Acupuncture and Knee Pain: Integrative Approaches Offered by Singaporean Specialists

Some people who are suffering from knee pain may avoid exercising or any activities that engage the knee movements, as they think it will worsen the pain. They may also overuse the other knee to relieve the painful knee, and this can lead to other injuries. By altering the way you use the knee, it can cause more damage and may actually increase the pain. What actually happens is the inactivity and avoidance of the use of the knee causes the muscles around the knee to weaken, causing further pain and instability. This can become a long-term problem leading to chronic pain and potential other problems with the knees. So, it is crucial to seek treatment for your knee to prevent any long-term problems. With an injury or a specific medical condition, proper care is needed to help alleviate the knee pain and to prevent more damage in the future. The objective is to effectively address the cause of the pain and to restore the normal function of the knee. With a wide variety of treatment options available, it can be confusing as to what is the best choice for you. Treatment options can range from medicines, physiotherapy, manipulation to complementary therapies.

Overview of Knee Pain

Of the population burdened by knee pain, the most commonly affected are athletes and the elderly. The demands of sports and exercise frequently lead to numerous internal derangements or structural injuries that will lead to degenerative joint conditions and eventually osteoarthritis. The elderly experience knee pain largely as a result of osteoarthritis as well. This is due to the fact that osteoarthritis is a degenerative, “wear-and-tear” type arthritis. Due to this, many sufferers of knee pain encounter long and frustrating recoveries. All in all, the prevalence of knee pain can take a huge toll on a person’s quality of life and often leaves individuals feeling a loss of independence.

The knee is the largest joint in the body and it is surely one of the hardest working. The knee is a weight-bearing joint that straightens, bends, and rotates when the body requires. Because of this, the knee is a joint that is frequently used and very often abused. Additionally, because it is a weight-bearing joint situated between the two longest bones in the body, it is the site of much injury and undue stress. Thus, knee pain is second only to lower back pain in annual diagnoses. In the recent National Health Interview Survey, nearly 50 million of the adults in the United States were reported to have been diagnosed with knee pain or a knee condition. This makes knee pain almost as prevalent as the common cold. With the aging baby-boomer generation, these numbers are only going to escalate.

Importance of Seeking Treatment

Knee pain has been a common clinical issue for years, and despite the rise of technology, people of all ages still continue to seek treatment due to the significant discomfort it brings. Even young adults are prone to injury and the devastating effects of untreated knee pain. Studies have confirmed that about 30 percent of patients with knee pain have some sort of disability. The most consistent conventional predictors of disability in persons with knee pain include older age, lower socioeconomic status, more comorbidity, and more severe pain. It can disrupt activities of daily living (ADL) such as lifting and carrying items, shopping, bathing, and walking. The disability can reach the extent that the person is unable to live alone or engage in substantial work. Any of these outcomes can lead to a reduced quality of life. An example of the far-reaching consequences of knee pain is its relationship with obesity, where knee pain has been shown to lead to an excess of energy intake and a significant increase in relative body weight, due to the fact that affected individuals are expending fewer calories through activity. This is particularly troubling as weight loss has been shown to reduce knee pain and its impact. This only further highlights the very important relationship between seeking treatment for knee pain and the ability to return to quality living.

Traditional Approaches for Knee Pain

Traditional therapies for knee pain seem inadequate in many patients. In a study, the use of paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of osteoarthritis produced no significant benefit over placebo. This may echo the feelings of patients who have tried these treatments and understand them to have limited effect on their knee pain. Medications such as NSAIDs will certainly produce an anti-inflammatory effect and help to manage pain in the short term. The use of paracetamol is not aimed at knee pain specifically but is commonly used to manage pain in more elderly patients. The literature does not support the use of opioid-based medications in the treatment of osteoarthritis. NSAIDs are also available in cream form and may be able to produce a more direct anti-inflammatory effect on the knee joint, rather than systemic effects. This could reduce gastrointestinal side effects and make them a more favorable treatment option. Unfortunately, it is difficult for patients to access these medications, and sufferers of chronic knee pain may experience that the relief of using creams is not substantial. In conclusion, medications have an analgesic and anti-inflammatory effect on the knee joint, but not one that has satisfied most patients with chronic pain.

