| BackgroundKnee osteoarthritis (KOA), a chronic degenerative disease of bones and joints, is very common in elderly people. It belongs to the scope of’Gubi’in TCM. Knee pain, swelling, stiffness and restricted movement are main clinical manifestations of KOA. As China is entering aging society, there are more than100million people over the age of60, among which more than50million suffer from KOA. Due to imbalanced diet, unhealthy living habits and lack of exercises, the incidence of KOA leads to an upward trend. The recurrent onsets of KOA lead to disability and make the patient suffer a lot, which reduces the patients’ quality of life to a great extent. It has become a serious social-economic problem. By now, the etiology and pathogenesis of KOA are still not clear, and there is no specific medicine but symptomatic treatment for it. Taking western medicine like non-steroidal anti-inflammatory drugs may lead to serious side effects and high rate of relapse. In UK, there are more than2000patients died of taking non-steroidal anti-inflammatory drugs for long time every year. Surgery is hardly accepted by patients since it is companied by serious trauma expensive cost and more complications. Therefore, doctors home and abroad are finding a treatment for KOA with obvious efficacy, less side effect, simple operation and easily accepted by patients. Large numbers of papers reported that combined treatment of TCM, i.e. acupuncture and moxibustion, massage, cupping, physiotherapy and Chinese herbs for oral administration or external use, has reached considerable effect and became the first choice for conservative treatment on KOA. The acupoint application and massage are traditional way of treating KOA in TCM. They are also clinical operative techniques that Chinese medicine nurses should master. Clinical studies have shown that acupoint application can play the role of drugs and acupoint stimulation simultaneously, which can dredge meridians and collaterals, adjust qi and relieve swelling and pain, so as to treat KOA effectively. Studies have also shown that massage with certain manipulations on corresponding points of body surface can adjust the balance of yin and yang, dredge meridians and collaterals, loosen adhesion, smooth the join. It has significant effect on improving joint range of motion. It is more easily accepted by patients since it has no side effect and provides a comfortable feeling. However, the acupoint application combined with massage treatment on knee osteoarthritis is seldom reported.ObjectiveTo study the clinical efficacy of the treatment of Hanbi Powder acupoint application combined with the acupoint massage on osteoarthritis of the knee. Base on clinical evidence. the study is guided by the basic theory of TCM and combined with clinical practice and flexible TCM nursing skills, to explore a simple, safe, effective and easily accepted treatment for KOA, thus to provide efficient care of high quality for patients.Methods90hospitalized patients with KOA were recruited according to case exclusion criteria and inclusion criteria from orthopedic department in a3A hospital from January of2012to December of2012. Subjects were randomly divided into three groups:test group, control group I and control group II,30patients in each group. Case inclusion criteria:meet the diagnostic criteria of KOA; TCM syndrome types were cold and dampness type or liver and kidney deficiency type; between40-75years old; without taking any steroid since1month before and during the experiment. Case exclusion criteria:failed to meet case inclusion criteria or diagnosis criteria; having other diseases with similar manifestations of KOA; having complication of other diseases affecting the knee joint; cases combined with vascular diseases of heart and cerebra or vital diseases; overweight (body mass Index is greater than30).Before treatments, there was no significant difference(P>0.05) between the3groups on gender, age, course of disease, condition, WOMAC scores and other symptoms scores as well. The baseline showed no significant difference.The control group I was treated with acupoint application therapy. The Hanbi Powder (3cm×3cm) was attached to the selected8points, which is the same as the observation group. Removed them after4～6h. Treatment was done once a day,10days for a course.The control group II was treated with acupoint massage therapy. The patient was on sitting or supine position, bending affected knees60degrees. The operator was on the affected side of the patients. Tapped limb60times and relaxed the limb following the channels and collaterals. Rubbed the knee region surrounding patella30times, alternately using palms until the local was reddish and warm. Pressed and kneaded selected points with thumb or index finger pulp, each acupoint30times, about1minute for each point. Force of massage should be penetrative. Intensity was suitable when patient feels sore, numb, distending like the sensation of qi. Repeatedly tapped the limb60times to relax. Flexed and extended the knee passively10times.The test group was treated with acupoint application combined with acupoint massage therapy. The specific steps were as following:Firstly, acupoint massage therapy was done like the control group II. Then The Hanbi Powder (3cm×3cm) was attached to the selected8points, which was the same as the control group I. Removed them after4-6h. Treatment was done once a day,10days for a course.Points selection of the three groups were the same,8points at once. The following points were selected alternatively:Yang/Yin Ling Quan, Internal/External Xi Yan, Zu San Li, Xue Hai, Liang Qiu, Cheng Shan, He Ding, Wei Zhong and A-shi point.The same daily conventional care and health education were carried out to all the three groups. WOMAC was used to observe curative effect and side effect. To compare the WOMAC scores, knee signs scores and clinical efficacy of the3groups after two courses of treatment, altogether20days.Efficacy was measured by Canada WOMAC score and knee signs evaluation. The evaluation standard was based on ’Guidelines of Clinical