Acupuncture and herbs outperform sulfasalazine for the alleviation of ankylosing spondylitis. Henan University of Traditional Chinese Medicine researchers investigated the benefits of drugs, acupuncture, and herbal medicine for the treatment of ankylosing spondylitis. The researchers conclude that acupuncture plus herbs is more effective than the sulfasalazine (an antirheumatic medication).

Three groups were compared. One received only drug therapy. Another received herbal medicine. Another group received herbal medicine plus acupuncture. The group receiving herbal medicine plus acupuncture achieved the highest positive patient outcome rate of 52.8%, with only a 2.8% adverse effect rate. The drug therapy group had an adverse effect rate of 38.7%. In additional to clinical subjective improvements, the acupuncture plus herbs group achieved the greatest improvements in radiographic changes and levels of C3, ESＲ，CＲP, and PHI. Primary outcome measures for the study included the following:

• Bath Ankylosing Spondylitis Patient Global Score (BAS-G)
• Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
• Bath Ankylosing Spondylitis Radiology Index (BASRI)
• Bath Ankylosing Spondylitis Metrology Index (BASMI)
• TCM Syndrome Differentiation (TCM Symptom) Scale

BAS-G is a global measure used to assess the well-being of patients with ankylosing spondylitis. BASDAI is a diagnostic tool used to determine patient reported disease activity in patients with ankylosing spondylitis. BASRI is an objective method used to grade radiographic changes in AS (ankylosing spondylitis) patients. BASRI is an instrument used to quantify the mobility of the spine in AS patients. TCM (Traditional Chinese Medicine) symptom improvement was evaluated based on the TCM Syndrome Differentiation Scale.

Laboratory parameters were quantified, including the erythrocyte sedimentation rate (ESR) and levels of C-reactive protein (CRP), parathyroid hormone (PTH), and complement 3 (C3). ESR is a blood test that often reflects inflammation levels in the body. CRP is a marker of inflammation in the body. PTH is a natural hormone secreted by the parathyroid glands. Elevated PTH levels indicate a possible development of AS. C3 is an immune system protein. Higher than normal levels of C3 are associated with active AS. The acupuncture plus herbal medicine group significantly outperformed the drug control groups across all objective and subjective measures (p<0.05).

Design
Researchers (Wang et al.) used the following study design. A total of 108 patients were treated and evaluated in this study. The patients received treatment for ankylosing spondylitis and were randomly divided into three groups: an acupuncture plus herbal medicine group, an herbal medicine group, and a drug group, with 36 patients in each group. For the drug group patients, sulfasalazine was administered. The acupuncture plus herbal medicine group received acupuncture in addition to the identical herbal formula administered to the herbal medicine group.

The statistical breakdown for each randomized group was as follows. The acupuncture plus herbal medicine group was comprised of 28 males and 8 females. The average age in this group was 26.5 years. The average course of disease in this group was 3.2 years. The herbal medicine group was comprised of 30 males and 6 females. The average age in this group was 26.3 years. The average course of disease in this group was 3.6 years. The drug group was comprised of 27 males and 9 females. The average age in this group was 25.9 years. The average course of disease in this group was 3.9 years. There were no significant statistical differences in gender, age, and course of disease relevant to patient outcome measures for patients initially admitted to the study.

Treatment
For the drug group, patients received sulfasalazine tablets (0.25 g). For the first 5 days of treatment, the tablets were orally administered three times per day, one tablet each time. After 5 days, the tablets were given three times per day, two tablets each time. The treatment lasted for 60 consecutive days. The acupuncture plus herbal medicine group patients received acupuncture and Chinese herbal medicine. The primary acupoints used for the treatment group included the following:

• GV6 (Jizhong)
• Extra points (Huatuojiaji)
• BL23 (Shenshu)
• GV2 (Yaoshu)
• GB34 (Yanglingquan)
• Extra points (Ashi)
• GB33 (Yangguan)
• GV14 (Dazhui)
• GV9 (Zhiyang)
• GV8 (Jinsuo)

Treatment commenced with patients in a sitting position. After disinfection of the acupoint sites, a disposable filiform needle was inserted into each acupoint with a high needle entry speed. For Jizhong, Huatuojiaji, and Ashi points, the needles were inserted obliquely into each acupoint, with a maximum insertion of 1.5 cun. After a deqi sensation was obtained, the needles were manually stimulated with the Ping Bu Ping Xie (mild attenuating and tonifying) manipulation techniques.

