Clinical effect of scraping therapy in the treatment of knee osteoarthritis

Jin‑Rong WEI, Hui‑Ping ZHANG, Shu‑Ying XU,Bo MA, Jin‑Hua ZHANG, Jia LIU

1Department of Nursing; 2Department of Traumatology and Orthopedics, Yangzhou Hospital of Traditional Chinese Medicine, Yangzhou, China

ABSTRACT

Objective: The objective of this study is to investigate the effect of scraping therapy in the treatment of knee osteoarthritis.

Materials and Methods: A total of eighty patients with knee osteoarthritis were assigned to the moxibustion group and the scraping therapy group according to the random numerical table method, with forty cases in each group. Patients in both two groups received functional exercise and moxibustion therapy, and those in the scraping therapy group were supplemented with scraping therapy. The serum indexes of interleukin‑1 (IL‑1), IL‑6, tumor necrosis factor‑alpha (TNF‑α), and superoxide dismutase (SOD) were detected before and after the treatment.The clinical syndrome integral and Visual Analog Scale (VAS) on pain of patients were assessed. The clinical therapeutic efficacy was evaluated and compared between the two groups.

Results: Patients in the scraping therapy group received better outcomes of serum IL‑1, IL‑6, TNF‑α, and SOD compared with those in the moxibustion group at 2 months after treatment (P ＜ 0.05). The scores of clinical syndrome integral and VAS on pain were decreased in two groups at 2 months after the treatment and were lower in the scraping therapy group than those in the moxibustion group (P ＜ 0.05). The overall effective rate in the scraping therapy group was higher than that in the control group (87.50% vs. 67.50%,P ＜ 0.05).

Conclusion: The scraping therapy is potentially effective to ameliorate the clinical symptom and pain degree of patients with knee osteoarthritis.

Keywords: Interleukin, knee osteoarthritis, moxibustion, pain, scraping therapy

INTRODUCTION

Knee osteoarthritis is a common chronic degenerative osteoarthritis, characterized by recurrent knee pain, swelling,deformity, limited movement, and even difficulty walking.[1]In the category of “Bi‑syndrome” and “knee pain” in the Chinese medicine, its incidence is related to the external invasion of wind cold and dampness evil, blood stasis accumulated in the local part, weakness in old people, deficiency of the liver,spleen, and kidney, or strain injury, and trauma.[2]According to the statistics, the incidence of knee osteoarthritis in people over 50 years old in China is 85%, more women than men,increasing with age.[3,4]At present, although the common treatment methods include drug treatment, nondrug treatment, surgical treatment,[5,6]the pathogenesis of knee osteoarthritis is not fully understood, and there is still a lack of better and economical special treatment methods.In recent years, our hospital used the characteristic scraping therapy of the traditional Chinese medicine to treat knee osteoarthritis, to improve local microcirculation, and enhance the body’s own potential disease resistance and immune function, so as to relieve pain, restore joint function, and achieve good therapeutic effects.

MATERIALS AND METHODS

This study was approved by the Ethics Committee of Yangzhou Hospital of the Traditional Chinese Medicine.

Materials

Patients with knee osteoarthritis who were hospitalized in the orthopedic department from August 2015 to August 2017 were selected.Patients met the following criteria: (1)patients had knee osteoarthritis in line with the diagnosis criteria of Guidelines for the Diagnosis and Treatment of Osteoarthritis (2007 edition)[7]made by the Orthopedic Branch of the Chinese Medical Association; (2) patients complicated with knee joint swelling in line with Western medicine diagnostic standards; (2) patients had floating patella test negative; (3) patients aged 40–80 years old,no limit in gender; (4) clinical syndrome integral had to be ≥5; and (5) patients were willing to accept and cooperate with the methods prescribed in this topic for the treatment.

A total of eighty cases of eligible patients were enrolled,36 cases of males and 44 cases of females, aged 46–80 years,with the average age of 66.30 ± 10.71 years.According to the random numerical table method, patients were divided into the moxibustion group and the scraping therapy group, forty cases in each group.In the moxibustion group,18 were male and 22 were female; the average age was 66.30 ± 11.71 years.In the scraping therapy group, 16 were male and 24 were female; the average age of patients was 67.00 ± 10.54 years.The difference was not statistically significant (P＞ 0.05) between the two groups in general data such as gender and age of patients.

