Effect of electro-acupuncture, massage, mud, and sauna therapies in patient with rheumatoid arthritis

Abstract

A 48-year-old married woman diagnosed with rheumatoid arthritis (RA) in 2007, came to our hospital in July 2014 with the complaint of severe pain and swelling over multiple joints, especially over small joints, which was associated with stiffness (more in morning), deformities of fingers and toes, with disturbed sleep and poor quality of life (QOL) for the past 7 years. She received a combination of electro acupuncture (14 sessions), massage (18 sessions), mud (18 sessions), and sauna (3 sessions) (EMMS) therapies for 30-min, 45-min, 30-min, and 15-min per session, respectively for 3 weeks. During and postintervention assessment showed reduction in visual analog scale score for pain, Depression Anxiety and Stress Scales and the Pittsburgh Sleep Quality Index scores. It also showed an increase in the scores of 10-Meter Walk Test, isometric hand-grip test, and short form-36 version-2 health survey. This result suggest that, the EMMS therapy might be considered as an effective treatments in reducing pain, depression, anxiety, and stress with improvement in physical functions, quality of sleep and QOL in patient with RA. EMMS therapies were tolerated and no side effects were reported by the patient. Though the results are encouraging, further studies are required with larger sample size and advanced inflammatory markers.

Full text

© 2015 Journal of Ayurveda & Integrative Medicine | Published by Wolters Kluwer - Medknow 295
Address for correspondence:
Dr. A. Mooventhan,
Department of Research and Development,
S-VYASA University, Bengaluru - 560 019, Karnataka, India.
E-mail: dr.mooventhan@gmail.com
Received: 05-Feb-2015
Revised: 18-Jun-2015
Accepted: 15-Aug-2015
Effect of electro‑acupuncture, massage, mud,
and sauna therapies in patient with rheumatoid
arthritis
Geetha B. Shetty1, A. Mooventhan2, N. Anagha3
Departments of 1Acupuncture and 3Naturopathy and Yoga, SDM College of Naturopathy and Yogic Sciences, Ujire, 2Department of Research
and Development, S‑VYASA University, Bengaluru, Karnataka, India
INTRODUCTION
Rheumatoid arthritis (RA) is a chronic, systemic,
polyarticular autoimmune inammatory disease causing
destruction of capsule and synovial lining of joints,
especially in the hands, feet and knees. It affects 3 times
more women than men and can lead to pain, altered
biomechanics and decreased quality of life (QOL).[1]
According to naturopathy accumulation of morbid matter
is the cause of diseases,[2] hence eliminating those morbid
matters is the cure for disease. To reduce pain and other
symptoms, use of complementary and alternative medicine,
which includes thermotherapy, acupuncture, massage
etc., has increased for RA patients.[3] Acupuncture[4] and
massage[5] therapies are commonly employed for most
of the pain management, mud[6] was shown to have
an anti-inammatory effect and sauna was assumed to
reduce pain and swelling by producing analgesic effect
and perspiration. Since these therapies were shown to
have effect on either one or the other RA symptoms, and
Acupuncture,[4] mud,[6] and sauna[7] therapies alone could
not signicantly improve pain,[4] erythrocyte sedimentation
rate (ESR)[4,6] compared to control[4] and clinico‑biochemical
and immunological indices[7] respectively in RA, we selected
A 48-year-old married woman diagnosed with rheumatoid arthritis (RA) in 2007, came to our hospital in July 2014 with
the complaint of severe pain and swelling over multiple joints, especially over small joints, which was associated with
stiffness (more in morning), deformities of ngers and toes, with disturbed sleep and poor quality of life (QOL) for the past
7 years. She received a combination of electro acupuncture (14 sessions), massage (18 sessions), mud (18 sessions),
and sauna (3 sessions) (EMMS) therapies for 30-min, 45-min, 30-min, and 15-min per session, respectively for 3 weeks.
