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Rheumatoid Arthritis Case Studies 2 CEUs

Center for Complementary and Integrative Medicine CEU Provider #: 50-2682 1120 NW 14th St, Suites 1472 1475 Miami, FL 33136 Phone: 305-243-4751 Fax: 305-243-3648 E-mail: icamp@med.miami.edu

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External Diseases Matthew S. Enright 2011

Rheumatoid Arthritis (RA)


Rheumatoid arthritis (RA) is a chronic type of arthritis. Early symptoms of RA include fatigue, joint pain, and stiffness. As it progresses, the symptoms of rheumatoid arthritis may feel like the flu, with achiness, muscle aches and loss of appetite. The causes of rheumatoid arthritis are unknown, although there may be a genetic component. Early and effective rheumatoid arthritis treatment can improve the prognosis and may help prevent joint and bone destruction associated with RA. Arthritis is a general term that means inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances, or other causes. It occurs in various forms, such as bacterial arthritis, osteoarthritis, or rheumatoid arthritis. Rheumatoid arthritis is a type of chronic arthritis that typically occurs in joints on both sides of the body (such as hands, wrists, or knees). This symmetry helps distinguish rheumatoid arthritis from other types of arthritis. In addition to affecting the joints, rheumatoid arthritis may occasionally affect the skin, eyes, lungs, heart, blood, or nerves. What Are the Symptoms of Rheumatoid Arthritis? Symptoms of rheumatoid arthritis include: Joint pain and swelling Stiffness, especially in the morning or after sitting for long periods Fatigue

RA affects everyone differently. For some, joint symptoms develop gradually over several years. For others, rheumatoid arthritis may progress rapidly and while other people may have rheumatoid arthritis for a limited period of time and then enter a period of remission. Who Gets Rheumatoid Arthritis? Rheumatoid arthritis affects about 1% of the U.S. population. While it is two to three times more common in females than in males, males tend to be more severely affected when they get it. It usually occurs in middle age, however, even young children and the elderly also can develop rheumatoid arthritis. What Causes Rheumatoid Arthritis? The exact cause of rheumatoid arthritis is unknown, but it is thought to be due to a combination of genetic, environmental and hormonal factors. With RA, something seems to trigger the immune system to attack the joints and sometimes other organs. There are theories that suggest that a virus or bacteria may alter the immune system, causing it to attack the joints. Other theories suggest that smoking may lead to the development of rheumatoid arthritis. How Does Rheumatoid Arthritis Affect the Body? Once the immune system is triggered, immune cells migrate from the blood into the joints and joint-lining tissue, called synovium. In the synovium, the immune cells produce inflammatory substances. The increased number of cells and inflammatory substances within the joint cause irritation, wearing down of

External Diseases Matthew S. Enright 2011

cartilage (cushioning material at the end of bones), and swelling and inflammation of the joint lining. Inflammation of the joint lining stimulates it to produce excessive joint fluid within the joint. As the cartilage wears down, the space between the bones narrows and if the condition worsens, the bones could rub against each other. As the joint lining expands, it may erode, or invade into, the adjacent bone, resulting in bone damage that is referred to as erosions. All of these factors cause the joint to become very painful, swollen, and warm to the touch. How Is Rheumatoid Arthritis Diagnosed? The diagnosis of rheumatoid arthritis is based on a combination of factors, including: The specific location and symmetry of painful joints, especially the hand joints. The presence of joint stiffness in the morning. Presence of bumps and nodules under the skin (rheumatoid nodules). Results of X-ray tests that suggest rheumatoid arthritis. Positive results of a blood test called the rheumatoid factor.

Most, but not all, people with rheumatoid arthritis have the rheumatoid-factor antibody in their blood. (Rheumatoid factors are actually antibodies that bind other antibodies.) Rheumatoid factor may sometimes be present in people who do not have rheumatoid arthritis. Other diseases can also cause the rheumatoid factor to be produced in the blood. Therefore, the diagnosis of rheumatoid arthritis is based on a combination of joint abnormalities as well as laboratory information and not just the presence of the rheumatoid factor in the blood. How Is Rheumatoid Arthritis Treated? There are many different ways to treat rheumatoid arthritis. Treatments include medications, rest and exercise, acupuncture, herbal medicine, homeopathy and surgery to correct damage to the joint. The type of treatment will depend on several factors including the person's age, overall health, medical history, and severity of the arthritis. Recent studies into the physiological reactions of the body to acupuncture have provided some scientific insight into how acupuncture affects pain. The findings focused on the ability of acupuncture to stimulate the production of endorphins, opiate-like substances produced in the brain whose function is to control pain in the body. Endorphins have been found to be nearly 1,000 times stronger than morphine. Thus, scientific validation as to how acupuncture controls pain. Along with the release of endorphins, another substance called cortisol is simultaneously released. Cortisol is the body's own natural anti-inflammatory drug. Controlling pain and reducing inflammation help to promote healing; this explains why acupuncture works so well for joint and structural disorders. It is also important to understand the circumstances surrounding the onset of the pain. Was there an accident or incident, did the pain gradually develop over a course of time or during a certain period of life, is the pain better or worse during a particular time of day? The characteristics of pain give important information about what is causing the body to send this signal. Once noticed, it is important to address the underlying problem not just turn down the discomfort. Otherwise the body will continue to send out

External Diseases Matthew S. Enright 2011

other warning signals until the core problem is corrected.

