Traditional Chinese medicine nursing protocols for knee osteoarthritis

ABSTRACT: Knee osteoarthritis (KOA), a complicated peripheral joint disorder, can be caused by non-modifiable and modifiable risk factors. At present, the treatment for osteoarthritis is mainly to manage symptoms and improve quality of life. Although some patients with osteoarthritis may choose pharmacological agents for pain relief, it has been confirmed that a variety of preparations and doses of pharmacological agents were ineffective. In recent years, Traditional Chinese medicine (TCM) has been shown unique superiorities in the treatment of osteoarthritis, including KOA. Therefore, this article primarily investigated the key points of common syndromes, TCM nursing methods and healthy guidance of KOA, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

KEY WORDS: knee osteoarthritis; joint stiffness; Traditional Chinese medicine nursing; syndrome differentiation

Knee osteoarthritis (KOA), a complicated peripheral joint disorder, ranks the eleventh worldwide regarding the years lived with disability[1-2]. It was estimated that the overall prevalence of KOA was 29.4% in 2009, higher than 12.3% of hip osteoarthritis, and the prevalence was the highest in people aged ≥65 years[3]. KOA can be caused by nonmodifiable (genetics, age and gender) and modifiable (body mass index, previous injury and physical activity) risk factors. Epidemiological studies suggest that up to 40% of KOA is caused by genetic factors[4], and meanwhile obesity and previous keen injury are both found to be significantly associated with an increased risk of developing KOA[5].

At present, the treatment for osteoarthritis is mainly to manage symptoms and improve quality of life. The patient education, exercise and weight loss are recommended as the first line of treatment[6-7]. Some patients with osteoarthritis may choose pharmacological agents for pain relief, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen. However, a variety of preparations and doses of pharmacological agents have been confirmed to be ineffective for osteoarthritis[8]. In recent years, Traditional Chinese medicine (TCM) has been shown unique superiorities in the treatment of osteoarthritis, including KOA. Wang et al. found that TCM fumigation combined with articular injection of sodium hyaluronate could effectively improve the function of knee joints and relieve pain in patients with KOA[9]. In addition, TCM fumigation with eliminating dampness and dispelling cold decoction could alleviate the symptoms and improve the knee activity of KOA patients with syndrome of cold-dampness due to kidney deficiency, without adverse reactions[10]. In view of this, State Administration of Traditional Chinese Medicine of the People’s Republic of China formulated a TCM nursing protocol for KOA, aiming at maintaining and developing the strengths of TCM, improving its efficacy and standardizing its behavior.

Keypointsofcommonsyndromes

Syndromeofwind-cold-dampnessarthralgia: limb joints with soreness and fixed pain like lancination or heavy sensation or swelling sensation in the diseased part, inflexible joints at movements, aversion to wind and cold, alleviated by heat; light-colored tongue with thin greasy coating.

Syndromeofwind-dampness-heatarthralgia: sudden onset, inflamed, scorching and painful diseased joints, even untouchable, alleviated by cold; accompanied by whole-body fever, or skin erythema and calluses; red tongue with yellow coating.

Syndromeofstaticbloodocclusion: fixed stabbing pain in limb joints with local stiffness or numbness; dark purple tongue with white and dry coating.

Syndromeofliverandkidneydeficiency: dull pain in the knee, soreness and weakness in the waist and knee, aggravated by fatigue; red tongue with thin coating.

Nursingforcommonsymptoms/syndromes

Kneepain

·Assess the pain inducements, nature, part, duration and concomitant symptoms, and make the pain score. In order to record the specific score, the numerical rating scale (NRS), a sort of self-assessment tool for pain, can be adopted.

·Take a physiotherapy according the doctor’s advice.

·Take auricular-plaster therapy following the doctor’s advice, and select the points like Shenmen, sympathia, subcortex, knee and so on.

·According to the doctor’s advice, perform TCM fumigation, TCM iontophoresis, moxibustion (Ashi, Yinlingquan, inner and outer knee eyes, etc.) and cupping (Yinlingquan, Zusanli and Jiexi, etc.).