During and postintervention assessment showed reduction in visual analog scale score for pain, Depression Anxiety and
Stress Scales and the Pittsburgh Sleep Quality Index scores. It also showed an increase in the scores of 10-Meter Walk
Test, isometric hand-grip test, and short form-36 version-2 health survey. This result suggest that, the EMMS therapy might
be considered as an effective treatments in reducing pain, depression, anxiety, and stress with improvement in physical
functions, quality of sleep and QOL in patient with RA. EMMS therapies were tolerated and no side effects were reported
by the patient. Though the results are encouraging, further studies are required with larger sample size and advanced
inammatory markers.
Key words: Electro-acupuncture, massage, mud therapy, rheumatoid arthritis, sauna therapy
CASE REPORT
ABSTRACT
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How to cite this article: Shetty GB, Mooventhan A, Anagha N. Effect
of electro-acupuncture, massage, mud, and sauna therapies in patient
with rheumatoid arthritis. J Ayurveda Integr Med 2015;6:295-9.

Shetty, et al.: Effect of EMMS therapies in rheumatoid arthritis
296 Journal of Ayurveda & Integrative Medicine | October-December 2015 | Vol 6 | Issue 4
the combination of electro‑acupuncture, massage, mud, and
sauna (EMMS) therapies to produce better improvement.
Hence, this study aimed at evaluating the effect of EMMS
therapies in pain, motor function, depression, anxiety, stress,
quality of sleep (QOS), and QOL in patient with RA.
CASE DESCRIPTION
A 48‑year‑old, married woman diagnosed with RA in
2007 underwent irregular conventional management. Her
symptoms, as described by her, began with moderate to
severe pain associated with swelling, stiffness (more in
morning) in multiple joints, especially over small joints,
elbow, shoulder, knee, and hip joints with symmetrical
distribution and deformities of ngers and toes. RA-factor
was positive and her physician advised methotrexate and
hydrochloroguine. Patient underwent those medications for
1‑year and stopped them after her symptoms improved.
Three years later, she was affected again with similar problems
and admitted in a private hospital for 6 days, underwent
treatment with methotrexate, hydroxychloroquine,
prednisolone, calcium, folic acid, multivitamin supplements,
and physiotherapy. At home, she was advised to continue
same medications with naproxen, rabeprazole sodium,
and diclofenac. Patient underwent those medications for
30 months, but she developed pufness of face, greying
of hair and generalized weakness, because of which she
developed fear of taking medication and stopped taking
medications. Following this, all those symptoms reduced,
except joint pain. Hence, she underwent locally available
herbal therapy (patient did not know the name of herbs),
but her symptoms worsened day by day and she became
stressed and depressed, especially due to deformities.
In 2013, she experienced palpitation and underwent
electro cardiogram, but ndings were normal. Later, she
underwent Ayurvedic medicine such as Sinhanad‑guggul
and Punarnava‑mandoor with diclofenac sodium but
she could not get improvement and became very much
depressed, which was associated with poor QOS and QOL.
When she visited us with the same complaints in July, 2014,
we suggested her to take combination EMMS therapies. She
stopped taking diclofenac and other Ayurvedic medications
on 1st and 3rd day of her stay in the hospital, respectively.
Timeline
A detail of the study from admission of the patient in
hospital to follow up has been given in Figure 1.
Intervention
Patient received clinical acupuncture for symptomatic
relief of RA. We used 27‑needles/session. Points given
were GV‑20, LI‑4, LI‑11, BL‑11, GB‑34, SP‑6, KI‑3,
ST‑44, EX‑28, and EX‑36, as described in Table 1.[5,8]
All points were pricked bilaterally except GV‑20. Patient
was informed about the procedure and sensations of
needle insertion, and response was sought. All needles left
for 30‑min, including 20‑min of electrical stimulation/
session to all points except GV‑20, EX‑28, and EX‑36
by using CMNS6‑1 needle stimulator, China. We used
1-cun liform locally manufactured stainless steel needles
with 0.38‑mm diameter and 25‑mm length. Patient
received 14 sessions of EA with 7 days rest period after
rst 7 sessions. This rest is traditionally indicated for
improvement and adaptation.[5,8] Along with acupuncture,
patient received 45‑min of Swedish massage, which
included touch, stroking, mild friction, mild kneading
and joint movements and 30‑min of hot‑mud application
to bilateral hands and legs for 1‑session/day for 6 days/
week; and sauna‑bath once/week for a period of
3 weeks. Assessments were done before, during, and after
intervention [Table 2].
