Bi Syndromes

by Alon Marcus DOM

Foundations For Integrative Musculoskeletal Disorders - An East-West Approach.

Painful Obstruction Bi (rheumatological) Syndromes are said to be due to Exterior/Interior pathogenic Wind, Cold, Damp and/or Heat which obstruct the channels and collaterals/vessels causing blockage of Qi and Blood circulation. Bi syndromes manifest as pain, soreness, aches, numbness or heaviness of muscles, sinews, and joints, and/or swelling and burning pain. In general, Painful Obstruction can be divided into four main categories:

1. Exterior attack of pathogenic Wind-Cold and Dampness.
2. Exterior attack of pathogenic Wind-Heat and Dampness, or transformation of Exterior Wind-Damp-Cold into Wind-Damp-Heat.
3. Obstruction by endogenous Wind-Damp-Heat or Wind-Damp-Cold.
4. Chronic Bi syndromes with complicating factors./li>

Herbal and acupuncture medicine can be very helpful in the treatment of articular and soft tissue rheumatological disorders. The following are basic patterns seen clinically. The treatment of pain in TCM is predicated basically on the saying "if there is free flow there is no pain." Therefore, formulas that restore flow are used. In general, therapies that can unblock flow and thus treat pain incorporate one or more of the following herbal categories (deficiency of Qi and Blood may also lead to obstruction).

• Blood moving.
• Qi regulating.
• Spicy Exterior releasing.
• Wind extinguishing.
• Warming.
• Damp resolving

Which include herbs that clear Heat and Dry Dampness, spicy Exterior releasing, purgatives, Dampness draining, Wind-Damp dispelling, aromatically transforming Dampness, Phlegm transforming as well as Qi moving.

 

The following is a general discussion on the treatment of Blood stasis as it pertains to Sprain/Strains as well as other musculoskeletal Painful Obstruction disorders. Blood stasis is in the opinion of this author the most important aspect in treating Painful Obstruction (especially in chronic patients). In clinical practice there are generally three main levels or degrees of eliminating Blood stasis. If too strong a method is chosen not only may this cause hemorrhaging (theoretically), but also it is said to waste or injure the Blood, Yin and fluids.

The first level is activating the Blood, regulating Qi and transforming stasis. This method uses medicinals such as Rhizoma Ligustici Wallichii (Chuan Xiong), Rhizoma Corydalis Yanhusuo (Yan Hu Suo), and Rhizoma Curcumae Longae (Jiang Huang) to promote Blood circulation and sweep away stasis and is used often in the postural/dysfunction phase of the degenerative cascade, with stasis and Painful Obstruction in the channels—in patient where pain increases when tissues are stressed for some time such as prolonged slouched seating, and stretching tissues excessively for prolonged periods. This type of pain is due to poor circulation and nourishment of sinews and excessive demand from overuse. Some of these herbs move the Blood by activating the Qi within the Blood (Yan Hu Suo and Yu Jin). This is the least "attacking" of the three tcm methods for treating Blood stasis.
The second level is to dispel stasis and activate the Blood. In this case, the stasis is first dispelled and this results in the activation of Blood circulation—often by opening vessels, thinning blood, and increasing microcirculation so that Blood can penetrate and dispel stasis as well as nourish tissues. Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Salviae Miltiorrhizae (Dan Shen), Flos Carthami Tinctorii (Hong Hua), Fasciculus Vascularis Luffae (Si Gua Lao), Gummi Olibanum (Ru Xiang), Myrrha (Mo Yao), Fructus Liquidambaris (Lu Lu Tong), Sanguis Draconis (Xue Jie), Lignum Sappan and (Su Mu) are representative herbs for this purpose and are used often in the instability and stabilization phases to increase circulation to ligaments and tendons—pain in instability stage is worse often when the patient does not move for a period of time (coctail party syndrome) and in morning and is better with some movement (posain). The patient often complains of his back being out and needs friquent manipulations.
The third level is braking stasis and dispersing mass. This is the strongest method of eliminating Blood stasis and is used for cases of substantial stagnant Blood such as seen in the stabilization phase (often with Phlegm herbs). In this case there usually is palpable masses, or spurs on X-rays—the pain may independent of motion and is more related to location of hypertrophy and if there is impingement of nerves, or if local congestion is severe. Semen Pruni Persicae (Tao Ren), Hirudo seu Whitmania (Shui Zhi), Eupolyphaga seu Oposthoplatia (Tu Bie Chong), (E Zhu) and (O Zhu) (although the last two are not commonly used in musculoskeletal medicine) are commonly used herbs, which brake stasis and disperse masses.
Care must be applied when using this method as it can damage Yin, Blood and Qi.
A fourth method in which Blood stasis herbs are used is known as dispelling stasis and generating the new. This method is used in cases where Blood stasis is hindering the generation of fresh Blood and also during recuperation from injuries where a residue of Blood stasis impedes the generation or growth of healthy new tissues or Blood. These herbs often have a vitalizing and tonifying effects on Blood. In the treatment of musculoskeletal disorders, this method is used often when Blood "de-stagnating" medicinals are added to other formulas during the recuperative period, in weak patients in order to enhance the clinical effect, and in chronic diseases. They are used often in the treatment of fractures as well—and can be used in the postural, instability, or stabilization phases of the degenerative cascade. Radix Angelica Sinensis (Dang Gui), Radix Rubrus Paeoniae Lactiflorae (Chi Shao), Radix Millettiae Reticulatae (Ji Xue Teng), Radix Achyranthis Bidentatae (Niu Xi), Herba Artemisiae Anomalar (Liu Ji Nu), and Pyritum (Zi Ran Tong) are particularly important as they can both vitalize and tonify Blood.

Bleeding in musculoskeletal disorders are generally associated with trauma. Trauma and stasis of Blood can result in transformative Heat. It is therefore common to add some cooling herbs when treating acute traumatic injuries. To treat Bleeding there are five major methods.

Clear Heat from the Blood division/depth (cool Blood).
Eliminate stasis to stop bleeding.
Tonify Qi/Spleen to hold the Blood in the vessels.
Astringent method for leaking Blood.
Hemestatics that are worm, cold or neutral.

Carbonizing (charring) an herb strengthens its hemestatic function. Care must be used when using hemestatics as they may cause Blood stasis.

In musculoskeletal disorders:

To cool the Blood herbs such as: Cortex Mountan Radicis (Mu Dan Pi), Radix Rehmanniae raw (Sang Di Huang), Cortex Lycii Radicis (Di Gu Pi), Rhizoma Imperatae (Bai Mao Gen), Fructus Gardeniae (Zhi Zi) and Radix Paeoniae Rubra (Chi Shao) are often used.
To vitalize the Blood and stop bleeding herbs such as: Radix Pseudoginseng (San Qi), Rhizoma Rhei (Da Huang), Pollen Typhae (Pu Huang), Lignum Sappan (Su Mu) and Faeces Trogopterorum (Wu Ling Zhi) are very commonly used.
To tonify Qi/Spleen arrest bleeding herbs such as: Radix Ginseng (Ren Shen) and Radix Astragali (Huang Qi) are mainly used.
Astringent herbs to stop bleeding such as: (Hai Piao Xiao), Stamen Nelumbinis Nucifera (Lian Xu), Semen Euryales Ferocia (Qian Shi), Galla Rhois Chinensis (Wu Bei Zi) and Pericarpium Papaveris Somniferi (Ying Su Ke) are sometimes used.
Warm hemestatics such as: Folium Artemisiae Argyi (Ai Ye), and Lignum Dalergiae Odiforae (Jiang Xiang) are sometimes used.
Cold hemestatics such as: Cacumen Biotae (Ce Bai Ye) and Rumiae Radix (Qian Cao Gen) are sometimes used.
Neutral hemestatics such as: Ophicalcitum (Hua Rui Shi), Pollen Typhae (Pu Huang), and Herba Agrimoniae (Xian He Cao) are sometimes used.