Methods

Patients in the moxibustion group received traditional moxibustion therapy on the basis of self‑functional training.The professional person guided the patient to do isotonic and isometric contraction exercises of the affected quadriceps.The patient was in the supine position, kept the affected knee joint straight, tighten his/her quadriceps muscle, lifted it and suspended for 5 s, and then puts it down, repeatedly.The training was completed for 20 min one time, two times/day.The selected acupoints for moxibustion therapy were Yinlingquan, Yanglingquan, Liangqiu, Ganshu, and Shenshu.Moxibustion on each acupoint was performed for 5 min,once daily.At the same time, give patients life guidance,specifically, inform them of avoiding running and jumping,squatting, climbing the mountain, climbing upstairs and downstairs, sedentary or long standing, and wearing high heels; keep knee joint warm and control the body weight; if there is discomfort, immediately rest.[8]

Patients in the scraping group received additional scraping therapy based on the treatment of the moxibustion group.The methods of self‑functional training and the operation of moxibustion were the same as that described in the moxibustion group.In addition, the regular blood test was done on the 1stday of admission.The nurse who was trained began to implement scraping treatment on that day according to the attending doctor’s advice.The course of treatment was ended after 30 days.The tool for scraping therapy was buffalo horn scraper.The scraping parts were back (traveling parts of Du‑meridian)and lower limbs (traveling parts of the gallbladder meridian of foot Taiyang).The selected acupoints were Neixiyan, Waixiyan,Yanglingquan, Liangqiu, Xuehai, Ganshu, and Shenshu.

The specific operation of scraping therapy was as follows:the skin was exposed and coated with scraping oil when scraping.(1) scraping the back: patients were in the prone position.The nurse used buffalo horn scraper to scrape the traveling parts of Du‑meridian on the back, from Dazhui acupoint to Yaoyangguan acupoint in the midline of the back,70 times/min, 5 min in total.The scraping spots appeared after scraping.(2) Scraping the limbs: Patients were in the supine position.The nurse used buffalo horn scraper at a 45°angle to evenly scrape Neixiyan and Waixiyan, and the upper,medial, and lateral sites of the knees and popliteal fossa, in mild reinforcing and attenuating manner, 3–5 min appropriate for each site (about 20–30 times), no more than 15–20 min, until the dark‑red spots appeared, and scraped more times at site with dense spots.However, based on the patients’ comfort, the appearance of scraping spots was not a must.Patients received scraping therapy again after the scraping spots disappeared,once every 3–5 days, with 4 weeks as a treatment course.In addition, advice patients not to scratch the scraped skin if they may feel mild pain and itching on the scraped site after 1–2 days of the appearance of scraping spots.

Observed indicators

Clinical symptom score

According to the grade of clinical symptoms in Guiding Principle of Clinical Research on New Drugs of the Traditional Chinese Medicine, the higher the clinical syndrome integral,the more serious the symptoms are.

Serum indicators

Serum leukocyte interleukin (IL)‑1, IL‑6, tumor necrosis factor alpha (TNF‑α), and superoxide dismutase (SOD) levels before treatment, at the end of treatment, and 2 months after treatment.

Pain improvement

A Visual Analog Scale (VAS) was used to assess the level of knee pain of patients before treatment, at the end of treatment, and 2 months after treatment.

Effect of treatment

(1) Cured: Patient has knee swelling, but pain symptom completely disappears, joint activity returns to normal, no obvious discomfort in walking upstairs and downstairs,normal local skin temperature, floating patella test negative,no recurrence within 1 year of follow‑up; (2) effective:the patient has knee swelling, pain symptoms basically disappears, joint activity basically returns to normal, but slight knee pain after excessive activity, floating patella test negative, normal local skin temperature, without recurrence within 1 year of follow‑up; (3) improved: knee swelling and pain symptoms are relieved, joint activity is basically normal,local skin temperature is slightly higher; and (4) ineffective:knee pain, swelling, and pain during the activities did not improve significantly or even worsen.

Statistical method

The SPSS software version 22.0 (Internaltional Business Machines Corporation, Armank, New York) was used.Measurement data were expressed as mean ± standard deviation, the comparison of data at different time points was analyzed using the variance analysis of repeated measurements, and inter‑group comparison using thet‑test.The count data are expressed as percentage (%), and intergroup ranked data were analyzed using the Mann–Whitney U‑test.The test level is 0.05,P＜ 0.05 is considered as statistically significant.