Outcome measures
Visual analog scale for pain
It was used to evaluate the patient’s overall pain intensity
of all the joints on a scale of 0–10, where 0 indicate no
pain and 10 indicate worst pain. Patient was asked to mark
a point on the scale to indicate her pain intensity.[5]
10‑meter walk test
It was used to assess walking speed in self‑selected
velocity and fast velocity. Patient was advised to walk
about 10‑m without assistance and the time was measured
Admission in hospital and rest
Baseline & Beginning of intervention
Followed up
343
DAY
13th July 2014
14th July 2014
21st July 2014
28th July 2014
03rd August 2014
04th August 2014
14th July 2015
1 day
7 day
Assessment at 8th day of intervention
7 day, rest period for Electro-Acupuncture
Assessment at 15th day of intervention
6 day
Completion of intervention 21st day
1 day
343 day
Post assessment & Discharge 22nd day
21
D
A
Y
1
Y
E
A
R
Figure 1: A detail of the study from admission of the patient in hospital
to follow up

Shetty, et al.: Effect of EMMS therapies in rheumatoid arthritis
Journal of Ayurveda & Integrative Medicine | October-December 2015 | Vol 6 | Issue 4 297
for the intermediate 6‑m. Four meters was left out to
allow for acceleration and deceleration. We assessed
3‑consecutive trials, average of which was considered
as nal value.[9]
Isometric hand‑grip test
Sphygmomanometer cuff was inated till the mercury
column rose to 30‑mmHg. Patient was advised to squeeze
the cuff as much as possible on 3‑successive occasions
with 10‑s interval. Maximum height of the mercury column
reached on each occasion was measured, average of which
was considered as nal value.[10]
The Pittsburgh Sleep Quality Index
It consists of 7‑components in 9‑item sleep questionnaire.
It was used to evaluate patient’s QOS over the preceding
month. A total score of 0–4 indicates good sleep quality,
5–10 indicates poor sleep quality, and >10 indicates sleep
disorder.[5,11]
Depression Anxiety and Stress Scales
It is a 42‑item questionnaire that includes 3‑self‑report
scales designed to measure state of depression, anxiety,
and stress. Each scale contains 14‑item where patient was
asked to use 4‑point severity/frequency scales to rate the
extent to which she has experienced each state over the
past week.[12]
Short form‑36 version‑2 health survey
It is a 36‑item questionnaire that measures health in 8
dimensions. For each dimension item scores were noted,
averaged and transformed into a scale of 0–100 where
0 indicates worst possible health and 100 indicates best
possible health. Reliability of its domains was shown to
have improvement over the previous version of short
form‑36.[13]
Blood and urine analysis
Blood and urine analysis were done to assess hemoglobin,
ESR, white blood cell (WBC) (total and differential
counts); reaction, protein, sugar, pus‑cells, red blood cells,
epithelial‑cells, casts, and crystals, respectively.
Follow‑up
Patient’s follow‑up was through mobile communication,
after 12th and 49th week of her discharge. From recent
follow‑up, as per patient and her son (who was with the
patient during hospital stay), there is no aggravation of
symptoms and improvement was seen in her health status,
moreover she started taking part in domestic activities such
as cooking etc., which was not the case before EMMS
therapy. Since, the patient did not visit our hospital after
discharge with any complaint; we did not do any kind of
clinical assessments.
