Treatment of knee osteoarthritis by acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously

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Methods: A total of 70 KOA patients visiting the Orthopedic Clinic, Hebei University of Chinese Medicine from September 2021 to September 2022 were enrolled and randomly divided into the treatment group and control group, with 35 cases per group. After excluding 2 cases of self-withdrawal in the control group, and 3 drop-out cases in the treatment group (2 with poor compliance, and 1 with personal affair), 33 in the former and 32 in the latter were finally included for the analysis. KOA patients in the treatment group were treated with acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously, while those in the control group were similarly managed but only targeting on the knee only. Interventions were given once every other day, for 12 sessions. The Visual Analogue Scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), active range of motion (AROM) of the knee, and serum IL-1β, TNF-α and MMP-3 before and after treatment were compared between groups. Results: The effective rate was significantly higher in the treatment group than the control group (90.63% vs. 69.70%, P <0.05). Post-treatment VAS score, WOMAC, and serum IL-1β, TNF-α and MMP-3 were significantly reduced, while AROM of the knee was significantly increased in both groups ( P <0.05), which were significantly pronounced in the treatment group than the control group ( P <0.05). Conclusion: Acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously is superior to the target of knee solely. It effectively masks pain, improves knee function, and increases AROM of the knee in KOA patients by lowering serum IL-1β, TNF-α and MMP-3. acupuncture Tuina massage simultaneous target on both the knee and ankle joints efficacy Figures Figure 1 Introduction Knee osteoarthritis (KOA), as a type of degenerative disease, is characterized by progressive destruction of cartilage and hyperosteogeny. Major manifestations consist of knee pain, stiffness, and limited activity with friction sounds [ 1 – 3 ] . The prevalence of KOA is 18% in China, which is sharply inflated to 85% among older adults of 65 years and above. In severe cases, KOA results in a 53% of disability rate that seriously affects the quality of life [ 4 ] . Muscle imbalance is the predominant pathogenic factor for KOA [ 5 ] . Medications and surgery are currently the mainstream approaches to treat KOA. However, drug therapy is accompanied by potential risks of organ damage and cardiovascular adverse events. While effective in pain relief of KOA, opioids are highly addictive. Surgical procedures for KOA are invasive and expensive, leading to postoperative complications [ 6 ] . Therefore, it is particularly important to seek an effective and safe treatment for KOA. Acupuncture is a treasure of traditional Chinese medicine (TCM), showing superb advantages in relieving pain and improving physical functions [ 7 ] . Tuina massage is a therapeutic massage technique long been originated in China. Serving as a type of conservative treatment of KOA, Tuina massage effectively masks pain and restores knee function via strengthening the muscle strength of peripheral muscle groups of the knee, correcting the force line of the lower limb, and intervening in the gait parameters [ 8 ] . Abundant evidence proves a close anatomic relationship between KOA and the ankle [ 9 – 11 ] . In the present study, we innovatively introduced a theory of “simultaneous regulation of both the knee and ankle joints”. The efficacy and safety of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA were explored, as well as the underlying mechanisms. Our findings are expected to provide clinical references to emphasize the role of acupuncture and Tuina massage in the treatment of KOA. Methods Study design A total of 70 KOA patients who visited the Orthopedic Clinic, Hebei Provincial Hospital of Traditional Chinese Medicine from September 1st, 2021 to September 30th 2022 were enrolled. They were randomly divided into the control group and treatment group using a random number table, with 35 cases per group. After excluding 2 drop-outs due to personal issues in the control group, and 2 due to poor compliance and 1 due to personal affairs in the treatment group, we finally included 33 cases in the control group and 32 in the treatment group. This study was approved by the Ethics Committee of Hebei Provincial Hospital of Traditional Chinese Medicine (No. HBZY2021-KY-040-01). Participants A clear diagnosis of KOA was made based on both the Western medicine and traditional Chinese medicine (TCM) criteria. Briefly, middle-aged and older adults with two or more of the following conditions were diagnosed with KOA by the Western medicine criteria: (1) age ≥ 50 years; (2) repeated pain of the knee within the past month; (3) morning knee stiffness ≤ 30 min; (4) range of motion of the knee with fricative sounds; (5) osteogenesis, narrowing of joint space, subchondral bone sclerosis and/or cystic changes on imaging scans [ 12 ] . Middle-aged and older adults with initial symptoms of dull pain, swelling, restricted flexion and extension, and friction sound of the knee that progressed slowly and constantly, and changed with the temperature were diagnosed with KOA by TCM criteria. In severe cases, knee deformity and muscle atrophy could be seen [ 13 ] . KOA patients at 40–75 years of age, who were in the onset stage and graded a minimum of 4 and above of the Visual Analogue Scale (VAS) were considered eligible. All participants provided written informed consent. Excluded were those with the use of agents that may influence the therapeutic efficacy within 2 weeks; tumors, infections, tuberculosis, rheumatoid arthritis or acute injuries; severe organ dysfunction; severe skin disease or knee rupture; mental illnesses; and pregnant or breastfeeding women. The clinical trial should be discontinued for severe adverse events or voluntary withdrawal for any cause. KOA patients mistakenly included who did not meet the inclusion criteria, and individuals with poor compliance, insufficient clinical data, and did not follow the standard treatment, were dropped out. Treatment regimens Acupuncture and Tuina massage for the knee were applied to all KOA patients based on standard procedures [ 14 – 15 ] . Briefly, Tuina massage was first given prior to acupuncture. In a supine position, meridians on the medial and lateral sides of the affected thigh were pressed and rolled, followed by a circular knead on both sides of the lower limb, with a frequency of 100 repeats per minute. Surrounding the pain point of the knee, rolling at a frequency of 50–100 repeats per minute was given to relieve pain. Then, patients were asked to lie face down, and the practitioner stood on the affected side. Knee flexion and relaxation of the popliteal fossa were achieved by one hand of the practitioner holding the ankle on the affected side, where the other hand rolled and kneaded the ankle at a frequency of 50–100 repeats per minute. Tuina massage was performed 25 minutes every other day, for a total of 12 sessions. In a supine position, acupuncture needles (0.30 mm×40 mm, Suzhou Medical Supplies, Suzhou, China) targeting the medial Xiyan (EX-LE5), Dubi (ST35), Yinlingquan (SP9), Yanglingquan (GB34), Liangqiu (ST34), and Xuehai (SP10) acupoints on the affected side were directly inserted 15–30 mm, and retained for 25 min [ 16 ] . Using an even reinforcing-reducing method, the sensation could be experienced as traveling to the knee after obtaining Qi (a specific needle sensation). Acupuncture was performed every other day, for 12 times in total. Tuina massage and acupuncture on the ankle were additionally performed in KOA patients of the treatment group [ 14 ] . In a supine position, the practitioner held the patient's heel with one hand and the toe with the other. Dorsiflexion, plantarflexion, inversion, and eversion of the ankle were slowly conducted. The inner and outer ankles held with both palms were then gently pressed to straighten the tendons and meridians. Massage for Shangqiu (SP05), Jiexi (ST41), Qiuxu (GB40), Kunlun (BL60), Taixi (KI3), Zusanli (ST36) and other acupoints was similarly