Needle-Warming Moxibustion plus Multirehabilitation Training to Improve Quality of Life and Functional Mobility of Patients with Rheumatoid Arthritis after Medication.

Objective: Patients treated with medication for rheumatoid arthritis (RA) often improve but continue to have active diseases. The study aims to investigate whether needle-warming moxibustion (NWM) plus multirehabilitation training can improve quality of life (QoL) and functional mobility of RA patients after medication.
Methods: Eighty-four RA patients were selected as study participants, including 42 patients receiving medication (medication group) and 42 patients receiving NWM plus multirehabilitation training (NWM + MRT group). The scores of disease symptoms, pain (visual analogue scale (VAS)), sleep quality (Pittsburgh Sleep Quality Index (PSQI)), functional mobility (Fugl-Meyer assessment scale (FMAS)), self-rating anxiety scale (SAS), self-rating depression scale (SDS), and QoL (SF-36) were compared before and after treatment. When patients were discharged from the hospital, they were given a questionnaire for treatment satisfaction.
Results: After treatment, decreases in the scores of the VAS, PSQI, SAS, and SDS were observed in both cohorts, especially in the NWM + MRT group (P < 0.05). The FMAS scores of upper limbs and lower limbs were increased after treatment, which were higher in the NWM + MRT group in comparison with the medication group (P < 0.05). Of note, patients in the NWM + MRT group scored higher in various dimensions of the SF-36 scale (P < 0.05), showing better QoL. The satisfaction survey showed that the NWM + MRT group had a higher proportion of patients being satisfied and a lower proportion of patients being dissatisfied (P < 0.05).
Conclusion: NWM plus multirehabilitation training could significantly attenuate disease symptoms, improve QoL, recover functional mobility, and reduce the risk of anxiety and depression in RA patients.

1. Introduction

Rheumatoid arthritis (RA) is an autoimmune disease characterized by erosive arthritis [1] and is difficult to cure. Failure to receive regular treatment in time can lead to joint deformity and loss of normal joint function, which has a serious impact on the quality of life (QoL) of patients [2]. According to previous research reports, the global incidence of RA is 0.2%–1%, with a predilection for women, a close association with genetic factors, and a rising incidence at younger ages, all of which impose a heavy burden on families and even society [3]. RA treatment and management have advanced profoundly over the last several decades, evolving from a strategy of providing symptomatic relief, to the implementation of therapeutic regimens that impact disease activity, and ultimately have been shown to slow or arrest structural joint damage [4, 5]. Clinically, it is extremely urgent to find a treatment scheme that can effectively improve the prognosis of RA patients.

In recent years, traditional Chinese medicine (TCM) has made remarkable progress in clinical treatment, and the integrated treatment of traditional Chinese and Western medicine has achieved multiple effects on many diseases. Among them, acupuncture is a characteristic treatment of TCM, which stimulates acupoints by acupuncture techniques to achieve the purpose of treating diseases [6]. Needle-warming moxibustion (NWM), a combination of acupuncture and moxibustion, works in such a way that the needle is inserted into the acupoint and then the moxa stick is burned on the needle handle [7]. With the help of the needle body, the heat is introduced into the acupoint, showing both the acupuncture effect and warm effect [8]. As proven by previous evidence, NWM can relieve pain, reduce inflammatory reaction, and help restore joint function [9]. Compared with traditional drug therapies, TCM acupuncture has shown higher safety and economic effects in treating chronic diseases, with less burden on patients, wider application, and stable effect [10]. However, there is a lack of reliable research confirmation regarding its application in RA. Moreover, RA is mainly manifested as severe joint pain, and few patients have been alleviated significantly in the initial stage of TCM treatment. Most RA patients are skeptical about TCM treatment, in addition to the great controversy over its clinical utility. At present, although there have been studies analyzing the impact of TCM on RA, the observation indicators are usually subjective (such as inflammatory factors and hemodynamics, ), ignoring objective functional evaluation [11, 12]. In addition, diversified rehabilitation training is often used to assist TCM treatment. Through diversified training forms and contents, it can help patients recover their health more comprehensively and effectively and consolidate the effect of TCM treatment [13]. Recent evidence has pointed out that multirehabilitation training is highly effective in the recovery of human joint function and the improvement of human bone metabolism [14], but the effect of combined implementation with NWM in RA is controversial. The study aims to investigate whether NWM plus multirehabilitation training can attenuate disease symptoms, improve QoL, and recover functional mobility of RA patients after medication, so as to provide more reliable and comprehensive references for clinical translation of TCM treatment of RA.

