Hui-dan Li,Xing Wei

1Tianjin University of Sport,No.16 Donghai Road,West Tuanbo New Town,Jinghai District,Tianjin 300381,China.

Abstract

Keywords: Gout; Acupuncture; Cupping therapy; Laser; Intermediate frequency; Ultrashort wave;Magnetic therapy.

Introduction

The incidence and prevalence of acute gouty arthritis are increasing with the total prevalence of gout in China is 1.52% [1],partly as a consequence of increased prevalence of comorbidities such as metabolic syndrome,type II diabetes,obesity,hypertension,and chronic kidney disease.Gouty arthritis is mediated by monosodium urate monohydrate crystal deposition in and around the joint space due to hyperuricemia [2].Pain and swelling are the most common symptoms of gouty arthritis during an acute attack,so the main goal of treatment is to reduce pain and relive joint swelling[3-4].Because of their anti-inflammatory and analgesic characteristics,non-steroidal anti-inflammatory drugs(NSAIDs) are often used as first-line therapy for the treatment of acute gout flares.But NSAIDs are also associated with clinically recognized risks of toxicities,especially related to their gastrointestinal and cardiovascular effects [5].Colchicine and systemic and locally injected corticosteroids are also appropriate options in many patients.However,colchicine is associated with risks of toxicity especially related to renal impairment and drug-drug interactions [6-8].Consequently,there is a need for new approaches that provide increased efficacy and/or tolerability in the treatment of acute gouty arthritis.

Non-drug therapies are now being increasingly evaluated for its role in acute and chronic gout with less toxic,side effects and better therapeutic effects.The aim of this overview is to summarize the non-drug modalities and the available evidence on the effectiveness of these modalities in acute gouty arthritis.

Basic treatments for acute gouty arthritis

In the acute stage,patients should rest in bed,keep joint elevation to accelerate the blood circulation and the regression of inflammatory factors [9].It can also cooperate with the local cold compress with chemical ice pack to reduce the tissues edema around the joints and relieve pain[10].Reducing purine intake is of great value,as 20% of uric acid derived from the decomposition of nucleotides from foods containing purines or nuclear proteins (exogenous) [11].Gout patients should limit alcohol,reduce the intake of high purine food,high fructose drinks,instead drink lots of water (2000 mL)daily.

The mechanisms of non-drug therapies for acute gouty arthritis

Non-drug treatments are described as being effective for the treatment of acute gouty arthritis.The mechanisms for non-drug treatments are various (Figure 1).It is found that traditional non-drug therapy,such as acupuncture and moxibustion,can activate coarse fiber and inhibit fine fiber pain,thus achieving analgesic effect [12].In addition,these therapies can effectively participate in the analgesia and repair of nerve injury and promote the recovery of nerve function through the influence on brain 5-hydroxytryptamine (5-HT);They also increase vascular elasticity,reduces resistance,and increases arterial blood flow,thus improving local circulation and promoting circulation of Qi and blood circulation [13].Modern non-drug therapies such as physical therapies,which can activate neurons to release enkephalin,so as to close the Ca2+channel,then preventing the release of substance P and glutamic acid by inhibit C fiber,and reducing the activity of pain sensitive neuron and blocking the nociceptive stimulus from primary neurons to the conduction of the secondary neurons; In addition,by increasing K+ion potential of spinal dorsal horn neurons,the cell membrane can be hyperpolarized,resulting in post-synaptic inhibition,leading to a significant increase in the pain threshold and achieving the purpose of analgesia[14].

The therapy can also inhibit inflammatory reaction through increasing anti-inflammatory factors,such as IL-10,IL-13 and reducing proinflammatory cytokine,such as TNF-α,thereby reducing inflammatory response[15].It can also dilate microvessel,increase blood flow volume,by which accelerate the recovery and regeneration of damaged nerves,so as to achieve analgesic effects[16].

Traditional non-drug therapies and modern non-drug therapies

Traditional non-drug therapies

Traditional Chinese medicine(TCM)has a long history in the treatment of gout,among which acupuncture,moxibustion and cupping are currently effective measures for treating acute gout arthritis,which can significantly alleviate acute inflammation of gout joints and prevent joint dysfunction without obvious toxic and side effects.

