Orthopedics and Traumatology Department of Chinese Medicine, Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Changning District, Shanghai, Shanghai 200052, China

ACUPUNCTURE-MOXIBUSTION TECHNIQUES

Observation on Clinical Effects of Acupotomy plus Cupping for Knee Osteoarthritis

Gu Jun-qing, Guo Yan-ming, Liang Yong-ying

Orthopedics and Traumatology Department of Chinese Medicine, Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Changning District, Shanghai, Shanghai 200052, China

Author:Gu Jun-qing, bachelor, associate chief physician.

E-mail: 13020117089@163.com

Objective: To observe the clinical effect of acupotomy plus cupping for knee osteoarthritis (KOA).

Methods: Sixty cases with KOA were randomly divided into a treatment group and a control group, 30 cases in each group. The patients in the treatment group were given acupotomy and cupping, while the patients in the control group were given injection of Sodium Hyaluronate. The index of severity for osteoarthritis (ISOA), the change of the effusion of knee joint and clinical effects were observed after treatment.

Results: The total effective rate was respectively 96.7% in the treatment group and 66.7% in the control group. The difference in the clinical effects between the two groups was statistically significant (P＜0.05). After treatment, ISOA scores and scores of knee effusion in the two groups were remarkably reduced than those before treatment (P＜0.05). The changes of the scores of the two indexes were statistically significant (bothP＜0.05).

Conclusion: Acupotomy plus cupping is better than injection of Sodium Hyaluronate in treatment of KOA.

Osteoarthritis, Knee; Small Knife Needle; Cupping Therapy; Pain Measurement

Knee osteoarthritis (KOA) is a common disease among the middle-aged and the old people. The recent epidemiological survey has shown that the morbidity rate of KOA was 33.3% in the residents above 40 years old, more women than men[1]. In recent years, we treated KOA with acupotomy plus cupping method, in comparison with the therapeutic effect of injection of Sodium Hyaluronate into the articular cavity. Now, the results are reported as follows.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnosis of KOA was based upon the relevant diagnostic criteria stipulated by American College of Rheumatology[2]. Knee pain in the majority of time during the recent 30 d; with crepitus; morning stiffness＜30 min every day; age ≥38 years old; bone enlargement shown in the examination of the knee joint. KOA could be diagnosed if the first four items or the first, second and fifth item or the first, fourth and fifth item were matched.

1.2 Inclusion criteria

In conformity with the above diagnostic criteria; with the age ranging from 38-75 years old; with Kellgren-Lawrence grading scale of knee joint X-ray plain film in Grade I-II[3](Grade I: doubtful narrowing of joint space and possible osteophytes; Grade II: definite osteophytes, doubtful narrowing of joint space; Grade III: moderate osteophytes, definite narrowing of joint space and some sclerosis); having signed the informed consent and willing to cooperate.

1.3 Exclusion criteria

Those accompanied by obvious organic diseases in the heart, lung, liver and kidney; those with the history of fainting needle and/or anesthetic allergy, those with coagulation dysfunction; those with bony or fibrous ankylosis of the knee joint shown in X-ray film; those with mental disorders; those quitted voluntarily during the treatment; and those not suitable for acupotomy due to other reasons.

1.4 Rejection and drop-out criteria

Rejection of criteria: the cases not in conformity with the inclusion criteria but enrolled by mistake, or in conformity with the inclusion criteria but not treated after the recruitment were rejected.

Drop-out criteria: the cases in conformity with the inclusion criteria but unable to finish the study due to certain reason were the drop-out cases. If adverse reaction happened, those would be listed in adverse reaction. Those terminated the treatment at the treatment time less than two weeks were judged as drop-out cases. Those cases dropped out voluntarily because of invalid effect after the treatment for two weeks were included in the analysis of the therapeutic effects.

1.5 Statistical methods

All data were processed by SPSS 18.0 version software for statistical analysis. The accounting materials were expressed by mean ± standard deviation, and One-way analysis of variance ort-test was adopted.Riditanalysis was adopted for grading materials.P＜0.05 indicated the statistical significance.

