Vol. 15, #2

An Innovative Technique For Relief Of Knee Pain
Ronald S. Shapiro, MD

ABSTRACT
Knee pain affects a significant portion of the population. Knee pain likely will become an even greater clinical challenge with obesity on the rise. Symptomatic and functional relief using conventional medical therapies may be limited due to their ineffectiveness and side effects. Acupuncture treatment offers a safe and effective method to control knee pain. An alternative, needleless acupuncture technique is described herein that may produce greater relief than traditional acupuncture. The advantage of this technique is that treatment time is shortened, fewer office visits are required, and results appear equal or superior to results of other pain-relieving modalities.
KEY WORDS
Acupoint Injection, Acupuncture, Arthritis Pain, Knee Pain, Joint Pain

INTRODUCTION
The National Center for Health Statistics household survey in 1979 reported that approximately 10% of the adult population tolerates a month or more of knee pain each year.1 Symptoms of knee pain in the US population ranged from 5.2% to 14.9% from ages 25-74. A follow-up survey and report by the National Health and Nutrition Examination Survey (NHANES III) described a greater incidence of knee pain in older Americans. The study conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics was designed to produce a nationally representative sample of the civilian, non-institutionalized US population. Overall, 18.1% of US men and 23.5% of US women aged 60 and older reported knee pain on most days for 6 weeks prior to their medical exam.2 Moreover, as the weight of the population increases, so does the incidence of knee pain.3

Acute knee pain, in contrast to chronic knee pain, also accounts for a significant number of patient visits. Annually, there are more than 1 million emergency department visits and 1.9 million primary care outpatient visits for acute knee pain.4

Minimally, knee pain diminishes the quality of life and can hamper performance in almost every segment of life. Many traditional medical therapies have significant drawbacks. Habituation, addiction, tachyphylaxis, and sedation pose a disadvantage to the use of analgesics and narcotics. Corticosteroids, used to control the local and systemic effects of the rheumatic and autoimmune diseases, often relieve joint pain. In the past, oral steroids were prescribed to suppress joint pain. However, often there are serious negative consequences, i.e., osteoporosis, loss of bone mineral density, avascular necrosis, adrenal suppression, and pathologic fractures.5-10 Subsequently, using steroids to treat joint pain has fallen into disfavor. Intra-articular steroid injection may also produce negative consequences such as osteomyelitis, septic arthritis, soft tissue calcification, and necrotizing fasciitis.11-17

The introduction of the non-steroidal anti-inflammatory drugs (NSAIDs) was met with enthusiasm, hope, and expectations. In the majority of instances, they do relieve joint pain. But, this widely anticipated pain solution may also have harmful consequences. In the United States, it was estimated that there were "41,000 hospitalizations and 3,300 deaths each year among the elderly that are associated with NSAIDs."18 Wolfe, in an earlier article, estimated that there were 20,000 deaths resulting from NSAID use.19 Singh reported that 107,000 patients are hospitalized annually for NSAID-related GI complications, and at least 16,500 NSAID deaths occur yearly among arthritis patients alone.20

Traditional care embraces a spectrum of therapy including physical therapy, exercise, analgesics, non-steroidal anti-inflammatory drugs, intra-articular injections, and surgery. Recent statistically significant controlled studies have reported the beneficial effect of acupuncture on the relief of knee pain.21-24 The degree and length of pain relief as well as rehabilitative parameters are explored. Acupuncture may benefit patients suffering from a variety of conditions producing knee pain.

The author used a traditional acupuncture approach to treat knee pain resulting from a variety of conditions. Most knee pain patients achieve successful results from this technique; however, time limitations stimulated an interest in finding a more time-efficient yet effective approach. Herein is described an innovative technique which is time-efficient and yields successful results, with excellent patient acceptance.

This method offers practitioners a relatively simple and consistently effective means to relieve knee pain and stiffness. Relief in the vast majority of patients lasts 3-4 weeks, precluding the need for more frequent treatment sessions. An additional advantage is that the practitioner is not required to search for points for a particular diagnosis nor commit them to memory.

METHODS
Traditional Acupuncture Treatment of Knee Pain
A wide variety of acupuncture "formulas and recipes" to treat the knee are described in texts.25-28 A mixture of points is recommended according to the diagnosis, which may include: knee disorders, knee sprain, arthritis of the knee, and injury to the knee. Table 1 lists numerous points proposed for knee pain. It is tedious to discover the correct prescription for the patient.