Swellingoftheknee

·Assess the swelling degree, inducing factors, as well as the skin temperature, color and completeness; measure the calf circumferences of the upper and lower patella.

·Apply local ice compress for the swelling patients due to wind-dampness-heat arthralgia, pay attention to avoiding congelation and observe the therapeutic effect.

·According to the doctor’s advice, take a physiotherapy and perform TCM fumigation, TCM Tazi and external dressing of TCM.

Kneestiffness

·Assess the occurrence time of stiffness, limited range of joint motion and activity of daily living.

·According to the doctor’s advice, take a hot medicinal compress therapy, conduct acupoint massage (Ashi, Yanglingquan, inner and outer knee eyes, Yinlingquan, Zusanli, Jiexi, etc.) and TCM fumigation.

TCMspecialnursing

Medications

InternalapplicationofChineseherbs

·Medication time: Each dose of herbs can be taken generally in twice or three times. The specific medication time depends on the property and function of herbs as well as the patients' pathological condition. Chinese herbs for relieving exterior and clearing heat should be taken 1 h before meals, in which application of exterior-reliving Chinese herbs should avoid wind chill, or putting on more clothes or having some porridge induces diaphoresis. Chinese herbs for promoting digestion, purgation, expelling parasites, tranquilization and tonification are taken respectively after meals, before meals, on an empty stomach in the morning, before sleep and on an empty stomach. Emergency drug use follows the doctor's advice.

·Medication temperature: The administered warm is usually adopted. For the patients with special treatment, the herbs should be taken according to the doctor's advice.

·Medication dose: 200 mL is taken per time for the adult; 100 mL is taken per time for the patients with heart failure and those of controlling the dose. The elderly and children should take herbs according to the doctor's advice.

Injection

·Inquire the history of allergy carefully before medication.

·Make allocation and administration according to the requirements and injection speed recommended in the drug instructions.

·Apply TCM injection alone, and use it right after it was ready.

·Chinese and western drugs should be separated when Chinese and western injections are in combination.

·It is inappropriate to use a venous channel for two or more kinds of drugs except for special instructions.

·Medication reactions are observed closely, especially for the elderly, children, people with liver and kidney dysfunction and those that use TCM injections initially. Medication is suspended, and the doctors should be told to deal with it if adverse reactions occur.

·Nursing for allergic reactions: stop to use the drugs immediately, change the infusion channel and inform the doctor; seal the liquid and channels that cause adverse reactions; do allergic identification and inform patients and their relatives firmly to avoid re-medication; guide the patients to have a bland diet during the treatment of allergic reactions, forbid to eat the food like fish, shrimps, etc.

ExternalapplicationofChineseherbs

·Keep dry and clean skin before medication, and do local debridement if necessary.

·Observe reactions closely after medication. For example, the doctor should be informed immediately if local symptoms like scorching heat, redness, pruritus and stabbing pain appear. The medication should be stopped immediately if the symptoms, such as dizziness, nausea, palpitation and shortness of breath, appear, and meanwhile, corresponding measures should be taken and the doctor should be informed.

·Use with caution for patients with allergic constitution.

Specialtechniques

TCMfumigation

·Perform TCM fumigation following the doctor’s advice.

·Nursing assessment: the condition of skin in the part of fumigation. It is used with caution to the patients with drug and skin allergy, heart, lung and brain disease, enema as well as the weak and elderly patients. It is unsuitable for pregnancy women and those during menstruation to take a sitz bath or fumigate the vulva.

·Before operation, tell the patients the process and notes of TCM fumigation, and communicate with the medical staff immediately if discomforts occur.

·Keep a warm operation environment, and close the door and window.

·Expose the fumigated part, and pay attention to keep warm and protect the privacy.

·Keep 50-70℃ of the liquid temperature. Sitz bath and wash can be conducted to prevent empyrosis when the liquid temperature is decreased to 37-40 ℃.

·Keep 20-30 min of TCM fumigation.

·Inquire the patients’ feelings, and regulate the liquid temperature timely.

·Tell the patients to have a rest for 30 min after TCM fumigation, and then go out in order to prevent invasion of exogenous pathogens.

