The clinical progress and potential mechanism of massage therapy on knee osteoarthritis

Si-Jia Dong, Chi Zhang, Jia-Hang Wu, Hao YinHospital of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China. Department of Chinese Medicine Orthopedics, Chengdu University of Traditional Chinese Medicine, Chengdu, China. Ziyang Hospital of Traditional Chinese Medicine, Ziyang, China.

Abstract Knee osteoarthritis (KOA) is a disease due to the degenerative pathological change of knee joint, which commonly occurs in the elderly. The main clinical characters of KOA are the pain, stiffness, and dysfunction of knee joint. Western medicine regarding to the treatment of KOA aims to relieve the pain and delay the progress of disease such as intra-articular injection and functional exercise. Traditional Chinese medicine (TCM) therapy includes massage, herb,acupuncture, microwave, etc. Among them, the massage technique has the advantages of simpleness, effectiveness and non-invasive manipulation. The present study compared the curative effects of different therapies on KOA including Western medicine therapeutic method, single massage, complementary TCM therapeutic method containing massage and integrated TCM and western medicine therapeutic method containing massage. We found that the effectiveness of single massage method is better than that of joint cavity injection. The effectiveness of massage in combination with herb and acupuncture is better than that of massage alone. The effectiveness of joint cavity injection or functional exercise combined with massage and acupuncture is better than that of the single articular cavity injection or functional exercise.However, more research and clinical trials are still needed to determine the exact mechanism of massage.

Key words: Knee osteoarthritis, Massage, Review

Background

Knee osteoarthritis (KOA) is a chronic and progressive knee joint disease due to the degenerative pathological change, which has the characteristics of high incidence and disability. The elderly are prone to suffer from it.Among people over 50 years old in China, the incidence of osteoarthritis is second only to cardiovascular disease.KOA has seriously affected the health and quality of life of the elderly, giving patients and the society a heavy financial burden [1]. At present, both the treatment of KOA with traditional Chinese medicine (TCM) and Western medicine (WM) have made some achievements.WM treatment, mainly including analgesic, NSAIDs,diseases modifying drugs and surgery procedures, is always accompanied with the occurrence of side effects.TCM treatment, including health education, medical exercise, acupuncture, massage, fumigation and hot compressed with Chinese herbs, etc. are still the main stream treatment of KOA according to the diagnosis and management of KOA: Chinese medicine expert consensus [2]. As one of the non-drug therapies in TCM,massage has been used to treat disease for more than five thousand years. The position of massagist appeared as early as the dynasty of Sui and Tang (B.C. 581～907). It is known to loosen adhesion of muscle and tendon ligaments, relieve spasm, and then improving the function of knee joint [3-5]. There is also evidence that massage can increase the local blood flow to break the pain cycle,increase blood flow to the vein or artery, and relieve pain of the affected area [6-7]. Due to the advantages of simple operation, remarkable effectiveness and no damage, the massage has been widely applied in the non-drug therapy in clinics. The therapeutic method of massage for KOA mainly include single massage, massage combined with the methods of TCM and/or WM. Recent relevant researches are reported as follows.

Single massage therapy

The massage technique contains pushing with one finger,rolling, pulling out, rotating, patellar rubbing, pressing and kneading, poking channels manipulation, etc. The massage therapy not only reduces pain but also in increases range of motion and extensor muscle strength[8-9]. Massage also has the abilities of promoting Qi to activate blood as well as relaxing the tendons and unblocking collaterals. The underlying mechanism mainly that it increase the blood flow of knee joint,improve the blood circulation of joint parts, accelerate the absorption of inflammatory substances, promote the penetration and diffusion of slip fluid to articular cartilage,and promote the metabolism and nutrients supplication of articular cartilage [10-11].

Yang Ji et al. thought that the essence of KOA was “the imbalance of mechanical balance” of the knee joint, and used “six steps and eight methods” (loosing patellar and subpatellar fat pad, scratching tendons, slicing and cutting,and so on) for the treatment of KOA. A total of 63 cases received the therapy and the total effective rate reached 91.67% [12]. Zhu Xiaoqin et al. used massage to treat 82 patients with KOA and compared them with 56 patients who received the intra-articular injection of sodium hyaluronate[13]. Massage manipulation containing kneading knee, deeply rubbing the knee, pressuring knee,separating tendons, bending and stretching knee, etc. was performed on patients in the treated group. Study demonstrated that the effective rates of treated and control group were 87.80% and 73.21% respectively,showing significant difference. In a clinical report before and after Chinese massage treatment (20 cases), the patients gained significantly faster gait speed, greater step width, and increased total support time [14].

