A Case Study on osteoarthritis of the knee

Introduction
Patients suffering with knee osteoarthritis find relief from alternative therapies including acupuncture when Western medicine has failed. Due to the growing age population in Australia, knee osteoarthritis is becoming increasingly prevalent and acupuncture can be seen as a cost effective and safe alternative to pharmacological or surgical intervention. The case study below is interesting as although the patient attained positive results, he still sought surgical intervention for his pain.

Literature Review

Traditional Chinese Medicine Perspective
Osteoarthritis of the knee can be classified as Bi syndrome (painful obstruction syndrome) (Flaws & Sionneau, 2005). It is seen as the invasion of external pathogens which invade the body and obstruct/block the flow of Qi and blood within the channels (Maciocia, 2004). The three main pathogens include wind, damp and cold and within their combination, different characteristics and symptomology can be seen. The weakness of defensive Qi (Wei Qi) could be the influencing factor for the invasion of external pathogenic factors assaulting the body, in this case the knees. The invasion of these external pathogenic factors can and will stagnate the harmonious flow of Qi and blood circulation so that pain can manifest. The pathogenic factors not only invade the channels but also affect the muscles and joints around the knee causing the blockage and a slow-down of circulation of Qi and blood. The clinical signs and symptoms may vary greatly due to the difference in pathogenic factors.
Some of the causative factors involved in osteoarthritis Bi syndrome of the knee include stagnation of Qi and blood, deficiency of liver and kidney, deficiency of Qi and blood and wind, damp, cold and heat.
Stagnation of Qi and blood can be brought about by overstrain, physical trauma or as a secondary effect of the external pathogenic factors as they can block the channels leading to pain and swelling of the knee joint (Maciocia, 2004).
The causative factors of deficiency of liver and kidney can come about due to overstrain, irregular eating habits, poor diet, prolonged sickness or a weak constitution and general old age. These may cause the consumption of Qi and blood leading to deficiencies of the liver and kidney. When looking at the correspondence of organs in relation to tissues, this can manifest as the tendons not properly being nourished as they relate to the liver and the bones not being properly nourished as they relate to the kidneys.
Wind as the predominant invader can be seen as a wandering type of obstruction with signs and symptoms manifesting as pain which tends to be moving or migrating randomly from location to location. Soreness can be seen in the muscles and joints but the quality of the pain can change quickly alternating between dullness and sharpness. Wind as an agent does not work solely however has a tendency to combine with other pathogens such as cold and damp. The main signs and symptoms include moving joint aches, pain and soreness which is not localised, aggravated by climatic changes, possibly accompanied with aversion to fever and wind, white tongue coating and a floating moderate pulse (Flaws & Sionneau, 2005; Maciocia, 2004).
An invasion of predominantly cold is referred to as painful Bi syndrome and characterised by severe pain and limitation of movement. The cold pathogen has the ability of freezing and contracting channels and tissues thus the blockage produces pain and loss of joint movement. Warmth and movement improve pain whereas cold and immobility enhance pain. The main signs and symptoms include severe joint aching and pain which is sharp in nature, exposure to cold will intensify the pain, pain which is alleviated by warmth, pain which is relatively established in location, reluctant for flexion or extension at the articulation, no presence of heat or redness, a pale tongue with white coating and a deep, tight or wiry pulse (Flaws & Sionneau, 2005; Maciocia, 2004).
The invasion of dampness is characterised with a sensation of numbness and heaviness as well as soreness and swelling in the muscles and joints. It is also called fixed Bi syndrome due to its localisation. Climatic factors are an influencing feature in the severity of pain. Some of the main symptoms include aching joints, pain, soreness, numbness and heaviness which is fixed in location, marked swelling of the affected area, difficulty flexing and extending the joints, worse pain in damp environments and rainy weather affecting the lower half of the body, a pale tongue with slimy white fur and a soggy moderate pulse (Flaws & Sionneau, 2005; Maciocia, 2004).
Heat is more a result of the other pathogens due to the obstruction. The main signs and symptoms which are associated with heat is joint aching and pain which is hot, swollen and distended and/or erythematous in the affected area, severe pain, difficulty in flexing and extending the joint, possible fever, thirst, aversion to heat, red tongue with yellow or slimy coating and a slippery rapid pulse (Flaws & Sionneau, 2005; Maciocia, 2004).
Traditional Chinese Medicine Treatment
The Osteoarthritis Research Society International reported that there was no statistical difference between the use of non-pharmacological modalities compared with pharmacological treatment for knee osteoarthritis with acupuncture listed as one of the 12 beneficial non-pharmacological modalities (Zhang et al., 2008). In addition, acupuncture is known to be a safe alternative to western medicine as it less liable to adverse events and is perceived to be less invasive (Vincent, 2001; White, Hayhoe, Hart, & Ernst, 2001).
Several randomised, controlled trials have shown acupuncture to reduce pain and improve function in treating knee osteoarthritis either on its own or as part of an adjunct therapy (Berman et al., 2004; Scharf et al., 2006; Vas, Mendez, & Perea-Milla, 2006; Witt et al., 2006). Interestingly, acupuncture performed by physiotherapists in a multicentre, randomised controlled trial provided no additional improvement in pain scores compared with advice and exercise alone on the WOMAC index (Foster et al., 2007). However this trial used fewer treatment sessions (than other trials) did not include a no treatment group and was performed by physiotherapists (not acupuncturists). There is also evidence that although both acupuncture and sham acupuncture improve pain and function in patients with knee osteoarthritis, there are no significant differences between the two which suggests that it could be due to a placebo effect (Scharf et al., 2006). Several studies have also suggested that acupuncture is a good replacement for non-steroidal anti-inflammatory drugs (NSAIDS) as it equally effective, has much less side effects and is cheaper (White, Foster, Cummings, & Barlas, 2006; White & Kawakita, 2006). In addition, Yousuf and colleagues (2007) found that acupuncture was cost effective when used as an adjunctive therapy as patients receiving acupuncture treatment used fewer medications and were hospitalised less often. The use of electro acupuncture has also been shown to provide significant improvements in the symptoms of knee osteoarthritis in the sole treatment or as an adjunct therapy (Chau et al., 2004; Tukmachi, Jubb, Dempsey, & Jones, 2004). Xu and colleagues (2007) reported that the Silver Spike Point Free acupuncture device was effective in treating the symptoms of knee osteoarthritis with a statistical significant reduction of stiffness according to the WOMAC index.