2. Materials and Methods

2.1. Patients

A total of 84 patients were given treatment for RA in our hospital from April 2020 to December 2021, including 42 patients who received medication (medication group) and 42 patients who received NWM plus multirehabilitation training (NWM + MRT group).

2.2. Eligibility Criteria

Inclusion criteria were as follows: patients aged >18, with a confirmed diagnosis of RA according to the previous literature [15] by our hospital, detailed clinical records, and signing informed consent. Exclusion criteria were as follows: complications with cardio-cerebrovascular diseases, nervous system diseases, organ dysfunction, and/or drug allergy; physically disabled patients who are unable to take care of themselves; mental and cognitive dysfunction; low treatment compliance.

2.3. Treatment Protocols

The patients in the medication group were given routine nursing and oral administration of drugs such as meloxicam tablets and iguratimod. During the treatment, the changes in the patient's vital signs were closely monitored, and the patient was instructed to strictly follow the doctor's instructions for medication. The patients in the NWM + MRT group received NWM plus multirehabilitation training. Acupuncture treatment was as follows: the acupoints selected were mainly Jianyu, Hegu, Quchi, and Shousanli for the upper limbs and Lingquan, Xuehai, and Zusanli for the lower limbs. After routine skin disinfection, acupuncture was performed using 38 filiform needles with a 10-min interval between each needling, and the needles were retained for 30 minutes. After the completion of acupuncture, moxibustion was used to apply hot compression on the acupuncture points and was discontinued until the patient felt an obvious burning sensation. For patients with severe pain, Ashi and Shenshu points were added during NWM. And in the case of obvious fever, the Dazhui point was added. Multirehabilitation training includes the following: (1) after admission, RA knowledge manuals were distributed to patients, which introduced the pathological situation of RA and the purpose of rehabilitation training and analyzed the purpose and precautions of acupuncture treatment for patients from the perspective of TCM. Additionally, successful cases of treatment were introduced to patients, so as to build their confidence in overcoming the disease. (2) Patients were reminded to actively or passively extend limbs and straighten joints in any state. When lying in bed, patients were instructed to alternate between supine and side-lying positions, as well as raise the upper and lower limbs and tense the muscles, so as to maintain the strength of the muscles and prevent muscle atrophy. (3) The patient was massaged regularly every day to improve muscle strength and endurance, and the patient's family members were instructed to learn massage skills. Each joint was massaged for about 10 min. After the local muscles were relaxed, the limbs were slowly and gently pulled to the normal position. (4) Patients were encouraged to ambulate early. According to the degree of the patient's condition, rehabilitation training with different amounts of exercise was set up to guide and assist the patients to correctly move their joints, waist, and legs, so as to avoid secondary injury caused by wrong movements in rehabilitation training. (5) Before each exercise, the patient was instructed to complete sufficient warm-up exercises to avoid muscle and joint injury caused by acute exercise. For those with serious joint involvement and inability to exercise fully, weight-bearing training was avoided at an early stage, and crutches were used to assist in walking. The poor posture of the patient was first corrected and then gradually transitioned to accelerated walking, obstacle crossing, etc. (6) During the training process, the patients were given active encouragement and warm assistance. Besides, the family members of patients were instructed to pay attention to some matters in the diet and life, all in an attempt to cooperate with the rehabilitation training of patients. The basic treatment cycle of the two groups was 12 weeks, and all investigations were conducted at the time of admission and after the completion of the basic treatment cycle.