RESULTS

Comparison of serum‑indicator levels

The differences were not statistically significant between the two groups in serum levels of serum IL‑1, IL‑6, TNF‑α, and SOD of patients before the treatment (P＞ 0.05).However, a decrease in the levels of serum IL‑1, IL‑6, and TNF‑α, and an increase in serum SOD level were found in both groups at the end of treatment and 2 months after treatment (P＜ 0.05);and the lower levels of serum IL‑1, IL‑6, and TNF‑α, and more elevated level of serum SOD in the scraping group than in the moxibustion group at both time points (P＜ 0.05).There were significant differences at time points, between groups,and “group × time” regarding serum IL‑1, IL‑6, TNF‑α, and SOD (P＜ 0.01) [Table 1].

Table 1: Comparison of serum levels between the two groups (±s)

Table 1: Comparison of serum levels between the two groups (±s)

*P＜0.05 compared with moxibustion group.IL: Interleukin, SOD: Superoxide dismutase, TNF: Tumor necrosis factor

Indicators Groups Before treatment At the end of treatment 2 months after treatment Ftime Finter‑group Fgroup × time IL‑1 (ng/L) Scraping group (n=40) 394.94±27.01 298.72±31.57* 251.13±27.80* F=905.594,P＜0.001 Moxibustion group (n=40) 393.86±28.56 337.88±29.32 284.52±23.58 IL‑6 (ng/L) Scraping group (n=40) 117.52±15.73 90.34±10.69* 48.11±7.43* F=866.609,P＜0.001 F=36.783,P＜0.001 F=9.940,P=0.002 Moxibustion group (n=40) 118.24±16.94 102.27±12.84 72.23±6.96 TNF‑α (ng /L) Scraping group (n=40) 136.62±14.24 90.00±10.85* 67.19±10.95* F=1115.687,P＜0.001 F=51.268,P＜0.001 F=35.646,P＜0.001 Moxibustion group (n=40) 136.25±15.59 111.43±11.23 81.27±9.02 SOD (U/mL) Scraping group (n=40) 102.64±17.10 144.70±18.51* 172.86±18.15* F=598.238,P＜0.001 F=42.558,P＜0.001 F=15.076,P＜0.001 F=13.279,P＜0.001 Moxibustion group (n=40) 105.66±13.79 133.17±16.16 157.67±15.60 F=11.489,P＜0.001

Clinical symptom integral

Before treatment, the difference was not statistically significant in the clinical symptom integral between the two groups (P＞ 0.05).However, the clinical symptom integral was lower in the scraping group than the moxibustion group at the end of treatment and 2 months after the treatment (P＜ 0.05) [Table 2].

Table 2: Clinical symptom scores between the two groups(±s points)

Table 2: Clinical symptom scores between the two groups(±s points)

*P＜0.05 compared with moxibustion group

Groups Before treatment At the end of treatment 2 months after treatment Scraping group(n=40)13.00±3.34 2.36±2.33* 3.78±1.46*Moxibustion group (n=40)13.13.±2.78 5.34±2.97 6.23±1.93

Knee pain Visual Analog Scale score

Before treatment, the difference was not statistically significant between the two groups regarding the VAS scores of knee pain (P＞ 0.05).The VAS score of knee pain was lower in patients of scraping group than those of moxibustion group at the end of treatment and 2 months after the treatment, and the differences were statistically significant (P＜ 0.05) [Table 3].

Table 3: Visual analog scale score of knee pain in two groups(±s points)

Table 3: Visual analog scale score of knee pain in two groups(±s points)

*P＜0.05 compared with moxibustion group

Groups Before treatment At the end of treatment 2 months after treatment Scraping group(n=40)8.68±1.58 1.58±1.06* 2.78±1.46*Moxibustion group (n=40)8.32±1.54 3.24±1.86 5.23±1.93

Effect of clinical treatment

The results of clinical efficacy evaluation showed that the total clinical efficiency was 87.50% in the scraping group, 67.50% in the moxibustion group; the difference was statistically significant between the two groups (P＜ 0.05) [Table 4].

Table 4: Comparison of clinical efficacy between the two groups n (%)

