Rheumatoid arthritis

CHAPTER 5 Rheumatoid arthritis

Rheumatoid arthritis (RA) is caused by inflammation of the synovium,¹ which is the lining of the joints, and it may be triggered by disordered immunity. It can lead to long-term joint damage, resulting in chronic pain, loss of function and even disability.

1 Western medical aetiology and pathology

The exact cause of RA is currently unknown. In fact, there probably is no single cause. Researchers are now debating whether RA is one disease or several different diseases with common features. Below are listed its several possible causes.

(1) Genetic aetiology

When the genetic marker HLA-DR4, a human leukocyte antigen that is a genetic anomaly, is found in white blood cells there is a risk for developing RA. The marker’s function is to distinguish one’s own cells from foreign invaders.² If HLA-DR4 cannot differentiate between the two, it may attack self cells.

(2) Immune system aetiology

One example of miscommunication in the body is something known as rheumatoid factor, which is an antibody that is directed to regulate other, normal, antibodies. This means that, although this lower-level antibody may not cause autoimmune disease directly, it may potentially trigger an existing autoimmune disease to flare up. A high level of rheumatoid factor, however, may point to a malfunctioning immune system. In general, the higher the level of rheumatoid factor present in the body, the more severe the disease activity. It is important to note that not all people with RA have an increased level of rheumatoid factor, and that not all people with an increased level of rheumatoid factor have RA. Additionally, the test for rheumatoid factor can give a false-negative result if it is performed too early in the course of the disease.

(3) Infection aetiology

It is possible that, in some people, RA may be triggered by an infection, although there is currently no proof of this. RA is not a contagious disease, although it is possible that a germ to which almost everyone is exposed may cause an abnormal reaction from the immune system in people who already have some susceptibility for RA.

2 Diagnosis by Western medicine

A diagnosis of RA is based on a complete medical and family health history, a physical examination, laboratory tests and radiography.

1. Medical history – the medical history is probably the best tool for diagnosing RA.

2. Physical examination – for such symptoms and signs as joint swelling, joint tenderness, loss of motion in damaged joints, joint malalignment, signs of RA in other organs including the skin, lungs and eyes.

3. Laboratory tests.

The most commonly used tests are:

• Complete blood count. People with RA often have a low red blood cell count, signalling anaemia. Anaemia can contribute to feelings of fatigue. People with a more aggressive form of the disease tend to have more severe anaemia. However, the white blood cell count (WBC) may be high, indicating that infection is present. A low WBC could suggest Felty’s syndrome,³ a complication of RA, or it may be caused by certain medications. Generally, the platelet count is raised when inflammation is present. However, it can also be lowered by certain drugs.

• Erythrocyte sedimentation rate (ESR). ESR measures the speed at which red blood cells fall to the bottom of a test tube. The more rapidly the red blood cells drop, the more inflammation is present. A high ESR indicates inflammation; the higher the rate, the more severe the RA. The ESR is frequently checked to monitor the success of treatment. This test is not specific to RA, but measures general inflammation in the body.

• C-reactive protein (CRP). CRP is normally found in the body, but levels are increased in the presence of inflammation. The higher the level of CRP, the more active the disease. Although ESR and CRP reflect similar degrees of inflammation, sometimes one will be raised when the other is not. This test may be repeated regularly to monitor inflammation and response to the treatment.

• Rheumatoid factor (RF). The test measures the amount of RF in the body. The higher the RF, the more severe the RA.

• Antinuclear antibodies (ANAs). This test detects a group of autoantibodies that are seen in about 30–40% of people with RA. Although commonly used as a screening tool, ANA testing is not used as a diagnostic tool because many people without RA or with other diseases can have ANAs.

• Imaging studies:

• Radiographs (X-rays) – X-rays may show swelling of the soft tissues and loss of bone density around the joints. When the disease progresses, X-rays can show small holes or erosions near the ends of bones and narrowing of the joint space due to loss of cartilage.

• Magnetic resonance imaging (MRI) – MRI can detect early inflammation before it is visible on an X-ray. MRI is particularly good at pinpointing synovitis (inflammation of the lining of the joint).

• Joint ultrasonography – this is a much less expensive way to look for joint inflammation before X-rays show damage.

• Bone densitometry – dual-energy X-ray absorptiometry (DEXA) is an important imaging method for measuring bone density, used primarily to detect osteoporosis. Osteoporosis may be especially severe in people with RA due to joint immobilization and the inflammatory response itself that may hasten bone loss. Women are particularly affected by osteoporosis following menopause.

