Clinical observation of warm needling moxibustion for rheumatoid arthritis

Lin Bing-bin (林兵賓)

Acupuncture and Tuina Department, Lanxi Hospital of Chinese Medicine, Zhejiang 321100, China

Clinical observation of warm needling moxibustion for rheumatoid arthritis

Lin Bing-bin (林兵賓)

Acupuncture and Tuina Department, Lanxi Hospital of Chinese Medicine, Zhejiang 321100, China

Objective:To observe the clinical efficacy of warm needling moxibustion at points on the back in treating rheumatoid arthritis (RA).

Methods:Sixty RA patients were randomized into two groups by the random number table, 30 in each group. The observation group was intervened by warm needling moxibustion at the points from the Governor Vessel on the back and Jiaji (EX-B 2) points, while the control group was by regular acupuncture.

Results:After intervention, the morning stiffness, joint pain index, joint swelling index and erythrocyte sedimentation rate (ESR) were significantly improved in both groups (P＜0.01); the inter-group difference was also statistically significant (P＜0.05). The total effective rate was 93.3% in the observation group versus 76.6% in the control group, and the difference was statistically significant (P＜0.01).

Conclusion:Warm needling moxibustion at points from the Governor Vessel on the back and Jiaji (EX-B 2) points can produce a higher efficacy than regular acupuncture in treating RA.

Arthritis, Rheumatoid; Warm needling Therapy; Acupuncture-moxibustion Therapy; Moxibustion Therapy; Point, Jiaji (EX-B 2); Governor Vessel

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disorder that primarily affects peripheral joints. It’s featured by chronic symmetrical polyarthritis, and regarded as a connective tissue disease that leads to destruction of joints through the erosion of cartilage and bone. The arthritis involves inflammation of the synovial membrane[1]. Because of its high deformity and disability rates, RA has become a common refractory disease. So far, there are limited methods in treating RA. Considering the significant adverse effects of long-term administration of Western medications, acupuncture and moxibustion have attracted more and more attention from the medical fields in China and abroad, as they are safe, cost-effective, and have little side effects. During the recent years, there have immerged a large amount of reports about treating RA with acupuncture and moxibustion, including warm needling moxibustion[2], acupoint injection[3], acupoint threadembedding[4], and bee venom acupuncture[5], etc. However, it’s rarely reported to treat RA with warm needling moxibustion at acupoints on the back. To seek an effective treatment protocol for RA, we adopted warm needling moxibustion to points from the Governor Vessel on the back and Jiaji (EX-B 2) points to tonify yang qi and enhance the immunity. The results are reported as follows.

1 Clinical Materials

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria of Western medicine

According to the diagnostic criteria of RA stipulated by American College of Rheumatology (ACR) in 1987[6]: morning stiffness ≥1 h and disease duration ≥6 weeks; swelling joints ≥3 and lasting for at least 6 weeks; swelling of wrist joints, metacarpophalangealjoints, and proximal interphalangeal joints ≥6 weeks; symmetric swelling joints ≥6 weeks; subcutaneous nodules; radiographic changes of the hand (at least osteoporosis and joint space narrowing); rheumatoid factors positive. RA can be confirmed when 4 of the above 7 items are met.

1.1.2 Diagnostic criteria of Chinese medicine

They are by referring the diagnostic criteria of joint Bi-impediment syndrome from the Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7]: localized pain and swelling in joints, morning stiffness that affects movement, aggravated by cold, and aversion to cold in the affected areas.

1.2 Inclusion criteria

Conforming to the above diagnostic criteria of Western and Chinese medicine; age between 20 and 65 years old; willing to participate in the study and having signed the informed consent form.

1.3 Exclusion criteria

Those who have been using immunosuppressants, Penicillamine, Chloroquine, or gold preparations for a long time; pregnant women or women during lactation period; those who with severe disorders of liver, kidney, lung, or cardio-cerebrovasucular diseases; having a history of serious drug allergy.

1.4 Statistical method

The SPSS 11.0 version statistical software was used for data processing. The measurement data were expressed by mean ± standard deviation analyzed by t-test; the enumeration data were analyzed by Chi-square test. A P value ＜0.05 presents a statistical significance

1.5 General data

Totally 60 RA patients were enrolled from the outpatient of our hospital. The subjects were numbered according to their visiting sequence and then randomized into an observation group and a control group by using the random number table, 30 patients in each group. In the observation group, the age range was 21-65 years old; in the control group, the age range was 20-63 years old. The statistical analyses showed that there were no significant differences in comparing data of gender, age, and disease duration (P＞0.05), indicating that the comparability (Table 1).

Table 1. Between-group comparison of general data (case)

2 Treatment Methods

2.1 Observation group

2.1.1 Points

Major points: Dazhui (GV 14), Shendao (GV 11), Zhiyang (GV 9), Mingmen (GV 4), and Jiaji (EX-B 2) points.

Adjunct points: Baihui (GV 20), bilateral Fengchi (GB 20), and Jianjing (GV 21).

