健骨颗粒冲剂治疗膝骨关节炎的实验研究与临床观察
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摘要
1.目的与意义
骨关节炎(OA)也称退行性骨关节病,本病是由于关节软骨完整性破坏以及关节软骨下骨板病变,导致关节症状和体征的一组异质性疾病。按照关节分布可以分为局限性和全身性骨关节炎。膝骨关节炎(简称KOA)局限性骨关节炎的常见病,临床上以关节疼痛、僵硬、活动受限、活动时可有磨擦响声为特征。本病中年以后多发,发病率随年龄增长而增高,严重危害着中老年人的健康。
OA的病因目前尚不完全明了,一般认为KOA发病的主要原因有生物力学因素、遗传因素、外源性因素等参与导致滑膜、软骨和骨的代谢改变,进而产生炎症,关节结构破坏。其最基本的病理改变是关节软骨的损伤退变。现代医学认为,软骨降解是软骨退变的一个重要方面。大量研究证实,OA软骨降解与细胞因子表达异常有关。在正常情况下,关节软骨基质的分解代谢和合成代谢平衡是通过分解性细胞因子和合成性细胞因子(即生长因子)的平衡来维持的。分解性细胞因子如白细胞介素-1(IL-1),主要是刺激生成特殊的基质金属蛋白酶(MMP),引起基质的降解,并可通过刺激滑膜细胞增殖和变性,诱导炎性介质形成,促进滑膜细胞金属蛋白酶分泌,抑制或干扰软骨细胞及表型表达等。其中肿瘤坏死因子α(TNF-α)、基质金属蛋白酶-3(MMP-3)是参与OA发病过程的重要介质。OA的发生与关节滑膜细胞增殖旺盛,分泌过多的TNF-α并释放入血有关,已有报道OA患者的滑膜内存在着高浓度的TNF-α。TNF-α能激活多型核细胞,刺激滑膜细胞产生前列腺素E2,促进软骨基质金属蛋白酶合成和分泌,引起关节软骨吸收、降解和破坏。有学者报道TNF-α主要影响滑膜炎症和免疫学反应,能诱发抗自身软骨的自身免疫反应,MMPs是参与关节组织损伤的主要因素,可以促进骨基质的降解,抑制软骨细胞合成具有透明软骨特性的蛋白聚糖和Ⅱ型胶原促进生成有纤维母细胞特性的Ⅰ型胶原,从而使软骨细胞变性,引起软骨缺损和软骨的生物力学改变,TNF-α、MMP-3在OA病情进展中具有潜在的协同效应。研究表明,MMP-3是金属蛋白酶的主要成员之一,主要在OA患者的滑膜细胞中表达,软骨细胞和单核细胞也有少量的表达。研究表明MMP-3是OA发病过程中重要的的生物学标志物,OA患者血清及关节液中MMP—3含量与病情密切相关。
祖国医学认为膝骨关节炎属痹证、骨痹范畴,多以肝脾肾亏虚为本,气滞血瘀痰凝、风寒湿邪侵袭,痹阻经络为标,属本虚标实之证。肝脾肾亏虚,筋骨失养是发病之本：中医学认为,膝为肝脾肾三经所系,筋骨肉之大会。肝藏血主筋,肾藏精主骨,脾主运化合肉。而0A的发生多为中老年人,肝肾渐亏,筋骨懈惰；筋失血养,无以柔韧；骨失髓养,无以强壮；肉失脾主,虚赢无力。所以KOA的发病与肝脾肾三脏虚弱关系最为密切。气滞、血瘀、痰凝是膝骨关节炎发病的重要环节：气为血帅,血为气母；气滞可致血瘀,血瘀加重气滞。由于膝关节是人体负重最大和关节面积最大的关节,亦是人体参与运动最重要的关节,最易受到损伤。膝关节损伤,脉络受损,血溢于外,阻塞经络,致气滞血阻,经络受阻。或由于肝脾肾亏虚,气血运行不畅、痰凝经络,膝关节及周围组织失养,从而引起关节软骨的退变,导致KOA的发生与发展。风寒湿外邪侵袭、痹阻经络,久而关节变形,活动受限,形成骨痹,其是KOA发病的重要因素。
目前西医针对骨关节炎治疗在于缓解疼痛、阻止和延缓疾病的进展、保护关节功能、改善生活质量。治疗原则以非药物治疗联合药物治疗为主,必要时手术治疗。非药物治疗包括患者的教育、运动和生活指导以及物理治疗。药物治疗分两大类：1)控制症状的药物：包括解热镇痛类,非甾体类抗炎药,阿片类药物,激素等；2)改善病情的药物(DMARAs)及软骨保护剂：此类药物—般起效慢,需治疗数周见效,具有降低基质金属蛋白酶、胶原酶等活性,既可抗炎、止痛、又可保护关节软骨,有延缓骨关节炎发展的作用。如双醋瑞因,它是IL-1抑制剂,可抑制软骨降解、促进软骨合成并抑制滑膜炎症。它不仅能有效地改善骨关节炎的症状,减轻疼痛,改善关节功能,还可以延缓骨关节炎病程的进展。
中医治疗本病主要在于解除疼痛症状,改善关节功能,保护关节结构。结合中医的整体观念,辨证论治,中药、针灸、推拿等多种手段综合运用,从膝关节局部用药和全身整体出发,充分发挥中医药的优势综合治疗,从而使患者的症状有效改善。
然而目前,单纯应用中、西医药对该病的治疗尚未取得突破性进展。其中,西医药治疗耗资较为昂贵,并普遍存在程度不一的胃肠道副作用,患者依从性差。相对而言,中医药治疗具有简便验廉、安全性较好的特点,适合长期使用,故越来越引起了医学界的关注。但单用中药往往起效较慢,对一些严重患者临床症状的快速控制不甚理想。中西医结合治疗能取长补短,使中药与西药充分发挥其治疗效果并能减轻西药的副作用。健骨颗粒冲剂是风湿科治疗骨关节炎临床应用二十多年的经验方,由淫羊藿、地黄、秦艽、杜仲、丹参、牛膝、延胡索等组成,具有补益肝肾,强筋健骨,活血止痛之功效。全方重用淫羊藿,杜仲,以滋补肝肾,强筋骨。本项研究拟对该方的作用机制进行探讨。
本课题拟分两部分对健骨颗粒冲剂治疗KOA的治疗进行研究。第一部分研究：通过测定大鼠膝OA模型血清和关节液中TNF-α、MMP-3的含量,探讨健骨颗粒冲剂治疗OA的作用机制；第二部分：通过健骨颗粒冲剂联合双醋瑞因治疗膝关节骨性关节炎的临床研究,观察健骨颗粒冲剂治疗膝骨关节炎的临床疗效,探讨中药复方联合西医结合治疗KOA的疗效；从动物实验与临床观察对健骨颗粒冲剂进行研究,并观察其联合西药在治疗KOA的优势。
2.健骨颗粒冲剂对大鼠膝骨关节炎血清和关节液中TNF-α、MMP-3的影响
2.1主要材料及试剂：健康Wistar大鼠48只,雌雄各半,体重180-220g。木瓜蛋白酶,大鼠白细胞介素TNF-α ELISA定量检测试剂盒,大鼠白细胞介素MMP-3ELISA定量检测试剂盒。中药健骨颗粒冲剂由独活,淫羊藿,杜仲,牛膝,徐长卿,秦艽,丹参,玄胡,生地,知母等组成。双醋瑞因,规格：50mg/片。
2.2动物模型与实验分组48只健康Wistar大鼠,适应性喂养1周后,随机抽取40只,分为四组,正常组,模型组,双醋瑞因组,健骨颗粒冲剂组,每组10只。除正常组外均予以造模,造模参照文献对大鼠右膝关节腔注射4%木瓜蛋白酶生理盐水溶液0.2m1,每隔3d注射1次,连续注射3次成功造模。根据成人和实验动物用量的换算公式,计算出给药量,双醋瑞因0.009g/kg,健骨颗粒冲剂2.7g/kg,正常组和模型组给与相应剂量的生理盐水,每日一次,4周后取材。
2.3标本采集：将大鼠仰卧捆绑于小动物手术台上,股动脉取血,离心后,置于-20℃冰箱保存。抽取各组动物膝关节冲洗液1ml后离心,取上清液-20℃冰箱保存待测。
2.4指标检测：酶联免疫吸附法检测血清和关节液中MMP-3和TNF-α含量。
2.5统计学分析：应用SPSS13.0软件进行统计分析。计量资料采用均数±标准差表示,组间差异采用单因素方差分析,以a=0.05为显著性水准。
2.6结果
2.6.1一般情况：正常组活泼,毛发光泽,能正常活动与饮食,无关节肿胀；模型组神态萎靡少动,毛发欠光泽,脱毛较明显,食少,局部肿胀,有明显舔舐及跛行现象。药物治疗组大鼠上述表现较模型组均有不同程度的改善。
2.6.2病理观察：正常组软骨基质染成粉红色,着色均匀,软骨表面光滑,软骨细胞排列整齐,四层结构清晰可辨,潮线完整。模型组关节软骨破坏最为严重,软骨表面粗糙不整,软骨表面糜烂、完全剥脱,形成缺损区。双醋瑞因组四层结构基本清晰,潮线基本完整,少许关节软骨细胞有轻度变性。健骨颗粒冲剂组关节软骨内有少许炎细胞浸润,关节软骨细胞有轻度变性,潮线基本完整。
2.6.3血清TNF-α、MMP-3指标各组之间比较：①TNF-α含量：各组间TNF-α含量比较,差异有统计学意义(F=75.035,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.778),差异无统计学意义。②MMP-3含量：各组间MMP-3含量比较,差异有统计学意义(F=77.336,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.847),差异无统计学意义。
2.6.4关节液TNF-α、MMP-3指标各组之间比较：①TNF-α含量：各组间TNF-α含量比较,差异有统计学意义(F=40.783,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.191),差异无统计学意义。②MMP-3含量：各组间MMP-3含量比较,差异有统计学意义(F=275.255,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.065),差异无统计学意义。
3.健骨颗粒冲剂联合双醋瑞因治疗治疗膝关节骨性关节炎临床研究。
3.1临床资料
