Exploring the Rule of Selecting Acupoints for Acupuncture

Treatment of Knee Osteoarthritis based on Literature Collection and

Analysis

Shichao Yu

†a

and Te Kian Keong

Department of Chinese Medicine, Universiti Tunku Abdul Rahman, Kajang Selangor, Malaysia

Corresponding author

Keywords: Acupuncture, Knee Osteoarthritis (KOA), Acupoints, Meridian Classification, Literature Collection,

Literature Study.

Abstract: Use computer search methods to search literature, which meets the inclusion criteria, on Randomized

Controlled Clinical Trial (RCT) about Acupuncture Treatment for Knee Osteoarthritis (KOA) from the

relevant databases of China National Knowledge Infrastructure (CNKI), Weipa Journal Full-text Database

(VIP), Wanfang Data Knowledge Service Platform, PubMed, etc. The date was from January 2005 to

January 2020. Import the retrieved and downloaded documents into NoteExpress2 for management, and

analyze the selected 569 documents that meet the requirements of acupuncture treatment of KOA, so as to

explore the rule of selecting acupoints for clinical acupuncture treatment of KOA based on literature

analysis, in order to provide reference and theoretical guidance for optimizing clinical treatment. The

selected acupoints to treat KOA with acupuncture are mainly located at and around the knee joint, and are

mainly distributed in the Three Yang Meridians of Foot, the Spleen Meridian of Foot-Taiyin, and the

acupoints outside the meridian (Extra Acupoints). The top 10 acupoints with appearance frequency are

mainly distributed in the Spleen Meridian of Foot-Taiyin (SP) (3), Extra Acupoints (EX) (3), Stomach

Meridian of Foot-Yangming (ST) (2), Gallbladder Meridian of Foot-Shaoyang (GB) (2), etc. The most

frequently used acupoints (the top 10 high-selected acupoints) are: "DuBi (ST35)" (544), "Neixiyan (EX-

LE4)" (533), “Xuehai (SP10)" (414), "Yanglingquan (GB34)" (392), "Liangqiu (ST34)" (339), "Zusanli

(ST36)" (318), "Yinlingquan (SP9)" (285), "Heding (EX-LE2)" (204), "Xiyangguan (GB33)" (84),

"Sanyinjiao (SP6)" (63). So, the selection of acupoints for the treatment of KOA with acupuncture, is

mainly based on the spleen meridian, stomach meridian, gallbladder meridian, and Extra Acupoints (EX).

The characteristics of acupoints selection are selecting local acupoints at and around the knee joint,

meanwhile, pays attention to the selection of specific acupoints, of which Wushuxue and Xiahexue are the

main points, and Yuanxue, Xixue, and Bahuixue are supplemented. When conduct treatment, the principles

of syndrome differentiation, and combining "selecting acupoints of the corresponding meridian" with

"selecting local acupoints" should be followed.

1 INTRODUCTION

Knee Osteoarthritis (KOA), also known as knee

hyperplastic arthritis, is a disease based on

degenerative pathological changes. This disease is

mainly characterized by primary or secondary

degeneration and structural disorder of knee articular

cartilage, accompanied by subchondral bone

hyperplasia and sclerosis, cartilage exfoliation, and

https://orcid.org/0000-0003-3936-7427

https://orcid.org/0000-0003-0477-2756

synovial aseptic inflammation (Liu 2013). The main

manifestation is knee pain, which is aggravated after

activities, especially when going downhill or

downstairs, but the symptoms can be relieved after

rest (Fan 2013). This disease belongs to the category

of " Arthralgia Syndrome, Flaccidity Syndrome,

Bone Impediment, etc. " in Chinese medicine. It has

the characteristics of high morbidity, easy

recurrence, and lingering course in clinical practice.

While causing physical and mental pain and

economic loss to patients, it also has an increasingly

Yu, S. and Keong, T.

Exploring the Rule of Selecting Acupoints for Acupuncture Treatment of Knee Osteoarthritis based on Literature Collection and Analysis.

