theeffectofelectroacupunctureondynamicbalanceduringstair...

Research ArticleTheEffect ofElectroacupunctureonDynamicBalanceduringStairClimbing for Elderly Patients with Knee Osteoarthritis

Meijin Hou 12 Xiangbin Wang23 Jiao Yu4 Shengxing Fu23 Fengjiao Yang23

Zhenhui Li23 Yanxin Zhang 235 and Jing Tao 23

1National Joint Engineering Research Centre of Rehabilitation Medicine TechnologyFujian University of Traditional Chinese Medicine Fuzhou Fujian 350122 China2Key Laboratory of Orthopaedics amp Traumatology of Traditional Chinese Medicine and Rehabilitation (FujianUniversity of TCM) Ministry of Education Fuzhou Fujian 350122 China3College of Rehabilitation Medicine Fujian University of Traditional Chinese Medicine Fuzhou Fujian 350122 China4Department of Rehabilitation Medicine e First Affiliated Hospital of Fujian Medical University Longyan China5Department of Exercise Sciences Faculty of Science e University of Auckland Auckland New Zealand

Correspondence should be addressed to Yanxin Zhang yanxinzhangaucklandacnz and Jing Tao taojing01fjtcmeducn

Received 3 September 2019 Revised 2 June 2020 Accepted 24 July 2020 Published 13 August 2020

Academic Editor Adolfo Andrade-Cetto

Copyright copy 2020 Meijin Hou et al 0is is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background Poor balance is one of the risk factors for falls in patients with knee osteoarthritis (KOA) which is related to thesymptoms Electroacupuncture (EA) is one of the traditional Chinese conservative methods commonly used to improve thesymptoms in patients with KOA Objective To assess whether EA increases the dynamic balance during stair negotiationamong patients with KOA Methods A total of 40 KOA patients were assigned to two groups randomly (true electro-acupuncture vs mock electroacupuncture) Acupoints around the knee were selected in the true electroacupuncture (TEA)group with electrical stimulation (2Hz) In the mock electroacupuncture (MEA) group about 2 cm next to the aboveacupoints the needles were inserted superficially without electrical stimulation All the participants received 11 sessions ofstimulation treatment in three weeks 0e primary outcome was margin of stability (MOS) Secondary outcomes included hipkinematics and kinetics as well as pain Results 0ere was no significant difference between the two groups for self-reportedpain (p 0585) During ascent there was no difference between groups in MOS value in both directions which was theanterior-posterior (AP) direction and medial-lateral (ML) direction at initial contact and toe-off as well as the midstance inthe gait cycle and no difference for the hip kinematics and kinetics between the groups was detected (pgt 005) For descent atthe toe-off event the TEA group was more unstable as compared to the MEA group in the AP direction (p 0029) but not inthe ML direction and the hip showed a larger internal rotator moment (p 0049) at the midstance the TEA group showed alower abductor moment than the MEA group (p 0003) Conclusions Based on the assessment results from the chosenpatients with KOA the TEA did not demonstrate a significant effect in improving the dynamic balance during stair negotiationin comparison with the MEA0is finding does not support EA as a conservative treatment to improve the dynamic balance insuch patients

1 Introduction

Among people age 45 years or older the overall prevalenceof symptomatic knee osteoarthritis (KOA) was 81 [1]Elderly people suffered a high risk of falls [2] and the fall-related injuries contributed to a huge economic burden [3]Elderly patients with KOA were 54 more likely to

experience a fall than those without KOA in the past year [4]So the economic burden of elderly KOA patients may behigher than those of their peers

A recent systematic review shows poor balance is one ofthe risk factors for falls in KOA patients [5] which is relatedto symptoms such as pain muscle weakness and limitationto range of joint motion [6] Balance refers to the stability to

HindawiEvidence-Based Complementary and Alternative MedicineVolume 2020 Article ID 3563584 8 pageshttpsdoiorg10115520203563584

maintain the centre of mass (COM) over the base of support(BOS) [6] and it can be divided into static and dynamicbalance 0e clinical standing balance tests such as the StepTest Single Leg Stance Test or laboratory-based measure-ments of standing balance such as the centre of pressure(COP) velocity and Biodex score show that KOA patientsperformed worse with regard to standing balance thanhealthy controls [7 8] For dynamic balance it refers to theability to maintain the COM on the BOS by considering thebody position and velocity while doing some dynamic tasks[9] and KOA patients also performed impairments such aslower Community Balance and Mobility Scale scores ascompared to the healthy controls [10] Conservative treat-ment such as transcutaneous electrical nerve stimulation(TENS) simultaneously combined with local heat [11] andelectrical stimulation combined with continuous passivemotion [12] can relieve pain and potentially improve thedynamic balance in KOA patients during gait Acupuncturecan improve the symptoms and functional activities of KOApatients [13] and alter the gait control strategy toward anormal pattern to meet the demand of supporting the body[14]

But most studies focused on the gait and paid less at-tention to the effect of the conservative treatment on thedynamic balance during stair negotiation Stair climbing is acommon activity of daily life 0e fall risk of stair walking ishigher than that of flat walking especially in stair descent[15] A previous study used the extrapolated centre of mass(XCOM) method to evaluate the dynamic balance whenKOA patients descended stairs and disclosed that olderindividuals showed reduced dynamic balance control ascompared with young individuals [16] 0erefore the aim ofthis study was to determine the efficacy of acupuncturecombined with electrical stimulation (true electro-acupuncture TEA) and mock electroacupuncture (MEA)for dynamic balance in patients with KOAWe hypothesizedthat TEA would be better thanMEA to improve the dynamicbalance in KOA patients during stair climbing especially indescent