3.1.1120例均为2011年3-11月南方医院中医科门诊和香港伍捷进中医推拿针灸医馆就诊的膝OA患者,其中85位来自南方医院中医科门诊,35位来自香港伍捷进中医推拿针灸医馆。随机分为A组(健骨颗粒治疗组)、B组(双醋瑞因治疗组)、C组(健骨颗粒加醋瑞因治疗组)各40例。A组男11例,女29例；年龄49-69岁,平均(61.00±5.08)岁；病程平均(3.20±1.10)年；根据OA影像学诊断标准、放射学诊断分级标准：Ⅰ级8例,Ⅱ级14例,Ⅲ级16例,Ⅳ级2例。B组男13例,女27例；年龄53～69岁,平均(62.38±4.00)岁；病程平均(2.88±1.27)年；影像学诊断分级：Ⅰ级9例,Ⅱ级16例,Ⅲ级14例,Ⅳ级1例。C组男12例,女28例；年龄46～68岁,平均(60.38±4.68)岁；病程平均(3.00±1.13)年；影像学诊断分级：Ⅰ级7例,Ⅱ级22例,Ⅲ级10例,Ⅳ级1例。3组性别、年龄、病程、关节影像学诊断分级等经统计学处理,差异均无显著性意义(P>0.05),具有可比性。
3.1.2诊断标准符合美国风湿病学会制订的OA诊断标准。
3.1.3排除标准排除继发性骨关节炎、感染性关节炎等其他原因所致的关节疾患；晚期、残毁性OA及伴有严重心、肝、肾等疾病、活动性胃肠病变者以及孕期或哺乳期妇女亦一律不能入组。
3.2治疗方法
A组服健骨颗粒冲剂,每天1剂,开水冲服,每次150mL,每天2次。B组服用双醋瑞因片,每次50mg,每天2次。C组以上2种药物联合服用,服法及剂量同上。3组均以1月为1疗程,治疗3疗程。
3.3观察指标与疗效标准
3.3.1观察指标定期复诊记录膝部关节疼痛、关节压痛、关节肿胀、关节活动及20m行走时间的变化情况；治疗前后定期复查血常规、尿常规、血沉(ESR)、C-反应蛋白(CRP)、肝肾功能、膝关节X线摄片。所有患者膝关节进行双侧评分,取平均值。
3.3.2关节指标观测评分标准①关节疼痛评分标准：0分：无痛；1分：轻度痛,可耐受,不影响睡眠；2分：中度痛,稍影响行动及睡眠；3分：重度痛,难以忍受,明显影响活动及睡眠。②关节压痛评分标准：0分：无压痛；1分：轻度压痛,按压关节周缘,患者称痛；2分中度压痛,压关节周缘,患者表情痛苦；3分：重度压痛。③关节肿胀评分标准：0分：无肿胀；1分：轻度肿胀；2分：中度肿胀；3分：明显肿胀。④关节功能活动障碍分级标准：0级：无关节活动受限；1级：关节活动轻度受限；2级：关节活动中度受限；3-4级：关节活动明显受限。⑤20m行走时间：以秒(s)计,重复2次,取平均值。
3.3.3疗效标准显效：症状体征基本消失,关节功能活动正常,5项观测指标皆有明显改善；好转：症状体征基本消失,偶尔有活动时酸痛,关节屈伸活动范围在80°-135°,能参加日常工作和劳动,5项观测指标4项以上有改善；无效：症状体征无明显改善,5项观测指标少于4项改善。
3.4.统计学方法
采用SPSS13.0统计软件分析,所有计量资料均以(x±s)表示,组内治疗前后比较采用配对t检验,多组间治疗前后差值比较采用单因素方差分析,多重比较采用LSD法；计数资料比较采用χ2检验,多组等级资料采用Kruskal-Wallis法检验。以P<0.05为差异有统计学意义。
3.5治疗结果
3.5.1三组治疗前一般资料比较。A组40例,B组40例,C组40例,三组治疗前患者年龄、性别、KOA病程均无显著性差异(P>0.05),具有可比性
3.5.2三组治疗前后临床指标比较见表3-7。
(1)关节疼痛比较：治疗3月后,治疗后A、B、C组患者膝关节疼痛有改善与好转,与治疗前相比较,差异有显著性意义(t=14.171,P=0.000；t=14.000,P=0.000；t=16.574,P=0.000)；三组关节疼痛程度治疗前后差值比较有差异(F=4.721,P=0.011),A组治疗前后差值高于B组,但两组组治疗前后的均数差进行组间比较,其差异无显著性意义(P=0.864)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.011,P=0.007)。
(2)关节压痛比较：治疗后三组关节压痛程度比较,C组治疗后改善优于A、B组,有统计学差异(χ2=10.484,P=0.005)。
(3)治疗后三组关节肿胀程度比较,C组治疗后改善优于A、B组,有统计学差异(χ2=15.740,P=0.000)。
(4)功能障碍比较：治疗3月后,治疗后A、B、C组患者膝关节功能障碍有改善与好转,与治疗前相比较,差异有显著性意义(t=10.494,P=0.000；t=9.802,P=0.000；t=14.207,P=0.000)；三组关节功能障碍程度治疗前后差值比较有差异(F=4.903,P=0.009),A组治疗前后差值高于B组,其差异无显著性意义(P=0.335)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.038,P=0.003)。
(5)行走时间比较：治疗3月后,治疗后A、B、C组患者行走时间有改善与好转,与治疗前相比较,差异有显著性意义(t=18.976,P=0.000；t=17.814,P=0.000；t=25.706,P=0.000)；三组行走时间治疗前后差值比较有差异(F=20.861,P=0.000)。A组治疗前后差值高于B组,其差异无显著性意义(P=0.497)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.000,P=0.000)。
3.5.3三组治疗前后实验室指标变化比较
(1)ESR比较：治疗3月后,治疗后A、B、C组患者ESR有改善与好转,与治疗前相比较,差异有显著性意义(t=5.262,P=0.000；t=5.046,P=0.000；t=7.44,P=0.000)；三组ESR治疗前后差值比较有差异(F=11.057,P=0.000)。A组治疗前后差值高于B组,其差异无显著性意义(P=0.626)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.000,P=0.000)。
(2)CRP比较：治疗3月后,治疗后A、B、C组患者CRP有改善与好转,与治疗前相比较,差异有显著性意义(t=4.477,P=0.000；t=5.101,P=0.000；t=7.879,P=0.000)；三组CRP治疗前后差值比较有差异(F=3.474,P=0.034),A组治疗前后差值高于B组,其差异无显著性意义(P=0.852)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.019,P=0.031)。
3.5.4三组显疗率比较C组显效率优于A、B组,组间比较,差异有显著性意义(χ2=11.706,P=0.003)。
3.5.5三组不良反应比较A、C组不良反应率低于B组,组间比较,差异有显著性意义(χ2=14.867,P=0.001)。
4.结论
实验研究和临床观察结果表明：
4.1健骨颗粒冲剂能降低膝骨性关节炎大鼠血清、关节液中的TNF-α、MMP-3的含量,其对机体细胞因子有调节作用,通过抑制滑膜炎症,减少各种细胞活性因子的渗出,从而减轻各种细胞因子对关节软骨基质的损害,改善软骨基质代谢,促进软骨修复；
4.2健骨颗粒冲剂治疗膝骨关节炎安全有效；
4.3健骨颗粒冲剂联合双醋瑞因治疗膝OA,临床疗效优于单用健骨颗粒冲剂或单用双醋瑞因,既可较快的控制临床症状,又可以持续消肿止痛,改善关节软骨代谢,抑制相关细胞因子,延缓病情进展,不仅疗效良好和持久,而且安全性好。
1.Objectives and significance
Osteoarthritis (OA) also called degenerative joint disease, the disease is the result of articular cartilage damage of integrity and articular cartilage under plate of bone lesions, leading to joint symptoms and signs are a heterogeneous group of diseases. According to the joint distribution can be divided into the limitations and systemic bone arthritis. Knee osteoarthritis (KOA) limitations of osteoarthritis in clinical common diseases, joint pain, stiffness, restricted activity, activity can be characterized with friction sound. The disease after the middle-aged multiple, the incidence increased with the growth of age, seriously endangering the health of the elderly.
