World Journal of Acupuncture – Moxibustion 29 (2019) 83–90

Contents lists available at ScienceDirect

World Journal of Acupuncture – Moxibustion

journal homepage: www.elsevier.com/locate/wjam

Clinical Research

The effect of five-knee-point acupuncture combined with herbal

package warm compress for knee osteoarthritis
Hui LIANG () a, Zhuo-rong LI () b,∗, Junwei CHEN () b, Hui-wen LUO (
) c
a
Rehabilitation Medicine Department, Jiangmen Second People’s Hospital, Jiangmen 529000, Guangdong Province, China (
,  529000, )
b
Rehabilitation Department, Jiangmen Wuyi Hospital of Traditional Chinese Medicine, Jiangmen Traditional Chinese Medicine Hospital Affiliated to Jinan
University, Jiangmen 529000, Guangdong Province, China (, ,  529000, )
c
Graduate School of Hunan University of Traditional Chinese Medicine, Changsha 410000, Hunan Province, China (, 
410000, )

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To observe the therapeutic effect differences among five-knee-point acupuncture combined
Available online 30 May 2019 with Chinese medication package warm compress therapy of Shēntòng Zhúyū Decoction ( gen-
eralized pain stasis-expelling decoction), simple five-knee-point acupuncture and simple Chinese medica-
Keywords:
Five-knee-point acupuncture tion package warm compress therapy of Shēntòng Zhúyū Decoction in treating knee osteoarthritis (KOA).
Shēntòng Zhúyū Decoction Methods: A total of 126 KOA patients were randomized into a five-knee-point acupuncture combined
Chinese medication package warm with Chinese medication package warm compress therapy group (combined treatment group), where
compress therapy there were 42 cases, including 28 cases of unilateral KOA and 14 cases of bilateral KOA, totally 56 af-
Knee osteoarthritis fected knees involved, a Chinese medication package warm compress therapy group (medication package
Bone bi group, 42 cases, including 22 cases of unilateral KOA, 20 cases of bilateral KOA, totally 62 affected knees
involved) and a five-knee-point acupuncture group (five-knee-point group, 42 cases, including 27 cases
of unilateral KOA, 15 cases of bilateral KOA, totally 57 affected knees involved). The basic health educa-
tion was provided in all of the groups. Additionally, in the combined treatment group, acupuncture was
applied to the five knee points on the affected side for 30 min. The warm compress with herbal package
of Shēntòng Zhúyū Decoction was given for 10 to 15 min. In the medication package group, the warm
compress with Shēntòng Zhúyū Decoction was exerted on the affected area for 10 to 15 min. In the five-
knee-point group, acupuncture was applied to SP 10, ST 34, EX-LE 2, EX-LE 4 and ST 35 and the needles
were retained for 30 min. The treatment in each group was given once a day, consecutively for 2 weeks.
Before and after treatment, the visual analogue scale (VAS) and Lysholm knee scale were adopted to eval-
uate the pain degree and knee joint motor function in KOA patients. The clinical therapeutic effects were
evaluated too.
Results: A total of 121 cases accomplished the final observation and 5 cases were dropped out in the
three groups, in which, 2 cases (2 affected knees) were dropped out in the combined treatment group,
1 case (2 affected knees) in the medication package group and 2 cases (3 affected knees) in the five-
knee-point group. VAS scores after treatment were all lower than those before treatment in the three
groups and the scores of Lysholm knee scale were all higher than those before treatment, indicating the
significant differences (all P < 0.05). The total effective rate was 98.1% (53/54) in the combined treat-
ment group, which was higher than 86.7% (52/60) in the medication package group and 92.6% (50/54)
in the five-knee-point group, indicating the significant differences (all P < 0.05). After treatment, VAS
score (2.24 ± 1.24) in the combined medication group was lower than (2.48 ± 1.38) in the medication
package group and (2.63 ± 1.44) in the five-knee-point group, presenting the significant difference (all P
< 0.05). The score of Lysholm knee scale was (60.50 ± 13.76) in the combined medication group, higher
than (52.23 ± 11.65) in the medication package group and (52.14 ± 11.77) in the five-knee-point group,
indicting the significant differences (all P < 0.05).

∗
Corresponding author.
E-mail address: lizhuorong007@163.com (Z.-r. LI).