Research on Chinese Medicine Treatment for Osteoarthritis’. Efficacy were measured by4grades:clinical control, effective, markedly effective, ineffective. Treatment efficiency=(control+markedly+effective)÷total number of cases x100%.Information and data of subjects were input into database. The Statistics Analysis System9.3was used. T test was used to compared scores before and after treatment for each group. Analysis of variance was used for comparison of multiple groups of measurement data (for pair comparisons, LSD was used when variance were equal, Games-Howell was used when it is not). Kruskal-Wallis rank sum test was used for comparison of multiple groups of ranked data(pair comparisons, Nemenyi test was used). P value less than or equal to0.05was considered statistically significant.Results 1) WOMAC scores for each item and the total score for the3groups before and after treatment were as following:Paired t-test showed that the WOMAC score of the three groups were improved after treatment (P<0.05). Variance analysis showed that,, the difference among the three groups in WOMAC scores for each item and the total scores was statistically significant (P<0.05). Between any two groups, there were significant differences in pain degree scores after treatment (P<0.05). Stiff scores were significant different (P <0.05) between the control group I and the control group Ⅱ, as well as the control group I and the observation group. Motion scores were statistically significant different (P<0.05) between the control group I and the control group II, as well as the control group I and the test group. Comparison of the total WOMAC scores shows significant differences (P<0.05).2) Knee signs evaluation of the3groups before and after treatment were as following:Paired t-test showed that in the control group I, range of motion score and swelling score had no significant difference (P>0.05) after treatment. The rest evaluation were ameliorated. Scores of each sign and total score of the control group II were improved after treatment (P<0.05), as well as the observation group. The variance analysis showed that there were significantly difference among3groups on scores of knee tenderness and range of motion (P<0.05), but not on joint swelling score (P>0.05). Pair comparison have shown that range of motion score after treatment was significant different(P<0.05) between the control group I and the control group Ⅱ, as well as the control group I and the observation group. There was no significant difference between the control group II and the test group (P>0.05). There was significant difference in tenderness score (P<0.05) between the control group I and the control group Ⅱ, the control group Ⅱ and the test group, but there was no significant difference (P>0.05) between the control group I and the observation group. The total scores between the control group I and the observation group, the control group II and the observation group were significantly different (P<0.05), the control group I and the control group Ⅱ had no significant difference (P>0.05).3) The general efficacy of the3groups were as following:Kruskal-Wallis rank sum test was used to compare the difference of general efficacy among the3groups, which showed that the difference was statistically significant (H=10.91,.P=0.0043). The Nemenyi test was used for pair comparisons, which showed that there was no significant difference between control group I and control group Ⅱ(χ2=2.21, P=0.3314) P>0.05; there was significant difference between control group I and the test group (χ2=10.85, P=0.0044) P<0.05; there was significant difference between control group II and the teat group (χ2=9.43, P=0.0283)P<0.05.Conclusions:1) Acupoint application, acupoint massage and acupoint application plus acupoint massage therapy can all improve WOMAC scores of KOA patients. All the3methods were effective on improving clinical symptoms such as knee pain, swelling, stiffness, etc and enhancing the activity of daily living. Acupoint application shows no significant effect on improving range of motion or alleviating swelling.2) According to WOMAC scores, on alleviating the symptoms of knee pain, acupoint application plus acupoint massage group was more effective than acupoint application group, while acupoint application group was better than massage group. Efficacy of the massage group is correspond to the acupoint application plus acupoint massage group on improving the knee stiffness, which is more excellent than acupoint application group. For improving patient activity, the acupoint application plus acupoint massage group is correspond to the massage group, which is better than the acupoint application group. For improving the overall symptoms of patients, the acupoint application plus acupoint massage group is more effective than the massage group, the massage group is superior to the acupoint application group.3) According to sign evaluation, for improving the range of motion, the acupoint application plus acupoint massage group is more effective than the massage group, which is superior to the acupoint application group. For improving the patient’s knee swelling, the efficacy of3groups have no significantly difference. For improving the knee tenderness, efficacy of the acupoint application plus acupoint massage therapy equals to the acupoint application therapy, which is better than massage therapy. For improving the total sign scores, efficacy of the acupoint application therapy and the massage therapy are worse than acupoint application plus acupoint massage therapy.4) The clinical efficacy of acupoint application plus massage group is superior to the acupoint application group and the massage group. Difference between acupoint application group and massage group are not significant.5) The Hanbi Powder acupoint application plus acupoint massage therapy on treating KOA can be operated by the nurses alone, having superiority as safe, effective, affordable, and patients are easy to accept, which is worthy of clinical application. |
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