As Qi and Blood are interdependent and the body’s resistance to strains is dependent, in part, on the condition of the True Qi and Blood, therefore Blood stasis may, and often does effect Qi and Organ functions. Loss of harmony of Qi and Blood may manifest with Organ symptoms and signs (usually at the weakest Organ). When the Liver is affected the patient’s pain may be more susceptible to emotional states, there may be increased depression and agitation, fatigue, numbness, changes in the nails, more severe muscle tension and spasm and subcostal and rib-side tension/sensitivity and/or pain. When the Heart is affected there may be exaggeration of symptomatolagy, insomnia, increased dreaming, palpitations, difficulty in memory and cognitive functioning, and epigastric tension/sensitivity. If the Qi and Blood of the Spleen/Stomach are disharmonious the patients limbs may become weak and atrophy, there may be loss of appetite, loose or sticky stools, abdominal distention especially after eating and periumbilical pulsations. If the Kidneys are affected there may be low back soreness/weakness, weakness and/or pain of lower extremities and knees, aggravation of symptoms by exertion, urinary symptoms, tinnitus, fear, anxiety and lower abdominal pulsations. If the Lungs are affected then one may see symptoms relating to respiration and/or failure of fluids to descend and reach the Kidneys with of shortness of breath, cough, phlegm, and tension/sensitivity of the chest and upper back muscles.

Therefore, for optimal treatment of sprains, strains and Painful Obstruction one should take a good history and treat the patient holistically.

Representing clinical approaches and formulas to the treatment Blood stasis and its complication in patients with musculoskeletal disorders are:

Transforming Blood stasis opening and regulating channels and collaterals/vessels is used for acute or chronic musculoskeletal pains, joint dysfunction and/or pathology, stiffness, and pain worsening at night or by inactivity.
• Qi Li San (Seven-Thousandths of a Pael Powder)
• Die Da Wan (Trauma Pill)
• Hou Luo Xiao Ling Dan (Fantastically Effective Pill to Invigorate the Collaterals).
Transforming Phlegm dispeling Wind and invigorating the Blood is used for patients with symptoms of weakness, paralysis, sequelae of stroke, fibromyalgia; with fatigue and heavy-pain, swelling, psychiatric symptoms; anxiety and fear, edema, and cardiovascular disease.
• Jia Wei Shi Wei Wen Dang Tang (Augmented Ten-Ingredient Decoction to Warm the Gallbladder)
• Jia Wei Ban Xia Bai Zhu Tian Ma Tang (Augmented Pinellia, Atractylodis Macrocephalae, and Gastrodia Decoction)
• Xiao Huo Luo Dan (Minor Invigorate the Collaterals Special Pill)
• Da Huo Luo Dan (Major Invigorate the Collaterals Special Pill)
Regulating Qi transforming stasis is used for disorders with distension pain, non-substential swelling, tension, and/or pain; in chest trunk subcostal/diaphragm or moodiness, cynicism, paranoia, functional nervous system disorders, psychiatric disorders, as well as sprain and strains, Liver disorders, and Heart diseases.
• Xue Fu Zhu Yu Tang (Drive Out Blood Stasis in the Mansion of Blood Decoction),
• Ge Xia Zhu Yu Tang (Drive Out Blood Stasis Below Diaphragm Decoction),
• Fu Yuan Huo Xue Tang (Revive Health By Invigorating the Blood Decoction).
Warming Yang and vitalizing Blood is used for patients with Interior Cold and Blood stasis with symptoms of cold extremities, sensitivity to cold, severe pain aggravated by cold, and painful obstruction of all four limbs.
• Dang Kui Si Ni San (Tangkuei Decoction for Frigid Extremities)
• Si Ni Tang (Frigid Extremities Decoction)
• Yang He Tang (Yang-Heartening Decoction).
Clearing Heat transforming stasis is used in disorders of burning pain, inflammation, bleeding, autoimmune diseases and septicemia.
• Xi Jiao Di Huang Tang (Rhinoceros Horn and Rhemannia Decoction)(
• Jia Wei Tao Hong Si Wu Tang (Augmented Four-Substance Decoction with Safflower and Peach Pit).
Dissipating nodules and transforming stasis is used in patients with nodules and masses such as enlarged lymph nodes, muscular and other sinew nodules (fibromyositis), joint mouse (free body), spurs, vertebral hypertrophy, splenomegaly, hepatomegaly, prostatic hypertrophy, goiter, and scrofula.
• Xiao Luo Wan Jia Wei (Augmented Reduce Scrofula Pill)
• Kang Gu Zeng Sheng Pian (Against Bony Hyperplasia Tablet)
• Ren Shen Bie Jia Qian Wan (Ginseng and Carapax Amydae Pill)
• Da Huang Zhe Chong Wan (Rhubarb and Eupolyphaga Pill).
Stoping bleeding transforming Blood stasis is used in patients with acute sprain/strains and contusions, and bleeding with purplish or black/brown colored blood.
• Shi Hui San (Ten Partially-Charred Substances Powder)
• Shi Xiao San (Sudden Smile Powder)
• Yunan Bai Yao (Yunan White Medicine).
Tonifying Qi and Blood transforming Blood stasis is used in patients with chronic diseases that have not healed despite treatment. Pain aggravated by activity or in afternoon, fatigue, shortness of breath, paleness, prolonged bleeding, sequelae of stroke, and muscular atrophy.
• Bu Yang Huan Wu Tang (Tonify the Yang to Restore Five [Tenths] Decoction)
• Shu Jing Huo Xue Tang (Relax the Channels and Invigorate the Blood decoction)
• Huang Qi Gui Zhi Wu Wu Tang (Astragalus and Cinnamon Twig Five Substance Decoction).
Nurturing Yin/Blood clearing Heat vitalizing and transforming Blood stasis is used in patients with chronic disorders that have damaged Yin fluids. Seen frequently in patients with concomitant internal diseases such as diabetes, phlebitis, deep venous thrombosis, chronic inflammatory diseases, and autoimmune diseases. Symptoms may present with burning pain, insomnia, night sweats, tacycardia, warmth of palms, soles of feet and chest, and night pain. The affected area and face are often dark, blackish, dry and lusterless or dry and hot.
• Da Bu Yin Wan Jia Jie (Argument Great Tonify Yin Pill)
• Yi Guan Jian (Linking Decoction)
• Hu Qian Wan (Hidden Tiger Pill)
• Si Miao Yang An Tang (Four-Valiant Decoction for Well Being).
Purging cracking and dispersing stasis is used in patients with severe accumulations and swelling of joints, severe inflammatory arthritis, septic arthritis, and acute abdominal disorders.
• Da Huang Zhe Chong Wan (Rhubarab and Eupolyphaga Pill)
• Xie Yu Xue Tang (Drain Static Blood Decoction).

The above formulas are often modified using herbs for Qi stagnation, spicy releasing, Wind dispaling, warming, and dampness resulving.