For Yaoshu, Shenshu, and Yanglingquan, the needles were inserted perpendicularly to a depth of 1.0 cun. Then, the needles were manipulated with the xie (attenuating) technique with rotational speed reaching 80 r/min. For Yangguan, Dazhui, Zhiyang, and Jinsuo, the needles were inserted perpendicularly, reaching a maximum depth of 1.5 cun. After obtaining a deqi sensation, the needles were applied with the bu (tonifying) technique. The needles were retained for 20 minutes. One acupuncture session was conducted daily for 60 consecutive days. The Chinese herbal formula (modified Wuling decoction) used in the study included the following ingredients:

• Zhu Ling 10 g
• Ze Xie 15 g
• Niu Xi 10 g
• Qiang Huo 6 g
• Fu Ling 10 g
• Fang Feng 6 g
• Gui Zhi 7 g

A 300 ml decoction was made from fresh herbs each day, divided into two parts, and was administered in two servings, one in the morning and one at night, for a total of 60 consecutive days.

Laboratory and clinical data indicates that acupuncture plus herbal medicine is more effective for the treatment of ankylosing spondylitis than sulfasalazine. Acupuncture plus herbs improves symptoms and disease related biomarkers. Given the results of this investigation, additional research is warranted.

Reference:
Wang F, Wang MJ. Clinical Observation of Acupuncture Combined with Modified Wulingtang for the Treatment of Ankylosing Spondylitis, Journal of Basic Chinese Medicine [J], 2017,23(08):1135-1138.

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Acupuncture is more effective for treating rheumatoid arthritis and improving markers of oxidative stress than pharmaceuticals. This was discovered in a recent study conducted at Gansu University of Traditional Chinese Medicine Affiliated Hospital. [1]

This study compared treatments of hot-filling acupuncture to pharmacology for 68 patients presenting with wind-cold-damp type rheumatoid arthritis. Outcomes were determined by measuring both pain relief by VAS (visual analog scale) and oxidative stress markers such as GSH-Px (glutathione peroxidase), SOD (superoxide dismutase), and MDA (malondialdehyde). Oxidative stress describes increased levels of ROS (reactive oxygen species), which damage cells and are believed to be participatory in the pathology of rheumatoid arthritis.

Following treatment, the total effective rate in the acupuncture group was 91.2%. The control group measured at 76.5%. At the 3 month follow-up, the acupuncture group continued to experience greater improvements with an effective rate of 88.3% while the control group measured lower at 70.6%.

Introduction
Patients were recruited and randomly assigned to the acupuncture or control group. The acupuncture group was comprised of 16 male and 18 female participants 41–70 years old with a mean age of 56. This group’s disease duration spanned 9–75 months, with a mean duration of 30.5 months. The control group was comprised of 18 male and 16 female participants 42-69 years old with a mean age of 54. This group’s disease duration spanned 10–72 months, with a mean duration of 32.3. There were no statistically significant differences between the two groups in terms of gender, age, disease severity, or pain scores (p>0.05) at the onset of the study.

Rheumatoid arthritis severity was assessed with the DAS-28 (Disease Activity Score 28), where a combination of examination, global pain scores, inflammatory markers, questionnaires, and medical imaging are all considered; total scores are calculated using a complex formula. Scores of >5.1 indicate active disease, scores of <3.2 indicate low disease activity, and scores of <2.6 indicate remission.

TCM diagnostic criteria include primary symptoms of severe joint pain in a fixed location, stiffness in the morning, and limited ability to bend and stretch. Secondary symptoms include heavy limbs, reduced joint mobility, numb skin or muscle, a white and greasy tongue coating, and a taut or bowstring pulse.

In addition to meeting the above criteria, participants were also required to be 40–70 years old with a disease duration of 5–80 months and a DAS-28 score of >2.6. They were also required to be able to give informed consent and not be participatory in glucocorticoid or DMARD (disease modifying anti-rheumatic drug) therapy.

Exclusion criteria included concurrent respiratory, hemopoietic, psychological, or other primary disease, suspected or confirmed lesions or skin disease in knee joints or surrounding areas, other immune disorders, pregnancy or lactation, and poor treatment compliance.

Treatment
Acupuncture group patients received hot-filling acupuncture administered at the following primary acupoints:

• Hegu (LI4)
• Zusanli (ST36)
• Sanyinjiao (SP6)
• Guanyuan (CV4)
• Qihai (CV6)

According to each patient’s most severely affected joints, additional acupoints were selected:

• For the elbow, Chize (LU5), Quchi (LI11), and Shousanli (LI10) were added.
• For the wrist, Yangchi (TB4), Wangu (SI4), Yangxi (LI5), and Waiguan (TB5) were added.
• For the knee, Yinlingquan (SP9), Yanglingquan (GB34), Heding (MLE27), Dubi (ST35), Xiyangguan (GB33), Liangqiu (ST34), and Xiyan (MNLE16) were added.
• For the ankle, Jiexi (ST41), Kunlun (BL60), and Xuanzhong (GB39) were added.