2.1.2 Methods

The patient was seated, straddling a straight chair, with hands rest on the back of the chair. After sterilization, filiform needles of 0.25 mm in diameter and 40 mm in length were used to perpendicularly insert into Dazhui (GV 14), Shendao (GV 11), Zhiyang (GV 9), and Mingmen (GV 4) by 25 mm. Afterwards, Jiaji (EX-B 2) points (0.5 cun away from T1, T3, T5, T7, T11, L1, and L3) were punctured with the needle tip towards the spine by an angle of 45°. When needling qi was obtained, Baihui (GV 20) was applied with even reinforcing-reducing manipulation. Bilateral Fengchi (GB 20) and Jianjing (GB 21) were punctured by 25 mm. When needling qi was obtained, 6-8 points were selected crosswise from the major points to receive warm needling moxibustion, i.e. T1, T5, T9, and L1Jiaji (EX-B 2) points were selected from the left side, then T3, T7, T11, and L3Jiaji (EX-B 2) points would be selected from the right side. A moxa roll of 1.5 cm in length was placed onto the handle of the needle and ignited from the bottom. It usually took about 15 min to burn out one segment of moxa, which would be replaced by another one. Each point was treated with two segments.

2.2 Control group

2.2.1 Points

Points selection by syndrome differentiation: For Bi-impediment syndrome due to wind, Geshu (BL 17) and Xuehai (SP 10) were selected; for Bi-impediment syndrome due to cold, Shenshu (BL 23) and Guanyuan (CV 4) were selected; for Bi-impediment syndrome due to damp, Pishu (BL 20) and Yinlingquan (SP 9) were selected.

Topical points selection: The points were selected depending on the affected joints including Jianzhen (SI 9), Quchi (LI 11), Waiguan (te 5), Yangxi (LI 5), Baixie (EX-UE 9), Xuehai (SP 10), Dubi (ST 35), Zusanli (ST 36), Kunlun (BL 60), Zhaohai (KI 6), Bafeng (EX-LE 10), and Ashi points around the affected joints.

The above points were selected on both sides.

2.2.2 Needling methods

Filiform needles of 0.25 mm in diameter and 40 mm in length were used for acupuncture treatment after standard sterilization with even reinforcing-reducing manipulation.

For both groups, the needles were retained for 30-40 min, 10 d as a treatment course, 3 courses in total with an interval of a week between two courses.

3 Therapeutic Efficacy

3.1 Measurements

The two groups were evaluated before and after intervention. According to the diagnostic criteria of RA stipulated by the ACR in 1987[6], the following items were estimated: joint swelling index (sum of the swelling degree of the joints), joint tender index (sum of the tender degree of the joints), and morning stiffness duration. The erythrocyte sedimentation rate (ESR) was also detected before and after intervention.

3.2 Criteria of therapeutic efficacy

The Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7]were referred.

Markedly effective: Symptoms were gone, swelling and pain were relieved from the affected joints, the joint function was restored normal, and the laboratory examinations showed normal.

Improved: Symptoms were reduced, the swelling and pain of joints were reduced, the function of joints was improved, and the laboratory examinations also showed improvement.

Invalid: Symptoms still existed, the function of the joints was not improved and the laboratory examinations didn’t show improvement.

3.3 Treatment result

3.3.1 Comparison of symptoms and examinations

In the observation group, the morning stiffness duration, joint tender index, joint swelling index, and ESR were significantly improved after the intervention (P＜0.01). After treatment, there were significant differences in comparing the morning stiffness duration, joint tender index, joint swelling index, and ESR between the two groups (P＜0.05), (Table 2).

Table 2. Comparison of symptom score and ESR

Table 2. Comparison of symptom score and ESR

Note: Compared with pre-treatment result in the same group, 1) P＜0.01; com pared with the control group after intervention, 2) P＜0.05

Group n Time Morning stiffness (h)Joint tender index Joint swelling index ESR (mm/h) Observation 30 Before treatment 1.5±0.54 9.7±0.45 6.8±0.51 37.05±11.26 After treatment 0.2±0.121)2)2.5±0.471)2)2.6±0.621)2)10.35±5.081)2)Control 30 Before treatment 1.6±0.41 9.2±0.47 6.6±0.56 38.58±9.05 After treatment 0.6±0.171)4.3±0.511)4.45±0.521)29.10±12.31)

3.3.2 Comparison of therapeutic efficacy

The total effective rate was 93.3% in the observation group versus 76.6% in the control group, and the difference was statistically significant according to Chi-square test (P＜0.01), indicating that the therapeutic efficacy of the observation group is higher than that of the control group (Table 3).