2.4. Endpoints

(1) Symptom improvement is as follows: (1) the scores (score range: 0–4, with higher scores indicating more severe illness) of disease symptoms (joint swelling, pain, and limitation of motion (LOM)) of the two groups before and after treatment were observed. (2) Pain: pain assessment employed the Visual Analog Scale (VAS) score (score range: 0–10 points, with higher scores indicating worse pain) and the Pittsburgh Sleep Quality Index (PSQI) score (score range: 0–21 points, with higher scores indicating poorer sleep quality). (3) Limb motor function: the Fugl–Meyer Assessment Scale (FMAS) score, with a score range of 0–66 for upper limb motor function and 0–34 for lower limb motor function, was used to evaluate limb motor function of the patients. The score was positively associated with limb motor function. (4) Psychological condition: patients' psychological anxiety and depression were assessed using the SAS (score range: 1–70) and SDS (score range: 1–72), respectively, with higher scores indicating more severe psychological conditions. (5) QoL : patients were scored by the SF-36 score from the domains of physical function (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social function (SF), role-emotional (RE), and mental health (MH), and the score was positively related to the QOL. (6) Treatment satisfaction: an anonymous satisfaction survey (10-point system) was conducted when patients were discharged from the hospital, with the criteria as follows: 0–3, dissatisfied; 4–6, need improvement; 7–9, satisfied; 10, very satisfied.

2.5. Statistical Processing

SPSS22.0 (IBM, USA) was utilized for data analysis. Categorical data were recorded by percentage (%) and compared using the Chi-square test. Quantitative data were recorded by mean ± standard deviation and independent samples were compared using the t-test and paired t-test. The difference was statistically significant when P < 0.05.

3. Results

3.1. Demographic Variables of Two Cohorts of Patients

In order to ensure whether the two cohorts of RA patients were comparable, statistical analysis was performed focusing on age, gender, BMI, course of disease, smoking, drinking, and educational level of patients in the two groups, and the results showed no difference (P > 0.05; Table 1).

Table 1

Demographic variables of RA patients after receiving either medication or NWM plus multirehabilitation training.

Variables	NWM + MRT group (n = 42)	Medication group (n = 42)	t or Z	P
Age	50.71 ± 3.42	51.79 ± 3.87	−1.495	0.143
Gender			0.057	0.811
Male	12 (28.57)	13 (30.95)
Female	30 (71.43)	29 (69.05)
BMI (kg/m2)	26.40 ± 3.66	27.36 ± 3.31	−1.154	0.255
Course of disease (years)	5.01 ± 2.31	5.13 ± 2.00	−0.236	0.815
Smoking			0.207	0.649
Yes	14 (33.33)	16 (38.10)
No	28 (66.67)	26 (61.90)
Drinking			0.049	0.825
Yes	18 (42.86)	17 (40.48)
No	24 (57.14)	25 (59.52)
Educational level			0.233	0.629
Below high school	31 (73.81)	29 (69.05)
High school and above	11 (26.19)	13 (30.95)

3.2. Attenuation of Disease Symptoms

No significant difference was found in the scores of joint swelling, joint pain, and LOM between the NWM + MRT group and the medication group prior to treatment (P > 0.05); but after treatment, the scores reflecting the disease symptoms of both the groups were reduced (P < 0.05). A better improvement in disease symptoms was observed in the NWM + MRT group (P < 0.05, Table 2), indicating NWM plus multirehabilitation training could attenuate the disease symptom of RA patients after medication.

Table 2

Disease symptom scores of RA patients after receiving either medication or NWM plus multirehabilitation training.

