Abstract: Background　Previous studies have shown that laboratory，imaging and clinical parameters differ significantly in rheumatoid arthritis（RA）patients by traditional Chinese medicine（TCM）syndrome，and studying these parameters can provide evidence for TCM syndrome differentiation.TCM syndrome-based analysis of musculoskeletal ultrasound findings of 28 joints in RA patients provide evidence for the treatment of this disease according to syndrome differentiation.Objective　To perform a TCM syndrome-based analysis of musculoskeletal ultrasound findings of 28 joints in RA patients，so as to provide a basis for incorporating musculoskeletal ultrasonography into TCM syndrome differentiation system of RA.Methods　From April 2017 to April 2018，120 inpatients and outpatients were selected from Department of TCM Rheumatology，China-Japan Friendship Hospital，and were divided into 4 commonly seen syndromes defined in Guidelines for Clinical Research of New TCM Drugs.Clinical and laboratory data were collected，including age，sex，course of RA，C-reactive protein（CRP），erythrocyte sedimentation rate（ESR），anti-cyclic citrullinated peptide（ACPA），rheumatoid factor（RF）（since anti-ACPA and RF were exponentially increased，it is convenient to process data using ln（ACPA+1）and ln（RF+1）for data statistics），28-tender joint count（TJC28），28-swollen joint count（SJC28），self-rated general health（GH）score，and Disease Activity Score 28（DAS28）．Findings of musculoskeletal ultrasound of 28 joints were also obtained，including synovitis joint count，synovitis score，Power Doppler（PD）joint count，PD score，and bone erosion count.Results　For the TCM syndromes of 120 patients，there were 42 cases of dampness-heat obstruction syndrome，32 cases of deficiency of liver and kidney syndrome，25 cases of cold-dampness obstruction syndrome，and 21 cases of phlegm-stasis obstruction syndrome.The average RA course of patients with deficiency of liver and kidney syndrome was longer than that of those with dampness-heat obstruction syndrome or phlegm-stasis obstruction syndrome（P<0.05）．The average levels of CRP，ESR，ln（RF+1），SJC28，self-rated GH score，DAS28 of patients with dampness-heat obstruction were higher than those of other three groups（P<0.05）．The average TJC28 of patients with dampness-heat obstruction was more than that of those with cold-dampness obstruction or phlegm-stasis obstruction（P<0.05）．Both average synovitis joint count and synovitis score of patients with dampness-heat obstruction and those with deficiency of liver and kidney were larger than those of patients with cold-dampness obstruction and those with phlegm-stasis obstruction（P<0.05）．Patients with dampness-heat obstruction showed greater average PD joint count and PD score compared with other three groups（P<0.05）．The average bone erosion count of patients with dampness-heat obstruction was less than that of those with deficiency of liver and kidney，but greater than that of those with cold-dampness obstruction（P<0.05）．The average bone erosion count of patients with deficiency of liver and kidney was greater than that of those with cold-dampness obstruction or phlegm-stasis obstruction（P<0.05）．Conclusion　Laboratory and clinical parameters are closely related to the TCM syndrome in RA patients.In particular，dampness-heat obstruction syndrome is associated with high RA disease activity.Moreover，TCM syndrome has a certain correlation with the musculoskeletal ultrasound findings of 28 joints in RA patients.The dampness-heat obstruction syndrome is closely related to synovitis and PD，while the deficiency of liver and kidney syndrome is accompanied by more bone erosion joints.

Key words: Arthritis, rheumatoid；Symptom complex；Ultrasonography；Musculoskeletal system

摘要： 背景　既往研究表明，不同中医证候类风湿关节炎（RA）患者实验室检查、影像学检查等临床指标具有一定的差异，同时临床指标能够为中医辨证提供依据。而探究不同中医证候RA患者28关节肌肉骨骼超声表现的差异，可为客观化RA的辨证论治提供依据。目的　分析不同中医证候RA患者28关节肌肉骨骼超声表现差异，为进一步将肌肉骨骼超声纳入RA中医辨证体系提供依据。方法　选取2017年4月—2018年4月在中日友好医院中医风湿病科住院及于门诊就诊的RA患者120例为研究对象。参照《中药新药临床研究指导原则》将患者分为湿热痹阻证、肝肾亏虚证、寒湿痹阻证、痰瘀痹阻证4大临床常见证候类型。收集患者性别、年龄、病程、C反应蛋白（CRP）、红细胞沉降率（ESR）、抗环瓜氨酸多肽抗体（ACPA）、类风湿因子（RF）〔由于ACPA与RF是呈指数级进行增加的，为处理数据方便本研究使用ln（ACPA+1）及ln（RF+1）进行数据统计〕，记录28关节压痛关节数目（TJC28）、28关节肿胀关节数目（SJC28）及一般情况（GH）自我评估得分，计算28关节疾病活动度（DAS28）。对患者行28关节肌肉骨骼超声检查，记录其滑膜炎关节数、滑膜炎积分、多普勒血流信号（PD）关节数、PD积分、骨侵蚀关节数。结果　120例患者中医证候辨证分型：湿热痹阻证42例、肝肾亏虚证32例、寒湿痹阻证25例、痰瘀痹阻证21例。肝肾亏虚证患者病程长于湿热痹阻证、痰瘀痹阻证患者（P<0.05）；肝肾亏虚证、寒湿痹阻证、痰瘀痹阻证患者CRP、ESR、ln（RF+1）、SJC28、GH自我评估得分、DAS28低于湿热痹阻证患者（P<0.05）；寒湿痹阻证、痰瘀痹阻证患者TJC28低于湿热痹阻证患者（P<0.05）。湿热痹阻证、肝肾亏虚证患者滑膜炎关节数、滑膜炎积分大于寒湿痹阻证、痰瘀痹阻证患者（P<0.05）；湿热痹阻证患者PD关节数、PD积分大于肝肾亏虚证、寒湿痹阻证、痰瘀痹阻证患者（P<0.05）；湿热痹阻证患者骨侵蚀关节数小于肝肾亏虚证患者，大于寒湿痹阻证患者（P<0.05）；肝肾亏虚证患者骨侵蚀关节数大于寒湿痹阻证、痰瘀痹阻证患者（P<0.05）。结论　RA的临床指标与中医证候具有密切关联，其中湿热痹阻证患者处于较高的疾病活动状态。同时中医证候与RA患者28关节肌肉骨骼超声下表现亦有一定的关联，湿热痹阻证与滑膜炎及PD密切相关，而肝肾亏虚证伴随着较多的骨侵蚀关节数。

关键词: 关节炎, 类风湿；证候；超声检查；肌肉骨骼系统