The etiology of OA is not completely clear, generally considered the pathogenesis of KOA is the main reason for biomechanical factors, genetic factors, exogenous factors involved in causing synovial membrane, cartilage and bone metabolism, and inflammation, joint structure damage. It's most basic pathological changes of articular cartilage injury. Modern medicine thinks, cartilage degradation is one of the important aspects of cartilage degeneration. Many studies show that, OA cartilage degradation and cytokine expression abnormalities related to. Under normal circumstances, the matrix of articular cartilage catabolism and anabolism balance is through the decomposition of cytokines and synthesis of cytokines (i.e. growth factor) to maintain the balance of. Decomposition of cytokines such as interleukin-1(IL-1), is mainly stimulated the creation of special matrix metalloproteinases (MMP), induced matrix degradation, and through the stimulation of proliferation of synovial cells and degeneration induced by inflammatory mediators, formation, promoting synovial cell metalloproteinase secretion, inhibit or interfere with cartilage cells and phenotypic expression and so on. The tumor necrosis factora(TNF-α), matrix metalloproteinase-3(MMP-3) is involved in the pathogenesis of OA and important medium. The occurrence of OA and synovial cell proliferation is exuberant, excessive secretion of TNF-aand released into the blood, it has been reported that OA patients with synovial memory in a high concentration of TNF-a. TNF-acan activate multiple nuclear cells, stimulate synovial cells produce prostaglandin E2, promote cartilage matrix metalloproteinase synthesis and secretion, caused by absorption, degradation and destruction of articular cartilage. Scholars have reported that TNF-amain effects of synovitis and immunological reaction, can induce resistance to the cartilage of the autoimmune reaction, MMPs is involved in joint tissue damage is the main factor, can promote bone matrix degradation, inhibition of chondrocyte biosynthesis is hyaline cartilage properties of the proteoglycan and collagen type Ⅱ promotes formation of fibroblast cell characteristics of type I collagen, so that the cartilage cell degeneration, causing cartilage defects and the biomechanics of cartilage change, TNF-a, MMP-3in OA progression of potentially synergistic effect. Research shows that, MMP-3is one of the main members of metalloproteinases, mainly in OA patients with synovial cells, cartilage cells and mononuclear cells also have a small amount of expression. The study indicates that MMP-3is OA in the pathogenesis of important biological markers, OA in serum and synovial fluid in MMP3content and disease are closely related.
TCM thinks of knee osteoarthritis belongs, bonerheumatism category, liver and spleen and kidney deficiency in this, qi stagnation and blood stasis phlegm, chill wet evil invasion, blockage of main and collateral channels as the standard, the virtual real standard of evidence. Liver spleen and kidney deficiency, and loss of support is the basis of the disease:in medicine, the knee for the liver spleen kidney three classics department, rib near the assembly. Liver storing blood main reinforcement, kidney essence bone, spleen transporting compound meat. While the OA occurred for the elderly, liver and kidney was waning, and idleness; reinforcement loss to raise, pliable; bone loss of bone marrow to raise, without strong meat; loss of spleen weakness, virtual win. So KOA and the incidence of liver spleen kidney three dirty was most closely related to. Stagnation of Qi, blood, phlegm is for knee osteoarthritis: an important link of gas as the commander of blood, blood gas and can cause blood stasis, blood stasis parent; exacerbation Qi stagnation. As the human knee is the biggest and largest weight-bearing joints joints, is also involved in the movement is the most important human body joint, the most vulnerable to injury. Knee joint injury, impaired blood spilled in context, main and collateral channels, obstruction, caused by qi stagnation and blood resistance, main and collateral channels blocked. Liver spleen and kidney deficiency or due to poor run, Qi and blood, phlegm main and collateral channels, knee joint and surrounding tissue loss of support, resulting in the degeneration of articular cartilage, resulting in the occurrence and development of KOA. Chill wet evil invasion, blockage of main and collateral channels, long and joint deformity, activity limitation, forming bone rheumatism, which is an important factor in the pathogenesis of KOA.
At present western medicine in treatment of osteoarthritis in pain relief, prevent and delay the progression of the disease, preserve joint function, improve the quality of life. Principles of treatment to non drug therapy combined with drug therapy, when necessary, operation treatment. Non drug therapy include patient education, exercise and life coach and physical therapy. Drug treatment is divided into two categories:1) control the symptoms of drug:including antipyretic analgesics, nonsteroidal anti-inflammatory drugs, opioids, such as hormone;2) to improve the condition of medication (DMARAs) and chondroprotective agents:these drugs generally slow onset, requiring treatment for several weeks to work, has reduced matrix metalloproteinases, collagenase activity, anti-inflammatory, analgesic, and can protect the articular cartilage, delay osteoarthritis development. As of diacerein, it is IL-linhibitor, can inhibit cartilage degradation, promoting cartilage synthesis and inhibition of synovial inflammation. It not only can effectively improve the symptoms of osteoarthritis, reduce pain, improve joint function, also can delay the progress of osteoarthritis.
Chinese medicine in the treatment of this disease mainly lies in the relief of pain symptoms, improve joint function, joint protection structure. Combined with the holistic concept of traditional Chinese medicine, treatment based on syndrome differentiation of traditional Chinese medicine, acupuncture, massage, etc. synthetically, the knee joint from the topical and systemic whole sets out, give full play to the advantages of traditional Chinese medicine comprehensive treatment, so that the patients symptoms improved.
However, simple application, western medicine on the treatment of the disease has not yet been achieved breakthrough progress. Wherein, western medicine treat-ment cost is more expensive, and the prevalence rate is not a gastrointestinal side effects, poor compliance of the patient. Relatively speaking, Chinese medicine treat-ment has the advantages of simple inspection of cheap, good safety characteristics, suitable for long-term use, it caused more and more medical attention. But the single use of traditional Chinese medicine often slow onset, for some serious clinical symptoms of patients with rapid control is not ideal. Combination of traditional Chinese and Western medicine treatment can learn from each other, so that the traditional Chinese medicine and Western medicine to give full play to its therapeutic effect and reduce the side effects of Western medicine. Jiangu granule is the Department of rheumatism for treatment of osteoarthritis clinical application for more than20years of experience, from Herba Epimedii, digitalis, Gentiana, eucommia, radix salviae miltiorrhizae, radix, yanhusuo etc., has the functions of invigorating liver and kidney, gluten bone health, promoting blood circulation and relieving pain. The reuse of epimedium, eucommia, to nourish liver and kidney, strengthening bones and muscles. The study on the side of the mechanism.
This article is divided two parts of Jiangu Granule in treating KOA treatment were studied. The first part of the study:the determination of the rat knee model of OA in serum and synovial fluid TNF-, the content of MMP-3, of Jiangu Granule in treating the action mechanism of OA; part second:Jiangu granule combined with diacerein treatment of knee osteoarthritis clinical research, observation of Jiangu Granule in treating knee osteoarthritis clinical efficacy, study of Chinese medicine combined with western medicine treatment of the effect of KOA; from the animal experiment and clinical observation of Jiangu granule for research, and to observe the combined with western medicine in the treatment of KOA advantage.
2. The effect of Jiangu Granule on rats with knee osteoarthritis in serum and synovial fluid TNF-, MMP-3
2.1The main materials and reagents:48healthy Wistar rats, male and female in half, weight180-220g. Papain, rat interleukin TNF-ELISA quantitative determination reagent kit, rat interleukin MMP-3ELISA quantitative determination reagent kit. Traditional Chinese medicine Jiangu Granule by Duhuo, epimedium, eucommia, hyssop, Radix Cynanchi paniculati, Gentiana, Salvia miltiorrhiza, Xuan Hu, raw land, Rhizoma Anemarrhenae. Diacerein, specification:50mg/.
2.2Animal model and experimental group:48healthy Wistar rats, adaptive feeding after1weeks, the random sampling of40, divided into four groups, the normal group, model group, diacerein group, Jiangu granule group,10rats in each group. Besides normal group were to be molding, molding in reference on rat right knee joint cavity injection of4%papain saline solution0.2ml, every3D1injection, continuous injection of3successful model. According to experimental animal and adult dosage conversion formula, calculated dose, diacerein Jiangu granule0.009g/kg,2.7g/kg, normal group and model group gives the corresponding dose of saline, once daily,4weeks after operation.
2.3Specimens collecte:the rats supine tied to small animal operation table, femoral artery blood, after centrifugation, at-20℃refrigerator. Extraction of each animal knee joint lavagelml after centrifugation, taking supernatant-20℃refrigerator testing.
2.4Indexes:enzyme-linked immunosorbent assay for the detection of in serum and synovial fluid MMP-3and TNF-content.
2.5Statistical analysis:SPSS13.0software was used for statistical analysis. Measurement data based on mean±standard deviation indicates, the differences between groups with single factor analysis of variance, witha=0.05is a remarkable level.
2.6Results
2.6.1General situation:normal group lively, shiny hair, normal activity and diet, no joint swelling; model group was dispirited move less, less glossy hair, hair removal is obvious, eat less, local swelling, has obvious licking and claudication phenomenon. The rats in the treated groups the performance compared with the model group were improved in different degree.
