TCM Acupuncture and Massage

Chapter 67 Bone and Joint Diseases (5)
([-]) Clinical manifestations

1. About 2 to 5 weeks before the appearance of joint symptoms, there are often manifestations of streptococcal infection in the upper respiratory tract, such as fever, sore throat, tonsil enlargement, etc., which can be completely recovered after penicillin treatment.Those with milder conditions may not have obvious feelings, and sometimes due to mild symptoms, patients have forgotten these initial manifestations when they go to the doctor for arthritis.

2. Rheumatoid arthritis manifests as redness, swelling, elevated skin temperature, pain, and joint dysfunction at the onset of diseased joints. Most of them occur in large joints such as knee joints, ankle joints, elbow joints, wrist joints, and shoulder joints.The above-mentioned joint symptoms can often be transferred from one joint to another in a relatively short period of time, which is called "migratory" in medicine.Another attack is often accompanied by systemic fever, carditis, subcutaneous nodules, erythema annulare and chorea.However, joint dysfunction is rarely left after the attack.

([-]) Diagnosis

1. Whether there is evidence of streptococcal infection recently, such as tonsillitis, pharyngitis, etc.

2. Whether there are joint symptoms, such as redness, swelling, heat, pain, dysfunction, etc.

3. Whether the relevant laboratory tests are abnormal, such as whether the anti-streptolysin O antibody, erythrocyte sedimentation rate, and C-reactive protein are abnormal, especially whether the anti-streptolysin O antibody is positive.

4. Whether the experimental treatment is effective.

5. With or without rheumatic carditis manifestations, such as myocarditis, pericarditis, etc.If the answer to the above questions is yes, the diagnosis of active rheumatoid arthritis is supported, otherwise the disease is not active.

([-]) Inspection

1. Four items of rheumatism check The four items of rheumatism, namely anti-streptolysin 0 antibody, erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor, are the most routine checks.

(1) Anti-streptolysin O antibody (ASO, commonly known as "anti-O"): After streptococcus infects the human body, it can induce an immune response in the human body and produce antibodies.Therefore, the presence or absence of streptococcal infection can be determined by the determination of these antibodies in the blood.If the antibody test is positive, it indicates a strep infection in the body.An anti-streptolysin 0 antibody test with a result higher than 500 units is abnormal, indicating that the patient has had streptococcal infection in the near future, which can be used as one of the diagnostic indicators for rheumatoid arthritis.A small number of strains may not produce anti-streptolysin O antibodies in vivo, so a negative anti-streptolysin O antibody test does not indicate no streptococcal infection.In addition, if there is a hemolytic reaction during the operation, serum contamination or hypercholesterolemia can increase the anti-streptolysin O antibody, so the interference of these factors should be excluded when analyzing the results.Anti-streptolysin O antibody detection is a simple and economical inspection method.However, due to the widespread application of antibiotics, a considerable proportion of patients with mild symptoms and atypical symptoms have accounted for a considerable proportion in recent years, so some patients have no increase in anti-streptolysin O antibody.

(2) Erythrocyte sedimentation rate (referred to as "erythrocyte sedimentation rate", ESR): In the diagnosis of rheumatoid arthritis, the erythrocyte sedimentation rate is the most convenient and commonly used detection method.The erythrocyte sedimentation rate refers to the distance that the suspended red blood cells in the blood sink naturally within 1 hour.Usually, the erythrocyte sedimentation rate is significantly increased in patients with rheumatoid arthritis.The normal adult erythrocyte sedimentation rate is 0-15 mm per hour for men and 0-20 mm for women.The sedimentation velocity of red blood cells is related to age and gender, and the erythrocyte sedimentation rate gradually increases with age.Women's erythrocyte sedimentation rate is faster than men's.Neonates settle slowly due to their high concentration of red blood cells.Pregnant women have increased blood volume and decreased red blood cell concentration, so the erythrocyte sedimentation rate is accelerated, and it returns to normal after delivery.Some components in the blood, such as fibrinogen, globulin, etc., can accelerate the sedimentation of red blood cells.Rheumatoid arthritis erythrocyte sedimentation rate increased, is due to decreased blood albumin, fibrin and globulin increase caused.Regular review of erythrocyte sedimentation rate is helpful for monitoring rheumatic activity.Increased erythrocyte sedimentation rate indicates that rheumatism is in the active stage; if anti-rheumatic treatment is effective, erythrocyte sedimentation rate can gradually return to normal; erythrocyte sedimentation rate remains normal several weeks after the end of treatment, indicating that the rheumatic activity is terminated.

