TCM Acupuncture and Massage

Chapter 68 Bone and Joint Diseases (6)
([-]) Etiology and pathogenesis

1. Traditional Chinese medicine is equivalent to the category of arthralgia, which is mainly caused by wind, cold, and dampness.

(1) Deficiency of righteousness: Insufficiency of righteousness is the internal factor of the disease.Specifically divided into insufficient endowment; excessive work and rest; serious illness, chronic illness or postpartum.

(2) Evil invasion: that is, exogenous evil invades the human body, which is an important external cause of the disease.Specifically, it includes abnormal seasonal climate; poor living environment; careless living adjustment.

(3) Phlegm turbidity and blood stasis: It is a pathological product formed during the disease process.Including injuries caused by diet, disorders of the seven emotions, and injuries caused by falls.

2. Modern medicine believes that rheumatoid arthritis is mainly related to the following factors:
(1) Immune factors: systemic immune diseases.

(2) Genetic factors: The incidence of RA in RA patient families is 2-10 times higher than that in healthy people.

(3) Infection factors: including Epstein-Barr virus, mycoplasma, Mycobacterium tuberculosis, etc.

(4) Endocrine disorders.

(5) Nutritional metabolism disorders.

(6) Incentives: cold and damp are the most common.

3. Pathological process
(1) Synovitis phase: manifested as acute or subacute synovitis.The joint is swollen and deformed due to exudation, the joint capsule is tense and painful, which in turn leads to joint dysfunction and limited mobility, and local osteoporosis occurs shortly thereafter.The pathological changes in this period are mainly in the synovium, which is the local immune response of rheumatoid, and the systemic immune response has not yet occurred, which can last for 6 to 12 months.This stage is equivalent to the clinical acute stage. The inflammatory process can be controlled or terminated. If timely and correct diagnosis and treatment can be performed, the patient can completely return to normal and the prognosis is good. It is a critical period for healing.

(2) Granuloma stage: At this time, the acute inflammation of the synovial membrane has subsided, and the exudate is gradually absorbed, and granulation tissue pannus appears in the synovial membrane, which covers and adheres to the articular cartilage, and invades into the cartilage, resulting in cartilage erosion.Finally, all the cartilage is destroyed, the joint capsule fibrosis, and then the joint cavity narrows.This period is characterized by: pannus formation.Pannus is a granulation tissue composed of new capillaries and fibroblasts in the synovium, and is one of the most important lesions of rheumatoid arthritis.The growth ability and destructive ability of pannus are very strong, which is an important factor causing the destruction of articular cartilage, as well as the key factor leading to intra-articular adhesion and later joint ankylosis.The pathological process of this period can spread to other organs from the joint synovium.During this period, rheumatoid factor can be detected in serum.Once rheumatoid factor appears, it is considered that the pathological process has transferred to the second stage, and it means that an autoimmune reaction has occurred, and its clinical process is gradually becoming more serious.Therefore, clinically, it is best not to wait for the patient to appear "rheumatoid factor positive" before diagnosis and treatment. Early diagnosis and early treatment are required.Equivalent to the clinical subacute phase.

(3) Fibrosis stage: after the destruction of articular cartilage, pannus continues to proliferate, causing bone tissue necrosis, fibrous tissue hyperplasia and calcification, and the joint cavity is significantly narrowed or completely disappeared.Due to ligament laxity, joint capsule fibrosis, and mechanical factors, joint contracture, subluxation, and total dislocation result in partial or complete loss of joint function, which is equivalent to the clinical chronic phase.Joint dysfunction in this stage is largely difficult to recover and can cause permanent disability.Therefore, early diagnosis and treatment should be made to avoid the occurrence of disability as much as possible.

([-]) Clinical manifestations

The disease is a chronic systemic disease characterized by symmetrical, multiple, and erosive peripheral arthritis.The onset of arthritis is characterized by chronicity, persistence, and progress. It often recurs, sometimes mild and sometimes severe, and gradually worsens. There are obvious individual differences in the degree and speed of the aggravation, and the disease may have temporary relief.

1. Incentives
A small number of patients can be traced to the incentive.Generally speaking, various infections, cold, humidity, fatigue, mental trauma, malnutrition, joint sprains, falls and fractures are often the predisposing factors for this disease.

