- Rheumatoid Arthritis (RA)
Epidemiology of RA
Rheumatoid arthritis (RA) rarely causes low back pain, but neck pain and neck stiffness account for 60% of the patients with rheumatoid arthritis whereas up to 86% will have radiographic evidence of cervical damage, because rheumatoid arthritis attacks the cervical apophyseal joints, particularly the synovial membranes. It is so common that it affects 2-3% of the population in the U.S.
Modern Western Etiology and Pathology of RA
Rheumatoid arthritis (RA) is a disabling inflammatory disease, with joint lesions secondary to a chronic synovitis responsible for the formation of pannus, a true localized malignant inflammatory proliferation, as well as chondrocyte diseases. It has an immunological origin, under the dual action of humoral immunity (immune complex) and cell-mediated immunity. It is self-sustained. Extraarticular conditions characterize the systemic rheumatoid disease: rheumatoid nodules, pleuropulmonary, vascular and pericardial manifestations, along with fever. These often alternate with articular manifestations.
From a pathogenic point of view, it appears to be a multiple factor condition. Genetic factors include excessive expression of class 11 HLA antigens. HLA-DR4 (DW4, DW14) is positive over 60 percent of Caucasians with RA and DR 1 positive in significant among Jews with RA.
Positive DR3 usually promotes intolerance to gold salts or D-penicillamine. RA is related to HLA (human leukocyte antigen)-DR, suggesting a genetic defect that makes the patient to be susceptible to this disease.
Environmental factors: The most important of these are infections. Among those implicated in RA are Epstein- Barr virus (EBV) and cytomegalovirus (CMV).
Hormonal factors: There is a preponderance of women among those who develop RA (three women to every man). This proportion decreases after menopause, and pregnancy is a favorable factor. The effects of female hormonal therapy are controversial.
Because the viral induction of RA theory is today gaining more and more credibility, the TCM concept of linking rheumatic disorders to exogenous pathologies demonstrates a high level of insight, which will be discussed later in TCM considerations of RA.
Clinical Manifestations of RA
Patients with rheumatoid arthritis develop joint pain, heat, redness, swelling and tenderness. The joint involvement is additive and symmetrical. The joints at greatest risk of being affected by the disease process include the proximal interphalangeal, metacarpal-carpal, wrist, elbow, hip, knee, ankle, and metatarsal-phalangeal joints. Patients have joint pain and stiffness most severely in the morning. Activity improves stiffness. As a component of systemic inflammation, afternoon fatigue, anorexia and weight loss are usual complaints.
In the axial skeleton, the cervical spine is most frequently affected. Neck movement frequently precipitates or aggravates neck pain, which is deep and aching in quality. Disease of the atlantoaxial joint is first felt in the upper part of the cervical spine and then radiates over the occiput into the temporal and frontal regions with more severe disease. Occipital headaches are frequently associated with active rheumatoid involvement of the cervical spine. Pain associated with rheumatoid disease in lower segments of the cervical spine is found in the lateral aspects of the neck and clavicles (C3-C4) and over the shoulders (C5-C6). Neurologic symptoms include paresthesias and numbness. The paresthesias have a burning quality, which may be attributed to an entrapment neuropathy
Western Physical examination of RA
Physical examination of a rheumatoid arthritis patient with cervical spine disease reveals diffuse joint inflammation characterized by heat, swelling, tenderness, and loss of motion. Examination of the cervical spine may show tenderness with palpation over the bony skeleton and limitation of all spinal movements. Inspection may show fixation of the head tilted down and to one side. This lateral tilt is caused by the asymmetrical destruction of the lateral atlantoaxial joints. The normal cervical lordosis may also be absent. With the neck flexed, the spinous process of the axis may be prominent in the midline of the neck of the patient with atlantoaxial subluxation. Palpation of the posterior pharynx during flexion may reveal abnormal separation of the anterior arch of the atlas from the body of the axis. Anteroposterior laxity may also be detected by applying pressure on the forehead while palpating the spinous process of the axis. In the patient with subluxation, the flexed head will glide backward as the subluxation is reduced. This test is not frequently utilized however for fear of causing neurologic symptoms.
Neurologic abnormalities may include loss of sensation and weakness of muscles of the upper or lower extremities. Positive Babinski signs may occur but are uncommon. Vertigo, nystagmus, dysphagia, or coma will be present in the occasional patient with vertebral artery compression. In general, neurologic abnormalities are very uncommon.
Laboratory Findings of RA
Abnormal laboratory findings include anemia, elevated erythrocyte sedimentation rate (ESR), and increases in serum globulins. Rheumatoid factors (antibodies directed against host antibodies) are present in 80% of patients with rheumatoid arthritis. Antinuclear antibodies are present in 30% of rheumatoid arthritis patients. Synovial fluid analysis demonstrates an inflammatory fluid characterized by poor viscosity, increased numbers of white blood cells, de- creased glucose, and increased protein.
Histologic examination of the synovium from affected joints demonstrates an inflammatory, hyper-plastic tissue characterized by mononuclear cell infiltration, synovial cell proliferation, fibrin deposition and fibrosis. Examination of the cervical spine apophyseal joints reveals pannus formation (synovial proliferation) associated with destruction of cartilage and subchondral bone.
Radiographic Studies of RA
Characteristic radiographic changes of rheumatoid arthritis include soft tissue swelling, bony erosion without reactive sclerotic bone, joint space narrowing, and periarticular osteopenia. Radiographic examination of the cervical spine includes anteroposterior, lateral, oblique and full flexion lateral views. The latter view is necessary to show maximal atlantoaxial subluxation.
The radiographic criteria for diagnosis of cervical spine rheumatoid arthritis include the following: (1) atlantoaxial subluxation of 2.5 mm or more, (2) multiple subluxation of C2-3, C3-4, C4-5, C5-6, (3) narrow disc spaces with little or no osteophytosis, (4) erosion of vertebrae, especially vertebral plates, (5) odontoid, small, pointed, eroded, loss of cortex, (6) basilar impression, (7) apophyseal joint erosion, blunted facets, (8) osteoporosis, generalized, (9) wide space (less than 5 mm) between posterior arch of the atlas and spinous process of the axis (flexion to extension), (10) osteo- sclerosis, secondary, atlantoaxial-occipital area (Fig. 23).