Western Medicine Perspective
Osteoarthritis is a leading cause of disability worldwide (Lopez & Murray, 1998) and is the most common form of arthritis in people aged over 65 in Australia although the aetiology of the age-related increase is unclear (Felson et al., 1987). Osteoarthritis is a degenerative joint disease that mainly affects weight-bearing joints and women have a greater risk of developing the disease than men (Felson, Lawrence, Dieppe et al., 2000). The clinical features of osteoarthritis include pain and stiffness with the major pathological feature being articular cartilage degeneration. As the disease increases in severity, pain, swelling, loss of cartilage, bone spur formation and decreased range of motion can occur with variable degrees of mild synovitis and thickening of the joint capsule (McCance & Huether, 2006). Overweight adults have a higher prevalence of knee osteoarthritis (Hart & Spector, 1993) and it has been suggested that inactive children and adolescents are at a greater risk of developing the disease (Jones, Glisson, Hynes, & Cicuttini, 2000). The literature has also shown that occupations such as labouring (Felson et al., 1987) as well as participation in sports such as soccer or running may also be associated with the disease (Kujala et al., 1995).

Western Medicine Treatment
There is no known cure for osteoarthritis (Felson, Lawrence, Hochberg et al., 2000) however the goal is to control the patients pain, improve mobility and function and quality of life. Treatment strategies for osteoarthritis of the knee include patient education (Keefe et al., 2004), physiotherapy, weight reduction (Miller et al., 2006), NSAIDS (Bruhlmann & Michel, 2003), glucosamine (Herrero-Beaumont et al., 2007) and surgery (Lavernia, Guzman, & Gachupin-Garcia, 1997).
The general consensus among the literature was the utilisation of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as a standard for measuring the outcomes of knee osteoarthritis. WOMAC measures pain, stiffness of the knee and difficulty performing daily activities.

Case
This is a case study of a 53 year old man called Roger (a pseudonym for his real name) who presented with pain in the anterior medial aspect of his right knee, interior to the patella. The pain had been intermittent for the previous 2 years and had progressively become intensified in the last 2 weeks. The pain was present most of the time but developed increasingly worse with high activity, climatic change or at the end of a days work. This made it very difficult for Roger as he worked long hours (12-16 hours, 7 days a week) in the metal industry and walked up stairs all day (he also found it difficult and painful walking down stairs). Roger was also a keen soccer player since his childhood, playing competitively for over 20 years. During this time, he sustained a lot of injuries to his knees.