Stainless steel, disposable, filiform needles (0.30 × 40 mm) were inserted bilaterally using the following technique: Following standard procedure, the selected points were disinfected while the patient was in a supine position. The researcher then applied pressure to the selected acupoint with their left thumb or forefinger. Next, they used their right hand to insert the needle 30–40mm deep. After achieving deqi, the needle was pressed and rotated forward 5 times using the right hand while continuous pressure was applied with the left finger or thumb.

To elicit sensation in the surrounding area, needle depth was increased in 5 stages. The needle was then gently lifted in 5 stages before it was pressed and rotated 5 times more. This process was repeated continuously for 1 minute before allowing the needle to rest at an appropriate depth. Needles were retained for 30 minutes, and treatment was administered once daily. A total of 4 courses were administered. Each course was comprised of 5 consecutive treatments, separated by 2–day breaks. Control group patients received pharmacological intervention with the following drugs and dosages:

• Etoricoxib 60 mg daily, after food
• Leflunomide 20 mg daily, after food
• Methotrexate 5 mg twice weekly, after food

All pharmaceuticals were administered for a total of 4 weeks.

Outcomes and Discussion
Outcomes for this study were measured after 4 weeks of treatment and at a 3 month follow-up. These outcomes were measured by VAS for pain, serum GSH-Px, SOD, and MDA. Total effective rates were also calculated for each group.

Mean pretreatment VAS scores were 7.12 in the acupuncture group and 6.99 in the control group. Following treatment, these scores fell to 1.32 and 2.96 respectively. At the 3-month follow-up, they had risen to 2.97 and 3.98. Although both groups experienced significant improvements in pain scores, improvements were significantly greater in the acupuncture group (p<0.05).
Serum levels of the biomarkers GSH-Px, SOD, and MDA were also assessed before and after treatment. GSH-Px and SOD are enzymes with antioxidant properties, while MDA is a marker of oxidative stress.

Mean pretreatment levels of GSH-Px were 67.34 U/L in the acupuncture group and 67.40 U/L in the control group. Following treatment, these scores increased to 80.50 U/L and 77.70 U/L respectively. They fell to 76.98 U/L and 69.00 U/L at the three-month follow-up.

Mean pretreatment levels of MDA were 5.57 µmol/L in the acupuncture group and 5.66 µmol/L in the control group. Following treatment, these scores fell to 3.55 µmol/L and 3.94 µmol/L respectively. They increased to 4.88 µmol/L and 4.29 µmol/L at the three-month follow-up. Although both groups experienced improvements across all biomarkers, improvements were significantly greater in the acupuncture group (p<0.05).

Total effective rates were calculated for each group according to TCM syndrome scores. Patients with a ≥95% improvement in symptoms were classed as recovered. Treatment was classed as markedly effective for patients with a 70–90% improvement in symptoms, effective for patients with a 30–70% improvement in symptoms, and ineffective for patients with a ≤30% improvement in symptoms. Recovered, markedly effective, and effective scores were added together to calculate the total effective rate.

There were 12 recovered, 13 markedly effective, 6 effective, and 3 ineffective cases in the acupuncture group, giving a total effective rate of 31/34 (91.2%). There were 8 recovered, 7 markedly effective, 11 effective, and 8 ineffective cases in the control group, giving a total effective rate of 26/34 (76.5%).

At the 3-month follow-up, there were 9 recovered, 14 markedly effective, 7 effective, and 4 ineffective cases in the acupuncture group with a total effective rate of 30/34 (88.3%). There were 5 recovered, 8 markedly effective, 11 effective, and 10 ineffective cases in the control group with a total effective rate of 30/34 24/34 (70.6%).

The results indicate that acupuncture effectively relieves pain and improves biomarkers for rheumatoid arthritis patients, and is more effective than conventional, pharmacological treatment.

Reference:
1. Zhang Fengfan, Yuan Bo, Tian Liang, Wang Yixin, Qiao Xiang, Zhang Tingzhuo, Li Xinglan, Wang Jinhai, Tian Jiexiang, Du Xiaozheng (2019) “Clinical Efficacy of Hot Needling Acupuncture for Rheumatoid Arthritis and Its Effects on Oxidative Stress” Chinese Journal of Information on TCM Vol. 26 (2) pp. 26-30.