RESULTS AND DISCUSSION
Result of our study showed, reduction in visual analog
scale (VAS), Depression Anxiety and Stress Scales (DASS),
Pittsburgh Sleep Quality Index (PSQI) scores, weight, body
mass index, ESR, lymphocytes, pus‑cells, and epithelial‑cells
with increase in 10‑Meter Walk Test, isometric hand‑grip
test, short form‑36 version‑2 (SF‑36v2) health survey
scores, hemoglobin, total WBC and neutrophils [Table 2].
There were better reduction in VAS and DASS scores
with improvement in 10‑Meter Walk Test, self‑selected
and fast velocities, hand‑grip (both hands), and SF‑36v2
health survey (all the 8‑components), which indicates the
better improvement in pain, depression, anxiety, stress,
motor-functions, and QOL, respectively in this patient.
Improvement in QOS was observed through reduction
in PSQI score but it did not reach the optimum level to
Table 1: Description of acupuncture points
Needling point Location Depth of needling; method
GV-20 (Baihui)* On the vertex of the skull, 5-cun behind the anterior hairline and 7−cun above
the posterior hairline in the middle
0.5−cun; oblique needling
LI-4 (Hegu)*** Highest point of the muscles on the back of the hand when the forenger and
thumb are adducted
0.5−1−cun perpendicular needling
LI-11 (Quchi)*** Lateral end of the elbow crease (when elbow is semi exed) 1−cun; perpendicular needling
BL-11 (Dashu)*** 1.5-cun lateral to lower border of spinous process of 1st thoracic vertebra 0.3−cun; perpendicular needling
GB-34 (Yanglingquan)*** In the depression anterior and inferior to the head of bula 1−cun; perpendicular needling
SP-6 (Sanyinjiao)*** 3-cun above the tip of the medial malleolus on the medial border of tibia 1−cun; perpendicular needling
KI-3 (Taixi)*** Mid way between the tip of the medial malleolus and medial border of tendoachilles 1−cun; perpendicular needling
ST-44 (Neiting)*** 0.5-cun proximal to the web margin between the 2nd and 3rd toes 0.3−cun perpendicular needling
EX-28 (Baxie)** On the dorsum of the hand, on the webs between the 5 ngers 1−cun; oblique needling
EX-36 (Bafeng)** On the dorsum of foot, 0.5-cun proximal to the border of the webs between 5-toes 0.5−cun; oblique needling
*Single needling, **bilateral needling without electrical stimulation (of 4 points, 3 points were used in each hand and foot except the points between 1st and 2nd nger and
2nd and 3rd toes), ***bilateral needling with electrical stimulation. GV=Governing vessel, LI=Large intestine, BL=Urinary bladder, GB=Gall bladder, SP=Spleen, KI=Kidney,
ST=Stomach, EX=Extra-ordinary points, cun=The breadth of the distal phalanx of the thumb at its widest point

Shetty, et al.: Effect of EMMS therapies in rheumatoid arthritis
298 Journal of Ayurveda & Integrative Medicine | October-December 2015 | Vol 6 | Issue 4
indicate good QOS. Mild increase in hemoglobin with
better reduction in ESR and Lymphocytes in blood
analysis and reduction in pus‑cells and epithelial‑cells in
urine analysis indicates the improvement in health while
reduction in chronic inammation.