Medications and Pain Management

A newer type of inflammation reducing injection involves synthetic forms of a substance called hyaluronic acid which is a component of joint fluid, but there is conflicting evidence about its effectiveness for knee pain.

Injections of corticosteroids directly into the joint can be considered as a treatment for knee pain. This treatment is appropriate when there is an inflammation in the knee, and it is often used in patients with rheumatoid arthritis as well as those with osteoarthritis. Corticosteroids have a powerful anti-inflammatory effect and can reduce swelling and pain rapidly, but there are also side effects including infection and damage to the tendons.

In patients with osteoarthritis who also have or are at high risk of developing a stomach ulcer, it is possible to take NSAIDS in combination with a drug called a proton pump inhibitor which reduces the amount of acid produced by the stomach, thereby reducing the risk of the stomach ulcer developing. Another type of drug known as a COX-2 inhibitor has similar efficacy to traditional NSAIDS for knee pain and less negative effect on the stomach and intestines. However, due to safety concerns there are strict regulations on its use.

There are several types of stronger painkillers called non-steroidal anti-inflammatory drugs (NSAIDS), some of which are available over the counter, such as ibuprofen and aspirin, and others which are available on prescription such as diclofenac and naproxen. They function to reduce the inflammation in the joint and thus reduce the pain. However, there are possible side effects and risks from taking these medications, such as damage to the stomach and kidneys, and they may exacerbate heart failure. It is recommended to take the lowest dose possible for the shortest amount of time necessary to reduce symptoms.

There are several types of medication that are used for managing knee pain, depending on the severity of the pain and its cause. Acetaminophen (paracetamol) is used to relieve pain and is often the first medication tried to relieve knee pain. However, there is evidence to suggest that it may be no more effective than a placebo in reducing pain and improving function in knee osteoarthritis.

Physical Therapy and Rehabilitation

High-level activities, especially in athletes, require more complex training programs. The physiotherapist will use specific exercises to simulate the actions performed in the activity. The final phase of treatment involves re-assessing the knee to check for any recurrence and prevent further injury. A home exercise program is provided to maintain the strength and flexibility gained during physiotherapy.

Static exercises are started once pain and swelling have consistently reduced to prevent quadriceps atrophy, which is a common problem in patients with knee joint effusion. Exercises may initially be performed without resistance in partial ranges of motion and then progressed to full ranges using closed chain and open chain exercises. The goal is to restore the patient to their pre-injury functional status. Any remaining instability issues are treated with exercises targeting the vastus medialis obliquus to improve patella tracking and proprioception.

Acupuncture has shown significant improvements in patients with various knee conditions. A study by Takeda et al. found that single needling resulted in better functional outcomes and joint proprioception compared to sham acupuncture or no treatment. This allows for immediate progression to exercises and strengthening with a lower risk of complications.

The physiotherapist and patient begin with an assessment of the knee and analysis of any causal factors and irritability of the condition to determine the appropriate treatment. Modalities such as electrical agents are used to reduce pain and swelling. Electrotherapy is commonly used in knee injury rehabilitation. It prepares the knee for exercise by causing muscle contraction and reducing muscle inhibition. It also helps reduce pain.

Physical therapy and rehabilitation are important for managing knee pain. The rehabilitative process and physical therapy need to be modified based on the severity of the condition or post-operative procedures. Rehabilitation focuses on reducing swelling and pain through elevation and ice. It is later modified to include range of motion exercises and strength training. Physiotherapy is the first line of treatment for conservative management, as studies have shown. It plays a major role before and after applying different physical treatment modalities.

