Role Of Acupuncture In Postoperative Rehabilitation After Total Knee
Pamela Avery, MD
To determine if acupuncture, through its analgesic, anti-inflammatory,
and immune system support mechanisms, can enhance the postoperative
recovery in patients having total knee arthroplasty.
A 29-year-old woman undergoing total knee replacement for severe pain,
swelling, and limited mobility.
History of Present Illness
A 29-year-old nurse presented with right knee pain, swelling, and limitation
of movement 9 months after right total knee replacement. She had a torn
anterior cruciate ligament as an 18-year-old athlete, and subsequently
underwent reconstruction with an allograft ligament as well as bone
graft to the femoral condyle and tibial plateau. A staphylococcal infection
developed and she required a hemi-knee replacement. She experienced
loosening and breakdown of the polyethylene components of the knee requiring
2 revisions. Ultimately, 9 years after the original injury, the patient
underwent total knee replacement due to severe pain, swelling, and limitation
of movement. Immediately following the procedure, the knee developed
dramatic swelling, bruising, and bleeding. She was treated conservatively
with gradual ambulation, narcotics, and physical therapy. Four months
postoperatively, she required manipulation of the joint while under
anesthesia, yet the joint remained swollen, painful, and poorly mobile.
By 8 postoperative months, active and passive manipulation of the joint
in physical therapy was replaced with a water-walking and swimming routine.
In addition, the continuous passive movement device was used in the
evenings without significant improvement. Consideration was given to
knee arthroscopy for lysis of adhesions and evaluation of stability
of the prosthesis to determine if a repeat knee reconstruction was indicated.
The patient desired a nonsurgical approach if possible and therefore
sought consultation concerning acupuncture.
All other past medical history was unremarkable except for a 5-year
history of infertility with subsequent lysis of adhesions via laparoscopy.
The physical examination revealed a significantly altered gait due to
a relatively immobile right knee. Well-healed surgical scars were present
on the medial aspect of the knee as well as laterally. The right knee
was stiff and limited in movement. Knee circumference was significantly
larger on the right vs the left (14 and 10 in, respectively). Flexion
was limited to 52º and extension stopped at 11º. Tenderness
to palpation existed at ST 36, 34; SP 9, 10; BL 40; KI 10; and LR 8 with tenderness throughout the SP meridian. Tongue inspection
revealed some mild scalloping of the edges.
From a Western perspective, the patient appeared to have limitation
of knee movement secondary to protracted swelling and subsequent pain,
and possible adhesions without clear evidence of prosthesis instability.
From a TCM perspective, she appeared to have obstruction at the knee
from the surgical procedure, and scar formation with an underlying SP
deficiency resulting in edema, pain, and relative immobility. Her prior
history of intra-abdominal adhesions supports the concept of adhesion
formation contributing to her limitation of flexion as an underlying
The patient was instructed to continue her traditional therapy of swimming
and water walking while using the same traditional medication regimen,
celecoxib and tramadol hydrochloride, as a trial of acupuncture was
instituted. She reported regularly to physical therapy for measurements
of knee circumference, flexion, and extension of the joint over a 12-week
|Table 1. Treatment Approaches
|1. Local points
||ST 34, 36; SP 9, 10 (4 Hz electrical stimulation, heat, and moxa)
||BL 40, KI 10, LR 8, GB 33
||Tai Yin/Yang Ming SP 6, 9,10; ST 36, 34 (4 Hz)
||Shao Yin/Tai Yang KI 3, SP 6, BL 60 (4 Hz)
|3. Percutaneous electrical nerve stimulation
||T-12, L-2, L-4, S-1 (2 Hz)
|Shen Men, Knee point (phase 1)
|Yamamoto Scalp Koryo Hand
||Yang knee point (G) 1 needle Correspondence points
on meridians I,J,F,E
An acupuncture treatment plan was developed to address both the anterior
and posterior aspects of the joint using the following set of points
and techniques. Four treatments were performed anteriorly and 4 posteriorly
for a total of 8 treatments over a 12-week period. De Qi was elicited
at all points using 0.30 Carbo needles. Low-frequency stimulation and
moxa or heat tonification were used. Each session lasted approximately
30 minutes, with 20 minutes of electrical stimulation and heat plus
5 minutes of moxibustion. The axes of treatment chosen were Tai Yin/Yang
Ming for the anterior surface with local points ST 34, 36; SP 9, 10
during the first 4 treatments (Table 1). Subsequently,
energy axis Shao Yin/Tai Yang was used posteriorly with percutaneous
electrical nerve stimulation (4 Hz) at lumbar segments T12-L5 (4 levels)
and local modules at BL 40, KI 10, LR 8, and GB 33. Microsystems of
the ear, hand, and scalp were variously used to enhance local points,
principal meridian energy circuits, and percutaneous electrical nerve
stimulation (posterior treatments).
|Table 2. Postoperative Progress
||Prior to treatment
|Knee circumference, in
The patient noted immediate reduction in pain and swelling within the
first 2 treatments (2 weeks). Knee circumference decreased by 2 in and
flexion improved by 16º as measured by physical therapy. Over the
next 4 weeks (5 treatments total), swelling diminished another 2 in
and flexion increased by another 20º. By the end of 12 weeks and
8 total treatments, knee circumference diminished a total of 4 in, flexion
increased by 48º, and extension improved by 11º to full extension
(0º) [Table 2].
