Use of acupuncture after arthroscopic knee surgery and its relationship to pain, physical activity and need of walking aid

Acupuntura em relação a dor, atividade física e a necessidade de apoio para a marcha, no pós-operatório das cirurgias artroscópicas no joelho

Abstracts

O presente estudo teve a finalidade de avaliar a eficácia da Acupuntura no pós-operatório das cirurgias artroscópicas no joelho utilizando-se a técnica "ao oposto" da Medicina Tradicional Chinesa. Os 36 pacientes portadores de gonalgias foram distribuídos conforme a patologia encontrada nas artroscopias cirúrgicas: 50,0% tinham lesão do menisco medial isolada, 19,44% lesão meniscal medial associada à artrose de joelho, 11,11% lesão meniscal lateral associada à artrose de joelho, 8,33% lesão meniscal lateral isolada de joelho, 2,77% apresentavam lesão em ambos os meniscos isolados, 2,77% lesão de ambos os meniscos associados à artrose de joelho, 2,77% apresentavam condromalácea de patela e 2,77% eram portador de corpo livre. Os pacientes do grupo I (acupuntura), 18, foram submetidos a 20 sessões de acupuntura, utilizando-se pontos de acupuntura contra-lateral ao joelho afetado, e os pacientes do grupo II (fisioterapia), 18, foram submetidos a 20 sessões de fisioterapia, associadas a antiinflamatórios não esteróides (AINEs). A análise estatística não paramétrica dos resultados obtidos nos dados subjetivos (intensidade da dor relatada, dificuldade de andar, agachar, de subir e descer degraus, correr, do uso de apoio para a marcha), evidenciou bons resultados na maioria dos parâmetros estudados. Embora os resultados fossem semelhantes, a acupuntura apresentou melhores resultados do tratamento mais precocemente, enquanto a fisioterapia mais tardiamente.

Acupuntura; Artroscopia; Fisioterapia; Joelho; Medicina Tradicional Chinesa

ORIGINAL ARTICLE

Use of acupuncture after arthroscopic knee surgery and its relationship to pain, physical activity and need of walking aid

Rassen Saidah^I; Alceu Gomes Chueire^II; Wilson Abou Rejaili^III; Nádia Regina Basso Peres^IV; João Bosco Guerreiro da Silva^V; Fulvio Schiavo^VI

^IAssociated Professor, PhD, Head of the Acupuncture Service of Medice Departament, FAMERP

^IIAssociated Professor, PhD, Head of Orthopedics and Traumatology Department FAMERP

^IIIOrthopaedist physician specialist in knee surgery by the Faculty of Medicine, USP Ribeirão Preto, from the Orthopedics and Traumatology of Santa Casa de Misericórdia de São José do Rio Preto, SP

^IVPhysioterapy specialist from Santa Edwiges hospital, under-graduate in "Didática de Ensino Superior" da UNORP, São José do Rio Preto, SP

^VAssistant Professor, Master from the Acupuncture Service of Medice Departament, FAMERP

^VIDoctor resident from the Acupuncture Service of Medice Departament, FAMERP

^{Correspondence}

SUMMARY

The purpose of this study was to evaluate the efficacy of Acupuncture in the postoperative arthroscopic knee surgery, using "The Opposite Side" technique from the Traditional Chinese Medicine. The 36 pain in the knee were grouped according to the disorders found during the arthroscopic surgery: 50% with isolated lesion of the medial meniscus, 19.44% with lesion of the medial meniscus associated to knee arthrosis ,11.11% with lesion of lateral meniscus associated to knee arthrosis, 8.33% with isolated lesion of lateral meniscus of the knee, 2.77% lesion of both isolated meniscus, 2.77%with lesion of both isolated meniscus, 2.77% with chrondomalacia patella, and 2.77% were free body carrier. Group I, 18 patients (Acupuncture) were submitted to 20 acupuncture session. Contralateral points of acupuncture were performed in the injured knee. Group II, 18 patients (Physiotherapy) were submitted to 20 physiotherapy sessions under the administration of nonsteroidal anti-inflammatory agents. The non-parametrical analysis of the results showed that either the subjective data (pain intensity, difficulty in walking, in crouching, on going upstairs/downstairs, on running, on using some support walking) presented good results in the majority of the studied parameters. Although, the results of the treatment were similar, the acupuncture showed better results since it presented earlier improvement than the physiotherapy.