performed as above mentioned. Acupuncture on the medial Xiyan (EX-LE5), Dubi (ST35), Yinlingquan (SP9), Yanglingquan (GB34), Liangqiu (ST34), Xuehai (SP10), Kunlun (BL60), Taixi (KI3), and Xuanzhong (GB39) acupoints was also similarly performed as above mentioned (Fig. 1 ). Outcome measures The degree of pain was assessed using the VAS [ 17 ] , and the pain, stiffness and physical function of the knee were evaluated by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [ 18 ] . The active range of motion (AROM) was measured using an articular protractor in a supine position where the knee was actively flexed to the maximum angle [ 19 ] . Serum samples were harvested for quantifying IL-1β, TNF-α and MMP3 levels via enzyme-linked immunosorbent assay (ELISA). Therapeutic efficacy Therapeutic efficacy was assessed based on the symptom score reduction (SSR) calculated as follows: symptom score reduction (%) = (WOMAC before treatment – WOMAC after treatment ) / WOMAC before treatment × 100%. It was categorized into cure (≥ 90% of SSR), efficacy (60%≤SSR < 90%), valid (30%≤SSR < 60%) and invalid (< 30% of SSR). The total efficacy rate (%) was the proportion of cure, efficacy and valid cases to the total case number. Statistical analysis Statistical analysis was performed using SPSS 26.0. Measurement data within the normal distribution were expressed as mean ± standard deviation ( \(\:\stackrel{-}{x}\) ±s); otherwise, they were expressed as the median (interquartile range, IQR). Enumeration and ranked data were described as frequency (constituent ratio). Measurement data between groups were compared by the t-test or Wilcoxon rank-sum test, and those within the group were compared by the t-test or Wilcoxon signed-ranked test. Intergroup comparisons of enumeration and ranked data were conducted by Chi-square test/Fisher’s exact test and Wilcoxon rank-sum test, respectively. P < 0.05 suggested a significant difference. Results Baseline characteristics A total of 33 KOA patients in the control group and 32 in the treatment group were finally included in our study. Their baseline characteristics, including gender, age, course of disease, body mass index (BMI) and affected knees (bilateral or unilateral) were comparable ( P > 0.05, Table 1 ). Table 1 Baseline characteristics of KOA patients (n = 65). Treatment group (n = 32) Control group (n = 33) P -value Male gender (n, %) 7 (21.9) 11 (33.3) P > 0.05 Age (years) 60.91 ± 8.75 58.03 ± 10.12 P > 0.05 Course of disease (years) 4.58 ± 4.40 4.06 ± 3.15 P > 0.05 BMI (kg/m 2 ) 26.39 ± 2.96 26.21 ± 3.63 P > 0.05 Unilateral side affected (n, %) 11 (34.4) 16 (48.5) P > 0.05 KOA, knee osteoarthritis; BMI, body mass index. Superior efficacy of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA After treatment, there were 18 efficacy, 11 valid and 3 invalid cases in the treatment group. A total of 13 efficacy, 10 valid and 10 invalid cases in the control group. The total efficacy rate was significantly higher in the treatment group than the control group (90.63% vs. 69.70%, P < 0.05, Table 2 ). Table 2 Total efficacy rate (n = 65). Cure Efficacy Valid Invalid Total efficacy rate (%) Treatment group (n = 32) 0 18 11 3 90.63 * Control group (n = 33) 0 13 10 10 69.70 * P < 0.05 vs. control group. Acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously effectively and safely relieves pain and stiffness, and improves function in KOA patients Both the VAS score and WOMAC were significantly reduced after treatment in the two groups, and more pronounced declines were seen in the treatment group than the control group ( P < 0.05, Table 3 ). It suggested the superior efficacy of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in alleviating pain and stiffness of KOA than targeting solely on the knee. In addition, AROM of the knee was significantly elevated in both groups after treatment, especially in the treatment group ( P < 0.05, Table 3 ). We therefore validated the clinical applicability of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously for masking pain and improving function in KOA patients. Notably, no cases of adverse events were reported, highlighting the high safety profile. Acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously favors the treatment of KOA by inhibiting inflammation and promoting tissue remodeling To further dig out the exact mechanism by which acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously alleviated KOA, we measured serum levels of IL-1β, TNF-ɑ and MMP-3, all established for their intertwined roles in the development of KOA. IL-1β and TNF-α are pro-inflammatory cytokines that can induce the production of MMP-3, a proteinase involved in tissue remodeling and degradation. Here, serum IL-1β, TNF-ɑ and MMP-3 levels all significantly decreased after treatment, especially in the treatment group ( P < 0.05, Table 4 ). Overall, acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously remarkably inhibited local inflammation and promoted tissue remodeling around the affected knee of KOA patients. Table 3 The VAS score, WOMAC and AROM before and after treatment (n = 65). VAS (points) WOMAC AROM (°) Before After Before After Before After Treatment group (n = 32) 10.13 ± 3.27 3.16 ± 1.37 *# 56.63 ± 16.75 17.63 ± 11.28 *# 108.72 ± 3.42 120.84 ± 6.62 *# Control group (n = 33) 9.82 ± 3.42 4.09 ± 2.17 * 49.70 ± 21.72 23.91 ± 12.54 * 110.42 ± 3.88 117.36 ± 4.88 * * P < 0.05 vs. before treatment; # P < 0.05 vs. control group. VAS, Visual Analogue Scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; AROM, active range of motion. Table 4 Serum IL-1β, TNF-ɑ and MMP-3 before and after treatment (n = 65). IL-1β (pg/mL) TNF-ɑ (pg/mL) MMP-3 (ng/mL) Before After Before After Before After Treatment group (n = 32) 2.48 ± 1.28 1.34 ± 0.54 *# 3.57 ± 1.20 2.00 ± 0.71 *# 20.37 ± 14.93 12.55 ± 5.82 *# Control group (n = 33) 2.89 ± 1.12 1.74 ± 0.92 * 4.10 ± 2.41 2.77 ± 1.54 * 23.26 ± 5.82 16.06 ± 7.24 * * P < 0.05 vs. before treatment; # P < 0.05 vs. control group. IL-1β, interleukin 1β; TNF-ɑ, tumor necrosis factor alpha; MMP-3, matrix metalloproteinase-3. Discussion KOA is a common chronic orthopedic disease with the main pathological characteristics of cartilage degradation, osteophyte formation, and subchondral bone changes. Typical manifestations of KOA include knee pain, swelling, and dysfunction. Middle-aged and older adults are frequently affected by KOA, resulting in a high disability rate [ 21 ] . KOA growingly endangers the well-being and quality of life with the aging population. The onset of KOA is closely linked with age, metabolism, infection, genetics, and exercises. Generally, pathogenic factors responsible for the development of KOA consist of immune factors, inflammatory response, cartilage damage, and biomechanics. Previous evidence shows that apoptosis of articular chondrocytes, extracellular matrix (ECM) degradation, and local inflammatory cell infiltration are predominant mechanisms for KOA [ 22 ] . During the development and progression of KOA, the dynamic balance of cartilage synthesis and decomposition is broken by inflammatory factors and cytokines. IL-1β and TNF-α are two pro-inflammatory factors that accelerate the catabolism of cartilage, thereby leading to the degeneration of articular cartilage [ 23 ] . Both of them can cause metabolic abnormalities in joint cartilage, resulting in loss, deformation, hyperplasia and structural damage of joint cartilage. Specifically, IL-1β and TNF-α stimulate ECM degradation, as well as the proliferation and differentiation of synovial fibroblasts, altogether leading to the articular cartilage injury [ 24 – 26 ] . Abundant inflammatory mediators produced by IL-1β and TNF-α further imbalance cartilage decomposition and synthesis, aggravating the pathological condition of KOA [ 27 ] . Wang et al. demonstrated a positive correlation of IL-1β and TNF-α levels with the severity of KOA [ 28 ] . Targeting serum IL-1β and TNF-α is a promising therapeutic strategy for KOA via suppressing ECM degradation and chondrocyte damage [ 29 ] . Matrix metalloproteinases (MMPs) play a significant role in cartilage destruction. MMP-3, as a family member of MMPs, not only breaks down cartilage, but also activates other MMPs to stimulate articular cartilage