Radiographic techniques, other than a plain X-ray, may be useful in discovering specific abnormalities in the cervical spine. Computed tomography is better than a plain radiograph in revealing soft tissue abnormalities in the spinal canal and may be able to detect the position of an eroded odontoid process which may not be seen on the open mouth view radiograph. Patients with arachnoid space obliteration with cervical subluxation on CT scan may be at risk for progressive myelopathy. Angiography may identify vertebrobasilar artery compression in the patient with neurologic signs of syncope, vertigo or visual changes. Myelography is usually reserved for patients who are candidates for surgical correction of cervical spine subluxation.
Magnetic resonance imaging (MRI) may be capable of detecting early inflammatory changes that are not apparent from standard radiography, but are seldom necessary in the routine evaluation of patients with RA.
Modern Western Differential Diagnosis and Diagnosis of RA
The diagnosis of rheumatoid arthritis is a clinical one based upon the history of the quality and duration of joint pain, distribution of joint involvement, presence of rheumatoid subcutaneous nodules and characteristic laboratory abnormalities (rheumatoid factor). In the setting of generalized, active disease, the finding of neck pain associated with multiple abnormalities including facet joint erosion without sclerosis, disc space narrowing without osteophytes, multiple subluxations, are most appropriately attributed to rheumatoid arthritis. The cervical spine abnormalities of ankylosing spondylitis, psoriatic arthritis, and diffuse idiopathic skeletal hyperostosis, are associated with new bone formation or ligamentous calcification, which differentiate them from rheumatoid arthritis. Occasionally, atlantoaxial subluxation may occur alone in the setting of little peripheral arthritis. In those circumstances other disease processes which may be associated with subluxation include ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, trauma or local infection.
The following summarizes essentials of diagnosis of RA: (1) Patients usually experience systemic symptoms of malaise, fever, weight loss and morning stiffness. (2) Onset is usually insidious and in small joints, especially in Metacarpophalangeal joints and wrists (Fig. 24). (3) Joint enlargement is spongy and warm and deformities are common (Fig. 24). (4) Extra-articular manifestations include subcutaneous nodules, pleural effusion, pericarditis, lymphadenopathy, splenomegaly with leukopenia, and vasculitis. (5) Changes in the later stage of rheumatoid arthritis may be juxta-articular osteoporosis and joint erosions, (6) Rheumatoid factor (RF) is usually present and ESR elevated and HLA-DR4 or DR1positive in most patients. (7).X-ray may show typical changes of RA in involved joints. (8) Neck pain is common in RA, accounting for up to 60% of the patients with OA.
Modern Western Treatment of RA
The treatment for control of generalized rheumatoid arthritis includes a regimen of patient education, physical therapy, non-steroidal anti-inflammatory drugs, antirheumatic agents (gold, penicillamine, hydroxychloroquine), corticosteroids, and immunosuppressive agents. Therapy is directed at the control of pain and stiffness, reduction of inflammation, maintenance of function, and prevention of deformity. Patients are educated about their disease so they may be an active participant in their care. They are encouraged to continue with as normal a life style as possible. Physical therapy provides temperature modalities (heat or cold) which relieve pain, exercises which maintain muscle strength, and assistive devices (canes, crutches) which promote normal function and ambulation.
Medications to control pain and inflammation are useful in the patient with rheumatoid arthritis. Aspirin is a very effective agent for rheumatoid arthritis if given in adequate doses to reach a serum concentration of 20 to 25 mg/di. In patients who are unable to take the number of tablets necessary to reach that serum level, who are intolerant of the drug, or who have no effect, other nonsteroidal anti-inflammatory medications are useful in controlling symptoms. These agents include ibuprofen, tolmetin, fenoprofen, indomethocin, piroxicam, sulinidac and mefenamic acid.
Patients who continue with joint inflammation or who demonstrate joint damage joint space narrowing, bony erosions or cysts) despite adequate nonsteroidal therapy are candidates for antirheumatic therapy. Antirheumatic agents, such as hydroxychloroquine, gold salts or penicillamine have a delayed onset of action compared to nonsteroidal drugs. However, the antirheumatic agents are capable of slowing the progression of joint destruction and may allow for healing of damaged osseous structures.
Systemic corticosteroids are effective in controlling the inflammatory components of rheumatoid arthritis but are unable to slow the progression of disease. Corticosteroids are also associated with a wide spectrum of toxicities ranging from hypertension and diabetes to cataracts and osteonecrosis of bone. Intraarticular corticosteroid injections are used when a single joint remains active in the face of general control of the arthritic process.
Immunosuppressives are associated with severe toxicities (aplastic anemia and cancer) which limit their benefit to the severely affected patient. Only a very small proportion of patients with rheumatoid arthritis require this therapy.
Rheumatoid arthritis of the cervical spine is responsive to the same therapy, which is effective in controlling generalized disease in western medicine. A major therapeutic dilemma for patients with cervical subluxation is the necessity for surgical fusion of the spine to control neck pain and neurologic signs. Despite the presence of marked subluxation, many patients with cervical spine disease are asymptomatic. Only less than two percent of the patients with cervical subluxation require surgical fusion for control of their disease. Most patients do well with conservative therapy including a cervical collar to decrease excess motion in the spine. It may also be appropriate for the patient with cervical subluxation to wear a collar in motor vehicles to prevent complications associated with whiplash injuries. Care should also be given to patients undergoing surgery so that hyperextension of the neck during intubation does not cause neurologic dysfunction. Surgical fusion of the cervical spine should be considered only for patients with severe pain, gross vertebral displacement, or progressive neurologic dysfunction including weakness. These patients benefit from decompression and fusion.
