Experimental Study And Clinical Observation Of Jiangu Granule In The Treatment Of Osteoarthritis

1.Objectives and significanceOsteoarthritis (OA) also called degenerative joint disease, the disease is the result of articular cartilage damage of integrity and articular cartilage under plate of bone lesions, leading to joint symptoms and signs are a heterogeneous group of diseases. According to the joint distribution can be divided into the limitations and systemic bone arthritis. Knee osteoarthritis (KOA) limitations of osteoarthritis in clinical common diseases, joint pain, stiffness, restricted activity, activity can be characterized with friction sound. The disease after the middle-aged multiple, the incidence increased with the growth of age, seriously endangering the health of the elderly.The etiology of OA is not completely clear, generally considered the pathogenesis of KOA is the main reason for biomechanical factors, genetic factors, exogenous factors involved in causing synovial membrane, cartilage and bone metabolism, and inflammation, joint structure damage. It’s most basic pathological changes of articular cartilage injury. Modern medicine thinks, cartilage degradation is one of the important aspects of cartilage degeneration. Many studies show that, OA cartilage degradation and cytokine expression abnormalities related to. Under normal circumstances, the matrix of articular cartilage catabolism and anabolism balance is through the decomposition of cytokines and synthesis of cytokines (i.e. growth factor) to maintain the balance of. Decomposition of cytokines such as interleukin-1(IL-1), is mainly stimulated the creation of special matrix metalloproteinases (MMP), induced matrix degradation, and through the stimulation of proliferation of synovial cells and degeneration induced by inflammatory mediators, formation, promoting synovial cell metalloproteinase secretion, inhibit or interfere with cartilage cells and phenotypic expression and so on. The tumor necrosis factora(TNF-α), matrix metalloproteinase-3(MMP-3) is involved in the pathogenesis of OA and important medium. The occurrence of OA and synovial cell proliferation is exuberant, excessive secretion of TNF-aand released into the blood, it has been reported that OA patients with synovial memory in a high concentration of TNF-a. TNF-acan activate multiple nuclear cells, stimulate synovial cells produce prostaglandin E2, promote cartilage matrix metalloproteinase synthesis and secretion, caused by absorption, degradation and destruction of articular cartilage. Scholars have reported that TNF-amain effects of synovitis and immunological reaction, can induce resistance to the cartilage of the autoimmune reaction, MMPs is involved in joint tissue damage is the main factor, can promote bone matrix degradation, inhibition of chondrocyte biosynthesis is hyaline cartilage properties of the proteoglycan and collagen type Ⅱ promotes formation of fibroblast cell characteristics of type I collagen, so that the cartilage cell degeneration, causing cartilage defects and the biomechanics of cartilage change, TNF-a, MMP-3in OA progression of potentially synergistic effect. Research shows that, MMP-3is one of the main members of metalloproteinases, mainly in OA patients with synovial cells, cartilage cells and mononuclear cells also have a small amount of expression. The study indicates that MMP-3is OA in the pathogenesis of important biological markers, OA in serum and synovial fluid in MMP3content and disease are closely related.TCM thinks of knee osteoarthritis belongs, bonerheumatism category, liver and spleen and kidney deficiency in this, qi stagnation and blood stasis phlegm, chill wet evil invasion, blockage of main and collateral channels as the standard, the virtual real standard of evidence. Liver spleen and kidney deficiency, and loss of support is the basis of the disease:in medicine, the knee for the liver spleen kidney three classics department, rib near the assembly. Liver storing blood main reinforcement, kidney essence bone, spleen transporting compound meat. While the OA occurred for the elderly, liver and kidney was waning, and idleness; reinforcement loss to raise, pliable; bone loss of bone marrow to raise, without strong meat; loss of spleen weakness, virtual win. So KOA and the incidence of liver spleen kidney three dirty was most closely related to. Stagnation of Qi, blood, phlegm is for knee osteoarthritis: an important link of gas as the commander of blood, blood gas and can cause blood stasis, blood stasis parent; exacerbation Qi stagnation. As the human knee is the biggest and largest weight-bearing joints joints, is also involved in the movement is the most important human body joint, the most vulnerable to injury. Knee joint injury, impaired blood spilled in context, main and collateral channels, obstruction, caused by qi stagnation and blood resistance, main and collateral channels blocked. Liver spleen and kidney deficiency or due to poor run, Qi and blood, phlegm main and collateral channels, knee joint and surrounding tissue loss of support, resulting in the degeneration of articular cartilage, resulting in the occurrence and development of KOA. Chill wet evil invasion, blockage of main and collateral channels, long and joint deformity, activity limitation, forming bone rheumatism, which is an important factor in the pathogenesis of KOA.At present western medicine in treatment of osteoarthritis