Clinical observation of kidney tonifying and collateral tonifying acupuncture combined with thermosensitive moxibustion in the treatment of knee osteoarthritis and its effect on TRACP and CTX-I

MAO Zhen, JIANG Run, ZHANG Hong-xin

1. Wuhan Caidian District People’s Hospital, Rehabilitation Pain Department, Wuhan 430061,China

2. Wuhan Caidian District People’s Hospital, Department of Rheumatology, Wuhan 430061,China

3. Jiang han university,Wuhan 430030,China

Keywords:Kidney tonifying and collateral tonifying acupuncture Thermal moxibustion Knee osteoarthritis Bone metabolism index

ABSTRACT

1. Introduction

Knee Osteoarthritis (KOA) is a kind of clinical disease with high incidence, which is mostly seen in elderly patients. The clinical manifestations are articular cartilage degeneration and bone hyperplasia, etc. The early symptoms of the disease are mainly pain,and with the progress of the disease, there will be joint deformity,spring and other dysfunction in the later stage[1].At present, nonsteroidal anti-inflammatory drugs and minimally invasive surgery are often given clinically, but most of them can only relieve symptoms, and the fundamental problems of patients have not been solved. A large number of epidemiology shows that the incidence of knee osteoarthritis in China is 30%, among which the elderly account for 62%[2].During the onset of knee osteoarthritis,knee joint pain is obvious and walking is difficult, which brings great inconvenience to patients' life. How to effectively treat knee osteoarthritis and reduce its incidence has become a hotspot of current research. In the previous study, we found that acupuncture at"Tongmin point" could relieve knee joint pain symptoms and play an effect of relieving pain by clearing collateral[3,4].Numerous studies have shown that[5],The cold coagulation syndrome of middle Yang deficiency in patients with knee osteoarthritis is high certification type. To this, should be in order to warm Yang tongluo law, another disease patients for elderly patients, not blindly warm, and should take into account tonifying kidney, kidney essence is sufficient,bones and muscles to strong. In the early stage, the symptoms are still not obvious, but should be from the perspective of consolidating the root and cultivating yuan, to protect the human body's vital qi. Therefore, this study adopted the acupuncture method of tonifying kidney and clearing collasals combined with heat sensitive moxibustion to observe the effect of its treatment on Yang deficiency and cold coagulation type knee osteoarthritis.Both TRACP and CTX-I reflect the related indicators of bone metabolism in human body[6,7].Its content is related to the degree of joint degeneration and has high specificity. Based on this objective index, this study made a preliminary discussion on the mechanism of treating knee osteoarthritis by tonifying kidney and clearing collateral acupuncture combined with heat-sensitive moxibustion. The results are reported as follows.

2. Materials and methods

2.1 General Information

A total of 90 patients diagnosed with knee osteoarthritis were enrolled from the department of Rehabilitation, department of Rheumatology and Department of Traditional Chinese Medicine of Caidian District People's Hospital of Wuhan. They were divided into acupuncture group, heat sensitive moxibustion group and routine group with 30 patients in each group. In the acupuncture group, there were 15 males and 15 females, with an average age of(56.25±1.68) years and an average course of disease of (5.82±1.25)years. In the heat sensitive moxibustion group, there were 14 males and 16 females, with an average age of (56.82±1.83) years and an average course of disease of (6.02±1.32) years. In the conventional group, there were 15 males and 15 females, with an average age of(57.06±1.83) years and an average course of disease of (6.21±0.86)years. There was no significant difference in general data among all groups (P ＞0.05). This study was approved by the Research Ethics Committee of Caidian District People's Hospital of Wuhan.

2.2 Diagnostic Criteria

The diagnostic criteria for knee osteoarthritis in the 2018 edition of the Guidelines for The Diagnosis and Treatment of Bone and Joint were used in this study[8].The basic conditions of the patient should have the following characteristics: (1) The patient is over 50 years old and has local knee pain when going up and down stairs or walking, and the disease has recurred in the last 3 months; (2)X-ray of the patient's knee showed narrowing of joint space with hyperosteogeny, etc. (3) When patients move the knee joint, the range of motion of the joint becomes smaller, and some patients even have friction sounds; (4) Patients often have morning stiffness,but each time is less than 30 minutes; (5) Some with joint deformity or enlargement. If (1) + any other 2 points are satisfied, the diagnosis can be made.

