Name: Nisha Shah
Date of Course: 7-9 Jun/2-4 Aug
Venue: RAF High Wycombe
Word count:
Abstract
Introduction:
One of the leading causes of the knee pain is the osteoarthritis. Many patients suffering from osteoarthritis of the knee, who have not been helped by one or more Western therapy regimes, find relief from alternative medical approaches including acupuncture. The use of acupuncture in osteoarthritis has been used widely; however there are only few case studies evident in the literature. Hence this case report has been studied to study the effectiveness of acupuncture with knee osteoarthritis.
Case report:
A 54 year old female patient presented with chronic knee pain. A thorough subjective and objective evaluation was carried out in the clinical settings. After the evaluation, the patient was diagnosed with osteoarthritis of the right knee joint. A literature review for the management of osteoarthritis proved acupuncture to be the treatment of choice for OA.
Conclusion:
This case report proves that osteoarthritis when treated with acupuncture points and physiotherapy helped in improving function and reducing disability.
Clinical background:
The most common cause of disability in the world is considered due to osteoarthritis (OA) (Jinks et al., 2002). More than 6 million people in the UK have painful osteoarthritis in one or both knees (Arthritis research, 2013). The prevalence increases as the age increases with 1 in every 5 adults aged 50-59 to almost 1 in every 2 adults aged over 80 having painful OA in one or both knees (Arthritis Research, 2013). Osteoarthritis has been the causative factor in the society leading to social, psychological and economical burdens in patients with substantial financial consequences (Egloff et al, 2012). Osteoarthritis is a disease process that includes focal and progressive damage to the articular cartilage and concomitant changes in the bone underneath the cartilage, including development of the marginal outgrowths, osteophytes (Kisner and Colby, 2007). The main symptoms associated with knee OA is pain, discomfort, limitation of activity and reduced participation (Jamtvedt, 2009). The risk factors include age, genetic predisposition obesity joint congruency increased mechanical pressure and greater density (Egloff et al., 2012).
The case describes a 54 year old female suffering from osteoarthritis. She works as a kindergarten teacher and her work requires long standing hours and also sitting crossed leg on the floor for playing with children. Due to the knee pain, she is unable to perform her job.
Aetiology:
OA occurs when the dynamic steady state between destructive forces and repair mechanisms destabilises the joint homeostasis (Egloff, 2012). This imbalance is thought to be the driving force in this progressive disease and may produce pain and disability (Egloff, 2012). Inflammation is the early feature seen in osteoarthritis which can be triggered by misalignment, overuse, trauma, crystal formation (Egloff, 2012). As the knee joint bears higher shear forces than the hip or ankle joint, OA is more common at the knee (Treppo et al., 2000, Lu et al., 2010) .
Literature Review:
Osteoarthritis is treated with a number of treatment techniques like stretching, strengthening, manual therapy (Jamtvedt, 2009). The electrical modalities like TENS, acupuncture, ultrasound are commonly used in the initial stage of pain and inflammation (Jamtvedt, 2009). In the present case study, the use of acupuncture will be discussed as it is widely used in clinical practice and there are only a few studies evident in the literature.
A blinded randomised controlled study was carried out by Jubb et al., (2008) to compare the effectiveness of acupuncture with that of a non penetrating sham placebo in patients with osteoarthritis. A total of 34 patients were included in each group who received treatment twice in a week for a total of 5 weeks. Reliable and valid outcome measures like WOMAC and VAS were used to measure functional component and the pain respectively. The results of the study showed that acupuncture provides greater symptomatic improvement than the non penetrating sham acupuncture for the treatment of osteoarthritis. Randomised controlled trials are considered as a very high quality study from the hierarchy of evidence. The subjects were blinded and randomly allocated which improves the internal validity of the study and thus makes the study more generalisable.
In a systematic review by White et al., (2006) acupuncture was considered to be the treatment of choice for patients whose symptoms are not controlled by education, exercise, weight loss.