2 Methods

0e study is a randomized controlled clinical trial (ChiCTR-IIR-16010284) whereby the ethical approval was obtainedfrom the Affiliated Rehabilitation Hospital of Fujian Uni-versity of Traditional Chinese Medicine Institutional ReviewBoard (No 2016KY-007-01) and each participant signed aninformed consent form voluntarily

21 Participants Forty patients (7 males) aged from 48 to 79with a diagnosis of bilateral symptomatic KOA in accor-dance with the random number table were assigned into anexperimental group (TEA group) and a control group (MEAgroup)

All participants met the following inclusion criteria (1)had been diagnosed by a physician with bilateral symp-tomatic KOA according to the clinical and radiographiccriteria proposed by the American College of Rheumatology

[17] (2) had both knees with grade 2 or 3 according to thestandards of the KellgrenLawrence grade [18] by radio-graphic examination and(3) maintained the ability to walkand climb stairs without assistance

Participants were excluded if they met any of the fol-lowing exclusion criteria (1) had asymptomatic KOA pa-tients or other neuromusculoskeletal diseases that may affectgait andor cognitive function such as lower extremityinjury rheumatoid arthritis neuropathic arthropathystroke or fracture (2) accepted intra-articular injectionsuch as a corticosteroid in the previous two months (3)accepted a total knee replacement or planned to have thesurgery in the following year and (4) underwent any bio-medical treatment such as medication exercise programmeor physical therapy traditional Chinese Medicine therapyand other rehabilitative therapy in the last week

22 Treatment Every participant of the experimental groupaccepted a 30-minute TEA treatment while the control groupreceived MEA treatment According to a previous study [19]and the clinical experience of the members of the researchgroup seven acupoints around the knees namely Neixiyan(EX-LE 4) Dubi (ST 35) Yanglingquan (GB 34) Yinlingquan(SP 9) Xuehai (SP 10) Liangqiu (ST 34) and Zusanli (ST 36)(Figure 1) were selected and acupunctured with a 15-inchsingle needle (030times 40mmWuxi JiajianMedical InstrumentsCo LTD China) through the skin to a depth of 15 inch by anexperienced acupuncturist 0en the needles were connectedto electric needling equipment (G6805 Shanghai MedicalInstruments Co LTD China) of which the 2Hz continuoussquare pulse at a maximal current intensity of patient tolerancewas chosen Each channel of G6805 has two electrodes and weused two channels One of the electrodes of the first channelwas connected to the needle that was inserted into theNeixiyan while the other one was connected to YinlingquanFor the second channel the electrodes were connected withYanglingquan and Liangqiu respectively During the 30-minute TEA stimulation all the patients reported ldquode qirdquosensations which is a feeling of heaviness numbness ordistention at the area of acupoints [20] In the MEA stimu-lation the same needle as the experimental group was piercedinto the skin at nearly 05 cm in depth at points that were 2 cmnext to the acupoints and away from the meridian by anotherexperienced acupuncturist And the electric needling equip-ment was also connected to the needles with no power Duringthe 30-minute MEA stimulation none of the patients had ldquodeqirdquo sensations

Both groups were treated for 3 weeks which consisted ofthe first week of treatment once a day continuous treatmentof 5 days and then followed by 2-day rest 0e treatment ofthe second week and the third week were once every otherday three times a week Finally every patient underwent atotal of 11 sessions of treatment

23Assessment Before and after treatment each participantwas assessed for their knee pain using a 5-point Likert-typeWestern Ontario and McMaster Universities OsteoarthritisIndex (WOMAC) where 0 means no pain 4 means worst

2 Evidence-Based Complementary and Alternative Medicine

imaginable pain and total score is 20 After the self-reportedpain evaluation all participants were asked to do the stairnegotiation test using a three-dimensional gait analysissystem (Motion Analysis Santa Rosa CA USA) with asampling rate of 100Hz Passive reflective markers with adiameter of 10mm were placed on the skin according to thecalibrated anatomical systems technique (CAST) protocol[21] anterior superior iliac spine posterior superior iliacspine great trochanter medial and lateral femoral epi-condyle medial and lateral malleolus aspect of the Achillestendon insertion on the calcaneus dorsal margin of the firstmetatarsal head dorsal aspect of the second metatarsal headand dorsal margin of the fifth metatarsal head Two forceplates (AMTI BP400600 Advanced Mechanical TechnologyInc Watertown MA USA) were used to collect groundreaction force data with a sampling rate of 1000Hz 0eAMTI custom stairs [22] were fixed to the two force platemeasure forces on each stair using a standard approach [23]After familiarization with the test process each participantperformed a stand static trial and then five valid trials ofstairs ambulation at a self-selected pace in the step-by-stepmanner without using the handrails When participants felttired they had a brief rest between trials

24 Data Analysis Local segment coordinate systems weredefined for the pelvis thigh shank and foot segments basedon markersrsquo position using Visual 3D Version 6 (C-MotionInc Germantown MA USA) Joint kinematics were cal-culated using an x-y-z Cardan angle rotation sequence Jointkinetics were calculated using inverse dynamics and thejoint moments were normalized to body mass (Nmkg)Centre of mass (COM) was calculated using a standardprocedure as described by David Winter [24] which waslocated in the pelvis

Based on the data of COM displacement the XCOMvalues were calculated as follows [25]