https://doi.org/10.1016/j.wjam.2019.05.010
1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
84 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90
Conclusion: Compared with the simple application of Chinese medication package warm compress ther-
apy of Shēntòng Zhúyū Decoction or the five-knee-point acupuncture therapy, five-knee-point acupuncture
combined with Shēntòng Zhúyū Decoction relieves the clinical symptoms of KOA patients more effectively
and achieves a better clinical therapeutic effect.
© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
Introduction
Knee osteoarthritis (KOA) is a kind of chronic osteoarthritis
manifested as progressive structural deformation, destruction,
loss, hyperosteogeny and adhesion of periarticular tissue and
subcartilage [1]. KOA is characterized as primary or secondary
degeneration of articular cartilage, the formation of new bone at
the edge of the joint and higher speed of degeneration than the
speed of repair and regeneration. It is manifested as joint pain,
swelling, stiffness, joint effusion and motor impairment. KOA is
especially seen in the middle-aged people and the elderly [2]. The
incidence of the disease of the population over 60 years old is
78.5% [3] and the incidence of the disease in female is higher than
that in male [4], especially in postmenopausal middle-aged and
elderly women [5]. This disease seriously affects the quality of life
of the patients. At present, for the clinical first-line treatment of
KOA, in western medicine, except the surgical treatment for the
severe cases, such as artificial joint replacement and high tibial
osteotomy, most patients take conservative treatment to relieve
joint pain and recover joint function, such as oral administration of
painkillers, non-steroidal anti-inflammatory drugs and nutritional
cartilage medications, as well as immunosuppressive agents and
joint cavity injection. These therapies relieve joint pain, but the
long-term medication may cause severe liver and kidney damage
and gastrointestinal reaction [6]. In the conservative treatment
with traditional Chinese medicine (TCM), acupuncture achieves
the definite effect of KOA and the comprehensive treatment with
other therapies has been extensively provided in clinical practice.
However, there are some shortcomings. For instance, the acupoint
selection is not unified, the duration of treatment is relatively
long, the therapeutic procedure is complicated and the disease
fails to be cured [7]. Therefore, it is necessary to explore a kind
of comprehensive acupuncture therapy with more standardized
and convenient manipulation and easy acceptance by the patients
with KOA. In more than ten years of clinical work, the authors
have summarized the experience in the treatment of KOA and
put forward a set of unique acupuncture therapy, named the five-
knee-point acupuncture therapy. The satisfactory therapeutic effect
has been obtained. Generally, KOA is identified as three patterns
in TCM, named kidney and marrow deficiency, yang deficiency
and cold stagnation, and blood stagnation [8]. It is found that
the proportion of blood stagnation pattern is the highest of these
three patterns in clinical practice. Hence, in this clinical study, the
therapeutic effect was observed focusing on such kind of pattern
of KOA. On the one hand, such clinical study is significant and
practical in terms of clinical demand, and on the other hand,
regarding the pattern identification and treatment determination,
the effect of the simple five-knee-point acupuncture therapy is
slightly unsatisfactory. It is known that the treating principle
is determined by the symptoms and pattern identification, the
herbal formula relies on the therapeutic method and is composed
by herbal medications. It is the reason why the herbal formula
for activating blood circulation, resolving stasis and promoting
circulation of meridian were added in this study. Shēntòng Zhúyū
Decoction ( generalized pain stasis-expelling decoction),
prepared by Qing-ren WANG, acts on removing obstruction and
stopping pain, especially for bi syndrome due to blood stagnation.
Such combined treatment should obtain the better effects theo-
retically. Therefore, in this study, acupuncture was combined with
Chinese herbal medication. The five-knee-point acupuncture ther-
apy is characterized as less acupoints and simple manipulation.
The Chinese herbal medication package warm compress therapy
with Shēntòng Zhúyū Deconction is characterized as convenient
operation and material preparation. The report is as follows.
Clinical data
General data
A total of 126 KOA cases were collected from the outpatients
and inpatients of the department of rehabilitation medicine, Jiang-
men Second People’s Hospital from May 2017 through October
2018. According to the random number table, they were random-
ized assigned into a five-knee-point acupuncture combined with
Chinese medication package warm compress therapy group (com-
bined treatment group), a Chinese medication package warm com-
press therapy group (medication package group) and a five-knee-
point acupuncture group (five-knee-point group), 42 cases in each
group. This study was approved by the ethics committee of the
Second People’s Hospital, Jiangmen, Guangdong Province (No. JY
2018-29). The differences were not significant statistically in gen-
der, age, lesion region, body mass and disease duration, indicat-
ing the comparability in the patients among the three groups. See
Table 1.
Diagnosis criteria
(1) Diagnosis criteria of western medicine
In reference to Guideline on Diagnosis and Treatment of Os-
teoarthritis [9] developed by the Orthopaedics Branch of Chinese
Medical Association in 2007, the diagnosis criteria of KOA includes
the following items:  1 repeated pain of knee joint at least for 1
month;  2 narrow joint space, osteophyte formation on joint mar-
gin, subcartilage bone sclerosis and cystic degeneration found in
the X-ray film in a standing or load-bearing position; 3 thick and
clear joint fluid, WBC < 2 0 0 0 counts / mL, presenting at least for
2 times;  4 aged over 40 years;  5 morning stiffness for at least
30 min every day;  6 rubbing sound or rubbing feeling presented
during knee joint movement. KOA is diagnosed when in compli-
ance with  1 + 2, 
1 +3 +
5 + 6 or 1 +4 + 5 +6.
(2) Clinical staging criteria
According to pain severity, the swelling and deformity of joint
and the results of X-ray film and CT scanning, KOA was identi-
fied into different clinical stages [10]. 
1 The stage I: slight dis-
comfort in joint movement, joint swelling and pain presented after
movement, no obvious cartilage damage shown in X-ray film and
CT scanning.  2 The stage II: obvious pain after a large amount
of motor activities and relieved after rest, no change found in X-
ray film, while mild cartilage damage discovered in CT scanning,
the condensation presenting in damaged joint in the isotopic de-
tection. 3 The stage III: aggravated osteochondral damage, joint
deformity, loss of some motor function, reduced joint space, cys-
tic change around the joint, and free body in interosseous space
 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90 85

found in X-ray film. 

5 The stage IV: obvious joint deformity, com-

Mean±SD

52.6 ± 6.4
49.3 ± 7.8
47.7 ± 8.3
plete loss of motor function, bone hyperplasia, exfoliated cartilage,
the narrowing of joint space, severe hyperplasia, even bone col-
lapse found in X-ray film.