TCM Considerations of RA
In the past, like OA, the TCM classification of patterns for RA has been confusing, because there was no rheumatoid arthritis, neither OA nor degenerative joint diseases such concepts in classics of TCM. My arguments for RA involve several points: (1) External pathogenic factors or influences like Cold, Dampness and Wind or latent pathogenic influences, are the primary causes of RA, which are different from that of OA. In OA, Kidney Yang deficiency is the primary cause. (2) Cold, Dampness and Wind or latent pathogenic influences usually turn into Heat causing Hot Bi in RA, and in contrast to OA, the microscopic view of RA is Hot Bi and Excess dominance. (3) Macroscopically, Wei Qi (defense Qi)) deficiency or other deficiency is the secondary factor which may confer the susceptibility to the above external pathogenic influences, but deficiency is usually not the primary cause. The following facts support my arguments:
(1) The presence in RA of common epitopes between inducting germs and the HLA groups was validated in 1988 with the discovery of a six-amino-acid polypeptide (gp I 10) common between the Epstein-Barr virus capsid and a DR4, DR 1 and DW14 antigenic subunit. Thus, when a viral agent possesses a common antigen with the “biological self,” the antibody produced by the threatened body to protect itself attacks, through the common marker, the “biological self.” The above discovery implicates that external pathogenic factors may trigger the pathological process of RA, and TCM considers the Epstein-Barr virus to be the latent pathogenic factors causing RA as mentioned previously in Part One.
In light of this modern research, the response given by Qi Bo to the Yellow Emperor in chapter 27 of Spiritual Axis (Lingshujing, 靈樞) when asked about fixed Bi or painful obstruction is most interesting:
Wind, Cold and Damp pathogenic factors settle externally in the intramuscular spaces. Their attack produces a humor. Under the influence of Cold, the humor clusters. This clustering separates the muscular layers, which split up. With this splitting there is pain. With the pain the Wei Qi (protective Qi) returns there. When the Wei Qi returns there is heat. With heat the pain is relieved. When the pain is relieved there is inversion. With this inversion other areas of BI (painful obstruction) develop. When they develop, they have similar features.
The above statement from Spiritual Axis also implicates that, Bi pattern like rheumatoid arthritis may be attributed primarily to the external pathogenic factors or influences—Wind Dampness and Cold or epidemic pathogenic influences or latent pathogenic influences in its early stage, and microscopically Hot Bi in certain locations of the body is the consequence of the fighting between Wei Qi and external pathogenic influences.
(2) The involved joints of RA are always apparently warm and red (Fig. 24). The pathological changes of RA are usually destructive (Fig. 23 & 25). Histologic examination of the synovium from affected joints demonstrates an inflammatory, hyper-plastic tissue characterized by mononuclear cell infiltration, synovial cell proliferation, fibrin deposition and fibrosis as mentioned previously. Synovial fluid from the involved joints is unclear and turbid, demonstrating the characters of inflammation, such as poor viscosity, increased numbers of white blood cells, decreased glucose, and increased protein (Fig. 25). The above findings are universal in RA irrespective of the systemic conditions or the pulse and tongue patterns. Therefore, they all support that microcosmic view of RA is definitely Hot Bi and Excess dominance.
(3) HLA-DR4, DR1, and DR3 are related to RA, suggesting some genetic defects that may confer the susceptibility to RA. In the other words in TCM, it is the patient’s congenital Wei Qi deficiency that makes the patient to be susceptible to the external pathogenic influences—Cold, Dampness and Wind or epidemic pathogenic influences or latent pathogenic influences. However, not all the HLA-DR positive people suffer from RA. This means that, Wei Qi deficiency is not the primary cause of RA but is the secondary cause, since Wei Qi only confer the susceptibility to RA. Clinically it is common that RA is alleviated or disappeared after the patient has moved to an area with dry and warm climate. From this clinical observation, it is obvious that external pathogenic influences are still the primary cause of RA.
(4) In RA, when fever, increase in serum globulins and elevation of ESR and WBC occur, it is suggested that RA is not only Hot Bi microcosmically but macrocosmically as well.
Dampness also plays an important role in RA. A predominance of Dampness manifests as heaviness of the body, fixed joint pain, sensitivity to the weather, especially dampness, which can trigger painful crises. These symptoms are accompanied by numbness and paresthesia, swelling and a progressive deformation of the joints (Fig. 23, 24 & 25). Subcutaneous nodules are freely movable, painless over bony prominences, considered to be virtually a pathognomonic sign of rheumatoid arthritis, and certainly do usually indicate a positive rheumatoid factor. They occur in 10 to 20 percent of the cases of RA and are located on the posterior aspect of the forearms, along the ulnar crest, near the elbows or on the dorsal aspect of the fingers. In TCM they indicate a knotting of turbid Phlegm in the collaterals, i.e. the accumulation of Dampness.
Visceral Disorders such as pleuropulmonary, pericardial, splenic and renal disorders can be interpreted as a spreading of the Bi or painful obstruction internally, as described in chapter 43 of Simple Questions (素問). Rheumatoid vasculitis corresponds to vessel Bi or painful obstruction. Ocular disorders can result from several mechanisms, such as the localization of anatomical correspondences of the Wood or Fire phase, or the involvement of the yang or yin Heel vessels. Sjögren’s syndrome indicates that the Fluids have been affected.
The severe and malignant forms of this disorder, characterized by rapid progression of the articular lesions and the emergence of a necrotic angiitis, are related to Toxic Heat.
After a period of time, rheumatoid arthritis may remain in conjunction with the appearance of Qi and Blood deficiency or stagnation, yang deficiency or yin deficiency, depending on the case. All these different patterns of deficiency are usually secondary, commonly seen in chronic phase of RA.
Since RA belongs to the pattern of external pathogenic factor type, Hot Bi, the TCM treatment of RA will be discussed later in the chapter Professor Wang’s Classification of Degenerative Joint Diseases and Rheumatologic Diseases.