XCOM COMposition +VCOM

gl1113968 (1)

where COMposition refers the position of the COM in theanterior-posterior (AP) and medial-lateral (ML) direction

which was relative to the global coordinate system (GCS) ofthe LAB VCOM was estimated by the AP and ML velocityof the COM g is the gravity (98mmiddotsminus2) and l was thedistance between the COP and the COM

0e margin of stability (MOS) value was calculated asfollows

MOS BOS minus XCOM (2)

As the position of the COM within the BOS whilepostural stability is sustained a decrease in the MOS in-dicates that the XCOM exceeds the BOS and stability istherefore disturbed In other words larger values indicategreater stability and negative values represent instability Inour study we calculated the MOS in the sagittal plane(MOSAP) and the frontal plane (MOSML) using MATLAB2016a (MathWorks Inc Natick MA USA)

25 Statistical Analysis For all the outcome parametersnamely pain scores gait velocity and step width and hip jointangles and moments as well as the MOS in two directionswere extracted to do the statistical analysis using the SPSSstatistical package Version 20 (SPSS Inc Chicago IL USA)and all significant levels were set at plt 0050e normality ofall outcome parameters was initially tested 0e analysis ofcovariance totally has greater statistical power to detect atreatment effect than the other methods [26] So we choosethe analysis of covariance (ANCOVA) to assess the differ-ences between these two different treatment effects on KOApatients Each outcome parameters used its own pretreat-ment data as the covariance

3 Results

36 (6 males) patients finished the research Four subjects didnot finish the study due to a car accident (n 1) scheduling(n 1) measurement rejection (n 1) and removal becauseof wrong treatment (n 1) After the drop out of 4 subjectsfrom the study each group had 18 individuals (Figure 2)

0ere was no significant difference between the groupsfor age (6111plusmn 862 years for the TEA group vs 6594plusmn 600years for theMEA group p 006) BMI (2289plusmn 247 kgm2

vs 2461plusmn 263 kgm2 p 0051) duration of KOA(10342plusmn 11325 months for the TEA group vs 9667plusmn14879 months for the MEA group p 075) and the male-female ratio (414 vs 216 p 037) For both study andcontrol groups the pain recorded from posttreatment wassignificantly improved in comparison with pretreatmentHowever no statistically significant differences have beenidentified (Tables 1 and 2)

31 Ascent 0e mean MOS value in both AP and MLdirections during ascent for each group is shown in Table 1and there was no between-group difference at initial contact(IC) and toe-off as well as the midstance (MS) in the gait cycleduring ascent After treatment there was no significant dif-ference between the groups for the velocity (052plusmn 006msvs 051plusmn 007ms p 0269) and step width (008plusmn003m vs 008plusmn 003m p 0434) Furthermore no

Xuehai

Zusanli

Dubi

Liangqiu

Yanglingquan

Neixiyan

Yinlingquan

Figure 1 0e location of acupoints

Evidence-Based Complementary and Alternative Medicine 3

Table 1 0e pain score and the temporal-distance kinematic and kinetic variables of the hip during ascent

Event VariablesTEA group (Meanplusmn SD) MEA group (Meanplusmn SD) Comparisons

between groupsBefore After Before After F value P

Pain 517plusmn 368 250plusmn 220 583plusmn 436 305plusmn 260 0304 0585Velocity (ms) 049plusmn 009 052plusmn 006 052plusmn 009 051plusmn 007 1267 0269Step width (m) 009plusmn 003 008plusmn 003 008plusmn 002 008plusmn 003 0626 0434

Hip angle (degree deg)

ICFlex (+)Ext (minus) 5472plusmn 1895 5171plusmn 1149 5982plusmn 1256 5617plusmn 1306 0530 0472Add (+)Abd (minus) 739plusmn 479 652plusmn 409 697plusmn 517 634plusmn 419 0000 0989Int (+)Ext (minus) minus536plusmn 869 minus251plusmn 740 minus689plusmn 804 minus204plusmn 658 0198 0659

MSFlex (+)Ext (minus) 2705plusmn 1034 2716plusmn 1415 2954plusmn 970 2692plusmn 868 0256 0616Add (+)Abd (minus) 579plusmn 390 382plusmn 362 392plusmn 455 330plusmn 458 0569 045677Int (+)Ext (minus) minus511plusmn 948 minus341plusmn 846 minus594plusmn 719 minus221plusmn 631 0631 0433

TOFlex (+)Ext (minus) 2050plusmn 570 1692plusmn 737 1900plusmn 746 2033plusmn 626 2789 0104Add (+)Abd (minus) minus189plusmn 483 minus484plusmn 309 minus251plusmn 450 minus365plusmn 318 2441 0128Int (+)Ext (minus) minus636plusmn 814 minus561plusmn 713 minus719plusmn 678 minus422plusmn 683 0688 0413

Hip moment (Nmkg)

ICFlex (+)Ext (minus) minus00495plusmn 01346 minus00939plusmn 01235 minus00226plusmn 01360 minus00572plusmn 01124 0519 0477Add (+)Abd (minus) 00328plusmn 00354 00236plusmn 00398 00421plusmn 00320 00317plusmn 00400 0194 0663Int (+)Ext (minus) 00314plusmn 00363 00346plusmn 00375 00444plusmn 00351 00388plusmn 00463 0015 0903