Key words: Acupuncture; Arthroscopy; Physical Therapy; Knee; Medicine, Chinese Traditional

INTRODUCTION

One of the curious aspects of Acupuncture treatments is the "Opposite Side" treatment of peripheric painful disorders as described in the Hoang Ti Nei Ching book, written above four thousand years ago. This has not yet been scientifically proved, nevertheless there is a scientific support for this phenomenon, when seen under the lights of neurophysiology through the crossover somato-somatic reflex ⁽¹²⁾.

The knee, from the Traditional Chinese Medicine standpoint, is related to the Gan (Liver) Energy and to the Energy Pathways crossing this region, which are six^(8,12). These six Energy Pathways correspond to three Yang and three Yin foot Energy Pathways. The Yang pathways correspond to Wei (Stomach), Dan (Gallbladder) and Pangguan (Bladder) and the Yin ones to the Gan (Liver), Shen (Kidney) and Pi (Spleen-Pancreas) pathways.

These six Energy Pathways, as understood by Traditional Chinese Medicine, are responsible for knee joint activities, of the nerves and blood circulation, as well as takes responsibility for the non traumatic and post-traumatic processes of the knee^(1,8,12).

Topographic correlation evidence that Acupuncture stimulus conduction is related to peripheric nerves nervous fibers, as proven in researches^(10,11), being associated to the knowledge of Neuro-anatomy and Neuro-physiology in relation to crossover reflex arc at knee level and to the energy pathways theory of Traditional Chinese Medicine.

Acupuncture needle insertion in points located in a healthy knee, through the somato-somatic contralateral reflex arc may interfere in the unbalanced mechanisms in the affected knee joint, and consequently in pain and knee movements⁽⁹⁾.

This work is largely applicable, and also proves the efficacy of the "Opposite side" treatment, for allowing the use of this technique in situations where it is difficult to insert acupuncture needles in the affected joint, as when using a plaster cast after a fracture and a surgery, in infectious and severe inflammatory processes, and mainly, in post operative period of arthroscopic surgery of the knee joint⁽¹²⁾.

The aim of this work is to study the clinical effects of Acupuncture benefits, as related to pain, physical activity and the need of walk aid in postoperative period of arthroscopic surgeries of the knee joint, using the "Opposite side" Traditional Chinese Medicine technique, in comparison to a group treated with physiotherapy and drugs.

MATERIAL AND METHODS

Thirty six patients in postoperative period following simple arthroscopic surgery of the knee joint, due to several diseases, all of them registered at the Acupuncture Service of the Medicine Department of Traumatology and Orthopedics Department of Faculdade de Medicina de São José do Rio Preto – SP. The patients were randomly allocated to two groups of 18 patients each. Group I patients underwent 20 acupuncture sessions without use of NSAIDs and Group II, 20 sessions of physiotherapy associated to Diclofenac 50 mg every 8 hours.

Patients age ranged from 17 to 77 years (average = 43 years); eleven (11) of them were female and twenty five (25) male. Twenty one of the knees (21) were right and fifteen (15) left.

The Acupuncture points were selected according to Chinese Medicine texts^(9,12). The selected points were: M-MI-27 (Heding), M-MI-16 (Xiyan), that are out of Energy Pathways; B-54 (Weizhong), located in Bladder pathway; E-35 (Dubai), E-36 (Zusanli), in Stomach pathway; VB-34 (Yanglingquan) in Gallbladder pathway; BP-9 (Yinlingquan), in Spleen-Pancreas pathway; R-10 (Yingu), in Kidney pathway; F-8 (Ququan), in Liver pathway. These points were inserted in the healthy knee, in the opposite side of the operated joint.

Patients were evaluated in both groups, additionally to baseline, after every five Acupuncture or Physiotherapy sessions in a total of four evaluations by the Knee Specialist Orthopedist, according to the case report form prepared by the Author and approved by the Institutional Ethics Committee of FAMERP (issue # 089/2001).

RESULTS

The 36 studied cases of knee pain were grouped according to the findings of the arthroscopic surgery, allowing the patients to be grouped as follows: 18 (50%) with symptoms compatible with medial isolated meniscus lesion, 7 (19.44%) with medial meniscus lesion associated to arthrosis of the knee joint, 4 (11.11%) with lateral meniscus lesion with knee arthrosis, 3 (8.33%) with isolated lateral meniscus lesion and 1 (2.77%) had lesion of medial and lateral menisci with knee arthrosis, 1 (2.77%) had patellar chondromalacia and 1 (2.77%) with a free articular body.