A study was carried out by Lu et al., (2010) proved that acupuncture is an effective mode of treatment for improving gait abnormalities in knee osteoarthritis.
In another randomised controlled trial by Foster et al., (2010) effect of acupuncture in addition to the exercise based physiotherapy was studied on 352 adults older than 50 years. The patient were randomised into three groups the control group received only advice and exercise, the second group received advice, exercise and true acupuncture and the third group received advice exercise and non penetrating acupuncture. The sub scale score by western Ontario and McMaster was used as an outcome measure for measuring the functional component. The results showed that addition of acupuncture in the course of exercise and advice showed no additional improvement in the pain scores. The patients were randomised and there was blinding of the therapist and the patients which eliminates bias and thus could be more representative to the OA patients. Since acupuncture was used in addition to the advice and exercise, it is difficult to predict which of the treatment proved to be more effective.
From the above review, we can conclude that there is a mixture of evidence with respect to the use of acupuncture in the treatment of acupuncture. Further high quality studies with a control group and acupuncture group needs have to be carried out to confirm the effectiveness of acupuncture. Also it can be proved that the combined use of acupuncture and physiotherapy lead to better results in terms of outcome measures. Hence Mrs X was initially given acupuncture for her pain and as her pain started slowly diminishing, the author introduced physiotherapy techniques like strengthening and stretching exercises with manual therapy.
Case report:
Mrs X complains of intermittent variety of pain in her right knee joint since 3 years for which she used to take pain medications. But since the last 6 months her symptoms worsened and hence she was referred to an orthopaedic surgeon. She was given corticosteroid injections which decreased her symptoms temporarily. But her symptoms recurred and her pain started after a month. On subjective assessment she was having a pain of 7/10 on the numeration rating scale which worsened with any weight bearing activities. She also complained of locking, clicking and giving way during walking activities. Her sleep was disturbed due to the pain. She was referred to the physiotherapy department with a diagnosis of osteoarthritis of the right knee joint. Due to the pain she was depressed, disturbed anxious. The blood test results ruled out the diagnosis of any inflammatory arthritis like the rheumatoid arthritis. There was no relevant history of any medical illness in the past.
The relevant Subjective and Objective assessment is mentioned in table 1 and 2
Table 1: Subjective
Table 2: Objective
The outcome measures which were used for test and retest of the patient were Numerating rating scale (NRS) for measuring pain. NRS is the most widely used tool for the assessment of pain in the clinical settings. As Pain is a multidimensional subjective experience, there is only a modest accuracy for identifying clinically important pain (Krebs et al., 2007). Range of Motion (ROM) was measured after each session using a standard goniometer. The other functional tests used by the author specific to the knee function were Western Ontario and McMaster (WOMAC). The WOMAC pain subscale ranges from 0 to 100 with higher values indicating more pain and reduced function. A study by Bellamy, (1997) proved that WOMAC is the most reliable and valid assessment tool for knee pain trials.
Management:
From the subjective and objective assessment, patient can be diagnosed as a case of Osteoarthritis. As she has taken several modalities and an injection therapy for her treatment before, but still continues to suffer from pain, the therapist decided to use acupuncture for her treatment. Acupuncture has been used widely for osteoarthritis of the knee joint as well as to improve the gait patterns in older ages (Lu et al., 2010). The primary aim of the treatment is to reduce pain and function. The patient was screened for all the possible contraindications of the acupuncture. Adequate information was provided to the patient. A consent form was signed by the patient before commencing the treatment. (Appendix 1).
First session:
In the first session, the therapist started with needling of the Liver 3 (LR3). Liver 3 is a distally located Yin point which helps to reduce pain, anxiety, stress and induces relaxation (Deadman et al., 1998). It is vital to use distal point when the knee is swollen due to the inflammation and swelling around the knee joint. Liver 3 helps in reducing the pain by stimulating the A Beta fibres which inhibits the pain carrying fibres like the A delta and C fibres through pre-synaptic inhibition (Longbottom, 2010). This will help in releasing the endogenous opiates like the endorphins and enkephalins which act at the substantia gelatinosa cells at the spinal cord, thus reducing pain (Robertson et al., 2006).