·Observe the local and systemic condition of patients during operation, and immediately inform the doctor and deal with it if discomforts occur.

·Record the temperature and time of TCM fumigation as well as the skin condition and feelings of patients after operation is finished.

TCMTazi

·Perform TCM Tazi according to the doctor’s advice.

·Nursing assessment: skin sensory perception. Appropriate temperature is suitable for the patients insensitive to sensory perception. It is used with caution for the patients allergic to TCM or infants. It is forbidden to use for the patients with skin vesicles, scar and rupture in the treatment part and those with active bleeding or tendency of bleeding.

·Expose the treatment part thoroughly, and be cautious to keep warm and protect privacy.

·Select the appropriate wad based on the treatment part, make the drug liquid soak and keep a proper humidity (no dripping).

·Keep a proper temperature of drug liquid (skin tolerance) to prevent the skin from empyrosis, and soak after reheating if the drug liquid is cold. For Reta and Yanfu, the temperature should be controlled in 45-60 ℃.

·Be cautious to make an inspection tour and observation, stop treatment and inform the doctor immediately to take measures when the erythema, pruritus, redness or vesicles appear in the local skin.

·Record the condition of skin in the treatment part and patients’ feeling after operation.

ExternaldressingofTCM

·According to the doctor’s advice, perform external dressing of TCM.

·Nursing assessment: assess the condition of skin in the external dressing part and patients’ sensory perception to the temperature; forbid to use it for the patients with drug and skin allergy and infants.

·Tell the patients the process and notes of external dressing of TCM before operation; inform the doctor to take corresponding measures immediately if discomforts occur.

·Keep the operation environment warm.

·Expose the part of medication thoroughly, and pay attention to keeping warm and protecting privacy.

·According to the doctor’s advice, confirm the part of medication and the medication area larger than the diseased area.

·Smear TCM evenly; keep some humidity and appropriate dressing of external fixation.

·Observe the local and systemic condition, immediately inform the doctor, and then take some measures following the doctor’s advice if some adverse reactions like erythema, pruritus and blister appear.

·Record the condition of skin in the external dressing part and patients’ feelings after operation.

Hotmedicinalcompress

·Apply hot medicinal compress following the doctor’s advice.

·According to the doctor’s advice, prepare the required herbs, then put them into a cloth bag, and make it into a TCM bag of hot compress at 60-70 ℃.

·Nursing assessment: assess the condition of skin in the part of hot medicinal compress, tolerance to the heat, previous history and history of drug allergy. It is forbidden in the abdomen for female patients during menstruation or pregnancy.

·Tell the patients to urinate thoroughly before hot medicinal compress.

·Take a suitable position.

·Keep the temperature of the herbal bag constant during hot medicinal compress, and immediately change another one or reheat after cooling. The temperature should be tolerated by the patients, usually not more than 70℃. However, for the elderly, infants and those with sensory disturbance, the temperature should be no more than 50℃ to avoid scalding.

·Observe the patients’ reactions and skin condition, and immediately inform the doctor to take measures when the symptoms like erythema, pruritus, vesicles appear in the local skin.

·Record the temperature, part and time of hot medicinal compress and the patients’ feelings after the operation is finished.

TCMiontophoresis

·Conduct TCM iontophoresis following the doctor's advice.

·Nursing assessment: the skin in the part of iontophoresis; it should be used with caution for pregnant women, infants and those with drug and skin allergy.

·Inform the patients of iontophoresis process and announcements before operation, and tell the doctor to deal with it if the discomfort appears.

·Keep the operating environment warm, expose the treatment part, pay attention to keeping warm and protecting the privacy.

·Select the prescription following the doctor’s advice, regulate the current intensity, and inquire the patients’ feelings during treatment. The current intensity should be regulated on time if discomforts occur.

·Observe the local and systemic condition, and inform the doctor to manage immediately if the allergy occurs, such as erythema, pruritus and vesicles.

·Record the iontophoresis skin condition and patients’ feelings after all the operations are finished.

Auricular-plastertherapy

·Embed beans at auricular points and select acupoints correctly according to the doctor's advice.

