformity or skin changes are present at this stage. Chronic cold-damp obstruction, if left untreated or incorrectly treated, can eventually turn into heat (inflammation), which is referred to as a cold-heat complex. In this pattern, patients present with a mix of cold symptoms (cold knees and feet, joint pain improved with heat) and hot symptoms (fever, dry and sore throat). The third pattern, damp-heat obstruction, is only present in the acute phase of rheumatoid arthritis, and manifests with sharp joint pain, red, hot, swollen joints and fever. Blood stasis obstruction is the final pattern common in patients that have a history of poor circulation, and is mainly caused by inactivity and/or advanced stages of disease. Blood stasis presents with painful and swollen joints and a purple, brown or black hue to the skin in the areas surrounding the joints (Zeng et al, 2014).
Treatment Plans
Because rheumatoid arthritis is a chronic and complex condition that is often progressive, it is important to not only treat patients when they are symptomatic, but also as long-term prevention. Upon review of the literature, a recommended number of acupuncture treatments ranges from 36 (Huang et al., 2018) to 90 (Zhu et al, 2018) for patients with RA. As it is very difficult to schedule treatments daily as in clinical trials, treatment may be lengthened to a time period of 6 months or longer, depending on severity of symptoms and stage of disease. Outcomes assessments may be used to track patients’ progress and re-assess the various components of the disease including: quality of life, pain levels, stress, sleep, anxiety, depression, joint range of motion, and activity levels. For pain levels, the visual analogue scale (VAS) is recommended, and for assessing overall quality of life, the rheumatoid arthritis quality of life questionnaire (RAQoL) or short form-36 health survey (SF-36) may be used (Chou & Chu, 2018). Dietary changes should always be addressed and will be discussed later on in this article. Objective measurements include tongue, pulse, auricular diagnosis, joint range of motion, x-ray and laboratory testing.
Treatment Plan #1: Wind-Cold-Damp
For patients in the early stages of RA, typically manifesting as a wind-cold-damp presentation, I recommend 3 to 6 months of treatment 2-3 times per week (depending on severity of pain) with re-exams completed monthly. Acupuncture plus moxibustion should be applied to GB-20 (Fengchi), BL-17 Geshu), BL-23 (Shenshu), Ren-4 (Guanyuan) and local ashi points (as a base protocol) with additional points selected dependent on location of pain. For Chinese herbal treatment at this stage, Wen Jing Juan Bi Tang Jia Jian (Warm the Channels and Alleviate Impediment Decoction with Additions and Subtractions) should be used as a base formula which can be modified specifically for each patient (Flaws & Sionneau, 2017). Patients should be advised to avoid exposing hands to cold water and to keep hands warm by wearing gloves during cold weather.
Treatment Plan #2: Blood Stasis
For patients with a chronic blood stasis type of RA, longer term treatment is needed due to its stubborn nature; therefore, a minimum of 6-8 months of treatment three times per week (90 treatments total) is required. Acupuncture points for blood stasis type RA include: local ashi points, UB-18 (Ganshu), UB-20 (Pishu), UB-23 (Shenshu), LI-4 (Hegu), LI-11 (Quchi), and ST-36 (Zusanli) (Zhu et al., 2018). Herbal treatment consists of a combination of modified Gui Zhi Fu Ling Wan plus Qi Fu Tang to activate the blood, break up blood stasis, resolve dampness and phlegm, boost the qi and raise the yang. Additional therapeutic results may be obtained from a local, topical application of herbal plasters such as Huo Xue San (Blood-Quickening Powder) or Jin Huang San (Golden Yellow Powder) and/or local dermal needling plus cupping (Zeng et al., 2014).
Alternative Approaches
Diet Therapy
Diet is one of the environmental factors that can either positively or negatively influence the severity of RA. Much evidence exists linking poor diet with an increased risk of RA, yet patients’ adherence to a healthy diet remains low; thus, it is particularly important to guide and encourage patients to make the necessary dietary changes. Excessive consumption of foods high in fat and sugar exacerbates RA, while consumption of foods high in n-3 polyunsaturated fatty acids (PUFAs) are shown to improve RA. A high-fat diet has been shown to “accelerate the development of collagen-induced arthritis” and “may prolong the inflammatory process” (Skoczyńska, & Świerkot, 2018). A cross-sectional study also revealed that people consuming drinks high in sugar (i.e. sodas, fruit juices) a minimum of 5 times per week were 3 times as likely to develop arthritis (Skoczyńska, & Świerkot, 2018).