(3) C-reactive protein (CRP): C-reactive protein is an acute phase response of the body to injury or inflammatory stimuli. C-reactive protein greater than 10 micrograms per milliliter can be considered abnormal.The concentration of C-reactive protein in the serum of patients is closely related to the inflammatory process, and the concentration of C-reactive protein in the serum of patients with acute inflammation and malignant tumors increases.The C-reactive protein in the active phase of rheumatoid arthritis is higher than normal and can return to normal after treatment. Therefore, C-reactive protein is often used to monitor the activity of rheumatism. C-reactive protein is also used to judge the degree of tissue damage, such as acute myocardial infarction, trauma infection, burns and surgery, etc. Within a few hours after the injury, C-reactive protein increases rapidly and reaches a peak in 2 to 3 days.If the healing is good after the operation, the C-reactive protein level will soon return to normal after 3 to 4 days.Therefore, C-reactive protein can also be used to judge whether there are complications in postoperative patients.

(4) Rheumatoid factor (RF): Rheumatoid factor is an autoantibody with denatured immunoglobulin G as its antigen, which exists in the serum of many patients. Found in serum, so it is called rheumatoid factor.Rheumatoid factor plays an important role in the pathogenesis of rheumatoid arthritis.But only a quarter of patients who were positive for rheumatoid factor had rheumatoid disease.Therefore, increased rheumatoid factor is not a definite factor in the diagnosis of rheumatoid arthritis.

The value of rheumatoid factor can be summarized in the following two points:
①To judge the activity of rheumatoid arthritis, the positive rate of rheumatoid factor in patients with rheumatoid arthritis is 70-80%. The continuous increase of rheumatoid factor in serum of patients with rheumatoid arthritis indicates that the disease is in the active stage.

② To estimate the prognosis, the level of rheumatoid factor is related to the severity of the disease.Such as rheumatoid factor at a higher titer, the prognosis is generally poor.

2. What problems should be paid attention to when taking blood to check the four items of rheumatism? The four items of rheumatism must be checked with fasting blood, that is, no food including water can be eaten after 8:[-] in the evening and before the blood is drawn the next morning, otherwise it will affect the accuracy of the test results. sex.In addition, since the test is serum, the whole blood should be placed gently after it is drawn, so as not to break the red blood cells or cause hemolysis.Patients should avoid violent vibrations during blood delivery.

([-]) Differential diagnosis

Rheumatoid arthritis often needs to be differentiated from rheumatoid arthritis, osteoarthritis, and gouty arthritis.

1. How to distinguish between rheumatism and rheumatoid arthritis Rheumatoid arthritis
The characteristic of arthritis is migratory, and so-called " migratory " is meant that the symptom of arthritis can transfer from one joint to another joint in a relatively short period of time.Inflammation in each joint lasts only a short time.Within 1 to 2 days, it can swim to several adjacent joints.And rheumatoid arthritis is then comparatively constant, although also can show as migratory property in the early stage sometimes, each joint inflammation duration is longer.After rheumatoid arthritis is cured, no joint deformity remains, but rheumatoid arthritis is a chronic process, which often leads to joint deformity due to the destruction of joint structure and bone.