Complementary treatment of TCM

Massage combined with TCM

Massage combined with oral administration of TCM has the potential to relax tendons and unblock collaterals,disperse wind and cold as well as activate blood circulation to dissipate blood stasis. It also helps to improve blood circulation around knee joint, promote the absorption of inflammation, and relieve even eliminate pain. The specific mechanism is mainly that TCM can decrease the levels of IL-1β and MMP13 in knee joint,followed by the decreased inflammation[15].

In addition, hot compress and fumigation-washing of TCM mediated the effects of both heat and herb, by which improving the local blood circulation of knee joint,helping herb penetrate skin, thereby improving the nutritional status of local bone and soft tissue,accelerating the absorption of inflammatory edema and pathological products.

Massage combined with the oral administration of TCM. Professor Hong thought that treatment of KOA should make full use of the advantages of TCM complementary treatment and reduce side effects to the maximum extent possible. He is good at using the herb with the function of clearing and activating the channels,such as of Jixueteng (Caulis Spatholobi), Leigongteng(Tripterygium), Qiancao (Radix Rubiae) and massage technique with the effect of warming channels, such as rolling and rubbing manipulation [16]. There is also emerging evidence that the WOMAC osteoarthritis index scores of the treated group given the combination of massage and TCM (60 patients with KOA) were higher than that of the control group given 1,8-Diacetoxy-3-carboxyanthraquinone (60 patients with KOA), showing significant difference [17].

Massage combined with the external application of TCM. Huang Guizhong et al. reported that 60 patients with KOA in the treated group were prescribed the hot compressing of TCM packet treatment [composed of:Honghua (Flos Carthami), Danggui (Radix Angelicae Sinensis), Guizhi (Ramulus Cinnamomi), Wujiapi (Cortex Acanthopanax Radicis), Luoshiteng (Caulis Trachelospermi), Qianghuo (Rhizoma et Radix Notopterygii), Lulutong (Fructus Liquidambaris)] with supplemental rolling knee method, while 60 patients in the control group were prescribed voltaren. The effective rates in the treated group and the control group exhibited the significant difference after both 6-month (80.0% vs 58.3%) and 12-month treatment (85.0% and 45.0%) [18].Tan Yanquan et al. performed the WM block therapy (the control group) of triamcinolone acetonide, lidocaine and gentamicin and the complementary TCM therapy (the treated group) on the treatment of KOA, consisting of the massage manipulation of kneading, point-pressing,rolling, twisting, rotating, flexion and extension,acupuncture at the points of Ashi, Xuehai (SP10),Liangqiu (ST34), Dubi (ST35), Yanglingquan (GB34),Weizhong (BI40), Kunlun (BL60) points and hot compressing of herb Ruxiang (Olibanum), Moyao(Myrrha), Niuxi (Radix Achyranthis Bidentatae), Guizhi(Ramulus Cinnamomi), Chuanxiong (Rhizoma Ligustici Chuanxiong), Duhuo (Radix Angelicae Pubescentis),Sangjisheng (Herba Taxilli), Tougucao (phrymaceae),Shenjincao (Herba Lycopodii). The total effective rate was 75% in the control group while that in the treated group was 92.3%, showing significant difference [19].

Massage combined with fumigation of TCM. In a study conducted by Hu Dezhi et al, 90 patients with KOA were divided into the group of Chinese herb fumigation:Shenjincao (Herba Lycopodii), Tougucao (phrymaceae),Kuanjinteng (Caulis Tinosporae), Haifengteng (Caulis Piperis Kadsurae), Honghua (Flos Carthami), Haitongpi(Cortex erythrinae orientalis), Niuxi (Radix Achyranthis Bidentatae), Aiye (Folium Artemisiae Argyi), Taoren(Semen Persicae), common Chuanxiong (rhizoma sparganii), Sumu (Lignum Sappan)], the group of massage: point-pressing Dubi (ST35), Xiyan (EX-LE5),Weizhong (BI40), Xuehai (SP10), Yinlingquan (SP9),Zusanli (ST36), Yanglingquan (GB34), Chengshan (BL57)and Ashi and the combined group with Chinese herb fumigation and massage. The results showed that the effectiveness of the combined group (92.30%) is superior to that of single group (66.7% and 63.3% respectively)[20]. In another clinical report of 61 patients with KOA,massage combined Chinese herb footbath fumigation and washing had better clinical efficacy [21].

