Therapeutic observation of ‘warming-unblocking needling technique’ for knee osteoarthritis due to deficiency of liver and kidney

Zhang Guo-xiao (张国晓), Zhao Yao-dong (赵耀东), Zhu Ling (朱玲)

Gansu University of Chinese Medicine, Lanzhou 730000, China

Abstract Objective: To compare the clinical efficacy between ‘warming-unblocking needling technique’ and reinforcing method by twirling in treating knee osteoarthritis (KOA) due to deficiency of liver and kidney.Methods: A total of 72 patients with KOA were divided into a warming-unblocking group and a reinforcing group by complete randomized method, with 36 cases in each group. Xuehai (SP 10), Heding (EX-LE 2), Liangqiu (ST 34), Neixiyan(EX-LE 4), Xizhong (Extra), Dubi (ST 35), Yinlingquan (SP 9), Zusanli (ST 36) and Yanglingquan (GB 34) were the main points in both groups. Taichong (LR 3), Taixi (KI 3) and Sanyinjiao (SP 6) were the combined points. ‘Warming-unblocking needling technique’ was applied in the warming-unblocking group, and reinforcing method by twirling was applied in the reinforcing group. The treatments were performed once a day, 10 times as a treatment course, at a 2-day interval between two courses,for 3 courses in total. The scores of Western Ontario and McMaster Universities osteoarthritis index (WOMAC) in the two groups were observed before and after the treatment, and the clinical efficacy was compared.Results: After treatment, the total effective rate was 94.3% in the warming-unblocking group and 87.9% in the reinforcing group, and the difference between the two groups was statistically significant (P＜0.05). The component scores of pain,stiffness and daily activities in WOMAC and total WOMAC scores in both groups decreased after treatment (all P＜0.01). The component and total WOMAC scores in the warming-unblocking group were lower than those in the reinforcing group(P＜0.05 or P＜0.01).Conclusion: ‘Warming-unblocking needling technique’ has significant efficacy than reinforcing method by twirling in treating KOA due to deficiency of liver and kidney. It can significantly improve pain, stiffness and daily functional activities of patients.

Keywords: Acupuncture Therapy; Warming-unblocking Needling Technique; Point, Heding (EX-LE 2); Pain Measurement;Osteoarthritis, Knee; Deficiency of Liver and Kidney

Knee osteoarthritis (KOA) is a common chronic,non-inflammatory and degenerative osteoarthritis in the elderly. It has a high rate of deformity and disability,seriously affecting the quality of life (QOL). KOA belongs to Bi-impediment syndrome in traditional Chinese medicine (TCM). Zheng's ‘warming-unblocking needling technique’ is a unique family-inherited manipulation created by Professor Zheng Kui-shan. The manipulation can significantly provoke the meridian qi and promote qi-flow and blood circulation by tuinu-pushing crossbow manipulation for maintaining needling sensation, so that qi can reach the disease location, thereby improving the clinical efficacy. In this study, we observed the difference in clinical efficacy between‘warming-unblocking needling technique’ and reinforcing method by twirling in the treatment of KOA due to deficiency of liver and kidney, and provided a reference for better clinical treatment.

1 Clinical Materials

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria in Western medicine

This study referred to the diagnosis of KOA in the Guidelines for Diagnosis and Treatment of Osteoarthritis(2018)[1]: ① repeated knee pain in the past 1 month;② X-ray (standing or weight loading) examination showed narrowing of the joint space, subchondral osteosclerosis and/or cystic changes, and osteophyte formation at the edge of the joint; ③ middle-aged and elderly patients (≥50 years); ④ morning stiffness≤30 min; ⑤ bony crepitus during activity. Combined with clinical manifestations, KOA can be diagnosed if patient met item ①, and any two items of ②-⑤.

1.1.2 Criteria of syndrome differentiation of TCM

The diagnosis of liver-kidney deficiency pattern referred to the Expert Consensus of Traditional Chinese Medicine Diagnosis and Treatment of Knee Osteoarthritis (2015)[2]. Primary symptom: dull pain of the joint. Secondary symptoms: soreness and weakness of waist and knees, heaviness and pain, aggravated after exertion. Tongue and pulse manifestations: a red tongue body lacking moisture, deep and thready pulse lacking strength.