Surgical Interventions

Partial knee replacement is a surgical procedure where the damaged surfaces of the articulating bones at the knee joint are removed and a prosthesis is then placed. This usually involves substantial postoperative pain and eventually short-term and long-term relief. Full knee replacement is generally done on older people when other treatments have failed. This is major surgery where the knee joint is replaced with an artificial joint usually made out of metal, plastic, or a combination of both. High tibial osteotomy is a surgical procedure generally prescribed for younger people with knee pain who are involved in heavy activities. This surgery involves realigning the knee joint by cutting the tibia and the fibula and then fixating using plates and screws. This is usually followed by several weeks of restricted weightbearing and an extensive amount of physiotherapy.

Surgical intervention is offered as a last option for patients with knee pain. Many factors such as physical health, lifestyle, age, the type and severity of knee pain, and the potential benefits from surgery must be taken into account. There are several types of surgery used to treat knee pain. Arthroscopy is a minimally invasive procedure involving a small incision where a camera is then inserted to allow the surgeon to view the inside of the knee joint. This procedure is sometimes followed by surgical tools and instruments to correct the problem.

Integrative Approaches for Knee Pain

Knee pain is commonly experienced by the middle-aged and elderly; it is a frequent complaint in the setting of a physician’s office. In a survey of 1039 adults over the age of 60, 37% men and 47% women reported knee pain in the past 30 days. 96% of those with frequent knee pain reported some disability. The Western medical treatment for degenerative osteoarthritis will usually begin with simple analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) for pain control. For moderate to severe pain, stronger opiate analgesics may be prescribed. There is no drug known to stop the progression of the disease, but in recent years glucosamine and chondroitin sulfate have been used as a remedy to slow the process. When drug therapy is no longer sufficient, joint injection or arthroscopic surgery may be recommended. These invasive procedures are usually followed by rehabilitation therapy in hopes of restoring some functional activity of the knee joint. Due to the invasiveness, cost and potential side effects from drug therapies to surgery, many patients may seek other less harmful alternatives for knee pain management. Acupuncture, an ancient form of Traditional Chinese Medicine, is one alternative therapy that has gained public attention in recent years, for its safe and effective treatment of chronic pain and degenerative joint diseases. This paper discusses acupuncture as a potential alternative therapy, especially for the elderly, in the treatment of knee pain due to osteoarthritis. The focus will be directed at the effectiveness of acupuncture and its value compared to the cascade of detrimental treatment commonly received in Western medicine. This paper also includes a case study of an elderly male patient with chronic knee pain, who received acupuncture treatment at the Raffles Pain Clinic in Singapore.

Acupuncture as a Complementary Therapy

Patient Selection – Acupuncture is a reasonable treatment option for patients with chronic pain whose activity is limited or who desire to avoid medication or medical interventions. It can also be a good supplement to other treatment methods that the patient may already be using. Before the patient begins acupuncture treatment, they should first discuss their condition with an acupuncturist to determine whether acupuncture is right for them. During this talk, the acupuncturist will consider the patient’s OA symptoms, general health, lifestyle, and personal needs in order to set a treatment plan.

Acupuncture has been used for over 2,500 years in China and other Eastern societies to treat many ailments and is effective in treating chronic pain conditions. In recent years, acupuncture has had a substantial increase in acceptance and utilization in the United States. In the year 2002, an estimated 8.2 million Americans used acupuncture. Although the majority of these treatments were for chronic pain conditions, including knee osteoarthritis (OA), one of the advantages of using acupuncture is that, compared to medication, it has no side effects and the cost of acupuncture is considerably less than many other forms of treatment. Often, it may provide pain relief when other treatments have failed.

Benefits of Acupuncture for Knee Pain

In the case of chronic degenerative or painfully arthritic knee conditions, constitutional treatment is suitable to correct underlying imbalances and strengthen the circulation of qi and blood throughout the body. Du meridian and Extra point needling can be used to tonify areas of deficiency in the knee whilst still potentially treating distal points. The attraction of treating knee problems with acupuncture is that there are usually a wide range of points that can be needled on the proximal and distal lower limb whilst still keeping the patient in a comfortable seated or supine position. This is particularly important when treating elderly or immobilized patients.

