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News Letter, Vol. 8 (3) March, 2017, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
http://www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878, Tel: (203) 637-7720

Case Discussion

Acupuncture  Treatment for  Infertility

Baby2

Amy S., a 36-year-old woman, is an OB-GYN at a Connecticut hospital, who delivers babies every day. When she finished her residency two years ago, she and her husband wanted to have a baby and tried for a pregnancy for a year to no avail. As a doctor, Amy is well aware of the workings of her body. She consulted the best endocrinologist and infertility specialist in the area, who checked her hormone levels, including the thyroid, pituitary gland, adrenal gland, ovaries, etc., only to find nothing was wrong. She was careful about nutrition, was at her ideal weight of 120 pounds and neither drank nor smoked. She also had an ultrasound study which showed no problem in her tubes, uterus or ovaries. Amy’s husband was also examined and shown to have a normal quantity and quality of sperm with no antisperm antibodies; the delivery of his sperm was also normal. He showed no retrograde ejaculation and no blockage in the ejaculatory duct.

Amy came to me for consultation and evaluation. She is an open-minded physician, devoted to her job, and works between 55 and 60 hours a week. Her husband is an emergency physician who works in the same hospital and he, too, works hard. Amy and her husband are often on call, causing much stress. They both keep irregular hours and often do not see much of each other. From her history, I could tell she was very stressed, unhelpful to her pregnancy situation.

Amy told me she had read an article which indicated that acupuncture plus IVF (in vitro fertilization) could help the patient increase the success rate for pregnancy. She tried it once without success.

Based on the above information, Amy has unexplained infertility. Unexplained infertility is, by definition, when a couple has not conceived after 12 months of contraceptive free intercourse.

In order to understand Amy’s condition, let’s discuss some basic physiology of women.

BBT

  • Basal Body Temperature (BBT) is women’s body temperature at rest (wake up time).
  • BBT rises after ovulation due to increased progesterone released from the corpus luteum after ovulation.
  • Ovulation can be detected on a fertility chart for the day BEFORE the temperature rises.
  • When ovulation is detected on a fertility chart, the chart shows a biphasic (lower temperatures followed by higher temperatures) pattern.
  • BBT stays in the higher range throughout the luteal (post-ovulation) phase until the next cycle begins.
  • BBT stays high if there is a pregnancy.

What is this BBT chart about?

·       Follicular phase

The follicular phase begins on Day 1 of the menstrual cycle. Estrogen and progesterone levels are at their lowest during menstruation. During this phase the uterine lining, or endometrial lining, both sheds through menstruation and begins a period of regrowth and thickening in preparation for an embryo should conception occur.

The follicular phase lasts about 10 to 14 days, or until ovulation occurs.

Before a woman ovulates, the basal body temperatures range from around 97.0 to 97.5 degrees Fahrenheit (36.1 to 36.3 Celcius). This is due to the presence of estrogen, which keeps temps down. Temperatures will vary from person to person, but should stay below your cover line. 

·       Luteal phase

The luteal phase begins when ovulation occurs. During ovulation, the ovaries release a single egg from only one of the two ovaries during each menstrual cycle. Ovulation is a process that begins when the level of luteinizing hormone or LH surges, and ends 16 to 32 hours later with the release of an egg from the ovary.

BBT

Once ovulation has occurred, the temps go up from around 97.6 to 98.9 F (36.4 to 36.6 C). The day after ovulation, the temp generally jumps up by at least 0.2 degrees F (0.11 degrees C), and then continues to rise somewhat. This increase in temperature is caused by the progesterone released from the follicle after ovulation.
The actual temperatures are less important than noting a pattern showing two levels of temperatures. If there is no pregnancy, then this temperature will stay elevated for 10 – 16 days, until the corpus luteum regresses. At this time, progesterone levels drop dramatically and you get your period.

If your Basal Body Temperature remains elevated for 18 days or more after ovulation, you should probably test for pregnancy.

Ovulation

  • After ovulation, the corpus luteum produces the heat-inducing hormone, progesterone to prepare the lining of the uterus for the implantation of a fertilized ovum. Progesterone causes the resting body temperature to rise after ovulation so that it is possible to identify ovulation for the day BEFORE the temperature rises.
  • A fertility chart that shows ovulation detected by BBT will have a BIPHASIC pattern. This means that it will show lower temperatures before ovulation, a rise (thermal shift), and then higher temperatures after ovulation. Ovulation usually occurs on the last day of lower temperatures. Then higher temperatures after ovulation.
  • To illustrate, see the image below. The blue dots represent daily temperature readings. Ovulation is identified by the vertical red line. The horizontal red line is a “cover line” to help to visualize the biphasic pattern.
  • BBT2

 

Conception takes time

  • A normal, healthy couple only has a 25 percent chance of conceiving each month, even when they have sex right around the time of ovulation. After a year of trying, 75 to 85 percent of couples will have conceived.
  • If your Basal Body Temperature remains elevated for 18 days or more after ovulation, you should probably test for pregnancy.

