Insights from Singapore, knee pain was reported to be a common problem among the elderly, with an overall prevalence of 49.3%. The Chinese Asian population has an even higher prevalence of 61.4%, whilst Indian and Malay populations report rates of 40.1% and 39.7% respectively. The frequency of severe knee pain increased from 10.2% in those aged 45-49 years to 27.8% among those aged 70 years and above. This would suggest that the prevalence of knee pain is likely to rise as Singapore’s population continues to age. Not only is knee pain a significant issue on its own, but it is also a common symptom of osteoarthritis, a chronic condition that is estimated to affect 9.2% of the adult population in Singapore. It has been established that osteoarthritis is the single greatest cause of disability in older adults, with Singapore reporting that 14% of the population over 45 years of age suffer from limited mobility due to musculoskeletal conditions. It is clear that knee pain has a significant impact on the quality of life for many older adults in Singapore. Traditional Chinese medicine (TCM), a popular alternative therapy in knee pain Singapore, places great emphasis on treating pain and illnesses related to the elderly. With a large percentage of elderly patients seeking acupuncture for the treatment of chronic pain, it is important to study the role of acupuncture in knee pain management in order to implement effective treatment strategies. An analysis of the utilization and perceptions of acupuncture for knee pain among elderly patients in Singapore is the first step in understanding what the patients expect and to determine if acupuncture is a viable treatment option.
Understanding Knee Pain
Although osteoarthritis can cause knee pain with or without activity, the other conditions typically affect the knee in a more acute or sub-acute manner, with pain being exacerbated by certain activities or positions. Understanding the mode of onset of the pain and specific aggravating/alleviating factors can give indications as to the underlying pathology. For example, in injury-related conditions such as ligament injuries or meniscal tears, the site and mode of onset of the pain can give a very clear diagnosis.
Current understanding of knee pain, whether acute or chronic, is poor and does not solely, or even largely, rely on structural damage. Medical conditions underpin the experience of knee pain and can interrelate with one another in a complex manner. This often makes it a real challenge to diagnose the precise cause of knee pain. This is further complicated by the fact that serious knee injuries and degeneration can be asymptomatic. In addition, x-ray and MRI results have poor concordance with symptoms. Typically, this leads to individuals being told that their knee pain is due to old age, that there is nothing that can be done, or in more severe cases, that a joint replacement is necessary. Yet, many clinical and experimental studies have shown that a number of therapies can substantially improve knee pain, presumably by targeting specific pathology.
Causes of Knee Pain
Knee pain can be the result of an injury or other medical conditions. Injury is the most common problem to affect the knee. Simple knee injuries often develop into a debilitating weaken the joint and lead to pain, aging increases the risk and our bodies are less able to heal around the knee. Fractures are another common injury that can cause a greater amount of pain. A break of the end of the thigh bone or the top of the shin bone or a torn ligament have been said to cause severe pain around the knee and may require surgical intervention. Dislocation of the kneecap is another injury that can cause pain. This happens when the knee is twisted or receives a direct blow while the foot is planted. This moves the kneecap to the side of its normal position. A dislocation often tears ligaments and can affect the smooth movement of the joint. This type of injury is unique in that it often leads to recurrent spells of pain or feelings that the knee is giving way. High force injuries may tear the muscles or cause a fracture. This can result in severe pain and damage to the muscle may cause it to weaken, causing more pain in the future. Muscle tears are a common sports injury and cause disorders, particularly increased pain when using the knee. Far more severe injuries such as cruciate ligament tears and tears to the cartilage can cause symptoms of pain and knee giving way, though this will be discussed in more detail in 2.2. With success rates of its treatment and the variety of different knee conditions, acupuncture often offers something for patients with this type of injury. Osteoarthritis involves a tightness of the synovial membrane which produces synovial fluid that causes joint swelling and an increase in volume of the knee. This causes stiffness and more pain, swelling or repeated effusion. A study and systematic review of the effectiveness of acupuncture for osteoarthritis of the knee found consistent evidence that acupuncture provides more than a placebo effect for the treatment of pain, being one of the most effectively treated symptoms of this condition. This reduces the symptoms and halts the progression of this condition, which will be shown later as acupuncture is also effective for prevention of knee pain.
