Chinese Approaches To Rheumatoid Arthritis
Chinese Approaches to Rheumatoid Arthritis (RA)
This article is the basis of a talk given to a RA support group. It does not require a background in either Western Medicine or Traditional Chinese Medicine(TCM) to understand. Most technical terms are explained in the text. Chinese terms (Capitalised) often have different meanings from their direct translations, this is especially true for organs and should not be confused with Western medical terms.
Western Medicine Overview
Rheumatoid Arthritis (RA) Is considered an auto immune system disorder. It causes chronic systemic inflammation leading to progressive damage of joints. Affecting more than 1% of the population it is more common for women and with age.
The disease starts as inflammation of the synovial membrane, the sac containing fluid in the joints. This fluid lubricates, protects and nourishes the cartilage. With repeated attacks the joint builds plaques on the cartilage known as Pannus. These slowly erode the cartilage creating the arthritic pain in the joint. The Pannus then turns fibrous restricting movement and eventually binding the two bones in the joint thereby making it immobile (anklyosis). It follows a cycle of relapse into inflammation and remission where some symptoms seem to reduce or disappear. However the damage done to the joints is accumulative and permanent.
It tends to affect joints bilaterally and often starts in the fingers. Later the other joints on the limbs, neck and jaw can be affected as can other organs in the body. Fatigue, stiffness, generalised aching and suppressed appetite are common symptoms. Some people develop bone nodules at various joints.
Attacks can be very painful leading to short term decreased movement and muscle spasms. The surrounding soft tissue may be affected causing stiffening of tendons, ligaments and other connective tissue.
The accumulative degradation and soft tissue stiffening is asymmetrical at the joint. This leads to deformity or even dislocation of joints. The associated pain can be continual or on movement. RA is a major cause of disability
Treatment usually follows a three fold path. Gentle and appropriate exercise, pain relief with anti-inflammatory drugs (ASA and NSAIDs) and some use of disease controlling drugs (DMARDs). The causes of the disease are not fully understood.
Chinese Approaches to RA
China has an unbroken tradition of medical practice going back over 2,500 years. Rooted in careful observation and experimentation the Chinese came up with the concept of Qi or Energy. We do not have a direct translation in the West but we have a rudimentary understanding in such language such as constitution, energy level, boisterous, lack lustre and spirited. Traditional Chinese Medicine (TCM) asked how and why these holistic differences come about. TCM includes Acupuncture, herbology, Tui Na (massage and manipulation) and Qi Gong (energy exercise). Tony also uses Dit Da, the martial version Tui Na alongside the Thirteenth Branch (Jup Yao) of directed energy work.
All arthritic type pain in joints is called Bi Syndrome (Painful Obstruction Syndrome) in TCM and can have a multitude of internal and external causes. It is a complex condition which was recognised as Multiple Joint (Li Jie) with or without Wind (pain moves from joint to joint) or Stubborn Bi (Wan Bi).
In the broadest sense External Factors attack the body from outside. These include things like germs in the Western sense but also include Heat (Inflammation), Cold (stiffness), Wind (symptoms and pain move from place to place).
Internal Factors include Damp (swelling) leading to Phlegm (deposits and accumulations) and Stagnation (fixation including blood clots). There can also be generalised Deficiency or Xu. This is best expressed as a constitutional weakness. It may be generalised or specific to an organ or system. It can be congenital, build from years of poor diet, exposure to environmental toxins, depleted resources after illness, emotional shock or having children for example. For RA sufferers a combination of weakened immune system or Wei Chi (your ability to fight off disease) and weak Kidney Qi (your natural reserves)is likely.
Latent Heat forms over time from Retained Pathogens. It is a bit like the guards (Wei Qi) and population (Kidney Qi) of a castle. If the guards are strong then any attack is repelled. If the population is strong then even if some of the enemy pass the outer guards the population can both subdue the attack and repair any damage done. However, if the population is weak the guards will not have the resources to function properly. If the attack is chronic the guards will draw too many resources from the population. When an external pathogen passes the guards it may remain hidden within the walls. This is a Retained Pathogen. Any further demands on the guards or population will allow its troublesome nature to flare up. In TCM this is known as Latent Heat. These demands include new illness, emotional stress and fatigue, poor diet, and environmental pathogens.
So we have a complex pattern. There is Heat and Damp in the joints during an attack. This congeals to form the Pannus, a form of Phlegm which then weakens the joint surfaces. In TCM bone spurs and the fibroids locking joints are a continuation of this Phlegm growth. The XU manifests as an inability to defend the attacks as well as an inability to maintain or repair the joints.
TCM approaches to treatment.
There are four separate issues to address; Build and support the background weakness. Disperse the hidden pathological factor. Reduce pain, heat and damp of the acute phase. Address the chronic damage of the joints.
There are also four treatment directions. Exercise, Acupuncture, herbs and lifestyle changes.
Exercise can be taught in regular specialised classes or tailored privately. Regular classes have the advantage of price, repeated learning chances and have a social aspect. Hopefully they are fun. Private classes allow for individualised specific routines for need and ability.
Both rely on home practice. The exercises I teach include-
Zhan Zhuang Qi Gong (Standing Like A Tree Energy Exercise) to build energy levels, relax the sinews and reduce stress. As such this may mitigate the frequency and severity of acute attacks. Adding specific exercises like Walk of the Medics will encourage the process of removing the Retained Pathogen.
Tai Chi and gentle movement will keep joints more flexible without causing structural damage. It can also mechanically move pathogenic factors in the joint especially Damp and Phlegm. It may act as a preventative to anklyosis as fibroids are stopped from fixing. As an additional advantage, daily practice will inform and help manage any changes in mobility.
