pissn 2287-3368 / eissn 2287-3376 REVIEW ARTICLE Korean Journal of Acupuncture Vol.35, No.4, pp.159-165, 2018 https://doi.org/10.14406/acu.2018.028 박장미 1 ㆍ이재성 1 ㆍ이은용 1 ㆍ노정두 2 ㆍ조나영 2 ㆍ이참결 1 1 세명대학교충주한방병원침구과, 2 세명대학교제천한병병원침구과 A Systematic Review on Thread Embedding Therapy of Knee Osteoarthritis Jang Mi Park 1, Jae Sung Lee 1, Eun Yong Lee 1, Jeong Du Roh 2, Na Young Jo 2, Cham Kyul Lee 1 1 Department of Acupuncture & Moxibustion Medicine, Semyung University Chungju Hospital of Korean Medicine, 2 Department of Acupuncture & Moxibustion Medicine, Semyung University Jecheon Hospital of Korean Medicine Objectives : This study was performed to review the efficacy of national and international randomized controlled trials (RCTs) investigating evidence on thread embedding therapy for knee osteoarthritis. Methods : Online databases (PubMed, EMBASE, Cochrane, NDSL, OASIS, CNKI) were searched for studies where thread embedding therapy was performed for Knee Osteoarthritis from their inception to July 2018. Two researchers independently performed the search. Only RCTs were selected. Eligible studies were selected first by the abstract and the title and then included after full-texts were read. Risk of bias of the included studies were evaluated using the Cochrane risk of bias assessment tool. Data were narratively summarized. Results : There were 334 studies retrieved from the databases, resulting in analysis of 3 RCTs. There was an average of 1.5 treatment visits over a 7 day period and evaluation tool used was efficacy rate, with traditional acupuncture being the most common control used in the trials. Statistically significant improvement by thread embedding therapy was reported. None of the included RCTs reported on adverse reactions. The risk of bias of the included studies was generally unclear. Conclusion : The review suggests that thread embedding therapy can be effective in knee osteoarthritis. But there was a lack of detailed information about the treatment procedures, and the risk of bias was unclear. Therefore, there is insufficient evidence for thread embedding therapy for knee osteoarthritis Key words : knee osteoarthritis, thread embedding, randomized controlled trials, systematic review 서론 골관절염 (Osteoarthritis) 은관절주위의연골세포및뼈의증식을특징으로하는관절질환이며원발성과속발성으로나눌수있다. 