Current diagnosis and medications

knee
Roger’s physician diagnosed him with osteoarthritis of the knee after an x-ray and magnetic imaging resonance (MRI). The MRI showed joint space narrowing (due to loss of articular cartilage) and slight osteophyte formation. He was prescribed Panadol and topically applied Voltaren. Roger had an intra-articular steroid injection in his knee 8 months prior (since the Panadol and Voltaren did not work) with relatively moderate but short-lasting results (2 months). On further consultation with his physician, he was advised to seek surgical intervention. He was initially unwilling to have surgery so sought acupuncture treatment instead.

Examination findings
On investigation of his knee, there was visible swelling with no redness of the skin. Pain was expressed with palpation and with flexion and extension of the knee joint. There was limited movement of the joint and crepitus on extension and flexion of the knee joint. Roger was positive for anterior drawer sign and the abductor stress test as described by Bickley & Szilagyi (2007).
Roger was of average height and appeared physically fit. He had regular bowel and urine movements and normal blood pressure (130/80). His pulse was found to be wiry and moderate in speed (the kidney position was somewhat weak) whilst his tongue was pink (with a slight white coating) with no central line visible, swelling or teeth marks on the outer aspects.

Diagnosis and treatment
Roger’s traditional Chinese medicine (TCM) diagnosis was anterior medial knee pain due to fixed Bi syndrome (cold and damp predominant) accompanied with stagnation of Qi and Blood and an underlying liver and kidney deficiency.
The TCM principle of treatment was to eliminate the dampness, scatter the cold, improve the flow of Qi and Blood, tonify liver and kidney and alleviate pain.

Initial treatment strategy
The strategy for the acupuncture treatment for Roger was to encompass a selection of auricular points, local and distal acupoints and the application of moxibustion. Treatments were done twice weekly for the initial 4 week period and then tapered to once weekly for 4 weeks. The needles used had a diameter of 0.25mm and assorted lengths (depending on the point) and left insitu for 25-30 minutes each session. An evaluation was undertaken at the end of 8 weeks to assess the progress of the acupuncture treatment. Both oral and topical herbal medicine was also included and discussed in detail below.
The acupoints selected are listed below.
• Xue Hai (Spleen 10) • Yang Ling Quan (Gallbladder 34)
• Zu San Li (Stomach 36) • Xi Yan (MN-LE-16)
• Yin Ling Quan (Spleen 9) • Liang Qiu (Stomach 34)
• Qu Quan (Liver 8) • Yin Gu (Kidney 10)
• Knee earpoint • PGE1 (ear prostaglandin)

Initial herbal preparation
The oral herbal preparation prescribed was a patent medicine of Du Huo Ji Sheng Wan with 20 pills consumed three times daily. In addition, glucosamine (50mg, twice daily) was prescribed. The topical herbal preparation prescribed was Zheng Gu Shui to be liberally applied three times a day.

Treatment outcomes
At the end of 12 treatments, there was a marked reduction in the swelling of the knee although he was still positive for the anterior drawer sign and the abductor stress test. The range of movement had improved on both flexion and extension with reduced levels of crepitus in the knee. Roger was pleased with the reduction in pain thus achieved although appeared sceptical. He noted pain was still present at the end of the day after hard physical work and walking downstairs. Roger decided to seek surgery in the hope of total cessation of his pain.

Conclusion
Following an 8 week period, Roger had reduced his level of pain. Even though glucosamine is not a traditional Chinese medicine, it was incorporated as previous patients have benefited from its continued use and is also supported by the literature.
Despite the literature’s positive results, electro-acupuncture was not used as I did not see the need at the time. The best evidence available has shown that managing knee osteoarthritis (with acupuncture or other non-pharmacological treatments), is an effective way of managing knee osteoarthritis. Greater randomised trials of Chinese herbal medicine are needed to evaluate the efficacy of their use in treating knee osteoarthritis as there is a lack of high level scientific studies in the literature.

Reference

Closeup of male runner holding injured knee as he stands on scenic mountain top with snow capped peaks

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DISCLAIMER

The information and reference materials contained here are intended solely for the general information of the reader. It is not to be used for treatment purposes, but rather for discussion with the patient’s own physician. The information presented here is not intended to diagnose health problems or to take the place of professional medical care.

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Rodd Sanchez Sydney acupuncture and Chinese medicine