Along with LR3, Spleen 9 and 10 which are segmental points in the yang meridian were used as they increase the blood flow and accelerates the healing process (Deadman et al., 1998). They are considered as the cardinal points for treating the knee osteoarthritis. Spleen 9 helps in stimulating the S1 and S2 dermatome, while Spleen 10 helps in stimulating the L2 and L3 dermatomes. Since they target the specific dermatomes at and around the knee joint, they help in reducing oedema. They also help in improving the flexion extension movement at the knee joint. Hence the use of this point is justified in Mrs X.
An additional point of stomach 34 was used which is located proximal to the knee joint. It is considered as an important point which helps in decreasing pain and swelling. According to the red book, ST34 is an important point for improving flexion and extension of the knee joint thus improving gait pattern (Deadman et al., 1998).
Gall Bladder 34 was also used in the first session which is located below the lateral aspect of the knee. GB 34 helps in activating the channel and reducing pain. According to Deadman et al., 1998, GB 34 is an essential point for reducing tightness of the muscles and stiffness of the joints around the knee joint. GB 34 and ST 34 were used for increasing the knee range of motion by relaxation of the structures around the knee joint. Hence they were used in the initial stages.
| points | side | Insertational Dept Stimulation | Stimulation | Time | Needle size | AD Effect | De-Qi | ||||
| P | H | O | Freq. | Movements | |||||||
| SP9 | RT | P
1-2cm
|
2 | clockwise | 10mins | 40mm | Pain while insertion of the needle | yes | |||
| SP10 | RT | P
2-3cm |
2 | Clockwise | 10mins | 40mm | nil | ||||
| LR3 | RT | P
1-2cm |
2 | Clockwise | 10mins | 30 mm | Wheal , feels warm for sometime but later on was ok. | yes | |||
| ST34 | RT | P
1-2cm |
2 | Clockwise | 10mins | 40mm | Nil | yes | |||
| GB34 | RT | P
2-3cm |
2 | Clockwise | 10mins | 40mm | nil | yes | |||
Second session:
In the second session the pain was reduced to 7/10 on a scale of NRS. The tenderness and mild swelling was still present around the knee joint. However, the patient still had difficulty in walking and restricted range of motion. Hence the same points were used in the second session. As the pain eased, dosage of the static exercises was increased.
| points | Side | Insertational Dept
Stimulation |
Stimulation | Time | Needle size | AD Effect | De-Qi | ||||
| P | H | O | Freq. | Movements | |||||||
| SP9 | RT | P
1-2cm |
2 | clockwise | 20mins | 40mm | Pain while insertion of the needle | yes | |||
| SP10 | RT | P
2-3cm |
2 | clockwise | 20mins | 40mm | nil | yes | |||
| LR3 | RT | P
1-2cm |
2 | Clockwise | 20mins | 30mm | Wheal | yes | |||
| ST34 |
|
RT | P
1-2cm |
2 | Clockwise | 20mins | 40mm | Nil | yes | ||
| GB34 |
|
RT | P
2-3cm |
2 | Clockwise | 20mins | 40mm | nil | yes | ||
Third session:
In the third session the Pain was reduced by 3/10 on the NRS scale. The range of motion also improved but the patient was still experiencing difficulty while walking. As the pain reduced, the author added some local points such as ST 35 and Xiyan 32 at the knee joint.
Stomach 35 is located lateral to the patellar ligament and is most effective when used in conjunction with the Xiyan 32. ST 35 and Xiyan 32 is indicated when the knee musculature is weak and to improve the range of motion (Deadman et al., 1998).