원발성골관절염은원인불명의골관절염을의미하며속발성골관절염은외상, 신진대사, 내분비장애, 과사용과관련이있다. 골관절염의주요임상증상은동통, 종창, 관절변형, 강직, 기능장애등이다 1). 이환율은나이에따라유병률이증가하며인구고령화추세에따라임상에서매우흔한질병이다. 남성보다여성에서유병률이높으며위험요소로는비만, 외상, 수술력, 직업등이있다. 골관절염의자연경과는매우다양하여일부에서는호전을보이고다른 Received November 2, 2018, Revised November 22, 2018, Accepted November 23, 2018 Corresponding author: Cham Kyul Lee Department of Acupuncture & Moxibustion Medicine, Semyung University Chungju Hospital of Korean Medicine, 63 Sangbang 4-gil, Cheogju 27429, Korea Tel: +82-43-841-1738, Fax: +82-43-856-1731, E-mail: leetaeho0331@hanmail.net This paper was supported by the Semyung University Research Grant of 2018. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2018, SOCIETY FOR MERIDIAN AND ACUPOINT 159
박장미ㆍ이재성ㆍ이은용ㆍ노정두ㆍ조나영ㆍ이참결 일부에서는안정적으로유지되나많은경우, 특히 65세이상의노인의경우에서는연령의증가에따른퇴행성변화로증상악화와함께보행장애를일으키는주원인이된다 2). 국내의한의학관절염연구는주로침, 한약, 봉약침, 뜸을대상으로하였으나 3-5), 매선요법을시험중재로한연구는양적, 질적으로부족하였다 6). 매선요법 (Thread Embedding Therapy) 은혈위나통증유발점같은특정부위에의료용실을피하조직층이나근육층에근육결방향으로혹은근육결과직각으로, 보통아래에서위로자입하는특수침술법으로내장된실은피하조직이나근육에서평균 28일, 피하층에서는최대 6개월의시기동안서서히부드럽게분해되어용해되어, 일반적인침술보다강력하고오래지속되는치료효과를나타낸다 7). 이에저자는실제임상에서동통성질환의치료에다용하고있는매선요법을 8-10) 퇴행성슬관절염에적용했을때그치료효과에대한근거를체계적문헌고찰방법을통해살펴보고자하였다. 또한사용한경혈, 도구, 자침깊이등에따른분석을통해퇴행성슬관절염에대한매선요법의임상연구가나아갈방향을모색하고자하였다. 2. 문헌선정 / 제외기준 1) 선정기준 : 1차적으로매선치료방법에차별을두지않고퇴행성슬관절염을대상질환으로하는무작위대조연구중매선요법을시험중재로설정한문헌으로하였다. 또한, 대조군의치료방법과출판연도에관계없이매선연구가선정되었다. 1차기준에맞는 3편의연구가선정되었으나각연구에서사용한평가지표가모두상이하였기때문에평가지표에대한제한은두지않기로하였다. 2) 제외기준 : 인간대상이아니거나매선요법을시험중재로설정하지않은연구, 증례보고나증례연구나단순고찰연구, 프로토콜보고문헌은제외하였다. 3. 비뚤림위험평가포함기준을만족하는연구를선택하고두명의평가자가독립적으로데이터추출및평가를수행하였다. 불일치가있는경우제 3의평가자에의해재평가되었다. 무작위대조군연구의비뚤림위험평가는 Cochrane risk of bias tool 을이용하여수행하였다. 대상및방법 1. 연구대상문헌검색은각데이터베이스의시작점에서부터 2018년 7월까지이루어졌으며문헌검색에는 PUBMED, EMBASE, Cochrane, NDSL, OASIS, CNKI 의 6개국내외데이터베이스를이용하였다. 검색어로는 osteoarthritis, knee, degenerative arthritis, catgut, thread, needle acupuncture, acupoints, implantation, embed, embedding therapy, maesun, 관절염, 퇴행성관절염, 關節炎, 膝关节骨性关节炎, 退行性关节炎, 骨关节病, 变形性骨关节病, 穴位埋线, 线程注入, 埋针, 埋线 을키워드로하였으며 PUBMED 에서는다음과같은검색식이사용되었다. : (osteoarthritis, knee or (knee and (osteoarthr* or degenerative arthritis or (osteoarthr* and deformans)))) and ((catgut or thread or needle or acupuncture or acupoints) and (implantation or embed*) or embedding therapy or maesun or catgut) 두명의연구자가독립적으로검색을시행하고, 불일치가발생한결과에대해서는 3자의평가에의해최종문헌을결정하였다. 