·Assess the condition of ear skin and degree of tolerance to the pain, prohibit to use them in the inflammatory, ruptured and frozen skin as well as in pregnant women.

·Keep the intensity of probe moderate and accurately seek the sensitive point in acpoint area.

·Scrub the ears with 75% alcohol.

·Observe the patients' condition, stop immediately and inform the doctor to deal with it if discomforts occur.

·Select one ear for routine performance, keep the beans usually for 3-7 days and use them in two ears alternately; guide the patients to press them correctly.

·Observe the fixed degree of auricular point sticking and the condition of symptoms and ear skin (redness, swelling, rupture, etc.).

·Record the bean-embedded location and time at auricular points as well as the patients' feelings after performance.

Moxibustion

·Perform moxibustion following the doctor’s advice and select the proper ways of moxibustion, such as moxibustion with moxa cone, moxibustion with moxa stick, moxibustion with moxa box, tec.

·Nursing assessment: the condition of skin in the area of moxibustion and acceptance level of patients to the moxibustion smell. It is unsuitable for moxibustion in the face, in the part of larger vessels as well as in the abdominal and lumbosacral portion of pregnant women.

·Regulate the room temperature timely, and maintain good indoor ventilation.

·Select a reasonable position to fully expose the part of moxibustion, and be cautious to keep warm and protect privacy.

·Do moxibustion from top to bottom, namely the top of the head and chest-back first, and then the abdomen and four limbs.

·During moxibustion, inquire the patients whether they feel a burning sensation, regulate the distance and flip the moxa ash into the kidney basin to avoid burning the skin.

·Pay attention to the moxibustion time. For instance, moxibustion is done for the patients with insomnia before sleep instead of moxibustion immediately before meals or after meals.

·After moxibustion, local reddish scorching skin is normal. The moxibustion-induced small vesicles can be absorbed by themselves, but for the large ones, the doctor should be informed immediately and corresponding measures are taken according to the doctor’s advice.

·Place the moxa cone or moxa stick in the flame-out bottle to extinguish the moxibustion fire immediately after moxibustion.

·Small-dose and short-time moxibustion is applied to the initially-used patients, and the dose is increased gradually when the patients are tolerant.

·After moxibustion, record the way, part and skin of moxibustion as well as the patient’s feelings.

Cupping

(1) Cupping jars with appropriate size are selected based on different parts. The cupping jars with bigger caliber are suitable for the lower back and hip, those with proper caliber for the flat part in the limbs and those with small caliber for joints. Consequently, the cupping jars with small or appropriate caliber should be selected for KOA.

(2) Others.

·Nursing assessment: observe the condition of skin in the cupping part and the patients’ tolerance to the pain. Cupping therapy is unsuitable in the parts including skin ulcer, edema, much hair, large blood vessels, and in the lumbosacral part of pregnancy women. It is also unsuitable for the patients with convulsion due to high fever and disturbances of blood coagulation.

·Take a reasonable position to make cupping part exposed completely, and pay attention to keep warm and protect the privacy.

·Check whether there is a break at the edge of jars, and whether it is glossy. Select proper cupping jars according to different parts.

·Observe the adhesion condition and skin color during cupping. Inquiry the patients’ feelings, and take off the jars immediately to avoid empyrosis if discomforts appear.

·Do cupping accurately, rapidly and steadily, and don’t pull the jars when taking off them.

·Keep a comfortable distance for the arrangement of many jars to avoid the pain induced by jar traction.

·Generally, the local flushed or cyanosis (blood stasis) skin is normal after the jars are taken off, and it will disappear spontaneously. It is unsuitable to do cupping in the previous site if local blood stasis is severe. It is unnecessary to deal with local vesicles, but if the vesicles are bigger, the liquid in them should be extracted using the injector after the local skin is sterilized, and the sterilized dressing is covered.

·Record the cupping part, time and patients’ feelings after all the operations are finished.

Acupointmassage

·Conduct acupoint massage according to the doctor's advice.

·Assess the skin condition around the massage area and degree of tolerance to the pain; prohibit using it in women during menstruation and pregnancy.

·For the operator, trim the fingernails to prevent the skin from injury.