(3) Identification criteria of the syndromes in traditional Chinese

Maximum
Disease duration (days)
medicine (TCM)

58
65
61
In reference to the criteria on bone bi syndrome of blood stag-
nation in Criteria of Diagnosis and Therapeutic Effects of the Disor-
ders in Traditional Chinese Medicine [8], The diagnosis criteria of
Minimum TCM include stabbing joint pain with fixed location, joint defor-
mity, motor impairment, or bent back, dark complexion, deep pur-
39
35

37
plish tongue and lips, deep or thready and string-taut pulse.
Mean±SD

55.3 ± 4.4

55.4 ± 4.8
55.6 ± 5.1

Inclusion criteria

(1) In compliance with the diagnosis criteria of KOA; (2) in

compliance with the stage I and the stage II in clinic; (3) in
Maximum

compliance with bone bi syndrome of blood stagnation; (4) aged

from 40 to 70 years; (5) in the recent 1 month, no use of the
72.7
76.2

74.1

other therapeutic methods that affect the observation results, such

Body mass (kg)

as medications, surgery, and the therapeutic methods other than

Minimum

this clinical research; (6) participating in this clinical observation

voluntarily and signing the informed consent.
48.7

50.3
49.1

Exclusion criteria
Bilateral
Lesion location (Cases)

(1) Complicated with severe organic diseases, i.e. heart, brain,

20
15
14

liver and kidney, hematopoietic diseases and severe mental ill-

ness; (2) complicated with bone tumor, bone tuberculosis, gout,
Unilateral

rheumatoid disease or acute trauma of knee joint, local skin lesion;

(3) obvious narrow joint space of knee, severe joint deformity that
affects the needle insertion, i.e. valgus and varus deformity;
28
22
27

(4) pregnant or lactating women; (5) susceptible to allergy or

fainting during the manipulation.
Mean±SD

56 ± 8
53 ± 9
55 ± 8

Rejection criteria

(1) Not in compliance with the inclusion criteria after recruited

Maximum

or in compliance with the exclusion criteria; (2) failing to obey the

requirement of treatment regimen, changing the treatment meth-
66

65
70

ods at will, failing to participate in the whole trial because of poor

compliance, or halfway out by him/herself because of failing to in-
Age (Year)

Minimum

sist on the trial.

Comparison of the general information of KOA patients among the groups.

44
42
40

Treatment methods
Male

During treatment, all of the patients in the three groups re-

25
23
26
Gender(cases)

ceived the same health education, including the precautions of

diet, motor movement and rest, as well as avoiding serious physi-
Female

cal exercise, weight-bearing walking, etc.

19
16
17

(1) Chinese medication package warm compress therapy group

Preparation of medication: the basic formula of Shēntòng Zhúyū

Cases

Decoction includes Qínjiāo (  Radix Gentianae Macrophyllae)

42
42
42

50 g, Chuānxiōng ( Rhizoma Chuanxiong) 75 g, Táorén ( Se-

men Persicae) 75 g, Hónghuā ( Flos Carthami) 75 g, Qiānghuó (
Combined treatment group
Medication package group

 Rhizoma et Radix Notopterygii) 50 g, Mòyào ( Myrrha) 50 g,

Five-knee-point group

Dāngguı̄ ( Radix Angelicae Sinensis) 75 g, Wŭlíngzhı̆ ( Fae-

ces Trogopterori) 75 g, Xiāngfù ( Rhizoma Cyperi) 50 g, Niúxı̄ (
 Radix Achyranthis Bidentatae) 75 g, Dìlóng ( Lumbricus) 75 g
and Gāncăo ( Radix et Rhizoma Glycyrrhizae) 50 g. The above
Groups

herbal medications were ground into powder.