DOI: 10.5220/0011233600003438

In Proceedings of the 1st International Conference on Health Big Data and Intelligent Healthcare (ICHIH 2022), pages 131-137

ISBN: 978-989-758-596-8

131

important impact on the public health and medical

care system and affects the development of society.

Conservative treatment is mainly used in the

early and middle stages of the disease. On the basis

of symptomatic treatment, the main purpose is to

relieve pain, improve joint stiffness, prevent further

damage to cartilage and synovium, and improve

joint function, thereby improving the quality of life

of patients. Severe joint deformities, difficulty

walking, and severe pain are usually treated with

surgery in the late stage. Previous literature reports

and patients’ clinical experience have shown that

acupuncture treatment of KOA has the advantages of

promoting qi, blood, activating blood, reducing

swelling, dredging the meridians and collaterals to

relieve pain, reducing the frequency of attacks, long-

lasting acupuncture effects, and no obvious side

effects (Tian 2019). On this basis, this study

analyzes and studies the literature on clinical studies

of acupuncture treatment of knee osteoarthritis

published in the past 15 years, and explores the rule

of selection of acupoints for the treatment of knee

osteoarthritis, and provides a reference for

optimizing clinical treatment and theoretical

guidance.

2 MATERIALS AND METHODS

2.1 Search Strategy

The relevant subject words used for retrieval are

determined by consulting "Medical Subject

Headings" (MeSH) and "Chinese Medical Subject

Headings" (CMeSH). According to the method of

computer search, we will use the set search terms to

search the articles and literature which belong to the

randomized controlled clinical trials (RCT) of

acupuncture and moxibustion treatment of Knee

Osteoarthritis published from January 2005 to

January 2020 in the relevant database. The databases

are China National Knowledge Infrastructure

(CNKI), Weipu Journal Full-text Database (VIP),

Wanfang Data Knowledge Service Platform,

PubMed, etc.

2.2 Search Terms

Main search terms:

English search terms: "Knee Osteoarthritis",

"KOA", "Acupuncture", "Acupuncture and

Moxibustion", "Electro-acupuncture", "Acupuncture

therapy", "Acupuncture treatment", etc.

Chinese search terms: 膝骨关节炎, 膝骨性关节

炎, 膝关节骨性关节炎, 退行性膝关节炎, 增生性

膝关节炎, 膝痹, 针刺, 针灸, 电针, 针灸治疗, 针灸

疗法, etc.

Use subject, title or keywords to search, and use

conjunctions such as "AND" and "OR" to construct

a logical search formula. The search terms of the

treatment methods and the search terms of the

disease names are connected with "OR"; the search

terms of the treatment methods are connected with

"AND", so are the disease names.

2.3 Literature Inclusion Criteria

① The research object of the literature must be

clearly diagnosed as knee osteoarthritis, and have

clear diagnostic criteria and efficacy evaluation

criteria, and these standards are international or

domestic diagnosis and treatment guidelines and

industry-recognized standards. ② The original

literature must be a randomized controlled trial

study. ③ There must be clear and standard names of

treatment acupoints. ④ Intervention measures are

based on acupuncture, electroacupuncture, etc. as the

main treatment methods, used alone or in

conjunction with other non-surgical therapies.

2.4 Literature Exclusion Criteria

① Does not meet the above inclusion criteria. ②

Uncontrolled clinical case studies with animals,

cells, etc. as the research object, or the research

object cannot be defined according to the content of

the literature. ③ The interference of drugs on the

research cannot be ruled out. ④ The studies without

controls, such as case observations, reviews, case

reports, expert experiences, comments, and self-

reports of physicians' experiences. ⑤ Self-

developed KOA diagnosis and efficacy evaluation

criteria, rather than selecting recognized or general

standards of literature. ⑥ Sample size in the

research was too small (n ≤ 10). ⑦ Repetitive

publication: keep the most recently published, and

exclude the rest; the staging reports of different

periods in the same long-term clinical study, keep

the final published literature (research has been

completed) or recently published literature (research

is not completed), and the rest are excluded. ⑧

Specific treatment methods, names of acupoints,

records or documents with inaccurate descriptions.