Acupuncture therapy.When stimulate the most painful place of patient suffering from acute gouty arthritis with acupuncture,it can regulate channels,improve local blood circulation and lessen pain.A meta-analysis showed that acupuncture combined with moxibustion had certain advantages over Western medicine alone in treating gouty arthritis [17].Li DHet al[18] found that acupuncture combined with bloodletting therapy could relieve symptoms and signs of gout patients up to 92.0%,significantly higher than the control group of patients treated with drugs.Xu LNet al[19]randomly divided 60 patients with acute gouty arthritis into two groups,and found that the level of pain,swelling,tenderness and activity function of the observation group (acupuncture and blood-letting combined with San-Huang ointment)were significantly lower than those of the control group(Western medicine).Zhang Xet al[20] found that the combination of ear acupuncture and warm acupuncture on the basis of Western medicine treatment could effectively improve the clinical efficacy of gouty arthritis.

Puncture cupping.Puncture cupping is a method combining blood-pricking therapy with cupping therapy.Previous studies have confirmed that this therapy can efficiently reduce the articular cavity uric acid salt deposition,reduce inflammatory cells infiltration,improve the effect of the ultrastructure of cartilage [21].In recent years,some scholars have applied it to patients with acute gout arthritis and achieved a good effect.In 2019,Wang Met al[22] treated 32 patients with acute gouty arthritis with the combination of knife needle and puncture cupping on the basis of conventional Western medicine treatment.The results showed that the total effective rate was 87.5%.In 2016,Qin ZZ [23] of 70 cases of acute gouty arthritis patients were randomly divided into treatment group (n = 35) and control group(n = 35),the treatment group received puncture bleeding in the most painful joint swelling,followed by glass cupping; The control group was treated with Western medicine for a total of 10 days.The results showed that the effective rate in the treatment group was 94.28% and 85.71%,and the levels of serum uric acid,C-reactive protein,erythrocyte sedimentation rate and VAS score were decreased in both groups,moreover,those indicators were better in the treatment group.In addition,during the experimental study,no adverse reactions occurred in the treatment group,while 5 patients in the control group had decreased appetite and diarrhea; 2 patients had mild liver function damage.

Figure 1 The mechanisms of non-drug therapies for acute gouty arthritis

Modern non-drug therapy

Physical therapies such as the application of sound,light,electricity,magnetism and thermal power and other physical factors are mostly used as modern non-drug therapies for the treatment of acute gouty arthritis.At present,laser therapy,electrotherapy,magnetic therapy and ultrasonic therapy are the most representative methods,which can effectively improve the acute symptoms of gout without obvious adverse reactions.

Laser therapy.Laser can promote the repair of diseased tissues and relieve inflammation,by which has a good effect in the treatment of acute gouty arthritis.Zong MRet al[24] by comparing the effects of He-Ne laser on 32 cases acute gouty arthritis patients with NSAIDs drugs on 30 cases,found in the third and seventh days,and the analgesic effect of treatment group was superior to that of the control group,and the analgesic effect of 7 days was better than the third day.During the treatment,2 patients in the control group had nausea and 1 patient had upper abdominal discomfort.There were no adverse reactions in the treatment group,and there were no abnormal liver and renal functions in the two groups after treatment.This indicates that He-Ne laser irradiation is effective in the treatment of acute gouty arthritis,with a short course of treatment and no pain or side effects.Yang HQ [25]adopted the laser rheumatism treatment machine with an output wavelength of 810 nm and a power of 500 mW and achieved a better therapeutic effect through the laser point burning therapy on acute gouty arthritis without obvious adverse reactions.In the research of Xu H [26],68 patients with gouty arthritis were randomly divided into two groups,38 patients in the treatment group received acupuncture in Jiao SY (SP6),Quan YL (SP9),Li ZS (ST36),A Shi acupoint,then received laser treatments (250-350 MW); 30 patients in the control group received drug treatment for 1 month.The results showed that the total effective rate in the treatment group was 97.4%,and that in the control group was 96.7%.The study showed that acupuncture combined with laser therapy had a significant effect on controlling the acute attack of gout arthritis,which was as effective as drug therapy.