Symptoms of Knee Pain
During the physical examination of a patient with knee pain, the location of the pain and the activity at the time the symptoms started should be determined. The pattern of pain, i.e. if the pain is sharp and constant, also provides insight into the knee problem.
Patellar (kneecap) pain is a common symptom with certain knee problems. If the patellar pain is a result of simple trauma to the knee, resting the knee and applying ice to the injured area may be sufficient. However, the knee is a complex joint and patellar pain can also be present with irritation to the surface of the articular cartilage or the synovial tissue. This pain may be activity related or occur with no activity at all. In this case, the pain may persist and become chronic.
The two most common symptoms of knee pain are the inability to extend the knee without pain and swelling in the knee. Swelling can occur for many reasons. If the swelling is a result of an injury to the ligaments, there may be some bleeding into the joint from the injured ligament. This is a case of severe pain. If the articular cartilage is damaged in the injured area, the damage to the cartilage might cause a meniscus tear and the flap of cartilage can cause severe pain and sudden swelling.
Traditional Treatment Approaches
The research was motivated by the researchers’ clinical experiences in managing knee pain patients. It was observed that while patients showed varied responses to acupuncture treatment, there was a high degree of skepticism regarding the effectiveness of acupuncture in the management of a musculoskeletal condition like knee pain. An extensive literature search revealed that this skepticism was not unfounded. Even though acupuncture is one of the most commonly used complementary medical treatments and is often sought after for musculoskeletal pain, the majority of studies investigating its efficacy are plagued by poor methodology, making it difficult to draw definitive conclusions on its clinical usefulness in this area. In an attempt to address these issues, a comprehensive understanding of the existing traditional treatment methods for knee pain is necessary; it will provide a useful platform of comparison for acupuncture and enable better identification of the subsets of patients who are more likely to benefit from acupuncture treatment. This will subsequently enable an improvement in the overall quality of clinical research in this field.
Physical therapy is often used in conjunction with other treatments, although there are times when physical therapy alone can be quite effective, especially in mild knee pain conditions. There are an abundance of techniques and modalities.
Innumerable traditional treatments are obtainable for those suffering from knee pain. Medication typically is the most familiar first line of knee pain defense. Anti-inflammatory drugs have been confirmed to notably lessen swelling and pain from the injury. Some persons find pain relief from acetaminophen and can serve as an alternative to persons who cannot take anti-inflammatory drugs. Patients with stomach problems, patients on medicines that can interfere with anti-inflammatory drugs, or those with other chronic or acute circumstances may want to reflect about alternative pain relief methods. Although there is a form of prescription drugs available for pain relief, as talked about above, there are still many who opt against opiate-based drugs due to fear of habit.
Medications for Knee Pain
More recently, the use of intra-articular corticosteroid and hyaluronan injections has become popular. Corticosteroids act to reduce joint inflammation and are often injected directly into the knee joint. A literature review supports the short-term benefit of reduced pain with corticosteroids. However, the long-term safety is unclear and the potential acceleration of osteoarthritis requires careful consideration. Viscosupplementation therapy with hyaluronan involves the intra-articular injection of a preparation designed to act as a lubricant and shock absorber in the joint. In contrast to corticosteroids, hyaluronan may provide longer-term pain relief with fewer potential adverse effects. However, strong evidence supporting its efficacy is conflicting and it has been the subject of recent disinvestment in certain health regions.
A recent update suggests that NSAIDs are effective and relatively safe in comparison to placebo in reducing pain and improving physical function in the short term for patients with knee and hip osteoarthritis. Despite this, concern about potential gastrointestinal and cardiovascular adverse effects, in addition to cost-effectiveness, may limit the long-term use of NSAIDs for some patients. Topical NSAIDs provide a valid alternative with fewer systemic and gastrointestinal effects compared to oral treatment. There is no strong evidence supporting the use of specific NSAIDs over others. A recent literature review has identified advantages in certain newer generation NSAIDs in terms of efficacy with similar toxicity profiles. However, they may not be cost-effective in primary care. Due to the complexity and number of options available, patient preferences must be considered when choosing the optimum NSAID therapy. This should also be done in conjunction with assessment of comorbidities and risk factors for gastrointestinal and cardiovascular adverse effects.