DISCUSSION

The pathogenesis of knee osteoarthritis is mainly related to free radicals, cytokines and growth factors, autoimmune reactions, and matrix metalloproteinase, of which TNF‑α,IL‑1, IL‑6, and SOD are the important media that affect the progression of osteoarthritis.[9,10]IL‑1 and IL‑6 are the initiators of inflammatory regulation that induces an acute‑stage inflammatory response.[11,12]TNF‑α is a multi‑functional inflammatory cytokine that accelerates the damage of bone and cartilage by stimulating the secretion of prostratin E by synoviocytes.[13]Moreover, it can promote the transformation of fibrin lysogen into fibrin lysozyme by stimulating human cartilage cells to release fibrin‑lysozyme activators, and then exacerbate the progression of arthritis.[14]However, scraping therapy can enlarge or rupture fine blood vessels to cause congestion, which, as a source of stimulation, forms a reflex,to activate physiological function, improve blood circulation,promote cell metabolism, accelerate toxin excretion, and reduce the content of IL‑1, IL‑6, and TNF‑α, thereby improving the immunity of the body.In addition, it makes subcutaneous capillary vessels broken, which, as a stimulus, activates SOD,enhances the functions of the important antioxidant defense system, and the removal of free radicals in the body, thus protecting cells from attacks and damage by free radicals.[15]In this study, at 2 months after interventions, the levels of serum IL‑1, IL‑6, and TNF‑α were lower, and the level of serum SOD was higher in the scraping group than those in the moxibustion group (P＜ 0.05), indicating that scraping therapy could indeed improve the levels of those indicators significantly, thus obtaining the effect of alleviating pain,inhibiting or exciting nerves, promoting qi‑blood circulation,regulating the functions of multiple secretory glands.

In the traditional Chinese medicine, the main mechanism of knee osteoarthritis is “deficiency and obstruction”, “deficiency”mainly refers to blood deficiency or liver and kidney deficiency,“obstruction” mainly refers to qi stagnation and blood stasis, or congealing cold, belonging to the syndrome of “deficiency in the root and excess in the surface”.The law of treatment should be mainly focused on “tonifying liver and kidney, activating the meridians and collaterals, promoting qi circulation and relieving pain”,[16,17]As the traditional characteristic sedative treatment of the traditional Chinese medicine, scraping therapy is also an external therapy with a long history.Base on the guidance of the theories of meridians and acupoints,the operator manually scrapes on the patient’ skin with special instruments (e.g., buffalo horn scraper) until the skin is flushing, or purplish red, or dark‑red spots and bleeding blisters appear, so as to activate the blood circulation and relieve pain.[18]By manually scraping to stimulate the patient’skin, acupoints, collaterals, and even deep tissue, it forces the external evils of wind, cold, and dampness invading the body and blood stasis to be expelled, thus playing the role in activating the blood, dredging meridians, loosening the adhesion, and improving local blood circulation.[19]In addition,scrapping stimulates the intuitive nerve of the patient’s skin,reflexively action on the vasomotor nerve, makes the blood vessels temporarily constrict, and then gradually dilates,so that the local blood volume and the blood flow increase significantly, which is, therefore, advantageous to the repair and renewal of the tissue and the restoration of the function.[20]

The operation part of scrapping is mainly related to 12 cutaneous regions.The skin, as one of the important components and the most superficial part of the meridians and collaterals system, is distributed by the qi of the collaterals.The skins that are treated with scraping therapy are distributed in thin collaterals, very small branches of meridians.Meridians,as the core of meridians and collaterals, have the major function of connecting the inner and the outer, makes the body an organic whole by connecting the limbs, tendons, joints,skins, and viscera, tissues, and other organs, and regulates qi and blood, yin and yang, body fluid of the whole body.[21,22]Therefore, through the function of the meridian and collaterals,scraping therapy, combined with moxibustion, restores the function of the affected limbs back to the normal.

In the process of implementing scraping therapy, disease health education was strengthened, which, to great extent,eliminated the patients’ fear of pain when scraping, so communication between the nurse and patients was smooth,patients were trusting in nursing staff, willing to cooperate with nursing work to compete scraping therapy.After intervention, pain degree of patients with knee osteoarthritis in scraping group was ameliorated more significantly than that in the moxibustion group.Moreover, the clinical total efficiency of the scraping group was higher than that of the moxibustion group, further indicating that scraping therapy reduced the patient’s pain and improved patients’ comfort to great extent.

CONCLUSION

In summary, this study reveals the mechanism of the effect of scraping therapy from the new angle of view of Chinese medicine characteristics, discusses the regulatory effect of scraping therapy on knee osteoarthritis, and provides the basic theoretical basis for the clinical treatment and nursing of knee osteoarthritis.In view of its advantages of relieving pain, shortening the course of disease and improving the quality of nursing work, it is worth further popularizing and studying clinically.

This article in the Chinese version was first published in the Nursing of Integrated Traditional Chinese and Western Medicine, Vol.4, No.10, 2018.For the sake of science communication of the traditional Chinese Medicine, it was authorized by the authors and Nursing of Integrated Traditional Chinese and Western Medicine for republication in English in the Journal of Integrative Nursing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.