		Joint swelling	Joint pain	LOM
NWM + MRT group (n = 42)	Before treatment	2.98 ± 0.95	3.29 ± 0.92	3.12 ± 0.33
	After treatment	0.90 ± 0.53	0.86 ± 0.35	1.38 ± 0.49
t		16.609	15.498	22.674
P		<0.001	<0.001	<0.001
Medication group (n = 42)	Before treatment	3.14 ± 1.05	3.12 ± 0.71	3.07 ± 0.26
	After treatment	1.21 ± 0.42a	1.29 ± 0.51a	1.71 ± 0.51a
t		12.235	13.929	16.505
P		<0.001	<0.001	<0.001

Compared with the NWM + MRT group, aP < 0.05.

3.3. Relief of Pain

As shown in Figure 1, the VAS and PSQI scores in the NWM + MRT group and medication group were not significantly different before treatment (P > 0.05), but the two scores were reduced statistically after treatment in both groups (P < 0.05), especially in the NWM + MRT group (P < 0.05). These data suggested that NWM plus multirehabilitation training could reduce the joint pain of RA patients after medication.

Figure 1

VAS and PSQI scores of RA patients after receiving either medication or NWM plus multirehabilitation training. (a) VAS scores before and after treatment. (b) PSQI scores before and after treatment. P < 0.05.

3.4. Recovery of Functional Mobility

As shown in Figure 2, the upper and lower limb FMAS scores in the NWM + MRT group and medication group showed no evident differences before treatment (P > 0.05). The posttreatment FMAS scores of upper limbs and lower limbs were increased statistically in both cohorts (P < 0.05) and were higher in the NWM + MRT group than in the medication group (P < 0.05), suggesting that NWM plus multirehabilitation training could maintain functional mobility of RA patients after medication.

Figure 2

FMAS scores of the upper and lower limbs of RA patients after receiving either medication or NWM plus multirehabilitation training. (a) FMAS scores of the upper limbs before and after treatment in the two groups. (b) FMAS scores of the lower limbs before and after treatment in the two groups P < 0.05.

3.5. Prevention of Anxiety and Depression

As shown in Figure 3, the SAS scores reflecting anxiety and SDS scores reflecting depression showed no obvious difference between the NWM + MRT group and medication group prior to treatment (P > 0.05), but the posttreatment SAS and SDS scores in both groups were reduced (P < 0.05), and the improvement of the psychological status was more significant in the NWM + MRT group compared with that in the medication group (P < 0.05). The data implied that NWM plus multirehabilitation training could prevent RA patients after receiving medication from anxiety and depression.

Figure 3

SAS and SDS scores of RA patients after receiving either medication or NWM plus multirehabilitation training. (a) SAS scores of the two groups before and after treatment. (b) SDS scores of the two groups before and after treatment P < 0.05.

3.6. Improvement of QoL

The SF-36 scores of the NWM + MRT group and medication group showed no difference in PF, RP, BP, GH, VT, SF, RE, and MH dimensions before treatment (P > 0.05). After treatment, the SF-36 scores were increased in both cohorts (P < 0.05), with more improvement of QoL in the NWM + MRT group compared with the medication group (P < 0.05, Table 3), which indicated that NWM plus multirehabilitation training could improve QoL of RA patients after medication.

Table 3

SF-36 scores of RA patients after receiving either medication or NWM plus multirehabilitation training.