in pain relief, prevent and delay the progression of the disease, preserve joint function, improve the quality of life. Principles of treatment to non drug therapy combined with drug therapy, when necessary, operation treatment. Non drug therapy include patient education, exercise and life coach and physical therapy. Drug treatment is divided into two categories:1) control the symptoms of drug:including antipyretic analgesics, nonsteroidal anti-inflammatory drugs, opioids, such as hormone;2) to improve the condition of medication (DMARAs) and chondroprotective agents:these drugs generally slow onset, requiring treatment for several weeks to work, has reduced matrix metalloproteinases, collagenase activity, anti-inflammatory, analgesic, and can protect the articular cartilage, delay osteoarthritis development. As of diacerein, it is IL-linhibitor, can inhibit cartilage degradation, promoting cartilage synthesis and inhibition of synovial inflammation. It not only can effectively improve the symptoms of osteoarthritis, reduce pain, improve joint function, also can delay the progress of osteoarthritis.Chinese medicine in the treatment of this disease mainly lies in the relief of pain symptoms, improve joint function, joint protection structure. Combined with the holistic concept of traditional Chinese medicine, treatment based on syndrome differentiation of traditional Chinese medicine, acupuncture, massage, etc. synthetically, the knee joint from the topical and systemic whole sets out, give full play to the advantages of traditional Chinese medicine comprehensive treatment, so that the patients symptoms improved.However, simple application, western medicine on the treatment of the disease has not yet been achieved breakthrough progress. Wherein, western medicine treat-ment cost is more expensive, and the prevalence rate is not a gastrointestinal side effects, poor compliance of the patient. Relatively speaking, Chinese medicine treat-ment has the advantages of simple inspection of cheap, good safety characteristics, suitable for long-term use, it caused more and more medical attention. But the single use of traditional Chinese medicine often slow onset, for some serious clinical symptoms of patients with rapid control is not ideal. Combination of traditional Chinese and Western medicine treatment can learn from each other, so that the traditional Chinese medicine and Western medicine to give full play to its therapeutic effect and reduce the side effects of Western medicine. Jiangu granule is the Department of rheumatism for treatment of osteoarthritis clinical application for more than20years of experience, from Herba Epimedii, digitalis, Gentiana, eucommia, radix salviae miltiorrhizae, radix, yanhusuo etc., has the functions of invigorating liver and kidney, gluten bone health, promoting blood circulation and relieving pain. The reuse of epimedium, eucommia, to nourish liver and kidney, strengthening bones and muscles. The study on the side of the mechanism.This article is divided two parts of Jiangu Granule in treating KOA treatment were studied. The first part of the study:the determination of the rat knee model of OA in serum and synovial fluid TNF-, the content of MMP-3, of Jiangu Granule in treating the action mechanism of OA; part second:Jiangu granule combined with diacerein treatment of knee osteoarthritis clinical research, observation of Jiangu Granule in treating knee osteoarthritis clinical efficacy, study of Chinese medicine combined with western medicine treatment of the effect of KOA; from the animal experiment and clinical observation of Jiangu granule for research, and to observe the combined with western medicine in the treatment of KOA advantage.2. The effect of Jiangu Granule on rats with knee osteoarthritis in serum and synovial fluid TNF-, MMP-32.1The main materials and reagents:48healthy Wistar rats, male and female in half, weight180-220g. Papain, rat interleukin TNF-ELISA quantitative determination reagent kit, rat interleukin MMP-3ELISA quantitative determination reagent kit. Traditional Chinese medicine Jiangu Granule by Duhuo, epimedium, eucommia, hyssop, Radix Cynanchi paniculati, Gentiana, Salvia miltiorrhiza, Xuan Hu, raw land, Rhizoma Anemarrhenae. Diacerein, specification:50mg/.2.2Animal model and experimental group:48healthy Wistar rats, adaptive feeding after1weeks, the random sampling of40, divided into four groups, the normal group, model group, diacerein group, Jiangu granule group,10rats in each group. Besides normal group were to be molding, molding in reference on rat right knee joint cavity injection of4%papain saline solution0.2ml, every3D1injection, continuous injection of3successful model. According to experimental animal and adult dosage conversion formula, calculated dose, diacerein Jiangu granule0.009g/kg,2.7g/kg, normal group and model group gives the corresponding dose of saline, once daily,4weeks after operation.2.3Specimens collecte:the rats supine tied to small animal operation table, femoral artery blood, after centrifugation, at-20℃refrigerator. Extraction of each animal knee joint lavagelml after centrifugation, taking supernatant-20℃refrigerator testing.2.4Indexes:enzyme-linked immunosorbent assay for the detection of in serum and synovial fluid MMP-3and TNF-content.2.5Statistical analysis:SPSS13.0software was used for statistical analysis. Measurement data based on mean±standard deviation indicates, the