2. How is osteoarthritis different from rheumatoid arthritis
Osteoarthritis, namely bone joint disease, also known as degenerative joint disease or hypertrophic arthritis, is a joint disease characterized by joint swelling, pain, stiffness and limited mobility.Differentiation between osteoarthritis and rheumatoid arthritis is generally not difficult.Rheumatoid arthritis is characterized as migratory, with short duration of inflammation in each joint.Within 1 to 2 days, it can walk to several adjacent joints, and no joint deformity remains after healing.Osteoarthritis mostly occurs in people over 50 years old. The common causes are injury, obesity, and congenital abnormalities, without systemic symptoms. The affected joints are weight-bearing joints and distal interphalangeal joints, and the course of the disease progresses slowly.

3. How to distinguish between rheumatoid arthritis and gouty arthritis
Acute rheumatoid arthritis tends to occur in adolescents, and there is a history of group A hemolytic streptococcal infection before the onset, such as pharyngitis or tonsillitis.It is characterized by symmetrical and migratory arthritis, which may be accompanied by myocarditis, endocarditis, annular erythema, and subcutaneous nodules.Anti-streptolysin O antibodies were elevated and serum uric acid was normal.Acute gout is characterized by recurrent acute arthritis and increased uric acid, which is significantly improved by colchicine treatment.The diagnosis needs to be found in the joint fluid of urate crystals phagocytized by neutrophils during the attack.

[-]. Point massage

([-]) Acupuncture therapy

1. Acupoints should be selected in sections.

(1) Mandibular joint: Xiaguan, Hegu.

(2) Spinal joints: Corresponding Jiaji points, Yinmen, Weizhong, Dazhui.

(3) Shoulder joints: shoulder joint, shoulder joint, shoulder front.

(4) Elbow joints: Quchi, Shaohai, Patio.

(5) Wrists, palms, and knuckles: Yangchi, Zhongquan, Daling, and Baxie.

(6) Lumbosacral joints: Yaoyangguan, Shiqizhui, and Jiaji points.

(7) Sacroiliac joints: Dachangshu, Xiaochangshu, tenderness points.

(8) Hip joint: Huanju, Julian.

(9) Knee joint: knee eye, Liangqiu, Yanglingquan.

(10) Ankle joints, metatarsophalangeal joints: Jiexi, Qiuxu, Taixi, Bafeng.

(11) Addition and subtraction: add Zhui and Quchi in the acute stage; add Neiguan, Xuehai, and Sanyinjiao for irritability; add Hegu and Taichong for severe pain.

2. Positioning
Xiaguan—take it with the mouth closed, the lower border of the zygomatic arch, the depression in front of the mandibular condyle.

Hegu—between the first and second metacarpal bones on the back of the hand, about the midpoint of the second metacarpal bone.

Yinmen—6 inches below the middle of the horizontal crease below the buttocks.

Weizhong—the center of the rouge stripes, between the two tendons.

Dazhui—under the spinous process of the seventh cervical vertebra.

Shoulder shoulder—When the upper arm is abducted, two depressions appear in the front depression.

Shoulder iliac—1 cun behind the shoulder.

In front of the shoulder - 1 inch in front of the shoulder.Quchi—elbow flexion, the midpoint of the line connecting the lateral end of the cubital crease and the lateral epicondyle of the humerus.

Shaohai—elbow flexion, at the midpoint of the line connecting the medial end of the cubital crease and the medial epicondyle of the humerus.

Patio—the depression about 1 inch above the olecranon ulna when the elbow is flexed.

Yangchi—In the transverse crease of the dorsum of the wrist, refers to the ulnar border of the common extensor tendon.

Zhongquan—in the transverse crease of the dorsum of the wrist, in the depression on the radial side of the tendon of the common extensor tendon Daling—in the center of the transverse crease of the wrist, between the two tendons.

Baxie - the back of the hand, hold the palm slightly, on the 1st to 5th fingers, at the red and white flesh border behind the web edge, there are a total of eight points on the left and right.

