Acupuncture Continuing Education

Acupuncture Knee Arthritis Treatments Found Effective

ST36 ST37

Guangzhou University of Traditional Chinese Medicine researchers find two different styles of acupuncture effective for the alleviation of knee osteoarthritis. Patients in the clinical trial had significant reductions in pain, stiffness, and joint immobility. The two styles tested were conventional acupuncture and four seas acupuncture. Results were very similar when comparing both groups. Four seas acupuncture produced a 96.7% total effective rate. Conventional acupuncture produced a 93.3% total effective rate. [1] 

Four seas acupuncture outperformed conventional acupuncture in one specific area. According to the participants’ self-rated scores, improvements and overall satisfaction were greatest in the four seas acupuncture group. Otherwise, the reductions in pain, stiffness, and joint mobility were similar across both acupuncture styles.

The results are intriguing given that the four seas style of acupuncture did not utilize standard local acupuncture points for the treatment of knee osteoarthritis (i.e., Xiyan, Xixia, Heding). The conventional acupuncture group received acupuncture needling at Xiyan, which is comprised of two acupoints: Neixiyan (MNLE16), Dubi (ST35). Neither group received needling at Xixia and Heding.

The four seas style of acupuncture focuses on promoting the free flow of qi and blood. In Traditional Chinese Medicine (TCM), the four seas are the sea of water and grain, sea of qi, sea of blood, and the sea of marrow. The four seas flow into the twelve main acupuncture channels and have a powerful effect on their related systems. When the four seas are functioning well, the human body is healthy. If they fall into dysfunction, disease occurs. Four seas acupuncture works on the basis set acupoint combinations to directly influence each one of the four seas, thus restoring a state of health.

The study’s inclusion criteria focus on patients with chronic, deficient knee osteoarthritis conditions. This, in part, explains the success of the four seas approach, given its focus on nourishing and sustaining the general health of the body. All participants admitted to the study had a type of knee osteoarthritis in the liver and kidney deficiency syndrome category. Diagnostic criteria for this syndrome include knee pain, aching of the lower back and knees, tenderness, swelling and reduced mobility of the affected joint, difficulty walking, and muscle atrophy. This was confirmed by tongue and pulse diagnosis, showing a tongue with red sides and a thin or thin-white coating, and a wiry, thin pulse.

All participants received a biomedical diagnosis of knee osteoarthritis, according to American College of Rheumatology guidelines. Diagnostic criteria included the following: frequent knee pain in the previous few months, bone proliferation at the edges of the knee joint, synovial fluid analysis showing typical markers for knee osteoarthritis, morning knee stiffness, knee crepitus upon movement, age 40 years or greater.

A total of 60 participants were randomly assigned to receive four seas acupuncture and moxibustion or conventional acupuncture and moxibustion. The four seas group consisted of 14 male and 16 female participants with a mean age of 54 years. The conventional acupuncture group consisted of 12 male and 18 female participants with a mean age of 52 years. The mean duration of disease for the two groups was 5.52 years and 5.74 years respectively. Exclusion criteria the following: serious cardiovascular, liver, or kidney disease, organ failure, malignant tumors, mental disorders, connective tissue disorders, bleeding disorders.


Four Seas
In this group, acupuncture treatment was administered according to the four seas theory. The points selected for the study were:

  • Dazhu (BL11)
  • Zusanli (ST36)
  • Shangjuxu (ST37)
  • Xiajuxu (ST39)

Patients were placed in a seated position and the selected points were disinfected following standard procedure. Dazhu was needled using a 25mm filiform needle, inserted obliquely towards the spine to a depth of 0.8 cun. The remaining points were needled using 40mm filiform needles inserted to a depth of 1.2 cun. After obtaining deqi, the needles were retained for 20 minutes. After the needles were removed, moxibustion was administered using a moxa cigar suspended over each point until a sensation of heat was felt by the patient. Treatment was administered once daily, with five consecutive days of treatment making up one course. A total of four courses of treatment were administered.


Conventional Acupuncture
In this group, the following points were selected according to TCM theory:

  • Neixiyan (MNLE16)
  • Dubi (ST35)
  • Xuehai (SP10)
  • Liangqiu (ST34)
  • Taichong (LV3)
  • Taixi (KD3)

Patients were treated in a seated position with their knees slightly bent. Following standard disinfection, 40mm filiform needles were inserted at Neixiyan and Dubi to a depth of 1–1.2 cun, taking care not to penetrate the joint capsule. This combination of points is also referred to as Xiyan. Xuehai and Liangqiu were needled to a depth of approximately 1.2 cun using 40mm needles. Taichong and Taixi were needled to a depth of 0.5–0.8 cun using 25mm needles. After obtaining deqi, needles were retained for 20 minutes, followed by suspended moxibustion as detailed above. Treatment was administered daily, with five consecutive days of treatment making up one course. A total of four courses of treatment were administered.

At the Healthcare Medicine Institute, many licensed acupuncturists have noted that patients are unable to comply with daily visits given issues with access to care, insurance coverage, and availability. Recommended are modified protocols to increase treatment intensity (e.g. electroacupuncture, added manual techniques) to facilitate patient recovery. To learn more, visit the acupuncture continuing education course: Acupuncture For Knee Pain >


The primary methods of assessment were the McGill pain Questionnaire (MPQ), Index of Severity for Osteoarthritis of the Knee (Lequesne MG), Lysholm Knee Scoring Scale (LKSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Japanese Orthopaedic Association Score for Osteoarthritic Knees (JOA). In addition, the participants self-assessed their improvement in symptom reporting and overall satisfaction with the treatment provided.

Both groups experienced significantly reduced MPQ and LKSS scores following treatment, with no significant difference between the two groups. Reductions were also seen in both groups’ Lequesne MG scores; notably, reductions in the four seas acupuncture group were significantly greater. WOMAC scores fell in both groups in the areas of pain, stiffness, and mobility, with total scores in the four seas acupuncture group being significantly lower. JOA scores improved for both groups; improvement was greater in the four seas group.


The two aforementioned types of acupuncture are safe and effective for the treatment of knee osteoarthritis. To learn more, contact your local licensed acupuncturist and inquire about knee treatments.


Chen Yin-yao (2018) “Therapeutic observations of Four Seas Theory-based Acupuncture-moxibustion for Knee Osteoarthritis of Liver-kidney Deficiency Type” Shanghai Journal of Acupuncture and Moxibustion, vol. 37 (7), pp. 804-808.


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