differences between groups with single factor analysis of variance, witha=0.05is a remarkable level.2.6Results2.6.1General situation:normal group lively, shiny hair, normal activity and diet, no joint swelling; model group was dispirited move less, less glossy hair, hair removal is obvious, eat less, local swelling, has obvious licking and claudication phenomenon. The rats in the treated groups the performance compared with the model group were improved in different degree.2.6.2Pathological observation of normal cartilage matrix:pink colored uniform, smooth surface, cartilage, cartilage cells are arranged in rows, four layers of structure clear, tidal line integrity. Model group of articular cartilage damage is most severe, the cartilage surface roughness is not whole, cartilage surface erosion, completely denuded, forming defect area. Double promote ray was group of four layer structure is basic and clear, the tidal line the basic integrity, little articular chondrocytes with mild degeneration. Jiangu granule group within articular cartilage have less infiltration of inflammatory cells, chondrocytes with mild degeneration, tidal line integrity.2.6.3Serum TNF-α, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=75.035, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.778), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=77.336, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.847), the difference was not statistically significant.2.6.4Synovial TNF-a, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=40.783, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.191), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=275.255, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein, Jiangu granule group and comparison group (P=0.065), the difference was not statistically significant.3. Clinical research of Jiangu granule combined with diacerein treatment of knee osteoarthritis.3.1Clinical data3.1.1120cases of were3～in2011November South Hospital Outpatient Department of traditional Chinese medicine and Hongkong Wu Jiejin massage acupuncture medical center clinic patients with knee OA,85of them from southern hospital outpatient department of traditional Chinese medicine,35from the Hongkong Wu Jiejin massage acupuncture museum. Were randomly divided into group A (Jiangu granules in treatment group), group B (diacerein treatment group), group C (Jiangu Granule plus vinegar ray was the treatment group40cases each). Group A male11cases, female29cases; age49～69years, average (61±5.08) years old; the average course of disease (3.20±1.10) years; according to OA imaging diagnostic criteria for, radiology diagnostic criteria:grade Ⅰ in8cases,14cases in grade Ⅱ,16cases in grade Ⅲ,Ⅳ in2cases. Group B male13cases, female27cases; age53～69years, average (62.38±4) years old; the average course of disease (2.88±1.27) years; imaging diagnosis grading:grade Ⅰ in9cases,16cases in grade Ⅱ,14cases in grade Ⅲ,Ⅳ in1cases. Group C male12cases, female28cases; age46～68years, average (60.38±4.68) years old; the average course of disease (3±1.13) years; imaging diagnosis grading:grade Ⅰ in7cases,22cases in grade Ⅱ,10cases in grade Ⅲ,Ⅳ in1cases.3groups of sex, age, course of disease, joint imaging diagnosis grading statistically, there were no significant differences (P>0.05), with comparable.3.1.2Diagnosis standards:In line with the American College of rheumatology for OA diagnosis standard.3.1.3Exclusion:Criteria to exclude secondary osteoarthritis, septic arthritis and other causes of joint disease; later, the ruined OA and accompanied by severe heart, liver, kidney disease, gastrointestinal lesions and activity in pregnant or lactating women also are not into the group.3.2Methods of treatmentA group of Jiangu granule clothing, daily1agent, boiling water,150mL each time,2times a day. B group taking diacerein tablets,50mg each time,2times a day. C group of more than2drugs in combination use, dosage and dosage. The3groups are in January forl courses,3courses of treatment.3.3Outcome measures and curative effect standard3.3.1Observation:knee joint pain index regular reexamination records, joint tenderness, swelling of the joints, joint activities and20m walking time changes before and after treatment; regular review of blood, urine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and kidney function, knee X line photograph. All patients with knee joint the bilateral score, average.3.3.2Joint target observation score standard:①The joint pain score standard:0points:painless;1:mild pain, can be tolerated, no effect of sleep;2:moderate pain, slightly affect the action and sleep;3:severe pain, unbearable, significantly affect the activity and sleep.②The joint tenderness score:0:no tenderness;1:mild tenderness, pressing joint circumference, patients referred pain;2moderate tenderness, pressure joint circumference, in patients with facial pain;3:severe tenderness.③The joint swelling score:0:no swelling;l:mild swelling;2:moderate swelling;3:marked swelling.④The joint function obstacle classification standard:level0:no limitation of joint movement;1grade:joint activity in mild restriction; grade2:joint activity of moderate restriction;3-4:joint activity was limited.