2.6.2Pathological observation of normal cartilage matrix:pink colored uniform, smooth surface, cartilage, cartilage cells are arranged in rows, four layers of structure clear, tidal line integrity. Model group of articular cartilage damage is most severe, the cartilage surface roughness is not whole, cartilage surface erosion, completely denuded, forming defect area. Double promote ray was group of four layer structure is basic and clear, the tidal line the basic integrity, little articular chondrocytes with mild degeneration. Jiangu granule group within articular cartilage have less infiltration of inflammatory cells, chondrocytes with mild degeneration, tidal line integrity.
2.6.3Serum TNF-α, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=75.035, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.778), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=77.336, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.847), the difference was not statistically significant.
2.6.4Synovial TNF-a, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=40.783, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.191), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=275.255, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein, Jiangu granule group and comparison group (P=0.065), the difference was not statistically significant.
3. Clinical research of Jiangu granule combined with diacerein treatment of knee osteoarthritis.
3.1Clinical data
3.1.1120cases of were3～in2011November South Hospital Outpatient Department of traditional Chinese medicine and Hongkong Wu Jiejin massage acupuncture medical center clinic patients with knee OA,85of them from southern hospital outpatient department of traditional Chinese medicine,35from the Hongkong Wu Jiejin massage acupuncture museum. Were randomly divided into group A (Jiangu granules in treatment group), group B (diacerein treatment group), group C (Jiangu Granule plus vinegar ray was the treatment group40cases each). Group A male11cases, female29cases; age49～69years, average (61±5.08) years old; the average course of disease (3.20±1.10) years; according to OA imaging diagnostic criteria for, radiology diagnostic criteria:grade Ⅰ in8cases,14cases in grade Ⅱ,16cases in grade Ⅲ,Ⅳ in2cases. Group B male13cases, female27cases; age53～69years, average (62.38±4) years old; the average course of disease (2.88±1.27) years; imaging diagnosis grading:grade Ⅰ in9cases,16cases in grade Ⅱ,14cases in grade Ⅲ,Ⅳ in1cases. Group C male12cases, female28cases; age46～68years, average (60.38±4.68) years old; the average course of disease (3±1.13) years; imaging diagnosis grading:grade Ⅰ in7cases,22cases in grade Ⅱ,10cases in grade Ⅲ,Ⅳ in1cases.3groups of sex, age, course of disease, joint imaging diagnosis grading statistically, there were no significant differences (P>0.05), with comparable.
3.1.2Diagnosis standards:In line with the American College of rheumatology for OA diagnosis standard.
3.1.3Exclusion:Criteria to exclude secondary osteoarthritis, septic arthritis and other causes of joint disease; later, the ruined OA and accompanied by severe heart, liver, kidney disease, gastrointestinal lesions and activity in pregnant or lactating women also are not into the group.
3.2Methods of treatment
A group of Jiangu granule clothing, daily1agent, boiling water,150mL each time,2times a day. B group taking diacerein tablets,50mg each time,2times a day. C group of more than2drugs in combination use, dosage and dosage. The3groups are in January forl courses,3courses of treatment.
3.3Outcome measures and curative effect standard
3.3.1Observation:knee joint pain index regular reexamination records, joint tenderness, swelling of the joints, joint activities and20m walking time changes before and after treatment; regular review of blood, urine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and kidney function, knee X line photograph. All patients with knee joint the bilateral score, average.
3.3.2Joint target observation score standard:①The joint pain score standard:0points:painless;1:mild pain, can be tolerated, no effect of sleep;2:moderate pain, slightly affect the action and sleep;3:severe pain, unbearable, significantly affect the activity and sleep.②The joint tenderness score:0:no tenderness;1:mild tenderness, pressing joint circumference, patients referred pain;2moderate tenderness, pressure joint circumference, in patients with facial pain;3:severe tenderness.③The joint swelling score:0:no swelling;l:mild swelling;2:moderate swelling;3:marked swelling.④The joint function obstacle classification standard:level0:no limitation of joint movement;1grade:joint activity in mild restriction; grade2:joint activity of moderate restriction;3-4:joint activity was limited.⑤The walking time in seconds (20m:s), repeated2times, and the average value.
3.3.3Standard of effect:Effect:signs and symptoms disappeared, joint function of normal,5observation indexes were improved significantly; Better:signs and symptoms disappeared, the occasional activities when the pain, joint flexion and extension in the range of80°-135°, can participate in daily work and labor,5indicators of4above improvement of symptoms and signs; Invalid:no significant improvement,5observation index less than improvement.
3.4. Statistical methods
Using SPSS13.0statistical analysis software, all the measurement data are (x±s), group before and after treatment were compared using the paired t test, multiple groups before and after treatment difference compared with single factor variance analysis, multiple comparison using LSD method; count data were compared with x2test, multiple groups of rank data using Kruskal-Wallis method inspection. Taking P<0.05as the difference was statistically significant.
3.5Treatment outcomes
3.5.1Comparison of general data:Between three groups before treatment.40cases of A group,40cases in B group,40cases in C group, three groups before treatment in patients with age, gender, the course of KOA had no significant difference (P>0.05), with comparable
3.5.2Three groups before and after treatment clinical indicators comparison (table3-7).
(1) Treatment of joint pain:After3months, after treatment, A, B, C group of patients with knee pain has improved and improved, and before treatment in comparison, there are significant difference (t=14.171, P=0.000; t=14.000, P=0.000; t=16.574, P=0.000); group three joint pain severity before and after treatment with difference difference comparison (F=4.721, P=0.011), A group before and after treatment difference is higher than that of B group, but the two groups before and after treatment, the mean difference were comparable between groups, the difference was not significant (P=0.864); C group before and after treatment is superior to that of A, difference between B group, there were significant differences (P=0.011, P=0.007).
(2) Joint tenderness comparison:joint tenderness degree after treatment in the three groups, group C is better than A, B group, there was statistically significant difference (χ2=10.484, P=0.005).
(3) Compared with joint swelling degree:group C is better than A, B group, there was statistically significant difference (x2=15.740, P=0.000).
(4) Dysfunction:treatment after3months, after treatment, A, B, C group of patients with knee joint dysfunction has improved and improved, and before treatment in comparison, there are significant difference (t=10.494, P=0.000; t=9.802, P=0.000; t=14.207, P=0.000); group three joint dysfunction degree before and after treatment are different (difference comparison F=4.903, P=0.009), A group before and after treatment difference than that of B group, the difference was not significant (P=0.335); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.038, P=0.003).
(5) Running time comparison:treatment after3months. after treatment, A, B, C group of patients walking time to improve and better, and before treatment in comparison, there are significant difference (t=18.976, P=0.000; t=17.814, P=0.000; t=25.706, P=0.000); three groups of traveling time difference value difference between before and after treatment (F=20.861, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.497); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).
3.5.3Laboratory indexes comparison
(1) ESR:comparison of treatment after3months, after treatment, A, B, C group of patients with ESR have improved and improved, and before treatment in comparison, there are significant difference (t=5.262, P=0.000; t=5.046, P=0.000; t=7.44, P=0.000); three groups before and after treatment with ESR difference difference between the (F=11.057, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.626); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).
(2)CRP:comparison of treatment after3months, after treatment, A, B, C group of patients with CRP have improved and improved, and before treatment in comparison, there are significant difference (t=4.477, P=0.000; t=5.101, P=0.000; t=7.879, P=0.000); three groups before and after treatment with CRP difference difference between the (F=3.474, P=0.034), A group before and after treatment difference than that of B group, the difference was not significant (P=0.852); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.019, P=0.031).
3.5.4Cure rate comparison:C group was significantly better than A and B, there was significant difference (χ2=11.706,P=0.003)
3.5.5Adverse reactions compared:adverse reactions in group A、C was lower than that in the B group, comparison between groups, there were significant differences (χ2=14.867,P=0.001)
4.Conclusion
Experimental study and clinical observation results show that:
4.1Jiangu granule can reduce osteoarthritis of knee joint fluid in rat serum, TNF-α, MMP-3content, its body cytokines have a regulatory role, through inhibition of synovial inflammation, reduce cell active factor out, thereby relieving various cytokines on articular cartilage matrix damage, improvement of cartilage matrix metabolism, promote cartilage repair;
4.2Jiangu Granule in the treatment of osteoarthritis of the knee is safe and effective;
4.3Jiangu granule combined with diacerein treatment knee OA, clinical curative effect was better than that of Jiangu granule or single use of diacerein, can rapid control of clinical symptoms, and can relieve pain, improve articular cartilage metabolism, inhibition of cytokines, delaying disease progress, not only has good curative effect and lasting, and good safety.