Table 1

Package with hemp cloth: a piece of hemp cloth of high

strength and heat conduction was used to prepare a rectangular
86 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90
Fig. 1. Gentle touching.
Fig. 2. Persistent warm compress.
Fig. 3. Persistent warm compress.
bag, 25 cm × 18 cm in size. One border of the bag was opened,
18 cm in length for the input of herbal powder.
Electric rice cooker: an old-style electric rice cooker, 10 L, San-
jiao brand, manufactured by Guangdong Hongsanjiao Electric Ap-
pliance Industry Co., Ltd.
Heating medication package:a proper amount of water was put
into the electric cooker, a steaming rack with a proper size and
height was placed inside of it. The hemp package of the herbal
powder of Shēntòng Zhúyū Decoction was placed on the steaming
rack and was heated for 30 min till water was boiled (100 °C), and
then, the cover of electric cooker was opened.
Treatment procedure: The patient was in supine comfortably
with the affected knee exposed. With a heat-insulating glove worn,
the practitioner removed the steamed herbal medication package
from the cooker. Firstly, the package was touched to the affected
knee intermittently and slowly (Fig. 1) to let the patient adaptive
to the temperature. When the patient adapted to the package tem-
perature, the package was put directly on the affected knee for per-
sistent warm compress (Fig. 2, Fig. 3). The package was removed
when the temperature was reduced gradually and the patient
felt the heat sensation was not strong enough. The duration of
treatment was 10 to 15 min (depending on the room temperature).
During treatment, the discomfort or aggravation on the affected
knee should be avoided because of the low temperature of the
package. The treatment was given once a day, continuously for 2
weeks.
(2) Five-knee-point acupuncture group
Acupoint selection: Xuèhăi ( SP 10), Liángqiū ( ST 34),
Hèdı̆ng ( EX - LE 2), Nèixı̄yăn ( EX - LE 4) and Dúbí (
 ST 35), all on the affected side were selected.
Manipulation: the patient was in supine with the affect knee
flexed comfortably and exposed. A soft cushion was put under the
knee. After routine sterilization at the acupoints, the stainless nee-
dles for single use, 0.30 mm × 40 mm, were selected. The needles
were inserted perpendicularly at SP 10 and ST 34, 25 to 40 mm in
depth. The needles were manipulated by lifting, thrusting and ro-
tating technique to ensure the needling sensation obtained in the
local area, i.e. soreness, numbness and distention. At EX - LE 2,
the needle was inserted transversely along the bottom surface of
patella, 25 to 40 mm in depth and the needle was rotated, without
lifting and thrusting, to ensure the needling sensation obtained in
the local area, i.e. soreness, numbness and distention. At EX - LE 4
and ST 35, the needles were inserted perpendicularly, 25 to 40 mm
in depth, and an angle of 90° was formed by the two needles at
the skin surface. The needles were manipulated to ensure the ar-
rival of soreness, numbness and distention in local area. All of the
needles were retained for 30 min. The treatment was given once
every day, consecutively for 2 weeks.
(3) Five-knee-point acupuncture plus Chinese medication package
warm compress therapy group (combined treatment group)
On the basis of acupuncture at SP 10, ST 34, EX - LE 2, EX - LE
4 and ST 35, the Chinese medication package warm compress ther-
apy of Shēntòng Zhúyū Decoction was exerted for 10 to 15 min. The
acupuncture therapy was the same as the five-knee-point acupunc-
ture group. The package warm compress therapy was the same as
the treatment in the Chinese medication package warm compress
therapy group. After treated with the five-knee-point acupuncture,
the herbal package warm compress was provided with a interval
of 2 h to avoid the infection as far as possibly. These two differ-
ent interventions were accomplished on the same day, once a day,
consecutively for 2 weeks.
Therapeutic effects
Observation indicators
(1) Pain evaluation
The internationally recognized visual analogue scale (VAS)
[11] was used in the evaluation of pain. It is a straight line 10 cm
(cm) in length. 0 cm (score of 0) indicates no pain and 10 cm (score
of 10) severe pain. A higher score indicates greater pain intensity,
i.e. slight pain (score 1 to 3), moderate pain (score 4 to 7) and se-
vere pain (score 8 to 10). The subject in research marks the value
of the line for the subjective feeling of pain intensity, and thus, the
score was recorded accordingly.
(2) Motor function evaluation of knee joint
Lysholm knee scale [12] was adopted to evaluate the motor
function of knee joint, including pain, swelling, instability, twist
locking, limping, supporting, stair climbing and squatting down.
The total score is 100, including the above 8 items (pain, score of
25; swelling, the score of 10; instability, the score of 25; twist lock-
ing, the score of 15; limping, the score of 5; support, the score of
5; stair climbing, the score of 10 and squatting down, the score of
5). A higher score indicates better knee joint function.
 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90 87

Table 2
Comparison of the clinical therapeutic effects on KOA in the patients of the three groups (Cases).

Groups Number of affected knees Remarkably effective Effective Improved No effect Total effective rate /%

Combined treatment group 54 35 13 5 1 98.1a , b

Medication package group 60 25 12 15 8 86.7
Five-knee-point group 54 22 14 14 4 92.6
a
Compared with the medication package group, P < 0.05.
b
Compared with five-knee-point group, P <0.05.

Table 3
Comparison of VAS score before and after treatment in KOA patients among the groups (Score, Mean ± SD).

Groups Number of affected knees Before treatment After treatment Different value

Combined treatment group 54 6.99 ± 1.41 2.24 ± 1.24a , b , c 4.74 ± 0.69d , e

Medication package group 60 6.95 ± 1.51 2.48 ± 1.38a 4.39 ± 1.67
Five-knee-point group 54 6.87±1.51 2.63±1.44a 4.24±1.95
a
Compared with those before treatment, P < 0.05.
b
Compared with the medication package group after treatment, P < 0.05.
c
Compared with the five-knee-point group after treatment, P < 0.05.
d
Compared with the difference value in the medication package group, P < 0.05.
e
Compared with the difference value in the five-knee-point group, P < 0.05.

The above-mentioned indicators were evaluated before and af-
ter the treatment.
Safety indicators
The safety was evaluated during the study, including infec-
tion, burning, allergy, fainting needle, stuck needle, broken needle,
hematoma and complications. When the above adverse reactions
occurred, the treatment according to the symptoms was given cor-
respondingly and recorded.
Evaluation criteria on therapeutic effects
The therapeutic effect was evaluated according to Lysholm knee
scale. Remarkably effective: the total Lysholm score > 80; effec-
tive: the total score of 65 to 80; improved: the total score of 35
to 60 and failed: the total score  30. The calculation formula is
followed.
The total effective rate = (the number of affected knees with re-
markably effect + the number of affected knees with effect) ÷ the
total number of the affected knees × 100%.
Statistical management
SPSS 21.0 software package was used for statistical manage-
ment. The measurement data were represented by mean ± stan-
dard deviation (Mean ± SD). All the data were performed nor-
mality test. If in accordance with the normal distribution, the
multiple-group econometric data were analyzed by single factor
variance analysis (One-way ANOVA). LSD and SNK methods were
used for the homogeneity of variance, and Tamhane’s T2 or Dun-
nett’s T3 method for patients with the heterogeneity of variance. If
not in compliance with the normal distribution, the rank sum test
is used. The enumeration data were analyzed by chi-square test. P
< 0.05 indicates the statistical significance of difference.
warm compress therapy group and 2 cases were dropped out in
the five-knee-point acupuncture group, of which, 1 case with uni-
lateral affected knee was due to the residence relocation and an-
other 1 case with bilateral affected knees was due to the voluntary
discontinuity of treatment.
(1) Comparison of clinical therapeutic effect on KOA in the patients
of the three groups
The total effective rate in the combined treatment group was
higher than those of the Chinese medication package warm com-
press group and the five-knee-point acupuncture group respec-
tively, indicating the significant difference (both P < 0.05). See
Table 2.
(2) Comparison of VAS score before and after treatment in KOA pa-
tients among the groups
The differences in VAS score were significant before and after
treatment in the three groups (all P < 0.05). After treatment,
VAS score in the combined treatment group was lower than the
Chinese medication package warm compress therapy group and
the five-knee-point acupuncture group respectively (both P <
0.05). The difference in VAS score was not significant between
the Chinese medication package warm compress therapy group
and the five-knee-point acupuncture group (P > 0.05). Before and
after treatment, the difference value of VAS score in the combined
treatment group was higher than those of the Chinese medication
package warm compress therapy group and the five-knee-point
acupuncture group, indicating the statistical significance (both
P < 0.05). Before and after treatment, the difference value of
VAS score in the Chinese medication package warm compress
therapy group had no statistical significance compared with the
five-knee-point acupuncture group (P > 0.05). See Table 3.
(3) Comparison of Lysholm score for knee joint motor function be-
fore and after treatment in KOA patients among the groups