결과 1. 문헌선정결과총 334편의논문이 6개온라인데이터베이스에서검색되었다. 검색된 334개의논문중 PUBMED 는 16개, EMBASE 는 31개, Cochrane은 24개, NDSL은 55개, OASIS 는 197개, CNKI 는 11개였다. 검색된 334 편의논문을초록과제목을통해일차적으로중복되는논문이거나, 퇴행성슬관절염이대상질환이아니거나인간대상이아니거나매선에관한연구가아닌것은제외하였으며, 추후본문고찰을통해매선을중요시험중재로선정하지않거나, 무작위대조연구가아닌문헌은제외하였다. 선정제외기준에따라분류한총 3편의 RCT(Randomized Controlled Trial) 논문을최종선정하였다. 문헌선정의과정은 Fig. 1에요약하였고, 최종단계에서제외된문헌은 Table 1에나열하였다. 2. 자료추출및분석최종선정된문헌은표본크기, 실험군, 대조군, 치료횟수및기간, 평가도구, 결과, 자침혈위, 자침도구, 조작법을세부항목으로자료추출하였다 (Table 2). 1) 발행연도 : 연도별분석에따르면퇴행성슬관절염에서매선요법의치료효과에관한 RCT 연구는비교적최근에이루어져 160 www.kjacupuncture.org
Table 1. Excluded studies Author (year) Lee (2014) Hou (2010) Zhang (2017) Yang (2015) Reason for exclusion Not RCT (case series 5 cases) Combination treatment(arthroscopic debridement of articular cavity combined with Huatan Xiaoyou Juanbi Decoction and catgut implantation) Not RCT (case series 30 cases) Not RCT (literature review) RCT, randomized controlled trial. Fig. 1. Flow diagram of selection process. *OA=Osteoarthritis. 2014년부터 2017년까지지난 4년간 3건의연구가수행되었다. 3 건의연구는모두중국에서시행되었으며국내에서이루어진 RCT 연구는부재하였다. 2) 연구표본크기및치료기간 횟수 : 실험군과대조군의총피험자수를분석한결과 3건의연구중 50명미만은 0건, 50 75명은 1건, 75 100 명은 1건, 100명이상의환자는 1건이었다. 치료기간의경우 1주미만의치료는 0건, 1 3 주의치료는 1건, 4주간의치료는 2건이었으며, 치료횟수의경우 5회미만의치료가 1건, 5회이상 10회미만의치료가 1건, 10회이상의치료가 1건이었다. 3) 평가지표 : 3건의연구모두각각다른평가지표를사용하였다. HSS(Hospital for Special Surgery) score 를사용한연구가 1 건, SF-36(36-Item Short Form Survey) score 를사용한연구가 1건이었으며나머지 1건의연구는 WOMAC(Western Ontario & McMaster Universities) 을평가지표로사용하였다. 4) 매선치료방법 : 매선치료방법의분석은크게 3가지유형으로분류되었다. 각각의유형은세부적으로자침혈위, 도구, 자침깊이, 조작법등의여러항목으로나눌수있었다. 3건의연구에서매선도구는 PLGA(Polylactic-Co-Glycolic Acid) 혹은 PGLA(Gla peptide) 를사용하였으며자침혈위는슬관절주변으로근위취혈을한경우가 2건, 팔회혈을활용한경우가 1건이었다. 근위취혈의경우 1건의연구에서는양릉천 (GB34), 음릉천 (SP9), 족삼리 (ST36), 혈해 (SP10), 양구 (ST34), 위중 (BL40), 학정 (EX-LE2), 치탄혈을사용하였다고제시하였으며, 다른 1건의연구에서는슬관절주위의 4개의혈위를선혈하였으나구체적인혈위명을제시하지는않았다. 팔회혈을사용한 1건의연구에서는 8개혈자리중대저 (BL11), 격수 (BL17), 단중 (CV17), 양릉천 (GB34) 4개의혈위를선혈하였다. 5) 실험군과대조군 : 3개의연구에서모두 1개의대조군이각연구별로설정되었다. 대조군의경우 2건의연구에서일반적인침치료가사용되었으며나머지 1건의연구에서는히알루론산나트륨주사요법을대조군으로사용하였다. 일반침치료를사용한 2건의연구중 Yang 의연구에서는혈해 (SP10), 양구 (ST34), 내슬안 (EX-LE4), 외슬안 (EX-LE5) 에 1.5 2 촌의깊이로 1분의보사후 30분간유침하였고, Wang 의연구에서는양구 (ST34), 혈해 (SP10), 독비 (ST35), 내슬안 (EX-LE4), 곡천 (LR8), 음릉천 (SP9), 양릉천 (GB34), 족삼리 (ST36) 등의혈자리를선혈하여보사법을사용한후 30분간유침하였다. 6) 치료효과 : 3개의선정논문에서각기다른종류의평가지표로매선치료의효과가측정되었으며, 총 260명의대상자에서의치료및실험효과가분석되었다. 실험군과대조군간의치료결과의비교는치료전과후를기준으로하여치료후의효과에대하여평가하였다. 실험군은대조군과비교했을때각평가지표에대해통계적으로유의한개선을보였다. Mai 등의연구에서단순히알루 www.kjacupuncture.org 161