1.2 Inclusion criteria

Those who met the above diagnostic criteria in Western medicine and of the syndrome differentiation of TCM; aged 50-80 years; those who were able to describe their own condition truly and objectively;serum rheumatoid factor (RF), antistreptolysin O, mucin and erythrocyte sedimentation rate (ESR) were all negative; imaging staging (Kellgren and Lawence method) graded 0-Ⅲ; not on related medications or underwent other therapies in the past 1 month; agreed to participate in this trial and signed informed consent.

1.3 Exclusion criteria

Those who did not meet the inclusion criteria;patients with severe gonyectyposis, gonycrotesis or systemic osteoarthropathy; patients with severe primary disease of internal medical system; unwilling to receive acupuncture treatment or intolerant of acupuncture; those with severe bleeding tendency;those with acupuncture contraindication such as skeletal tuberculosis, bone tumor, local infections and infectious diseases; those with severe mental and psychological diseases; women during pregnancy or lactation.

1.4 Elimination and dropout criteria

Those who had formally received at least one time of treatment in this trial but had not completed the whole course and had not recovered; those who had severe discomfort during the treatment that were unable to continue the trial; those who did not receive the prescribed treatment during the trial, or received other treatment without authorization, or had to take other drugs that affected the data; those who presented with other severe diseases during the treatment; dropped out because of various reasons or loss to follow-up.

1.5 Statistical methods

All data were statistically analyzed by the SPSS version 20.0 statistical software. Measurement data in normal distribution and homogeneous variance were expressed as mean ± standard deviation (x ±s).Independent sample t-test was applied to the comparison between groups. Paired sample t-test was applied to the comparison of intra-group data.Chi-square test was applied to the comparison of counting data. P＜0.05 was considered to indicate a statistically significant difference.

1.6 General data

A total of 72 patients with KOA due to deficiency of liver and kidney were enrolled from Acupuncture Center Clinic of the Affiliated Hospital of Gansu University of Chinese Medicine. They were randomly divided into a warming-unblocking group and a reinforcing group by complete randomized method,with 36 cases in each group. During the treatment, 1 patient in the warming-unblocking group dropped out and 3 patients in the reinforcing group dropped out.There were 4 dropout cases in total and the dropout rate was 5.6%.

There were no significant differences in the data of gender, age and duration of disease between the two groups (all P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Treatment Methods

2.1 Warming-unblocking group

Main points: Xuehai (SP 10), Heding (EX-LE 2),Liangqiu (ST 34), Neixiyan (EX-LE 4), Xizhong [Extra,located at the inferior border of apex of patella, the midpoint of the line between Neixiyan (EX-LE 4) and external Xiyan (EX-LE 5)], Dubi (ST 35), Yinlingquan(SP 9), Zusanli (ST 36) and Yanglingquan (GB 34).

Combined points: Taichong (LR 3), Taixi (KI 3) and Sanyinjiao (SP 6).