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

132

2.5 Data Extraction and Literature

Quality Evaluation

Import the retrieved literature into NoteExpress2.

Two researchers respectively read the titles and

abstracts of the retrieved literature, screened

according to the inclusion and exclusion criteria,

carefully read the full text of the literature that may

be included, and clarified their conformity; cross-

checked the selected literature, Discuss the dispute

or invite a third party to make a ruling. Finally,

literature that meets the standards will be included.

Extract acupoint prescriptions and the meridians

they belong to and other information in the

literature. As the acupoint A’shi has strong

subjectivity and uncertainty, so it is excluded from

the statistics. With reference to "Acupuncture and

Moxibustion" New Century 3rd Edition (Wang

2012), the aliases and meridians of acupoints are

standardized. For example, the unified standard of

“Wai Xi Yan”, "Du Bi" and "Outer Knee Eye" is

"Du Bi" (ST35); “Nei Xi Yan”,"Knee Eye" and

"Inner Knee Eye" are unified as "Inner Knee Eye"

(EX-LE4); the unified standard of "Jue Gu", "Xuan

Zhong", "Extreme Bone", and "Hanging Bell" is

"Xuan Zhong" (GB39).

After completing the data extraction, use the

Microsoft Office 2019 Excel software to design a

data extraction table. Enter the names and locations

of acupoints used in the literature, and the meridians

which belong to, into the table in turn, and count the

total frequency of use of all acupoints in the

literature.

2.6 Statistical Analysis

We used incidence, frequency, percentage, and other

indicators to statistically describe and analyze the

characteristics of the meridian and distribution of the

related acupoints in the included literature via Excel

and SPSS 17.0 software. And focused on analyzing

the characteristics of the top 10 high-selected

acupoints.

3 RESULTS

3.1 Results of Literature Search

According to the set and unified search strategy, the

literature about acupuncture treatment of KOA that

had been published in the past 15 years was

searched, a total of 3574 articles were roughly

retrieved. According to the inclusion and exclusion

criteria which were set, and the repetitive documents

in the database were merged, 569 valid documents

that met the requirements were finally screened out,

including 541 Chinese documents and 28 foreign

documents.

3.2 Descriptive Analysis

3.2.1 Incidence and Frequency Analysis of

Acupoints with Acupuncture Treating

KOA (see Table 1)

The acupoints appearing in the acupuncture

prescriptions in the 569 literature that fit this

research are summarized and sorted out, while A’shi

points and customized acupoints are excluded. And

then arranged the acupoints in descending order of

appearance frequency. The top 10 high-selected

acupoints are: "DuBi (ST35)" (544), "Neixiyan

(EX-LE4)" (533), “Xuehai (SP10)" (414),

"Yanglingquan (GB34)" (392), "Liangqiu (ST34)"

(339), "Zusanli (ST36)" (318), "Yinlingquan (SP9)"

(285), "Heding (EX-LE2)" (204), "Xiyangguan

(GB33)" (84), "Sanyinjiao (SP6)" (63).

Appearance frequency of acupoints =

[Appearance Incidence of acupoints ÷ total number

of prescriptions] ×100%

Table 1 The Incidence and Frequency of Top 10 High-

Selected acupoints.

Ranking Acupoint Incidence

Frequenc

(

)

1 Du Bi (ST35) 544 95.60

Neixiyan

(

EX-LE4

)

533 93.67

3 Xuehai (SP10) 414 72.76

Yanglingquan

(GB34)

392 68.89

Liangqiu

(

ST34

)

339 59.58

Zusanli

(ST36)

318 55.89

Yinlingquan

(SP9)

285 50.09

Heding

(EX-LE2)

204 35.85

Xiyangguan

(GB33)

84 14.76

Sanyinjiao

(

SP6

)

63 11.07

Exploring the Rule of Selecting Acupoints for Acupuncture Treatment of Knee Osteoarthritis based on Literature Collection and Analysis

133

3.2.2 Classification and Analysis of

Acupoints to the Meridians in the

Treatment of KOA by Acupuncture

(see Table 2).