박장미ㆍ이재성ㆍ이은용ㆍ노정두ㆍ조나영ㆍ이참결 Table 2. Key Data of Studies Acupoints Tools Method Result (A>B, C) Evaluation index Treatment N /Period Intervention Control Sample size Study PGLA 2 cm/90 (GB34, SP9, ST36) 1.5 cm/70 (SP10, ST34) 2 mm/90 (Zhi tan xue) 2 mm/45 (EX-LE2) 1 cm/90 (BL40) GB34, SP9, ST36, SP10, ST34, BL40, EX-LE2, Zhi tan xue 5X/1 m 1. HSS score 5 w: p>0.05 3 m: p<0.05 6 m: p<0.01 B: the sodium hyaluronate injection(n=60) 120 A: Thread Embedding Therapy+ the sodium hyaluronate injection(n=60) Mai (2014) PLGA Subcutaneous Thread Embedding 10X/1 m WOMAC 1. p<0.01 Four acupoints around the knee joint B: traditional acupuncture therapy(n=40) 80 A: Thread Embedding Therapy(n=40) WANG (2016) PGLA Line body double-rotation embedding BL11, BL17, CV17, GB34 2X/15 d SF-36 score 1. PF: p<0.05 2. BP: p<0.05 3. GH: p<0.05 B: traditional acupuncture therapy(n=30) 60 A: Thread Embedding Therapy(n=30) YANG (2017) HSS : Hospital for Special Surgery, WOMAC : Western Ontario & McMaster Universities, SF-36 : 36-Item Short Form Survey, PF : Physical Functioning, BP : Bodily Pain, GH : General Health, PGLA : Gla peptide, PLGA : Polylactic-Co-Glycolic Acid, N : Number, M : Months, D: Days. *A : Intervention group, B : Control group. 론산나트륨주사요법으로치료한대조군과매선요법과히알루론산나트륨주사의병행치료를적용한실험군두그룹모두에서퇴행성슬관절염에일정한효과를나타내었다. 즉각적인치료효과에있어서는두그룹간에큰차이를보이지않았으나단기간및장기간치료효과에있어서는실험군과대조군간에유의미한차이가있었다. 치료 5주후실험군에서는 60%, 대조군에서는 53.3% 의우수한치료율 (p<0.05) 을나타내었으며치료 3개월후실험군 70%, 대조군 45% 의치료율 (p<0.05), 치료 6개월후실험군 76.7%, 대조군 35% 의치료율 (p<0.01) 로 HSS score에서우수한치료율을나타내어히알루론산나트륨주사와함께매선치료를병행한것이단기간및장기간의치료효과면에서이점이있음을나타내주었다. Yang 등의연구에서두군의 PF(Physical Functioning) 점수는치료전에는통계적으로유의하지않았다 (p>0.05). 반면두군의 PF 점수는치료후에유의하게증가하여실험군은대조군에비해유의하게높았으며통계적으로유의한차이를보였다 (p<0.05). 또한두군의 BP(Bodily Pain) 점수와 GH(General Health) 점수차이는치료전통계적으로유의하게차이가나지않았으나 (p>0.05) 치료후유의하게감소하여치료군의 BP와 GH 점수는대조군에비해유의하게낮았으며통계적으로유의한차이를보였다 (p<0.05). 두그룹은 6개월동안추적관찰되었으며, 치료그룹에서 3회재발하여 10% 를차지하였고, 14회재발은 46.67% 로그차이는통계적으로유의했다 (p<0.05). Wang 의연구에서는실험군에서 87.5%, 대조군에서 55.5% 의치료율을보여통계적으로유의한차이를보였다 (p<0.05). 