MSFlex (+)Ext (minus) minus03513plusmn 02381 minus02101plusmn 02567 minus01914plusmn 01919 minus01924plusmn 02025 2076 0159Add (+)Abd (minus) minus05913plusmn 02111 minus05727plusmn 02023 minus05267plusmn 02006 minus06107plusmn 01357 0712 0405Int (+)Ext (minus) minus02504plusmn 01071 minus02265plusmn 01137 minus02219plusmn 00890 minus02482plusmn 00701 0643 0429

TOFlex (+)Ext (minus) minus00139plusmn 01001 minus00093plusmn 00659 00603plusmn 00756 001471plusmn 00608 0117 0734Add (+)Abd (minus) 00163plusmn 01713 00742plusmn 00402 00617plusmn 00562 00823plusmn 00504 0232 0633Int (+)Ext (minus) minus00060plusmn 00763 00115plusmn 00256 00237plusmn 00221 00261plusmn 00199 2084 0159

Margin of stability (m)

IC AP direction 00926plusmn 01251 01041plusmn 01085 00851plusmn 01234 01123plusmn 01073 0089 0768ML direction minus00282plusmn 01115 minus00546plusmn 01020 minus00301plusmn 01085 minus00625plusmn 00914 0057 0813

TO AP direction minus01665plusmn 00387 minus01769plusmn 00344 minus01677plusmn 00288 minus01797plusmn 00360 0050 0825ML direction minus01344plusmn 00281 minus01390plusmn 00290 minus01334plusmn 00291 minus01380plusmn 00317 0004 0947

MS AP direction minus00080plusmn 00190 minus00049plusmn 00077 minus00044plusmn 00219 minus00021plusmn 00119 0610 0440ML direction minus00641plusmn 00538 minus00462plusmn 00606 minus00658plusmn 00620 minus00522plusmn 00613 0077 0783

MIN AP direction minus01642plusmn 00396 minus01741plusmn 00363 minus01637plusmn 00343 minus01767plusmn 00394 0093 0762ML direction minus01368plusmn 00272 minus01412plusmn 00268 minus01354plusmn 00281 minus01396plusmn 00316 0012 0914

(i) Withdrawal (n = 1)(ii) Removed (n = 1)

Completed study (n = 18)

Randomized (n = 40)

Allocated to TEA group (n = 20)

(i) Withdrawal (n = 1)(ii) Measurement rejection (n = 1)

Assessed for eligibility ( n = 82)

Excluded (n = 42)(i) Not meeting eligibility

criteria (n = 29)(ii) Refused to participate

withdrew consent (n = 13)

Allocated to MEA group (n = 20)


Analyzed for efficacy (n = 18) Analyzed for efficacy (n = 18)

Figure 2 Flow chart of study procedure


difference for the hip kinematics and kinetics between thegroups was detected (pgt 005) (Table 1)

32 Descent After treatment the velocity of stair descentshowed no significant difference between the two groups(053plusmn 005ms vs 053plusmn 008ms p 0273) with the TEAgroup walking faster than before 0e same situation wasshown in the step width (011plusmn 003m vs 012plusmn 004mp 0549) Table 2 also shows the details of the MOS valuein both directions and the hip variables At the initialcontact the MOS as well as the hip kinematics and kineticsdid not significantly differ between the TEA group andMEAgroup (pgt 005) At the toe-off the TEA group was moreunstable than the MEA group in the AP direction duringstair descent (minus02451plusmn 00264m vs minus02107plusmn 00544mp 0029) but did not differ in the ML direction and thehip showed a larger internal rotator moment in TEA groupafter treatment comparing with the MEA group (00403plusmn00423Nmkg vs 00079plusmn 00267Nmkg p 0049) At themidstance the TEA group showed a lower abductor mo-ment than the MEA group (minus06554plusmn 01338Nmkg vsminus07744plusmn 00956Nmkg p 0003)

4 Discussion

0e purpose of our study was to investigate the efficacy ofTEA for dynamic balance during stair walking in patientswith KOA We found that the effect of TEA was limited fordynamic balance in KOA patients during descent stairwalking and no more efficacious than MEA during ascentstair walking

For KOA patients poor balance is related to pain andmuscle weakness [6] A network meta-analysis showed thatacupuncture with electrical stimulation or heat pain couldrelieve symptoms in most KOA patients and may be betterthan other acupuncture methods [27] 0e main effect of EAon KOA was to ease the pain and remarkably improvephysical function [28] However there was no significantdifference in pain scores between the TEA group and MEAgroup in our study and it did not agree with those reviewsand two studies with similar interventions [29 30] Onepossible reason for the discrepancy is the MEA setting inacupuncture trials which is still controversial because thenonpenetrating and superficial acupuncture needle tech-niques are not totally inert 0us MEA may have placeboeffects [31] Furthermore acupuncture has a convergence

Table 2 0e temporal-distance kinematic and kinetic variables of the hip during descent



Velocity (ms) 049plusmn 009 053plusmn 005 053plusmn 010 053plusmn 008 1240 0273Step width (m) 012plusmn 003 011plusmn 003 013plusmn 004 012plusmn 004 0366 0549


ICFlex (+)Ext (minus) 2563plusmn 1154 2068plusmn 864 2709plusmn 710 2472plusmn 572 2627 0115Add (+)Abd (minus) minus323plusmn 626 minus482plusmn 486 minus450plusmn 521 minus377plusmn 505 2327 0258Int (+)Ext (minus) minus895plusmn 932 minus916plusmn 714 minus1053plusmn 656 minus672plusmn 668 2491 0124