degradation [ 30 ] . TCM categorizes KOA into the medical conditions of bone arthritis and knee arthritis, manifesting as knee pain, deformity, and difficulty walking. Described as early as in the Lingshu Chapter of Huangdi Neijing ( Inner Canon of the Yellow Emperor ), a round-shaped needle punctures to treat knee arthritis. Currently, acupuncture has been broadly recommended to KOA patients [ 31 – 32 ] . The knee and ankle joints are closely linked and interact during lower limb movement. Biomechanical changes in one of them rapidly get entangled with the other one, further altering the overall biomechanical pattern of the lower limbs. The ankle joint is relatively motility and highly controllable. An effective control and correction of biomechanical factors of the ankle is capable of reducing the load on the knee joint. Consequently, lowered mechanical state and pressures within the knee are favorable to the treatment of KOA. Tuina massage on the muscles and ligaments around the knee and ankle joints has definite effects on dredging meridians, smoothing joints, and correcting joint force lines and angles, unveiling irreplaceable advantages in easing clinical symptoms of KOA. Based on the traditional treatment of acupuncture acupoints of the knee [ 33 – 34 ] , this study innovatively adopted a novel theory of “simultaneous regulation of both the knee and ankle joints”. KOA patients in the treatment group were additionally given to acupuncture on Kunlun, Taixi, and Xuanzhong acupoints. Finally, a self-designed acupuncture regimen with the major acupoints of medial Xiyan, Dubi, Yinlingquan, Yanglingquan, Liangqiu, Xuehai, Kunlun, Taixi, and Xuanzhong was formulated to target both the knee and ankle joints simultaneously. Xiyan and Dubi acupoints are the most common tender points in KOA. Previous evidence shows that acupuncture effectively alleviates local inflammation, masks pain around the patella, and relieves swelling and limited range of motion of the patella via reducing IL-1β, TNF-α, and MMP-3 levels in joint fluids of KOA patients [ 35 ] . Acupuncture on the Yinlingquan and Yanglingquan acupoints has a proved analgesic effect against KOA-induced chronic pain of the knee. It accelerates local circulation, enhances the muscle strength of the knee, and suppresses inflammatory response by lowering IL-1β and TNF-α levels in the synovial fluid [ 36 ] . Grounding on traditional knee acupoints, an additional acupuncture on Kunlun, Taixi and Xuanzhong offers a better efficacy than the traditional treatment of KOA. Mechanically, this approach inhibits ECM degradation, local inflammation and stimulation of rich nerve endings by lowering serum IL-1β, TNF-α and MMP-3 levels, thereby achieving analgesic effects [ 37 – 39 ] . Xuanzhong, Kunlun and Taixi acupoints are located around the ankle joint. While relieving knee pain, acupuncture on them restores the normal biomechanics of the ankle. According to our clinical experiences, we recommended acupuncture on Kunlun, Taixi and Xuanzhong first, followed by that on knee acupoints, thus emphasizing an increased efficacy in treating KOA based on the theory of “simultaneous regulation of both the knee and ankle joints”. Our data showed significantly declines of the VAS and WOMAC, and increases in the AROM of the knee in both groups. In comparison to the control group, acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously provided a higher total efficacy rate in KOA patients, probably due to the much more decreased serum IL-1β, TNF-α and MMP-3 levels. Knee lesions are tightly related to the balance of stress in the ankle joint. An improvement of the biomechanical line of the ankle joint is beneficial to reduce the internal pressure of the knee, and prevent the damage to the knee joint cartilage. Overall, we proved the efficacy and safety of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA, offering novel insights into the TCM therapies for KOA. Conclusion Acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously is superior to the target of knee solely. It effectively masks pain, improves knee function, and increases AROM of the knee in KOA patients by lowering serum IL-1β, TNF-α and MMP3. Declarations 1.Consent to Publish declaration: not applicable. 2.Ethics and Consent to Participate declarations:Acquired. Ethics Committee: Medical Ethics Committee of Hebei Provincial Hospital of Traditional Chinese Medicine. Approval number: HBZY2021-KY-039-01. 3.Funding Declaration:Acquired. Funder name:Hebei Provincial Administration of Traditional Chinese Medicine. Grand ID:2022057 4.Data Availability declaration:Agree. 5.Author Contribution Statement: First Author (Author An Huang) Conceived and designed the study protocol, including the research objective of evaluating the efficacy and safety of acupuncture combined with Tuina massage for concurrent knee and ankle joint intervention in knee osteoarthritis (KOA). Responsible for participant recruitment and conducted initial screening of the 70 enrolled KOA patients. Oversaw the implementation of randomization to divide patients into the treatment group and control group (35 cases each), and recorded the initial participant information. Drafted the initial manuscript and took charge of data organization for the excluded cases.Performed statistical analyses using professional software (e.g., SPSS, SAS) on the final valid samples (33 control cases, 32 treatment cases), Second Author (Author Yanjun Wang) Co-designed the study methodology, particularly optimizing the standard operating procedures for acupuncture and Tuina massage interventions to ensure consistency across both knee and ankle joints. Supervised the implementation of interventions in both groups throughout the study period, conducted regular on-site inspections to monitor treatment compliance, and documented the reasons for participant drop-outs (e.g., tracking the details of poor compliance in 2 treatment group cases). Contributed to data verification, cross-checked the final sample sizes (33 in the control group and 32 in the treatment group), and revised the manuscript for methodological accuracy. Third Author (Author Xiaotian Wang) Responsible for the ethical approval application of the study and ensured compliance with the Declaration of Helsinki guidelines. Managed the entire data collection process, including collecting clinical outcome indicators (e.g., knee pain scores, joint function assessments) and safety monitoring data (e.g., adverse reactions to acupuncture/Tuina) for all participants. Independently verified the completeness and accuracy of the collected data, especially for the 5 excluded cases, and compiled the final dataset for statistical analysis. Fourth Author (Author Yang Liu) Designed the statistical analysis plan of the study, including sample size calculation (justifying the initial enrollment of 70 cases) and selection of appropriate statistical methods (e.g., independent samples t-test for between-group comparisons, chi-square test for categorical data like drop-out reasons). Generated statistical reports and visualized results (e.g., tables, figures) for manuscript inclusion. Fifth Author (Author Xiaomin Yang) Served as the clinical supervisor of the study, with expertise in acupuncture and Tuina therapy for musculoskeletal diseases. Trained and certified the therapists responsible for delivering acupuncture and Tuina interventions to ensure uniform technique standards for both knee and ankle joints. Conducted regular audits of the treatment process to ensure adherence to the study protocol, provided solutions for unexpected clinical issues (e.g., addressing mild adverse reactions), and reviewed the clinical data to ensure its clinical rationality and authenticity. Corresponding Author (Author Jiaxiang Yang) Initiated the research idea and obtained the necessary funding support for the study. Provided overall guidance on the study design, implementation, and data analysis, and made critical decisions on key study issues (e.g., handling of drop-out cases, adjustment of intervention protocols if needed). Revised the manuscript critically for important intellectual content, ensured that all authors meet the ICMJE authorship criteria, and took responsibility for the integrity of the data and the