Results The differences in Lysholm score were significant statistically

A total of 121 cases accomplished the final observation and 5
cases were dropped out in the three groups, in which, 2 cases (the
affected knees on one side) were dropped out due to the volun-
tary discontinuity of treatment in the combined treatment group,
1 case (bilateral affected knees) was dropped out due to the volun-
tary discontinuity of treatment in the Chinese medication package
before and after treatment in each group (all P < 0.05). The
Lysholm score in the combined treatment group was higher than
those of the Chinese medication package warm compress therapy
group and the five-knee-point acupuncture group (both P < 0.05).
The score in the Chinese medication package warm compress
therapy group was not different statistically as compared with the
five-knee-point acupuncture group (P > 0.05). Before and after
88 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90
Table 4
Comparison of Lysholm score for knee joint motor function before and after treatment in KOA patients among the groups (Score, Mean ± SD).
Groups Number of affected knees
Combined treatment group 54
Medication package group 60
Five-knee-point group 54
a
Compared with those before treatment, P < 0.05.
b
Compared with the medication package group after treatment, P < 0.05.
c
Compared with the five-knee-point group after treatment, P < 0.05.
d
Compared with the difference value in the medication package group, P < 0.05.
e
Compared with the difference value in the five-knee-point group, P < 0.05.
Table 5
Comparison of adverse reactions in KOA patients among the groups (Cases).
Groups Cases No adverse reactions
Combined treatment group 40 37
Medication package group 41 39
Five-knee-point group 40 38
a
Compared with the medication package group after treatment, P < 0.05.
b
Compared with the five-knee-point group after treatment, P < 0.05.
treatment, the difference value of Lysholm score in the combined
treatment group was higher than those of the Chinese medication
package warm compress therapy group and the five-knee-point
acupuncture group, indicating the statistical significance (both P
< 0.05). Before and after treatment, the difference value of the
Lysholm score in the Chinese medication package warm compress
therapy group had no statistical significance as compared with the
five-knee-point acupuncture group (P>0.05). See Table 4.
(4) Comparison of adverse reactions in KOA patients among the
groups
Of the patients in the three groups (except the dropped-out
cases), 3 cases had adverse reactions in the combined treatment
group, of which, 2 cases had fainting needle (manifested as dizzi-
ness, nausea and cold sweating) and 1 case was allergic to herbal
medication (manifested as red papules on the knees and itching).
2 cases had adverse reactions in the Chinese herbal medication
package warm compress therapy group, of which, 1 case had al-
lergy (manifested as red skin, itching, scratching) and 1 case was
scalded (manifested as scattered blisters of different sizes on the
knees). 2 cases had adverse reactions in the five-knee-point group,
of which, 1 case had fainting needle (manifested as dizziness, pal-
pitation, pale complexion, nausea and slight cold sweating) and 1
case had stuck needle (manifested as failure to rotate, left, thrust
and withdraw needle at acupoints, combined with intolerable pain
in local area).
Regarding the total occurrence rate of the adverse reactions, the
differences were not significant statistically in the combined treat-
ment group as compared with those of the Chinese herbal medi-
cation package warm compress therapy group and the five-knee-
point acupuncture group (both P > 0.05). See Table 5.
Discussion
Knee osteoarthritis (KOA) is a kind of non-inflammatory and
degenerative joint disorder and its pathological changes includes
degeneration of joint cartilage, subchondral bone change, the
formation of the osteophyte on the joint margin, synovial change,
ligament relaxation or contracture, joint capsule contraction, etc.
[13]. According to statistical record [14], KOA accounts for about
40% of all arthritis, which seriously affects the normal life of the
middle-aged people and the elderly. The disease may cause disabil-
ity and brings a huge burden on the social economy. Such disease
is in the category of bi syndrome in TCM, firstly seen in Huángdì
Nèijı̄ng ( The Yellow Emperor’ s Inner Classic). It is men-
Before treatment After treatment Different value
33.61 ± 7.64 60.50 ± 13.76a , b , c 26.89 ± 6.12d , e
33.26 ± 7.08 52.23 ± 11.65a 18.97 ± 14.98
33.99 ± 7.44 52.14 ± 11.77a 18.15 ± 9.88
With adverse reactions Total adverse reactions occurrence rate%
3 7.50%a , b
2 4.88%
2 5.00%
tioned in Chapter 55 of Sùwèn (• Basic Questions)
that the bone disease manifested as heaviness of limbs, soreness
and pain of joints and caused by cold is named as bone bi syn-
drome. Such statement is the source of the theory of bi syndrome
in TCM. The etiology of bi syndrome has been early recorded in
Huángdì Nèijı̄ng ( The Yellow Emperor’ s Inner Classic).
For example, it is said in the Chapter 43 of Sùwèn (•
Basic Questions) [15] that bi syndrome results from the interaction
of pathogenic wind, cold and damp. In pathogenesis, the weakness
of defensive yang, the invasion of pathogenic wind, cold and damp
or lingering traumatic injury leads to qi and blood obstruction in
meridians. The treating methods focus on eliminating wind and
cold, activating blood circulation, resolving stasis and promoting