또한동통, 관절강직, 생리기능등 WOMAC 지표의개선정도에서도실험군이대조군에비해우수한결과를나타내었다 (p<0.01). 7) 부작용 : 3개의연구에서모두매선요법적용후의부작용에대한보고는없었다. 3. 비뚤림위험평가 Cochrane risk of bias tool 을사용하여 3개연구의비뚤림위험을평가하였다 (Fig. 2). 1) 무작위배정순서생성 : 모든연구에서무작위배정을하였으나 Mai 의연구, Yang 의연구에서는배정순서생성에대한설명이부족하여불명확한위험으로분류되었으며, Wang 의연구에서는등록번호의홀수, 짝수로실험군과대조군을분류하여높은위험이관찰되었다. 2) 배정은폐판정 : 모든연구에서배정은폐에대한언급이없으므로불명확한위험으로분류되었다. 3) 연구참여자, 연구자눈가림 : 매선치료의특징으로인해연구 162 www.kjacupuncture.org
Fig. 2. Risk of RCT bias summary (+), Low risk of bias; ( ), High risk of bias; (?), Unclear of bias; RCT, randomized controlled trials; RCT, randomized controlled trials. 가완전히눈가림되지않았기때문에 3개의연구모두고위험으로분류되었다. 4) 결과평가눈가림 : 모든연구에서결과평과의눈가림에대한언급이없으므로불명확한위험으로분류되었다. 5) 불완전한결과자료 : 모든연구에서결측치가없었기때문에 3개의연구모두낮은위험이관찰되었다. 6) 선택적결과보고 : 프로토콜및사전정의된계획에대한보고가없었기때문에 3건의연구는모두명확하지않은위험으로분류되었다. 고 찰 퇴행성슬관절염에서는대부분의경우보존적치료를먼저시작하며심한동통이지속되거나관절의불안정성, 변형, 운동제한등이진행하면수술적응이된다 11). 현대의학에서현재사용되는보존적치료방법으로는체중감소, 근육강화운동, 진통제, NSAIDs (Nonsteroidal anti-inflammatory drug), 관절내스테로이드주사, 히알루론산나트륨주사등이있다. 하지만 NSAIDs 는위장관장애등의합병증을유발할수있고관절내스테로이드주사요법은전신부작용및스테로이드의반복주사에따른연골의파괴, 감염의위험성이따르게되므로주의하여사용되어져야한다 12). 매선요법은자침및유침을통한물리적자극효과와매선으로생긴조직손상부위의무균성염증반응을통한조직회복의화학적자극효과를가지며이로써장기간유침을필요로하는골관절염과같은제반동통성질환에유용한치료법이다 13). 이에매선요법이현재양방에서보편적으로시행되고있는보존적치료에따르는부작용및한계점을보완 대체할것을기대할수있다. 현재임상에서골관절염과같은동통성질환에매선치료를다용하는추세이나이에대한연구가아직미미한실정으로, 앞으로임상에서의폭넓은적용을위해서는매선치료의유효성과안전성의근거가뒷받침되어야한다고사료된다. 퇴행성슬관절염에대한매선요법의치료효과를평가하기위해 6개의온라인데이터베이스를검색하고미리설정한기준에따라검토, 선별하여 3개의 RCT 논문을선정하였다. 선정된 3개의연구는모두최근 10년내중국에서시행되었으며이는최근에야퇴행성슬관절염에대한매선치료연구가시도되고있음을시사한다. 3개의연구에서매선요법을적용한치료기간및횟수를분석한결과실험군에서는평균적으로 1주일에 1 2 회의매선치료를받았으며, 즉각적인치료효과보다는장기간의치료효과에서좋은결과를나타내었다. 이는퇴행성슬관절염에서주 1 2 회의매선치료가가지는치료지속효과를뒷받침할수있다. 3개의연구는각각다른평가지표를사용하였다. Mai 의연구에서사용된 HSS score 는슬관절치료전후상태를공통적이고객관적으로비교할수있는임상적평가방법으로서, 기본적으로슬관절의상태를각항목에따라정량화하여비교할수있도록하여각항목마다환자의주관적인증상이나객관적인슬관절상태에따라일정한점수간격을두고정도를측정한다 14). 그러나실제로 HSS knee score 로슬관절의상태를측정시각항목마다설정된기준이모호하거나해석하기어렵게되어있어관찰자마다다른점수를나타낼가능성이있다 15). Yang 의연구에서는 SF-36 score 를평가지표로사용하였다. SF-36 은총 36개의문항으로이루어져있으며, 신체적기능, 신체적역할, 통증, 일반적건강, 정신적건강, 정서적역할, 사회적기능, 활력의 8개의범주로구성되어있다 16). Yang 의연구에서는 8가지범주중 PF(Physical Functioning), BP(Bodily Pain), GH(General Health) 세가지항목에서유의한결과를나타내었다. Wang 의연구에서는 WOMAC을평가지표로 www.kjacupuncture.org 163