骨关节炎(OA)也称退行性骨关节病,本病是由于关节软骨完整性破坏以及关节软骨下骨板病变,导致关节症状和体征的一组异质性疾病。按照关节分布可以分为局限性和全身性骨关节炎。膝骨关节炎(简称KOA)局限性骨关节炎的常见病,临床上以关节疼痛、僵硬、活动受限、活动时可有磨擦响声为特征。本病中年以后多发,发病率随年龄增长而增高,严重危害着中老年人的健康。
OA的病因目前尚不完全明了,一般认为KOA发病的主要原因有生物力学因素、遗传因素、外源性因素等参与导致滑膜、软骨和骨的代谢改变,进而产生炎症,关节结构破坏。其最基本的病理改变是关节软骨的损伤退变。现代医学认为,软骨降解是软骨退变的一个重要方面。大量研究证实,OA软骨降解与细胞因子表达异常有关。在正常情况下,关节软骨基质的分解代谢和合成代谢平衡是通过分解性细胞因子和合成性细胞因子(即生长因子)的平衡来维持的。分解性细胞因子如白细胞介素-1(IL-1),主要是刺激生成特殊的基质金属蛋白酶(MMP),引起基质的降解,并可通过刺激滑膜细胞增殖和变性,诱导炎性介质形成,促进滑膜细胞金属蛋白酶分泌,抑制或干扰软骨细胞及表型表达等。其中肿瘤坏死因子α(TNF-α)、基质金属蛋白酶-3(MMP-3)是参与OA发病过程的重要介质。OA的发生与关节滑膜细胞增殖旺盛,分泌过多的TNF-α并释放入血有关,已有报道OA患者的滑膜内存在着高浓度的TNF-α。TNF-α能激活多型核细胞,刺激滑膜细胞产生前列腺素E2,促进软骨基质金属蛋白酶合成和分泌,引起关节软骨吸收、降解和破坏。有学者报道TNF-α主要影响滑膜炎症和免疫学反应,能诱发抗自身软骨的自身免疫反应,MMPs是参与关节组织损伤的主要因素,可以促进骨基质的降解,抑制软骨细胞合成具有透明软骨特性的蛋白聚糖和Ⅱ型胶原促进生成有纤维母细胞特性的Ⅰ型胶原,从而使软骨细胞变性,引起软骨缺损和软骨的生物力学改变,TNF-α、MMP-3在OA病情进展中具有潜在的协同效应。研究表明,MMP-3是金属蛋白酶的主要成员之一,主要在OA患者的滑膜细胞中表达,软骨细胞和单核细胞也有少量的表达。研究表明MMP-3是OA发病过程中重要的的生物学标志物,OA患者血清及关节液中MMP—3含量与病情密切相关。
祖国医学认为膝骨关节炎属痹证、骨痹范畴,多以肝脾肾亏虚为本,气滞血瘀痰凝、风寒湿邪侵袭,痹阻经络为标,属本虚标实之证。肝脾肾亏虚,筋骨失养是发病之本：中医学认为,膝为肝脾肾三经所系,筋骨肉之大会。肝藏血主筋,肾藏精主骨,脾主运化合肉。而0A的发生多为中老年人,肝肾渐亏,筋骨懈惰；筋失血养,无以柔韧；骨失髓养,无以强壮；肉失脾主,虚赢无力。所以KOA的发病与肝脾肾三脏虚弱关系最为密切。气滞、血瘀、痰凝是膝骨关节炎发病的重要环节：气为血帅,血为气母；气滞可致血瘀,血瘀加重气滞。由于膝关节是人体负重最大和关节面积最大的关节,亦是人体参与运动最重要的关节,最易受到损伤。膝关节损伤,脉络受损,血溢于外,阻塞经络,致气滞血阻,经络受阻。或由于肝脾肾亏虚,气血运行不畅、痰凝经络,膝关节及周围组织失养,从而引起关节软骨的退变,导致KOA的发生与发展。风寒湿外邪侵袭、痹阻经络,久而关节变形,活动受限,形成骨痹,其是KOA发病的重要因素。
目前西医针对骨关节炎治疗在于缓解疼痛、阻止和延缓疾病的进展、保护关节功能、改善生活质量。治疗原则以非药物治疗联合药物治疗为主,必要时手术治疗。非药物治疗包括患者的教育、运动和生活指导以及物理治疗。药物治疗分两大类：1)控制症状的药物：包括解热镇痛类,非甾体类抗炎药,阿片类药物,激素等；2)改善病情的药物(DMARAs)及软骨保护剂：此类药物—般起效慢,需治疗数周见效,具有降低基质金属蛋白酶、胶原酶等活性,既可抗炎、止痛、又可保护关节软骨,有延缓骨关节炎发展的作用。如双醋瑞因,它是IL-1抑制剂,可抑制软骨降解、促进软骨合成并抑制滑膜炎症。它不仅能有效地改善骨关节炎的症状,减轻疼痛,改善关节功能,还可以延缓骨关节炎病程的进展。
中医治疗本病主要在于解除疼痛症状,改善关节功能,保护关节结构。结合中医的整体观念,辨证论治,中药、针灸、推拿等多种手段综合运用,从膝关节局部用药和全身整体出发,充分发挥中医药的优势综合治疗,从而使患者的症状有效改善。
然而目前,单纯应用中、西医药对该病的治疗尚未取得突破性进展。其中,西医药治疗耗资较为昂贵,并普遍存在程度不一的胃肠道副作用,患者依从性差。相对而言,中医药治疗具有简便验廉、安全性较好的特点,适合长期使用,故越来越引起了医学界的关注。但单用中药往往起效较慢,对一些严重患者临床症状的快速控制不甚理想。中西医结合治疗能取长补短,使中药与西药充分发挥其治疗效果并能减轻西药的副作用。健骨颗粒冲剂是风湿科治疗骨关节炎临床应用二十多年的经验方,由淫羊藿、地黄、秦艽、杜仲、丹参、牛膝、延胡索等组成,具有补益肝肾,强筋健骨,活血止痛之功效。全方重用淫羊藿,杜仲,以滋补肝肾,强筋骨。本项研究拟对该方的作用机制进行探讨。
本课题拟分两部分对健骨颗粒冲剂治疗KOA的治疗进行研究。第一部分研究：通过测定大鼠膝OA模型血清和关节液中TNF-α、MMP-3的含量,探讨健骨颗粒冲剂治疗OA的作用机制；第二部分：通过健骨颗粒冲剂联合双醋瑞因治疗膝关节骨性关节炎的临床研究,观察健骨颗粒冲剂治疗膝骨关节炎的临床疗效,探讨中药复方联合西医结合治疗KOA的疗效；从动物实验与临床观察对健骨颗粒冲剂进行研究,并观察其联合西药在治疗KOA的优势。
2.健骨颗粒冲剂对大鼠膝骨关节炎血清和关节液中TNF-α、MMP-3的影响
2.1主要材料及试剂：健康Wistar大鼠48只,雌雄各半,体重180-220g。木瓜蛋白酶,大鼠白细胞介素TNF-α ELISA定量检测试剂盒,大鼠白细胞介素MMP-3ELISA定量检测试剂盒。中药健骨颗粒冲剂由独活,淫羊藿,杜仲,牛膝,徐长卿,秦艽,丹参,玄胡,生地,知母等组成。双醋瑞因,规格：50mg/片。
2.2动物模型与实验分组48只健康Wistar大鼠,适应性喂养1周后,随机抽取40只,分为四组,正常组,模型组,双醋瑞因组,健骨颗粒冲剂组,每组10只。除正常组外均予以造模,造模参照文献对大鼠右膝关节腔注射4%木瓜蛋白酶生理盐水溶液0.2m1,每隔3d注射1次,连续注射3次成功造模。根据成人和实验动物用量的换算公式,计算出给药量,双醋瑞因0.009g/kg,健骨颗粒冲剂2.7g/kg,正常组和模型组给与相应剂量的生理盐水,每日一次,4周后取材。
2.3标本采集：将大鼠仰卧捆绑于小动物手术台上,股动脉取血,离心后,置于-20℃冰箱保存。抽取各组动物膝关节冲洗液1ml后离心,取上清液-20℃冰箱保存待测。
2.4指标检测：酶联免疫吸附法检测血清和关节液中MMP-3和TNF-α含量。
2.5统计学分析：应用SPSS13.0软件进行统计分析。计量资料采用均数±标准差表示,组间差异采用单因素方差分析,以a=0.05为显著性水准。
2.6结果
2.6.1一般情况：正常组活泼,毛发光泽,能正常活动与饮食,无关节肿胀；模型组神态萎靡少动,毛发欠光泽,脱毛较明显,食少,局部肿胀,有明显舔舐及跛行现象。药物治疗组大鼠上述表现较模型组均有不同程度的改善。
2.6.2病理观察：正常组软骨基质染成粉红色,着色均匀,软骨表面光滑,软骨细胞排列整齐,四层结构清晰可辨,潮线完整。模型组关节软骨破坏最为严重,软骨表面粗糙不整,软骨表面糜烂、完全剥脱,形成缺损区。双醋瑞因组四层结构基本清晰,潮线基本完整,少许关节软骨细胞有轻度变性。健骨颗粒冲剂组关节软骨内有少许炎细胞浸润,关节软骨细胞有轻度变性,潮线基本完整。
2.6.3血清TNF-α、MMP-3指标各组之间比较：①TNF-α含量：各组间TNF-α含量比较,差异有统计学意义(F=75.035,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.778),差异无统计学意义。②MMP-3含量：各组间MMP-3含量比较,差异有统计学意义(F=77.336,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.847),差异无统计学意义。
2.6.4关节液TNF-α、MMP-3指标各组之间比较：①TNF-α含量：各组间TNF-α含量比较,差异有统计学意义(F=40.783,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.191),差异无统计学意义。②MMP-3含量：各组间MMP-3含量比较,差异有统计学意义(F=275.255,P=0.000)。组间两两比较,模型组高于正常组、双醋瑞因组、健骨颗粒冲剂组(P=0.000,P=0.000,P=0.000)；双醋瑞因组与健骨颗粒冲剂组比较(P=0.065),差异无统计学意义。
3.健骨颗粒冲剂联合双醋瑞因治疗治疗膝关节骨性关节炎临床研究。
3.1临床资料