meridian circulation [16]. In this study, we applied the treating
method to emphasize on activating blood circulation and resolving
stasis, especially for KOA of blood stagnation pattern.
At present, in clinical practice, the surgical treatment and
medication conservative treatment are adopted mainly in western
medicine. Due to severe trauma, high risk and expensive cost, the
surgical treatment is hardly accepted by the patients, moreover,
the failure rate and the repair rate of artificial prosthesis are high
and many related complications may be induced. The conserva-
tive treatment, taking the medication, is disadvantageous in its
frequent medication, poor effect, and long course of treatment,
serious side effect and poor compliance. In TCM, acupuncture and
herbal medication are predominated in treatment of KOA. The clin-
ical study [17] indicates that acupuncture has been highly accepted
by the patients. The unique therapeutic effect of such therapy has
been increasingly displayed. Acupuncture acts on promoting the
circulation in meridians, activating qi and blood circulation, anti-
inflammation and analgesia. A large amount of clinical practice
has proved that acupuncture presents a satisfactory effect on
KOA. Modern medicine [16] shows that the underlying effect
mechanism of acupuncture for treating KOA is by stimulating the
local acupoints, which may be related to the improvement of
local blood circulation, the effective inhibition of the release of
central analgesic neurotransmitters and the effective control of the
expression of related inflammatory substances. Besides, a rich and
valuable clinical experience has been accumulated in treatment
of KOA with herbal medication. The effect of herbal medication
is significant relatively, mainly for benefiting qi, nourishing blood,
eliminating wind and damp, warming meridian, expelling cold,
promoting circulation in meridian, activating blood circulation to
resolve stasis, tonifying the liver and kidney and strengthening
tendon and bone [18]. It is reported in literature [19] that the
 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90
effective mechanism of TCM in treatment of KOA is potentially
related to the up-regulation of sex hormones, the down-regulation
of the level of nitric oxide, the improvement of microcirculation,
the decrease of intraosseous pressure, the inhibition of synovitis,
the regulation of abnormal cytokine level, the inhibition of matrix
degradation enzyme, the promotion of chondrocyte proliferation
of cartilage cells and the suppression of chondrocyte apoptosis. In
summary, either acupuncture therapy or Chinese herbal medica-
tion has its own outstanding effect and mechanism in treatment
of KOA. If these two interventions are combined together, the
therapeutic effect must be complemented with each other. In this
study, the five-knee-point acupuncture therapy was combined
with the herbal medication warm compress with Shēntòng Zhúyū
Decoction ( generalized pain stasis-expelling decoction).
The five knee points included Xuèhăi ( SP 10), Liángqiū (
 ST 34), Hèdı̆ng ( EX-LE 2), Nèixı̄yăn ( EX-LE 4) and
Dúbí ( ST 35). SP 10 is the key acupoint of the spleen merid-
ian of foot-taiyin, for treatment of blood disorders. It is the site
of the convergence of qi and blood, acting on transformation and
transportation of the essential substance of qi and blood. ST 34
is the xi-cleft point of the stomach meridian of foot-yangming. Xi-
cleft point especially acts on relieving acute disorder and stopping
pain and ST 34 is good for swelling and pain of knee joint and
motor impairment of the lower limbs. EX-LE 2 is an extra point,
mainly for soreness and pain of knee joint, weakness of legs and
feet, tuberculous arthritis, beriberi, etc. It is also good for promot-
ing motor function, and it is used in the treatment of various knee
joint diseases, sequelea of cerebral vascular disease. EX-LE 4 is also
an extra point, good for the treatment of knee swelling and pain,
tuberculous arthritis, leg pain and peripheral soft tissue inflam-
mation. ST 35 is on the stomach meridian of foot-yangming and
the knee cavity is involved in its deep anatomical structure. This
acupoint acts on activating blood circulation, promoting circula-
tion in meridian, eliminating wind and cold, regulating pain, stop-
ping spasm, removing swelling, stopping pain and benefiting motor
function and it is for the treatment of knee joint disorders caused
by various reasons. The following 4 reasons were considered in se-
lection of these five acupoints in the research. Firstly, all of the five
acupoints are located around the knee joint, in which, SP 10 and
ST 34 are located above the knee joint, EX-LE 2 is in the center,
EX- LE 4 and ST 35 are on the lower border of the patella. These
five acupoints were stimulated simultaneously by the surrounding
needling technique. The center of the affected site was stimulated
at first (EX- LE 2), and then two acupoints were stimulated in the
upper and lower parts of the affected site separately (i.e. SP 10 and
ST 34 in the upper and EX-LE 4 and ST 35 in the lower). Such sur-
rounding needling technique of acupuncture increases the stimu-
lation intensity and ensures the instant effect on the base of the
correct needling method. Secondly, both the physiological anatom-
ical structural change and the pathological change of knee joint
result in a quite poor blood circulation in the local area. TCM ex-
plains it as malnutrition of muscles and tendons in etiology. The
spleen and stomach are the postnatal foundation and the source of