Prognosis of RA
The course of rheumatoid arthritis cannot be predicted at time of onset. Some patients develop sustained disease, which is associated with joint destruction and resistance to therapy. Patients with seropositive generalized disease, with nodules, who are older, are at greater risk of developing cervical spine disease. The natural history of cervical subluxation is usually benign. Despite persistent subluxation, progressive neurologic sequelae are uncommon. Patients who are at greater risk of neurologic damage are those with subaxial subluxations since the spinal column diameter is narrower at lower levels. On occasion severe neurologic dysfunction or death is associated with cervical subluxation. Patients with RA are not disabled specifically because of cervical spine disease, but patients with cervical spine involvement have extensive generalized involvement, which usually affects their functional status and their ability to function in daily life. Most patients at early stage of RA respond satisfactorily to TCM treatments. However, the improvement from TCM treatment decreases as the stage of RA advances.
Fig 23. Radiographic changes of rheumatoid arthritis of the cervical spine:
Corresponding diagrams of the above radiologic changes:
The above x-ray films show that the pathological changes of RA are usually destructive, implicating RA is Hot Bi, Excess dominance in microcosmic view. (from Dieppe P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
Fig. 24. Early stage of RA:
Rheumatoid arthritis (RA) mostly attacks the metacarpophalangeal joints (90%) and the cervical spine (60%). In contrast to OA, the affected joints of peripheral type of RA are red, warm, swelling and spongy. Deformity due to destructive pathological changes is common. The above facts indicate that RA in TCM is Hot Bi, Excess dominance at least in the microcosmic view. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
Fig. 25. Diagram of RA:
Normal Joint: Joint affected by RA: Histological pathology of RA:
The histological changes of RA demonstrate the characters of destructive inflammation, supporting that, in contemporary Chinese medicine, the microcosmic view of RA is definitely Hot Bi and Excess dominance, irrespective of the systemic conditions or the pulse and tongue patterns. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
- Seronegative Spondyloarthropathy
Seronegative spondyloarthropathy includes ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, and colitic arthritis. These disorders have the following common features: onset usually before age 40, inflammatory arthritis of the spine (Fig. 26) or peripheral large joints (or both), the absence of auto antibodies in the serum like rheumatoid factor, etc, and a striking association with HLA-B27 (Human leukocyte antigen) which confers susceptibility to these diseases.
Present in only 8% of normal Caucasians and 3% of normal blacks, HLA-B27 is positive in 90% of patients with ankylosing spondylitis and 75% with Reiter’s syndrome. HLA-B27 also occurs in 50% of the psoriatic and colitic arthritis patients who have sacroiliitis; patients with only peripheral arthritis in these two syndromes do not show an increase in HLA-B27.
That HLA-B27 itself and not some other nearby gene confers susceptibility to these diseases has been demonstrated by experiment with transgenic rats. When the human HLA-B27 gene is expressed in rats, the animals develop a spinal and peripheral arthritis, psoriasiform nail and skin changes, and bowel inflammation. Thus, having HLA-B27 is crucial to the development of a spondyloarthropathy.
Infection also appears to play a key role in some of the spondyloarthropathy, especially Reiter’s syndrome, which characteristically develops days to weeks after a bacterial dysenteric or nongonococcal venereal infection. The interplay of susceptibility genes and environmental infections is demonstrated by the fact that the risk of developing Reiter’s syndrome is 0.2% in the general population, 2% in the HLA-B27 individuals, and 20% in patients with HLA-B27 who become infected with Salmonella, Shigella, or enteric organisms. The transgenic rats, which express human HLA-B27, also demonstrate the importance of infection in the pathogenesis of spondyloarthropathy; rats raised in germ-free environments do not develop arthritis. Despite these gains in our understanding of the importance of HLA-B27 and infection, the way in which genes and infection cause spondyloarthropathy is not yet known.
In TCM, seronegative spondyloarthropathy is attributed primarily to the external pathogenic factors or influences, such as Wind, Cold, Dampness, and latent pathogenic influences or epidemic pathogenic influences in its early stage. For example, Reiter’s syndrome triggered by some epidemic infections by Salmonella, Shigella, or enteric organisms, is a typical case of disease pattern caused by epidemic pathogenic influences in TCM. All the above pathogenic factors usually turn into heat causing Hot Bi. The involved joints of seronegative spondyloarthropathy are usually warm and red; their synovial fluid is turbid and inflammatory; patients may have fever, or elevation of ESR, WBC and globulin, etc. The above facts also support that seronegative spondyloarthropathy is Hot Bi, Excess dominance at least microcosmically. Patients may have deficiency as the internal etiologic cause, especially congenital instability or deficiency of the Wei Qi (defense Qi). The positive findings of HLA-B27 are interpreted in TCM as Congenital Wei Qi (the defense Qi) deficiency, which may confer the susceptibility to the external pathogenic factors. Deficiency is usually not the director cause. However, as the stage of seronegative spondyloarthropathy advances, deficiency of different internal organs will become more and more dominant. Therefore, like rheumatoid arthritis, seronegative spondyloarthropathy also belongs to external pathogenic factor type, Hot Bi. Its TCM treatment will be detailed in the, Professor Wang’s Classification of Degenerative Joint Diseases and Rheumatologic Diseases.
Ankylosing spondylitis (AS)
Modern western medicine previously considered ankylosing spondylitis one type of rheumatoid arthritis, called central type of rheumatoid arthritis. Currently, modern western medicine has reclassified ankylosing spondylitis as an independent disease from rheumatoid arthritis, but into the category of seronegative spondyloarthropathy because in AS, rheumatoid factor remains negative in this central type of arthritis and HLA-B27 is usually positive. However, contemporary Chinese medicine still put it in the same pattern as rheumatoid arthritis because they both belong to external pathogenic factor type Hot Bi.
Clinical Manifestations: Ankylosing spondylitis is a chronic inflammatory disease of the joints of the axial skeleton, manifested clinically by back pain and progressive stiffening of the spine. The age at onset is usually in the late teens or early 20s. The incidence is greater in males than in females, and symptoms are more prominent in men, with ascending involvement of the spine more likely to occur. The onset is usually gradual, with intermittent bouts of back pain that may radiate down the thighs. As the disease advances, symptoms progress in a cephalad direction and back motion becomes limited, with the normal lumbar curve flattened and the thoracic curvature exaggerated. Chest expansion is often limited as a consequence of costovertebral joint involvement. Radicular symptoms due to cauda equina fibrosis may occur years after onset of the disease. In advanced cases, the entire spine becomes fused, allowing no motion in any direction. Transient acute arthritis of the peripheral joints occurs in about 50% of cases, and permanent changes in the peripheral joints- most commonly the hips, shoulders, and knees-are seen in about 25%.