2.3 Inclusion Criteria

(1) The patient meets the above diagnostic criteria after X-ray examination; (2) Subjects in this study have not received acupuncture treatment in the past three months; (3) Subjects fully understand this study and are willing to cooperate.

2.4 Exclusion Criteria

(1) The patient had previous serious cardiovascular diseases, such as organic heart disease and malignant arrhythmia; (2) The patient has a history of severe allergic reactions, especially around the knee joint, and a large number of rashes; (3) There was a history of tumor,and the knee pain was caused by tumor metastasis; (4) people with serious mental system diseases, such as severe schizophrenia and major depression; (5) Patients with a history of needle-sickness or intolerance to moxibustion.

2.5 Cases of suspension

(1) The patient had previous serious cardiovascular diseases, such as organic heart disease and malignant arrhythmia; (2) The patient has a history of severe allergic reactions, especially around the knee joint, and a large number of rashes; (3) There was a history of tumor,and the knee pain was caused by tumor metastasis; (4) people with serious mental system diseases, such as severe schizophrenia and major depression; (5) Patients with a history of needle-sickness or intolerance to moxibustion.

2.6 Treatment Methods

2.6.1 Routine group

Methods: Oral drug combined with articular cavity injection

In the conventional group, diclofenac sodium sustained-release tablet (Digen, National drug approval word H10970209) was selected, 0.1 g daily, taken after meals for 4 weeks.

Sodium hyaluronate was injected into the articular cavity.Operation: The patient was supine, and routine skin disinfection was performed. Sodium hyaluronate was extracted 2 mL, and the needle was injected at the lower edge of the patella, and the tip of the needle was injected into the joint cavity. If there was effusion, the fluid was extracted first, and then sodium hyaluronate was slowly injected.

2.6.2 Heat sensitive moxibustion group

Heat sensitive moxibustion was given on the basis of routine group.

The patient was placed in supine position, and mild moxibustion was given around the subjects' bilateral knee joints (Yinlingquan -Yanglingquan - Xuehai - Liangqiu). When there was heat conduction at a certain point, it was a heat sensitive point, and a total of 4 heat sensitive points were selected. Moxibustion was applied at the same place for each treatment. Moxibustion time 20 minutes, once a day,5 times a week, continuous treatment for 4 weeks.

2.6.3 acupuncture group On the basis of heat sensitive moxibustion group, "tonifying kidney and dredging collateral" acupuncture was given.

Acupoint selection: Tongmin Acupoint (bilateral), Taixi acupoint(bilateral)

Methods of operation: (1) Pain-sensitive acupoint exploration:press around the knee joint (Yinlingquan - Yanglingquan - Xuehai- Liangqiu) with the thumb abdomen. If the patient has obvious pain, appropriate marks should be made, and a total of 8 painsensitive acupoints should be selected. (2) Von Frey electronic pain meter (HTC, Life Science) was used to place the instrument horizontally. When each index returned to zero, the probe was used to detect the marked area. When the pain was unbearable, the pain threshold was recorded; (3) After the pain threshold was measured,the patient was given a proper rest, and the same method was used for the second measurement. The average value of the two points was taken at the same point, and the maximum value of the first four points was taken; (4) Acupuncture was performed on the selected 4 pain-sensitive points and Taixi point. After the qi was obtained by acupuncture, the needle was left for 30 minutes, 5 times a week for continuous treatment for 4 weeks.

2.7 Observation of curative effect

2.7.1 Main outcome measures

(1)Visual analog scale (VAS)[9],This scale is used to assess knee pain. The higher the score, the more severe the pain, on a scale of 0 to 10. Assessment was performed before treatment, after treatment,and after a 2-week follow-up.

(2)The JKOM scale developed by The Japanese Orthopaedic Society was used[10,11].This scale consists of five parts: knee pain degree, daily living status, normal activity status, stiffness and health status. Each part is made up of multiple sub-items, and the lower the score, the better the knee function. Assessment was performed before treatment, after treatment, and after 2 weeks of follow-up.