1.6 General data

Totally, 60 cases with KOA were recruited from the inpatient or outpatient of our hospital from January of 2012 to September of 2013. They were randomly divided into a treatment group and a control group by the digital envelope, 30 cases in each group. By statistical management, the difference in the gender formation between the two groups was not statistically significant. The data of the accounting materials in the two groups were in the normal distribution and the variance was even. Byt-test, the average age and average duration between the two groups were not statistically different (allP＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Therapeutic Methods

2.1 Treatment group

The patient took a supine position with the knee flexed to 60°. First, Ashi point was detected around the knee joint, i.e. tenderness at the joint capsule, medial and lateral patellar retinaculum of the knee, and medial and lateral collateral ligament of the knee. Tenderness was marked as the spot for needle insertion. After routine disinfection, 1% Lidocaine was used at every inserting spot for surface anesthesia, and No.4 needle knife of Han-zhang Model I was inserted perpendicularly into the skin. When the needle knife was resisted under the skin, first the needle knife was used to strip off horizontally and then to cut by lifting and thrusting action vertically for 2-3 times, till the patient felt sore and distension, and then the needle reached the bone surface. After relaxation, cups were applied to the needle hole and retained for 5 min. After the cups were taken off, the needle holes were covered with aseptic gauze. Three days after the treatment, the functional training of the quadriceps muscle of thigh was cooperated.

2.2 Control group

First, the routine puncture was given to the knee joint cavity for the patients in the control group. After the patient took a supine position, with the lower limb straightened, No.7 syringe was inserted into the joint capsule from the lateral and superior part of the patella, inward and inferiorly on the lateral side of the quadriceps muscle of thigh, to extract the effusion from the joint cavity. Then, 2 mL Sodium Hyaluronatewas injected (produced by Shandong Bausch & Lomb Freda Pharmaceutics Co., Ltd.). One day after the treatment, the functional training of the quadriceps muscle of thigh was combined.

In two groups, the treatment was given once every week, five sessions made one course, and totally one course of the treatment was given. The reason why the therapeutic effects were observed three months after the treatment in this study was that osteoarthritis is a chronic degenerative change, the improvement of mid- and long-term therapeutic effect is of far more clinical value than the improvement of the instant therapeutic effect. In addition, acupotomy is a micro-invasive treatment, and certain post-operative reaction would take place several days and even one to two weeks after the treatment. The reaction would influence the judgment of the real therapeutic effect.

3 Observation of Therapeutic Effects

3.1 Observed indexes

3.1.1 Index of severity for osteoarthritis (ISOA)[4]

ISOA was determined before the treatment and three months after the treatment. This scale includes the six items for assessment of rest pain, motion pain, tenderness, tumefaction, morning stiffness and walking ability of the knee. The total scores are 23 points. The higher the scores are, the more severe the condition of arthritis will be.

3.1.2 Assessment of knee joint effusion

Self-designed ultrasonic diagnostic assessing method of knee joint effusion was used to assess the severity of knee joint effusion before the treatment and three months after the treatment.

3 points: Severe effusion. B-mode ultrasound examination showed that the diameter of non-echo area for suprapatellar bursa effusion ≥10 mm.

2 points: Medium effusion. B-mode ultrasound examination showed that the diameter of non-echo area for suprapatellar bursa effusion ≥5 mm, but＜10 mm.

1 point: Mild effusion. B-mode ultrasound examination showed that the diameter of non-echo area for suprapatellar bursa effusion ≥2 mm, but＜5 mm.

0 point: No effusion. B-mode ultrasound examination showed that the diameter of non-echo area for suprapatellar bursa effusion ＜2 mm.

3.2 Criteria of therapeutic effects

The criteria of the therapeutic effects in this study were stipulated based upon the relevant criteria ofDiagnosis and Treatment Scheme for Traditional Chinese Medicine Clinic[5].