Spondylitic heart disease, characterized chiefly by atrioventricular conduction defects and aortic insufficiency, occurs in 3-5% of patients with long-standing severe disease. Nongranulomatous anterior uveitis is associated in as many as 25% of cases and may be a presenting feature. Pulmonary fibrosis of the upper lobes, with progression to cavitation and bronchiectasis mimicking tuberculosis, may occur, characteristically long after the onset of skeletal symptoms. Constitutional symptoms similar to those of rheumatoid arthritis are absent in most patients.
Laboratory Findings: The erythrocyte sedimentation rate (ESR) is elevated in 85% of cases, but serologic tests for rheumatoid factor are characteristically negative. Anemia may be present but is often mild. HLA-B27 is found in 90% of patients with ankylosing spondylitis. Because this antigen occurs in 8% of the normal population, it is not a specific diagnostic test. Persons with other joint diseases such as rheumatoid arthritis, OA, do not show a higher than normal incidence of HLA-B27.
Imaging: The earliest radiographic changes are usually in the sacroiliac joints. In the first few months of the disease process, the sacroiliac changes may be detectable only by CT scanning. Later, erosion and sclerosis of these joints are evident on regular radiographs. Later, involvement of the apophysial joints of the spine, ossification of the annulus fibrosis, calcification of the anterior and lateral spinal ligaments, and squaring and generalized demineralization of the vertebral bodies may occur. The term “bamboo spine” has been used to describe the late radiographic changes. Additional x- ray findings include periosteal new bone formation on the iliac crest, ischial tuberosities and calcanei, and alterations of the pubic symphysis and sternomanubrial joint similar to those of the sacroiliacs. Radiologic changes in peripheral joints, when present, tend to be asymmetric and lack the demineralization and erosions seen in rheumatoid arthritis.
Essentials of modern western diagnosis include: (1) chronic pain in lumbar spine and mostly in young male adult; (2) progressive stiffness in back and limitation of back motion and of chest expansion, usually starting from lower lumbosacral to higher vertebrae (Fig. 26); (3) transient (50%) or permanent (25%) peripheral arthritis; (4) x-ray reveals bamboo spine and bilaterally symmetrical SI joint involvement (Fig. 26); (5) elevation of ESR, negative rheumatoid factor (RF), but positive HLA-B27 (This feature is not useful diagnostically).
Modern western differential diagnosis: In contrast to ankylosing spondylitis, rheumatoid arthritis predominantly affects multiple, small, peripheral joints of the hands and feet, spares the sacroiliac joint, has little effect on the rest of the pine except for Cl-C2, causes rheumatoid nodules, associated with rheumatoid factor, and is not associated with HLA-B27. The history and physical findings of ankylosing spondylitis serve to distinguish this disorder from other causes of low back pain such as disk disease, osteoporosis, soft tissue trauma, and tumors. The single most valuable distinguishing radiologic sign of ankylosing spondylitis is the appearance of the sacroiliac joints, although a similar pattern may be seen in Reiter’s syndrome and in the arthritis associated with inflammatory intestinal diseases and psoriasis. A spondyloarthropathy associated with hidradenitis suppurativa has been described in blacks. In DISH, there is exuberant osteophyte formation. The osteophytes are thicker and more anterior than the syndesmophytes of ankylosing spondylitis, and the sacroiliac joint is not affected. The x-ray appearance of the sacroiliac joints in spondylitis should be distinguished from that in osteitis condensans ilii. In some geographic areas and in persons with appropriate occupations, brucellosis and fluoride poisoning may be important in the differential diagnosis.
Modern western treatment: A. Basic program: The general principles of managing chronic arthritis apply equally well to ankylosing spondylitis. The importance of postural and breathing exercises should be stressed. B. Drug therapy: The nonsteroidal anti-inflammatory agents are employed in the treatment of this disorder. Of these, indomethacin appears to be the most effective, though it can be quite toxic. The dosage of indomethacin is usually 25-50 mg three times a day, but the least amount should be used that will provide symptomatic improvement. Agents such as naproxen, fenoprofen, tolmetin, sulindac, piroxicam, and other newer NSAIDs are valuable alternatives and may be used as primary therapy. Indomethacin may produce a variety of untoward reactions, including headache, giddiness, nausea and vomiting, peptic ulcer, renal insufficiency, depression, and psychosis. Sulfasalazine can be effective in patients who do not respond to NSAIDS. C. Physical Therapy may be helpful for rehabilitation.
Prognosis: Almost all patients have persistent symptoms over decades; rare individuals experience long-term remissions. The severity of disease varies greatly, with about 10% of patients having work disability after 10 years. Developing hip disease within the first 2 years of disease onset presages a worse prognosis. TCM treatment usually has satisfactory results in early stage.
In 15-20% of patients with psoriasis, arthritis co- exists. The patterns or subsets of arthritis that may accompany psoriasis include the following: (1) A spondylitic form with sacroiliitis and spinal involvement predominating; 50% of these patients are HLA-B27 positive. (2) Joint disease that resembles rheumatoid arthritis in which polyarthritis is symmetric. Usually, fewer joints are involved than in rheumatoid arthritis, and rheumatoid factor is absent from the serum. (3) An oligoarticular form that may lead to considerable destruction of the affected joints. (4) A pattern of disease in which the distal interphalangeal joint s are primarily affected. Early, this may be monarticular, and often the joint involvement is asymmetric. Pitting of the nails and onycholysis are frequently associated. (5) A severe deforming arthritis (arthritis mutilans) in which osteolysis is severe.