3.1.1120例均为2011年3-11月南方医院中医科门诊和香港伍捷进中医推拿针灸医馆就诊的膝OA患者,其中85位来自南方医院中医科门诊,35位来自香港伍捷进中医推拿针灸医馆。随机分为A组(健骨颗粒治疗组)、B组(双醋瑞因治疗组)、C组(健骨颗粒加醋瑞因治疗组)各40例。A组男11例,女29例；年龄49-69岁,平均(61.00±5.08)岁；病程平均(3.20±1.10)年；根据OA影像学诊断标准、放射学诊断分级标准：Ⅰ级8例,Ⅱ级14例,Ⅲ级16例,Ⅳ级2例。B组男13例,女27例；年龄53～69岁,平均(62.38±4.00)岁；病程平均(2.88±1.27)年；影像学诊断分级：Ⅰ级9例,Ⅱ级16例,Ⅲ级14例,Ⅳ级1例。C组男12例,女28例；年龄46～68岁,平均(60.38±4.68)岁；病程平均(3.00±1.13)年；影像学诊断分级：Ⅰ级7例,Ⅱ级22例,Ⅲ级10例,Ⅳ级1例。3组性别、年龄、病程、关节影像学诊断分级等经统计学处理,差异均无显著性意义(P>0.05),具有可比性。
3.1.2诊断标准符合美国风湿病学会制订的OA诊断标准。
3.1.3排除标准排除继发性骨关节炎、感染性关节炎等其他原因所致的关节疾患；晚期、残毁性OA及伴有严重心、肝、肾等疾病、活动性胃肠病变者以及孕期或哺乳期妇女亦一律不能入组。
3.2治疗方法
A组服健骨颗粒冲剂,每天1剂,开水冲服,每次150mL,每天2次。B组服用双醋瑞因片,每次50mg,每天2次。C组以上2种药物联合服用,服法及剂量同上。3组均以1月为1疗程,治疗3疗程。
3.3观察指标与疗效标准
3.3.1观察指标定期复诊记录膝部关节疼痛、关节压痛、关节肿胀、关节活动及20m行走时间的变化情况；治疗前后定期复查血常规、尿常规、血沉(ESR)、C-反应蛋白(CRP)、肝肾功能、膝关节X线摄片。所有患者膝关节进行双侧评分,取平均值。
3.3.2关节指标观测评分标准①关节疼痛评分标准：0分：无痛；1分：轻度痛,可耐受,不影响睡眠；2分：中度痛,稍影响行动及睡眠；3分：重度痛,难以忍受,明显影响活动及睡眠。②关节压痛评分标准：0分：无压痛；1分：轻度压痛,按压关节周缘,患者称痛；2分中度压痛,压关节周缘,患者表情痛苦；3分：重度压痛。③关节肿胀评分标准：0分：无肿胀；1分：轻度肿胀；2分：中度肿胀；3分：明显肿胀。④关节功能活动障碍分级标准：0级：无关节活动受限；1级：关节活动轻度受限；2级：关节活动中度受限；3-4级：关节活动明显受限。⑤20m行走时间：以秒(s)计,重复2次,取平均值。
3.3.3疗效标准显效：症状体征基本消失,关节功能活动正常,5项观测指标皆有明显改善；好转：症状体征基本消失,偶尔有活动时酸痛,关节屈伸活动范围在80°-135°,能参加日常工作和劳动,5项观测指标4项以上有改善；无效：症状体征无明显改善,5项观测指标少于4项改善。
3.4.统计学方法
采用SPSS13.0统计软件分析,所有计量资料均以(x±s)表示,组内治疗前后比较采用配对t检验,多组间治疗前后差值比较采用单因素方差分析,多重比较采用LSD法；计数资料比较采用χ2检验,多组等级资料采用Kruskal-Wallis法检验。以P<0.05为差异有统计学意义。
3.5治疗结果
3.5.1三组治疗前一般资料比较。A组40例,B组40例,C组40例,三组治疗前患者年龄、性别、KOA病程均无显著性差异(P>0.05),具有可比性
3.5.2三组治疗前后临床指标比较见表3-7。
(1)关节疼痛比较：治疗3月后,治疗后A、B、C组患者膝关节疼痛有改善与好转,与治疗前相比较,差异有显著性意义(t=14.171,P=0.000；t=14.000,P=0.000；t=16.574,P=0.000)；三组关节疼痛程度治疗前后差值比较有差异(F=4.721,P=0.011),A组治疗前后差值高于B组,但两组组治疗前后的均数差进行组间比较,其差异无显著性意义(P=0.864)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.011,P=0.007)。
(2)关节压痛比较：治疗后三组关节压痛程度比较,C组治疗后改善优于A、B组,有统计学差异(χ2=10.484,P=0.005)。
(3)治疗后三组关节肿胀程度比较,C组治疗后改善优于A、B组,有统计学差异(χ2=15.740,P=0.000)。
(4)功能障碍比较：治疗3月后,治疗后A、B、C组患者膝关节功能障碍有改善与好转,与治疗前相比较,差异有显著性意义(t=10.494,P=0.000；t=9.802,P=0.000；t=14.207,P=0.000)；三组关节功能障碍程度治疗前后差值比较有差异(F=4.903,P=0.009),A组治疗前后差值高于B组,其差异无显著性意义(P=0.335)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.038,P=0.003)。
(5)行走时间比较：治疗3月后,治疗后A、B、C组患者行走时间有改善与好转,与治疗前相比较,差异有显著性意义(t=18.976,P=0.000；t=17.814,P=0.000；t=25.706,P=0.000)；三组行走时间治疗前后差值比较有差异(F=20.861,P=0.000)。A组治疗前后差值高于B组,其差异无显著性意义(P=0.497)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.000,P=0.000)。
3.5.3三组治疗前后实验室指标变化比较
(1)ESR比较：治疗3月后,治疗后A、B、C组患者ESR有改善与好转,与治疗前相比较,差异有显著性意义(t=5.262,P=0.000；t=5.046,P=0.000；t=7.44,P=0.000)；三组ESR治疗前后差值比较有差异(F=11.057,P=0.000)。A组治疗前后差值高于B组,其差异无显著性意义(P=0.626)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.000,P=0.000)。
(2)CRP比较：治疗3月后,治疗后A、B、C组患者CRP有改善与好转,与治疗前相比较,差异有显著性意义(t=4.477,P=0.000；t=5.101,P=0.000；t=7.879,P=0.000)；三组CRP治疗前后差值比较有差异(F=3.474,P=0.034),A组治疗前后差值高于B组,其差异无显著性意义(P=0.852)；C组治疗前后差值优于A、B组,差异有显著性意义(P=0.019,P=0.031)。
3.5.4三组显疗率比较C组显效率优于A、B组,组间比较,差异有显著性意义(χ2=11.706,P=0.003)。
3.5.5三组不良反应比较A、C组不良反应率低于B组,组间比较,差异有显著性意义(χ2=14.867,P=0.001)。
4.结论
实验研究和临床观察结果表明：
4.1健骨颗粒冲剂能降低膝骨性关节炎大鼠血清、关节液中的TNF-α、MMP-3的含量,其对机体细胞因子有调节作用,通过抑制滑膜炎症,减少各种细胞活性因子的渗出,从而减轻各种细胞因子对关节软骨基质的损害,改善软骨基质代谢,促进软骨修复；
4.2健骨颗粒冲剂治疗膝骨关节炎安全有效；
4.3健骨颗粒冲剂联合双醋瑞因治疗膝OA,临床疗效优于单用健骨颗粒冲剂或单用双醋瑞因,既可较快的控制临床症状,又可以持续消肿止痛,改善关节软骨代谢,抑制相关细胞因子,延缓病情进展,不仅疗效良好和持久,而且安全性好。
1.Objectives and significance
Osteoarthritis (OA) also called degenerative joint disease, the disease is the result of articular cartilage damage of integrity and articular cartilage under plate of bone lesions, leading to joint symptoms and signs are a heterogeneous group of diseases. According to the joint distribution can be divided into the limitations and systemic bone arthritis. Knee osteoarthritis (KOA) limitations of osteoarthritis in clinical common diseases, joint pain, stiffness, restricted activity, activity can be characterized with friction sound. The disease after the middle-aged multiple, the incidence increased with the growth of age, seriously endangering the health of the elderly.