Clinical cure: Knee pain and swelling disappeared completely, without uncomfortable sensation in walking and climbing the stairs.

Remarkable effect: No knee pain or swelling at rest, pain in motion occasionally, no pain in walking, without impact on work and life.

Effect: Knee pain appeared sometimes, still slight pain in walking, slight difficulty climbing the stairs, with limited motion of the knee.

Failure: No obvious improvement of the knee pain, swelling and pain in motion.

3.3 Results

3.3.1 Clinical effects

The total effective rate was 96.7% and 66.7% respectively in the treatment group and the control group. The difference in the clinical effects between the two groups was statistically significant (P＜0.05), indicating that the therapeutic effect was better in the treatment group than that in the control group (Table 2).

3.3.2 Change of ISOA

The differences of ISOA scores before the treatment between the two groups were not statistically significant (P＞0.05). After treatment, ISOA scores in the two groups were all significantly different from those of the same group (P＜0.05). In comparison of the variance values before and after treatment between the two groups, the difference was statistically significant (P＜0.05), indicating that the improvement of the knee joint symptoms was better in the treatment group than in the control group (Table 3).

Table 2. Comparison of clinical effect between the two groups (case)

3.3.3 Change of score of knee joint effusion

Before the treatment, the differences in effusion scores between the two groups were not statistically significant (P＞0.05). After treatment, the scores of knee joint effusion in the two groups were all significantly different from that of the same group(P＜0.05). In comparison of the variance values after treatment between the two groups, the differences were statistically significant (P＜0.05), indicating that the improvement of the knee joint effusion was better in the treatment group than in the control group (Table 4).

Table 3. Comparison of ISOA change between the two broups (point)

Table 3. Comparison of ISOA change between the two broups (point)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group, 2) P＜0.05

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Table 4. Comparison of score of knee joint effusion between the two groups (point)

Table 4. Comparison of score of knee joint effusion between the two groups (point)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group, 2）P＜0.05

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4 Discussion

KOA is a chronic degeneration or loss of the articular cartilage and bone regeneration at the articular border and under the cartilage. In the early lesion of the cartilage, the balance of stresses of the soft tissues inside and outside the joint is destroyed, and the adhesion of the muscles, ligaments and joint capsule around the joint caused by scars and contracture can further aggravate the deformity of the joint and loss of the functions[6-7]. The relationship between the factors of soft tissue injury and myodynamia and osteoarthritis has been increasingly emphasized[8].

KOA belongs to the scope of bone Bi-Impediment syndrome in traditional Chinese medicine[9-12]. Its occurrence is closely related to contraction of pathogenic wind, cold and dampness and obstruction of meridians by blood stasis. As a micro-invasion therapy, acupotomy can be used to relax and cut the soft tissues of spasmodic muscle fiber and ligament and joint capsule, in certain effects to relieve the internal high pressure of the joint capsule and surrounding soft tissues, eliminate tumefaction, change the force line around the joint, and prevent the aggravation of the deformity of the knee joint[13-14]. In combination with the cupping method, the suction pressure produced by cupping method can suck out the stagnant blood and effusion from the needle hole, in the obvious effects to relieve the pressure of the local tissues and reduce the level of pain-inducing factor in the local lesion.

It has been proven by this study that acupotomy plus cupping method is better than injection of sodium hyaluronate into the joint cavity in the therapeutic effect for KOA, and is small in incision, less suffering to the patients, and needs to be popularized in the clinical application.

Conflict of Interest

The authors declared that there was no conflict of interest in this article.

Acknowledgments

This work was supported by Shanghai Training Plan for Outstanding Young Clinical Talents of Traditional Chinese Medicine (No. ZYSNXD011-RC-XLXX-20110006).

Statement of Informed Consent

All of the patients in the study signed the informed consent.

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Translator:Huang Guo-qi

R246.2

: A

Date:June 26, 2014