TOFlex (+)Ext (minus) 3296plusmn 1156 3140plusmn 1226 3812plusmn 842 3691plusmn 800 0750 0393Add (+)Abd (minus) 174plusmn 516 036plusmn 417 221plusmn 446 102plusmn 502 0095 0760Int (+)Ext (minus) minus328plusmn 722 minus215plusmn 781 minus321plusmn 788 062plusmn 678 1658 0207

Hip moment (Nmkg)

ICFlex (+)Ext (minus) 00546plusmn 00855 00722plusmn 00945 00716plusmn 00910 00909plusmn 00750 0047 0829Add (+)Abd (minus) 00043plusmn 00420 00142plusmn 00375 00069plusmn 00509 00112plusmn 00487 0062 0805Int (+)Ext (minus) 00085plusmn 00182 00142plusmn 00270 00060plusmn 00301 00090plusmn 00224 0320 0575


TOFlex (+)Ext (minus) 01324plusmn 01367 01473plusmn 00962 02055plusmn 00726 02041plusmn 00796 2309 0138Add (+)Abd (minus) 00007plusmn 00962 00184plusmn 00882 00164plusmn 00869 00162plusmn 00614 0111 0742Int (+)Ext (minus) 00246plusmn 00433 00403plusmn 00423 00020plusmn 00358 00079plusmn 00267 4192 0049


IC AP direction minus00769plusmn 01579 minus00728plusmn 01604 minus00654plusmn 01498 minus01088plusmn 01419 1009 0323ML direction minus00188plusmn 01889 minus00483plusmn 02012 minus00728plusmn 02172 minus00255plusmn 02118 0687 0413





effect which means that its effect may be weakened with theprolongation of intervention time and the effect will bedifferent if the acupoints are selected differently Plaster et al[32] studied patients with KOA and indicated that bothelectroacupuncture and manual acupuncture cannot in-crease muscle strength It may be the reason why TEAcannot improve the dynamic balance of patients with KOA0e main strategy used to control the gait balance is the hipstrategy as the hips play a significant role in stabilizing theCOM both in the AP and ML directions [33] Meta-analysis revealed that KOA patients may adopt kinematicand kinetic alterations during stair climbing such as in-creasing hiptrunk flexion angle [34] Early-stage KOApatients with knee pain may decrease their hip abductormuscle strength when negotiating stairs [35] 0e resultsshowed that there were little remarkable differences in hipangle and moments between the two groups Exerciseprogrammes that focused on lower limb muscle strengthtraining were beneficial for patients with KOA to improvedynamic balance using a modified Star Excursion BalanceTest [36] 0erefore the combination of electroacupunctureand hip muscle strength training may be more effective forKOA patients to improve their dynamic balance

Most studies [7 8 10] assess dynamic balance by usingscales or balance tests and fewer studies focused on dynamicbalance when individuals do some daily activities such as stairclimbing 0e demands for dynamic balance control duringnegotiation of stairs are higher than level walking A previousstudy used the XCOMmethod to evaluate the dynamic balancefor descent stair walking [16] 0e dynamic stability indexshows that speed is an important factor for dynamic stabilityassessment [37] Slower walking velocities increase the stability[38] Gait speed shows a strong correlative relationship withCOM velocity [39] 0e results of this study showed that thespeed of the TEA group during ascent and descent increasedafter treatment Although the difference between TEA andMEA was not statistically significant the possible influence ofspeed on dynamic stability should still be considered Due tothe speed increase after treatment the XCOMshould be greaterand the MOS should be less 0is is in agreement with ourascent stair walking results Even though the speed increasedafter treatment there was no significant difference in the MOSvalues But for descent stair walking the MOS in the APdirection at the toe-off event after treatment was more unstablethan before its treatment 0is may be related to the greaterbalance control needs in descent as compared with ascent [40]

0is study had several limitations One of the limitationswas that all participants accepted the fixed TEA or MEAtreatment Subject-specified acupuncture treatment mightbe more effective for patients with KOA Treatmentaccording to syndrome differentiation plays an importantpart in traditional Chinese medicine Acupuncture acu-points need to be selected according to the syndrome dif-ferentiation However it was prohibited in our study 0esecond limitation was that we did not assess other balance-related factors such as muscle strength

0e third limitation was related to the use of MEA Mostof the Chinese people are familiar with acupuncture andunderstand the feeling of acupuncture so it is difficult to do

MEA 0e position of acupoints and ldquode qirdquo sensations arethe key points for acupuncturersquos effect We need to deviatefrom the position of acupoints as much as possible andreduce the subjectsrsquo sensations to the greatest extent Nev-ertheless the multiple factors in the MEA group (depth andposition of acupuncture and the electrical stimulation in-tensity) may have some treatment effect In future researchthese factors need to be better controlled for theMEA group

5 Conclusion

Based on the assessment results from the chosen patientswith KOA the TEA did not demonstrate a significant effectin improving the dynamic balance during stair negotiationin comparison with the MEA 0is finding does not supportelectroacupuncture as a conservative treatment to improvethe dynamic balance in such patients

Data Availability

0e data that support the findings of this study are availableon request from the first author Meijin Hou

Conflicts of Interest

0e authors declare no conflicts of interest

Authorsrsquo Contributions

XBW and JT conceived and designed the study MJH per-formed the experiments analysed the data and results andwrote the paper JY assisted in recruiting participants andcollecting motion data SXF FJY and ZHL assisted with dataextraction YXZ developed the MATLAB code and reviewedthe paper All authors read and approved the finalmanuscript