Clinical manifestations: Although psoriasis usually precedes the onset of arthritis, in 20-25% of patients the arthritis precedes the skin disease. Arthritis is at least five times more common in patients with severe skin disease than in those with only mild skin findings. Occasionally, however, patients may have a single patch of psoriasis (typically hidden in the scalp, gluteal cleft, or umbilicus) and are unaware of its connection to the arthritis. Thus, a detailed search for cutaneous lesions is essential in patients with arthritis of new onset. Also, the psoriatic lesions may have cleared when arthritis appears-in such cases, the history is most useful in diagnosing previously unexplained cases of mono- or oligo-arthritis. Nail pitting, a residue of previous psoriasis, is sometimes the only clue.
Laboratory Findings: Laboratory studies show an elevation of the sedimentation rate, but rheumatoid factor is not present. Uric acid levels may be high, reflecting the active turnover of skin affected by psoriasis. There is a correlation between the extent of psoriatic involvement and the level of uric acid, but gout is no more common than in patients without psoriasis. Desquamation of the skin may also reduce iron stores.
Imaging: Radiographic findings are most helpful in distinguishing the disease from other forms of arthritis. There are marginal erosions of bone and irregular destruction of joint and bone, which, in the phalanx, may give the appearance of a sharpened pencil. Fluffy periosteal new bone may be marked, especially at the insertion of muscles and ligaments into bone. Such changes will also be seen along the shafts of metacarpals, metatarsals, and phalanges. Paravertebral ossification occurs, which may be distinguished from ankylosing spondylitis by the absence of ossification in the anterior aspect of the spine.
Essentials of modern western diagnosis: (1). Psoriasis precedes the onset of arthritis in most patients. (2). Arthritis is usually asymmetrical, with “sausage” appearance of fingers and toes (Fig. 27). (3). Rheumatoid factor is usually negative. (4). Sacroiliac joint involvement is common, and ankylosing spondylitis may be associated (Fig. 26).
Modern western treatment: Treatment regimens are symptomatic. Non- steroidal anti-inflammatory drugs are useful. Anti- malarials may exacerbate the psoriasis. Gold therapy is often effective. In resistant cases, methotrexate has been used with some success, but it should be employed only by those fully conversant with its use. Successful treatment of the skin lesions commonly- though not invariably-is accompanied by an improvement in peripheral articular symptoms. Sulfasalazine may also be effective.
In TCM, the “sausage” appearance of the involved joints (Fig. 27) implicates that the microcosmic view of psoriatic arthritis is not only Hot Bi, but also is associated with Qi and blood stagnation. And the psoriasis itself is due to mostly Wind and Dampness.
Reiter’s syndrome, also called “reactive arthritis,” is a clinical tetrad of urethritis, conjunctivitis (or, less commonly, uveitis), mucocutaneous lesions, and arthritis. It occurs most commonly in young men, is associated with HLA-B27 in 80% of white patients and 50-60% of blacks, and often follows infection (see above). Most cases of Reiter’s syndrome develop within days or weeks of either a dysenteric infection (with Shigella, Salmonella, Yersinia, Campy- lobacter) or a sexually transmitted infection (with Chlamydia trachomatis or perhaps Ureaplasma urealyticum). Whether the inciting infection is sexually transmitted or dysenteric does not affect the subsequent manifestations but does influence the sex ratio: The ratio is 1.0 after enteric infections but 9:1 with male predominance after sexually transmitted infections.
Although affected joints are culture-negative, fragments of putative organisms have been identified in swollen joints. The exact role of infection remains unclear. The arthritis is most commonly asymmetric and frequently involves the large weight-bearing joints (chiefly the knee and ankle); sacroiliitis or ankylosing spondylitis (Fig. 26) is observed in at least 20% of patients, especially after frequent recurrences. Systemic symptoms including fever and weight loss are common at the onset of disease. The mucocutaneous lesion may include balanitis, stomatitis, and keratoderma blennorrhagicum, resembling pustular psoriasis with involvement of the skin and nails. Carditis and aortic regurgitation may occur. While most signs of the disease disappear within days or weeks, the arthritis may persist for several months or even years. Recurrences involving any combination of the clinical manifestations are common and are sometimes followed by permanent sequelae, especially in the joints.
X-ray signs of permanent or progressive joint disease may be seen in the sacroiliac as well as the peripheral joints.
Essentials of modern western diagnosis include: (1) Urethritis, (2) Conjunctivitis, rash and other mucocutaneous lesions, and (3) Low back pain due to sacroiliitis and spondylitis (Fig. 26) and arthritis of the knees and ankles, in at least 20% of patients.
Gonococcal arthritis can initially mimic Reiter’s syndrome, but the marked improvement after 24-48 hours of antibiotic administration and the culture results distinguish the two disorders. Rheumatoid arthritis, idiopathic ankylosing spondylitis, and psoriatic arthritis must also be considered. The association of Reiter’s syndrome and HIV has been debated, but evidence now indicates Reiter’s syndrome is equally common in sexually active men regardless of HIV status.
In modern western medicine, NSAIDs have been the mainstay of therapy. Antibiotics may also have some role. Antibiotics given at the time of a nongonococcal venereal infection reduce the chance that the individual will develop Reiter’s syndrome and the chance of a relapse in those who have a history of Reiter’s syndrome. Tetracycline given for 3 months to patients with Reiter’s syndrome associated with C trachomatis reduces the duration of symptoms. Tetracyclines have anti-inflammatory properties, so the response need not be attributed solely to an antimicrobial effect. Patients with enteric Reiter’s syndrome do not respond to antibiotics. Patients who fail NSAIDs and antibiotics may respond to sulfasalazine.
In TCM, extra vertebral manifestations of Reiter’s syndrome, such as conjunctivitis and urethritis are considered to be due to the Damp Heat, Excess dominance.
Inflammatory Intestinal Diseases
One-fifth of patients with inflammatory bowl disease may complain of back pain due to central type of arthritis (Fig. 26). Arthritis complicates Crohn’s disease somewhat more frequently than it does ulcerative colitis. In both diseases, two distinct forms of arthritis occur. The first is peripheral arthritis-usually a nondeforming asymmetric oligoarthritis of large joints-in which the activity of the joint disease parallels that of the bowel disease. The arthritis usually begins months to years after the bowel disease, but occasionally the joint symptoms develop earlier and may be prominent enough to cause the patient to overlook intestinal symptoms. The second form of arthritis is spondylitis that is indistinguishable by symptoms or x-ray from ankylosing spondylitis (Fig. 26) and follows a course of independent of bowl disease. About 50% of these patients are HLA-B27 positive. In addition, fistula formation from inflammatory bowl disease reaching to the retroperitoneum may cause back pain as well.