6 Pregnancy Tips

  1. Have Intercourse Often: Sperm can survive in a woman’s body for up to 5 days. To increase your odds, you should have sex frequently 3 days before ovulation and continuing for 2 to 3 days after you think you’ve ovulated.
  2. Lie Low after Sex: Sperm has to swim upstream to meet your eggs, stay in bed for at least a few minutes after intercourse.
  3. Create a Sperm-Friendly Environment: Avoid putting any chemicals into your vagina, such as vaginal sprays, scented tampons, artificial lubricants, and douching. They can alter the normal acidity of the vagina.
  4. Know When You Ovulate: Please use the above chart to estimate your ovulation day. You might also use an over-the-counter ovulation predictor kit (OPK) to check for hormonal changes in your urine before ovulation.
  5. De-Stress: Try acupuncture, yoga, meditation, or long walks to reduce stress. Research indicates that stress can interfere with getting pregnant.
  6. Maintain a Healthy Weight: Studies show that weighing too little — or weighing too much — can disrupt ovulation and may also affect production of key reproductive hormones. A healthy BMI is between 18.5 and 24.9.
  7. healthy-bmi-chart

Definition of Infertility:

a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.(WHO).

There are many causes of infertility, including the following:

 For the male:

  1. Impaired production and function of sperm, low sperm concentration. Normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration, and the chances of conception lessen. A count of 40 million sperm or higher per milliliter of semen indicates increased fertility; also, if a sperm changes its shape and mobility or is slow, the sperm may not be able to reach or penetrate the egg.
  2. The malfunction of the Hypothalamic-Pituitary-Gonadal Axis: if the axis is not working properly, the male hormone level will be disturbed and the sperm will be both low in count and slow in activity.
  3. The testes system, including transportation and maturation.

 For the female:

  1. Fallopian tube damage or blockage.
  2. Endometriosis.
  3. Ovulation disorders.
  4. Hormonal causes, such as hypothyroidism,
  5. Early menopause.
  6. Polycystic ovary syndrome.
  7. Fibroid in the uterine.

Even though there are many women who cannot conceive because of the above reasons, there are also 15-20 % of couples who cannot conceive due to unexplained reasons, and Amy falls into this category. Therefore, many couples have to use the following technology for help.

Assistant Reproductive Technology:

  1. Intrauterine Insemination (IUI)

Intrauterine insemination is the placement of a man’s sperm into a woman’s uterus using a long, narrow tube, which usually help the sperm to go upstream to meet eggs. The successful rate sometimes can be 20%.

  1. In Vitro Fertilization (IVF)

Eggs and sperm are taken from the couple and are incubated together in a dish in a laboratory to produce an embryo. The embryo then will be placed into the woman’s uterus, where it may implant and result in a successful pregnancy.

  1. IVF stimulation protocols in the US generally involve the use of 3 types of drugs:

1), Medications to suppress the luteinizing hormone (LH) surge and ovulation until the developing eggs are ready.

There are 2 classes of drug used for this:

GnRH-agonist (gonadotropin releasing hormone agonist) such as Lupron,

GnRH-antagonist such as Ganirelix or Cetrotide

Lupron essentially “shuts down” the body’s reproductive hormone system.

While shut down, IVF patients use a follicle stimulating hormone (FSH) drug like Gonal-F or Follistim, to cause the recruitment and development of follicles. Dosages of FSH are adjusted based upon each patient’s response and it is continued until the follicles are mature.

2), FSH product (follicle stimulating hormone) to stimulate development of multiple eggs

Gonal-F, Follistim, Bravelle, Menopur

3), HCG (human chorionic gonadotropin) to cause final maturation of the eggs

The ovaries are stimulated with the injectable FSH medications for about 7-12 days until multiple mature size follicles have developed.

Ovulation cannot occur naturally while on Lupron because LH, which triggers ovulation, is suppressed. This prevents a premature surge of the LH before the retrieval, which could cause loss of the cycle. Once the eggs are mature, an injection of Human chorionic gonadotropin (hCG) or LH is given to stimulate ovulation. Egg retrieval is scheduled 35 hours later.