The findings of the pre and postoperative evaluations underwent McNEMAR, Signal test, exact FISHER test and MANN-WITHNEY statistic tests.

Regarding the reported pain, it was found that patients in both groups had a significant improvement from the first evaluation and this was not changed through the last evaluation.

In regard to the walking scale, in both groups there was a significant improvement from pre to postoperative situation, occurring from the second evaluation.

Regarding crouching ability, there was a significant improvement for Group I earlier than in Group II.

Regarding the values for going upstairs and downstairs there was a significant improvement in both groups, starting in the second evaluation.

In regard to the ability to run, there was a significant improvement for Group I and non significant for Group II.

Regarding need of walking aid there was an improvement in the first evaluation for both groups.

DISCUSSION

It is rare to find in the indexed literature works reporting knee joint pain with Acupuncture treatment, mainly with the "Opposite side" Traditional Chinese Medicine technique⁽¹²⁾.

Classically, Traditional Chinese Medicine recommends the "Opposite side" treatment for acute processes^(11,12). We opted for using this technique in chronic cases, finding in our series a significant improvement of the reported pain in several studied parameters⁽¹²⁾ and, also in this series, in patients in postoperative period of arthroscopic knee surgery.

Studies performed by several authors demonstrated that acupuncture points are related to peripheric nerves ^(3,13) and also to the autonomic nervous system, through the dorsal branch of the spinal nerve⁽¹²⁾.

Thus, there is a relationship of the acupuncture points with the stimulated nerve terminations, with influence in neurophysiology of spinal nerves located in the knee from the small branches located inside the joint acting as nociceptors to their origin, at a medullary level⁽¹⁰⁾.

Beyond the stimulus by the Acupuncture needle in the receptors, studies demonstrated the effects of the micro-trauma caused by the insertion and manipulation of the needle. This microscopic lesion causes immunologic and inflammatory responses, with a local vasodilation causing changes in autonomic nervous system tonus, reflecting in medullary reflex arc ⁽⁵⁾.

Correlating Traditional Chinese Medicine concepts, in regard to "Opposite side" treatment, with neuro-anatomy and neuro-physiology, it is observed that a stimulus performed in a knee may have effect over the opposite side knee through the contralateral somato-somatic reflex arc ^(3,4,6,7). This means that, for instance, an stimulus in the anterior region of the left knee, may have a response in flexor muscles of the right knee, and an stimulus in the posterior region of the left knee, may have an extensor response in the right knee.

During the proposed treatment time of 20 Acupuncture sessions, it was looked for evaluating the benefits of Acupuncture over recovery of the patients in postoperative period of arthroscopic knee surgery, being pain the basic issue and its effects on walking, crouching, going up and downstairs, running and need of walking aid.

There is no doubt that pain is a limiting factor for physical and daily activities of any individual and in clinical features appearing later. Thus, it can be understood that elimination or relief of knee pain may contribute to its biodinamics.

Our findings suggest that, in above conditions, it may occur a faster recovery of the operated knee, helping biodinamics balance, and avoiding inflammatory process. Treatment aiming these situations should be implemented as soon as possible, according the results from Yamamura ¹¹ and Saidah⁽⁹⁾.

The advantages found are related to not using NSAIDs with their potential side effects as described in literature, the possibility to workout the knee earlier, for using the opposite side knee, avoiding patient discomfort and infection risks, and, as demonstrated, in regard to physiotherapy in early phases, making Acupuncture an excellent adjuvant for treatment a posteriori with physiotherapy.

In this study there was not a control group (Sham Acupuncture) due to medical ethics concerns and also for the insertion of Acupuncture needles insertion in points not considered as Acupuncture points, may have a relative effect^(1,2).

CONCLUSION

The results of the treatment with 20 Acupuncture sessions in 18 patients, postoperatively to arthroscopic knee surgery using the "Opposite side" Traditional Chinese Medicine technique, according to the used methodology, presented a significant improvement in most of the studied parameters, with earlier results, while physiotherapy showed better results later; nevertheless the results were similar at the end of the treatment.

Trabalho recebido em 12/06/2002

Aprovado em 05/12/2002

Work performed at the Acupuncture Service of the Medical Department and Orthopedics and Traumatology of the Medical School of São José do Rio Preto, São José do Rio Preto, SP

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Publication Dates

• Publication in this collection
  16 Apr 2003
• Date of issue
  Jan 2003

History

• Accepted
  05 Dec 2002
• Received
  12 June 2002