(3)The knee function was assessed by ly-Sholm knee score Scale[12].The scale mainly evaluates the knee function, including walking, joint swelling, knee stability, claudication, etc. The better the knee function, the higher the score. Assessment was performed before treatment, after treatment, and after 2 weeks of follow-up.

2.7.2 Secondary outcome measures

Serum TRACP and CTX-I were measured before and after treatment. 3-5 mL of venous blood was taken from all patients on an empty stomach and placed in a 4℃ refrigerator for 24 h, centrifuged at 3000 r/min for 30 min. The upper serum was taken and stored in a -80 ℃ refrigerator for testing. TRACP and CTX-I levels were determined by ELISA, and were tested twice before and after treatment, strictly according to the kit instructions.

2.8 Efficacy evaluation criteria

According to the curative effect standard of knee osteoarthritis in Guiding Principles for Clinical Research of New Chinese Medicine[13].

① Cure: clinical symptoms and signs score decreased by ＞85%;

② Significant effect: the clinical symptoms and signs were significantly relieved, and the score was reduced by 60%～85%;

③ Effective: the clinical symptoms and signs are slightly relieved,and the score is reduced by 35%～60%;

④ Invalid: the clinical symptoms and signs did not change, and the score decreased ＜35%.

2.9 Statistical processing

All data were analyzed by SPSS 22.0 software. Shapiro-wilk test was used to test the normality of the data. If the data were normal distribution, the mean value difference (±s) was used. For comparison of multiple groups, one-way ANOVA was used. If there were differences between groups, Bonferroni method was used for pairwise comparison. If it does not conform to normal distribution,kruskal-Wallis test is selected. Chi-square test was used for counting data, and P＜0.05 was considered statistically significant.

3. Results

3.1 Comparison of VAS scores at different time points in each group

As can be seen from Table 1, there was no statistically significant difference in VAS score among all groups before treatment (P＞0.05).After treatment, VAS scores in all groups decreased, and the decrease degree in acupuncture group was the most obvious, with statistical significance (P＜0.05). After 2 weeks of follow-up, VAS scores of each group were significantly different (P＜0.05). The results showed that the combination of tonifying kidney and tongluo acupuncture combined with heat sensitive moxibustion could significantly improve the knee pain symptoms of patients with knee osteoarthritis,and its effect was the best.

Table 1 Comparison of VAS scores at different time points in each group (score,n=30,±s)

Table 1 Comparison of VAS scores at different time points in each group (score,n=30,±s)

GroupBefore the treatment After treatment Followed up for 2 weeks Regular group7.65±1.03 4.92±0.85 5.86±1.23 Thermal moxibustion group7.83±1.21 3.85±0.62* 4.62±1.30*Acupuncture group7.90±1.35 2.25±0.74* 3.02±1.23*F 1.5613.2521.32 P 0.3500.0030.000 Note: Compared with the conventional group, *: P＜0.05.

3.2 JKOM total score of each group at different time points was compared

As shown in Table 2, there was no statistically significant difference in total JKOM score among all groups before treatment (P＞0.05).After treatment, the total JKOM score of all groups decreased, and the improvement degree of acupuncture group was the greatest, and the difference between groups was statistically significant (P＜0.05).After 2 weeks of follow-up, the total JKOM score of each group was significantly different (P＜0.05). The results showed that the combination of tonifying kidney and tongluo acupuncture and heat sensitive moxibustion could improve the function of knee joint.

Table 2 Comparison of JKOM scores at different time points in each group(score,n=30,±s)

Table 2 Comparison of JKOM scores at different time points in each group(score,n=30,±s)

Note: Compared with the conventional group, *: P＜0.05.

?GroupBefore the treatment After treatment Followed up for 2 weeks Regular group47.92±1.03 28.38±0.85 30.86±1.23 Thermal moxibustion group 48.31±1.2122.34±1.30*24.62±1.30*Acupuncture group48.14±1.3517.82±0.74*19.02±1.23*F 2.5615.6823.68 P 0.520 0.001 0.000

3.3 Comparison of LY-Sholm knee score at different time points in each group

According to Table 3, there was no significant difference in ly-Sholm knee score among all groups before treatment (P＞0.05).After treatment, ly-Sholm knee score increased in all groups, and the difference between groups was statistically significant (P＜0.05).After 2 weeks of follow-up, the ly-SholM knee score of each group was significantly different (P＜0.05). The results showed that tonifying kidney and clearing collatals acupuncture combined with heat sensitive moxibustion could improve the function of knee joint,and the curative effect was better than conventional therapy.