⑤The walking time in seconds (20m:s), repeated2times, and the average value.3.3.3Standard of effect:Effect:signs and symptoms disappeared, joint function of normal,5observation indexes were improved significantly; Better:signs and symptoms disappeared, the occasional activities when the pain, joint flexion and extension in the range of80°-135°, can participate in daily work and labor,5indicators of4above improvement of symptoms and signs; Invalid:no significant improvement,5observation index less than improvement.3.4. Statistical methodsUsing SPSS13.0statistical analysis software, all the measurement data are (x±s), group before and after treatment were compared using the paired t test, multiple groups before and after treatment difference compared with single factor variance analysis, multiple comparison using LSD method; count data were compared with x2test, multiple groups of rank data using Kruskal-Wallis method inspection. Taking P<0.05as the difference was statistically significant.3.5Treatment outcomes3.5.1Comparison of general data:Between three groups before treatment.40cases of A group,40cases in B group,40cases in C group, three groups before treatment in patients with age, gender, the course of KOA had no significant difference (P>0.05), with comparable3.5.2Three groups before and after treatment clinical indicators comparison (table3-7).(1) Treatment of joint pain:After3months, after treatment, A, B, C group of patients with knee pain has improved and improved, and before treatment in comparison, there are significant difference (t=14.171, P=0.000; t=14.000, P=0.000; t=16.574, P=0.000); group three joint pain severity before and after treatment with difference difference comparison (F=4.721, P=0.011), A group before and after treatment difference is higher than that of B group, but the two groups before and after treatment, the mean difference were comparable between groups, the difference was not significant (P=0.864); C group before and after treatment is superior to that of A, difference between B group, there were significant differences (P=0.011, P=0.007).(2) Joint tenderness comparison:joint tenderness degree after treatment in the three groups, group C is better than A, B group, there was statistically significant difference (χ2=10.484, P=0.005).(3) Compared with joint swelling degree:group C is better than A, B group, there was statistically significant difference (x2=15.740, P=0.000).(4) Dysfunction:treatment after3months, after treatment, A, B, C group of patients with knee joint dysfunction has improved and improved, and before treatment in comparison, there are significant difference (t=10.494, P=0.000; t=9.802, P=0.000; t=14.207, P=0.000); group three joint dysfunction degree before and after treatment are different (difference comparison F=4.903, P=0.009), A group before and after treatment difference than that of B group, the difference was not significant (P=0.335); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.038, P=0.003).(5) Running time comparison:treatment after3months. after treatment, A, B, C group of patients walking time to improve and better, and before treatment in comparison, there are significant difference (t=18.976, P=0.000; t=17.814, P=0.000; t=25.706, P=0.000); three groups of traveling time difference value difference between before and after treatment (F=20.861, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.497); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).3.5.3Laboratory indexes comparison(1) ESR:comparison of treatment after3months, after treatment, A, B, C group of patients with ESR have improved and improved, and before treatment in comparison, there are significant difference (t=5.262, P=0.000; t=5.046, P=0.000; t=7.44, P=0.000); three groups before and after treatment with ESR difference difference between the (F=11.057, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.626); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).(2)CRP:comparison of treatment after3months, after treatment, A, B, C group of patients with CRP have improved and improved, and before treatment in comparison, there are significant difference (t=4.477, P=0.000; t=5.101, P=0.000; t=7.879, P=0.000); three groups before and after treatment with CRP difference difference between the (F=3.474, P=0.034), A group before and after treatment difference than that of B group, the difference was not significant (P=0.852); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.019, P=0.031).3.5.4Cure rate comparison:C group was significantly better than A and B, there was significant difference (χ2=11.706,P=0.003)3.5.5Adverse reactions compared:adverse reactions in group A、C was lower than that in the B group, comparison between groups, there were significant differences (χ2=14.867,P=0.001)4.ConclusionExperimental study and clinical observation results show that:4.1Jiangu granule can reduce osteoarthritis of knee joint fluid in rat serum, TNF-α, MMP-3content, its body cytokines have a regulatory role, through inhibition of synovial inflammation, reduce cell active factor out, thereby relieving various cytokines on articular cartilage matrix damage, improvement of cartilage matrix metabolism, promote cartilage repair;4.2Jiangu Granule in the treatment of osteoarthritis of the knee is safe and effective;4.3Jiangu granule combined with diacerein treatment knee OA, clinical curative effect was better than that of Jiangu granule or single use of diacerein, can rapid control of clinical symptoms, and can relieve pain, improve articular cartilage metabolism, inhibition of cytokines, delaying disease progress, not only has good curative effect and lasting, and good safety.