Painkillers and anti-inflammatory drugs are the most frequently prescribed medications for knee pain. Further to the biopsychosocial model of patient management and the principles of best practice management in primary care, paracetamol is recommended as first-line pharmacologic therapy. This should be used at regular intervals to provide optimum pain relief rather than on an as-required basis. Unfortunately, pain relief from paracetamol alone is often insufficient. Non-steroidal anti-inflammatory drugs (NSAIDs) may be required in addition to or as a replacement for paracetamol.
Physical Therapy for Knee Pain
Physical therapy is another important part of the treatment of knee pain. Physical therapy involves exercises and application of modalities to help regain maximal function of the knee. Physical therapy programs can be done at home or at a physical therapy clinic. The physical therapy program will help increase the strength of the muscles around the knee to further support the knee. The therapist will also work on flexibility of the knee and will also work on weight reduction if the patient is overweight. Specific exercises will help in the prevention of the pain to return. These exercises may include other strengthening or flexibility exercises. It is very important that patients take physical therapy very seriously. It is sometimes very easy for the patient to blow off an appointment, but the failure to attend all appointments or the failure to do the exercises will only prolong the recovery of knee pain.
Surgical Options for Knee Pain
All surgical procedures are associated with some adverse effects. It is important to know the potential harm and likelihood of benefit when considering an invasive procedure for knee pain. Measures to help decide if surgery is the right option for knee pain, compared to other invasive procedures in truly placebo-controlled trials, are still required.
Keyhole (or arthroscopic) procedures have become much more common over the past 20 years. They involve inserting a camera into the knee joint, often with subsequent washing out of the joint with sterile fluid or trimming of torn meniscal cartilage. This is most commonly performed on a day case basis and is often used to relieve symptoms of a “locked” knee or swelling. This procedure is constantly evolving and is highly dependent on surgeon skill and preference. Randomized controlled trials comparing this to a placebo or non-operative intervention are required to determine the true efficacy of arthroscopy for knee pain.
Knee surgery could significantly reduce knee pain and disability due to the variety of surgical procedures often used to treat knee pain. Knee replacement surgery involves resurfacing the knee joint. In a knee replacement, the ends of the bones that form the knee joint are resurfaced with a metal or plastic prosthesis. The most common indication for total knee replacement is osteoarthritis. It is a common surgical procedure, over 120,000 knee replacements are performed annually in England and Wales. National Institute for Health and Clinical Excellence (NICE) guidelines indicate when arthroplasty should be offered to people with osteoarthritis. These are if they have severe pain and disability and radiographic evidence of osteoarthritis. Single studies will suggest that arthroplasty is cost effective, however, this is not supported by national evidence and the use of total knee replacement is still highly variable.
Acupuncture as an Alternative Approach
Acupuncture is now an increasingly recognized and validated treatment option for those suffering from knee pain. It should not be seen as a ‘alternative’ to conventional Western approaches, but rather as a valid and reliable first line of attack for knee pain. Acupuncture can reduce pain to levels where damaged knee joints can be helped by exercise and strengthening, thus preventing further degeneration of the joint. There are no adverse side effects associated with acupuncture in comparison to many of the Western pharmacological approaches. It is a relatively low-cost treatment option, particularly when compared to surgery. It can have far-reaching effects on lifestyle and quality of life as reducing chronic knee pain improves general mobility and the ability to undertake activities such as climbing, rising from a chair, and taking a few steps. This also improves mood and vitality. Acupuncture causes few complications as long as it is practiced by a trained professional. When a patient’s knee pain has been very effectively treated by acupuncture, it is a good idea to consider reducing the frequency of treatment to ‘top up’ to prevent recurrence of symptoms. This might be in the form of treatments every 3-6 months. Acupuncture is very useful in the management of arthritis knee pain. The treatment aim will be to reduce inflammation and pain, attempt to regenerate damaged tissue, and address underlying imbalances that might be causing general ‘wear and tear’ on the joints. With regular maintenance treatment, many patients find that their symptoms stabilize or even decrease over time.