박장미ㆍ이재성ㆍ이은용ㆍ노정두ㆍ조나영ㆍ이참결 사용하였다. WOMAC 은퇴행성슬관절염환자의동통과기능상태를평가하는종합지표로서, 퇴행성관절염환자의증상의중증도와치료의효과판정에광범위하게사용되고있으며많은연구들을통해서안전성이입증되고있으나 17) 환자가직접설문작성하는자기기입식평가도구로서통증, 강직, 신체적기능으로나뉘는각각의세부문항에서가중치를두지않고세가지항목의점수를합산한총점이대개연구에서활용되며, 아직까지유효성은입증되지않고있다 18). 각평가지표들이갖는의미와장단점을확인하여슬관절질환에대한임상연구에서국제적으로통용될수있는좀더신뢰도와타당도가높은객관적인평가도구가필요할것으로사료된다. 3건의연구에서는각각다른방식의치료방법을사용하였다. 치료도구는공통적으로 PGLA 혹은 PLGA 가사용되었으나자침혈위와깊이, 조작법이모두다르거나치료방법에대한구체적인설명이부족한연구도있어각치료법에대한비교 분류에제한이있었다. 대조군치료에서는 2건의연구에서전통적인일반침치료를사용했다. 이는퇴행성슬관절염에대한매선치료와일반침치료를비교하는것이일반적인치료목적이었다는것을나타낸다. 퇴행성슬관절염에서매선요법의치료효과에대한 3개의 RCT 연구에서실험군과대조군을비교했다. 각평가지수에서실험군은대조군과비교하여통계적으로유의한차이를보였고, 이는매선요법이퇴행성슬관절염에유효한치료법임을나타낸다. 다만, 본연구는퇴행성슬관절염에서의매선요법의치료효과와안전성을평가하기위한연구로서매선을시험중재로설정한인간대상의 RCT 논문을주선정기준으로설정하였으며대조군의치료방법에대한제한을두지않았기때문에 Mai의연구에서사용된 the sodium hyaluronate injection 의경우그치료효과에대한근거가부족하여 19) 시험중재인매선요법과비교했을때매선의치료효과에대한타당성이부족하다는한계점이있었다. 또한위기준에부합하는연구수자체가많지않아평가지표에대한명확한기준을설정할수없었다. 향후이러한부분들을보완하여대조군및치료의평가지표에대한여러가지기준을설정한상태에서정확한연구를할필요가있겠다. 3개의연구에서모두매선요법적용후의부작용에대한보고는없었으므로매선치료가퇴행성슬관절염에대한매선치료가부작용위험이없는안전한치료법인지에대해서는확인할수없었다. 비뚤림위험을분석한결과, 모든연구에서연구방법에대한설명이지나치게간결했거나무작위순서생성, 배정은폐판정, 결과평가눈가림, 선택적결과보고에대한언급이부족하였고, 매선 치료의중재적특성으로인해이중눈가림을효과적으로설계하는데는한계가있었다. 퇴행성슬관절염에대한매선치료의효능을입증하기위해서는낮은비뚤림위험을가진임상연구를위한연구설계과정에서의개선이요구된다. 결론적으로 3건의연구결과를종합했을때매선치료가일반적인단독침치료나양방에서의히알루론산나트륨주사요법과같이현재퇴행성슬관절염에일반적으로사용되는치료법보다통계적으로더효과적임을시사한다. 그러나매선치료에있어그조작방법이나퇴행성슬관절염의치료효과에대한평가지표에대한공통기준이불분명하여이러한결과에대한해석은제한적일수있다. 또한본연구는사람을대상으로한무작위대조연구로범위를제한하였고이기준에맞는퇴행성슬관절염에서의매선치료에대한임상연구가턱없이부족한실정으로인해보다다양한실험결과를확인할수없었다. 퇴행성슬관절염에대한매선치료의치료가능성은보였지만관련연구가중국데이터베이스에편중되고치료방식과평가지표에통일성이없었으며 RCT 의질평가에있어근거가불분명하였다는한계가있었다. 향후퇴행성슬관절염및기타통증질환에서매선치료를적용한임상연구가지속적으로이루어져그근거를바탕으로매선요법의임상적용이활발하게이루어지기를바란다. 감사의글 This paper was supported by the Semyung University Research Grant of 2018. References 1. Yang CD, Zhao D, Yu LZ, Bao JL, Zhang XH, Fan JN et all. Therapy of Acupoint Embedding Thread in the Treatment of Motor System Disease Osteoarthritis. China Academic Journal Electronic Publishing House 2015 ; 21 : 86-88. 2. David T.F. Osteoarthritis of the knee. N Engl J Med 2006 ; 354 : 841-8. 3. An BJ, Kim KT, Kang MS, Song HS. Effect of Bee Venom-acupuncture on Patients with Osteoarthritis of Knee Joint. Korean Acupuncture & Moxibustion Medicine Society. 2006 ; 4 : 15-20. 4. Byun H, Baek ST, Park IS, Kim KS, Kim SW, Choi SM et all. 164 www.kjacupuncture.org
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