Total knee arthroplasty is a common surgical treatment for severe knee
pain and limitation of movement secondary to various medical conditions,
most commonly rheumatoid arthritis and osteoarthritis. While the obvious
goal of joint replacement is to achieve improved function and decrease
pain, it is still a challenge to consistently accomplish this for each
patient. One review of 724 replaced knees revealed that only one-third
flexed to 105º, while nearly one-half did not flex beyond 90º.1
Patients with the lowest levels of function tended to have the least
flexion and vice versa. Commonly, patients with decreased flexion often
require knee manipulation under anesthesia. One theory is that adhesions
may contribute to the restriction of movement and manipulation can rupture
these adhesions. In an effort to identify prognostic indicators for
knee manipulation, 1 review compared the records of 60 osteoarthritic
patients (94 knees) who required knee manipulation after total knee
arthroplasty vs 28 patients (48 knees) who did not.2 The authors concluded
that an increase in knee dimension by 12% or greater was a critically
independent variable that significantly predisposed patients to manipulation.
They also showed that quadriceps adhesions were another major factor
leading to manipulation. Another study looked at factors that influenced
the postoperative range of motion after total knee arthroscopy.3 That
study showed factors influencing the postoperative range of motion in
total knee arthroplasty to include preoperative range of motion, the
primary indication for arthroplasty, heights of postoperative joint
line, patellar thickness, postoperative pain, and successive postoperative
Acupuncture has been used to decrease pain and swelling, particularly
in acute musculoskeletal disorders. Although acupuncture has been praised
for thousands of years, studies of efficacy in patients with osteoarthritis
have given conflicting results.4-6 To date, no previous studies have
examined the role of acupuncture in the rehabilitative process after
total knee arthroplasty. Studies have validated the classic acupuncture
conduits and shown them to be distinguishable from lymphatic, vascular,
and nervous system pathways. Acupuncture also appears to be more than
just a simple method of pain relief; it may reduce inflammation and
support the immune system, among many other properties.7
Based on this patient's severely limited mobility at start of treatment
and the length of time from surgery, it is reasonable to assume that
the acupuncture treatments significantly contributed to the increased
range of motion ultimately observed. No other variables were changed
in her treatment, and no progress had been seen clinically for several
months. She was able to increase function significantly and continued
improvement is expected. This case demonstrates that acupuncture may
be used to decrease pain and swelling after total knee arthroplasty,
even in the extended postoperative phase, thereby increasing mobility
and restoring function. If AP knee dimension and adhesion formation
are critical variables in predicting which patients may require subsequent
manipulation due to immobility, and if postoperative pain influences
final range of motion after total arthroplasty, one can theorize that
acupuncture applied early in recovery may have significant benefit.
Controlling pain and swelling early in the postoperative period could
result in early increased function and decreased formation of adhesions,
improving the functional outcome after total knee arthroplasty.
Forster IW, Wallace WA. Effect of total knee arthroplasty on maximal
flexion. Clin Orthop. 1989;247:168-174.
D, Lombardi AV Jr, Mallory TH, Vaughn BK. Knee manipulation following
total knee arthroplasty: analysis of prognostic variables. J Arthroplasty.
Saito S, Yamamoto K, Sano S. Factors influencing the postoperative
range of motion in total knee arthroplasty. Bull Hosp Jt Dis. 1993;53:35-40.
Chang LW, Shaw L-C. Efficacy of acupuncture on osteoarthritic pain:
a controlled, double-blind study. N Engl J Med. 1975;293:375-378.
BV, Iuhl IV, Vilbek H, Bulow HH, Dreijer NC, Rasmussen HF. Acupuncture
treatment of severe knee osteoarthritis: a long-term study. Acta
Anaesthesiol Scand. 1992;36:519-525.
BM, Lao L, Greene M, et al. Efficacy of traditional Chinese acupuncture
in the treatment of symptomatic knee osteoarthritis: a pilot study.
Osteoarthritis Cartilage. 1995;3:139-142.
RA. Demythologizing acupuncture part 1: the scientific mechanisms
and the clinical uses. Altern Complement Ther. 1997;1:125-131.
Dr Pamela Avery is a Board-certified Anesthesiologist with credentials
in Pain Management, and practices Medical Acupuncture for Meriter Health
System's Complementary Medicine Program in Madison, Wisconsin. Dr Avery
integrates complementary medicine with traditional Western techniques,
and works closely with patients' primary care physicians.
Meriter Hospital Complementary Medicine Program
202 So Park St
Madison, WI 53715