Effect of moxibustion at sensitized-acupoints on quality of life in patients with chronic superficial gastritis

Huang He(黄河),Feng Fang (冯芳),Wang Jing (王晶),Fang Yuan (方园),Liu Mi(刘密),3,Chang Xiao-rong (常小荣),Xie Hui(谢辉)

1 School of Acupuncture,Moxibustion &Tuina,Hunan University of Chinese Medicine,Changsha 410208,China

2 Chenzhou No.1 People’s Hospital,Hunan Province,Chenzhou 423000,China

3 Liuyang Hospital of Chinese Medicine,Hunan Province,Liuyang 410300,China

Abstract

Keywords: Moxibustion Therapy;Moxa Stick Moxibustion;Heat-sensitive Moxibustion;Gastritis, Superficial; Quality of Life;Propensity Score Matching;Cohort Study

Chronic superficial gastritis (CSG)is a common digestive disease,and it is clinically manifested as non-specific dyspepsia.In mild cases, patients present with abdominal distension and fullness,gastralgia,belching,acid reflux and reduced food intake. While in the severe cases,it may affect their quality of life.Modern medicine has partly understood the pathogenesis of this disease,but there is still no specific treatment protocol[1].Acupuncture had a better clinical effect on CSG[2],and basic research also confirmed that acupuncture could effectively protect the gastric mucosa[3].A systematic review showed that the clinical efficacy of acupuncture in the treatment of CSG was superior to the conventional Western medicine in terms of safety and effectiveness[4].The clinical efficacy of acupuncture in the treatment of CSGhasbeen affirmed by evidence-based research.

With the deepening of theory and clinical research of acupuncture in recent years,more and more studies have shown that acupoints have different functional states.Some scholars put forward the theory of acupoint sensitization and believe that acupoints have two functional states,‘resting’and‘sensitized’.Sensitized acupoints are the specific manifestation of a disease on the body surface.When the body is in a disease state,the corresponding changes of acupoint sensitization may occur at the relevant acupoints,such as tenderness,nodules or string-like changes[5-6].Given relevant stimulation,the sensitized acupoints can present with‘small stimulation producing strong response’[7],that is,selecting sensitized acupoints to receive certain intervention measures can produce more significant clinical efficacy than using the resting acupoints[8-9].Under the premise of the same acupoints and stimulation amount,is there any difference in the curative effect of acupoints between different states?In this study,CSGpatientswere selected asthe subjectsto observe the difference in clinical efficacy between moxibustion at sensitized acupoints and non-sensitized acupoints.

1 Clinical Materials

1.1 Diagnostic criteria

This study referred the diagnostic criteria for CSGin the Consensus on Chronic Gastritis in China(2017,Shanghai)[1].Mucosal erythema,mucosal bleeding points or plaques,mucosal roughness with or without edema,hyperemia and exudation were observed under endoscopy.

1.2 Inclusion criteria

Those aged 20-75 years old;who met the diagnostic criteria for CSG;confirmed the diagnosis within 1 month before included in the trial;agreed to participate in this trialand signed informed consent.

1.3 Exclusion criteria

Those with mental,intellectualor language disorders;with peptic ulcer,severe dysplasia of gastric mucosa or malignant change confirmed by pathological diagnosis;patients with severe primary diseases of heart,brain,liver,kidney,or hematopoietic system;women during pregnancy or breastfeeding,or those who were planning for pregnancy in 6 months;who were participatingin other clinicaltrials.

1.4 Statistical methods

All data were statistically analyzed by SPSS version 19.0 statistical software.The process of propensity score matching (PSM)was implemented by PSM extension program.Counting data were processed by Chi-square test.TheRiditanalysis was used for ranked data.Measurement data in normal distribution were expressed as mean± standard deviation(±s).Pairedt-test was applied to intra-group comparisons.Independent samplet-test was applied to the between-group comparisons.Repetitive measurement and analysis of variance was applied for multiple measurements. All statistics were two-sided tests andP＜0.05 was considered to indicate a statistically significant difference.

1.5 Generaldata

CSG patients were recruited from the Acupuncture and Tuina Rehabilitation Department of the First Hospital of Hunan University of Chinese Medicine,the Acupuncture Rehabilitation Department of the Second Affiliated Hospital of Hunan University of Chinese Medicine,and the Acupuncture and Tuina Department of the Affiliated Hospital of Hunan Academy of Chinese Medicine between December 2018 and July 2019.All cases were naturally divided into a sensitized acupoint group and a non-sensitized acupoint group according to whether the patient presented with acupoint sensitization.The non-randomized grouping is suitable for clinical prospective cohort study[10], but it is easy to lead to research bias due to the imbalance of baseline data between groups[11].Therefore,PSM method was applied in this study to reduce the influence of covariates on the research results by balancing the baseline data between groups.