3 Chinese medicine aetiology and pathology

Although Chinese medicine does not refer to RA by name, it does address diseases called Bi syndromes , some of which have symptoms and signs that may be similar to those of RA. Bi means obstruction and it is caused by pathogens creating blockage in the channels. This blockage prevents Qi and Blood from travelling through the channels smoothly and performing their functions of warming and nourishing the joints and extremities, thus causing serious symptoms.

Chinese medicine says: ‘The four external evils known as Wind, Cold, Heat and Dampness attack the human body and cause Bi syndromes’. Chinese medicine teaches that exterior pathogens can attack the body when Qi and Blood are deficient and so cannot protect the body very well. This attack, coupled with the Qi and Blood deficiency, can result in Bi syndrome. Thus, the aetiology of Bi syndrome is complicated. It involves some combination of the external pathogens Wind, Dampness, Cold and Heat that invade the body as a result of an internal deficiency of Qi and Blood. These external pathogens stay in the channels and obstruct the flow of Blood and Qi, causing Bi syndrome.

(1) Invasion of external pathogens

Bi syndrome is due to the combined invasion of Wind, Cold, Dampness and/or Heat, although Cold and Heat cannot attack simultaneously. Wind is the most important pathogenic factor as it always leads other pathogens to attack the body. This attack can occur if the weather changes suddenly, if people live in a cold or rainy place or wear few clothes, when people jog in extremely cold and damp weather, or if people sweat profusely thereby causing the pores to open. Any of these factors can facilitate the invasion of external Wind, Cold, Dampness or Heat. When the external pathogens stagnate in the channels for a long time, this can also lead to Blood stasis and to symptoms of Heat in the Blood. Or if Cold-Dampness stagnates in the body for a long time, this can also turn into a Heat syndrome.

(2) Deficiency of Liver and Kidney create internal conditions that allow external pathogens to invade the body

The Liver stores Blood, and the Kidney stores Essence. Liver Blood is nourished by Kidney Essence; Kidney Essence is replenished by Liver Blood. Chinese medicine believes that Blood can transform into Essence, but the source of Blood and Essence is the same: food Essence. This is why Chinese medicine says: ‘Essence and Blood have a common source’ and ‘The Liver and Kidney have a common source’. Therefore, a deficiency of Essence may lead to a deficiency of Blood. And a long history of deficient Liver Blood may also cause deficient Kidney Essence. Both ultimately lead to Kidney and Liver deficiency. Essence and Blood have a function to nourish muscles, tendons and bones. When deficient, this results in ‘an emptiness of the joints’, giving the external pathogens a chance to invade the body, leading to Bi syndrome.

4 General treatment principle

It is important to distinguish what the invading external pathogens are, based on the symptoms and signs, in order to determine the correct treatment. If the pain is migratory and involves many joints, it is due mainly to pathogenic Wind. If the pain is relatively severe and fixed in one or more areas, it is due to Blood stasis. If pain is accompanied by a feeling of cold or heat in the affected joints, it is mainly due to pathogenic Cold or Heat, respectively. If the involved joints feel heavy, coupled with numbness or swelling, it is mainly due to pathogenic Dampness.

In the acute phase, the treatment needs to dispel pathogenic Heat or Cold, remove obstruction in the channels, and dispel external pathogenic Wind and Dampness. In the chronic phase, the treatment needs to nourish the Liver and Kidney, remove Blood stasis and smooth the channels.

Differentiation and treatment

1 Wind-heat-dampness syndrome

Clinical manifestations

Redness, swelling around the joints, and a heat sensation and pain in the damaged joints. The joint is too painful to be touched, but the pain can be relieved by cold. There may be fever and thirst. The tongue is red, with a dry, yellow coating. The pulse is slippery and rapid.

Treatment principle

Dispel pathogenic Wind, Heat and Dampness, remove obstruction in the channels and stop pain.

Acupuncture

BL-17 Geshu, SP-10 Xuehai, Du-14 Dazhui and LI-11 Quchi.

Supplementary treatment

If the patient has skin lesions, specifically erythematic, annular and subcutaneous nodules, add Dan Shen Salviae miltiorrhizae Radix 15 g, Hong Hua Carthami Flos 10 g, Tao Ren Persicae Semen 10 g and Zi Cao Arnebiae/Lithospermi Radix 10 g, and needle HE-7 Shenmen, Front head line 1 (extra), and local points around the skin lesions.

2 Wind-cold-dampness syndrome

Clinical manifestations

Joint pain aggravated by cold and relieved by warmth, and a cold sensation in the extremities. The tongue is pale with a whitish, thin or greasy coating. The pulse is floating and slow.

Treatment principle

Dispel pathogenic Wind-Cold-Dampness, remove obstruction in the channels and stop pain.

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Tags: Treating Autoimmune Disease with Chinese Medicine

Jan 19, 2017 | Posted by admin in MUSCULOSKELETAL MEDICINE | Comments Off

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