qi and blood manufacture, they dominate muscles and their merid-
ians contain abundant qi and blood. Hence, the treatment must fo-
cus on strengthening the spleen and stomach and promoting blood
production to nourish muscles. Of the above five knee points, 3
acupoints are related to the spleen and stomach, i.e. SP 10, ST 34
and ST 35. Combined with the extra points, EX-LE 2 and EX-LE
4, these five knee points coordinately stimulate qi and blood cir-
culation in meridians and regulate the imbalance of yin and yang
to strengthen the antipathogenic qi and eliminate pathogens ulti-
mately. Thirdly, the physiological anatomic structure is extremely
complicated. Except the complicated structure of bone structure of
the knee joint, there are various kinds of muscles, tendons and lig-
aments. Under the surface of SP 10, there is the medial vastus mus-
89
cle. The straight femoral muscle, lateral vastus muscle and inter-
mediate vastus muscle are under ST 34. EX-LE 2 is located beneath
the quadriceps tendon, EX- LE 4 is under the patellar ligament and
medial retinaculum, and ST 35 is under the patellar ligament and
lateral retinaculum. Of them, the patellar ligament is the extension
of the quadriceps tendon. Knee joint capsule and alar fold are un-
der EX-LE 4 and ST 35. The needles were inserted deeply at these
five acupoints and manipulated to ensure the arrival of qi. Such
needling manipulation achieves the positive regulation on the cor-
responding muscles, ligaments and folds and contributes to reliev-
ing and removing joint pain, swelling, stiffness and motor impair-
ment. Fourthly, according to literature report, regarding the rule
of acupints selection in treatment of KOA with acupuncture, the
acupoints are commonly from the affected meridians and local af-
fected area [20]. It has been indicated in some studies [21] that
the acupoints on the spleen meridian, stomach meridian and gall-
bladder meridian are commonly selected in acupuncture, and the
specific acupoints are greatly considered too. In this study, the five
knee points are in compliance with the above selection principle
as the local acupoints and the acupoints from the spleen merid-
ian and stomach meridian. The acupoints in the five-knee-point
acupuncture therapy are highly reliable, rational and practical. In
summary, such acupuncture therapy is the surrounding needling
in technique and aims to regulate qi and harmonize blood in sub-
stance. Additionally, in terms of the anatomic structure of knee, i.e.
muscles, tendons, ligaments, such acupuncture therapy contributes
to the positive regulation.
Shēntòng Zhúyū Decoction ( generalized pain stasis-
expelling decoction) was from Yı̄lín Găicuò ( Correction
of Errors in Medical Works), written by Qing-ren WANG, the famous
medical master of Qing Dynasty. The herbal medications composed
in the formula work on removing obstruction, promoting circula-
tion in meridian and stopping pain and are mainly for bi syndrome
of blood stagnation by activating blood circulation, removing sta-
sis, eliminating wind and damp and promoting meridian circula-
tion. The original record of this formula in ancient book is for oral
administration with decoction. However, in this trial, the formula
was adopted as an innovative external application with Chinese
herbal package. All of the ingredients of this formula, with prop-
erly increased dosage, were ground into powder. The powder was
sealed in a package. The affected site was warmed intermittently
with the steamed-hot package. When the patient adapted to the
package temperature, the package was placed sustainably on the
affected site. Technically, using the boiled water, the effective com-
ponents of the herbal medications are dissolved and precipitated
gradually, which are attached on the package. In the direct warm
compress with steam, herbal medication and heat involved, the ef-
fective components of herbal medication are penetrated through
the skin under the action of heat, directly work to the affected site.
After absorbed by capillaries, the effective components go through
to the focus, acting on activating blood circulation, removing sta-
sis, promoting meridian circulation, warming meridian to disperse
cold, eliminating wind and damp, removing swelling and stopping
pain. This therapy is advantageous at the better dissolution of the
effective components of herbal medication and direct penetration
to the bone. During the treatment with this therapy, the concentra-
tion of the medication can be increased up to the maximum in the
local area to display the greatest pharmacological effect. With such
package warm compress therapy, the high concentration of medi-
cation is maintained at the focus for a longer time and the thera-
peutic effect is persistent. Compared with the traditional oral ad-
ministration of Chinese medication, this therapy not only removes
the patient’s fear of taking medication orally, but also reduces the
stimulation of Chinese herbal medication to gastrointestinal tract
and avoid the adverse reactions, e.g. vomiting, diarrhea and poor
appetite, thereby, the patient’s compliance is improved.
90 H. LIANG, Z.-r. LI and J. CHEN et al. / World Journal of Acupuncture – Moxibustion 29 (2019) 83–90
The innovation of this study is the combination of five-knee-
point acupuncture therapy and Chinese medication package warm
compress with Shēntòng Zhúyū Decoction. Such treatment not only
displays the common characteristics of the external application,
but also gives full play of the respective characteristics of acupunc-
ture and Chinese herbal medication and co-achieves the effect of