Qi Stagnation

Qi is often stagnant is patient that suffer from pain and from life stresses. Commonly used Qi moving herbs in musculoskeletal pain are: Radix Linderae Strychnifoliae (Wu Yao), Lignum Aquilariae (Chen Xiang), and Flos Rosae Rugosae (Mei Gui Hua) as well as Radix Curcumae (Yu Jin), and Rhizoma Corydalis (Yan Hu Suo) which moves the Qi within the Blood.

For retrograde flow of Qi with nausea/vomiting/hiccups/ belching and sometimes for swelling: Haematitum (Dai Zhe Shi), Pericarpium Citri Reticulatae (Qing Pi), Fructus Immaturus Citri Aurantii (Zhi Shi), and Calyx Diospyri Kaki (Shi Di) can be used.

Spicy Exterior Releasing

Spicy Exterior releasing herbs are used mainly for Exterior syndromes. Commonly used Spicy warm Exterior releasing herbs for musculoskeletal pain are: Ramulus Cinnamomi Cassiae (Gui Zhi), Radix Ledeboriella (Fang Feng), Rhizoma et Radix Notopterygii (Qiang Huo), Radix Angelicae Dahuricae (Bai Zhi), and Herba cum Radix Asari (Xi Xin).

Spicy cool Exterior releasing herbs for musculoskeletal pain are: Fructus Viticis (Man Jing Zi), and Radix Puerariae (Ge Gen).

The spicy character of these herbs also moves Qi and are used often to warm the channels and assist in moving Qi Blood and stopping pain.

Wind can be due to Exterior or Interior causes. Interior Wind can arise from deficiency of Yin/Blood or excess stagnation transformative Heat. Commonly used Wind extinguishing herbs for musculoskeletal pain are: Rhizoma Gastrodiae Elatae (Tian Ma), Lumbricus (Di Long), Buthus Martensi (Quan Xie), Scolopendra (Wu Gong), and Bombys Batryticatus (Jiang Can). They are used often in patients with muscle spasms, headaches and deep seated obstructions (because of their penetrating qualities).

Warming Channels

To warm the channels, joints and sinews: Radix Lateralis Aconiti (Fu Zi), Radix Aconiti Carmichaeli (Chuan Wu), Radix Aconiti Kusnezoffii (Cao Wu), and Cortex Cinnamomi Cassiae (Rou Gui) are used in patients with severe pain and cold contraction of tissues (stiffness).

Dampness

As noted above there are many types of herbs that deal with Dampness.

Dampness is considered the central pathogenic factor in Painful Obstruction Bi Syndromes (although in this authors experience as stated above Blood vitalizing is often more important). As Dampness is a viscous, substantial, and sticky pathogen, and therefore, attracts and adheres to other Pathogenic factors, as well as the body, Bi syndromes are often said to be difficult to eliminate. When treating Dampness, one must analyze the patient condition to ascertain if Dampness is predominant. Or if for example, Heat in Damp-Heat, Wind in Wind-Damp, Yang/Spleen/Kidney deficiency in Cold-Damp, Qi deficiency or stagnation in Damp accumulation, is predominate. The condition may be predominately Hot, Cold or it may be mixed. When mixed, the degree of the involved Pathogenic factors must be understood. Another aspect is the location of Dampness and is it from endogenous or exogenous origin. Therefore, when treating Damp syndromes, complex treatment principles may be warranted.

The root of Dampness, which is ether exogenous or endogenous, is said often to be Spleen deficiency. Other common causes of Dampness are Kidney Yang deficiency (the source of Spleen Yang), failour of the Lungs to regulate Qi and move the fluids down and excessive intake of sweat and rich foods which weaken the Spleen/pancreas. Thus addressing the Spleen/pancreas or other causitive factors is needed often.

In musculoskeletal disorders:

In patient with Damp-Heat with symptoms of swollen hot joints and/or other symptoms signs of Damp-Heat. To clear Heat and Dry Dampness: Cortex Phellodendri (Huang Bai), and Radix Acutellariae Baicalensis (Huang Qin) are used to drain, dry and clear Damp-Heat. They are used also as "balancing" herbs in Spicy and Worm formulas to protect Yin/fluids.

 

To dispel Dampness via the surface spicy Exterior releasing herbs: Ramulus Cinnamomi Cassiae (Gui Zhi), Radix Ledebouriella (Fang Feng), Rhizoma et Radix Notopterygii (Qiang Huo), and Herba cum Radix Asari (Xi Xin) are used especially in Exterior cold syndromes.

Fructus Viticis (Man Jing Zi), and Radix Puerariae (Ge Gen) are used in Exterior Heat syndromes.

Purgatives such as: Rhizoma Rhei (Da Huang) and Herba Aloes (Lu Hui) are sometimes used when constipation is a factor.

Dampness bland draining/percipitating: Poriae Cocos (Fu Ling), Polypori Umbellati (Zhu Ling), Semen Coicis Lachrma-jobi (Yi Yi Ren), Semen Plantaginis (Che Qian Zi), Rhizoma Dioscoreae (Bei Xie), Rhizoma Alismatis Orientalitis (Ze Xie), and Radix Stephaniae Tetrandrae (Han Fang Ji) are used to drain Dampness via urination and to drain Heat, especially in patients with edema and/or swelling.

Wind-Dampness dispelling: The majority of herbs in this category can be used in musculoskeletal disorders.

Radix Angelicae Pubescenis (Du Hou), Radix Clematidis (Wei Ling Xian), Excrementum Bombycis Mori (Can Sha), Cortex Acanthopanacis (Wu Jia Pi), Agkistrodon seu Bungarus (Bai Hua She), and Lignum Pini Nodi (Song Jie) are used for Cold conditions.

Radix Gentianae (Qin Jiao) [both hot and cold conditions], Ramus Lonicerae Japonicae (Ren Dong Teng) Ramulus Mori Albae (Sang Zhi), Herba Siegesbeckiae (Xi Xian Cao), Folium Clerodendri Trichotomi (Chou Wu Tong), Caulis Trachelospermi (Lou Shi Teng), and Ramus Tinosporae Sinensis (Kuan Jin Teng) are used for Hot conditions.

Cortex Erythrinae (Hai Tong Pi), Zaocys Dhumnades (Wu Shao She), and Exuviae Serpentis (She Tui) are neutral.

Aromatically transforming Dampness: Herba Eupatorii Fortunei (Pei Lan), Rhizoma Atractylodis (Cang Zhu), and Fructus Amomi (Sha Ren) are used mainly for Dampness at the Exterior, middle burner (digestive symptoms), and in edema.

Phlegm transforming: Bulbus Fritillariae Thunbergii (Zhe Bei Mu), Radix Trichosanthis Kirilowii (Tian Hua Fen), Succus Bambusae (Zhu Li), Herba Sargassii (Hai Zao), are used sometimes to treat hot Phlegm swelling with nodular tissues in muscles and/or joints.

Rhizoma Pinelliae Ternatae (Ban Xia), Rhizoma Arisaematis (Tian Nan Xing), Rhizoma Typhonii Gigaantei (Bai Fu Zi), and Radix Platycodi Grandiflori (Jie Geng) are sometimes used for cold Damp/Phlegm swelling with nodular and tight muscles and/or joints.

Qi regulating: Pericarpium Citri Reticulatae (Chen Pi), and Pericarpium Citri Reticulatae Viride (Qing Pi) are used to move fluids by moving Qi in middle burner or extremities.