accuracy of the data analysis. Communicated with the journal during the submission process, responded to peer review comments, and finalized the manuscript for publication. All authors have read and approved the final manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 6.Conflict of interest: None. Acknowledgement I am deeply grateful to the many individuals and organisations that have been instrumental in the completion of this research.Firstly, I would like to extend my sincerest gratitude to my supervisor, Mr Eric Yeung.His consistent support throughout the research period, invaluable guidance and insightful feedback have been fundamental to the progress of this project.In the face of my endless questions, Ms Yang always answered them patiently, guided me to reflect on my existing ideas, and gave me the freedom to explore new ideas.Without Ms Yang's careful guidance, this study would not have been possible.I would also like to express my sincere gratitude to the teachers and other research partners at the Hebei Provincial Hospital of Traditional Chinese Medicine.Their collaborative spirit, knowledge and constructive criticism have greatly enhanced the quality of my research.I have gained a lot from working with them, and their contributions have been very meaningful to this study.In addition, I would like to express my heartfelt gratitude to the Hebei Provincial Administration of Traditional Chinese Medicine for their financial support, which made it possible for me to carry out this research and pursue my academic aspirations.I would also like to express my special thanks to your journal.In the vast world of academia, journals are like a bright lighthouse, illuminating the path of dissemination for research results.Its rigorous review process and professional editorial team not only polished the paper in detail, but also gave me many valuable suggestions, which prompted me to continuously improve the research content, so that the results can be presented in front of the academic community in a better quality.Journals provide a key platform for academic exchanges and help the research results to attract attention and discussion in a wider range of fields, which greatly enhances the impact of the research.Finally, I cannot express my gratitude enough to my family and friends.They accompanied me with love, encouragement and understanding during the difficult process of research.Their consistent support has been a constant source of spiritual motivation for me, and I am truly grateful for their companionship in my life.In conclusion, I would like to express my sincere gratitude to all those who have contributed to this study.Their support, leadership and collaboration were key elements in the success of the study.It has been an honour to work with such wonderful people. 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Changes in serum and joint fluid MMP-13 and TNF-α levels in patients with knee osteoarthritis [J]. China Medical Herald, 2017, 14(15): 98–101. Zhang Haifeng, Chen Shutao, Mao Jiaona, et al. Effect of thermal moxibustion on IL-1β, TNF-α, and MMP-13 in rabbit models of knee osteoarthritis [J]. China Journal of Traditional Chinese Medicine and Pharmacy, 2018, 33(9): 3913–3917. TOKAI N, YOSHIDA S, KOTANI T, et al. Serum matrix metalloproteinase 3levels are associated with an effect of iguratimod as add-on therapy to biological DMARDs in patients with rheumatoid arthritis[J]. PLoSOne, 2018, 13(8): e0202601. Guo Yi, Zhai Wei, Huang Juan, et al. Clinical practice guide for evidence-based acupuncture: knee osteoarthritis [M]. Beijing: China Press of Chinese Medicine, 2015. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee [J]. Arthritis Care Res (Hoboken), 2012, 64(4): 465–474. Ye Bihong, Song Fengjun, Zheng Shili, et al. Electric heating acupuncture for the treatment of early and middle stage yang deficiency cold-coagulated knee osteoarthritis [J]. Journal of Zhejiang Chinese Medical University, 2015, 39(02): 144–146. Sun Duicang, Jia Pingye, Zheng Fangjiang. Clinical observation of 68 cases of infrapatellar fat pad damage by six-point matrix acupuncture [J]. Chinese Journal of Reproductive Health, 2013, 19(01): 69–70. Yang R, Liao HY, Huang ZH. Clinical observation on the treatment of knee osteoarthritis by acupuncture combined with cupping exercise therapy[J]. Shanghai Journal of Acupuncture and Moxibustion. 2021, (02):194–199. (in Chinese) Hu Hua, Li Liantai, Liu Yanwei, Wang Shujun, Xie Shuangxi, Sun Jianjun.Efficacy of acupuncture at “relative point” combined with quadriceps isometric contraction training for elderly patients with knee osteoarthritis[J].Chinese Journal of Multiple Organ Diseases in the Elderly.2024,(07):528–531. Li SM, Li TL, Guo R, Chen P, Du WS, Kang SB, Yan MZ, Cheng WZ. Effectiveness and safety of acupotomy for knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2021;22(1):824. Shi GX, Tu JF, Wang TQ, Yang JW, Wang LQ, Lin LL, Wang Y, Li YT, Liu CZ. Effect of Electro-Acupuncture (EA) and Manual Acupuncture (MA) on Markers of Inflammation in Knee Osteoarthritis. J Pain Res. 2020;13:2171–2179. Chen H, Shao X, Li L, Zheng C, Xu X, Hong X, Li X, Wu M. Electroacupuncture serum inhibits TNFαmediated chondrocyte inflammation via the RasRafMEK1/2ERK1/2 signaling pathway. Mol Med Rep. 2017;16(5):5807–5814. Additional Declarations No competing interests reported. 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07:13:40","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":112678,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7496069/v1/9d108bffbc4dd70032c31744.html"},{"id":92474783,"identity":"7903b034-a17b-40ab-bd88-9919e9fb7874","added_by":"auto","created_at":"2025-09-30 07:13:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":458155,"visible":true,"origin":"","legend":"\u003cp\u003eAcupuncture combined with Tuina massage targeting the knee solely versus both the knee and ankle joints simultaneously.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7496069/v1/544b46ebac385d3ad8dbeb7e.png"},{"id":107481945,"identity":"fd4a4926-828b-456b-8c19-75d7c5ef4f36","added_by":"auto","created_at":"2026-04-22 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Major manifestations consist of knee pain, stiffness, and limited activity with friction sounds \u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The prevalence of KOA is 18% in China, which is sharply inflated to 85% among older adults of 65 years and above. In severe cases, KOA results in a 53% of disability rate that seriously affects the quality of life \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Muscle imbalance is the predominant pathogenic factor for KOA \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Medications and surgery are currently the mainstream approaches to treat KOA. However, drug therapy is accompanied by potential risks of organ damage and cardiovascular adverse events. While effective in pain relief of KOA, opioids are highly addictive. Surgical procedures for KOA are invasive and expensive, leading to postoperative complications \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Therefore, it is particularly important to seek an effective and safe treatment for KOA.\u003c/p\u003e\u003cp\u003eAcupuncture is a treasure of traditional Chinese medicine (TCM), showing superb advantages in relieving pain and improving physical functions \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Tuina massage is a therapeutic massage technique long been originated in China. Serving as a type of conservative treatment of KOA, Tuina massage effectively masks pain and restores knee function via strengthening the muscle strength of peripheral muscle groups of the knee, correcting the force line of the lower limb, and intervening in the gait parameters \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Abundant evidence proves a close anatomic relationship between KOA and the ankle \u003csup\u003e[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In the present study, we innovatively introduced a theory of \u0026ldquo;simultaneous regulation of both the knee and ankle joints\u0026rdquo;. The efficacy and safety of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA were explored, as well as the underlying mechanisms. Our findings are expected to provide clinical references to emphasize the role of acupuncture and Tuina massage in the treatment of KOA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eA total of 70 KOA patients who visited the Orthopedic Clinic, Hebei Provincial Hospital of Traditional Chinese Medicine from September 1st, 2021 to September 30th 2022 were enrolled. They were randomly divided into the control group and treatment group using a random number table, with 35 cases per group. After excluding 2 drop-outs due to personal issues in the control group, and 2 due to poor compliance and 1 due to personal affairs in the treatment group, we finally included 33 cases in the control group and 32 in the treatment group. This study was approved by the Ethics Committee of Hebei Provincial Hospital of Traditional Chinese Medicine (No. HBZY2021-KY-040-01).