Acknowledgments

0e authors would like to express appreciation to Anmin Liuand Yunru Ma for reviewing this paper 0is research wasfunded by the National Natural Science Foundation of China(Grant no 81273819) Science and Technology PlatformConstruction Project of the Fujian Science and TechnologyDepartment (Grant no 2015Y2001) and the Fujian KeyLaboratory of Rehabilitation Technology

References

[1] X Tang S Wang S Zhan et al ldquo0e prevalence of symp-tomatic knee osteoarthritis in China results from the ChinaHealth and Retirement Longitudinal Studyrdquo Arthritis ampRheumatology vol 68 no 3 pp 648ndash653 2016

[2] S G Qi Z H Wang L M Wang and M Zhang ldquoCurrentstatus of falls and related injuries among Chinese elderly in2013rdquo Zhonghua Liu Xing Bing Xue Za Zhi vol 39 no 4pp 439ndash442 2018

[3] K Peng M Tian M Andersen et al ldquoIncidence risk factorsand economic burden of fall-related injuries in older Chinesepeople a systematic reviewrdquo Injury Prevention vol 25 no 1pp 4ndash12 2019


[4] T O Smith E Higson M Pearson and M Mansfield ldquoIsthere an increased risk of falls and fractures in people withearly diagnosed hip and knee osteoarthritis Data from theosteoarthritis initiativerdquo International Journal of RheumaticDiseases vol 21 no 6 pp 1193ndash1201 2016

[5] D G Manlapaz G Sole P Jayakaran and C M ChappleldquoRisk factors for falls in adults with knee osteoarthritis asystematic reviewrdquo PMampR vol 11 no 7 pp 745ndash757 2019

[6] K Bennell R S Hinman T V Wrigley M W Creaby andP Hodges ldquoExercise and osteoarthritis cause and effectsrdquoComprehensive Physiology vol 1 no 4 pp 1943ndash2008 2011

[7] G L Hatfield M Adam M Wenman C A Hammond andM A Hung ldquoClinical tests of standing balance in the kneeosteoarthritis population systematic review and meta-anal-ysisrdquo Physical erapy vol 96 no 3 pp 324ndash337 2015

[8] T Lawson A Morrison S Blaxland M WenmanC G Schmidt and M A Hunt ldquoLaboratory-based mea-surement of standing balance in individuals with knee os-teoarthritis a systematic reviewrdquo Clinical Biomechanicsvol 30 no 4 pp 330ndash342 2015

[9] Y-C Pai and J Patton ldquoCenter of mass velocity-positionpredictions for balance controlrdquo Journal of Biomechanicsvol 30 no 4 pp 347ndash354 1997

[10] J Takacs S J Garland M G Carpenter and M A HuntldquoValidity and reliability of the community balance and mo-bility scale in individuals with knee osteoarthritisrdquo Physicalerapy vol 94 no 6 pp 866ndash874 2014

[11] T Maeda H Yoshida T Sasaki and A Oda ldquoDoes trans-cutaneous electrical nerve stimulation (TENS) simultaneouslycombined with local heat and cold applications enhance painrelief compared with TENS alone in patients with knee os-teoarthritisrdquo Journal of Physical erapy Science vol 29no 10 pp 1860ndash1864 2017

[12] F Tok K Aydemir F Peker I Safaz M A Taskaynatan andA Ozgul ldquo0e effects of electrical stimulation combined withcontinuous passive motion versus isometric exercise onsymptoms functional capacity quality of life and balance inknee osteoarthritis randomized clinical trialrdquo RheumatologyInternational vol 31 no 2 pp 177ndash181 2011

[13] X Lin K Huang G Zhu Z Huang A Qin and S Fan ldquo0eeffects of acupuncture on chronic knee pain due to osteo-arthritisrdquo e Journal of Bone and Joint Surgery vol 98no 18 pp 1578ndash1585 2016

[14] Y-H Liu I-P Wei T-M Wang T-W Lu and J-G LinldquoImmediate effects of acupuncture treatment on intra- andinter-limb contributions to body support during gait in pa-tients with bilateral medial knee osteoarthritisrdquoe AmericanJournal of Chinese Medicine vol 45 no 1 pp 23ndash35 2017

[15] K Wang K Delbaere M A D Brodie et al ldquoDifferencesbetween gait on stairs and flat surfaces in relation to fall riskand future fallsrdquo IEEE Journal of Biomedical and HealthInformatics vol 21 no 6 pp 1479ndash1486 2017

[16] Y Koyama H Tateuchi R Nishimura et al ldquoRelationshipsbetween performance and kinematickinetic variables of stairdescent in patients with medial knee osteoarthritis an eval-uation of dynamic stability using an extrapolated center ofmassrdquo Clinical Biomechanics vol 30 no 10 pp 1066ndash10702015

[17] R Altman E Asch D Bloch et al ldquoDevelopment of criteriafor the classification and reporting of osteoarthritis classifi-cation of osteoarthritis of the kneerdquo Arthritis amp Rheumatismvol 29 no 8 pp 1039ndash1049 1986

[18] J H Kellgren and J S Lawrence ldquoRadiological assessment ofosteo-arthrosisrdquo Annals of the Rheumatic Diseases vol 16no 4 pp 494ndash502 1957

[19] T W Lu I P Wei Y H Liu et al ldquoImmediate effects ofacupuncture on gait patterns in patients with knee osteoar-thritisrdquo Chinese Medical Journal vol 123 no 2 pp 165ndash1722010

[20] PWhite P Prescott and G Lewith ldquoDoes needling sensation(de qi) affect treatment outcome in pain Analysis of datafrom a larger single-blind randomised controlled trialrdquoAcupuncture in Medicine vol 28 no 3 pp 120ndash125 2010