		NWM + MRT group (n = 42)	Medication group (n = 42)
PF	Before treatment	66.02 ± 5.63	67.76 ± 5.28
	After treatment	78.02 ± 4.77	74.12 ± 5.06a
t		−16.489	−12.697
P		<0.001	<0.001
RP	Before treatment	52.17 ± 4.22	53.98 ± 5.27
	After treatment	67.86 ± 4.12	64.93 ± 5.58a
t		−20.008	−17.719
P		<0.001	<0.001
BP	Before treatment	55.83 ± 4.00	55.74 ± 4.02
	After treatment	67.57 ± 4.51	62.57 ± 4.01a
t		−13.722	−14.745
P		<0.001	<0.001
GH	Before treatment	53.67 ± 4.61	54.00 ± 4.34
	After treatment	67.88 ± 4.62	61.07 ± 4.15a
t		−14.490	−8.869
P		<0.001	<0.001
VT	Before treatment	52.88 ± 5.07	54.33 ± 4.74
	After treatment	68.14 ± 4.76	61.83 ± 5.51a
t		−16.551	−12.851
P		<0.001	<0.001
SF	Before treatment	54.26 ± 5.28	53.81 ± 4.42
	After treatment	67.55 ± 4.17	61.12 ± 3.88a
t		−12.535	−11.981
P		<0.001	<0.001
RE	Before treatment	55.62 ± 5.04	56.79 ± 5.12
	After treatment	71.02 ± 5.00	67.48 ± 5.29a
t		−13.653	−14.896
P		<0.001	<0.001
MH	Before treatment	51.67 ± 4.74	50.52 ± 4.92
	After treatment	64.69 ± 4.84	60.90 ± 4.19a
t		−14.628	−13.861
P		<0.001	<0.001

Compared with the NWM + MRT group, aP < 0.05.

3.7. Better Treatment Satisfaction

The satisfaction survey showed that the NWM + MRT group had a higher proportion of patients being satisfied (P=0.008) and a lower proportion of patients being dissatisfied (P=0.026) with treatment compared with the patients in the medication group (Table 4), suggesting that NWM plus multirehabilitation training could offer a better treatment satisfaction for RA patients.

Table 4

The satisfaction degree of RA patients after receiving either medication or NWM plus multirehabilitation training.

	NWM + MRT group (n = 42)	Medication group (n = 42)	Z	P
Very satisfied	23 (54.76%)	11 (26.19%)	7.115	0.008
Satisfied	14 (33.33)	17 (40.47%)	0.460	0.498
Less satisfied	4 (9.53%)	7 (16.67%)	0.941	0.332
Dissatisfied	1 (2.38%)	7 (16.67%)	4.974	0.026

4. Discussion

RA is one of the prime reasons for joint deformity and loss of joint function, which has a very high incidence in the world and may appear at any age [16]. At present, there is no effective cure for RA in clinics, and the purpose of clinical treatment is to alleviate disease development and control its malignant manifestations [17]. Nonsteroidal anti-inflammatory drugs are the most commonly used drugs for RA. However, for active-stage RA, they can only relieve symptoms and signs, but cannot eliminate the cause of inflammation, with a long treatment cycle and low economic effects [18]. As the effect of TCM in treating chronic diseases has been gradually recognized clinically, the treatment of RA has gradually changed from drug conservative treatment to TCM combined rehabilitation training treatment.

In this study, we first compared the patients' clinical baseline data for statistical analysis, and the results showed no statistical significance between the groups, ensuring the reliability of the experimental results. Subsequently, we investigated the symptom scores of the two groups, and the results showed significantly reduced symptom scores, with a more significant improvement in the NWM + MRT group. As we all know, the manifestations of active RA are mainly recurrent limb swelling and pain and LOM [19]. Traditional drug therapy relieves joint pain by inhibiting the release of inflammatory mediators in the joint tissue [20]. However, acupuncture and moxibustion of TCM repair inflammatory damage in RA through thermal conduction and mechanical stimulation of acupoints [21]. On the other hand, acupuncture is shown to interfere with cholinergic nerve function at the central level and affects the release of glucocorticoid receptors and melatonin, thus effectively repairing tissue inflammatory injury [22]. Alonso et al. found enhanced release levels of preproopiomelanocortin and preprodynorphin in the hypothalamus of mice by acupuncture; preproopiomelanocortin and preprodynorphin have positive effects on anti-inflammatory pain and a strengthening analgesic effect in the human body [23], which also explained the excellent effect of acupuncture and moxibustion of TCM on relieving RA pain. Similarly, we investigated the pain of patients through the VAS and PSQI scores, and the results were consistent with the above, which showed the remarkable application results of NWM plus multirehabilitation training. Ju et al. found that acupuncture also achieved an excellent analgesic effect for patients with skeletal muscle pain [24], which can also support our experimental results.