This result might be attributed to effect of EMMS
therapies on RA in various aspects such as pathological,
psychological, mechanical etc. Acupuncture might reduce
pain and inammation through release of endogenous
opioids (encephalin, dynorphin, β‑endorphin, and
endomorphin), serotonin[4] and by lowering tumor necrosis
factor‑alpha (TNF‑α) and vascular endothelial growth
factor in peripheral blood and joint synovia to improve
internal environment for genesis and development of RA,
respectively.[14] Reduction of inammatory cells inltration
might have allowed diseased joints to heal because TNF is
known to destroy articular cartilage, bone resorption, and
inhibit bone formation by stimulating protein‑degrading
enzymes.[1]
Mud therapy might reduce pain, swelling and stiffness, while
improve motor functions and daily activities. In a previous
study, mud pack was shown to be safe and effective in
reducing objective and subjective indices of RA activity
for 3 months.[6] Massage might reduce pain, swelling, stress
and anxiety; promote muscle relaxation and mobility along
with improvement in QOS.[5] Sauna might produce positive
effect on locomotor system, psycho‑emotional status, and
pain.[7] Elevated levels of both depression and anxiety
occur in RA and have direct effect on pain via different
mechanisms.[14] The reduction in depression, anxiety and
stress scores by EMMS therapies might attribute to overall
well‑being of this patient because those are associated with
higher levels of disease activity, pain, fatigue, work disability,
health service use, lower treatment compliance, increased
suicide risk, and mortality in RA.[15]
Strengths of this study
This is a rst RA case, reporting the effects of EMMS
therapies. It was well tolerated and no side effects were
reported by the patient throughout the study period. It
showed more effectiveness in RA, especially in reducing
pain, and ESR which was not shown in previous
studies where, they used particular treatments such as
acupuncture,[4] mud,[6] and sauna.[7]
Limitations of this study
Changes in major inammatory markers were not assessed;
validity and reliability of this result may vary because of
single case. Hence, further well planned clinical observational
studies with advanced markers are suggested with this
positive singular report. Studies are required with large
sample size and advanced techniques to validate our results.
CONCLUSION
Results of this study suggest that combination of
electro‑acupuncture, massage, mud, and sauna therapies
were well tolerated and effective in patient with RA.
Table 2: Baseline, during and postassessments
of the subject
Variables Baseline
1st day
During Post
8th day 15th day 22nd day
Height (cm) 152 - - -
Weight (kg) 55.7 - - 53.1
Body mass index (kg/m2) 24.11 - - 22.98
Visual analog scale score for pain 8.2 4.3 2.7 1.9
10-Meter Walk Test
Self-selected velocity (m/s) 0.24 0.33 0.36 0.52
Fast velocity (m/s) 0.35 0.57 0.63 0.72
IHGT (mmHg)
Right hand 10.67 13.33 14.00 16.67
Left hand 8.67 11.33 12.00 14.67
PQSI 11 - - 7
DASS
Depression 31 - - 8
Anxiety 21 - - 8
Stress 23 - - 6
SF-36v2 health survey
Total score 12.36 - - 63.33
Physical functioning 5 - - 50
RLPH 0 - - 62.5
RLEP 16.67 - - 75
Energy/fatigue 18.75 - - 56.25
Emotional well being 25 - - 75
Social functioning 0 - - 50
Pain 10 - - 65
General health 20 - - 80
Blood analysis
Hemoglobin (g%) 9 - - 10
ESR (mm/h) 100 - - 55
White blood cells
Total count (cells/cumm) 7800 - - 9900
Neutrophils (%) 44 - - 65
Eosinophils (%) 2 - - 2
Basophils (%) 0 - - 0
Lymphocytes (%) 54 - - 33
Monocytes (%) 0 - - 0
Urine analysis
Reaction Acidic - - Acidic
Albumin Nil - - Nil
Sugar Nil - - Nil
Pus-cells (per hpf) 30-35 - - 7–8
Red blood cell Nil - - Nil
Epithelial cell (per hpf) 7-8 - - 3–4
Casts Nil - - Nil
Crystals Nil - - Nil
IHGT=Isometric hand-grip test, PQSI=Pittsburgh Sleep Quality Index, DASS=Depression
Anxiety and Stress Scale, SF-36v2=Short form-36 version-2, RLPH=Role limitations due
to physical health, RLEP=Role limitations due to emotional problems, ESR=Erythrocyte
sedimentation rate, cumm=Cubic millimeter, hpf=High power eld

Shetty, et al.: Effect of EMMS therapies in rheumatoid arthritis
Journal of Ayurveda & Integrative Medicine | October-December 2015 | Vol 6 | Issue 4 299
INFORMED CONSENT
An informed written consent was obtained from the patient
for reporting this case.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
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