Methods: The points selected in this study were determined based on our long-term clinical experience[3]. Xizhong [Extra, located at inferior border of apex of patella, the midpoint of the line between Neixiyan (EX-LE 4) and Dubi (ST 35)] was Zhao Yao-dong’s empirical point. The locations of the rest points referred to the Nomenclature and Location of Acupuncture Points (GB/T 12346-2006)[4], (Figure 1).After routine disinfection with a sterile cotton swab dipped in iodine, the physician pressed the points with the pressing hand, and punctured with needle-holding hand using Hwato brand sterile disposable acupuncture needles (0.30 mm in diameter and 40 mm in length).Xuehai (SP 10) and Liangqiu (ST 34) were perpendicularly punctured by 35-40 mm in depth[3].Heding (EX-LE 2) was obliquely punctured with the tip of the needle upwards by 35-40 mm in depth. Neixiyan(EX-LE 4), Xizhong (Extra) and Dubi (ST 35) were punctured with the tip of the needle towards the articular cavity by 35-40 mm in depth. Yinlingquan(SP 9), Zusanli (ST 36) and Yanglingquan (GB 34) were perpendicularly punctured by 35-40 mm in depth. The‘warming-unblocking needling technique’ was applied to the above points after the arrival of qi, which was,increased the pressure of left hand, and twisted the needle with the right thumb forward for 9 times, after the feeling of tightness under the needles, continuously and slightly heavily-thrust and gently-lifted 9 times with the tip of the needle pulling the sensitive part, and the thumb twisted and pressed the needle forward for 9 times again. With the tip of the needle pushing the sensitive part, Tuinu-pushing crossbow manipulation was performed for maintaining needling sensation, to maintain the tightness under the needles, and the physician could clearly felt the impulse of the meridian qi beneath the pressing hand. At the same time, the physician applied closing method (that was, tightly pressed the point with the pressing hand, making the same direction of the pressure with the meridian qi transmitting, thus promoting qi to reach the disease location) with the pressing hand, and held for 1 min.Taichong (LR 3) was obliquely punctured with the tip of the needle upwards by 35-40 mm in depth. Taixi (KI 3)was perpendicularly punctured by 35-40 mm in depth.After the arrival of qi, the reinforcing method by twirling was performed for 1 min.

2.2 Reinforcing group

Main points and combined points: The same as those in the warming-unblocking group.

Methods: The acupuncture angles and depths were the same as those in the warming-unblocking group,while the manipulation was to perform reinforcing method by twirling[5]. After routine disinfection, the physician pressed the points with the pressing hand,and punctured the points with the needle-holding hand quickly by 35-40 mm in depth. After the arrival of qi, the physician twisted the needle with the right thumb forward by 90°, maintaining the frequency at 50-90 times/min, and manipulated the needle for 1 min.

The retention of needles in the above two groups was 30 min. Then the physician slowly removed the needles and pressed the pinholes. The treatments were performed once a day, 10 times as a treatment course,at a 2-day interval between two courses, for 3 courses in total.

3 Observation of Curative Efficacy

3.1 Observation items

The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) was selected in this study as the observation item, covering pain, stiffness and daily activities. It was scored before and after treatment,required to be truthful. Twenty points stood for completely normal, over 20 points for a varying decline of self-care ability. A score of less than 80 points was considered mild, 80 to 120 points stood for moderate,and more than 120 points stood for severe. The severity of the symptoms and signs of participants was positively correlated with the total score[6].

3.2 Criteria of curative efficacy

According to the Guiding Principles for Clinical Study of New Chinese Medicines[7]and curative effect index,the efficacy criteria of this study were established.Curative effect index = (WOMAC total score before treatment - WOMAC total score after treatment) ÷WOMAC total score before treatment × 100%.

Cured: The symptoms and signs disappeared, and the curative effect index ≥95%.

Marked effect: The symptoms and signs were significantly improved, and the curative effect index≥70%, but ＜95%.

Effective: The symptoms and signs were improved,and the curative effect index ≥30%, but ＜70%.

Figure 1. Point locations

Invalid: The symptoms and signs were not obviously improved or even worse, and the curative effect index＜30%.

3.3 Results

3.3.1 Comparison of clinical efficacy

No adverse reactions occurred during the treatment.The total effective rate was 94.3% in the warmingunblocking group and 87.9% in the reinforcing group.The comparison result was presented as Z=-2.161,P=0.031 by non-parametric rank-sum test, which suggested that the difference in the total effective rate between the two groups was statistically significant,and the warming-unblocking group was superior to the reinforcing group in treating KOA due to liver-kidney deficiency (Table 2).