The etiology of OA is not completely clear, generally considered the pathogenesis of KOA is the main reason for biomechanical factors, genetic factors, exogenous factors involved in causing synovial membrane, cartilage and bone metabolism, and inflammation, joint structure damage. It's most basic pathological changes of articular cartilage injury. Modern medicine thinks, cartilage degradation is one of the important aspects of cartilage degeneration. Many studies show that, OA cartilage degradation and cytokine expression abnormalities related to. Under normal circumstances, the matrix of articular cartilage catabolism and anabolism balance is through the decomposition of cytokines and synthesis of cytokines (i.e. growth factor) to maintain the balance of. Decomposition of cytokines such as interleukin-1(IL-1), is mainly stimulated the creation of special matrix metalloproteinases (MMP), induced matrix degradation, and through the stimulation of proliferation of synovial cells and degeneration induced by inflammatory mediators, formation, promoting synovial cell metalloproteinase secretion, inhibit or interfere with cartilage cells and phenotypic expression and so on. The tumor necrosis factora(TNF-α), matrix metalloproteinase-3(MMP-3) is involved in the pathogenesis of OA and important medium. The occurrence of OA and synovial cell proliferation is exuberant, excessive secretion of TNF-aand released into the blood, it has been reported that OA patients with synovial memory in a high concentration of TNF-a. TNF-acan activate multiple nuclear cells, stimulate synovial cells produce prostaglandin E2, promote cartilage matrix metalloproteinase synthesis and secretion, caused by absorption, degradation and destruction of articular cartilage. Scholars have reported that TNF-amain effects of synovitis and immunological reaction, can induce resistance to the cartilage of the autoimmune reaction, MMPs is involved in joint tissue damage is the main factor, can promote bone matrix degradation, inhibition of chondrocyte biosynthesis is hyaline cartilage properties of the proteoglycan and collagen type Ⅱ promotes formation of fibroblast cell characteristics of type I collagen, so that the cartilage cell degeneration, causing cartilage defects and the biomechanics of cartilage change, TNF-a, MMP-3in OA progression of potentially synergistic effect. Research shows that, MMP-3is one of the main members of metalloproteinases, mainly in OA patients with synovial cells, cartilage cells and mononuclear cells also have a small amount of expression. The study indicates that MMP-3is OA in the pathogenesis of important biological markers, OA in serum and synovial fluid in MMP3content and disease are closely related.
TCM thinks of knee osteoarthritis belongs, bonerheumatism category, liver and spleen and kidney deficiency in this, qi stagnation and blood stasis phlegm, chill wet evil invasion, blockage of main and collateral channels as the standard, the virtual real standard of evidence. Liver spleen and kidney deficiency, and loss of support is the basis of the disease:in medicine, the knee for the liver spleen kidney three classics department, rib near the assembly. Liver storing blood main reinforcement, kidney essence bone, spleen transporting compound meat. While the OA occurred for the elderly, liver and kidney was waning, and idleness; reinforcement loss to raise, pliable; bone loss of bone marrow to raise, without strong meat; loss of spleen weakness, virtual win. So KOA and the incidence of liver spleen kidney three dirty was most closely related to. Stagnation of Qi, blood, phlegm is for knee osteoarthritis: an important link of gas as the commander of blood, blood gas and can cause blood stasis, blood stasis parent; exacerbation Qi stagnation. As the human knee is the biggest and largest weight-bearing joints joints, is also involved in the movement is the most important human body joint, the most vulnerable to injury. Knee joint injury, impaired blood spilled in context, main and collateral channels, obstruction, caused by qi stagnation and blood resistance, main and collateral channels blocked. Liver spleen and kidney deficiency or due to poor run, Qi and blood, phlegm main and collateral channels, knee joint and surrounding tissue loss of support, resulting in the degeneration of articular cartilage, resulting in the occurrence and development of KOA. Chill wet evil invasion, blockage of main and collateral channels, long and joint deformity, activity limitation, forming bone rheumatism, which is an important factor in the pathogenesis of KOA.
At present western medicine in treatment of osteoarthritis in pain relief, prevent and delay the progression of the disease, preserve joint function, improve the quality of life. Principles of treatment to non drug therapy combined with drug therapy, when necessary, operation treatment. Non drug therapy include patient education, exercise and life coach and physical therapy. Drug treatment is divided into two categories:1) control the symptoms of drug:including antipyretic analgesics, nonsteroidal anti-inflammatory drugs, opioids, such as hormone;2) to improve the condition of medication (DMARAs) and chondroprotective agents:these drugs generally slow onset, requiring treatment for several weeks to work, has reduced matrix metalloproteinases, collagenase activity, anti-inflammatory, analgesic, and can protect the articular cartilage, delay osteoarthritis development. As of diacerein, it is IL-linhibitor, can inhibit cartilage degradation, promoting cartilage synthesis and inhibition of synovial inflammation. It not only can effectively improve the symptoms of osteoarthritis, reduce pain, improve joint function, also can delay the progress of osteoarthritis.
Chinese medicine in the treatment of this disease mainly lies in the relief of pain symptoms, improve joint function, joint protection structure. Combined with the holistic concept of traditional Chinese medicine, treatment based on syndrome differentiation of traditional Chinese medicine, acupuncture, massage, etc. synthetically, the knee joint from the topical and systemic whole sets out, give full play to the advantages of traditional Chinese medicine comprehensive treatment, so that the patients symptoms improved.
However, simple application, western medicine on the treatment of the disease has not yet been achieved breakthrough progress. Wherein, western medicine treat-ment cost is more expensive, and the prevalence rate is not a gastrointestinal side effects, poor compliance of the patient. Relatively speaking, Chinese medicine treat-ment has the advantages of simple inspection of cheap, good safety characteristics, suitable for long-term use, it caused more and more medical attention. But the single use of traditional Chinese medicine often slow onset, for some serious clinical symptoms of patients with rapid control is not ideal. Combination of traditional Chinese and Western medicine treatment can learn from each other, so that the traditional Chinese medicine and Western medicine to give full play to its therapeutic effect and reduce the side effects of Western medicine. Jiangu granule is the Department of rheumatism for treatment of osteoarthritis clinical application for more than20years of experience, from Herba Epimedii, digitalis, Gentiana, eucommia, radix salviae miltiorrhizae, radix, yanhusuo etc., has the functions of invigorating liver and kidney, gluten bone health, promoting blood circulation and relieving pain. The reuse of epimedium, eucommia, to nourish liver and kidney, strengthening bones and muscles. The study on the side of the mechanism.
This article is divided two parts of Jiangu Granule in treating KOA treatment were studied. The first part of the study:the determination of the rat knee model of OA in serum and synovial fluid TNF-, the content of MMP-3, of Jiangu Granule in treating the action mechanism of OA; part second:Jiangu granule combined with diacerein treatment of knee osteoarthritis clinical research, observation of Jiangu Granule in treating knee osteoarthritis clinical efficacy, study of Chinese medicine combined with western medicine treatment of the effect of KOA; from the animal experiment and clinical observation of Jiangu granule for research, and to observe the combined with western medicine in the treatment of KOA advantage.
2. The effect of Jiangu Granule on rats with knee osteoarthritis in serum and synovial fluid TNF-, MMP-3
2.1The main materials and reagents:48healthy Wistar rats, male and female in half, weight180-220g. Papain, rat interleukin TNF-ELISA quantitative determination reagent kit, rat interleukin MMP-3ELISA quantitative determination reagent kit. Traditional Chinese medicine Jiangu Granule by Duhuo, epimedium, eucommia, hyssop, Radix Cynanchi paniculati, Gentiana, Salvia miltiorrhiza, Xuan Hu, raw land, Rhizoma Anemarrhenae. Diacerein, specification:50mg/.
2.2Animal model and experimental group:48healthy Wistar rats, adaptive feeding after1weeks, the random sampling of40, divided into four groups, the normal group, model group, diacerein group, Jiangu granule group,10rats in each group. Besides normal group were to be molding, molding in reference on rat right knee joint cavity injection of4%papain saline solution0.2ml, every3D1injection, continuous injection of3successful model. According to experimental animal and adult dosage conversion formula, calculated dose, diacerein Jiangu granule0.009g/kg,2.7g/kg, normal group and model group gives the corresponding dose of saline, once daily,4weeks after operation.
2.3Specimens collecte:the rats supine tied to small animal operation table, femoral artery blood, after centrifugation, at-20℃refrigerator. Extraction of each animal knee joint lavagelml after centrifugation, taking supernatant-20℃refrigerator testing.
2.4Indexes:enzyme-linked immunosorbent assay for the detection of in serum and synovial fluid MMP-3and TNF-content.
2.5Statistical analysis:SPSS13.0software was used for statistical analysis. Measurement data based on mean±standard deviation indicates, the differences between groups with single factor analysis of variance, witha=0.05is a remarkable level.
2.6Results
2.6.1General situation:normal group lively, shiny hair, normal activity and diet, no joint swelling; model group was dispirited move less, less glossy hair, hair removal is obvious, eat less, local swelling, has obvious licking and claudication phenomenon. The rats in the treated groups the performance compared with the model group were improved in different degree.