The Dermajet
This technique employs the use of an instrument, the Dermajet (Robbins Instruments Inc,  Chatham, NJ). The device (Figure 1) is a spring-loaded, forced-air system that when triggered at the skin surface delivers 0.1 mL of a solution producing a subcutaneous wheal.

Table 1. Recommended Acupuncture Points to Treat Knee Pain, Obtained From Various Tests

Stomach

Kidney

Gallbladder

Bladder

Liver

Spleen

Governing Vessel

ST 31

KI 10

GB 31

BL 11

LV 6

SP 12

GV 3

ST 34

GB 33

BL 37

LV 8

ST 35

GB 34

BL 40

ST 36

GB 38

BL 54

ST 37

BL 61

ST 38

ST 44



Carbocaine (mepivacaine hydrochloride) 2%; and Serapin, an extract from the Pitcher Plant, salts of the volatile bases from Sarraceniaceae (High Chemical, Levitown, PA) in equal mixture, are placed in the sterile 5-mL solution chamber of the Dermajet. After priming, the device is cocked, and the replaceable sterile tip is placed perpendicular to and touching the epidermis at the selected site (described below). The wheal produced may vary in its fullness depending upon the character of the patient's skin and subcutaneous tissue and frequently, there will be a small visible hole at the center.

More recently, a Dermajet Gun (Figure 1) became available (Robbins Instruments Inc). This was found to be even more time-efficient. The solution chamber in the gun holds 10 mL of fluid, allowing more treatment without having to reload. Moreover, the total and individual point treatment delivery time is substantially shortened as the gun may be "fired" without having to manipulate a cocking lever.

Figure 1. Dermajet solution chamber (1), cocking lever (2), trigger (3), Dermajet Gun 10-mL solution chamber (4), trigger handle (5). Inset: Changeable tips – stainless steel for gun (A), plastic for Dermajet (B).

Figure 2. Graphic illustration of the VAS (simplified from Nogier): With each beat of the heart (1) a pulse wave is generated down the arterial tree (2). Stimulation of an acupuncture point (3) results in an adrenergic discharge producing peripheral vasoconstriction (4). With the cardiac output remaining constant, the pulse beat has greater amplitude and the apex of the pulse is displaced slightly proximal (5). This is perceived by the examining thumb as the pulse becomes stronger and displaced slightly distal (6).

Vascular Autonomic Signal
The 2nd component of this technique incorporates the Nogier vascular autonomic signal. Points that require and respond to treatment around the knee area are easily identified using the signal. The vascular autonomic signal is a useful technique in identifying acupuncture points. Not only does it detect the acupuncture point, but it also identifies points that are involved in pathology.

In 1945, René Leriche observed that very light stimulations of the skin could trigger a change in the pulse. In 1966, Nogier discovered that stimulation of a point on the ear similarly could produce a change in the character and position of the radial pulse. It is this change in the character of the pulse that is referred to as the vascular autonomic signal. Nogier presents his classic detailed description of how he discovered the signal and "how to take the VAS" in his book, From Auriculotherapy to Auriculomedicine.29

I learned that stimulation of an acupuncture point will produce the characteristic pulse change for 2 beats. If the point involved is associated with disease or pathology, the examiner will feel 3 beats and frequently, a sustained change in the pulse while the point is being stimulated (signal-positive points). Furthermore, in an effort to simplify my understanding of the vascular autonomic signal and enable me to teach it to others, I developed a graphic concept briefly presented in Figure 2.

Touching or hovering above a point with a finger, a sharp or blunt point, or an instrument will produce the vascular autonomic signal. Interpreting and extrapolating from Nogier, I concur that when an acupuncture point is stimulated, there is a systemic adrenergic discharge. This causes peripheral vasoconstriction. The radio-palmar arch vessels in the hand constrict, and assuming cardiac output remains constant, greater arterial intra-luminal pressure develops, amplifying the radial pulse. Also, because of the peripheral vasoconstriction, the apex of the pulse is displaced proximally.

Nogier recommends taking the pulse using the tip of the thumb. Because the thumb has greater cortical representation than the fingers in the brain, he believes that it is more sensitive and receptive to the subtle change in the radial pulse. By using the tip of the thumb, the examiner will not be distracted or deceived by one's own thumb pulse. While taking the pulse, the examiner's arm should be parallel to the patient's, and only light thumb pressure should be applied to avoid masking the signal (Figure 3).

Figure 3. Taking the vascular autonomic signal. Apply only light pressure with the tip of the thumb. The apex of the radial pulse becomes more pronounced and shifts slightly proximal (perceived slightly distal on the examiner's thumb) when the VAS is positive.