LOM, another important clinical feature of RA, is also a focus of close attention in clinical treatment. Its pathogenic mechanism mainly lies in the damage of joint cells and tissues and the gradual atrophy of the skeletal muscle under the continuous release of joint proinflammatory factors, thus limiting motor function [25]. In our experiment, the posttreatment FMAS scores of the upper and lower limbs were statistically increased in both groups, indicating that the joint activity of patients has been significantly improved. Among them, the scores were higher in the NWM + MRT group compared with the medication group, which also show that the patients can obtain a more obvious improvement in joint activity through acupuncture plus multirehabilitation training. The treatment mechanism of traditional drugs is consistent with the above, which also lies in alleviating the symptoms by inhibiting inflammatory cells and factors, so that the function of joint tissues can gradually return to the normal level [26]. TCM treatment can not only inhibit the development of inflammation through acupuncture, but also stimulate the activity of joint cells as well as their proliferation ability, thus accelerating the rehabilitation of joint injury. Gao et al. indicated that the stimulation of NWM contributed to obviously suppressed levels of proinflammatory factors such as IL-1β, IL-17, and ICAM, obvious changes in the Fas/FasL protein, and synovial hyperplasia suppression, thus promoting the formation of a large number of osteoblasts [27]. Moreover, under rehabilitation training, the regeneration ability of joint cells and tissues is stimulated, which consolidated the stimulation effect of acupuncture, further improving the rehabilitation of patients. The research by Lange et al. also fully demonstrated the important role of rehabilitation training in improving the condition of RA patients [28], whose effect is not only reflected in the improvement of clinical symptoms but also in the significant positive significance to patients' psychology, QoL, and other aspects. Therefore, in this study, we also evaluated patients with SAS, SDS, and SF-36 scores. The results showed better psychological and QoL improvements in the NWM + MRT group versus medication group, which we believe is due to the excellent effect of NWM on the one hand and the more comprehensive improvement of patients through rehabilitation training on the other. As is known to all, in the long-term treatment of chronic diseases, patients generally have great negative psychology due to the torture of diseases, expensive medical expenses, fear and anger about diseases, etc., which makes the patients suffer great physical and psychological distress [29]. TCM and NWM combined with multirehabilitation training have a higher economic effect and will not cause too much economic burden to patients. Additionally, in the process of assisting patients to complete the training, it can subtly enhance the patients' sense of trust and dependence on the medical staff while deepening the patients' understanding of the disease, so that patients can get a better treatment experience. This results in differences in the psychological status and QoL between the two groups. Finally, the patient satisfaction survey results were consistent with our expectations, that is, the patients in the NWM + MRT group gave a higher satisfaction evaluation, indicating that NWM plus multirehabilitation training has a higher clinical application value.

NWM plus multirehabilitation training can effectively improve the clinical symptoms of RA patients, enable them to obtain better treatment experience, and further improve their psychological state and QoL, which is worth promoting in clinical use. However, there are still several shortcomings in this study to be addressed. For example, first, the indexes of this evaluation are mostly objective scores, and the lack of subjective monitoring indexes leads to the inability to further prove the actual effect of acupuncture combined with multirehabilitation training. Second, due to the short trial period, we were unable to evaluate the long-term prognostic impact of NWM plus multirehabilitation training on patients. Third, basic experiments are needed to further explore the specific action mechanism of NWM on RA. In the follow-up study, we will launch more comprehensive experiments bearing in mind the above limitations, so as to obtain more comprehensive results for clinical reference.