acupuncture and medication. The results indicated that the total
effective rate of the combined treatment was higher than the Chi-
nese medication package warm compress therapy group and the
five-knee-point acupuncture group, indicating a significant differ-
ence in statistic. VAS score in the combined treatment group was
lower than the Chinese medication package warm compress ther-
apy group and the five-knee-point acupuncture group and Lysholm
score was higher than the Chinese medication package warm com-
press therapy group and the five-knee-point acupuncture group,
indicating significant differences in statistic separately. In sum-
mary, the results of this study indicated that the therapeutic ef-
fect of the combined treatment with the five-knee-point acupunc-
ture therapy and the Chinese medication package warm compress
therapy with Shēntòng Zhúyū Decoction was much more significant
than either the simple use of the five-knee-point acupuncture ther-
apy or the simple use of the Chinese medication package warm
compress therapy. Moreover, this study showed that the combined
treatment did not induce many adverse reactions. Hence it was
high in safety. The surrounding needling technique was used in the
five-knee-point acupuncture therapy at the focus. This acupuncture
therapy is characterized as less acupoints, easy location and simple
operation. Additionally, a new thought and practical value of the
external application of Shēntòng Zhúyū Decoction was explored in
the study so as to provide a new and easily acceptable approach
to the external application of Chinese herbal medication. However,
due to the limitation of time, the long-term follow up was not car-
ried out yet in this trial. A large-scale sample, multi-center ran-
domized controlled trial and the follow-up visit of the long-term
effect should be analyzed scientifically in the future.
References
[1] Goldman L H, Tang K, Facchetti L, Heilmeier U, Joseph G B, Nevitt M C,
et al. Role of thigh muscle cross-sectional area and strength in progression of
knee cartilage degeneration over 48 months-data from the osteoarthritis ini-
tiative. Osteoarthr Cartil 2016;24(12):2082–91.
[2] Xiong J, Zhu DC, Chen RX, Ye WG. Report quality of randomized controlled tri-
als of moxibustion for knee osteoarthritis based on CONSORT and STRICTOM.
Chin Acupunct Moxibust 2015;35(8):835–9.
[3] Ye GP, Zhu DY, Li L, Wu MX. Randomized controlled study on treating knee os-
teoarthritis with warming needle moxibustion in different depths. Chin J Tradit
Chin Medi Pharm 2015;30(8):2886–9.
[4] Zhang YT, Liu NY. Literature research on knee osteoarthritis treated with
acupuncture at meridian sinews acupuncture technique. Chin Acupunct Moxi-
bust 2015;35(S1):102–10.
[5] Tian W. Practical orthopaedics, 313. Beijing: The People’s Medical Publishing
House; 2008.
[6] Du SG, Guo ZH, Kong QQ, Wang XC. Clinical study on arc edge needle-s-
calpel in treatment of knee osteoarthritis. Chin J Tradit Chin Med Pharm
2018;33(4):1657–60.
[7] Zhao PQ, Guan XF. Research progress of acupuncture and moxibustion in the
treatment of knee osteoarthritis. J Clinic Acupunct Moxibust 2015;31(3):79–82.
[8] State Administration of Chinese Medical Sciences. Criteria of diagnosis and
therapeutic effects of the disorders in traditional Chinese medicine. Nanjing:
Nanjing University Press; 1994. p. 48–9.
[9] Orthopedic Branch of the Chinese medical Association (Qiu Guixing) Guide-
line on diagnosis and treatment of osteoarthritis (edition 2007). Chin J Orthop
2007;27(10):793.
[10] Chen F, Shi XB. Present situation and research progress of clinical staging of
knee osteoarthritis. J Guangxi Med Univ 2018;35(3):412–15.
[11] Wei XX. Clinical pain in western and Chinese medicine. Beijing: China Press of
Traditional Chinese Medicine; 1996. p. 14–15.
[12] Marx RG, Jones EC, Allen AA, Altchek DW, O’Brien SJ, Rodeo SA, et al. Relia-
bility,validity,and responsiveness of four knee outcome scales for athletic pa-
tients. J Bone Joint Surg Americ Volum 2001;83-A(10):1459–69.
[13] Loeser RF, Goldring SR, Scanzello CR, Goldring MB. Osteoarthritis: a disease of
the joint as an organ. Arthr Rheum 2012;64(6):1697–707.
[14] Yang YK, Lu XH, Qu YM. Effects on 42 cases of knee osteoarthritis treated with
external application of herbal medicine and acupuncture. J Sichuan Tradit Chin
Med 2016;34(12):160–2.
[15] Wang QQ. Selection of internal medicine. Beijing: China Press of Traditional
Chinese Medicine; 2002. p. 23–5.
[16] Li JW, Zheng SJ, Zhang JC, Huang JJ, Liu XG. Effect of acupuncture plus different
frequency shock-wave interventions on pain reactions and motor function in
knee osteoarthritis patients. Acupunct Res 2015;40(4):300–3.
[17] Zhang H, Zhao BX, Song Y, Ji B, Zhang P, Liu YL. Modern clinical research and
the rules of acupoint selection in treatment of knee osteoarthritis with moxi-
bustion in recent ten years. Inf Tradit Chin Med 2015;32(2):118–21.
[18] Li L. Research progress of knee osteoarthritis in recent 10 years. Nei Mongol J
Tradit Chin Med 2016;12(16):99–100.
[19] Liu WC, Huang SJ. Research progress of Chinese medicine in treatment of knee
osteoarthritis. Chin J Tradit Med Traumat Orthoped 2016;24(12):79–82.
[20] Liu Q, Liu W, Wu YH. Study on rules of acupoint selection for acupuncture
treatment of knee osteoarthritis in modern literature. Shandong J Traditi Chin
Med 2015;34(11):824–6.
[21] Ling SS, Li ML, Luo EW, Zhou XL. A summary and analysis of acupuncture and
moxibustion treatment of knee osteoarthritis in recent 5 years. Clini J Chin
Med 2017;9(6):57–9.