When the signal is positive (present), the examiner will notice the peak of the radial pulse becomes higher (a more pronounced pulse) and the peak also moves slightly proximal in the subject (shifts distally towards the tip of the examiner's thumb) (Figure 2).

Patient Evaluation
The examination included observation of gait and range of motion including the degree of knee joint extension and flexion with and without weight bearing (climbing and descending at least 3 stairs). The patient is examined for local changes such as edema or discoloration and crepitus. Lastly, using the dorsum of the distal fingers, the joint is examined for local areas of heat or relative warmth compared to contiguous areas (Figure 4). Consistently, heat localized in the painful areas which, when palpated, confirms the areas where pain is occurring.

Technique
The instrument and components are either heat or gas sterilized prior to each use. The plastic parts of the instrument are better maintained with gas sterilization or steam sterilization at 270°F. Replaceable plastic tips for the Dermajet and stainless steel tips for the Dermajet Gun are available, allowing multiple uses of the instruments on a given day.

Figure 4. Use the dorsum of the fingers to explore the areas of increased warmth. It may be perceived by either touching or close to the skin.

Figure 5. Locations of the 4 knee quadrants, ST 36, and the "eye of the knee" are demonstrated.

Figure 6. Exploring with the tip of the Dermajet Gun while identifying the positive VAS points using the radial pulse. Upon identifying a positive VAS, the Dermajet Gun is fired producing a wheal from the subcutaneous instillation of 0.1-mL of the fluid expressed from the solution chamber.

Figure 7. Post Dermajet treatment of the knee. Multiple subcutaneous wheals produced by the Dermajet Gun at the 6 "standard" knee points and positive VAS points. After treatment, spot bandages or a gauze dressing is applied where necessary.

The patient is seated on the exam table with knees exposed and flexed over the side. The gloved practitioner cleanses the entire knee with isopropyl alcohol. The radial pulse is palpated with the examiner's non-dominant thumb, while the Dermajet held in the dominant hand searches for and treats positive signal points.

In all cases, treatment is initiated incorporating the same 6 "standard" points: 4 peripheral knee quadrants, ST 36, and the "eye of the knee" (Figure 5). While palpating the radial pulse with the non-dominant thumb, the instrument held in the dominant hand slowly moves and hovers just above the area or may actually slide across the skin surface.  When the 3 or more beats are felt, the instrument is placed on the skin and triggered, which introduces the solution subcutaneously producing a wheal at the selected point (Figure 6).

To complete treatment, the practitioner must recall the areas where localized warmth was identified, then repeat the same maneuver of hovering and moving the Dermajet to identify positive points. When a positive point (3 or more beats) is identified, installation of 0.1 mL of the solution is delivered by actioning the instrument. Even though some patients complained of posterior knee pain, treatment is administered only to the anterior, medial, and lateral knee. (Figure 7 illustrates completed treatment of a patient's knee.) Then, the area is cleansed with alcohol and if required, either spot bandages or gauze dressings are applied. Generally, most patients require a total of 10 to 16 points treated per knee. (Do not use this technique on patients with documented or suspected joint infection.)

Post-treatment, the patient is asked to flex and rotate the knee while sitting, standing and walking, flex the knee with weight bearing, and to ascend and descend the stair steps per pre-treatment. The degree or absence of pain with each movement is noted and recorded using a pain scale of 1-10 (10 being the most severe).

CASE REPORT
A 63-year-old man had intermittent bilateral knee pain for over 40 years. He had repeated knee trauma resulting from playing football and service-related parachute jumping. Knee x-rays showed degenerated cartilage and osteoarthritic changes bilaterally. The patient complained of global pain greater in the left knee. The pain occurred with movement; and in the preceding 5 years, he sporadically had a limp. Climbing and descending stairs was painful and he was unable to squat.

Analgesics and non-steroidal anti-inflammatory drugs provided minimal pain relief. The patient's history included type 2 diabetes mellitus of 3 years' duration, hypertension, prostatitis, benign prostatic hyperplasia, and remote renal calculi. Oral hypoglycemics and antihypertensives were his only medications.

The more painful left knee was initially treated in 1998 with the Dermajet technique. With 2 follow-up visits at 1 and 7 months, he became asymptomatic. Symptoms were mild upon returning and he did not seek treatment again until 2001. At that time, both knees were symptomatic and were retreated using the same protocol. Full pain relief was obtained; for 2 years, the patient experienced only mild intermittent pain and reported no limping. Two years later, pain was present globally in both knees with posterior pain being more pronounced on the right. The patient's gait was slightly guarded; there was no edema, erythema, or crepitus of the knees. Walking and both climbing and descending stairs produced pain. Squatting to 30° resulted in moderately severe pain. Warmth and moderate tenderness was present bilaterally at the inferior medial and lateral knee areas.