[21] A Cappozzo F Catani U Della Croce and A LeardinildquoPosition and orientation in space of bones duringmovementanatomical frame definition and determinationrdquo ClinicalBiomechanics vol 10 no 4 pp 171ndash178 1995

[22] U D Croce and P Bonato ldquoA novel design for an instru-mented stairwayrdquo Journal of Biomechanics vol 40 no 3pp 702ndash704 2007

[23] A Z Alshawabka A Liu S F Tyson and R K Jones ldquo0euse of a lateral wedge insole to reduce knee loading whenascending and descending stairs in medial knee osteoarthritispatientsrdquo Clinical Biomechanics vol 29 no 6 pp 650ndash6562014

[24] D A Winter Biomechanics and Motor Control of HumanMovement University of Waterloo Press Waterloo CanadaFourth edition 1987

[25] A L Hof M G J Gazendam W E Gazendam andW E Sinke ldquo0e condition for dynamic stabilityrdquo Journal ofBiomechanics vol 38 no 1 pp 1ndash8 2005

[26] A J Vickers and D G Altman ldquoStatistics notes analysingcontrolled trials with baseline and follow up measurementsrdquoBMJ vol 323 no 7321 pp 1123-1124 2001

[27] S Li P Xie Z Liang et al ldquoEfficacy comparison of fivedifferent acupuncture methods on pain stiffness and func-tion in osteoarthritis of the knee a network meta-analysisrdquoEvidence-Based Complementary and Alternative Medicinevol 2018 Article ID 1638904 19 pages 2018

[28] N Chen J Wang A Mucelli X Zhang and C WangldquoElectro-acupuncture is beneficial for knee osteoarthritis theevidence frommeta-analysis of randomized controlled trialsrdquoe American Journal of Chinese Medicine vol 45 no 5pp 965ndash985 2017

[29] S Ahsin S Saleem A M Bhatti R K Iles and M AslamldquoClinical and endocrinological changes after electro-acu-puncture treatment in patients with osteoarthritis of thekneerdquo Pain vol 147 no 1 pp 60ndash66 2009


[31] X-K Wu E Stener-Victorin H-Y Kuang et al ldquoEffect ofacupuncture and clomiphene in Chinese women with poly-cystic ovary syndromerdquo JAMA vol 317 no 24 pp 2502ndash2514 2017

[32] R Plaster W B Vieira F A D Alencar E Y Nakano andR E Liebano ldquoImmediate effects of electroacupuncture andmanual acupuncture on pain mobility and muscle strength inpatients with knee osteoarthritis a randomised controlledtrialrdquo Acupuncture in Medicine vol 32 no 3 pp 236ndash2412014

[33] D Winter ldquoHuman balance and posture control duringstanding and walkingrdquo Gait amp Posture vol 3 no 4pp 193ndash214 1995


[34] H Iijima K Shimoura T Aoyama and M TakahashildquoBiomechanical characteristics of stair ambulation in patientswith knee OA a systematic review with meta-analysis towarda better definition of clinical hallmarksrdquo Gait amp Posturevol 62 pp 191ndash201 2018

[35] Y Suzuki H Iijima K Shimoura T Tsuboyama andT Aoyama ldquoPatients with early-stage knee osteoarthritis andknee pain have decreased hip abductor muscle strength whiledescending stairsrdquo Clinical Rheumatology vol 38 no 8pp 2249ndash2254 2019

[36] L Al-Khlaifat L C Herrington S F Tyson A Hammondand R K Jones ldquo0e effectiveness of an exercise programmeon dynamic balance in patients with medial knee osteoar-thritis a pilot studyrdquo e Knee vol 23 no 5 pp 849ndash8562016

[37] T Caderby E Yiou N Peyrot M Begon and G DalleauldquoInfluence of gait speed on the control of mediolateral dy-namic stability during gait initiationrdquo Journal of Biome-chanics vol 47 no 2 pp 417ndash423 2014

[38] S A England and K P Granata ldquo0e influence of gait speedon local dynamic stability of walkingrdquo Gait amp Posture vol 25no 2 pp 172ndash178 2007

[39] A Lee T Bhatt R Smith-Ray E Wang and Yi-C Pai ldquoGaitspeed and dynamic stability decline accelerates only in lateliferdquo Journal of Geriatric Physical erapy vol 42 no 2pp 73ndash80 2018

[40] B J McFadyen and D A Winter ldquoAn integrated biome-chanical analysis of normal stair ascent and descentrdquo Journalof Biomechanics vol 21 no 9 pp 733ndash744 1988


maintain the centre of mass (COM) over the base of support(BOS) [6] and it can be divided into static and dynamicbalance 0e clinical standing balance tests such as the StepTest Single Leg Stance Test or laboratory-based measure-ments of standing balance such as the centre of pressure(COP) velocity and Biodex score show that KOA patientsperformed worse with regard to standing balance thanhealthy controls [7 8] For dynamic balance it refers to theability to maintain the COM on the BOS by considering thebody position and velocity while doing some dynamic tasks[9] and KOA patients also performed impairments such aslower Community Balance and Mobility Scale scores ascompared to the healthy controls [10] Conservative treat-ment such as transcutaneous electrical nerve stimulation(TENS) simultaneously combined with local heat [11] andelectrical stimulation combined with continuous passivemotion [12] can relieve pain and potentially improve thedynamic balance in KOA patients during gait Acupuncturecan improve the symptoms and functional activities of KOApatients [13] and alter the gait control strategy toward anormal pattern to meet the demand of supporting the body[14]