Articular and soft tissue syndromes often are said to be variations of Wind-Damp Obstruction. Patients may suffer from joint pains that increase with changing weather, especially rainy days. When there is predominance of Wind, there would be migrating joint pains. Since it is said, "to treat Wind first treat Blood" it is common to add Blood herbs to Painful Obstruction formulas. Depending on the patient constitution, Organ health, pathogenic factors and anatomical variations, symptoms and signs can vary. A patient with Wind-Damp pathogens may show a thick white tongue coat. Other patients may have a swollen tongue with thin white coat. The pulse may be slow, slippery, wiry, or soft.

Phytotherapy: Juan Bi Tang (Remove Painful Obstruction).

Acupuncture

Sedation techniques LI11, 8, 4, TH5, 10, BL12, 13, DU14, DU16, GB20, 31, LU7.
Tonification technique ST36.
For predominance of Dampness:
• Sedation technique SP9, RN9, LU7, GB34, ST40.
• Tonification technique BL20.

Wind-Damp-Cold

When there is a predominance of Cold the pain can be more severe and may affect the low back and lower extremities (although any joint can be affected). The pain improves with warmth. The tissues feel tight and the joints are stiff (because of the tightening affect of Cold pathogen). There is usually little or no swelling. Wind-Damp-Cold is seen often with arthrosis.

Phytotherapy:

• Xiao Huo Luo Dan (Minor Invigorate the Collaterals Special Pill)
• Wu Tou Tang (Aconite Decoction)

• The following variation can be used.

Radix Aconiti Carmichaeli Praeparata (Zhi Chuan Wu) 9g
Radix Aconiti Kusnezoffii Praeparata (Zhi Cao Wu) 9g
Honey-fried Herba Ephedrae (Zhi Ma Huang) 9g
Ramulus Cinnamomi (Gui Zhi) 12g
Rhizoma Zingiberis (Gan Jiang) 9g
Radix Astragali (Huang Qi) 15g
Poriae Cocos (Fu Ling) 15g
Rhizoma Dioscoreae Hypoglaucae (Bei Xie) 15g
Myrrha (Mo Yao) 3g
Honey-fried Radix Glycyrrhizae (Zhi Gan Cao) 6g

For severe pain add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g

For joint swelling add: Rhizoma Artisaematis (Tian Nan Xing) 3g, Semen Coicie (Yi Yi Ren) 30g

Acupuncture

• Sedation technique LI4, TH5, BL12, BL13, GB30, GB31, GB35, ST34.
• Moxa at ST36, DU4, RN4, RN6, BL20, DU14.

Wind-Damp-Cold—Interior Heat

This pattern may be seen in patients with joint and soft tissue pains and symptoms of Wind-Cold-Damp, but signs such as tongue, lips, eyes, or pulse showing Interior Heat. These are patients with Exterior Bi syndromes and Excess Heat internally. Often Heat is lodged in the Large Intestines, Stomach due to dietary habits or from Liver, Gall Bladder, stagnant Qi and transformative Heat. It can also be seen in patients with Yin deficient constitutions. The joints and soft tissues are not red, hot or particularly swollen. The patient bowels and urine may show signs of Heat. There may be mouth sores and thirst. There may be hidden pathogens with Exterior Wind-Damp-Cold, especially in patients with weak immune systems (Yin/Yang deficiency weak Defensive/antipathogenic Qi). The tongue body may be red and dry and possibly with yellow or off-white coat. The pulse may be rapid, over-flowing, slippery or tidal or may be deep and forceful. This pattern is said also to develop from warm and dry formulas, and/or pharmaceutical drugs (particularly steroids).

Herbal Treatment

• Da Qiang Huo Tang.

Acupuncture

• Sedation technique DU14, LI11, LI4, ST25, BL12, TH5, GB34, SP9, SP10.
• Followed by tonification at ST36, SP6, BL20.

Wind-Damp-Cold—Chronic Pain—Blood Stasis, Qi stagnation

This pattern is seen often in patient with chronic painful arthralgias. The pain patterns are mixed, showing characteristics of Wind-Damp-Cold and Blood stasis Qi stagnation. Often the patients show signs of deficiency as well. Since chronic disease result often in Blood stasis and since it is said "to treat Wind first treat Blood" it is common to add Blood moving herbs to Painful Obstruction formulas, especially if traumatic or due to chronic disease—with or/wout signs of Blood stasis (i.e. pulse tongue signs). Because Qi moves the Blood and Qi and Blood are mutually dependent, herbs that regulate Qi are added as well. It is important to remember that this pattern may be seen in patients with or without clear symptoms and signs of Blood stasis. This type of formula can be used in patients with Painful Obstruction (Bi) syndrome that have not responded to Wind-Damp obstruction formulas and/or chronic Cold type formulas.

Phytotherapy:

• Shen Tong Zhu Yu Tong.

Acupuncture

• Sedation technique BL17, BL18, BL57, SP10, SP8, LI11, LI4, LI15, TH11, GB41 and Ashi (tender) points.
• After sedation the same points are moxaed with direct-skin moxa or by warming the needles.
• For deficiency add: SP6, BL23, BL20, DU4, RN17.

Wind-Phlegm-Obstruction—Chronic Pain/ Numbness

This pattern is seen often when puffy swelling, numbness, tremors, and possibly itchiness is predominant. Phlegm usually results from constitutional weakness of the Spleen/pancreas or from dietary irregularities which damage the digestive energy of the Spleen and Stomach. Phlegm can also arise from Heat or Cold that congeals fluids, from Qi stagnation that fails to move fluids. Phlegm obstruction can block Nutritive Qi and Blood with resulting numbness and swelling. Other symptoms such as light headedness, dizziness, vertigo, chest discomfort, or nausea may or not be seen. The tongue may be dark and swollen and coat may be greasy. The pulse may be wiry, slippery, or soft.

Phytotherapy: Ban Xia Bai Zhu Tian Ma Tang.

Acupuncture

• Sedation technique followed by moxa: ST40, 36, BL13, BL43, BL20, BL59, RN12, DU3.
• Sedation technique: GB20, GB31, GB33, GB38, LU7, LI4, LI11, TH5.

Qi-Stagnation-Cold

This pattern is seen in patients with morning pain or with posain. Soon after the patient gets up from bed, and moves the affected joint (as warmth and nourishment return to tissues), the pain disappears until the next morning or until a posture is again maintained for a prolonged period. Often the patient can perform most of daily activities pain free—as commonly seen in self reducing disc with morning low back pain. The patient may or not show other symptoms of Qi stagnation and Cold.

Phytotherapy: Modified Xiao Huo Luo Dan.

Acupuncture

• Sedation techniques followed by moxa LR3, LR2, LI4, BL18, GB34, GB30, GB35, GB41, 43.
• Tonification and moxa RN4, DU4, DU14, BL23, BL52, ST36.

Wind-Damp-Heat

This pattern may be seen in patient that have active inflammation. The joints may be worm, swollen and stiff. Patients often complain of pain that is severe. The pulse may be rapid and soft or rapid and slippery or wiry. The tongue may be red and have off-white or yellow greasy coat.

Phytotherapy: Early stages - Xuan bi tang (Disband Painful Obstruction Decoction). The following modification can be used.

Gypsum (Shi Gao) 25g
Semen Coicis (Yi Yi Ren) 20g
Excrementum Bombycis Mori (Can Sha) 9g
Rhizoma Pinelliae (Ban Xia) 9g
Fructus Forsythiae (Lian Qiao) 9g
Fructus Gardeniae (Zhi Zi) 9g
Radix Gentianae (Qin Jiao) 12g
Radix Sileris (Fang Feng) 9g
Ramulus Cinnamomin (Gui Zhi) 9g
Herba Ephedra (Honey fried is preferable) (Ma Huang) 6g

 

When Damp-Heat is chronic or severe and there is muscle spasms during strain of the affected joints (during weight bearing and often relaxation when joint not stressed i.e. involetary protective spasm), a modification of Si Miao Wand (Four-Marvel Pill) can be used. This formula can be used for lumbar or lower extremity disorders. The author often uses variations of the formula below for patients with radiculopathy from disc disease. Some patients do well when Xiao Huo Luo Dan is given at the same time.