According to the requirements of the cohort study,139 subjects were initially included after the recruitment information was released.And then,all the participants were observed for sensitized sensations by moxibustion at Zhongwan(CV 12),Neiguan(PC 6)and Zusanli(ST 36).The patients were naturally divided into a sensitized acupoint group(102 cases)and a non-sensitized acupoint group(37 cases)according to whether there was acupoint sensitization.Before matching,the results of comparison between the two groups suggested that the distribution of age,disease duration,the traditional Chinese medicine(TCM)symptom score and short-form 36-item health survey (SF-36)score were imbalanced(allP＜0.05),(Table 1).In order to ensure the balance of the baseline data between the two groups,the four covariate samples between the groups were matched and balanced by the PSM function of the SPSS version 19.0 statistical software[11],1:1 nearest neighbor matching was used,

and caliper was set at 0.15.A total of 29 pairs of patients in the two groups were successfully matched.The unbalanced covariates of age,disease duration,TCM symptom score and SF-36 score between the two groups reached equilibrium after matching (allP＞0.05),(Table 2).

Table1.Comparison of general data between thetwo groups before matching

Table2.Comparison of general data between thetwo groups after matching

2 Treatment Methods

2.1 Seeking for sensitized points

The temperature in the detection room was maintained at 25-30 ℃.The patients took a comfortable position, with the acupoints fully exposed.Moxibustion at Zhongwan (CV 12), Neiguan (PC 6) and Zusanli(ST 36)was performed according to the standard of sensitized point seeking operation in the

Practical Book of Heat-sensitive Moxibustion[12].Different moxibustion sensations of patients during moxibustion were observed.The following special sensations were regarded as acupoint sensitization:heat penetration,that was,the warm sensation penetrated from skin surface of the moxibustion part into deep tissues; heat expansion, that was, the warm sensation expanded around taking the moxibustion point as the center; heat transmission, that was, the warm sensation transmitted from the moxibustion point to distant part; slight topical heat but significant distal heat; slight superficial heat but obvious deep heat;other non-heat sensations generated in the moxibustion area[5-7].

2.2 Treatment methods

After the detection for sensitized points, patients in both groups had the same moxibustion treatment at Zhongwan (CV 12), Neiguan (PC 6) and Zusanli (ST 36).The treatment was performed for 30 min, once the other day,continuing for 8 weeks.And 4-month follow-up was done after treatment.

3 Observation of Curative Efficacy

3.1 Observation items

3.1.1 TCM symptom score

The main symptoms included abdominal distension and fullness, gastralgia, and the secondary symptoms included belching, acid reflux and reduced food intake.The main symptoms were scored 0, 2, 4 and 6 points corresponding to no,mild,moderate and severe symptoms respectively, while the secondary symptoms were scored 0, 1, 2 and 3 points.

3.1.2 SF-36 score

SF-36 included 8 dimensions:physical function,role-physical,role-pain,general health,vitality,social function, role-emotional and mental health. The lower the score, the more severe the disease.

3.2 Criteria of curative efficacy

According to the curative efficacy criteria in the

Guiding Principles for Clinical Study of New Chinese Medicines[13],the efficacy criteria in this study were established. The improvement rate of TCM symptom score = (Pre-treatment score - Post-treatment score) ÷ Pre-treatment score × 100%.

Cured: Clinical symptoms disappeared basically, and the improvement rate of TCM symptom score was≥95%.

Markedly effective: Clinical symptoms were reduced significantly,and the improvement rate of TCM symptom score was≥75%,but ＜95%.

Effective:Clinical symptoms were reduced,and the improvement rate of TCM symptom score was ≥50%,but ＜75%.

Invalid:There were no obvious improvements in clinical symptoms,and the improvement rate of TCM symptom score was＜50%.

3.3 Results

3.3.1 Comparison of the clinical efficacy between the two groups

After treatment,the total effective rate was 100.0%in the sensitized acupoint group and 79.3% in the non-sensitized acupoint group.The difference between the two groups was statistically significant(P＜0.01),indicating that moxibustion at sensitized acupoints had a better effect than at non-sensitized acupoints(Table 3).

3.3.2 Comparison of the TCM symptom score between the two groups

Compared with the same group before treatment,the TCM symptom scores in both groups decreased significantly after treatment and at follow-up(allP＜0.01).Comparison between groups showed that the TCM symptom scores of the patients after treatment and at follow-up in the sensitized acupoint group were significantly lower than those in the non-sensitized acupoint group(allP＜0.01),indicating that the improvement in TCM symptom score in the sensitized acupoint group was superior to that in the non-sensitized acupoint group with moxibustion treatment at the same group of acupoints,also with a better long-term efficacy (Table 4).

3.3.3 Comparison of the SF-36 score between the two groups

Compared with the same group before treatment,the SF-36 scores of the CSG patients in both groups increased significantly after treatment and at follow-up(allP＜0.01).Comparison between groups showed that the SF-36 scores of the patients after treatment and at follow-up in the sensitized acupoint group were significantly higher than those in the non-sensitized acupoint group(allP＜0.01),indicating that the improvement in the SF-36 score in the sensitized acupoint group was superior to that in the non-sensitized acupoint group with moxibustion treatment at the same group of acupoints (Table 5).