Yaoyangguan—below the spinous process of the fourth lumbar vertebra.

Seventeen vertebrae - under the spinous process of the fifth lumbar vertebra.

Dachangyu—1.5 cun below the spinous process of the fourth lumbar vertebra, approximately on the level line of the upper edge of the iliac crest.

Xiaochangshu—level with the first posterior sacral foramen, 1.5 cun lateral to the posterior midline.

Ring jump—on the lateral part of the femur, lying on the side with the femur flexed, at the intersection of the most convex point of the greater trochanter and the lateral middle 1/3 of the line connecting the sacral hiatus.

Julian - at the hip, at the midpoint of the line connecting the anterior superior iliac spine and the most convex point of the greater trochanter of the femur.

Knee eye - knee flexion, the depression on both sides of the patellar ligament.Called inner and outer knee eyes.

Liangqiu—2 cun above the outer upper border of the ilium.

Yanglingquan—the depression anteriorly and inferiorly to the head of the fibula.

Jiexi—the center of the anterior transverse crease of the ankle joint, between the two tendons.

Qiuxu—in the depression in front of the lower lateral malleolus.

Taixi—In the depression at the midpoint of the line connecting the highest point of the medial malleolus and the Achilles tendon.

Bafeng - dorsal side of the foot, between the 1st to 5th toes, between the red and white flesh on the posterior edge of the toe web, four points on one side, a total of eight points on the left and right sides.

Neiguan—2 cun above the transverse crease of the wrist, between the two tendons.

Sea of ​​Blood—Bend the knee, 2 cun above the inner border of the patella.

Sanyinjiao—3 cun above the tip of the medial malleolus, on the posterior border of the tibia.

Taichong—in the depression between the junction of the first and second metatarsal bones.

([-]) Self-massage
1. Neck self-massage

(1) Loosening the neck: Use the index, middle and ring fingers to push and rub the base of the neck, and then use the thumb, index and middle fingers to hold the base of the neck to relax the muscles.Then use the food and middle two fingers to rub the muscles near the transverse process of the cervical spine to make them feel sore and swollen.And go down along the tendons to take the muscles of the back of the neck and the sternocleidomastoid muscle, take the shoulder well, and lift the upper edge of the trapezius muscle.

(2) Neck pulling: performed by others.Standing on the healthy side of the patient, spread one hand apart, press the tiger's mouth or thumb tightly against the diseased neck of the patient, put the other hand on the top and temporal part of the affected side, apply force with both hands, and push the neck to one side.Pay attention not to compress the carotid artery with the hands touching the neck, and not to use too much force.

(3) Neck movement: performed by others.Put one hand on the opponent's head and the other on the neck, and then make the neck stretch back, rotate left and right, bend the healthy side, and circle around.The range of activities should be as large as possible, but should be slow, so as not to cause dizziness, pain and other discomfort.

(4) Shujin: along the direction of the brachial plexus on the affected side, press the Tianjiao, Quepen, Zhongfu, and Jiquan points each for 1 minute with the thumb pressing method to make the local area, upper limbs, shoulders and back feel sore, heavy, and swollen Numb feeling, generally feel loose and comfortable after letting go.Finally, rub the affected limb with both hands for a while.

（5）点穴：用拇指点压落枕穴（手背，第2、3掌骨间，掌指关节后0.5寸处）5分钟。

2. Shoulder self-massage

(1) Shoulder rolling: Use the rolling method along the front of the shoulder to the acromion and to the ribs for about 10 minutes.

(2) Shoulder grip: Use the thumb, index, and middle fingers to hold the biceps, deltoid, supraspinatus, and teres muscles for 10 minutes.

(3) Acupuncture points: Press Jiantiao, Jianjing, Quchi, Hegu for 3 minutes each.

(4) Turning shoulders: operated by others.Put your hand on the patient's shoulder, and hold the forearm of the affected limb with the other hand to make a circular movement. The technique should be gentle, from small to large, and slowly move the affected limb around the top of the head for several times. shoulder.

