Your Doctor Says You Have Osteoarthritis, But Don’t Go Under The Knife Just Yet

Your Doctor Says You Have Osteoarthritis, But Don’t Go Under The Knife Just Yet

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Over the last 20 years, the number of Americans seeking acupuncture treatment has continued to rise.17 While less than 1% of the U.S. population sought acupuncture treatment in the early 90’s, over 12 million Americans received acupuncture in 201018 Another intervention that uses thin filiform needles to penetrate the skin is dry needling (DN). A procedure commonly used by Western-based, health care professionals (i.e. physicians, osteopaths, chiropractors, physical therapists, etc.), DN has also gained popularity in the United States for the treatment of neuromusculoskeletal conditions over the past 10 years. The purpose of this paper is to shed a little light on how & why DN does what it does, especially as it pertains to hip & knee osteoarthritis.

According to the CDC arthritis and other rheumatic conditions are the most common cause of disability among US adults, and were the most common cause of disability among US adults for the past 15 years.18 They also state that nearly 1 in 2 people may develop symptomatic knee OA by age 85 years.17 Interestingly, two in three people who are obese may develop symptomatic knee OA in their lifetime. One in 4 people may develop painful hip arthritis by age 85 years. (19)

As physical therapists, we treat a variety of patients that come into our doors with the diagnosis of OA of the hip, knee, or ankle respectively. For many of these patients common treatments physical therapists utilize are exercise and manual techniques (Instrument soft tissue mobilization, joint mobilizations, or manipulations), which can be very effective in treating subjective pain, loss of range of motion, and functional disability. Bajaj et al concluded that those subjects that had more severe degenerative findings on an x-ray had a higher number of trigger points (TrPs) in the surrounding musculature.1  Bajaj also stated the greater number of TrPs may be associated with central and peripheral sensitization caused by OA. This is due to persistent nociceptive input from the OA joints leading to increased responsiveness of dorsal horn neurons processing input from the joint or surrounding tissue.1 This is why DN can be so effective in treating this population due to the high number of TrPs, which is one of the main indications for its use and its effect on the pain pathway to the spinal cord / nervous system.

dry needlingDN has many mechanisms sited in the literature including biochemical, biomechanical, endocrinological, neurovascular, supraspinal and segmental to name a few. 2-5 After evaluating a  patient, I explain his or her condition, expectations of recovery, and future plan of care, I then suggest the use of  DN if appropriate.  Occasionally, the patients seem to have a confused look on their face and ask me “you use needles for that.” I then explain to them that DN is used for many diagnoses, but find it very effective for OA for its ability to reduce pain (2-5), increase blood flow to the joint & surrounding musculature through vasodilation5-10 (increase in blood flow), and mechanotransduction in tissue restructuring / healing. (6-10, 12-14)  Interestingly, the addition of electricity to acupuncture may further enhance outcomes for treating chronic pain. (5-7, 12)  Evidence from multitude trials supports the use of electroacupuncture for its physiological effects, predominantly opioid analgesia and increased microvasodiliation. (5, 8-12)

To summarize, DN is used very routinely in the management of hip, knee, and ankle OA. As a reminder if we just utilize DN as the primary treatment most treatment effects are short-lived, so compliance to the home exercise program if vital. Also, your physical therapist should employ additional treatment interventions including but not limited to manual techniques, corrective taping, core & hip strengthening, lower extremity stretching, and re-education to functional activities like walking and squatting to manage the patients overall condition.

If this is something you as a patient are interested in please contact OSI Physical Therapy to see if there is a therapist in your area or please contact us via telephone to discuss this with a therapist to see if you are appropriate for the treatment.

Thanks,

– Saul

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1. Bajaj P, Bajaj P, Graven-Nielsen T, Arendt-Nielsen L (2001) Osteoarthritis and its association with muscle hyperalgesia: an experimental controlled study. Pain 93: 107-114.

2. Hinman RS, McCrory P, Pirotta M, Relf I, Forbes A, Crossley KM, et al. Acupuncture for chronic knee pain: a randomized clinical trial. JAMA. 2014;312(13):1313-22.
3. Acupuncture Effect Not Clinically Meaningful; http://www.apta.org/PTinMotion/2015/8/Viewpoints/. Accessed August 3, 2015.
4. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444-53.
5. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-65.
6. Vas J, White A. Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis–an exploratory review. Acupunct Med. 2007;25(1-2):29-35.
7. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford). 2007;46(3):384-90.
8. Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. 9. Ann Intern Med. 2004;141(12):901-10.

10. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford). 1999;38(4):346-54.

11. Barnes PM, Bloom B, Nahin RL (2008) Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report : 1-23. 2. Dunning J, Butts R, 12. Mourad F, Young I, Flannagan S, et al. (2014) Dry needling: a literature review with    implications for clinical practice guidelines. Phys Нer Rev 19: 252-265.

13. Zhang, Y. and J.M. Jordan, Epidemiology of osteoarthritis. Clin Geriatr Med, 2010. 26(3): p. 355-69.
14. Martel-Pelletier, J., Pathophysiology of osteoarthritis. Osteoarthritis Cartilage, 1999. 7(4): p. 371-3.
15. Carter, D.R., et al., The mechanobiology of articular cartilage development and degeneration. Clin Orthop Relat Res, 2004(427 Suppl): p. S69-77.
16. Kapoor, M., et al., Role of proinflammatory cytokines in the pathophysiology of osteoarthritis. Nat Rev Rheumatol, 2011. 7(1): p. 33-42.
17. Zhang, W., et al., OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage, 2008. 16(2): p. 137-62.

18. American Academy of Orthopaedic Surgeons. Osteoarthritis. http://orthoinfo.aaos.org/topic.cfm?topic=a00227  Accessed 04-07-2014
19. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26-35.
20. Sacks JJ, Luo Y-H, Helmick CG. Prevalence of specific types of arthritis and other rheumatic conditions in the ambulatory health care system in the United States, 2001–2005.  Arthritis Care & Research. 2010;62 (4):460-464.

Saul Helgeson

Saul Helgeson

Saul Helgeson, DPT, PT, Cert-DN. Saul specializes in treating a variety of patient populations including simple to complex spinal care, vestibular and concussion rehabilitation, temporomandibular joint dysfunction, and neuropathic conditions. He also enjoys working with the active population from novice to very competitive athletes including triathletes for a variety of shoulder, hip, and ankle injuries. Saul utilizes an eclectic approach to patient care utilizing functional movement analysis, biomechanical joint assessment, and hands-on manual therapy techniques. He also employs instruments (Dry Needling and Graston instruments) for soft tissue restrictions, neural mobility, and tendinopathies.

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