Inspired by Siqueira et al 2018.
This paper popped up on PubCrawler this morning. I’m not sure why it took so long to get onto PubMed. It relates to a case series of acupuncture treatment of runners with knee pain who were treated in the city of Curitiba, Paraná, Brazil in 2015. The paper was submitted to Acta Ortopédica Brasileira in August 2016, and accepted two years later. After that sizeable delay, presumably going through revisions and resubmissions, it has taken another 8 months to reach publication and listing.
According to Wikipedia, Curitiba is the best ‘Brazilian Big City’ in which to live, and it sits in the south of the country about midway between São Paulo and Florianópolis, or about the same distance as Rio de Janeiro is from São Paulo, but in roughly the opposite direction ie southwest of São Paulo.
So why highlight a case series on knee pain in runners? Well the team performed some nice objective measurements before and after a short course of treatment. There were 34 runners who volunteered for the study. They had been running for an average of 7 years and trained for an average of 7 hours a week. I interpret the report as suggesting they had suffered with knee pain for an average of 2 years and 9 months. The research team measured quadriceps strength, and EMG signal amplitude and median frequency from the components of the muscle accessible to surface electrodes ie rectus femoris, vastus lateralis and vastus medialis. The paper is open access, so I was able to have a quick look at the results whilst I was still in bed this morning. The other thing I noticed (for the first time) is that the abstract on PubMed as well as the full text on PubMed Central were available in both English and Portuguese and I could swap between them with the click of a mouse – excellent! It is nearly four years since the knees were treated, but the potential audience to read about it is bigger than usual because of access and language.
The results are nice too. With a course of five weekly treatments of 3 or 4 needles for 60 minutes muscle strength was restored in the affected knee, and pain was diminished. Interestingly the strength of the good (not directly treated) knee improved as well – a statistically relevant change, but a modest one in terms the percentage change of course.
The only aspect that made me wince a little was the choice of points – ST35 (Dubi) and EX-LE-4 (Neixiyan), plus one or two on the contralateral scalp (over the relevant sensory and motor cortices). I love the name Dubi, which means ‘calf’s nose’. If you have ever felt a calf’s nose you will appreciate the lovely soft areas on each side. They are certainly a good deal softer than those on the knee, but the name makes it easy to interpret the intended position of the point. The not so nice bit comes when the needles in these points enter the joint space within a relatively short depth. There is a clear risk of inoculation, and whilst septic arthritis resulting from direct inoculation is very rare,[2–4] we have to consider whether or not there is any advantage in entering a joint space that is devoid of the sort of nerves through which the effects of acupuncture are mediated. When we used to teach these points on BMAS Intermediate courses we deliberately changed the angulation to a shallow approach towards the side of the patella tendon. This way the needle tip would touch the capsule of the joint, which has relevant deep somatic nerve endings, but would not risk entering the joint space.
Are we being too cautious? Some would argue so, but the combination of no logical advantage and a tiny risk of a serious condition with joint destructive potential, leads the iconoclast in me to opt for caution, and use electroacupuncture to muscle points around the joint instead.
As for the scalp points, well we talked about that last week.
So I sent an email to the lead author, Ana Paula, in Brazil. I noticed that they used 30mm needles, and I thought it was possible that they did not penetrate the joint. This is her response:
Boa tarde Mike!
Que interessante seu blog semanal.
O tamanho da agulha utilizada foi de 30×30, perpendicular à articulação do joelho, a profundidade utilizada foi de 5mm à 1cm, dependendo do limiar de dor do voluntário. As agulhas não penetram na articulação do joelho.
Agradeço pelo contato,
…and in English via Google Translate:
Good afternoon, Mike!
How interesting your weekly blog.
The size of the needle used was 30×30, perpendicular to the knee joint, the depth used was 5mm to 1cm, depending on the pain threshold of the volunteer. The needles do not penetrate the knee joint.
Thanks for the contact,
1 Siqueira APR, Beraldo LM, Krueger E, et al. REDUCTION IN KNEE PAIN SYMPTOMS IN ATHLETES USING AN ACUPUNCTURE PROTOCOL. Acta Ortop Bras 2018;26:418–22. doi:10.1590/1413-785220182606167896
2 Laing AJ, Mullett H, Gilmore MFX. Acupuncture-associated arthritis in a joint with an orthopaedic implant. J Infect 2002;44:43–4. doi:10.1053/jinf.2001.0911
3 Tien C-H, Huang G-S, Chang C-C, et al. Acupuncture-associated Listeria monocytogenes arthritis in a patient with rheumatoid arthritis. Jt Bone Spine 2008;75:502–3. doi:10.1016/j.jbspin.2007.08.010
4 Woo PCY, Lau SKP, Yuen K-Y. First report of methicillin-resistant Staphylococcus aureus septic arthritis complicating acupuncture: simple procedure resulting in most devastating outcome. Diagn Microbiol Infect Dis 2009;63:92–5. doi:10.1016/j.diagmicrobio.2008.08.023