Massage combined with acupuncture

The method of acupuncture combined with massage has been widely involved in the treatment of KOA.Acupuncture could relieve pain while massage could clear and activate the channels. The combination of them has been traditionally thought to increase the analgesic effect, accelerate the circulation of blood and lymph in the tissue, and adjust the mechanical balance of the knee joint [22].

Acupuncture. Study has demonstrated that the effectiveness of combination of acupuncture [Xiyan(EX-LE5), Dubi (ST35)] and rolling knee manipulation(45 cases) is superior to that of intra-articular injection of sodium hyaluronate (45 cases) in patients with KOA(88.89% vs 62.22%) [23]. There is also evidence that the effectiveness of treatment group with the combined treatment of massage manipulation (kneading, pressing,poking channels and pushing) and acupuncture[Weizhong (BI40), Shenmai (BL62), Taixi (KI3) and Mingmen (GV4)] was better than that of control group with the oral administration of glucosamine sulfate capsules (94% vs 74%), exhibiting significant difference[24]. Doctor Jin thought that the incidence of KOA is associated with the disorder of spleen and stomach channels. To correct the injury of channels, the acupuncture at Zusanli (ST36) point and massage of quadriceps along the spleen and stomach channels were used.

Warm-acupuncture. The heat effect of warmacupuncture has the potential to accelerate the blood and lymphatic circulation, promote the excretion of metabolites and the absorption of inflammatory exudates.Moreover, the combination of warm-acupuncture and massage could inhibit the regulated upon activation normal T cell expressed and secreted and monocyte chemotactic protein-1-mediated inflammatory response significantly [25].

Warm-acupuncture at the points of Dubi (ST35), Xiyan(EX-LE5), Yanglingquan (GB34), Liangqiu (ST34),Xiyangguan (GB33), Heding (EX-LE2), Zusanli (ST36),Xuanzhong (GB39) and massage method (dissolution,pushing patella, flexion and extension) were selected for KOA treatment in 48 patients. The total effective rate reached 87.5% [26]. 100 patients with KOA were selected and randomly divided into the control group accepting TDP light irradiation combined with acupuncture[Neixiyan (EX-LE4), Dubi (ST35), Xuehai (SP10),Liangqiu (ST34), Yanglingquan (GB34), Yinlingquan(SP9), Heding (EX-LE2), Zusanli (ST36) points] and the treated group accepting massage manipulation (muscles,pull rotation, push and pull reduction method) combined with warm-acupuncture at the points above. The results indicated that the effective rate of the treatment group was higher than that of the control group, whereas the onset time and the average treatment times of the treatment group was lower than that of the control group[27]. The specific mechanism is that mainly that warm-acupuncture combined with massage reduce the level of inflammatory cytokines IL-1β and TNF-α significantly [28].

Electro-acupuncture. The dense wave in the low frequency pulse current produces the effect of relieving pain and the spasm of muscle and blood vessel, which is suitable for KOA treatment. Studies have demonstrated that massage and electro-acupuncture can reduce the content of methane dicarboxylic aldehyde and NO in the synovial fluid, increase the activity of superoxide dismutase, inhibit the destruction of free radicals in the knee joint, and enhance the scavenging capacity of oxygen free radicals [29].

76 patients with KOA were prescribed the electro-acupuncture at Xiyan (EX-LE5), Heding(EX-LE2), Xuehai (SP10), Liangqiu (ST34), Xiyangguan(GB33), Zusanli (ST36) and Ashi points with supplemental massage manipulation (rolling,point-pressing and kneading). According the results,electro-acupuncture can effectively enhance the analgesic effect of massage and the effective rate was up to 85%[30]. Liu Hongbo et al. applied the massage combined with electro-acupuncture at Xuehai (SP10), Liangqiu(ST34), Neixiyan (EX-LE4), Dubi (ST35), Yinlingquan(SP9), Yanglingquan (GB34), Zusanli (ST36) points in 38 patients. The effective rate was 92.1% using the Lysholm knee function evaluation table [31].

The integrative therapy of Chinese and WM containing massage technique.

Intra-articular injection

The specific mechanism of intra-articular injection of sodium hyaluronate is supplying the endogenous hyaluronate, eliminating the pain caused by algogenic substance, improving joint activity, protecting protein polysaccharide from precipitation and promoting the biosynthesis of cartilage matrix polymer hyaluronic acid.Zheng Xiao et al. divided 60 patients randomly into two groups. The treatment group was given both sodium hyaluronate knee joint cavity injection and massage manipulation, while the control group was given the knee joint injection of sodium hyaluronate. The difference was statistically significant that the effective rate of treatment group was higher than that of the control group [32].