·Keep the strength even and moderate, and pay attention to keep warm for the patients and protect their privacy.

·Observe the patients' reactions closely when operation is done; stop the massage and take corresponding measures once discomforts occur.

·Record the massage acupoints, techniques and time as well as the patients' feelings.

TCMnursingintheperioperativeperiod

(1) Insomnia: Take auricular-plaster therapy, and select the points like Shenmen, subcortex, heart, etc.

(2) Pain: Pain assessment; Take auricular-plaster therapy, and select the points like Shenmen, sympathia, subcortex, knee, etc.

(3) Dysuria: Assist the patients to take a suitable position; take a hot compress therapy for the lower abdomen; according to the doctor’s advice, perform acupoint massage (Qihai, Guanyuan, Yinlingquan, Sanyinjiao, etc.), auricular-plaster therapy (brain, kidney, urinary bladder, sympathia, Shenmen, subcortex, etc.), hot medicinal compress (Qihai, Guanyun, Yinlingquan, etc.), moxibustion (Qihai, Guanyuan, Zhongji, etc.) and acupoint application (Shenque, etc.).

Healthyguidance

Dailylife

·Avoid the invasion of pathogenic factors wind, cold and dampness into the body, and pay attention to keeping warm locally.

·Enhance the protection for knees, and wearing the kneecap for keeping warm.

·Elevate the diseased limb with a soft pillow, and avoid climbing mountains.

·Control the body weight appropriately and increase the outdoor activities for prevention osteoporosis.

·Go to a doctor if the infection occurs at any site.

Dietaryguidance

·Syndrome of wind-cold-dampness arthralgia: It is advisable to eat the food that can expel wind, remove dampness, warm meridians and dredge collaterals, such as ginger, garlic and spicy noodles. This kind of food should be taken warmly. The raw, cold in nature and greasy food, including persimmon, crab, clam’s meat and kelp, should be forbidden.

·Syndrome of wind-dampness-heat arthralgia: It is advisable to eat the food that can clear heat and remove dampness, such as coix seed and white gourd. The raw, cold, spicy, greasy and dry food, including onion, litchi, dog meat and mutton, should be forbidden. Dietary formula: Coix seed & white gourd soup.

·Syndrome of static blood occlusion: It is advisable to eat the food that can activate blood, dredge collaterals, warm meridians and invigorate yang, such as hawthorn, agaric, black bean, walnut and black chicken soup. The spicy, dry and greasy food like the fat and barbecue should be forbidden.

·Syndrome of liver and kidney deficiency: It is advisable to eat the food that can tonify qi and blood, nourish liver and kidney, such as Chinese yam and wolfberry. The seafood and greasy food, including fish, shrimp and egg, should be forbidden.

Emotionaladjustment

·Patiently tell the treatment and rehabilitation processes to the patients and introduce successful cases to make them cooperate positively.

·Carry out the collective health education or patients’ exchanging meeting, and create more communicating chances for patients to enhance their confidence in treatment.

·Guide the patients to take the activities that can distract attention, such as reading newspaper, listening to music and chatting. A suggestive therapy should be used to relive negative emotions for patients with anxiety and depression.

·Fight for the family support, and encourage the relatives to accompany the patients frequently.

Rehabilitationguidance

(1) Early functional training

·Muscular training. Quadriceps femoris training: tighten the thigh muscle and try to unbend knee joints for 5-10 seconds; straight leg raise: tighten and unbend knee joints in bed, and slightly uplift to make them get out of the bed for 5-10 seconds.

·Joint training. Bending and extending exercises of knee joints without any loads; Dorsal stretch and plantar flexion of ankle joints.

·The patients can walk and swim properly.

(2) Advanced functional training

The postoperative functional training should be performed according to the doctor's advice.

·Take a horizontal position and uplift the diseased limb on day of operation.

·Six hours after operation, guide the patients to conduct the dorsal stretch and plantar flexion of ankle joints under no condition of fatigue.

·Following the doctor's advice, assist the patients to use the lower limb continuous passive motion (CPM) machine to take the bending and extending exercises of knee joints after total knee arthroplasty.