2. Prodromal symptoms
Before obvious joint symptoms appear, there may be prodromal symptoms such as fatigue, weight loss, loss of appetite, low-grade fever, numbness and tingling in hands and feet, and muscle aches all over the body for several weeks to months.

3. Onset type
(1) Invasive type: about 759/6.The first symptoms are often in the joints, manifested as morning stiffness, swelling and pain in the joints, especially in the interphalangeal joints of the middle fingers. The upper limbs are more common than the lower limbs, and they are mostly symmetrical and last for several weeks. Migratory manifestations are often accompanied by low-grade fever, fatigue, weakness, general malaise, loss of appetite, and weight loss.

(2) Acute attack type: about 8 to 15%.Joint and systemic symptoms were more serious.Due to the involvement of the synovium and the tissues around the joints, the joints swell and cause severe pain. Patients often need to stay in bed and dare not move. It lasts for 1 to 2 months. Generally, there is no fever. Appropriate treatment is usually required to relieve the pain.

(3) Intermittent attack type: about 15 to 20%.It is characterized by joint swelling and pain that recurs periodically. Each attack lasts for several days to several weeks and subsides on its own.Any joint can be violated, but it is more common in fingers, toes, ankles, and knee joints.Most of them can be terminated by themselves, the prognosis is good, and generally no joint damage is caused, and no sequelae are left.

(4) Adult Still's disease type: about 3 to 5%.Because the multi-system damage of the whole body is obvious, it is also called "systemic symptom type".It often manifests as sudden high fever for unknown reasons, reaching above 39-40°C, which can last for several weeks or months, accompanied by light red maculopapules on the trunk and limbs.Most patients have organ damage symptoms of hepatosplenomegaly.The joint symptoms are not prominent at the beginning, and generally only a few joints are involved, and the knees, ankles, wrists and other large joints are the main ones.Most of the typical symptoms appear weeks, months or even years after the fever.

(5) Atypical onset type: very atypical in the early stage, often preceded by long-term low-grade fever, fatigue, tiredness, and lassitude. Metatarsophalangeal joint pain, and then spread to multiple joints.

(6) Juvenile type: under the age of 16, the symptoms are basically the same as those of the adult Still disease type.

4. Joint manifestations Single joints, small joints and multiple joints can be involved at the onset of the disease, but most of them are 1 to 3 joints. Later, the number of affected joints can increase to 4 to 10, or even more, and most of them are symmetrical.It can affect any synovial joint in the whole body, and these joints are all movable joints.Mainly the joints of the limbs, especially the small joints of the hands and feet.The most commonly affected joints are the proximal interphalangeal joints, metacarpophalangeal joints, and wrist joints. Other commonly affected joints are interphalangeal, metatarsophalangeal, ankle, knee, elbow, shoulder, hip, temporomandibular, and atlantoaxial joints.Rarely invade the distal finger (toe) joints and spine.

(1) Morning stiffness: It is one of the important diagnostic criteria for rheumatoid arthritis.It is caused by poor blood circulation near the joints at night.Morning stiffness mostly occurs in fingers and wrist joints.And can be divided into light, medium and heavy three degrees.

①Light—stiffness relieved within 1 hour after waking up in the morning.

②Medium—stiffness relieved within 1 to 4 hours after waking up in the morning.

③Heavy—relief of stiffness for more than 4 hours in the morning or stiffness all day long.

(2) Pain: It is one of the typical symptoms of rheumatoid arthritis.Often finger, wrist, toe, ankle joint pain first, or single, or multiple, one after another, gradually spread to the elbow, shoulder, knee, hip, and temporomandibular joint, mostly symmetrical.The degree of pain is related to the severity of the lesion and individual tolerance, and is often aggravated by weather changes, cold stimulation, and mood swings.Pain is characterized by aggravation at rest and continuous activity and relief after moderate light activity.

①In the early stage, it manifests as migratory pain in the small joints of the extremities, and its degree is relatively mild; when the pain gradually involves from the small joints of the extremities to the large joints and the pain site changes from migratory to fixed, the pain is severe.

②Mobile stage—severe joint pain and limited physical activity.

③ Stable period - the condition is relatively stable, and the joints are dull pain.