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eA clear diagnosis of KOA was made based on both the Western medicine and traditional Chinese medicine (TCM) criteria. Briefly, middle-aged and older adults with two or more of the following conditions were diagnosed with KOA by the Western medicine criteria: (1) age\u0026thinsp;\u0026ge;\u0026thinsp;50 years; (2) repeated pain of the knee within the past month; (3) morning knee stiffness\u0026thinsp;\u0026le;\u0026thinsp;30 min; (4) range of motion of the knee with fricative sounds; (5) osteogenesis, narrowing of joint space, subchondral bone sclerosis and/or cystic changes on imaging scans \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMiddle-aged and older adults with initial symptoms of dull pain, swelling, restricted flexion and extension, and friction sound of the knee that progressed slowly and constantly, and changed with the temperature were diagnosed with KOA by TCM criteria. In severe cases, knee deformity and muscle atrophy could be seen \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eKOA patients at 40\u0026ndash;75 years of age, who were in the onset stage and graded a minimum of 4 and above of the Visual Analogue Scale (VAS) were considered eligible. All participants provided written informed consent. Excluded were those with the use of agents that may influence the therapeutic efficacy within 2 weeks; tumors, infections, tuberculosis, rheumatoid arthritis or acute injuries; severe organ dysfunction; severe skin disease or knee rupture; mental illnesses; and pregnant or breastfeeding women.\u003c/p\u003e\u003cp\u003eThe clinical trial should be discontinued for severe adverse events or voluntary withdrawal for any cause. KOA patients mistakenly included who did not meet the inclusion criteria, and individuals with poor compliance, insufficient clinical data, and did not follow the standard treatment, were dropped out.\u003c/p\u003e\n\u003ch3\u003eTreatment regimens\u003c/h3\u003e\n\u003cp\u003eAcupuncture and Tuina massage for the knee were applied to all KOA patients based on standard procedures \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Briefly, Tuina massage was first given prior to acupuncture. In a supine position, meridians on the medial and lateral sides of the affected thigh were pressed and rolled, followed by a circular knead on both sides of the lower limb, with a frequency of 100 repeats per minute. Surrounding the pain point of the knee, rolling at a frequency of 50\u0026ndash;100 repeats per minute was given to relieve pain. Then, patients were asked to lie face down, and the practitioner stood on the affected side. Knee flexion and relaxation of the popliteal fossa were achieved by one hand of the practitioner holding the ankle on the affected side, where the other hand rolled and kneaded the ankle at a frequency of 50\u0026ndash;100 repeats per minute. Tuina massage was performed 25 minutes every other day, for a total of 12 sessions.\u003c/p\u003e\u003cp\u003eIn a supine position, acupuncture needles (0.30 mm\u0026times;40 mm, Suzhou Medical Supplies, Suzhou, China) targeting the medial Xiyan (EX-LE5), Dubi (ST35), Yinlingquan (SP9), Yanglingquan (GB34), Liangqiu (ST34), and Xuehai (SP10) acupoints on the affected side were directly inserted 15\u0026ndash;30 mm, and retained for 25 min \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Using an even reinforcing-reducing method, the sensation could be experienced as traveling to the knee after obtaining Qi (a specific needle sensation). Acupuncture was performed every other day, for 12 times in total.\u003c/p\u003e\u003cp\u003eTuina massage and acupuncture on the ankle were additionally performed in KOA patients of the treatment group \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. In a supine position, the practitioner held the patient's heel with one hand and the toe with the other. Dorsiflexion, plantarflexion, inversion, and eversion of the ankle were slowly conducted. The inner and outer ankles held with both palms were then gently pressed to straighten the tendons and meridians. Massage for Shangqiu (SP05), Jiexi (ST41), Qiuxu (GB40), Kunlun (BL60), Taixi (KI3), Zusanli (ST36) and other acupoints was similarly performed as above mentioned. Acupuncture on the medial Xiyan (EX-LE5), Dubi (ST35), Yinlingquan (SP9), Yanglingquan (GB34), Liangqiu (ST34), Xuehai (SP10), Kunlun (BL60), Taixi (KI3), and Xuanzhong (GB39) acupoints was also similarly performed as above mentioned (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eThe degree of pain was assessed using the VAS \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, and the pain, stiffness and physical function of the knee were evaluated by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The active range of motion (AROM) was measured using an articular protractor in a supine position where the knee was actively flexed to the maximum angle \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Serum samples were harvested for quantifying IL-1β, TNF-α and MMP3 levels via enzyme-linked immunosorbent assay (ELISA).\u003c/p\u003e\n\u003ch3\u003eTherapeutic efficacy\u003c/h3\u003e\n\u003cp\u003eTherapeutic efficacy was assessed based on the symptom score reduction (SSR) calculated as follows: symptom score reduction (%) = (WOMAC\u003csub\u003ebefore treatment\u003c/sub\u003e \u0026ndash; WOMAC\u003csub\u003eafter treatment\u003c/sub\u003e) / WOMAC\u003csub\u003ebefore treatment\u003c/sub\u003e \u0026times; 100%. It was categorized into cure (\u0026ge;\u0026thinsp;90% of SSR), efficacy (60%\u0026le;SSR\u0026thinsp;\u0026lt;\u0026thinsp;90%), valid (30%\u0026le;SSR\u0026thinsp;\u0026lt;\u0026thinsp;60%) and invalid (\u0026lt;\u0026thinsp;30% of SSR). The total efficacy rate (%) was the proportion of cure, efficacy and valid cases to the total case number.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using SPSS 26.0. Measurement data within the normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u0026plusmn;s); otherwise, they were expressed as the median (interquartile range, IQR). Enumeration and ranked data were described as frequency (constituent ratio). Measurement data between groups were compared by the t-test or Wilcoxon rank-sum test, and those within the group were compared by the t-test or Wilcoxon signed-ranked test. Intergroup comparisons of enumeration and ranked data were conducted by Chi-square test/Fisher\u0026rsquo;s exact test and Wilcoxon rank-sum test, respectively. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 suggested a significant difference.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eBaseline characteristics\u003c/h2\u003e\u003cp\u003eA total of 33 KOA patients in the control group and 32 in the treatment group were finally included in our study. Their baseline characteristics, including gender, age, course of disease, body mass index (BMI) and affected knees (bilateral or unilateral) were comparable (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of KOA patients (n\u0026thinsp;=\u0026thinsp;65).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale gender (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (21.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.91\u0026thinsp;\u0026plusmn;\u0026thinsp;8.