When acupuncture treatment of KOA, the selected

acupoints are mainly distributed in the Three Yang

Meridians of Foot, the Spleen Meridian of Foot-

Taiyin, and the acupoints outside the meridian

(Extra Acupoints). The top 10 acupoints with

appearance frequency are mainly distributed in the

Spleen Meridian of Foot-Taiyin (SP) (3), Extra

Acupoints (EX) (3), Stomach Meridian of Foot-

Yangming (ST) (2), Gallbladder Meridian of Foot-

Shaoyang (GB) (2), etc. (See Table 2). It embodies

the principle of "the meridian goes through, and the

main treatment is reached" in the acupuncture and

moxibustion theory.

Proportion of acupoints = [Number of selected

acupoints in the meridian ÷ 10*] × 100% (*: the

number of selected acupuncture points in the top

ten).

Table 2 The meridians where the top 10 high-selected

acupoints belonging to and their classification.

Meridian Acupoints Number

Proportion

acupoints

(%)

Spleen

Meridian of

Foot-Taiyin

(SP)

Xuehai

(SP10),

Yinlingquan

(SP9),

Sanyinjiao

(SP6)

3 30

Extra

Acupoints

(EX)

DuBi (ST35),

Neixiyan (EX-

LE4), Heding

(EX-LE2)

3 30

Stomach

Meridian of

Foot-

Yangming

(ST)

Liangqiu

(ST34),

Zusanli (ST36)

2 20

Gallbladder

Meridian of

Foot-

Shaoyang

(GB)

Yanglingquan

(GB34),

Xiyangguan

(GB33)

2 20

3.2.3 Analysis on the Distribution

Characteristics of Acupoints in the

Treatment of KOA with Acupuncture

(see Table 3).

Classified according to the location of the top 10

high-selected acupoints, the acupoints commonly

used in clinical practice are mainly concentrated

around the knee joint (90%). The main acupoints are

the "DuBi (ST35)", "Neixiyan (EX-LE4)", Xuehai

(SP10)", "Yanglingquan (GB34)", "Liangqiu

(ST34)", "Zusanli (ST36)" and so on. It embodies

the principle of "where the acupoints are and where

the main treatment is".

Proportion of acupoints = [Number of acupoints

in the meridian ÷ 10*] × 100% (*: The total number

of acupoints in the top 10 high-selected is 10.).

Table 3 Analysis on the distribution characteristics of

acupoints in the treatment of KOA with acupuncture.

Location

Acupoints

Numbe

Proportio

n of

acupoints

(%)

Around

the knee

joint

Xiyangguan

(GB33),

Yanglingquan

(GB34),

Xuehai (SP10),

Heding (EX-LE2),

DuBi (ST35),

Neixiyan

(EX-LE4),

Yinlingquan (SP9),

Liangqiu (ST34),

Zusanli (ST36)

9 90

Lower

extremities

(except the

acupoints

around the

knee joint)

Sanyinjiao (SP6) 1 10

3.2.4 Analysis of the Characteristics of the

Top 10 High-Selected Acupoints in the

Treatment of KOA with Acupuncture

(see Table 4).

Analyzing the characteristics and properties of the

top 10 high-selected acupoints, it can be seen that

acupoints in common meridians are mainly

distributed around the knee joint and play a role in

local treatment; the proportion of specific acupoints

is also relatively high, especially the Wushu

acupoints (Wushuxue), He acupoints (Hexue).

Wushu acupoints (Wushuxue) are the parts where

the meridian Qi starts, runs, and converges in the

viscera. Stimulating Wushu acupoints can dredge the

meridians, reconcile and harmony the Qi and blood.

He acupoints (Hexue) are distributed around the

elbow and knee joints, the Qi and blood flow into

the He acupoint and then merge deeply into the

ICHIH 2022 - International Conference on Health Big Data and Intelligent Healthcare

134

viscera. Stimulating He acupoints can regulate and

harmony Qi and blood.

Table 4 Analysis of the characteristics of the top 10 high-

selected acupoints in the treatment of KOA with

acupuncture.