According to Traditional Chinese Medicine (TCM), nothing within the human body can function independently. Pain is the bodys warning signal or alarm. It tells you something is wrong. If you ignore your bodys alarm, similarly to the fire alarm in your house, severe problems can form soon.

Case 1: A 57 year old male presented with swollen and pain in both hands and the right knee. The patient stated that his pain was worse in the early morning and felt heaviness, numbness, and restricted movement until about 2 hours after being awake. When the patient was exposed to cold weather, it gets worse and has used a heating pad at times which seemed to provide relief. Patient also stated that his pain was worse with weather changes going into winter and could usually tell when it was going to rain. Patient also presented with aversion to cold, loose stools and clear, long urination and a desire to be warm. The tongue was pale with thin, white fur and a deep, tight pulse.

1. Which of the following would best describe or diagnosis the above referenced symptoms: A Wind Cold Damp B Kidney Yin Deficiency C Wind Heat Invasion D Bi Syndrome

2. What would be the appropriate treatment principle: ABCDOpen channels and collaterals and relieve pain Resolve Exterior Tonify Kidney Yin Expel Wind Damp, warm channels and scatter cold

3. True or False, the follow Acupuncture point prescription would be effective in treating this syndrome: GB 20, UB 17, 23, CV 4, SP 9, 4. Which of the following herbal formulas would be effective in treating this syndrome: ABCDYu Ping Feng Wan Juan Bi Tang Shen Tong Zhu Yu Wan None of the above

Case 2: A 26 year old male presented with pain in the left ankle along with swelling, heaviness and restricted movement primarily in the left ankle. Patient stated that the right ankle can have similar issues, but is intermittent. The left ankle presented was hot to the touch and red to inspection. Patient statedthat ice seems to relieve his symptoms temporarily. The patient also presented with fever, sweating (without physical exertion), aversion to wind, feeling thirsty but sometimes no desire to drink, scanty urination

External Diseases Matthew S. Enright 2011

(sometimes with a reddish hue), a red tongue with thin yellow fur and a ______________, ______________ pulse. *Typically, this pattern is seen in those with the acute, active stage of RA.

5. Which of the following would best describe or diagnosis the above referenced symptoms: A Wind Cold Damp B Kidney Yin Deficiency C Wind Damp Heat Invasion D Bi Syndrome

6. Which of the following would best describe the quality of the pulse for the above referenced symptoms A Slippery B Rapid C None of the above D A and B

7. What would be the appropriate treatment principle: ABCDExpel Wind Damp, clear heat Resolve Exterior Tonify Kidney Yin Expel Wind Damp, warm channels and scatter cold

8. True or False, the use of moxibustion would be beneficial for this patient:

9. Which of the following herbal formulas would be effective in treating this syndrome: EFGHBai Hu Jia Zhi Tang Ma Huang Tang You Gui Wan None of the above

Case 3: A 36 year old female presented with pain and constant aching in the left shoulder and left elbow with swelling and a limited range of motion. In addition, the patient presented with a somber white facial complexion and complained of heart palpitations, shortness of breath (without physical exertion), overall lack of energy, lassitude and a pale tongue with white fur and a fine, tight pulse. * This pattern is mostly seen in the later stages of RA where there is joint rigidity and deformation. (Characteristics of the disease).

10. Which of the following would best describe or diagnosis the above referenced symptoms: A Wind Cold Damp B Qi and Blood deficiency with phlegm stasis C Wind Heat Invasion D Bi Syndrome

External Diseases Matthew S. Enright 2011

11. What would be the appropriate treatment principle: ABCDTonify Qi Nourish Blood Transform Phlegm All of the above

12. True or False, the follow Acupuncture point prescription would be effective in treating this syndrome: ST 36, SP 6, Sp 9, local points 13. Which of the following herbal formulas would be effective in treating this syndrome: ABCDHaung Qi Gui Zhi Wu Tang Dang Gui Nian Tong Tang A and B None of the above

Case 4: A 58 year old male presented with a limited range of motion in the both elbows and muscular atrophy, an overall feeling of stiffness, unceasing aching pain which is worse upon exposure to cold and during the winter and better with warmth and during the summer. Patient also stated he had symptoms of dizziness, tinnitus, long, clear urination, nocturia, soreness and weakness in his lower back and knees, a pale tongue with white fur and a deep, weak pulse. 14. Which of the following would best describe or diagnosis the above referenced symptoms: A Wind Cold Damp B Liver Qi Stagnation C Liver / Spleen Disharmony D Liver blood Kidney yin and yang deficiency with phlegm stasis

15. What would be the appropriate treatment principle: ABCDTonify Kidneys Tonify Yang Nourish Liver All of the above

16. True or False, the follow Acupuncture point prescription would be effective in treating this syndrome: UB 23, 52, DU 4, local points + moxibustion 17. Which of the following herbal formulas would be effective in treating this syndrome: ABCDLong Dan Xie Gan Wan Shen Qi Wan A and B None of the above

External Diseases Matthew S. Enright 2011

Examination Answers for Rheumatoid Arthritis Case Studies: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

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The above signature confirms that I have read the associated material and answered all of the questions on my own to receive continuing education credits or units. *Return only the Examination Answers portion as well as the attached credit card authorization form for $30.00 (it is not necessary to send back the course material.) *CEUs will be awarded with a passing grade of 85% or higher.

Center for Complementary and Integrative Medicine CEU Provider #: 50-2682 1120 NW 14th St, Suites 1472 1475 Miami, FL 33136 Phone: 305-243-4751 Fax: 305-243-3648 E-mail: icamp@med.miami.edu