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

3.3.2 Comparison of the WOMAC score

The comparison results of the scores of pain, stiffness and daily activities in WOMAC between the two groups were presented as P＞0.05 before treatment, indicating that the two groups were comparable. After 3 courses of intervention, the scores of pain, stiffness and daily activities in WOMAC in the two groups decreased(P＜0.01), indicating that both acupuncture manipulations could significantly improve the knee symptoms of patients with KOA due to deficiency of liver and kidney. After treatment, the WOMAC stiffness score, daily activity score and total score in the treatment group were different from those in the control group (P＜0.05) and the difference in the pain score was statistically significant (P＜0.01), which suggested that ‘warming-unblocking needling technique’ had a better effect in improving WOMAC pain score, stiffness score, daily activity score and total score than reinforcing method by twirling in the patients with KOA due to deficiency of liver and kidney,especially in relieving the pain.

Table 3. Comparison of the WOMAC scores between the two groups (x ±s, point)

4 Discussion

KOA is characterized by joint pain, stiffness, swelling,and limited functional activity. It belongs to Bi-impediment syndrome in TCM. TCM believes that the disease location of KOA is in tendon, bone and joint[8],and the cause is closely related to the deficiency of liver and kidney. Treatment for KOA based on invigorating liver and kidney can produce certain curative efficacy[9-11], and significantly improve pain and stiffness of knee joint and the abilities of daily living (ADL)[12-13].Related studies suggested that treatment for KOA based on invigorating liver and kidney could reduce the levels of serum inflammatory factors such as matrix metalloproteinase-1 (MMP-1), interleukin (IL), tumor necrosis factor-α (TNF-α), prostaglandin E2(PGE2) and 5-hydroxytryptamine (5-HT), and increase the contents of protective protein factors such as tissue inhibitor of metalloproteinase 1 (TIMP-1), adiponectin (AD),transforming growth factor-β1 (TGF-β1) and bone morphogenetic protein (BMP)[14-18].

Based on the above pathogenesis, treating KOA due to liver-kidney deficiency by Zheng's ‘warmingunblocking needling technique’ can combine the functions of acupoints and acupuncture manipulation to unblock localized qi and blood flow, regulate functions of related Zang-fu organs, and fundamentally improve the symptoms of KOA. Its mechanism may include the following three aspects.

Firstly, from the perspective of running course of the meridians, the Stomach Meridian passes through the superolateral side of the knee joint. Acupuncture at acupoints near the knee joint on this meridian can unblock the qi and blood flow of the superolateral side of the knee joint to relieve pain. The Gallbladder Meridian passes through the lateral side of the knee joint. Acupuncture at acupoints near the knee joint on this meridian can unblock the qi and blood flow in the lateral side of knee, meanwhile, disperse and promote liver and bile and regulate qi movement, so as to invigorate the transportation and transformation function of spleen and stomach, nourishing tendon and bone with qi, blood and essence. The Spleen Meridian passes through the anteromedial side of the knee joint.Acupuncture at acupoints near the knee joint on this meridian can unblock the qi and blood flow in the anteromedial side of knee, also invigorate spleen and benefit qi, and promote blood circulation for removing obstruction in collaterals. In addition, spleen is the acquired foundation. It dominates muscles, governs transportation and transformation, and commands blood. It is a key hub for the transportation and transformation of the body. Therefore, acupuncture at acupoints on this meridian can regulate the transportation of spleen qi and the dispersal of food nutrients, make the body metabolism in order, and nourish the muscles that can be thick and strong without flaccidity and limp wilting. The Kidney Meridian passes through the posteromedial side of the knee joint.Acupuncture at acupoints on upper and lower limbs of this meridian can unblock the qi and blood flow in the medial side of knee, nourish the kidney yin and enrich the marrow, so that the tendon and bone can be strong and powerful. The Liver Meridian passes through the medial side of the knee joint. Acupuncture at acupoints on upper and lower limbs of this meridian can provoke the qi and blood of Liver Meridian, and promote the liver blood downward the knee joint, and therefore the joint can flex-extend freely nourished by liver blood.The lesion and pain in KOA mainly affect the medial,lateral and anterior sides of the knee joint. Therefore,acupuncture at the corresponding acupoints of the above meridians can unblock the qi and blood circulation in the entire knee joint from different directions and angles. At the same time, it can fundamentally regulate functions of the related Zang-fu organs through the conduction function of meridian qi,to achieve the effect of nourishing the liver and kidney,benefiting blood and relaxing tendons, and unblocking collaterals for relieving pain, and thus improving knee function.