Table 3 Comparison of Ly sholm scores at different time points in each group(score,n=30,±s)

Table 3 Comparison of Ly sholm scores at different time points in each group(score,n=30,±s)

Note: Compared with the conventional group, *: P＜0.05.

GroupBefore the treatment After treatment Followed up for 2 weeks Regular group53.26±2.35 68.01±2.6860.21±1.08 Thermal moxibustion group 53.65±1.38 72.35±2.01* 68.32±2.21*Acupuncture group53.85±1.57 87.56±2.68* 80.25±2.01*F 2.3216.9818.52 P 0.46 0.001 0.001

3.4 Comparison of serum TRACP and CTX-I contents in each group before and after treatment

According to Table 4, there was no significant difference in serum TRACP and CTX-I contents among all groups before treatment(P＞0.05). After treatment, serum TRACP and CTX-I contents decreased, and the differences between groups were statistically significant (P＜0.05). The results showed that tonifying kidney and tongluo acupuncture combined with heat sensitive moxibustion could regulate serum TRACP and CTX-I and improve bone metabolism.

Table 4 Comparison of the levels of TRACP and CTX-I in serum of each group before and after treatment (pg/mL,n=30,±s)

Table 4 Comparison of the levels of TRACP and CTX-I in serum of each group before and after treatment (pg/mL,n=30,±s)

Note: Compared with the conventional group, *: P＜0.05.

TRACPCTX-I Before the treatment Group After treatment After treatment Before the treatment Regular group 12.68±1.23 9.32±1.03 16.35±2.01 13.25±1.86 Thermal moxibustion group 12.05±1.37 7.98±1.37* 16.82±3.14 11.36±1.46*Acupuncture group 12.53±1.38 6.01±1.42* 16.64±3.65 9.35±1.23*F 3.0117.522.8918.93 P 0.39 0.0010.41 0.001

3.5 Clinical response rate

The total effective rates of acupuncture group, heat sensitive moxibustion group and conventional group were 96.7%, 80% and 66.7%, respectively, and the differences among all groups were statistically significant (P＜0.05).

Table 5 Clinical efficacy of each group(n=30)

4. Discussion

4.1 Clinical treatment status of knee osteoarthritis

Knee osteoarthritis is a common clinical disease, with the increase of age, the incidence of this disease gradually increased[14].The disease belongs to the category of "bone bi" in Traditional Chinese medicine, and its incidence is mainly caused by external factors and internal factors. If it is external factors, it is mostly the invasion of wind cold and damp evil, and the internal factors are mostly the deficiency of qi and blood of the body, and the joint is lost in the cultivation, and the incidence is accumulated over a long period of time[15].Throughout the current clinical, the treatment of this disease from the wind and dehumidification, warm channels and collaterals,although the symptoms of patients are temporarily relieved, but easy to relapse. This study from the concept of "cure the disease must be based on this", using the acupuncture method of tonifying kidney and clearing collaterals, the therapy with the help of the effect of"Tongmin point" clearing collaterals and relieving pain, combined with Taixi, has tonifying kidney essence, regulating Yin and Yang,clearing collaterals and relieving pain. Heat sensitive moxibustion is an improvement of traditional moxibustion. Moxibustion on "heat sensitive point" has better curative effect than conventional therapy.