Table3.Comparison of theclinical efficacy between the two groups(case)

Table4.Comparison of the TCM symptom score between the two groups( ±s, point)

Table4.Comparison of the TCM symptom score between the two groups( ±s, point)

Note:Compared with the same group before treatment,1) P＜0.01

Group n Before treatment After treatment Follow-up Sensitized acupoint 29 14.34±1.60 7.62±1.121)4.41±1.211)Non-sensitized acupoint 29 13.79±1.37 9.45±1.241) 6.55±0.911)t-value 1.404-5.900-7.603 P-value 0.166 0.000 0.000

Table5.Comparison of the SF-36 scorebetween thetwo groups( ±s, point)

Table5.Comparison of the SF-36 scorebetween thetwo groups( ±s, point)

Note:Compared with the same group before treatment,1) P＜0.01

Group n Before treatment After treatment Follow-up Sensitized acupoint group 29 96.75±6.22 118.38±4.491) 131.38±3.311)Non-sensitized acupoint group 29 99.29±4.60 113.03±4.021) 124.84±2.901)t-value-1.767 4.775 8.000 P-value 0.083 0.000 0.000

4 Discussion

CSG is one of the dominant indications of acupuncture and moxibustion, and it is also a hot spot in clinicalresearch of acupuncture and moxibustion[14-15].Our research team’s clinical studies over the years have shown[16-17]that moxibustion at Zhongwan(CV 12),Neiguan(PC 6) and Zusanli(ST 36)can effectively relieve the clinical symptoms in patients with superficial gastritis,and the long-term efficacy is more stable.The mechanism may be related to inducing the body to produce a large amount of heat shock proteins 70(HSP70)to inhibit the release of inflammatory cytokines.Modern basic studies on acupuncture showed that the action mechanism of Zhongwan(CV 12),Neiguan(PC 6)and Zusanli(ST 36)in treating this disease might be through regulating the blood nitric oxide/plasma endothelin(NO/ET)content to improve gastric mucosal blood flow, and ultimately preventing gastric mucosal damage[18-19].

In recent years,more and more clinical reports have shown that acupoint may have different functional states according to different states of the body,that is,acupoint has two functional states,‘resting’and‘sensitized’.When the body is in the state of disease,the corresponding changes of acupoint sensitization may occur at the relevant acupointson the skin surface,such as tenderness,topical nodules or string-like changes[5-6].Acupoints are both reaction points and treatment points of diseases. A large number of clinical studies suggested that sensitized acupoints were the specific manifestations of the disease on the body surface.Given specific stimulation,the sensitized acupoints could present with‘small stimulation producing strong response’[7],that is,selecting sensitized acupoints for certain intervention measures may produce better clinical efficacy than selecting resting-state acupoints[8-9].A recent study on acupoint sensitization showed that acupoints are specific,dynamic and sensitized body surface reaction sites in diseased states[20].Itsmanifestationshad variousforms,with disease specificity,and were also the acupuncture stimulation sites that regulate human functions to achieve the purpose of disease prevention and treatment.The occurrence of sensitization was mostly characterized by neurogenic inflammatory response.The inflammatory mediator in the‘acupoint sensitization pool’might be a biological program of endogenous regulation and initiation factor,that was,acupoint sensitization was the dynamic change process associated with diseased state[21].

Based on previousclinical observations and literature studies,we found that CSGpatients were more prone to have acupoint sensitization at Zhongwan(CV 12),Neiguan(PC 6)and Zusanli(ST 36).Therefore,in this study,grouping was based on whether these acupoints were sensitized or not.A cohort study wasused instead of a conventional randomized controlled trial to explore the efficacy difference in the treatment of CSGbetween sensitized and non-sensitized acupoints. The occurrence of acupoint sensitization is related to the patient’s own disease state and hasitsown characteristics.The cohort study is an observational study,which can objectively confirm the causality of the intervention effect under natural grouping[10-11].However,the non-random design of the cohort study can easily lead to an imbalance in the distribution of certain baseline covariates between the sensitized acupoint group and the non-sensitized acupoint group,resulting in selection bias.Therefore,in this study,PSM method was applied to eliminate the possible bias caused by covariates by balancing the mixed effects between variables and corresponding covariates[22-23],so as to make the analysis results more authentic and reliable.In this study,4 covariates of the baseline data before matching,including age,disease duration,TCM symptom score and SF-36 score were all unbalanced. Hence,the 1:1 nearest neighbor matching method was applied,and the caliper value was set at 0.15.As a result,a total of 29 pairs of patients in the two groups were successfully matched, so that the 4 covariates of the two groups were balanced.

In summary,TCM symptom score and SF-36 score were used in this study to compare the clinical difference between moxibustion at sensitized acupoints and non-sensitized acupoints in patients with CSG.After PSM processing,it was confirmed that the clinical efficacy of moxibustion at sensitized acupoints was better than at the non-sensitized acupoints in the treatment of CSGpatients,and the curative effect was more superior and stable.It provided an in-depth reference for using acupuncture and moxibustion to treat CSG,and abetter guide for clinicalpractice.

Conflict of Interest

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

Acknowledgments

This work was supported by National Basic Research Program of China (973 Program,国家重点基础研究发展计划, No.2015CB554502).

Statement of Informed Consent

Informed consent was obtained from the patients in this study.

Received:19 November 2019/Accepted:24 February 2020