Secondly, from the perspective of acupoints selection,there were both local points and distant points. Xiyan(EX-LE 5), Xizhong (Extra) and Dubi (ST 35) were selection of local points. Xuehai (SP 10), Heding(EX-LE 2), Liangqiu (ST 34), Yinlingquan (SP 9), Zusanli(ST 36) and Yanglingquan (GB 34) were selection of proximal points. The selection of the points was to unblock the qi and blood circulation in the knee joint over all, so as to invigorate spleen for benefiting qi,promote blood circulation for removing obstruction in collaterals, soften rigidity of muscle and relieving pain,thus achieving the maximum effect. According to the theory that ‘an acupoint can treat the disorders where its meridian distributes’, Taichong (LR 3), Taixi (KI 3) and Sanyinjiao (SP 6) were selected, which represented the selection of distant points and the principle of point selection based on syndrome differentiation, thus promoting the meridian qi provoked by acupoints to run through the meridians towards the knee joint, so as to free the joints, invigorate the liver and kidney, benefit marrow and strengthen bones. Therefore, acupuncture at the above points for the treatment of KOA due to liver-kidney deficiency can unblock the qi and blood flow around the knee joint, and make the kidney essence and liver blood spread all over the knee joint maximally.

Finally, from the perspective of acupuncture manipulation, Zheng's 'warming-unblocking needling technique’ is a unique manipulation that is simple and easy-to-learn, formed by Professor Zheng Kui-shan, the'Northwest Acupuncture King’ through his clinical experience. The manipulation can significantly provoke the meridian qi and promote qi-flow and blood circulation by Tuinu-pushing crossbow manipulation for maintaining needling sensation, so that qi can reach the disease location, thereby achieving triple effects of‘warming’, ‘dredging’ and ‘reinforcing’. According to the yin-yang theory, ‘warming’ belongs to yang. Yin and yang have the characteristics of mutual rooting and interaction, so that yin can grow with yang. Meanwhile,‘warming’ can supplement ‘dredging’ and ‘reinforcing’.‘Reinforcing’ is to nourish liver and kidney, and benefit qi and blood. ‘Warming’ and ‘dredging’ can make‘reinforcing’ not stagnated. However, reinforcing method by twirling is mainly for benefiting, and its effect of ‘warming’ and ‘dredging’ is relatively weaker than that of the ‘warming-unblocking needling technique’. In TCM theory, nine is for yang-reinforcing and six is for yin-reinforcing[19]. As to the treatment quantity, the ‘warming-unblocking needling technique’uses the number of nine-yang, which is twisting and pressing for nine times, and heavily-thrusting and gently-lifting for nine times, making the warm invigoration function to the maximum. However,reinforcing method by twirling is a minor and slow twirling manipulation in the localized acupoint area. It is gentle, and less than the ‘warming-unblocking needling technique’ in the stimulation quantity. From the perspective of manipulation, ‘warming-unblocking needling technique’ includes twisting and pressing, and emphasizes hard-pressing closing method by the pressing hand, which can promote meridian qi to quickly transmit through meridians to the disease location. However, reinforcing method by twirling only has the twirling method, which reduces the promoting effect of meridian qi transmitting.

In this study, acupoints around the knee joint were fully selected, combined with the ‘warming-unblocking needling technique’ to circulate qi to the maximum extent, the qi and blood in the joint were replenished maximally, and the joint was nourished by abundant qi and blood. Results in this study suggested that the‘warming-unblocking needling technique’ produced more significant efficacy than the reinforcing method by twirling in treating KOA due to deficiency of liver and kidney, and thus is worth promotion.

Conflict of Interest

The authors declare that there is no conflict of interest in this article.

Acknowledgments

This work was supported by Project of Zheng’s Acupuncture Manipulation Academic School Heritage Work Room, Gansu Province (甘肃郑氏针法学术流派传承工作室建设项目, No. 9983999957).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 18 June 2019/Accepted: 25 July 2019