Controlling the intestinal inflammation usually eliminates the peripheral arthritis in both TCM treatment and modern western treatment. In western medicine, the spondylitis often requires NSAIDS, which need to be used cautiously since these agents may activate the bowel disease in a few patients. Range-of-motion exercises as prescribed for ankylosing spondylitis can be helpful.
In TCM, gastrointestinal symptoms from inflammatory bowl disease can also be interpreted as a spreading of the Bi or painful obstruction internally to the gastrointestinal system, as described in chapter 43 of Simple Questions (素問). The gastrointestinal pattern of this disease is usually Hot Bi, Excess dominance in microcosmic view. However, when the gastrointestinal symptoms of this disease has become chronic for years, Spleen Qi deficiency is almost always involved.
The x-ray changes of spine arthritis in ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome and colitic arthritis are the same, named seronegative spondyloarthropathy, with which patients usually have progressive stiffness in back and limitation of back motion. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
The “sausage” appearance of fingers and toes of peripheral type of psoriatic arthritis implicates that the microcosmic view of psoriatic arthritis in TCM is not only Hot Bi, but is also associated with Qi and Blood stagnation. In fact, in contemporary Chinese medicine, all the diseases that belong to seronegative spondyloarthropathy are in the category of external pathogenic factor type, which microcosmic view is Hot Bi and Excess dominance. (From Dieppe, P., et al: Atlas of Rheumatology, Lea & Febiger, 1986)
- Polymyalgia Rheumatica
Polymyalgia rheumatica is characterized by pain and stiffness of the neck, shoulder girdle and low back around the pelvic girdle area, frequently in association with fever, malaise, and weight loss. Anemia and a markedly elevated sedimentation rate (ESR) are almost always present. Because of the shoulder girdle and pelvic area stiffness and pain, patients have trouble combing their hair, putting on a coat, or getting up out of a chair. In contrast to polymyositis, polymyalgia rheumatica does not cause muscular weakness. A few patients have joint swelling, particularly of the knees, wrists, and sternoclavicular joints. The differential diagnosis of malaise, anemia, and a markedly elevated sedimentation rate includes multiple myeloma, other malignant disorders, and chronic infections such as bacterial endocarditis. In modern western medicine, patients with polymyalgia rheumatica by itself are treated with prednisone, 10-20 mg/d. If the patient fails to experience a dramatic improvement within 72 hours, the diagnosis should be doubted. Within 1-2 months after beginning treatment, the patient’s symptoms and laboratory abnormalities will resolve. Slow tapering of the prednisone reduces the likelihood of relapse. The total duration of treatment varies considerably but ranges from 6 months to more than 2 years.
Polymyalgia rheumatica and giant cell arteritis probably represent a spectrum of one disease: Both affect the same population (patients over the age of 50), show preference for the same HLA haplotypes, i.e. HLA-DR4 or HLA-DRB1, and show similar patterns of cytokines in blood and arteries. Polymyalgia rheumatica and giant cell arteritis also frequently coexist. Clinically, the important difference between the two conditions is that polymyalgia rheumatica alone does not cause blindness and responds to low-dose (10-20 mg/d) prednisone therapy, whereas giant cell arteritis can cause blindness and requires high-dose therapy (40-60 mg/d).
Essentials of modern western diagnosis for polymyalgia rheumatica involve: (1) pain and stiffness of the neck, shoulder, low back and pelvic girdle area (buttocks, hip and upper thighs); (2) diffused muscle pain in proximal musculature, morning stiffness & normal strength; (3) Fever, malaise, anemia and weight loss; (4) elevation of ESR; (5) responding well to small dosage of Prednisone; (6) patient’s age over 50; (6) occasional inflammatory arthritis and joint effusion in knees and other peripheral joints.
Obviously, in TCM, polymyalgia rheumatica is in the category of external pathogenic factor type Hot Bi. It shares the same TCM treatment principles as rheumatoid arthritis and seronegative spondylopathy, and usually responds well to TCM treatments because the external evils mostly stay in the relatively shallow part of the body, e.g. underneath the skin or in the muscles.
- Fibromyalgia (Fibrositis)
Fibromyalgia also called fibrositis, is one of the most common rheumatic syndromes in routine acupuncture practices, affecting 3-10% of the general population. It shares many features with the chronic fatigue syndrome, namely, an increased frequency among women aged 20-50, absence of objective findings, and absence of diagnostic laboratory tests. While many of the clinical features of the two conditions overlap, musculoskeletal pain predominates in fibromyalgia whereas lassitude dominates the chronic fatigue syndrome.
The cause in western medicine is unknown, but sleep disorders, depression, viral infections, and aberrant perception of normal stimuli have all been proposed. Fibromyalgia can be a complication of hypothyroidism, rheumatoid arthritis, or, in men, sleep apnea.
The patient complains of chronic aching pain and stiffness, frequently involving the entire body but with prominence of pain around the neck, shoulders, low back, and hips. Fatigue, sleep disorders, subjective numbness, chronic headaches, and irritable bowel symptoms are common. The patient feels incapable of performing normal activities, and even minor exertion aggravates pain and increases fatigue. Patients occasionally trace the onset of symptoms to an acute event or viral-like illness. Physical examination is normal except for bone gap points of pain produced by palpation of various areas such as the trapezium, the medial fat pad of the knee, and the lateral epicondyle of the elbow.
Modern Western Diagnosis and Differential Diagnosis
Essentials of modern western diagnosis include: (1) prominence of pain around neck, shoulder, low back and hip and chronic widespread musculoskeletal pain with multiple tender points; (2) fatigue, headache and numbness common; (3) most frequent in females aged 20-50 and in older age; (4) absence of objective inflammation and negative lab tests.