Modified Si Miao Wand:

Cortex Phellodendri (Huang Bai) 12g
Rhizoma Arisaematis (Tian Nan Xing) 3g
Semen Coicis (Yi Yi Ren) 20g
Rhizoma Atractylodis (Cang Zhu) 12g
Radix Achyranthis Bidentatae (Niu Xi) 12g
Lumbricus (Di Long) 12g
Bombyx Batryticatus (Jiang Can) 9g
Radix Paeoniae Alba (Bai Shao) 20g
Rhizoma Anemarrhenae (Zhi Mu) 9g
Rhizoma Dioscoreae Hypoglaucae (Bei Xie) 15g
Rhizoma Dioscoreae Nipponicae (Chuan Shan Long) 20g
Radix Gentianae (Long Dan Cao) 6g
Radix Paeoniae Rubrae (Chi Shao) 9g
Poriae Cocos (Fu Ling) 12g
Radix Glycyrrhizae (Gan Cao) 6g
Herba cum Radix Asari (Xi Xin) 6g

For symptoms of muscle spasms add: bai hua she 5g, wu gong 3g, quan xie 4g, mu gua 9g,  di gu pi 20g

Acupuncture

• Sedation techniques/bleeding DU14, DU10, BL18, SP10, SP9, LI11, LI4, ST44, jing-well points

Wind-Damp-Heat—Chronic Disease, Blood Stasis

This pattern is seen often in patients with Rheumatoid and other chronic inflammatory type arthritis. The joints are swollen, red, painful and possibly deformed. The pulse and tongue may or may not show signs of Heat and Dampness. A variation of Two-Marvel Powder (Er Miao San) can be used.

Cortex Phellodendri (Hunag Bai) 15g
Rhizoma Atractylodis (Cang Zhu) 12g
Lumbricus (Di Long) 12g
Caulis Lonicarae (Jin Yin Teng) 15g
Radix Clematidis (Wei Ling Xian) 9g
Cortex Cinnamomi (Gui Pi) 6g
Rhizoma Arisaematis (Tian Nan Xing) 9g
Radix Gentianae (Long Dan Cao) 12g
Poriae Cocos (Fu Ling) 15g
Radix Gentianae (Qin Jiao) 12g
Semen Persicae (Tao Ren) 12g
Flos Carthami (Hong Hua) 6
Radix Ligustici (Chuan Xiang) 6g
Radix Angelicae Dahuricae (Bai Zhi) 9g
Herba cum Radix Asari (Xi Xin) 6g

 

For acute flar take out: Radix Ligustici (Chuan Xiang) 6g, Radix Angelicae Dahuricae (Bai Zhi) 9g, Cortex Cinnamomi (Gui Pi) 6g

Add: Gypsum (Shi Gao) 25g, Flos Loncerae (Jin Yin Hua) 12g, Fructus Forsythiae (Lian Qiao) 9g, Ramulus Cinnamomin (Gui Zhi) 9g

For Joint deformities, spasms and chronic disease take out: Cortex Cinnamomi (Gui Pi) 6g, Radix Gentianae (Long Dan Cao) 12g, Flos Carthami (Hong Hua) 6, Radix Angelicae Dahuricae (Bai Zhi) 9g, Herba cum Radix Asari (Xi Xin) 6g

Add: Radix Paeoniae Rubrae (Chi Shao) 9g: Radix Paeoniae Alba (Bai Shao) 20g, Angelica Sinesis (Dang Gui) 15g, Agkistrodon (Bai Hua She) 5g, Scolopendra (Wu Gong) 3g, Buthus Martensi (Quan Xie) 4g, Eupolyphaga seu Opisthoplatia (Tu Bie Chong) 4g, Herba Epimedii (Yin Yang Hou) 9g, Rhizoma Frynari (Gu Sui Bu) 12g, Radix Polygonum Multiflorum (He Shao Wu) 12g

Acupuncture

Commonly used points are: Sedation techniques/bleeding GV-14, 10, UB-17, Sp-10, 9, LI-11, 4, Well (distal-nail) points. Use cupping/bleeding at UB-43 and over swollen areas. Tonify St-36, Sp-6, CV-4, UB-20.

Wind-Damp-Cold—Weakens of, Liver, Kidneys, Qi and Blood

This pattern is seen most often in elderly patients or in patients with chronic arthrosis. The main symptoms are cold pain in the back and knees and stiff joints. Some patients may complain of a sense of numbness/ache and feeling fatigue or heaviness. The pain improves with heat and may worsen in changing weather. The joints and soft tissues are cold and not particularly swollen. The pulse may be weak (deep, fine, soft, thready) or hidden (not obvious, very deep). The tongue may be pale. The representative formula is Du Huo Ji Shen Tong. The following modification can be used:

Angelicae Pubescentis (Due Huo) 12g
Radix Gentianae (Qin Jiao) 12
Radix Sileris (Fang Feng) 9g
Radix Ligustci (Chuan Xiong) 9g
Radix Rehmanniae (Shu Di Huang) 12g
Ginseng (Ren Shen) 6g
Radix Achyranthis Bidentatae (Niu Xi) 12g
Ramulus Cinnamomin (Gui Zhi) 9g
Radix Paeoniae Alba (Bai Shao) 15g
Radix Dispsacus (Xu Duan) 9 g
Radix Polygonum Multiflorum (He Shao Wu) 12g
Ramus Loranthi (Sang Ji Sheng) 6g
Stamen Nelumbinis (Lian Xu) 3g

For severe pain add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g

For Swelling add: Yi Yi Ren 20g, Bi Xie 12g

Acupuncture

Commonly used points are: Sedation technique LI-4, TW-5, UB-12, 13. Tonification and Moxa at St-36, Sp-6, K-3, 7, GV-4, CV-4, 6, UB-20, 18, 23, GV-14.

• shoulder- 3 shoulder needles, 1. extra Jian Qian, LI 15, TH 14,  2. LI 15, TH 14, SI 9, 3, LI 15, TH 14, LI 14
• elbow- LI 10, 11, TH 5, 10, LU 5, LI 4
• wrist- LI 5, TH 4, SI 5, LI 4
• spine- DU 3, 12, 26, Yintang
• hip- GB 29, 30, 39
• buttocks- BL 36, 54, SP 9
• knee- ST 34, 35, GB 33, 34
• ankle- BL 60, 62, KI 6, GB 40, ST 41

Many natural therapies have been evaluated in the treatment of arthritis. A review article on natural therapies by Pizzorno (1985) suggested that dietary and other natural interventions might be helpful for both inflammatory and non-inflammatory arthritis. A few of the more popular therapies are reviewed here:

Professor Norman Childers from Rutgers University found that elimination of the genus Solanaceae (the night shade family of plants) from the diet may be beneficial. This includes tomatoes, potatoes, egg plant, peppers and tobacco. It is suggested that these glycoalkaloids found in Solanaceae plant inhibit normal collagen repair in the joints or promote inflammatory degeneration.
Dr. Kaufman showed that niacinamide may provide major improvement in osteoarthritis symptoms. Time release niacinamide capsules 400mg three twice a day, is the modern version of his regime. One needs to wait three weeks before judging efficacy. The condition is controlled, but not cured, so it is necessary to continue on the treatment for long periods. He also suggests it is occasionally useful in rheumatoid arthritis. Liver damage and glucose intolerance are possible side effects of this treatment, thus periodical liver function and glucose tolerance tests are warranted. A test at three months and a year, and the absence of deterioration are considered adequate safeguards. Hepatic dysfunctions with doses under 3 gm per day are unlikely to be problomatic. Shark cartilage, or less expensive alternative forms of cartilage, gives additional benefit to the niacinamide. These seem to have a synergistic effect with niacinamide (Dorman personal communication).
Sulfur-containing compounds, including methionine a sulfur-containing amino acid, are important in the maintenance of cartilage, especially proteoglycans and glycosaminoglycans. Injectable glycosaminoglycan polysulfate and activated acid-pepsin-digested calf tracheal cartilage, as well as other glycosaminoglycans have yielded positive results.
Vitamin E at 600 mg a day has shown benefit, possibly due to its membrane-stabilizing effect. This effect may be due to its ability to inhibit the activities of the lysosomal enzymes and stimulate increased deposition of proteoglycan.
Vitamin C between 1,000 and 3,000 mg a day can have positive affects on collagen synthesis and repair.
Yucca at 2 to 4 gm 3 times daily is recommended. In a double blind study, the saponin extract of Yucca showed a positive therapeutic benefit.
Cherries, Hawthorn berries and blueberries are rich sources of anthocyanidins and proanthocyanidins. These compounds are beneficial in enhancing collagen matrix integrity and structure.
Elimination of all refined carbohydrates and increase intake of fish and other "healthy" fatty acids is recommended often as part of the so called anti-inflammatory diet.
If one is taking pharmaceutical NSAIDs the consumption of deglycyrrhizinated licorish or Robert's formula is recommended to protect the intestinal tract from the damaging effects of the NSAIDs.
Ginger has been noted in ayurvedic and in OM to be useful in rheumatism.
Sea Cucumber has a reputation in the far east for the management of arthritis.
Capsaicin is commonly used in the treatment arthritis.
Intra-articular ("purified") hyaluronic acid injections may have a protective effect on cartilage damage in osteoarthritic joints.
Acetyl merystoleate is reported to help both osteoarthritis and RA.
There have been many studies showing the benefit of essential fatty acid supplements RA.
The systemic effects of oral proteases and peptidases such as Serratia peptidase have been shown to help patients with RA.
Boswellia serrata have been used in the treatment of RA.
Feverfew as been used for RA and other inflammatory diseases.
Sting Nettle extract has been shown to inhibit biosynthesis of acrachidonic acid metabolites.
Willow bark extracts contain salicin, and other derivatives including salicylic acid.
Folic acid supplementation may lower toxicity in patients treated with methotrexate for RA.
Pulsed electromagnetic fields may be of benefit as shown in a double-blind study.
Exercise therapy is very important.
Photopheresis may be helpful in seronegative psoriatic arthritis.
Counseling and special stress management skills are helpful for RA patients.

Chondroitin Sulfate. Chondroitin Sulfate has been compared to nonsteroidal anti-inflammatory (NSAIDs) in a randomized, multicenter, double-blind study using 400-mg chondroitin sulfate three times per day. Patients treated with NSAIDs had rapid and plain reduction of clinical symptoms, which reappeared after the end of the treatment. In the chondroitin sulfate group however, the therapeutic response appeared later in time but lasted up to 3 months after the end of treatment. Chondroitin sulfate treated osteoarthritis patients had a slow but gradual increase in activity, and these benefits lasted after the end of treatment (Morreale, Manopulo, Galati, et al 1996).

Glucosamine Sulfate. Glucosamine sulfate stimulates cartilage regeneration, protects against joint destruction, and alleviates the symptoms of knee osteoarthritis. Glucosamine sulfate is not an analgesic and takes several weeks before a symptomatic relief can be obtained. Glucosamine sulfate has been shown to help knee arthritis when injected (Reichelt, Forster, Fischer, et al 1994) and when taken orally (Lopes Vaz 1982).

Glycosaminoglycan. Glycosaminoglycan (GAGPS) injections into the knee in a double-blind, placebo-controlled trial showed immediate decrease in the pain after the injections of 43% with the GAGPS and 33% with the placebo. Pain relief in the GAGPS versus the placebo was not different at other intervals. At 6 weeks the Lequesne Index decreased 20% after the GAGPS and 9% after the placebo. At 10 weeks the Lequesne Index decreased 24% after the GAGPS and 13% after the placebo. The decrease in the Lequesne Index at 13 weeks was 31% after the GAGPS and 15% after the placebo. Other measured parameters tended to be more favorably influenced by the GAGPS than placebo. There was minimal side effects which occurred in approximately 8% of the cases (Pavelka, Karel et al 1995).

Ginger. Ginger has been noted in ayurvedic and in OM to be useful in rheumatism. Ginger has been shown in 261 patients with knee osteoarthritis and with moderate to severe pain in randomized double-blind, placebo-controlled, multicenter, parallel group, 6-week study to be helpful. The study showed that ginger extract containing 255 mg and 500-1,500 mg of dried galanga rhizomes given twice daily can result in a reduction in knee pain on standing. Evaluating secondary efficacy variables showed a consistently greater response in the ginger extract group compared with the control group. There was a reduction in knee pain on standing, a reduction in knee pain after walking 50 feet, and a reduction in the Western Ontario and McMaster Universities osteoarthritis composite index that was greater in the ginger group compared with the placebo group. The change in global status and reduction in intake of acetaminophen were greater in the ginger extract group. The subjects who received ginger extract had more gastrointestinal complaints than the placebo group. These GI complaints were mostly mild (Altman and Marcussen 2001).

Ginger has been shown to be helpful also in inflammation and rheumatism in a study of 28 patients with rheumatoid arthritis, 18 with osteoarthritis, and 10 with muscular discomfort using powdered ginger. In the arthritic patients, over 75% had varying degrees of relief from pain and swelling. All the patients with muscular discomfort had pain relief. There were no reported side effects with regards to ginger consumption from 3 months to 2.5 years. Doses ranged from 50 gms of raw fresh ginger daily, to 3 or 4 gms of powdered ginger, per day (Srivastava and Mustafa 1992).

Ginger is known to act as a dual inhibitor of both cyclooxygenase and lipoxygenase and can inhibit leukotriene and prostaglandin synthesis, as well as reduce carrageenan-induced raw-paw edema in animal models of inflammation. Ginger has also been shown in in-vitro studies to inhibit the production of tumor necrosis factor through inhibition of gene expression in human osteoarthritic synoviocytes and chondrocytes (Hamilton 2001).

Sea Cucumber. Sea Cucumber has a reputation in the far east for the management of arthritis. The scientific name is Pseudocolochirus axiologus. The creature contains a multitude of biologically active chemical moieties, one of which is effective against arthritis, and some against cancer— holothurin. The dose is 500mg BID with food (Dorman personal communication).