4.2 Clinical effect of "tonifying kidney and clearing collaterals" acupuncture combined with heat sensitive moxibustion on knee osteoarthritis

Sodium hyaluronate is the main component of synovial fluid of joints, which can protect articular cartilage, reduce bone friction and improve local inflammation in joints. Injection of sodium hyaluronate into the knee cavity can effectively relieve joint pain and improve joint function[16].Diclofenac sodium is a non - steroidal anti - inflammatory drug with anti-inflammatory and analgesic effects[17].Injection of sodium hyaluronate with articular cavity is a common clinical method, so it is the routine treatment in this study.The results of this study showed that after 4 weeks of treatment, the acupuncture group was superior to the heat sensitive moxibustion group and the conventional group in improving VAS score, JKOM total score and Ly-SholM knee joint score. During the 2-week follow-up, the long-term efficacy of acupuncture and moxibustion group was stable, and there was no rebound trend. Compared with the heat-sensitive moxibustion group and the conventional group, the difference was statistically significant (P＜0.05). It can be concluded that the effect of tonifying kidney and tongluo acupuncture combined with heat sensitive moxibustion was significantly better than that of heat sensitive moxibustion group and conventional moxibustion group in improving knee joint symptoms (P＜0.05). During the whole study, the acupuncture group experienced acupuncture pain and local bruising after acupuncture, which was mostly relieved after a few days by local massage and hot compress. There were no serious adverse events, showing a high safety.

4.3 Effects of "Tonifying kidney and clearing collasals"acupuncture combined with heat sensitive moxibustion on TRACP and CTX-I

With the growth of human age, the incidence of knee osteoarthritis will increase, which is mainly manifested as the destruction of bone,the reduction of bone mass, and the imbalance of bone metabolism.If the human bone mass is not coordinated for a long time, the muscle tissue attached to the knee joint gradually ages, the cartilage becomes thin or forms osteophytes, and the resistance drops sharply.In the event of slight acute and chronic injuries, environmental changes become easy to induce knee osteoarthritis[18].TRACP is an important marker of osteoclast activity and bone resorption. It exists in osteoclasts and its content can objectively reflect the level of bone reconstruction in the body[19].Ctx-I is an important marker of bone cell growth and metabolism. It is a metabolite of type I collagen decomposition and a specific indicator of type I collagen[20].When bone turnover was accelerated in the body, its content increased significantly. Compared with the traditional bone metabolism index,its inspiration degree is higher, and it can objectively reflect the bone metabolism in the body, and it is also a research hotspot in recent years[21].In this study, TRACP and CTX-I were taken as objective indicators, not only to observe the influence of kidney-tonifying and collection-clearing acupuncture combined with heat-sensitive moxibustion therapy on serum TRACP and CTX-I content, but also to explore the mechanism of kidney-tonifying and collectionclearing acupuncture combined with heat-sensitive moxibustion therapy on KOA. The results showed that the serum TRACP and CTX-I contents of the acupuncture group were significantly decreased after treatment, and the differences were statistically significant compared with the heat sensitive moxibustion group and the conventional group (P＜0.05). It indicates that tonifying kidney and tongluo acupuncture combined with heat sensitive moxibustion may affect the expression of TRACP and CTX-I through regulating bone metabolic pathway, so as to relieve the pain symptoms of KOA patients, and the specific mechanism needs to be further explored.

4.4 Research significance and deficiency

In conclusion, kidney-tonifying and collection-clearing acupuncture combined with heat-sensitive moxibustion can significantly relieve pain symptoms in patients with knee osteoarthritis, with stable longterm efficacy and high safety. Meanwhile, it can regulate TRACP and CTX-I expression levels in KOA patients and improve bone metabolism, which has high clinical value. However, there are still shortcomings in this study. The number of included patients is small,the study area is limited, and the included syndrome type is only Yang deficiency cold coagulation type, lacking broad spectrum.Large-scale, multi-center randomized controlled studies are needed in the future to further verify the scientific nature of this therapy,and the mechanism of action of tonifying kidney and tongluo acupuncture combined with "heat sensitive moxibustion" on knee osteoarthritis needs further discussion.

Contribution of authors:

MAO Zhen: The designer and executor of the whole experiment,responsible for data sorting, article writing and modification;Contribution of 35%;

Jiang Run: the executor of the whole experiment, responsible for data statistics, contributing 25%;

Duan Jun: Clinical subject recruitment, contribution 5%;

Liu Jian: Clinical subject recruitment, contribution 5%;

Li LAN: Clinical subject recruitment, contribution 5%;

Chen Yulin: Clinical subject recruitment, contribution 5%;

Xie Lu: Clinical subject recruitment, contribution 5%;

Zhang Hongxing: Director of the national Natural Science Project in the early stage, guiding the clinical trial, contributing 15%.