Fibromyalgia is a diagnosis of exclusion. A detailed history and repeated physical examination can obviate the need for extensive laboratory testing. Rheumatoid arthritis and systemic lupus erythematosus virtually always present with objective physical findings or abnormalities on routine testing, including the erythrocyte sedimentation rate. Thyroid function tests are useful, since hypothyroidism can produce a secondary fibromyalgia syndrome. The diagnosis of fibromyalgia probably should not be made in a patient over age 50 and should never be invoked to explain fever, weight loss, or any other objective signs. Polymyalgia rheumatica produces shoulder and girdle pain, is associated with anemia and an elevated sedimentation rate, and occurs after age 50.
Modern Western Treatment
Patient education is of paramount importance. Patients can be comforted by the knowledge that they have a recognizable diagnosable syndrome that can be managed by means of specific though imperfect therapies and that the course is not progressive. Placebo-controlled trials have demonstrated modest efficacy of amitriptyline, chlorpromazine, or cyclobenzaprine.
Amitriptyline is initiated at a dosage of 10 mg at bedtime and gradually increased to 40-50 mg depending on its efficacy and toxicity. Exercise programs are also beneficial. NSAIDs are generally ineffective. Opioids and corticosteroids are ineffective and should never be used to treat fibromyalgia.
TCM Considerations of fibromyalgia
TCM considers fibromyalgia to be Bi pattern caused by either external pathogenic factors or internal organ deficiency. The Bi pattern can be either Cold or Hot, and the deficiency may occur in different organs or be manifested as different organ patterns as mentioned previously. The external pathogenic factors of fibromyalgia include Wind, Cold and Dampness or latent and epidemic pathogenic influences. So it is not uncommon that patients suffer from pain symptoms like fibromyalgia after they have gone through acute virous infections like flue and Hepatitis A or bacterial infections like streptococcus tonsillitis and acute pneumonia, etc. Fibromyalgia may be classified into the borderline Bi pattern, which can be either Hot or Cold microcosmically as well as either Excess or Deficiency in different organs macrocosmically. The TCM treatment of borderline Bi pattern will be detailed in Chapter III of Part Two.
Prognosis of fibromyalgia
Most patients have chronic symptoms. Patients usually respond well to Tuina, herbs and acupuncture especially acupuncture treatment, with all of which, most do eventually resume in creased activities. Progressive or objective findings do not develop.
- Post Lyme Disease Syndrome
Post Lyme disease syndrome means that patients have the symptoms and signs of stage III of Lyme disease, but they do not have the evidence of existing spirochete Borrelia infection anymore, i.e. they do not respond to antibiotics therapy anymore. Therefore, post Lyme disease syndrome is considered a pure auto-immunity response triggered by spirochete Borrelia. Patients with post Lyme disease syndromes usually complain of back and neck pain and vast muscular pain similar to those symptoms of fibromyalgia. They may also experience peripheral arthritis in large joints and have a higher frequency of the class II histocompatibility complex allele HLA-DR4 than those patients with brief Lyme arthritis at early stage or normal control subjects. Because the affected joints are inflammatory, showing significant increase in WBC in the joint fluid and destructive lesions by joint biopsy, TCM considers post Lyme disease to be Hot Bi, Excess dominance in microcosmic view. TCM regards the spirochete Borrelia causing Lyme disease as the latent pathogenic influence causing Bi pattern. Therefore, post Lyme disease syndrome may be classified into External pathogenic factor type, Hot Bi.
- Fascitis of Back and Neck
This disease is also called myofacial fibrositis, myofascitis, rheumatism, myofascial pain syndrome and myofibrositis. Western medicine usually put it into the category of chronic strain of the back and neck, because its common cause is mechanical strain, which belongs to mechanical back and neck pain. However, the history of mechanical strain can not be traced in certain types of fascitis and the causes of these types are obviously non-mechanical origins. Therefore, the fascitis hereby is only defined as those types of fascitis caused by non-mechanical origins. The non-mechanical causes in TCM involve the following:
(1) Cold and Dampness: The patient has a history of attack by exogenous Cold and Dampness before the onset of the disease. This may occur in taking a cold bath right after physical exertion, exposure to cold at night, especially when the areas of back and neck are exposed to direct blowing by electric fan for a long time. Prolonged exposure to cold and dampness may also cause this disease, which is more serious in bad weather. The Cold and Dampness may turn into Heat.
(2) Latent or epidemic pathogenic factors: With common cold or tonsillitis the patient may also suffer from back and neck pain as well as stiffness in the back and neck regions which will ease when the infection is controlled. This disease may also be caused by such factors as fatigue, prolonged anxiety, weakening of neuro-regulation function and the body’s protective ability against exogenous wind, cold and dampness.
Symptoms and Diagnosis
Pain and tingling and distending sensation in back or neck, weakness in the neck with radiating pain to the shoulder or weakness in the waist with radiating pain to the buttock and legs, which become worse when the weather is cold, rainy or overcast. Proper activity may, however, ease the pain somewhat. In fact, the clinical features of fascitis are very similar to those of fibromyalgia, except that the pain of fascitis is usually limited one or two spots of the back or neck, while the pain of fibromyalgia is much more widespread to multiple areas of the body.
- Tender spot: Tender spots are found most often in the Cervical or scapular region, both sides
of the vertebral column, the lumbar vertebral transverse processes and areas around the ilium and the sacroiliac articulation. In the other words, the tender spot may be located at any bone gap points of the back and neck. There is reflex pain on pressing a tender spot.
(3) Muscular tension: When the pain in the back or neck is severe, there will evident muscular tension; when the pain abates, cords may still be felt, caused possibly by fascial adhesion. These cords are painful on pressing. Nodes of varying sizes, from that of soybeans to that of rice grains may be palpable, mostly around the sacroiliac articulation, the wing of the ilium, upper back and neck along the Taiyang UB meridians. These nodes are adipocele formed by protrusion of fat from ruptured fasciae, which is a manifestation of stagnation of Qi and Blood.
Like fibromyalgia, because it shows absence of objective inflammation and negative lab tests, fascitis is classified into the category of borderline type of Bi pattern.