(5) Stretching: Massage the affected shoulder with your hands, abduct the affected shoulder, bend forward, extend backward, and rotate the shoulder 6 times each.

(6) Loose shoulders: Finally, use the rubbing method to rub repeatedly from the shoulder to the forearm for 10 minutes.

3. Waist self-massage

(1) Spine push: operated by others.From Dazhui point, push down along the bladder meridian to the two lumbosacral points.

(2) Rubbing the back and waist: operated by others.Rub the back from top to bottom, focusing on the affected area, 18 times.

(3) Pressing the back and waist: operated by others.Use your thumb or elbow joint to press along the Du Vessel and the Bladder Meridian. The pressure should be soft and not too strong.

(4) Rolling back and waist: operated by others.From the back to the sacrum, use the rolling method repeatedly, focusing on the affected area, and roll 18 times in total.

(5) Knocking on the back and waist: Knock on the back and waist with empty fists from top to bottom, with gentle force, 18 times.

(6) Wipe the back and waist: Use both hands to rub repeatedly from the back to the waist until the local area is slightly hot and reddish, about 5 minutes.

(7) Exercising the waist: Standing on the hips, rotating the waist forward, backward, left and right, bending forward and backward, 18 times.

(8) Acupuncture: Use the middle finger to rub the posterior superior iliac spine, Shiqizhui, waist eye, and Yaoyangguan, each point for 1 minute.

4. Knee self-massage
(1) Acupuncture: Press Xuehai, Liangqiu, Weizhong, Knee Eye, Yanglingquan, Yinlingquan, Zusanli with your fingers for half a minute each.

(2) Tendon loosening: Sit on the bed, place both lower limbs flat, and roll in front, back, left and right of the thigh and knee joint for 3 minutes in each position.

(3) Muscle relaxation: Stretch both lower limbs, use one-finger Zen push around the patella, focus on the upper edge of the patella and the eye of the knee for about 3 minutes, then use the palm kneading method around the patella and on the patella for 5 minutes.

(4) Move the patella: Stretch both lower limbs, place the thumb on the upper edge of the patella, press and release, 9 times in total.Then use the thumb and middle finger on the upper and lower edge of the patella to push the patella 9 times towards the thigh and calf.

(5) Diathermy: Around the patella, use the hypothenar rubbing method to penetrate the knee joint.

(6) Loose knees: Finally, move both lower limbs, do flexion and extension, and squat down 9 times each.

Rheumatoid arthritis
An overview of the disease

([-]) Relevant knowledge

1. Concept Rheumatoid arthritis (RA), referred to as rheumatoid, is a systemic immune disease characterized by chronic polyarticular inflammation.Arthritis is mainly based on the synovial membrane of the joint cavity and may involve other organs.In most cases, the disease will not affect people's lives, but in a few people, it can cause severe disability and completely disable the patient's ability to work.

2.患病率RA 在世界各地均有发病，但各个国家和地区的患病率不同。全世界患病率平均为1％；美国为3％；日本为0.3％；我国为0.29％。我国以东北、华北地区为多。女性是男性2～3倍，可在任何年龄发生。

Usually, the prevalence rate increases with age, with the peak incidence at the age of 40-60.

3. Anatomical knowledge of related joints Joints, called synovial joints in full, are the most differentiated form of bony connections.The basic structure of the joint includes the articular surface, joint capsule, and joint cavity.Among them, the surface of the articular surface is covered with cartilage, which is called articular cartilage; the joint capsule is a capsule composed of fibrous connective tissue membrane, which is attached to the periphery of the articular surface and the nearby bone surface.It can be divided into inner and outer layers (the outer layer is the fibrous membrane and the inner layer is the synovium); the joint cavity is a closed cavity surrounded by the articular cartilage and the synovial layer of the joint capsule, which contains a small amount of synovial fluid and is under negative pressure.

(End of this chapter)