Capsaicin. The following information comes from a practitioner perspective article by Deal and Chad (1994). Capsaicin is commonly used in the treatment arthritis. Topical capsaicin (extracted from chili papers) may be beneficial in diabetic neuropathy, post herpetic neuralgia, post mastectomy pain syndrome, reflex sympathetic dystrophy and other musculoskeletal pains. Purified capsaicin has its effect on type C- sensory neurons. It depletes substance P, a neurotransmitter of pain, from type C-neurons. Substance P is involved also in the exacerbation of the inflammation of arthritis. When the type C-neurons are repeatedly exposed to purified capsaicin they cease to synthesize, store and release substance P. The pain impulses are diminished. Substance P and prostaglandin PG 2 levels in synovial tissue decrease with regular joint application of topical capsaicin. Patients suitable for capsaicin therapy include those with 1 or 2 painful joints. The 2 strengths of topical capsaicin that are available are .025% and .075%. For most patients with mild to moderate pain .025% strength is a logical place to start. Patients should be instructed to apply a small amount of capsaicin to the skin covering of the effected joint. For example, for a knee, a pea-size dab cream is sufficient. Capsaicin should be applied 3 to 4 times a day. Once pain relief has been established with 4 times a day it may be reduced to 2 times a day depending on pain relief. Patients should be directed to wash their hands thoroughly after applying capsaicin cream because inadvertent transference can cause temporary burning and stinging in the eyes or other sensitive mucous membranes (a roll-on is available). Relief usually occurs within a few days. Adverse effects can be burning and stinging. The burning may be as short lived as 2 to 4 days. It is often worsened after bathing while exercising or perspiring. Topical anesthetics such as lidocaines before application of the cream may reduce burning. The patient should be instructed to continue applications for at least 2 weeks before evaluation of efficacy. No apparent systemic effects including drug-drug-food reactions have been reported.

In this author’s experience the use of capsaicin role-on (which contain also Boswellia serrata and Methyl-sulfonyl-methane or MSM) has been useful in arthrosis, and rheumatoid arthritis of any joint, tendinitis of most tendons including epicondylitis, and in bursitis. Patient compliance however can be problematic due to burning.

Antioxidants. Antioxidant intake may be protective against the progression of osteoarthritis and development of pain, but not in prevention of oseoarthritis. A study that evaluated 640 participants found the incidence and progression of osteoarthritis to occur in 81 and 68 knees respectively. There was no significant association between the incidence of arthritis and any nutrient. There was a 3-fold reduction in the risk of osteoarthritis progression found for both the middle tertile and the highest tertile of vitamin C intake. This related mostly to a reduced risk of cartilage loss. Those with high vitamin C intake also had a reduced risk of developing knee pain. A reduction in the risk of osteoarthritis progression was seen for beta-carotene and vitamin E intake but they were less consistent. A high intake of antioxidant nutrients, particularly vitamin C, may reduce the risk of cartilage loss and disease progression in people with osteoarthritis (McAlindon, Timothy et al 1996).

Hyaluronic Acid. Intra-articular ("purified") hyaluronic acid injections may have a protective effect on cartilage damage in osteoarthritic joints—by the removal of noxious substances from the joint space through the lymphatic system (Ghosh, Peter et al 1995). Interestingly however, a 5 year follow-up study of the relationship between hyaluronic acid and osteoarthritis of the knee showed that higher hyaluronic acid levels were significantly related to disease duration, minimum joint space and previous surgery at entry-baseline of patients studied. The data suggested that hyaluronic acid levels predict disease outcome and osteoarthritis of the knee and confirmed that a serum level of keratin sulfate was not a useful prognostic marker for osteoarthritis (Sharif, Mohammed, et al 1995).

Acetyl Merystoleate. Acetyl merystoleate (CMO) is a product obtained from mice. In the 1970’s Dr Dehl working at NIH discovered that mice do not ordinarily suffer from arthritis and it turned out that they have a metabolic product CMO, which is peculiar to their species. Dr. Dehl has "cured" his own arthritis and that of friends with this product. It seems there are at least three sources of this material with varying degree of purity and as far as Dr. Wright was able to determine in July 1996, the best comes from Dr. Dehl and his daughter. The name they use is Myristin. It is recommended that one capsule be taken twice a day for five days (only) and this may need to be repeated once at the most. Benefit from Myristin has been reported in other health problems including emphysema, chronic bronchitis and hypertension. Other animals, which have been found to contain this substance, are sperm whales, and the anal glands of male beavers (Dorman personal communication).

DMSO. It has also been suggested recently that Acetyl merystoleate (CMO) be applied directly over the affected part of the body with DMSO. The concentration of DMSO in water needs to be balanced carefully. At present 70% seems the optimal. Too high a concentration is apt be hygroscopic and too low a concentration not carry the substance. It has also been found that mineral deficiency contributes to degenerative arthritis, both osteoarthritis and rheumatoid arthritis. The best of both worlds, therefore, seems to add some mineral to the DMSO at the same time. (Vanadium, Chromium, Selenium, Boron and other are included in what has become the Tahoma [Dr. Wright] clinic dispensary’s routine). The capsule of the Myristin oil can be opened, applied to the skin and then rubbed in with "DMSO with minerals." The skin surface needed might be as much as the front of the whole thigh on both sides (Dorman personal communication).

Pulse Electromagnetic Fields. A double-blind pilot study involving 27 patients with osteoarthritis predominantly of the knee were treated with pulsed electromagnetic field which consisted of 18 half-hour periods of exposure to an extremely low frequency (less than 30 Hz). Varied, pulsating electromagnetic fields averaging 10 to 20 gauss of magnetic energy at a coil current of up to 2 amperes. The pulsed phase duration was 67 ms, including 15 micropulses with a pause duration of 0.1 second. These sessions were given at a frequency of 3 to 5 per week and extended over a period of approximately 1 month. Twenty-five of 27 patients completed the study. In patients with active treatment, there was an average improvement of 34% at midpoint, 36% at the end of treatment and 47% 1 month later. The placebo group showed an average improvement of 8% at midpoint, 10% at the end of treatment and 14% 1 month later. There was no toxicity noted. The authors conclude decreased pain and improved functional performance of these patients treated with pulse electromagnetic fields suggests this modality has potential as an effective means of improving symptoms in osteoarthritic patients (Trock, David et al 1993).

Exercise. The Arthritis Foundation states that physical therapy may be the most valuable treatment for the estimated 16 million people in the United States who have osteoarthritis. Systematic reviews and subsequent RCTs have found that both exercise and education may help reduce the burden of pain and disability in people with hip or knee osteoarthritis and had the strongest evidence for any of the non-invasive-chemical interventions. Practitioners should prescribe a low impact exercise program involving keeping the joints flexible, preserving the strength of the muscles on which the joints depend for their stability and protecting diseased joints against further damaging stresses. Those with osteoarthritis may benefit by doing exercise in the morning. Trying to get 10 repetitions is beneficial but if the pain persists they can go down to 5 repetitions. If they have no pain they should work towards 20 repetitions (Hamilton 2001).

Essential Fatty Acids. Greenland Eskimos and the Japanese population have lower incidences of inflammatory disease, which may be related to the consumption of cold-water marine fish. There have been many studies showing the benefit of essential fatty acid supplements in RA patients. Effects of altering dietary essential fatty acids on requirements for non steroidal anti-inflammatory (NSAIDs) drugs in rheumatoid arthritis has been shown (Belch et al 1988). The affect from NSAIDs is mediated through inhibition of cyclo-oxygenase enzymes, thereby decreasing production of the 2 series prostaglandins (PGs). The lipoxygenase enzyme is not affected however, allowing leucotriene (LT) production, e.g., LTB4 (an inflammatory mediator). Treatment with evening primrose oil (EPO) which contains gamma-linolenic acid (GLA) leads to production of the 1 series PGs, e.g., PGEI, which has less inflammatory effects. GLA can inhibit LT production as well. Eicosapentaenoic acid (EPA, fish oil) treatment provides a substrate for PGs and LTs, which are also less inflammatory (Dorman ibid).