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCourse of disease (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.58\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnilateral side affected (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (34.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16 (48.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eKOA, knee osteoarthritis; BMI, body mass index.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSuperior efficacy of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAfter treatment, there were 18 efficacy, 11 valid and 3 invalid cases in the treatment group. A total of 13 efficacy, 10 valid and 10 invalid cases in the control group. The total efficacy rate was significantly higher in the treatment group than the control group (90.63% vs. 69.70%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTotal efficacy rate (n\u0026thinsp;=\u0026thinsp;65).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEfficacy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValid\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInvalid\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal efficacy rate (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e90.63\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e69.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. control group.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcupuncture combined with Tuina massage for both the knee and ankle joints simultaneously effectively and safely relieves pain and stiffness, and improves function in KOA patients\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBoth the VAS score and WOMAC were significantly reduced after treatment in the two groups, and more pronounced declines were seen in the treatment group than the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). It suggested the superior efficacy of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in alleviating pain and stiffness of KOA than targeting solely on the knee. In addition, AROM of the knee was significantly elevated in both groups after treatment, especially in the treatment group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We therefore validated the clinical applicability of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously for masking pain and improving function in KOA patients. Notably, no cases of adverse events were reported, highlighting the high safety profile.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAcupuncture combined with Tuina massage for both the knee and ankle joints simultaneously favors the treatment of KOA by inhibiting inflammation and promoting tissue remodeling\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo further dig out the exact mechanism by which acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously alleviated KOA, we measured serum levels of IL-1β, TNF-ɑ and MMP-3, all established for their intertwined roles in the development of KOA. IL-1β and TNF-α are pro-inflammatory cytokines that can induce the production of MMP-3, a proteinase involved in tissue remodeling and degradation. Here, serum IL-1β, TNF-ɑ and MMP-3 levels all significantly decreased after treatment, especially in the treatment group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Overall, acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously remarkably inhibited local inflammation and promoted tissue remodeling around the affected knee of KOA patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe VAS score, WOMAC and AROM before and after treatment (n\u0026thinsp;=\u0026thinsp;65).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eVAS (points)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eWOMAC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eAROM (\u0026deg;)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e10.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e56.63\u0026thinsp;\u0026plusmn;\u0026thinsp;16.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e17.63\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e108.72\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e120.84\u0026thinsp;\u0026plusmn;\u0026thinsp;6.62\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e9.82\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e49.70\u0026thinsp;\u0026plusmn;\u0026thinsp;21.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e23.91\u0026thinsp;\u0026plusmn;\u0026thinsp;12.54\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e110.42\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e117.36\u0026thinsp;\u0026plusmn;\u0026thinsp;4.88\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. before treatment; \u003csup\u003e#\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. control group.\u003c/p\u003e\u003cp\u003eVAS, Visual Analogue Scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; AROM, active range of motion.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSerum IL-1β, TNF-ɑ and MMP-3 before and after treatment (n\u0026thinsp;=\u0026thinsp;65).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eIL-1β (pg/mL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTNF-ɑ (pg/mL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMMP-3 (ng/mL)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment group (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e20.37\u0026thinsp;\u0026plusmn;\u0026thinsp;14.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e12.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003csup\u003e*#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e\u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e\u003cp\u003e23.26\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e16.06\u0026thinsp;\u0026plusmn;\u0026thinsp;7.24\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. before treatment; \u003csup\u003e#\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. control group.\u003c/p\u003e\u003cp\u003eIL-1β, interleukin 1β; TNF-ɑ, tumor necrosis factor alpha; MMP-3, matrix metalloproteinase-3.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eKOA is a common chronic orthopedic disease with the main pathological characteristics of cartilage degradation, osteophyte formation, and subchondral bone changes. Typical manifestations of KOA include knee pain, swelling, and dysfunction. Middle-aged and older adults are frequently affected by KOA, resulting in a high disability rate \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. KOA growingly endangers the well-being and quality of life with the aging population. The onset of KOA is closely linked with age, metabolism, infection, genetics, and exercises. Generally, pathogenic factors responsible for the development of KOA consist of immune factors, inflammatory response, cartilage damage, and biomechanics. Previous evidence shows that apoptosis of articular chondrocytes, extracellular matrix (ECM) degradation, and local inflammatory cell infiltration are predominant mechanisms for KOA \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDuring the development and progression of KOA, the dynamic balance of cartilage synthesis and decomposition is broken by inflammatory factors and cytokines. IL-1β and TNF-α are two pro-inflammatory factors that accelerate the catabolism of cartilage, thereby leading to the degeneration of articular cartilage \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Both of them can cause metabolic abnormalities in joint cartilage, resulting in loss, deformation, hyperplasia and structural damage of joint cartilage. Specifically, IL-1β and TNF-α stimulate ECM degradation, as well as the proliferation and differentiation of synovial fibroblasts, altogether leading to the articular cartilage injury \u003csup\u003e[\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Abundant inflammatory mediators produced by IL-1β and TNF-α further imbalance cartilage decomposition and synthesis, aggravating the pathological condition of KOA \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Wang et al. demonstrated a positive correlation of IL-1β and TNF-α levels with the severity of KOA \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Targeting serum IL-1β and TNF-α is a promising therapeutic strategy for KOA via suppressing ECM degradation and chondrocyte damage \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Matrix metalloproteinases (MMPs) play a significant role in cartilage destruction. MMP-3, as a family member of MMPs, not only breaks down cartilage, but also activates other MMPs to stimulate articular cartilage degradation \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTCM categorizes KOA into the medical conditions of bone arthritis and knee arthritis, manifesting as knee pain, deformity, and difficulty walking. Described as early as in the Lingshu Chapter of Huangdi Neijing (\u003cem\u003eInner Canon of the Yellow Emperor\u003c/em\u003e), a round-shaped needle punctures to treat knee arthritis. Currently, acupuncture has been broadly recommended to KOA patients \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. The knee and ankle joints are closely linked and interact during lower limb movement. Biomechanical changes in one of them rapidly get entangled with the other one, further altering the overall biomechanical pattern of the lower limbs. The ankle joint is relatively motility and highly controllable. An effective control and correction of biomechanical factors of the ankle is capable of reducing the load on the knee joint. Consequently, lowered mechanical state and pressures within the knee are favorable to the treatment of KOA. Tuina massage on the muscles and ligaments around the knee and ankle joints has definite effects on dredging meridians, smoothing joints, and correcting joint force lines and angles, unveiling irreplaceable advantages in easing clinical symptoms of KOA.\u003c/p\u003e\u003cp\u003eBased on the traditional treatment of acupuncture acupoints of the knee \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e, this study innovatively adopted a novel theory of \u0026ldquo;simultaneous regulation of both the knee and ankle joints\u0026rdquo;. KOA patients in the treatment group were additionally given to acupuncture on Kunlun, Taixi, and Xuanzhong acupoints. Finally, a self-designed acupuncture regimen with the major acupoints of medial Xiyan, Dubi, Yinlingquan, Yanglingquan, Liangqiu, Xuehai, Kunlun, Taixi, and Xuanzhong was formulated to target both the knee and ankle joints simultaneously. Xiyan and Dubi acupoints are the most common tender points in KOA. Previous evidence shows that acupuncture effectively alleviates local inflammation, masks pain around the patella, and relieves swelling and limited range of motion of the patella via reducing IL-1β, TNF-α, and MMP-3 levels in joint fluids of KOA patients \u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e. Acupuncture on the Yinlingquan and Yanglingquan acupoints has a proved analgesic effect against KOA-induced chronic pain of the knee. It accelerates local circulation, enhances the muscle strength of the knee, and suppresses inflammatory response by lowering IL-1β and TNF-α levels in the synovial fluid \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Grounding on traditional knee acupoints, an additional acupuncture on Kunlun, Taixi and Xuanzhong offers a better efficacy than the traditional treatment of KOA. Mechanically, this approach inhibits ECM degradation, local inflammation and stimulation of rich nerve endings by lowering serum IL-1β, TNF-α and MMP-3 levels, thereby achieving analgesic effects \u003csup\u003e[\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e. Xuanzhong, Kunlun and Taixi acupoints are located around the ankle joint. While relieving knee pain, acupuncture on them restores the normal biomechanics of the ankle. According to our clinical experiences, we recommended acupuncture on Kunlun, Taixi and Xuanzhong first, followed by that on knee acupoints, thus emphasizing an increased efficacy in treating KOA based on the theory of \u0026ldquo;simultaneous regulation of both the knee and ankle joints\u0026rdquo;.\u003c/p\u003e\u003cp\u003eOur data showed significantly declines of the VAS and WOMAC, and increases in the AROM of the knee in both groups. In comparison to the control group, acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously provided a higher total efficacy rate in KOA patients, probably due to the much more decreased serum IL-1β, TNF-α and MMP-3 levels.\u003c/p\u003e\u003cp\u003eKnee lesions are tightly related to the balance of stress in the ankle joint. An improvement of the biomechanical line of the ankle joint is beneficial to reduce the internal pressure of the knee, and prevent the damage to the knee joint cartilage. Overall, we proved the efficacy and safety of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating KOA, offering novel insights into the TCM therapies for KOA.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAcupuncture combined with Tuina massage for both the knee and ankle joints simultaneously is superior to the target of knee solely. It effectively masks pain, improves knee function, and increases AROM of the knee in KOA patients by lowering serum IL-1β, TNF-α and MMP3.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e1.Consent to Publish declaration: not applicable.\u003c/p\u003e\n\u003cp\u003e2.Ethics and Consent to Participate declarations:Acquired.\u003c/p\u003e\n\u003cp\u003eEthics Committee: Medical Ethics Committee of Hebei Provincial Hospital of Traditional Chinese Medicine. \u0026nbsp; Approval number: HBZY2021-KY-039-01.\u003c/p\u003e\n\u003cp\u003e3.Funding Declaration:Acquired.\u003c/p\u003e\n\u003cp\u003eFunder name:Hebei Provincial Administration of Traditional Chinese Medicine. Grand ID:2022057\u003c/p\u003e\n\u003cp\u003e4.Data Availability declaration:Agree.\u003c/p\u003e\n\u003cp\u003e5.Author Contribution Statement:\u003c/p\u003e\n\u003cp\u003eFirst Author (Author An Huang)\u003c/p\u003e\n\u003cp\u003eConceived and designed the study protocol, including the research objective of evaluating the efficacy and safety of acupuncture combined with Tuina massage for concurrent knee and ankle joint intervention in knee osteoarthritis (KOA). Responsible for participant recruitment and conducted initial screening of the 70 enrolled KOA patients. Oversaw the implementation of randomization to divide patients into the treatment group and control group (35 cases each), and recorded the initial participant information. Drafted the initial manuscript and took charge of data organization for the excluded cases.Performed statistical analyses using professional software (e.g., SPSS, SAS) on the final valid samples (33 control cases, 32 treatment cases),\u003c/p\u003e\n\u003cp\u003eSecond Author (Author Yanjun Wang)\u003c/p\u003e\n\u003cp\u003eCo-designed the study methodology, particularly optimizing the standard operating procedures for acupuncture and Tuina massage interventions to ensure consistency across both knee and ankle joints. Supervised the implementation of interventions in both groups throughout the study period, conducted regular on-site inspections to monitor treatment compliance, and documented the reasons for participant drop-outs (e.g., tracking the details of poor compliance in 2 treatment group cases). Contributed to data verification, cross-checked the final sample sizes (33 in the control group and 32 in the treatment group), and revised the manuscript for methodological accuracy.\u003c/p\u003e\n\u003cp\u003eThird Author (Author Xiaotian Wang)\u003c/p\u003e\n\u003cp\u003eResponsible for the ethical approval application of the study and ensured compliance with the Declaration of Helsinki guidelines. Managed the entire data collection process, including collecting clinical outcome indicators (e.g., knee pain scores, joint function assessments) and safety monitoring data (e.g., adverse reactions to acupuncture/Tuina) for all participants. Independently verified the completeness and accuracy of the collected data, especially for the 5 excluded cases, and compiled the final dataset for statistical analysis.\u003c/p\u003e\n\u003cp\u003eFourth Author (Author Yang Liu)\u003c/p\u003e\n\u003cp\u003eDesigned the statistical analysis plan of the study, including sample size calculation (justifying the initial enrollment of 70 cases) and selection of appropriate statistical methods (e.g., independent samples t-test for between-group comparisons, chi-square test for categorical data like drop-out reasons). Generated statistical reports and visualized results (e.g., tables, figures) for manuscript inclusion.