Treatment was administered by following the protocol. Eight weeks post-treatment, the patient was still asymptomatic. His gait was more fluid, ascending and descending stairs produced no pain, and was able to perform a full squat without discomfort.

RESULTS
In my practice, 43 patients with unilateral or more frequently, bilateral knee pain from a variety of etiologies, have been treated with the Dermajet technique; 14 men and 29 women, ages 24 to 86 years old, have undergone treatment. Their knee pain diagnoses included osteoarthritis, gouty arthritis, arthritis accompanying collagen diseases (i.e., lupus), psoriatic arthritis, degenerative joint disease, posttraumatic arthritis, post knee joint replacement, and knee pain of incompletely diagnosed etiology.

Patients scored their pain on a scale of 1 to 10, with 10 representing the most severe pain. Immediately after the procedure, each was asked to report pain relief. A pain level less than 2 was reported by 40 patients; most had no pain. Most patients with chronic conditions experienced 3 to 4 weeks of pain relief; however, in some patients, the relief was variable.

In addition to pain relief, most patients reported less stiffness, greater mobility, and were able to perform painless weight bearing flexion, gaining 20° to full flexion. Edema about the knee, when present pretreatment, variably diminished post-treatment. Tender areas prior to treatment became non-tender post-treatment. Areas with increased warmth became cooler. Patients with posterior knee pain symptoms were relieved with anterior, medial, and/or lateral treatment.

Five patients were offered knee replacement by orthopedic surgeons if knee pain remained intolerable. All were able to postpone surgery with the Dermajet procedure. Most patients were able to substantially curtail or eliminate analgesics and non-steroidal anti-inflammatory drugs.

DISCUSSION
Acupuncture can provide effective safe pain relief and enhance mobility. When indicated, traditional medical therapy should be explored and undertaken; acupuncture can be considered a useful adjunctive. This technique produces immediate and dramatic results, has prolonged therapeutic effects, is time-efficient, and enjoys high patient acceptance. The disadvantages include the initial cost of instrumentation, mild injection discomfort, and the need for instrument sterilization.

The technique described herein provides physicians with a safe and effective method to treat knee pain from a variety of causes. It provides physicians with a valuable tool to safely relieve knee pain without having to rely on other options that may have deleterious effects.

CONCLUSION
Future controlled studies would be useful to verify if the Dermajet technique is superior to traditional acupuncture of the knee as well as comparing it to conventional medical measures in treating knee pain.

DISCLAIMER
The author has no financial relationship or agreement with Robbins Instruments Inc.