2.6.2Pathological observation of normal cartilage matrix:pink colored uniform, smooth surface, cartilage, cartilage cells are arranged in rows, four layers of structure clear, tidal line integrity. Model group of articular cartilage damage is most severe, the cartilage surface roughness is not whole, cartilage surface erosion, completely denuded, forming defect area. Double promote ray was group of four layer structure is basic and clear, the tidal line the basic integrity, little articular chondrocytes with mild degeneration. Jiangu granule group within articular cartilage have less infiltration of inflammatory cells, chondrocytes with mild degeneration, tidal line integrity.
2.6.3Serum TNF-α, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=75.035, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.778), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=77.336, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.847), the difference was not statistically significant.
2.6.4Synovial TNF-a, MMP-3:①TNF-a content:TNF-a content compared among the groups, the difference was statistically significant (F=40.783, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein Jiangu granule group and comparison group (P=0.191), the difference was not statistically significant.②MMP-3content:MMP-3content comparison groups, the difference was statistically significant (F=275.255, P=0.000). Comparison between two two groups, normal group, model group was significantly higher than that of diacerein group, Jiangu granule group (P=0.000, P=0.000, P=0.000); diacerein, Jiangu granule group and comparison group (P=0.065), the difference was not statistically significant.
3. Clinical research of Jiangu granule combined with diacerein treatment of knee osteoarthritis.
3.1Clinical data
3.1.1120cases of were3～in2011November South Hospital Outpatient Department of traditional Chinese medicine and Hongkong Wu Jiejin massage acupuncture medical center clinic patients with knee OA,85of them from southern hospital outpatient department of traditional Chinese medicine,35from the Hongkong Wu Jiejin massage acupuncture museum. Were randomly divided into group A (Jiangu granules in treatment group), group B (diacerein treatment group), group C (Jiangu Granule plus vinegar ray was the treatment group40cases each). Group A male11cases, female29cases; age49～69years, average (61±5.08) years old; the average course of disease (3.20±1.10) years; according to OA imaging diagnostic criteria for, radiology diagnostic criteria:grade Ⅰ in8cases,14cases in grade Ⅱ,16cases in grade Ⅲ,Ⅳ in2cases. Group B male13cases, female27cases; age53～69years, average (62.38±4) years old; the average course of disease (2.88±1.27) years; imaging diagnosis grading:grade Ⅰ in9cases,16cases in grade Ⅱ,14cases in grade Ⅲ,Ⅳ in1cases. Group C male12cases, female28cases; age46～68years, average (60.38±4.68) years old; the average course of disease (3±1.13) years; imaging diagnosis grading:grade Ⅰ in7cases,22cases in grade Ⅱ,10cases in grade Ⅲ,Ⅳ in1cases.3groups of sex, age, course of disease, joint imaging diagnosis grading statistically, there were no significant differences (P>0.05), with comparable.
3.1.2Diagnosis standards:In line with the American College of rheumatology for OA diagnosis standard.
3.1.3Exclusion:Criteria to exclude secondary osteoarthritis, septic arthritis and other causes of joint disease; later, the ruined OA and accompanied by severe heart, liver, kidney disease, gastrointestinal lesions and activity in pregnant or lactating women also are not into the group.
3.2Methods of treatment
A group of Jiangu granule clothing, daily1agent, boiling water,150mL each time,2times a day. B group taking diacerein tablets,50mg each time,2times a day. C group of more than2drugs in combination use, dosage and dosage. The3groups are in January forl courses,3courses of treatment.
3.3Outcome measures and curative effect standard
3.3.1Observation:knee joint pain index regular reexamination records, joint tenderness, swelling of the joints, joint activities and20m walking time changes before and after treatment; regular review of blood, urine, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and kidney function, knee X line photograph. All patients with knee joint the bilateral score, average.
3.3.2Joint target observation score standard:①The joint pain score standard:0points:painless;1:mild pain, can be tolerated, no effect of sleep;2:moderate pain, slightly affect the action and sleep;3:severe pain, unbearable, significantly affect the activity and sleep.②The joint tenderness score:0:no tenderness;1:mild tenderness, pressing joint circumference, patients referred pain;2moderate tenderness, pressure joint circumference, in patients with facial pain;3:severe tenderness.③The joint swelling score:0:no swelling;l:mild swelling;2:moderate swelling;3:marked swelling.④The joint function obstacle classification standard:level0:no limitation of joint movement;1grade:joint activity in mild restriction; grade2:joint activity of moderate restriction;3-4:joint activity was limited.⑤The walking time in seconds (20m:s), repeated2times, and the average value.
3.3.3Standard of effect:Effect:signs and symptoms disappeared, joint function of normal,5observation indexes were improved significantly; Better:signs and symptoms disappeared, the occasional activities when the pain, joint flexion and extension in the range of80°-135°, can participate in daily work and labor,5indicators of4above improvement of symptoms and signs; Invalid:no significant improvement,5observation index less than improvement.
3.4. Statistical methods
Using SPSS13.0statistical analysis software, all the measurement data are (x±s), group before and after treatment were compared using the paired t test, multiple groups before and after treatment difference compared with single factor variance analysis, multiple comparison using LSD method; count data were compared with x2test, multiple groups of rank data using Kruskal-Wallis method inspection. Taking P<0.05as the difference was statistically significant.
3.5Treatment outcomes
3.5.1Comparison of general data:Between three groups before treatment.40cases of A group,40cases in B group,40cases in C group, three groups before treatment in patients with age, gender, the course of KOA had no significant difference (P>0.05), with comparable
3.5.2Three groups before and after treatment clinical indicators comparison (table3-7).
(1) Treatment of joint pain:After3months, after treatment, A, B, C group of patients with knee pain has improved and improved, and before treatment in comparison, there are significant difference (t=14.171, P=0.000; t=14.000, P=0.000; t=16.574, P=0.000); group three joint pain severity before and after treatment with difference difference comparison (F=4.721, P=0.011), A group before and after treatment difference is higher than that of B group, but the two groups before and after treatment, the mean difference were comparable between groups, the difference was not significant (P=0.864); C group before and after treatment is superior to that of A, difference between B group, there were significant differences (P=0.011, P=0.007).
(2) Joint tenderness comparison:joint tenderness degree after treatment in the three groups, group C is better than A, B group, there was statistically significant difference (χ2=10.484, P=0.005).
(3) Compared with joint swelling degree:group C is better than A, B group, there was statistically significant difference (x2=15.740, P=0.000).
(4) Dysfunction:treatment after3months, after treatment, A, B, C group of patients with knee joint dysfunction has improved and improved, and before treatment in comparison, there are significant difference (t=10.494, P=0.000; t=9.802, P=0.000; t=14.207, P=0.000); group three joint dysfunction degree before and after treatment are different (difference comparison F=4.903, P=0.009), A group before and after treatment difference than that of B group, the difference was not significant (P=0.335); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.038, P=0.003).
(5) Running time comparison:treatment after3months. after treatment, A, B, C group of patients walking time to improve and better, and before treatment in comparison, there are significant difference (t=18.976, P=0.000; t=17.814, P=0.000; t=25.706, P=0.000); three groups of traveling time difference value difference between before and after treatment (F=20.861, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.497); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).
3.5.3Laboratory indexes comparison
(1) ESR:comparison of treatment after3months, after treatment, A, B, C group of patients with ESR have improved and improved, and before treatment in comparison, there are significant difference (t=5.262, P=0.000; t=5.046, P=0.000; t=7.44, P=0.000); three groups before and after treatment with ESR difference difference between the (F=11.057, P=0.000). A group before and after treatment difference than that of B group, the difference was not significant (P=0.626); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.000, P=0.000).
(2)CRP:comparison of treatment after3months, after treatment, A, B, C group of patients with CRP have improved and improved, and before treatment in comparison, there are significant difference (t=4.477, P=0.000; t=5.101, P=0.000; t=7.879, P=0.000); three groups before and after treatment with CRP difference difference between the (F=3.474, P=0.034), A group before and after treatment difference than that of B group, the difference was not significant (P=0.852); C group before and after treatment is superior to that of A, difference between B group, there was significant difference (P=0.019, P=0.031).
3.5.4Cure rate comparison:C group was significantly better than A and B, there was significant difference (χ2=11.706,P=0.003)
3.5.5Adverse reactions compared:adverse reactions in group A、C was lower than that in the B group, comparison between groups, there were significant differences (χ2=14.867,P=0.001)
4.Conclusion
Experimental study and clinical observation results show that:
4.1Jiangu granule can reduce osteoarthritis of knee joint fluid in rat serum, TNF-α, MMP-3content, its body cytokines have a regulatory role, through inhibition of synovial inflammation, reduce cell active factor out, thereby relieving various cytokines on articular cartilage matrix damage, improvement of cartilage matrix metabolism, promote cartilage repair;
4.2Jiangu Granule in the treatment of osteoarthritis of the knee is safe and effective;
4.3Jiangu granule combined with diacerein treatment knee OA, clinical curative effect was better than that of Jiangu granule or single use of diacerein, can rapid control of clinical symptoms, and can relieve pain, improve articular cartilage metabolism, inhibition of cytokines, delaying disease progress, not only has good curative effect and lasting, and good safety.
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