In acute traumatic injuries involving pain and inflammation, it is often beneficial to use local needling on specific points that are known to have a strong analgesic and anti-inflammatory effect. An example would be the use of the knee command point Xiyangguan (GB33), which has the effect of moving qi and blood in the lower limb and benefits the joints. This point is needled contralaterally to disperse and descending technique. Ashi points are also commonly used for their effect at moving qi and blood, also employing a variety of needling techniques. In injuries involving Blood stagnation, moxibustion is often used as an effective adjunct to needling.

From the Chinese perspective, knee problems can be classified under the traditional disease categories of Bi syndrome, Wei syndrome, or bone degeneration and can result from traumatic injury, overuse, poor circulation, or disruptions in the flow of qi and blood through the area. Osteoarthritis of the knee, a common biomedical diagnosis, is effectively a form of joint Bi syndrome characterized by degeneration of joint surfaces and alteration in the synovial fluid. Acupuncture has been reported to be highly effective in the treatment of knee osteoarthritis, and in one particular study, the effects of needling were comparable to that of arthroscopic lavage.

Western medicine views knee pain as a symptom of an underlying pathology. Of the musculoskeletal pain presentations, knee pain is one of the most common complaints prompting a patient to seek treatment. It also has the distinction of being one of the leading causes of disability and loss of independence in people over the age of 65. The “biomechanical overload” theory, wherein muscle imbalances lead to joint misalignment and increased compressive force at certain points in the joint, underlies many classical orthopedic diagnoses such as iliotibial band friction syndrome, chondromalacia patellae, and degeneration of the meniscus and/or articular cartilage. These conditions are often amenable to acupuncture treatment.

Singaporean Specialists in Acupuncture

In Singapore, the Ministry of Health has implemented a set of regulations that alternative treatments like acupuncture will seek to register and train practicing traditional Chinese medicine (TCM) practitioners and therapists. This is to ensure minimum standards of TCM practice and to protect patient safety. This means that those seeking acupuncture treatment in Singapore can rest assured that these registered TCM practitioners and therapists are well qualified in acupuncture and will provide a good standard of care. This move will also serve to dispel any doubts concerning the safety and effectiveness of TCM treatment, including acupuncture.

Enhancing the effects of acupuncture using an electrical charge – clinically known as electroacupuncture – has also shown to produce desirable results. A further study found that knee pain in elderly patients due to osteoarthritis was significantly decreased after receiving electrically charged acupuncture.

Acupuncture is a widely growing treatment for knee pain, largely due to its non-invasive attributes and comparatively lesser side effects. Research has shown that acupuncture can be an effective treatment for all types of knee pain. For example, a study showed that acupuncture is an effective treatment for osteoarthritis. Compared with the control group, patients who had acupuncture reported a significant reduction in knee pain and showed improvement in function.

The art of acupuncture and treatment of knee pain Doan and his colleagues have brought to light the clinical aspects of using acupuncture to treat knee pain. Based on an understanding of traditional Chinese medicine, they speculate that an individual TCM diagnosis and specific point selection will greatly improve acupuncture outcomes for the treatment of knee pain. However, their studies are shared with biases; for example, Doan expresses skepticism on subjective effects and clear effectiveness on sham. Though specific diagnosis and treatment may yield clearer results on knee pain, this may not reflect the realities of modern acupuncture utilization. As seen in the case of the MAS group, individuals may not show any significant improvement with a standardized treatment specific for an illness. Nonetheless, approaching the methodology in the same way would still validate TCM theory. Tang presents a positive approach to using acupuncture for knee pain through discussing the physiological effects of acupuncture on the knee. Though his studies are also biased in trying to prove TCM theory, Tang raises valid points for creating acupuncture treatments that would fit the modern paradigm. Since TCM acupuncture is primarily point-oriented, he suggests that using different needling techniques to elicit neurophysiological responses and more research on acupoint mechanism may provide enough of a bridge to integrate with biomedicine.

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