How Acupuncture Works for Knee Pain
From a Western medicine explanation, acupuncture points are seen as places where nerves, muscles, and connective tissues can be stimulated. The stimulation increases blood flow while at the same time triggering the activity of the body’s natural painkillers.
The body’s attempt to repair damage to the cartilage and bone includes the development of extrinsic pathogenic factors (for example, “wind dampness” in TCM terminology) which obstruct the circulation of blood and vital energy to the knee joint. This is described by the TCM concept of “obstruction of the channels by wind, cold, and dampness”. Due to this theory of disease taking place in the body, it is necessary to use acupuncture as a mode of healing. Acupuncture targets points in the channels where there is an obstruction of energy, and it helps to augment the yin and eliminate the yang, with the end result being pain relief and promotion of self-healing in the body.
With the progression of knee osteoarthritis, the harmony (or balance between yin and yang) in the knee’s microcosmic environment becomes deranged. This ultimately results in the breaking down of the articular cartilage in the joint. The body’s reaction to pain and inflammation in the joint is an increase in yang energy with a deficiency of yin. The ultimate result of this is the body’s failure to actively repair the damaged tissue.
Acupuncture theory and practice is rooted in traditional Chinese medicine (TCM). According to TCM, the human body is a delicate balance of two opposing and inseparable forces: yin and yang. When the fine balance between yin and yang is disturbed, pain and disease begin to take root in the body. Yin and yang are bound to the naturalistic concepts of heaven, earth, the human body, and the changes that take place in the body, as well as the body’s relationship to environmental influences.
Benefits of Acupuncture for Knee Pain
In acupuncture theory, musculature and the strength of muscle contraction are controlled by the energy termed “qi” that flows throughout the body. Injured or weakened muscle is a result of disrupted qi in that area. Acupuncture aims to restore the normal circulation of qi by stimulating points along the affected channels. In terms of knee pain, the channels are the Stomach and Gall Bladder, and possibly the Kidney. Usually, the points are located below the knee, and sometimes in the hands or feet. Stimulation of these points will increase blood flow to the affected muscles and allow increased strength and flexibility. This can halt degeneration and return the individual to their normal active lifestyle.
Acupuncture can have several important and direct benefits for those suffering from knee pain. These include: pain relief, reduced inflammation, and improved muscle strength. In addition to providing pain relief, the true benefit of acupuncture in treating knee pain lies in its ability to reduce inflammation and restore normal function to the affected area. This is of particular concern to those suffering from osteoarthritis, which is the leading cause of knee pain. By reducing inflammation, there is less pain, allowing the individual to perform the necessary exercise in order to strengthen the musculature around the knee.
Finding a Knee Pain Specialist in Singapore
However, it is equally important for a patient to make an informed decision when finding a medical professional for conventional treatment of knee pain. In order to start treatment with Western medicine, a patient must see a general physician and then subsequently be referred to an orthopedic specialist. There is no guarantee that a specialist will be focused on knee-related ailments and the journey to find one can be tough and frustrating. Treatment will also mean dealing with invasive procedures; in the worst-case scenario, knee replacement surgery. This is a crucial procedure that requires much thought and consideration, typically for older patients. Younger patients and athletes will probably pursue other alternatives before considering knee replacement surgery. Stepping down from the specialist, physiotherapy treatment may not be the most effective or ideal for the patient. This may be due to the physiotherapist having a lack of experience in dealing with knee pain or an absence of the professional knowledge and skills to effectively improve the knee condition of the patient. With these variables in mind, it is difficult for a patient to find the right type of treatment and the right type of specialist for the treatment of knee pain in physiotherapy or conventional Western medicine. These patients, in particular, may want to consider seeking a knee pain specialist in acupuncture.