From this session the patient was taught some active leg exercises of the knee joint which included flexion, extension, abduction and adduction. The patient was advised to perform these exercises once daily. The author also started stretching of hamstrings and quadriceps from this session.
| points | side | Insertational Dept
Stimulation |
Stimulation | Time | Needle size | AD Effect | De-Qi | ||||
| P | H | O | Freq. | Movements | |||||||
| SP9 |
RT |
P
1-2cm
|
2 | clockwise | 20mins | 40mm | Pain while insertion of the needle | yes | |||
| SP10 | RT | P
2-3cm
|
2 | clockwise | 20mins | 40mm | nil | yes | |||
| LR3 | RT | P
1-2cm |
2 | Clockwise | 20mins | 30mm | Tingling sensation just for few seconds and then settled down. | yes | |||
| ST34 | RT | P
1-2cm |
2 | Clockwise | 20mins | 40mm | Nil | yes | |||
| GB34 | RT | P
2-3cm |
2 | Clockwise | 20mins | 40mm | nil | yes | |||
| ST35 | RT | Oblique+ upward
1-2cm |
2 | Clockwise | 20mins | 40mm | nil |
yes |
|||
| EX32
|
RT | Oblique+ upward
1-2cm |
2 |
Clockwise |
20mins | 40mm | nil |
yes |
|||
Fourth session:
After quick assessment, the author decided to cease the distal point SP 10. Since Mrs X had no longer swelling or tenderness around the joint and the author had already started with local points, SP 10 was no longer required. The patient was still experiencing mild pain while walking, hence the acupuncture was still continued using 6 points.
In this session the author introduced some patellar mobilisations and manual therapy techniques for achieving pain free movements. The exercises were continued same as the last session.
| points | side | Insertational Dept
Stimulation |
Stimulation | Time | Needle size | AD Effect | De-Qi | ||||
| P | H | O | Freq. | Movements | |||||||
| SP9 | RT | P
1-2cm |
2 | clockwise | 20mins | 40mm | Pain while insertion of the needle | yes | |||
| LR3 | RT | P
1-2cm |
2 | Clockwise | 20mins | 25mm | Wheal | yes | |||
| ST34 |
|
RT | P
1-2cm |
2 | Clockwise | 20mins | 40mm | Nil | yes | ||
| GB34 |
|
RT | P
2-3cm |
2 | Clockwise | 20mins | 40mm | nil | yes | ||
| ST35
|
RT | Oblique+ upward
1-2cm |
2 | Clockwise | 20mins | 40mm | nil | yes | |||
| EX32 | RT | Oblique+ upward
1-2cm |
2 | clockwise | 20mins | 40mm | nil | yes | |||
Fifth session:
The patient was not experiencing pain or discomfort during walking. Acupuncture was continued in this session to improve the range of motion and strength of the muscles. Strengthening exercises were taught to the patient using weight cuffs. The author also taught her self-stretching of the quadriceps and hamstring muscles. Gait training was started along with some proprioceptive training to gain her confidence and reduce the fear of fall in her mind.
| points | side | Insertational Dept
Stimulation |
Stimulation | Time | Needle size | AD Effect | De-Qi | ||||
| P | H | O | Freq. | Movements | |||||||
| SP9 | RT | P
1-2cm |
2 | clockwise | 20mins | 40mm | Pain while insertion of the needle | yes | |||
| LR3 | RT | P
1-2cm |
2 | Clockwise | 20mins | 30mm | nil | yes | |||
| ST34 |
|
RT | P
1-2cm |
2 | Clockwise | 20mins | 40mm | Nil | yes | ||
| GB34 |
|
RT | P
2-3cm |
2 | Clockwise | 20mins | 40mm | nil | yes | ||
|
ST35 |
RT | Oblique+ upward
1-2cm |
2 | clockwise | 20mins | 40mm | nil | yes | |||
| EX32
|
RT | Oblique+ upward
1-2cm |
2 | Clockwise | 20mins | 40mm | nil | yes | |||
On each session, all the points were stimulated by rotating the needle clockwise in order to achieve the qi effect. Qi will help in stimulating A delta and A beta fibres which will help reducing the pain
Sixth Session:
The author ensured the patient is doing her exercises in a correct movement pattern. The dosage of exercises was increased. The patient was confident and pain free. There was a significant change in the WOMAC scores indicating improvement for the pain and function. She was able to perform her all her activities without pain. She was now able to sit cross legged and kneel down bearing weight on her knees. Mrs X responded well to acupuncture as a result she was able to return to her activities of daily living and her job at the kindergarten school.