Table 3. Comparison of clinical efficacy (case)

4 Discussion

RA is a chronic systemic disease of unknown etiology. The major symptoms are persistent pain, swelling, deformity, and impaired function of the affected joints. If it’s not treated properly, RA will lead to joint deformity which may seriously affect daily life. Western medicine treats RA majorly by relieving pain. In traditional Chinese medicine, RA falls under the scope of joint Bi-impediment and it’s caused by deficiency in the root and excess in the manifestations. The deficient healthy qi should be the key factor in the development of this disease. When the deficient healthy qi fails to protect the body from invasion of external pathogens, the pathogens such as wind, cold, and damp will intrude and block meridians, tendons and bones, subsequently leading to stagnation in blood vessels, accumulation of body fluids, blocked Ying-Nutrient and Wei-Defensive qi, phlegm and stasis, and thus there occurs RA. The pathogenic factors of RA can be summarized to be deficiency, pathogen, and stagnation. Therefore, RA should be treated by tonifying the healthy qi to defend the external pathogens or to expel the contracted pathogens.

The Governor Vessel is the sea of the yang meridians, i.e. the gathering place of the yang meridians. It functions to regulate the general yang qi and activate the body function. The Governor Vessel is closely related to the kidney, brain, and marrow, and directly or indirectly associated with Zang-fu organs and meridians. Therefore, stimulating the points from the Governor Vessel can modulate the qi-blood of all meridians and the function of Zang-fu organs[8]. Baihui (GV 20), Dazhui (GV 14), Shendao (GV 11), Zhiyang (GV 9), andMingmen (GV 4) are where the yang qi of the Governor Vessel accumulates. Baihui (GV 20) works to enhance yang qi; Dazhui (GV 14) is the crossing point of the hand and foot yang meridians with the Governor Vessel, and it can reinforce yang qi to expel cold and regulate the general yang qi; Shendao (GV 11) tonifies yang qi and calms mind; Zhiyang (GV 9) supplements yang qi of the heart and lung and also tonifies qi and blood; Mingmen (GV 4) works to strengthen kidney yang, and cultivate the primordial.

Jiaji (EX-B 2) points are located in between the Governor Vessel and Bladder Meridian of Foot Taiyang, and connected with Zang-fu organs, brain, and marrow via meridians. According to the Western medicine, the distribution of Jiaji (EX-B 2) points is extremely related to the spinal nerves. The posterior branches of spinal nerves run through this group of points, which should be the major neurophysiological foundation of the action of Jiaji (EX-B 2) points. Acupuncture at Jiaji (EX-B 2) points does not only unblock and regulate the qi-blood of meridians, but also modulate the sensory and motor nerves[8-10]. Fengchi (GB 20) is the crossing point of the Meridian of Foot Shaoyang and Yang Link Vessel, and works to dispel wind and refresh mind.

When moxa is burning, the heat can be induced into skins, muscles, tendons, and bones via the acupuncture needles, working to dilate capillaries, accelerate the topical circulation of blood and lymph, promote metabolism, for dispelling cold and damp, supplementing qi and blood, and activating blood circulation to relieve impediment. Besides, moxibustion can trigger the production of heat shock protein, and the heat shock protein further evokes the immune system, which is believed to be a significant action mechanism of moxibustion[11-12]. Warm needling therapy combines the needling and moxibustion, producing both the effects of acupuncture and moxibustion to warm meridians and expel cold[13-15].

The current study shows that warm needling moxibustion at the back points can significantly relieve the symptoms of RA, enhance the immune function, and it can produce a higher therapeutic efficacy than regular acupuncture.

Conflict of Interest

There was no conflict of interest in this article.

Statement of Informed Consent

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

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Translator: Hong Jue (洪玨)

溫針灸治療類風(fēng)濕性關(guān)節(jié)炎臨床觀察

目的：觀察溫針灸背部腧穴對(duì)類風(fēng)濕性關(guān)節(jié)炎(rheumatoid arthritis, RA)的臨床療效。方法：將60例RA患者按隨機(jī)數(shù)字表隨機(jī)分為2組，每組30例。觀察組采用溫針灸背部督脈穴及夾脊穴治療，對(duì)照組采用常規(guī)針刺治療。結(jié)果：治療后，兩組患者晨僵、關(guān)節(jié)疼痛指數(shù)、關(guān)節(jié)腫脹指數(shù)及紅細(xì)胞沉降率(erythrocyte sedimentation rate, ESR)都有明顯改善，與本組治療前差異均有統(tǒng)計(jì)學(xué)意義(P＜0.01)；觀察組與對(duì)照組亦有統(tǒng)計(jì)學(xué)差異(P＜0.05)。觀察組總有效率為93.3%，對(duì)照組為76.6%，兩組總有效率差異有統(tǒng)計(jì)學(xué)意義(P＜0.01)。結(jié)論：溫針灸背部督脈穴及夾脊穴治療RA的療效優(yōu)于常規(guī)針刺治療。

關(guān)節(jié)炎,類風(fēng)濕; 溫針療法; 針灸療法; 灸法; 穴,夾脊; 督脈

R246.2 【

】A

30 August 2014/Accepted: 15 October 2014

Author: Lin Bing-bin, bachelor, associate chief physician of traditional Chinese medicine.

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