Assessment of damp-heat impeding syndrome in rheumatoid arthritis: development and validation of a diagnostic scale

doi:10.19852/j.cnki.jtcm.2026.05.021

Abstract

Abstract:

OBJECTIVE: To develop a novel quantitative scale for Damp-Heat Impeding Syndrome (DHIS) in rheumatoid arthritis (RA) and to enhance diagnostic reliability through a combined consensus- and data-driven approach grounded in Traditional Chinese Medicine (TCM) principles, thereby addressing the limitations of existing expert-consensus-based tools.

METHODS: Scale items were selected from the China Rheumatoid Arthritis Registry of Patients with Chinese Medicine (CERTAIN) database, a prospective, multicenter, observational disease registry for RA patients receiving TCM treatment, and refined through expert consultation. Based on TCM theory and clinical guidance, items were categorized into three domains: disease-related, heat-related, and dampness-related. A two-stage statistical method was applied to estimate item scores and determine cutoff values for each domain. According to TCM diagnostic principles, DHIS is identified only when the scores in all three domains exceed their respective thresholds. To enhance clinical applicability, two versions of the scale were developed: one including pulse manifestations and one excluding them.

RESULTS: The dataset was divided based on follow-up time into a development set (n = 6680) and a validation set (n = 3882), both from the CERTAIN database. A DHIS diagnostic scale was developed with two versions: Version 1 included pulse manifestations (11 items), and Version 2 excluded them (10 items). The scale comprised three domains: disease-related, heat-related, and dampness-related. Key symptoms included joint pain as well as tongue and pulse features such as yellow tongue coating and slippery pulse. Secondary symptoms included sticky stool and greasy tongue coating. In the development set, Version 1 achieved a Youden index of 0.83 and sensitivity of 0.89; in the validation set, it achieved 0.78 and 0.86, respectively. Cronbach’s α was 0.78 for Version 1 and 0.75 for Version 2.

CONCLUSIONS: Both versions of the DHIS diagnostic scale demonstrated good internal consistency and strong diagnostic performance, supporting their utility in identifying DHIS among RA patient.

Key words: arthritis, rheumatoid, damp-heat impeding syndrome, diagnostic scale, sensitivity and specificity

LI Yanting, SUN Ao, GONG Xun, TANG Xiaopo, LIU Weixiang, XIA Congmin, WANG Jian, SONG Mengge, PENG Qiuwei, MA Xieli, ZHOU Xiaohua, JIANG Quan. Assessment of damp-heat impeding syndrome in rheumatoid arthritis: development and validation of a diagnostic scale[J]. Journal of Traditional Chinese Medicine, 2026, 46(5): 1286-1294.

Figures/Tables 6

References 30

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Item	Development study (n = 6680)	Validation study (n = 3882)
Age (years, $\bar{x}$ ±s)	55.6±13.3	54.3±12.5
Gender (female, %)	84.5	84.4
BMI (kg/m², $\bar{x}$ ±s)	22.7±3.2	22.6±3.3
Disease duration (months, $\bar{x}$ ±s)	93.6±101.9	85.2±97.4
DAS28-CRP ($\bar{x}$ ±s)	4.8±1.5	4.7±1.6
DAS28-ESR ($\bar{x}$ ±s)	5.3±1.6	5.28±1.7

Item	Development study (n = 6680)	Validation study (n = 3882)
Age (years, $\bar{x}$ ±s)	55.6±13.3	54.3±12.5
Gender (female, %)	84.5	84.4
BMI (kg/m², $\bar{x}$ ±s)	22.7±3.2	22.6±3.3
Disease duration (months, $\bar{x}$ ±s)	93.6±101.9	85.2±97.4
DAS28-CRP ($\bar{x}$ ±s)	4.8±1.5	4.7±1.6
DAS28-ESR ($\bar{x}$ ±s)	5.3±1.6	5.28±1.7

Item	Approval rating (%)
1. Joint pain	95.62
2. Joint swelling	97.81
3. Morning joint stiffness	95.62
4. Swelling, warmth to the touch, and joint pain, including both pressure pain and self-perceived discomfort	97.08
5. Sensation of heat upon touching the joint or a subjective feeling of warmth	94.89
6. Redness of the skin in the area surrounding the joint	91.97
7. Restless and agitated	83.21
8. Feeling thirsty but not wanting to drink	83.94
9. Sticky stool	87.59
10. Burning sensation during urination	78.10
11. Urine with a yellow coloration	94.16
12. Reddish tongue	93.43
13. Enlarged tongue shape	74.45
14. Thick tongue coating	91.24
15. Greasy tongue coating	96.35
16. Yellow tongue coating	97.08
17. Rapid pulse	89.78
18. Slippery pulse	93.43
19. Increased anti-CCP antibody concentration	85.40
20. Elevated RF level	84.47
21. Elevated platelet level	74.45
22. Elevated CRP level	94.89
23. Elevated ESR level	94.16

Item	Approval rating (%)
1. Joint pain	95.62
2. Joint swelling	97.81
3. Morning joint stiffness	95.62
4. Swelling, warmth to the touch, and joint pain, including both pressure pain and self-perceived discomfort	97.08
5. Sensation of heat upon touching the joint or a subjective feeling of warmth	94.89
6. Redness of the skin in the area surrounding the joint	91.97
7. Restless and agitated	83.21
8. Feeling thirsty but not wanting to drink	83.94
9. Sticky stool	87.59
10. Burning sensation during urination	78.10
11. Urine with a yellow coloration	94.16
12. Reddish tongue	93.43
13. Enlarged tongue shape	74.45
14. Thick tongue coating	91.24
15. Greasy tongue coating	96.35
16. Yellow tongue coating	97.08
17. Rapid pulse	89.78
18. Slippery pulse	93.43
19. Increased anti-CCP antibody concentration	85.40
20. Elevated RF level	84.47
21. Elevated platelet level	74.45
22. Elevated CRP level	94.89
23. Elevated ESR level	94.16

Domain	Item	Item score	Cut-off point
	Swelling, warmth to the touch, and joint pain, including both pressure pain and self-perceived discomfort	-	-
A: Disease-related domain		-	1
	Joint pain (including pressure pain and conscious pain)	1	-
	Joint swelling	1	-
B: Heat domain		-	1
	Sensation of heat upon touching the joint or a subjective feeling of warmth	1	-
	Redness of the skin in the area surrounding the joint	1	-
	Yellow tongue coating	1	-
C: Dampness domain		-	2
	Sticky stool	1	-
	Thick tongue coating	2	-
	Greasy tongue coating	1	-
	Feeling thirsty but not wanting to drink	2	-
	Slippery pulse	2	-

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