The patient responded well to acupuncture and therefore treatment was progressed by introducing more local points as her fear of injury subsided. Hence acupuncture helped in attaining the goals of the patient of reducing pain and able to do her activities of daily living. According to (Longbottom, 2010) acupuncture points are employed as a means of managing homeostatic balance, a balance between yin and yang, which helps in maintaining an adequate balance between the sympathetic and parasympathetic nervous system.
Discussion:
In the present case study, from the subjective and objective assessment, Mrs X was diagnosed as a case of OA of the right knee joint. As other forms of treatment like the injection therapy and ultrasound failed in her case, the author decided to use acupuncture for her treatment. The author used a variety of local, segmental and distal points over a period of 5 sessions for approximately 30 – 45 minutes once a week. The patient responded well to acupuncture and reduced her pain by 70 %. At the end of the treatment, there was a significant difference found in the scores of the outcome measures like the NRS and WOMAC. She was also able to return to her activities of daily living including her job.
From the literature, it is very vital as the pain decreases, the patient should be subjected to physiotherapeutic exercises for the OA knee. In the initial stages along with acupuncture static exercises could be given to induce relaxation and to maintain the muscle strength (Kisner and Colby, 2007). As the pain decreases, the author used more local points like the spleen 9 and 10. Further the active movements in the pain free range along with some patellar mobilisation was started. The exercises will help the patient in achieving a permanent lengthening around the tissues and provide a distraction force which will help in alleviating pain.
Throughout the present case study, a combination of clinical reasoning and evidence based research using Western acupuncture in order to manage pain and subsequently enhance rehabilitation was employed with the integration of manual, acupuncture and exercises techniques in order to successfully manage OA.
Limitations:
This case study is a good example for the use of acupuncture in the Osteoarthritis; however it is difficult to imply the findings of a single case study in our daily clinical practice, hence further high quality studies considering the use of acupuncture alone are necessary. There are a number points which can be used for the treating osteoarthritis other than the ones mentioned in this study. The efficacy of various points used in treatment of osteoarthritis is necessary to find out. This will help in saving time and energy in determining points.
Acknowledgements:
I would like to acknowledge my gratitude to Mrs. X for her compliance and Mrs. Jennie Longbottom who trained me with the basics of Acupuncture along with clinical reasoning.
References:
Bellamy N (1997). Osteoarthritis clinical trials: candidate variables and clinimetric properties. J Rheumatol, 24(4):768-78
Deadman, P., Baker, K., & Al-Khafaji, M. (1998). A Manual of Acupuncture: Point Cards. Journal of Chinese Medicine Publications
Jamtvedt, G. (2009). Physiotherapy in patients with knee osteoarthritis: Clinical practice compared to findings from systematic reviews
Jinks, C., Jordan K., Croft, P. (2002). Measuring the population impact of knee pain and disability with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain. 100(1-2), 55-64
Jubb, R. W., Tukmachi, E. S., Jones, P. W., Dempsey, E., Waterhouse, L. and Brailsford, S. (2008). A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee. Acupuncture in Medicine, 26(2), 69-78
Kisner, C., & Colby, L. A. (2007). Therapeutic Exercise: Foundations and Techniques FA Davis Company. Printed in the United States of America, 256, 648-79
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Lu, T. W., Wei, I. P., Liu, Y. H., Hsu, W. C., Wang, T. M., Chang, C. F., & Lin, J. G. (2010). Immediate effects of acupuncture on gait patterns in patients with knee osteoarthritis. Chinese Medical Journal (English Edition), 123(2), 165
Robertson, V. J., Robertson, V., Ward, A. R., Low, J. L., & Reed, A. (2006). Electrotherapy explained: principles and practice. Butterworth-Heinemann Medical
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