Rheumatoid arthritis (RA) is an idiopathic, alloplasmatic and systemic autoimmune disease characterised by symmetrical and chronic inflammation of the peripheral joints resulting in progressive destruction of articular and periarticular structures. The affected joints develop many villous folds, and thickening is caused by an increase in the size and number of synovial cells. The inflamed synovium produces a number of chemicals, including collagenase, which can contribute to cartilage destruction. The hyperplastic synovial tissue, or pannus, can erode the joint cartilage, articular capsule and ligaments, eventually leading to severe deformity. Rheumatoid arthritis is prevalent in both China and in the West. In China, morbidity is approximately 3% and in the West, statistics range from 0.2% – 5.3%. The incidence of rheumatoid arthritis in women aged between45-55 is three times higher than in their male counterparts.
Chinese Medicine Perspective of Rheumatoid Arthritis
Chinese medicine does not have a specific term for what is defined in Western medicine as rheumatoid arthritis, but ancient medical texts describe a similar disorder known as Bi Bing 痹病, or “Obstruction Disease”. The ancient texts further classified Bi Bing as Xing Bi 行痹or Travelling obstruction, Tong Bi 痛痹or Painful Obstruction, Zhuo Bi 着痹and Re Bi 热痹or Heat Obstruction, all of which are characterised by joint deformity causing pain and limited mobility. Other terms are Gu Bi 骨痹 or Bone Obstruction, Shen Bi 肾痹or Kidney Obstruction, Wan Bi 顽痹or Stubborn Obstruction, Gui Bei 龟背or Tortoise Back, Li Jie Feng 历节风, Gu Chui Feng 骨槌风or Bone Mallet Wind, and He Xi Feng 鹤膝风or Crane Knee Wind.
Professor Jiao Shu De , the renowned TCM rheumatologist followed the teachings of Zhang Zhong Jing who created the name Wang Bi” 尪痹 for “arthralgia in all joints of the extremities characterised by swelling, pain and fatigue …”. This describes the disease today known as rheumatoid arthritis, which is characterised by joint deformity, damage to sclerotin, contraction of ligaments, stiffness and restriction of movement. The name “Wang Bi” was officially confirmed as the Chinese medical term in December 1981. It is defined by four patterns: (1) Exuberant kidney deficiency cold pattern as indicated by Bu Shen Qu Han Zhi Wang Tang (Tonify the Kidney and dispersing coldness Decoction); (2) Kidney deficiency with superficial mild heat pattern as indicated by Jia Jian Bu Shen Zhi Wang Tang (Modified Tonify the Kidney Decoction); (3) Kidney deficiency with superficial Heat Excess pattern as indicated by Bu Shen Qing Re Zhi Wang Tang (Tonify the kidney and dispel heat Decoction); (4) Damp-heat with damage to kidney pattern as indicated by Bu Shen Qing Hua Zhi Wang Tang (Tonify the kidney and clear heat decoction). In 1994, Wang Bi was finally incorporated as an official disease name into the “People’s Republic of China Pharmaceutical and Disease Pattern Diagnosis Standards” to refer to the Western disease known as rheumatoid arthritis.
Aetiology and Pathogenesis
Aetiology: Internal factors (genetic inheritance and lifestyle causing damage to the kidney and deficiency) and external factors (pathogenic invasion)
Pathogenesis: Deficiency of kidney yang and damage to the Du Mai (Governing Vessel); invasive attack by pathogenic damp-cold damaging the kidney, bone, ligaments, muscle as well as causing obstruction to the network vessels with subsequent infiltration of the zang fu organs.
Disease location: Network vessels, blood vessels intimately connected with the kidney, liver and the spleen with affiliated involvement of the lung, heart, skin, muscle, ligaments, bone and joints as well as the generalised involvement of the body and zang fu organs.
Disease nature: The ‘ben’ or root is deficiency (kidney, governing channel and spleen yang deficiency, insufficiency of the liver blood) and the ‘biao’ or manifestation is excess (pathogenic wind, damp and cold causing obstruction to the network vessels coupled with the accumulation of damp and phlegm turbidity with prolonged constraint transforming into heat)
Disease development: Early stage of superficial manifestations (skin, muscle, ligament, bone and joints) followed by the gradual infiltration into the interior (zang fu organs such as the lung, spleen, liver, kidney and heart).
Rheumatoid arthritis (RA) can be classified according to whether it is in the active phase or the remission phase. The treatment principle is to combine the strategies of tonifying the deficiency by supporting the zheng qi, and removing the excess by expelling the pathogen. In the active stage of the disease, the focus is primarily on addressing the manifestation by expelling the pathogen, and supporting the zheng qi is secondary. In the remission phase, the priority is to support and strengthen the zheng qi and treatment aimed at expelling the residual pathogen is secondary. As there is both deficiency and excess, in the clinical situation the two phases can alternate,. Therefore, and one should adhere to the principle of treating the manifestation in the acute phase and treating the root in the remission phase.
This article was first published at the Pearls of Wisdom Seminar in 2009
About Professor Yan Xiao Ping
Professor Professor Yan Xiao Ping is the head of the Department of Rheumatology and Musculoskeletal Department of the Sino-Japanese Friendship Hospital in Beijing. She is the nominated academic successor of Professor Jiao Shu De, the revered icon of Ch… Read more »