(3) Swelling: Joint swelling is an objective sign of rheumatoid arthritis.Manifested as diffuse swelling of the joints.The small joints of the limbs are prone to swelling, and the finger joints are mostly fusiform swelling; the knee joints are mostly swollen like a crane's knee.Joint swelling and local skin color changes are related to the progression of the disease.Affected joints are mildly swollen, local skin color is not red, spread slowly to other joints, the condition is relatively stable, and mostly develop insidiously; affected joints are obviously swollen, local skin color is red, spread quickly to other joints, and most of them are acute development.

(4) Joint friction noise: It indicates that the articular cartilage has been destroyed.

(5) Movement disorder: it is a common sign of rheumatoid arthritis.

①Early stage—mainly due to pain.

②Medium stage—mainly due to fibrous tissue hyperplasia, cartilage and bone erosion.

③Late stage—the joint space narrows or even disappears due to secondary bone hyperplasia, and joint dislocation occurs.

(6) Joint deformity: it usually occurs in the later stage of the disease course.The hands and feet are the most characteristic and common.

5. Extra-articular manifestations

(1) Rheumatoid nodules: the incidence rate is 15-25%.It mostly occurs in the joint capsular process and the places that are often compressed, most often in the elbow and under the olecranon process, followed by the coccyx, posterior occiput, scalp, spine and other parts, the Achilles tendon sheath, the palmar tendon sheath and the tendon sheath around the ankle can also happen.Rheumatoid nodules are organized granulomas that form in association with small vessel damage.Its appearance is more common in the active stage of rheumatoid arthritis, and it can be used as one of the indicators for definite diagnosis, judgment of lesion activity and prognosis.

(2) Vasculitis: It first damages microcirculatory blood vessels, and can accumulate in any organ of the body. It mostly occurs in patients with severe disease, obvious arthritis, and high titer of rheumatoid factor.

(3) Damage to the organs of the whole body: including the heart, liver, spleen, lung, kidney, eyes and nerves.

(4) Anemia: the incidence rate is 16-65%.

([-]) Inspection

1. Blood test

(1) Blood routine: There is usually no abnormality in the early stage; anemia may appear after prolonged illness.

(2) Four items of rheumatism: erythrocyte sedimentation rate (ESR), anti-streptolysin O antibody (ASO), C-reactive protein (CRP), and rheumatoid factor (RF).

① Erythrocyte sedimentation rate: It can be used as a reliable indicator for judging the activity of inflammation, its rise and fall is consistent with the activity of rheumatoid, and it can also be used as a sign for judging the curative effect and diagnosis.Increased erythrocyte sedimentation rate indicates tissue damage, which can be caused by a variety of reasons. Although it is not specific, it has certain value in the identification of diseases and the judgment of activity.The rapid increase of erythrocyte sedimentation rate in rheumatoid patients is not affected by antirheumatic drugs, which can be distinguished from rheumatoid arthritis (the erythrocyte sedimentation rate drops rapidly after treatment).Rheumatoid joint swelling and pain have improved significantly, inflammation has subsided, and erythrocyte sedimentation rate continues to increase or does not decrease, indicating that relapse or deterioration may occur at any time.If the patient exhibits arthralgia, few clinical symptoms, and normal erythrocyte sedimentation rate for many times, it is difficult to diagnose rheumatoid arthritis.

② Anti-streptolysin 0 antibody: This value increased in 30% of rheumatoid patients.Generally can be divided into four types:

ASO increased, RF (-) - normal ASO for rheumatic fever, RF (+) - poor prognosis, ASO increased, RF (+) - normal ASO for rheumatoid, RF (-) - ruled out rheumatoid.

③ C-reactive protein: In the early stage of rheumatoid and acute rheumatism, this value increases, and the positive rate is 80-90%. The clinical significance of CRF is the same as that of erythrocyte sedimentation rate, which is a good indicator of inflammation.During the rheumatoid active phase, CRF increased significantly, which was parallel to the increase of erythrocyte sedimentation rate, but appeared earlier and disappeared sooner than it. The higher the CRF content, the higher the lesion activity.In the recovery period of inflammation, if CRF is positive, it indicates that there is still the possibility of sudden clinical symptoms. CRF positive, can be seen in a variety of inflammatory diseases.However, it is usually negative in viral infection, so it can be used clinically as an indicator to distinguish bacterial infection from viral infection.