Dao Yin massage can help prevent and reduce pain locally and improve background Xu.
A sample daily routine could include ;
Massage St36 and Kidneys on waking.
30 mins daily routine -Warm up exercises(10mins), Walk of Medics(5mins), Zhan Zhuang (15mins)
10 mins- hand massage (3mins) finger exercises (3mins) two or more times.
2 mins gentle Tai Chi exercise for any other affected joints throughout the day.
10 mins Zhan Zhuang and final massage of kidneys, St36 and Ah Si points before bed.
Acupuncture can be used primarily to reduce local pain. Local points paired to distal points on affected channels are a standard approach. Extra ordinary points such as Baxie and Si Feng are also appropriate. Local moxa (burnt mugwort) is only applied during remission to disperse Cold and Damp. It should be used with care as joints can be burnt out and is not advised in the acute phase. Stick moxa is quite easy to use and the patient can be taught to self treat with time.
Specific acupuncture points can also help more generally to reduce Phlegm, Heat, Damp and tonify the Xu. St40 on the leg, LI11 at the elbow, Sp9 at the knee and Kd3 or Sp6 on the ankle respectively. Individual prescriptions will change depending on need at the time. These points can be added to the exercise routines above.
Chinese Herbal intervention would try to address all the problems simultaneously. Where as acupuncture is very effective at dispersing pathogenic factors, herbs can also tonify or build Qi. Standard formulas like Bu Zhong Yi Qi Tang are aimed at tonifying and Du Huo Ji Shen Tang for the pain of Wind and Damp. Either would be modified by the TCM practitioner for individual need. Modern powdered formulas are easy to use and are drunk like tea. Individual herbs are rarely used. Formulas are balanced for individual circumstances and can only be supplied under qualified supervision.
Lifestyle advice centres around sleep, exercise and diet. These choices revolve around the idea of balance. Nothing is fully good or bad, just the amount and timing.
Too little sleep and late nights can hamper healing and recuperation. Traditionally the Chinese recommendation is in bed and asleep before 11PM. You can rise early but you should feel refreshed. We need more sleep in the winter then the summer. As RA sufferers have already depleted energy levels proper sleep is essential.
Lying down in bed too much will encourage the stagnation element of the disease. General exercise like walking will counteract this tendency. Of course too harsh or strenuous activity may both damage the joints and deplete the already compromised reserves. Too much lying down or sitting on soft sofas will also put stress on the back.
The Chinese idea of a healthy diet is quite different from a Western one. All foods have health characteristics and not just flavours. Phlegm forming and Damp foods should be avoided. This includes raw or cold foods, bananas, wheat, mushrooms, aubergines, sugar, deep fried and fatty foods and eating to excess. The general diet for arthritis also excludes tomatoes, potatoes and rhubarb. There is good news though, we should eat heartily and enjoyably. Stock made from bone is a good source of calcium and builds the depleted Qi. You can add aromatic herbs, spices, ginger and garlic to disperse the Damp and Phlegm. Cooked pears can also disperse Phlegm. Sweet flavours can build Qi, but not refined sugar! Sit after eating for a few minutes to let your digestion work too.
During the acute phase hot, spicy and fried foods should also be avoided, although pungent and bitter flavours may help. Many foods like nuts and shellfish have mild allergenic and therefore inflammatory effects. It can take a long time to work out which foods affect you adversely. Chinese dietary advice is built on thousands of years of experimentation and reflection. Hot, wholesome, warm but not too spicy is a good starting point.
As for the environment, the Chinese words are already a clue. You must protect yourself from cold, wind and damp. This is primarily for the External environment. With time you can start to discern the feeling of Heat, Wind, Damp and Phlegm as they manifest Internally. Keeping damaged joints protected is essential. Clearly habits like wearing gloves when washing up or getting things from the freezer and avoiding sitting in draughts are advantageous.
Also, when new illnesses come try not to stop your natural bodily response. Using the castle analogy above, when under attack the occupants can make a lot of noise to try to scare the attackers away. Sweating and fevers are like this noise. As you are attacked the old Retained Pathogen rises to the surface. If you suppress the natural symptoms with too many pain killers (which can be Cold) or take decongestants the effect may be to lock in the new Pathogen with the old and they then both return to cause more problems later. I would like to emphasise that I do not suggest you don't take prescribed medication, rather allow yourself to heal naturally first. Food choices and acupuncture are very useful at this stage.
The TCM approach therefore has several aspects and phases. The initial interview usually takes about one and a half hours as the foundations are established. Most later consultations would be shorter and include inspection and adjustment of treatment plans. This is usually quite intensive at the onset, perhaps weekly or fortnightly. Time between consultations would then increase with need.
At the beginning lifestyle,diet and exercise strategies can be explored. Once learnt these three would be the foundation of self healing. Their continued use is free and have the best value for money of all treatments.
Acupuncture treatment would likely be focused on pain relief and reducing stronger symptoms. As these dissipate then time between treatments is likely to expand. Some people find a regular treatment fortnightly to quarterly work well as a preventative measure. This could then be supplemented during acute phases when necessary.
Herbal intervention also adjusts with time but usually settles to a repeat prescription, or perhaps two for different phases. The cost of a month's herbs is about the same as a consultation so can be more value for money in terms of ongoing treatment. All herbal supplies require regular consultation.
There are treatment choices depending on need and ability to pay outlined below. Of course commitment to self healing regimes is best.
G. Maciocia, (ed2 2008) The Practice of Chinese Medicine. Elsevier
Gould. B.E. (ed3 2002) Pathophysiology for the Health Proffesions. Saunders