On the other hand, a healthy diet can actually lower the risk of developing RA, and specific foods are known to combat RA inflammation, such as healthy fats found in fish and extra virgin olive oil. Plant polyphenols produce anti-oxidant effects and lower pro-inflammatory cytokines in RA patients, which can be found abundantly in: dried plums, red grapes, mangoes, grapefruits, apples, oranges, spinach, tomatoes, potatoes, soybeans, wheat, oats, and cocoa. The following spices and teas are also recommended for their rich content of polyphenols: black pepper, ginger, allspice, caraway, bay leaves, cinnamon, licorice, paprika, clove, nutmeg, chili pepper, bilberry, rooibos tea and green tea (Skoczyńska, & Świerkot, 2018).
Weight Management
One of the risk factors for the development of RA is high body mass index (BMI). A systematic review of 400,609 participants in which 13,562 had RA, concluded that “there was a 13% increase in RA risk for every 5 kg/m2increase in BMI. Obesity was associated with higher DAS28, tender joint counts, inflammatory marker levels, patient global evaluation and pain scores, as well as physical function scores” (Skoczyńska, & Świerkot, 2018). This research demonstrates the strong need for nutritional counseling in RA patients (as well as the general population) in order to reduce risk factors, prevent the onset of disease and improve RA symptoms.
Supplementation
Western herbs and supplements may be used in place of medications or as an adjunct therapy for the management of RA. Meta-analyses confirmed the potent effects of curcumin (1,000 mg daily) in relieving pain and decreasing inflammatory markers measured in blood serum and synovial fluid, with results equal to standard doses of methotrexate. Pomegranate extract (500 mg daily) has also been shown to significantly reduce DAS28, ESR levels, pain and inflammation in RA sufferers. Several other herbs containing powerfully active phytochemicals can be used to reduce RA symptoms: arnica montana, boswellia serrata, horsetail, devil’s claw, panax notoginseng, willow, sesamum indicum, comfrey, ginger and ashwagandha (Skoczyńska, & Świerkot, 2018).
Biomedical Considerations
Several laboratory tests may be used to diagnose and monitor the progress of RA. Certain lab tests are favored over others due to their sensitivity or specificity, and often a combination of lab tests is needed to draw a more comprehensive conclusion. Rheumatoid factor (RF) is the most commonly used test for diagnosing rheumatoid arthritis, as it is positive in 80% of RA patients. Despite this, a positive RF is not entirely specific to RA patients and may be positive in healthy individuals; therefore, it is more reliable when diagnosing patients already presenting with RA symptoms (Rheumatoid Arthritis, n.d.). For early detection and to predict severity and irreversible damage to the joints, anti-cyclic citrullinated peptide (anti-CCP) antibody testing is recommended. Although its sensitivity is low, it has a high specificity for RA and is positive in 60-70% of RA patients, making it an ideal test to be used in combination with RF. In fact, studies show that “simultaneously doing both RF and anti-CCP tests leads to the timely diagnosis of rheumatoid arthritis, with the dramatic increase in sensitivity and specificity of test” (Soroush, Mahmoudi, & Akhlaghi, 2016).
Non-specific laboratory tests that are also recommended for patients with rheumatoid arthritis include: antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR), C-reactive protein, complete blood count (CBC) and comprehensive metabolic panel (CMP). A positive ANA confirms the presence of autoimmune disease, although it does not help to specify a particular diagnosis, so it is important to also test for RF and anti-CCP as well. ESR and CRP both test for levels of inflammation and disease activity and are useful in monitoring and evaluating the patient’s progress. A CBC is useful in assessing red and white blood cell count. A decrease in red blood cell count and hemoglobin are used to diagnose anemia, while an increase in white blood cell count is linked to viral infection, a suspected a cause of RA. Because RA can become a systemic disorder and commonly prescribed medications can cause organ damage, a comprehensive metabolic panel (CMP) is useful in monitoring liver and kidney function (Rheumatoid Arthritis, n.d.).
Diagnostic imaging may also be used to diagnose and monitor joint changes in RA patients. X-rays can aid in the diagnosis of RA as well as show deterioration or destruction of the joints in more advanced stages, while ultrasound and MRI can detect earlier stages of RA joint dysfunction (Rheumatoid Arthritis, n.d.).
Community Resources
The Arthritis Foundation has both local, state and national resources available to help patients find access to quality medical care, health tracking tools and online educational information. They work with state and federal governmental officials as advocates for better care and access to medications. The foundation also funds scientific investigation to seek out a cure and helps RA patients and their families support one another through their social media community and fundraising events (Mission & Vision, n.d.). In addition, the website for the American College of Rheumatology provides patients and healthcare providers with valuable information about RA, available treatments, facts about medications, frequently asked questions, and educational videos (Patient and Caregiver Resources, n.d.).
Case Studies and Prognosis
The following is a brief overview of three individual case studies of patients diagnosed with rheumatoid arthritis treated in my clinic using a combination of acupuncture and Chinese herbal medicine.