A number of studies, including placebo-controlled studies, have shown GLA to be an effective treatment for RA in doses ranging from approximately 500 mg to 6 gm of GLA from borage oil or primrose oil. Fatty acids can regulate cell activation, immune responses, and inflammation. Fatty acid supplementation appears to be well tolerated and is an effective treatment for diseases characterized by acute and chronic inflammation (Rothman, Deborah et al 1995). Omega-3 fatty acids (fish oils) have moderate benefit in RA but much less than Naproxen (NSAID). The positive changes in a vegetarian diet in RA patients appears to be due to changes in the bacterial flora (Kjeldsen-Kragh, Jens 1996).

An in vitro study showed that incorporation of omega-3 fatty acids into articular cartilage chondrocyte membranes results in a dose-dependent reduction in the expression and activity of proteoglycan degrading enzymes and, the expression of inflammation-inducible cytokines and cyclooxygenase-2 (COX-2), but not the constitutively expressed COX-1. Omega-3 fatty acid supplementation can specifically affect regulatory mechanisms involved in chondrocyte gene transcription. Omega-3 fatty acid supplementation can affect molecular mechanisms that regulate the expression of catabolic factors involved in articular cartilage degradation (Curtis, Hughes, et al 2000).

Protease and Peptidase Enzymes. Several studies have appeared so far which refer to the systemic effects of oral proteases and peptidases such as Serratia peptidase (SP). Studies show repression of edema and repression of blood vessel permeability induced by histamine or bradykinin. These enzymes also effect the kallikrein-kinin system and the complement system, thus modifying the inflammatory response. Clinically, SP has been used as an anti-inflammatory agent in the treatment of RA, traumatic injury, and post-operative inflammation, as well as chronic sinusitis to improve the elimination of bronchopulmonary secretions, and to facilitate the therapeutic effect of antibiotics in the treatment of infections. In the urological field, SP has been used successfully for cystitis and epididymitis (Dorman personal communication). Bromelain is a proteolytic enzyme, which comes from the stem of the pineapple plant and has long been used to reduce swelling and inflammation. Bromelain is used at 80-320 mg/day.

Boswellia Serrata. Gum resin extracts of Boswellia serrata have been used in the treatment of RA. The terpenoids and gum resin are potent anti-inflammatory compounds that inhibit 5-lipoxygenase. In evaluating more than 260 individuals with RA, Boswellia extract was found to be effective. Boswellia extract is a disease-modifying agent and can replace other disease-modifying therapies. Early use is beneficial. Therapy is well tolerated and shows high levels of safety for early use and long-term therapy. The long-term effects of Boswellia extracts on the joints and the anatomy however are not yet clear. Dose ranges are three 400 mg tablets 2 or 3 times daily (Etzel 1996).

Feverfew. Tanacetum parthenium or feverfew as been used for RA and other inflammatory diseases. Volatile oils are its chief constituents with sesuiterpene lactones, especially parthenolide being most active (Goenewegen and Knight 1986). Extracts rich in sesuiterpene lactones can produce a dose-dependent inhibition of thromoxane B2 and leukotriene B4 and thus have anti-inflammatory effects (Summer 1992). Feverfew can be prescribed at 25-150 mg/day of dried powdered leaf or 150-250 mg/day of standardized extracts.

Sting Nettle. Sting Nettle or Urtica Dioica flower extract has been shown to inhibit biosynthesis of acrachidonic acid metabolites in vitro. Extracts have shown strong concentration dependent inhibition of cyclooxygenase derived reaction. A phenolic acid isolate from the extract inhibits the synthesis of leukotriene B4 in a concentrated dependent manner (Obersties and Giller 1996). Extracts of the leaf have been recommended for arthritic pain and dose is usually 750 mg/bid.

In interviewing 18 self-selected patients with joint pain who used nettle sting showed all but one were sure that the nettles had been very helpful, and several considered themselves cured. There were no side effects, except a transient urticarial rash. Nettle sting is useful, safe and a cheap therapy that may be beneficial for joint pain (Randall et al 1999).

Willow Bark Extract. Willow or Salix bark extracts contain salicin, and other derivatives including salicylic acid. The extract is an NSAID (herb) except that fewer side-effects have been reported as compared to aspirin or other pharmaceutical NSAIDs. In a study of low back pain patients received oral willow bark extract at 120 mg/day (low-dose) or 240 mg/day of willow bark extract (high-dose) in a 4-week blinded trial. The percentage of pain-free patients in the last week of treatment was 39% in the group receiving the high-dose extract, 21% in the group receiving the low-dose extract and 6% in the placebo group. The response rate in the high-dose group was evident after one week of treatment. Significantly more patients in the placebo group required pain medication during each week of the study (Chrubasik et al 2000).

Folic Acid. Folic acid supplementation may lower toxicity in patients treated with methotrexate for RA. Folic acid however does not seem to improve treatment efficacy. Low blood folate levels and increased mean corpuscular volumes are associated with substantial methotrexate toxicity. Daily dietary intakes of more than 900 nmol or 400 ug of folic acid were associated with less methotrexate toxicity (Morgan Sarah et al 1994).

Selenium. Plasma selenium levels were found to be significantly lower in RA patients than healthy controls. Selenium appears to be an important factor in RA. The low selenium values in RA are probably not just a nonspecific consequence of inflammation, but a sign of depletion of stores or redistribution of total body selenium (Kose, Kader, et al 1996).

Exercise. A study of dance-based exercise program in individuals with RA showed dance-based exercise to be a safe and efficient activity to improve physical fitness and psychological well being in individuals with RA. Positive changes in depression, anxiety, fatigue and tension were observed after the 12-week exercise program. These findings provide evidence in favor of aerobic exercise in individuals with rheumatoid arthritis. It is of primary interest to note that a weight-bearing activity with limited ground impact does not provoke short term adverse effects on the joints (Noreau, Luc, et al 1995).

Photochemotherapy. Eight patients with psoriasis and seronegative arthritis received photopheresis for 12 weeks, followed by photopheresis plus psoralen-ultraviolet A irradiation (PUVA) for another 12 weeks. Four patients had marked improvement of joint symptoms that lasted more than 12 months after the therapy. These responders had a higher CD4:CD8 ratio than poor responders prior to therapy Vahlquist, Carin, et al 1996). Photochemotherapy may be used for RA as well (Haberman, Herbert 1995).

Counseling. Counseling and special stress management skills in RA patients may result in less helplessness, less pain and greater mobility continuing several months after completion compared to those who had no counseling. There is evidence that the coping capacity of persons with RA are severely challenged by major life stresses associated with the disease (Tamkins 1996).

General recommendations for RA:

Identify and avoid food allergens.
Zinc (picolinate or citrate), 30 mg, 2-3 times a day.
Copper, 2-4 mg/day.
Niacinamide, as for osteoarthritis, in selected cases.
Fish oil, 6-15 g/day.
Borage oil, to supply 750-1,500 mg/day of gamma-linolenic acid.
Vitamin E, 800 IU/day.
Selenium, 200-300 µg/day.
Hydrochloric acid, 40-70 grains per meal, if hypochlorhydric.
Vitamin C (buffered). Watch for exacerbation of joint pain and reduce dose if this occurs.
Vitamin K, 50-100 mg, 3 times a day.
Bromelain, 3-4 capsules, 3 times a day on empty stomach.
Ginger.
Chicken or type II cartilage.