Electroshock therapy.Electrotherapy has a good effect on the improvement of pain,swelling and other inflammatory symptoms,and has the characteristics of simple operation,low price and no side effects.In recent years,it has been applied to patients with acute gouty arthritis.Electroshock therapies mainly include direct current therapy,low frequency electric therapy and medium frequency electrotherapy,high frequency electric therapy.Guo Yet al[27] randomly divided 114 patients with acute gouty arthritis into a treatment group and a control group.The control group (51 cases) received NSAID drugs,and the treatment group (63 cases)received medium frequency pulsed electric therapy combined with Chinese medicine foot bath therapy.After 7 days,the effective rate was 60.78%in the control group and 87.30% in the treatment group.The decrease rate of inflammatory index and serum uric acid was 64.71% in the control group and 90.48% in the treatment group.Compared with the ankle function scores before and after treatment,the treatment group (7.14 ± 0.35) was significantly better than the control group (3.30 ± 0.21).This indicated that the combined treatment of medium frequency pulsed electric and Chinese medicine foot bath therapy has a better therapeutic effect on the acute gouty arthritis.Ultrashort wave therapy is one of the most widely used high frequency electrotherapy.Xu Qet al[28]found that oral medication combined with ultrashort wave therapy could effectively improve swelling and pain symptoms and joint function of patients with acute gouty arthritis,and reduce the levels of C-reactive protein,serum uric acid and erythrocyte sedimentation rate.The total effective rate in the treatment group was 95.12%,which was superior to simple drug therapy.The effects of ultrashort wave combined with plum needle treatment had also been proved,as the level of uric acid in patients received ultrashort wave treatment fell significantly after treatment[29].

Magnetic field therapy.Magnetic field therapy is believed to be able to greatly relieve the pain.Shen SGet al[30] treated patients with acute gouty arthritis with low-frequency magnetic stimulation therapy accompanied by active joint exercise.After 14 days of treatment,the patient's pain was significantly reduced,swelling disappeared,and range of motion of the joint increased,and there was no recurrence during the follow-up of 1 year.Magnetic therapy can not only be combined with acupuncture therapy but also with laser therapy for acute gouty arthritis.Ding Q [31] reported 40 patients with gouty arthritis were randomly divided into treatment group and control group,control group treated with single factor magnetic therapy apparatus(frequency of magnetic field intensity is 0.2 - 0.4 T,20 - 80 times/min,treatment time 20 min/times),the treatment group on the basis of the magnetic therapy combined with He-Ne laser(35 mW output power and wavelength of 0.6328 microns,each irradiation (10 min) and pain points in treatment of integrated factors in a complex bleed,1 times a day,10 times for a period of treatment.After 1 - 3 courses of treatment,the symptoms of facet joint pain were all improved to different degrees without adverse reactions.According to the disappearance or alleviation of the symptoms of soft tissue swelling and heat pain around the facet joint of lower limbs and the examination of uric acid in the laboratory,the total effective rate in the treatment group was 95% and the total effective rate in the control group was 75%.Current the application of magnetic field therapy in acute gouty arthritis is less,most scholars believed that basic mechanism of magnetic stimulation in the treatment of pain similar to electric stimulation,which interfere with the transmission of pain signals[32],but its specific mechanism is not clear,its application in the patients with gout and the specific mechanism of action is worth further study.

Ultrasonic therapy.Ultrasonic drug delivery therapy can dilate local blood vessels in tissues,accelerate blood flow circulation,reduce the excitability of peripheral nerves,thus reducing inflammation,relieving swelling and adhesion [33],and thereby improving the pain threshold.Transdermal administration can also lead to drug efficacy through local tissue absorption and reduce the first-pass effect of liver and decrease the toxic and side effects to some extent.Liu HBet al[34]treated 28 cases of patients with gouty arthritis with ultrasonic drug penetration therapy combined with conventional drug treatment,found that after the three course treatment group total effective rate was 96.4%,and the conventional drug treatment of the control group was 71.4%,indicating that ultrasonic drug penetration therapy combined with conventional drug treatment of gouty arthritis curative effect is better than that of pure drug therapy.Yang Yet al[35] randomly divided 59 cases into experiment group and 58 cases in the control group,patients in the observation group received Santeng Santu Simiao Soup[a common prescription for arthritis,including Jinyinteng(Honeysuckle Stem),Daxueteng(Sargentgloryvine Stem),Luoshiteng (Trachelospermum Jasminoides),et al]combined with ultrasound therapy,continuous treatment 2 weeks later found that the clinical effective rate of observation group (98.28%) was superior to that of the control group (88.14%); Serum uric acid,erythrocyte sedimentation rate,white blood cell count and C-reactive protein were significantly lower in both groups than before treatment.

Conclusion

The non-drug therapies,especially the increasing varieties of modern physical therapies,have achieved good effects in the treatment of acute gouty arthritis with the characteristics of less toxicity and side effects,which are worthy of wide use.