\u003c/p\u003e\n\u003cp\u003eFifth Author (Author Xiaomin Yang)\u003c/p\u003e\n\u003cp\u003eServed as the clinical supervisor of the study, with expertise in acupuncture and Tuina therapy for musculoskeletal diseases. Trained and certified the therapists responsible for delivering acupuncture and Tuina interventions to ensure uniform technique standards for both knee and ankle joints. Conducted regular audits of the treatment process to ensure adherence to the study protocol, provided solutions for unexpected clinical issues (e.g., addressing mild adverse reactions), and reviewed the clinical data to ensure its clinical rationality and authenticity.\u003c/p\u003e\n\u003cp\u003eCorresponding Author (Author Jiaxiang Yang)\u003c/p\u003e\n\u003cp\u003eInitiated the research idea and obtained the necessary funding support for the study. Provided overall guidance on the study design, implementation, and data analysis, and made critical decisions on key study issues (e.g., handling of drop-out cases, adjustment of intervention protocols if needed). Revised the manuscript critically for important intellectual content, ensured that all authors meet the ICMJE authorship criteria, and took responsibility for the integrity of the data and the accuracy of the data analysis. Communicated with the journal during the submission process, responded to peer review comments, and finalized the manuscript for publication.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e6.Conflict of interest: None.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI am deeply grateful to the many individuals and organisations that have been instrumental in the completion of this research.Firstly, I would like to extend my sincerest gratitude to my supervisor, Mr Eric Yeung.His consistent support throughout the research period, invaluable guidance and insightful feedback have been fundamental to the progress of this project.In the face of my endless questions, Ms Yang always answered them patiently, guided me to reflect on my existing ideas, and gave me the freedom to explore new ideas.Without Ms Yang's careful guidance, this study would not have been possible.I would also like to express my sincere gratitude to the teachers and other research partners at the Hebei Provincial Hospital of Traditional Chinese Medicine.Their collaborative spirit, knowledge and constructive criticism have greatly enhanced the quality of my research.I have gained a lot from working with them, and their contributions have been very meaningful to this study.In addition, I would like to express my heartfelt gratitude to the Hebei Provincial Administration of Traditional Chinese Medicine for their financial support, which made it possible for me to carry out this research and pursue my academic aspirations.I would also like to express my special thanks to your journal.In the vast world of academia, journals are like a bright lighthouse, illuminating the path of dissemination for research results.Its rigorous review process and professional editorial team not only polished the paper in detail, but also gave me many valuable suggestions, which prompted me to continuously improve the research content, so that the results can be presented in front of the academic community in a better quality.Journals provide a key platform for academic exchanges and help the research results to attract attention and discussion in a wider range of fields, which greatly enhances the impact of the research.Finally, I cannot express my gratitude enough to my family and friends.They accompanied me with love, encouragement and understanding during the difficult process of research.Their consistent support has been a constant source of spiritual motivation for me, and I am truly grateful for their companionship in my life.In conclusion, I would like to express my sincere gratitude to all those who have contributed to this study.Their support, leadership and collaboration were key elements in the success of the study.It has been an honour to work with such wonderful people.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAyral X, Pickering EH, Wood worth TG, et al. Synovitis: a potential predictive factor of structural progression of medial tibiofemoral knee osteoarthritis - results of a 1-year longitudinal arthroscopic study in 422 patients. Osteoarthritis Cartilage. 2005; 13(5): 361\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDziedzic KS, Healey EL, Porcheret M, et al. Implementing the NICE osteoarthritis guidelines: a mixed methods study and cluster randomized trial of a model osteoarthritis consultation in primary care\u0026ndash;the Management of OsteoArthritis in Consultations (MOSAICS) study protocol. Implement Sci. 2014; 9: 95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGrory B, Weber K, Lynott JA, et al. American Academy of Orthopaedic Surgeons. The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on Surgical Management of Osteoarthritis of the Knee. 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J Pain Res. 2020;13:2171\u0026ndash;2179.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen H, Shao X, Li L, Zheng C, Xu X, Hong X, Li X, Wu M. Electroacupuncture serum inhibits TNFαmediated chondrocyte inflammation via the RasRafMEK1/2ERK1/2 signaling pathway. Mol Med Rep. 2017;16(5):5807\u0026ndash;5814.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"acupuncture, Tuina massage, simultaneous target on both the knee and ankle joints, efficacy","lastPublishedDoi":"10.21203/rs.3.rs-7496069/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7496069/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003eTo state the efficacy and safety of acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously in treating knee osteoarthritis (KOA).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A total of 70 KOA patients visiting the Orthopedic Clinic, Hebei University of Chinese Medicine from September 2021 to September 2022 were enrolled and randomly divided into the treatment group and control group, with 35 cases per group. After excluding 2 cases of self-withdrawal in the control group, and 3 drop-out cases in the treatment group (2 with poor compliance, and 1 with personal affair), 33 in the former and 32 in the latter were finally included for the analysis. KOA patients in the treatment group were treated with acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously, while those in the control group were similarly managed but only targeting on the knee only. Interventions were given once every other day, for 12 sessions. The Visual Analogue Scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), active range of motion (AROM) of the knee, and serum IL-1β, TNF-α and MMP-3 before and after treatment were compared between groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe effective rate was significantly higher in the treatment group than the control group (90.63% vs. 69.70%, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). Post-treatment VAS score, WOMAC, and serum IL-1β, TNF-α and MMP-3 were significantly reduced, while AROM of the knee was significantly increased in both groups (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), which were significantly pronounced in the treatment group than the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAcupuncture combined with Tuina massage for both the knee and ankle joints simultaneously is superior to the target of knee solely. It effectively masks pain, improves knee function, and increases AROM of the knee in KOA patients by lowering serum IL-1β, TNF-α and MMP-3.\u003c/p\u003e","manuscriptTitle":"Treatment of knee osteoarthritis by acupuncture combined with Tuina massage for both the knee and ankle joints simultaneously","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 07:13:35","doi":"10.21203/rs.3.rs-7496069/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a67fc230-b511-4855-bda0-a5feb34301c2","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-18T13:54:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 07:13:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7496069","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7496069","identity":"rs-7496069","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}