REFERENCES

  1. National Health and Nutrition Examination Survey. Basic data on arthritis of the knee, hip and sacroiliac joints in adults 25-74 years. United States, 1971-1975. Hyattsville, Md: National Center for Health Statistics; 1979 Publication Number (PHS) 79-1661, Vital and Health Statistics Series 11, No. 213.
  2. Anderson RE, Crespo CJ, Ling SM, Bathon JM, Bartlett SJ. Prevalence of significant knee pain among older Americans: results from the Third National Health and Nutrition Examination Survey. J Am Geriatr Soc. 1999;47:435-438.
  3. Casper J, Bergt K. Effects of exercise on osteoarthritis: a review. J Strength Cond Res. 1998;12:120-125.
  4. Jackson JL, Malley PG, Kroenke K. Evaluation of knee pain in primary care. Ann Intern Med. 2003;139:576-588.
  5. Loddenkemper K, Grauer A, Burmester GR, Buttgereit F. Calcium, vitamin D and etidronate for the prevention and treatment of corticosteroid induced osteoporosis in patients with rheumatic diseases. Clin Exp Rheumatol. 2003;21:19-26.
  6. Emkey R, Delmas PD, Goemaere S, et al. Changes in bone mineral density following discontinuation or continuation of alendronate therapy in glucocorticoid-treated patients: a retrospective, observational study.  Arthritis Rheum. 2003;48:1102-1108.
  7. Pearce G, Ryan PF, Delmas PD, et al. The deleterious effects of low-dose corticosteroids on bone density in patients with polymyalgia rheumatica. Br J Rheum. 1998;37:292-299.
  8. Epstein NN, Tuffanelli DL, Epstein JH. Avascular bone necrosis.: a complication of long-term corticosteroid therapy. Arch Dermatol. 1965;92:178-180.
  9. Loddenkemper K, Grauer A, Burmester GR, et al. Prevalence of vertebral deformities and symptomatic vertebral fractures in corticosteroid treated patients with rheumatoid arthritis. Rheum (Oxf).  2001;40:1375-1383.
  10. Jardinet DR, Lefebvre C, Depresseux G, et al. Longitudinal analysis of bone mineral density in pre-menopausal female systemic lupus erythematosus patients: deleterious role of glucocorticoid therapy at the lumbar spine. Rheum (Oxf). 2000;39:389-392.
  11. Jawed S, Allared SA. Osteomyelitis of the humerus following steroid injections for tennis elbow. Rheum (Oxf). 2000;39:923-924.
  12. Mont MA, Myers TH, Krackow KA, Hungerford DS. Total knee arthroplasty for corticosteroid associated necrosis of the knee. Clin Ortho Related Res. 1997;338:124-130.
  13. Tillander B, Larlsson MH, Norlin R. Effect of steroid injections on the rotator cuff: an experimental study in rats. J Shoulder Elbow Surg. 1999;8:271-274.
  14. Chazerain P, Rolland DR, Cordonnier C, Ziza JM. Septic hip arthritis after multiple injections into the joint of hyaluronate and glucocorticoid. Rev Rheum Engl Erectile Dysfunction. 1999;66:7-8,436.
  15. Garcia-Porrua C, Blanco FJ, Atanes A, et al. Septic arthritis by Aspergillus Fumigatus: a complication of corticosteroid infiltration. Br J Rheum. 1997; 36:610-611.
  16. Toussirot E, Kremer P, Benmansour A, Wendling D. Giant calcification in soft tissue after shoulder corticosteroid injection. J Rheum. 1996;23:181-182.
  17. Hofmeister E, Engelhardt S. Necrotizing fasciitis as complication of injection Into greater trochanteric bursa. Am J Orthop. 2000;30:426-427.
  18. Griffin MR. Epidemiology of nonsteroidal anti-inflammatory drug associated gastrointestinal injury. Am J Med. 1998;104(3A):23A-29A: discussion 41S-42S.
  19. Wolfe MM. NSAIDs and the gastrointestinal mucosa. Hospital Pract. 1996;31:37-44,47-48.
  20. Singh G. Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med. 1998;105(1B):31S-38S.
  21. Nastund JN, Ulla-Britt O, Sten Lundegreg T. Sensory stimulation (acupuncture) for the treatment of idiopathic anterior knee pain. J Rehabil Med. 2002;4:231-238.
  22. Tillu AT, Sumedha Vowler S. Effect of acupuncture on knee function in advanced osteoarthritis of the knee: a prospective, non-randomized controlled study.  Acupunct Med. 2002;20:19-21.
  23. Christensen BVI, Bilbek IU, Bulow H, Dreijer HH, Rasmussen HG. Acupuncture treatment of severe knee osteoarthritis: a long-term study. Acta Anaesthesiol Scand. 1992;36:519-525.
  24. Jensen R, Gothesen O, Liseth K, Baerheim A. Acupuncture treatment of patellofemoral pain syndrome. J Altern Complement Med. 1999;5:521-527.
  25. The Academy of Traditional Chinese Medicine. An Outline of Chinese Acupuncture. Peking, China: Foreign Languages Press; 1975.
  26. Lee JF, Cheung CS. Current Acupuncture Therapy. Oakland, CA; GRT Book Printing; 1978.
  27. Chu LSW, Yeh SDJ, Wood DD. Acupuncture Manual, A Western Approach. New York, NY: Marcel Dekker, Inc; 1979.
  28. Chaitow L. The Acupuncture Treatment of Pain. Wellingborough, England; Thorsons Publishers Limited; 1979.
  29. Nogier PFM. From Auriculotherapy to Auriculomedicine. Saint Ruffine, France: Maisonneuve; 1983.

AUTHOR INFORMATION
Dr Ronald S. Shapiro is Associate Clinical Professor of Medicine at Medical College of Ohio, and practices Internal Medicine, Nephrology, and Pain Control in Toledo, Ohio. Dr Shapiro received his PhD in Acupuncture from University of Oriental Studies, Monterey Park, California.

Ronald Shapiro, MD, PhD*
3930 Sunforest Ct
Toledo, OH 43623
Phone/Fax: 419-841-2138 • E-mail: rshapiro@edok.com

*Correspondence and reprint requests

Home   Contact Information   Search

Copyright ©2001 American Academy of Medical Acupuncture. All Rights Reserved.