Cate

gory

Characterist

ics of

acupoints

Acupoints

Numbe

Proport

ion of

acupoi

nts (%)

Acu

point

s in

com

mon

meri

dians

Xiyangguan

(GB33), Xuehai

(SP10), Heding

(EX-LE2),

DuBi

(ST35),

Neixiyan

(EX-LE4)

5 50

Spec

ific

acup

oints

Wushuxue

Yanglingquan

(GB34),

Yinlingquan

(SP9),

Zusanli

(ST36)

3 30

Hexue

Yanglingquan

(GB34), Zusanli

(ST36)

2 20

Xixue

Liangqiu

(ST34)

1 10

Bahuixue

Yanglingquan

(GB34)

1 10

Jiaohuixue

Sanyinjiao

(SP6)

1 10

4 DISCUSSIONS

Knee osteoarthritis (KOA) is a common disease in

middle-aged and elderly people. The main

pathological change of KOA is degeneration of

articular cartilage, involving bone, synovium, joint

capsule and other joint structures, accompanied by

cartilage destruction and osteophyte formation. The

main clinical manifestations of this disease are pain,

swelling, stiffness, and dysfunction of knee joint

(Chen 2019). This disease belongs to the category of

" Arthralgia Syndrome, Flaccidity Syndrome, Bone

Impediment, etc. " in Traditional Chinese Medicine.

The theoretical system of TCM has a unique

understanding of the etiology, pathogenesis, and

syndrome differentiation of this disease. The nature

of the disease is exterior excess and interior

deficiency. The pathogenesis of which is the

external seems excessive, and the internal is the

deficiency syndrome, which is mainly represented

by stagnation of tendons and muscles, deficiency of

liver and kidney, insufficiency of qi and blood, lack

of nourishment for tendons and bones, marked by

the inclusion of wind, cold, damp and pathogenic

factors and the internal production of phlegm and

blood stasis (Yu 2015). Acupuncture therapy has the

functions of adjusting Yin and Yang, harmonizing

Qi and blood, dispersing meridians and dredging

collaterals, reducing swelling and relieving pain.

Selecting local acupoints can dredge the meridians,

regulate qi and blood, relieve or eliminate "Pain

caused by obstruction and stagnation of Qi and

blood", thereby reducing symptoms like pain,

stiffness, swelling and so on.

It can be seen from this study that the acupoints

selected for the treatment of the disease are mainly

located around the knee joint. The meridians belong

to are mainly distributed in the three Yang meridians

of foot, the Spleen Meridian of Foot-Taiyin (SP) and

Extra Acupoints (EX), among which the top 10

acupoints with frequency are mainly distributed in

the Spleen Meridian of Foot-Taiyin (SP) (3), Extra

Acupoints (EX) (3), Stomach Meridian of Foot-

Yangming (ST) (2), Gallbladder Meridian of Foot-

Shaoyang (GB) (2), etc. The most frequently used

acupoints are "DuBi (ST35)", "Neixiyan (EX-LE4)",

"Xuehai (SP10)", "Yanglingquan (GB34)",

"Liangqiu (ST34)", "Zusanli (ST36)", "Yinlingquan

(SP9)", "Heding (EX-LE2)", "Xiyangguan (GB33)",

"Sanyinjiao (SP6)". Local acupoints selection of the

knee joint reflects the principle of acupuncture and

moxibustion: "where the acupoints are, the main

treatment reaches". Acupuncture on the acupoints

around the knee joint can not only achieve the

original effect of acupuncture, but also play a role in

relieving adhesion, so as to improve the symptoms

such as stiffness of the knee joint.

