Updated: Sep 29, 2019
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.
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).
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).