Functional exercise

Strength training is a kind of aerobic activity that could avoid painful arc and not aggravate cartilage load. It can enhance the strength of quadriceps and the muscles around the knee joint and promote joint synovial fluid circulation, improve the nutrition of articular cartilage,strengthen the stability of the knee joint, and prevent the knee joint from further injury. According to the knee joint function assessment standards of Japan's big three medical school, 78 patients with KOA were divided into two groups and 39 cases in each one. The treated group was treated with massage combined with muscle strength training while the control group was treated with single massage. After 20 times treatments, the score of the treated group was higher than that of the control group,suggesting that muscle strength were closely related to the joint functional activity [33-34]. In a blind,randomized controlled trial study of 18 patients with KOA, the combination exercise-based therapy with massage therapy may lead to clinical improvement in patients [35]. In another study conducted by Huang Jian et al. massage and function training is involved in the prevention and treatment of KOA via decreasing the level of IL-1β, TNF-α, methane dicarboxylic aldehyde and NO while increasing the activity of superoxide dismutase[29].

The others

Microwave radiation could make full use of the heat effect and thermal externality effect to achieve the goal of anti-inflammation and anti-analgesic via prompting excitability of neuromuscular and improving local blood circulation and nutrition. Pan Xun et al. reported that effective rates of control and treated group were 73.4%and 96.7% while the recurrence rate of those were 40.0%and 10.0% respectively, in which the control group was given the knee joint cavity injection of drug while the treated group was given the complementary of acupuncture [Futu (ST32), Xuehai (SP10), Dubi (ST35),Liangqiu (ST34), Xiyan (EX-LE5), Yanglingquan (GB34),Zusanli (ST36) and Sanyinjiao (SP6), Ashi], kneading knee manipulation and microwave treatment [36].

Discussion

KOA is also called “arthralgia syndrome”, “heumatism”and “arthralgia syndrome in knee” in TCM, in which the deficency liver, spleen and kidney is the foundation and the invasion of cold dampness, trauma and improper diet and overtiredness is the inducing factors [37]. Modern medicine has demonstrated that multiple factors could result in the occurrence of KOA, such as the metabolic disorders of synthesis and catabolism of cartilage matrix,subchondral bone damage and joint inflammation [38].WM treatment of KOA is still retained at the stage of symptomatic treatment including oral analgesics, articular cavity injection of sodium hyaluronate, arthroscopy and artificial knee replacement, etc. However, these therapies always lead to the occurrence of adverse reactions and surgical trauma [39]. Compared with the treatment of WM, treatment strategies of TCM containing massage is more accurate, cheaper and safer.

As one of the most important non-drug therapies,massage method can improve the stability of the knee joint, relieve joint pain and improve joint stiffness. It also improves the quality of survival in patients with KOA[40]. The long-term efficacy of massage has accumulated considerable experience in the treatment of KOA, and it has a good prospect for delaying the process of KOA.

The effectiveness of treating KOA with massage is certain [41]. Massage has the potential to regulate the body’s physiological and pathological conditions by touching the specific parts of body surface, achieving the effectiveness of promoting the circulation of Qi and blood as well as clearing and warming channels [42]. On the one hand, the massage acts at the local area of human body. On the other hand, the force of massage can be converted into a variety of energy and information and then has curative effect on the body’s nervous, circulation,sports system and analgesia through the regulation of nerves and body fluids [43].

The blockage of channels with phlegm and blood stasis is responsible for the occurrence of KOA [44]. Massage therapy can produce the intensive heating effect on the affected site, by which directly promote the circulation of Qi and blood of the body. Besides, massage therapy could promote lymph back-flow, accelerate the absorption of local blood stasis and inflammatory tissue as well as relieve the spasm of muscle and tissue, providing a good foundation for restoration of limb function.

Massage therapy includes variety of methods and each academic school has its own characteristics. However,there is a great difference between each other and lack unified standard. Furthermore, in the previous experiments, the discussion about the relationship between the quantity and effect of the massage therapy is still relatively rare, it is difficult to unify due to the strength and the time of massage therapy are all controlled by handlers. The mechanisms of action should also be further elucidated. In the future work, we should summarize the massage therapy in all academic schools,explore the relationship between the quantity and effect,and develop more research from the levels of cytology,molecular biology and so on.