Case #1
A 46-year-old female presented with a pain level of 7/10 and swelling of the proximal and distal interphalangeal joints bilaterally, bilateral wrist and knee pain, fatigue and insomnia. She was unable to work or type due to the chronic pain and fatigue. Her tongue was pale, purple and swollen, and her pulses were systemically deep and blocked. RF factor was positive and C-reactive protein was elevated. Treatment consisted of bi-weekly acupuncture for 5 months using the following points: Ling Gu, Wu Hu 1 & 2, 88.25, 66.04, Jianzhong and SP-9. Evergreen Circulation SJ (modified) was prescribed, 4.5 grams TID for 3 months. This patient’s pain was reduced to 2/10 and she noted marked improvement in range of motion and swelling of the finger joints, wrists and knees, and was able to return to work.
Case #2
A 37-year-old female presented with systemic joint pain (6/10), weakness, numbness and burning pain in the extremities, making it difficult to walk at times. Acupuncture was performed bilaterally on ST-36, LI-4, LIV-3, LI-11, SP-10, LIV-8 and GB-34. Course of treatment was 2 times per week for 3 months, then monthly for prevention. Chinese herbal treatment was comprised of Su He Tang Jiawei (II) - 3 capsules BID plus Shenjin Guizhi Shayao Zhimu Tang - 2 caps BID, given for a course of 2 months. This patient was initially on disability, and following her course of treatment, her pain and numbness disappeared. She was able to then resume working, only experiencing occasional, brief flare-ups quelled by acupuncture.
Case #3
A 38-year-old male presented with acute onset of left anterior shoulder joint pain (6/10), fatigue and insomnia. CCP antibodies and RF were both positive. Acupuncture was performed contralaterally on ST-38, Xiyan, LIV-8, 77.18, Ling Gu and Fan Huo Jie. Additional points included: Du-20, Yintang and Anmian. This patient was treated weekly for 6 months. Herbal treatment consisted of Dang Gui Nian Tong Tang 30g, Evergreen Herbs Astringent Complex 30g, Jiang Huang 20g and Yan Hu Suo 20g dosed at 4.5 grams 3 times per day for a total of 3 months. Shoulder pain improved to 1/10 on the pain scale and RF factor was negative upon post-treatment re-test.
References
Chou, P., & Chu, H. (2018). Clinical Efficacy of Acupuncture on Rheumatoid Arthritis and Associated Mechanisms: A Systematic Review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925010/pdf/ECAM2018-8596918.pdf
Flaws, B., & Sionneau, P. (2007). The treatment of modern western medical diseases with Chinese medicine a textbook & clinical manual. Boulder, CO: Blue Poppy Press.
Huang, A., Pang, Y., Tang, Q., Xu, J., Lin, J., & Li, J. (2018, March 12). Clinical therapeutic effects on rheumatoid arthritis treated with the assisted therapy of acupuncture at the points detected with thermosensitive moxibustion in Zhuang medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29701040
Mission & Vision. (n.d.). Retrieved from https://www.arthritis.org/about-us/mission-vision.php
Patient and Caregiver Resources. (n.d.). Retrieved from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Patient-and-Caregiver-Resources
Rheumatoid Arthritis. (n.d.). Retrieved from https://labtestsonline.org/conditions/rheumatoid-arthritis
Skoczyńska, M., & Świerkot, J. (2018). The role of diet in rheumatoid arthritis. Reumatologia, 56(4), 259-267. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142028/
Soroush, M., Mahmoudi, M., & Akhlaghi, M. (2016, August 21). Determination of Specificity and Sensitivity of Rheumatoid Factor and Anti CCP Tests in Patients with RA in Private Clinic in Tehran, Iran. Retrieved from http://biomedpharmajournal.org/vol9no2/determination-of-specificity-and-sensitivity-of-rheumatoid-factor-and-anti-ccp-tests-in-patients-with-ra-in-private-clinic-in-tehran-iran/
Xu, Y., Hong, S., Zhao, X., Wang, S., Xu, Z., Ding, S., . . . Pang, G. (2018). Acupuncture Alleviates Rheumatoid Arthritis by Immune-Network Modulation. Retrieved from https://www.worldscientific.com/doi/pdf/10.1142/S0192415X18500520
Zeng, S., Fratkin, J., Wang, J., Ma, X., Wang, H., & Lardner, H. F. (2014). TCM case studies:autoimmune disease. Beijing: Peoples Medical Publishing House.
Zhu, Y., Yu, H., Pan, Y., Yang, J., Wu, B., Hu, X., & Cao, Y. (2018, May 12). Acupuncture combined with western medicine on rheumatoid arthritis and effects on blood stasis. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29797911
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