④Rheumatoid factor: Normal people are negative, about 80% of adult RA patients are positive, and children are 30%.Serum RF-positive patients, especially those with high titer, have more severe joint lesions and poorer prognosis than RF-negative patients.In addition, serum RF positivity was associated with extra-articular lesions and rheumatoid vasculitis.In sero-RF-negative patients, synovitis is generally mild and rarely develops into extraarticular rheumatoid disease. RF is not specific for the diagnosis of RA, because in addition to RA, some normal people can also have RF positive in various diseases, and RF negative cannot exclude RA.However, RF showed a higher titer and was positive for many consecutive times, and its specificity was enhanced.In contrast, RF titers in other diseases were lower than those in RA patients.

2. X-ray examination In the early stage, rheumatoid arthritis lacks specific X-ray features with diagnostic value, and needs to be combined with symptoms, signs and laboratory tests.In the advanced stage, a reliable diagnosis can be made if joint destruction and typical deformities characteristic of the disease are seen.X-ray examination of the affected joints of this disease is not only to confirm the diagnosis, but also to provide an objective and reliable indicator for the stage of the disease, the choice of treatment methods and the progress of the disease.

X-ray staging of rheumatoid arthritis:
(1) Early stage (osteoporosis stage): generalized osteoporosis and soft tissue swelling.

(2) Middle stage (destructive stage): In addition to the early stage, there are erosions at the edge of the bone end, cystic changes in the subchondral area, and narrowing of the joint space.

(3) Late stage (severe damage stage): In addition to the above findings, there are severe joint damage, bone resorption, dislocation and deformity.

(4) End stage (ankylosing stage): the joint has been fibrous or bony ankylosis.This staging is based primarily on the degree of joint destruction shown on x-rays, not on the length of the disease.However, the early stage is roughly equivalent to the synovitis stage in the pathological process, the middle stage is equivalent to the granulomatous stage, and the late and late stages are equivalent to the fibrosis stage.

([-]) Diagnosis

Clinically, it is generally based on the diagnostic criteria revised by the American College of Rheumatology at the 1987st Annual Meeting of Rheumatology in 51:
1. Joint stiffness for at least 1 hour in the morning (≥ 6 weeks).

2.3. Swelling of 3 or more joints (≥6 weeks).

3. Swelling of the wrist, metacarpophalangeal joint or proximal interphalangeal joint (≥6 weeks).

4. Symmetrical joint swelling (≥6 weeks).

5. Subcutaneous nodules.

6. Hand X-ray changes.

7. Rheumatoid factor positive (titer> 1:32).If more than 4 indicators are present, the diagnosis can be made.

([-]) Identification

This disease needs to be differentiated from osteoarthritis, gout, psoriatic arthritis, ankylosing spondylitis, rheumatoid arthritis, infectious arthritis and other diseases.According to clinical manifestations and related examinations, it is not difficult to identify.

([-]) Treatment

The principle of treatment for rheumatoid arthritis is comprehensive treatment, the purpose of which is to control the activity of the disease, prevent the aggravation or deterioration of arthritis, enhance physical fitness and immunity, consolidate the therapeutic effect, prevent joint insufficiency and disability, and restore joint function and labor. ability.

1. Psychiatric treatment Once a patient knows that he has rheumatoid arthritis, he will feel more or less mentally worried or depressed.Therefore, when a doctor formulates a treatment plan, in addition to drug treatment, the first thing to do is to formulate an appropriate mental treatment plan.The mental treatment plan is mainly to care about the patient, talk more with the patient, strengthen the confidence of the patient to overcome the disease through different examples, let go of the burden of being tortured by the chronic disease, and explain the nature of the disease and the method of overcoming the disease to the patient, so that the patient Be able to actively cooperate with treatment, and appropriately participate in recreational and sports activities or work and study, so as to help patients restore their normal mental state, and then achieve the purpose of treating diseases.

2. Exercise therapy At present, rheumatologists have clearly pointed out that it is necessary to actively maintain the mobility of joints and enhance the muscle strength of limbs.However, excessive exercise can have the opposite effect.Therefore, how to coordinate rest and exercise well is very important.It is generally believed that the following two principles must be followed, that is, the standard of not feeling tired the next day after exercise; try to carry out exercise training in the early stage of rheumatoid arthritis.

(End of this chapter)