Analysis of the top 10 high-selected acupoints:

"DuBi (ST35)", is mainly used to treat knee joint

pain, numbness, and difficulty in squatting and

standing up flexibly. Acupuncture or moxibustion

"DuBi (ST35)" and "Neixiyan (EX-LE4)" can

dredge the meridians and smooth the joints, thereby

reducing knee joint pain and improving knee joint

mobility. "Heding (EX-LE2)" can relax and smooth

the tendons, dredge the meridians and activate the

collaterals, mainly used for the treatment of knee

joint pain. "Xuehai (SP10)" means where the blood

gathering, via acupuncture and moxibustion can

remove blood stasis and dredge the meridian, by

regulating the release of vasoactive factors, changing

the shape of capillaries, accelerating the blood flow

rate, and changing the hypercoagulable state of the

blood (Zhao, 2004). In the theory of Traditional

Chinese Medicine, the spleen controls the limbs,

hands and feet, and "Yinlingquan (SP9)" is the He

acupoints (Hexue) of the spleen meridian, so

stimulate this point can treat diseases of the limbs,

such as knee joint pain and paralysis of the lower

Exploring the Rule of Selecting Acupoints for Acupuncture Treatment of Knee Osteoarthritis based on Literature Collection and Analysis

135

limbs. The three yin meridians of the kidney, liver,

and spleen converge in "Sanyinjiao (SP6)", so

stimulating this acupoint can strengthen the spleen,

nourish the liver, benefit the kidney, and strengthen

tendons and bones (Jin 2017). It has a good

treatment effect on the arthralgia of Qi deficiency

and blood stasis type (Huang 2011). "Liangqiu

(ST34)", as the Xi acupoint (Xixue) of the Stomach

Meridian of Foot-Yangming (ST), is mainly used to

treat diseases of the waist and knee joints, such as

pain, clod and numbness of lower limbs, knees, feet

and waist; joints difficulty in squatting, flexion and

extension (Zou 2021). "Zusanli (ST36)", is the He

acupoint (Hexue) of the Stomach meridian.

Warming acupuncture at this point can improve

local circulation, promote the absorption of

inflammatory mediators, and reduce the

inflammatory response of knee osteoarthritis (Guan

2020). Acupuncture at "Liangqiu (ST34)", and

Zusanli (ST36) can tonify the spleen, nourish Qi and

blood, regulate the movement of Qi, relieving spasm

and pain, invigorating spleen to eliminate dampness,

and can destroy the wind with promoting blood

circulation, nourish muscles and veins, rejuvenate

and strong the tendons, and lubricate joints (Tian

2013). "Yanglingquan (GB34)" is the place where

the Qi of Gallbladder Meridian of Foot-Shaoyang

(GB) gathers and confluents, and it also is the

Xiahexue (lower confluent point) of the gallbladder.

Moxibustion in Yanglingquan can improve the

flexion and extension of the knee joint (Wang 2020).

The tendons gather in "Yanglingquan (GB34)".

Therefore, this acupoint is often selected for the

treatment of knee osteoarthropathy. "Xiyangguan

(GB33)", located in the Gallbladder Meridian of

Foot-Shaoyang (GB), can promote the flow of Qi

and blood of knee joint, mainly used to treat knee

joint swelling and pain, lower leg muscle spasm, calf

numbness, knee arthritis, lower limb paralysis, etc.

(Wu 2020)

5 CONCLUSIONS

In summary, when selecting acupoints to conduct

treatment of knee osteoarthritis with acupuncture,

the principles of syndrome differentiation, and

combining "selecting acupoints of the corresponding

meridian" with "selecting local acupoints" should be

followed. The selection of acupoints for treatment of

KOA with acupuncture, is mainly based on the

spleen meridian, stomach meridian, gallbladder

meridian, and Extra Acupoints (EX). Select local

acupoints at and around the knee joint, and local

stimulation is the main method of treatment; At the

same time, it pays attention to the selection of

specific acupoints, of which Wushuxue and

Xiahexue are the main points, and Yuanxue, Xixue,

and Bahuixue are supplemented. This is consistent

with our actual clinical operation, so patients can

have a higher degree of recognition and compliance

based on the curative effect, which also provides a

certain scientific basis for the selection of

therapeutic acupoints in the clinic. Reviewing this

study, there are also problems such as the quality of

the included literature is not enough uniform, and

the various syndrome types involved are not further

refined. These may have an impact on the analysis

results. In future research, measures should be taken

to avoid these influencing factors, so as to obtain a

better evidence-based basis and provide reference

basis and theoretical guidance for optimizing clinical

treatment.

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