But most studies focused on the gait and paid less at-tention to the effect of the conservative treatment on thedynamic balance during stair negotiation Stair climbing is acommon activity of daily life 0e fall risk of stair walking ishigher than that of flat walking especially in stair descent[15] A previous study used the extrapolated centre of mass(XCOM) method to evaluate the dynamic balance whenKOA patients descended stairs and disclosed that olderindividuals showed reduced dynamic balance control ascompared with young individuals [16] 0erefore the aim ofthis study was to determine the efficacy of acupuncturecombined with electrical stimulation (true electro-acupuncture TEA) and mock electroacupuncture (MEA)for dynamic balance in patients with KOAWe hypothesizedthat TEA would be better thanMEA to improve the dynamicbalance in KOA patients during stair climbing especially indescent

2 Methods

0e study is a randomized controlled clinical trial (ChiCTR-IIR-16010284) whereby the ethical approval was obtainedfrom the Affiliated Rehabilitation Hospital of Fujian Uni-versity of Traditional Chinese Medicine Institutional ReviewBoard (No 2016KY-007-01) and each participant signed aninformed consent form voluntarily

21 Participants Forty patients (7 males) aged from 48 to 79with a diagnosis of bilateral symptomatic KOA in accor-dance with the random number table were assigned into anexperimental group (TEA group) and a control group (MEAgroup)

All participants met the following inclusion criteria (1)had been diagnosed by a physician with bilateral symp-tomatic KOA according to the clinical and radiographiccriteria proposed by the American College of Rheumatology

[17] (2) had both knees with grade 2 or 3 according to thestandards of the KellgrenLawrence grade [18] by radio-graphic examination and(3) maintained the ability to walkand climb stairs without assistance

Participants were excluded if they met any of the fol-lowing exclusion criteria (1) had asymptomatic KOA pa-tients or other neuromusculoskeletal diseases that may affectgait andor cognitive function such as lower extremityinjury rheumatoid arthritis neuropathic arthropathystroke or fracture (2) accepted intra-articular injectionsuch as a corticosteroid in the previous two months (3)accepted a total knee replacement or planned to have thesurgery in the following year and (4) underwent any bio-medical treatment such as medication exercise programmeor physical therapy traditional Chinese Medicine therapyand other rehabilitative therapy in the last week

22 Treatment Every participant of the experimental groupaccepted a 30-minute TEA treatment while the control groupreceived MEA treatment According to a previous study [19]and the clinical experience of the members of the researchgroup seven acupoints around the knees namely Neixiyan(EX-LE 4) Dubi (ST 35) Yanglingquan (GB 34) Yinlingquan(SP 9) Xuehai (SP 10) Liangqiu (ST 34) and Zusanli (ST 36)(Figure 1) were selected and acupunctured with a 15-inchsingle needle (030times 40mmWuxi JiajianMedical InstrumentsCo LTD China) through the skin to a depth of 15 inch by anexperienced acupuncturist 0en the needles were connectedto electric needling equipment (G6805 Shanghai MedicalInstruments Co LTD China) of which the 2Hz continuoussquare pulse at a maximal current intensity of patient tolerancewas chosen Each channel of G6805 has two electrodes and weused two channels One of the electrodes of the first channelwas connected to the needle that was inserted into theNeixiyan while the other one was connected to YinlingquanFor the second channel the electrodes were connected withYanglingquan and Liangqiu respectively During the 30-minute TEA stimulation all the patients reported ldquode qirdquosensations which is a feeling of heaviness numbness ordistention at the area of acupoints [20] In the MEA stimu-lation the same needle as the experimental group was piercedinto the skin at nearly 05 cm in depth at points that were 2 cmnext to the acupoints and away from the meridian by anotherexperienced acupuncturist And the electric needling equip-ment was also connected to the needles with no power Duringthe 30-minute MEA stimulation none of the patients had ldquodeqirdquo sensations

Both groups were treated for 3 weeks which consisted ofthe first week of treatment once a day continuous treatmentof 5 days and then followed by 2-day rest 0e treatment ofthe second week and the third week were once every otherday three times a week Finally every patient underwent atotal of 11 sessions of treatment

23Assessment Before and after treatment each participantwas assessed for their knee pain using a 5-point Likert-typeWestern Ontario and McMaster Universities OsteoarthritisIndex (WOMAC) where 0 means no pain 4 means worst






gl1113968 (1)







3 Results





Xuehai

Zusanli

Dubi

Liangqiu

Yanglingquan

Neixiyan

Yinlingquan











Hip moment (Nmkg)











Randomized (n = 40)














4 Discussion











Hip moment (Nmkg)















5 Conclusion


Data Availability






Acknowledgments


References
















































gl1113968 (1)







3 Results





Xuehai

Zusanli

Dubi

Liangqiu

Yanglingquan

Neixiyan

Yinlingquan











Hip moment (Nmkg)











Randomized (n = 40)














4 Discussion











Hip moment (Nmkg)















5 Conclusion


Data Availability






Acknowledgments


References




















































Hip moment (Nmkg)











Randomized (n = 40)














4 Discussion











Hip moment (Nmkg)















5 Conclusion


Data Availability






Acknowledgments


References














































4 Discussion











Hip moment (Nmkg)















5 Conclusion


Data Availability






Acknowledgments


References

















































5 Conclusion


Data Availability






Acknowledgments


References












































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