  1. Egg Retrieval: this is the process used to remove the eggs from the ovaries so they can be fertilized.
  1. Fertilization: the sperms are placed in a dish with the egg and left overnight in an incubator. Fertilization usually occurs on its own. However, sometimes, a single sperm is injected into an egg using a needle. This process is called intracytoplasmic sperm injection (ICSI). About 60% of IVF in the Unites States is performed with ICSI.Embryos that develop from IVF are placed into the uterus from 1 to 6 days after retrieval.
  1. Embryo Transfer: a long, thin tube will be inserted through the vagina and into the uterus and injects the embryo into the uterus. The embryo should implant into the lining of the uterus 6 to 10 days after retrieval.

Now, more and more evidence show acupuncture as an excellent adjunct to IVF. In one article published in Evidence Based Complement Alternative Medicine, 2012, Zheng, et al found out that Twenty-three trials ( a total of 5598 participants)  indicate that acupuncture, especially around the time of the controlled ovarian hyperstimulation, improves pregnancy outcomes in women undergoing IVF.

(Evid Based Complement Alternat Med. 2012;2012:543924. doi: 10.1155/2012/543924. Epub 2012 Jul 2.

The role of acupuncture in assisted reproductive technology.

Zheng CH1, Zhang MM, Huang GY, Wang W.)

Another study also showed significant improvement of odds with acupuncture treatment.

Reprod Biomed Online. 2015 Jun;30(6):602-12. doi: 10.1016/j.rbmo.2015.02.005. Epub 2015 Feb 24.

Impact of whole systems traditional Chinese medicine on in-vitro fertilization outcomes.

Hullender Rubin LE1, Opsahl MS2, Wiemer KE2, Mist SD3, Caughey AB3.

The following acupuncture protocols are used to help IVF patients:

  1. Lupron Routine: to help suppress the luteinizing hormone (LH), and reduce the side effects of Lupron, Ganirelix or Cetrotide
  1. Diji (SP8), Zhongji (Ren 3), Xuehai (SP6), Zusanli (St 36), Sanyinjiao (SP6), Hegu (LI4), Taicong (Lv3).
  2. Cerebrum acupoints(HP-Zone)

Yameng(DU15), Fengfu(DU16),Naohu(DU17)

Tianzhu(UB10),Fengchi(GB20),Wangu(GB12)

  1. Huatuojiaji:
  1. FSH Routine: to help stimulation of multiple eggs.
  2. Cerebrum acupoints(HP-Zone)

Yameng(DU15), Fengfu(DU16),Naohu(DU17)

Tianzhu(UB10),Fengchi(GB20),Wangu(GB12)

  1. Intersection-Zone:

Baihui(Du20),Sishencong(EX-HN-1),Touwei(St8)

  1. Abdominal Zone: Guanyuan (Ren 4),Zigong (EX Points)
  2. Sacrum-Zone:

Mingmen (DU4),Shenshu (UB23), Eight Liao Points (UB31-UB34).

  1. HCG Routine: to improve the final maturation of the eggs
  2. One day before egg retrieval: Neiguan (PC6) , Zusanli(St36), Pishu (UB20), Shenshu (UB23), Ganshu(UB18) , Diji (SP8), Taixi (Kid3), Taicong (Liv 3), Quchi (LI11).
  3. Three hours before egg retrieval: Zigong (Extra Points), Sanyinjiao (SP6), Hegu(LI 4), Neiguan(PC6), Taicong(Liv 3), Quchi(LI11).
  1. After Egg Retrieval: Many patients showed the following symptoms, such as abdominal tender, emotional unsteady, headache, weight gain, nausea and sometimes vomiting, etc.

On the same day: Qihai (Ren 6), Shuidao (St 28), Daimai(GB26), Yinlingquan(Sp9), Sanyinjiao(SP6), Zusanli(St36), Xiaguan (St7), Quchi(LI11), Taicong(Liv3).

  1. For the mobility and viability of Sperm:

Zhongji(Ren3), Guanyuan(Ren4), Zusanli(St36), Taixi(Kid3), Shenshu(UB23), Mingmen(Du 4), Dahe(Kid12), Sanyinjiao(SP6).

  1. Before the Embryo Transfer:

For continues three days: Qihai(Ren6), Guanyuan(Ren7), Sanyinjiao(SP6), Zusanli(St36), Taixi(Kid3), Xuehai(Sp10), Pishu(UB20), Shenshu(UB23), and Ganshu(UB18).

  1. After the Embryo Transfer:

Within 24 hours: Quchi(LI11), Neiguan(PC6), Sanyinjiao(SP6), Zusanli(St36), Taicong(Liv3).

Within 36 hours: Quchi(LI11), Zusanli(St36), Xuehai(Sp10), Diji(Sp8), Taixi(Kid3), Taicong(Liv3), Ear Shenmen, Ear Neifenmi, Ear Zigong.

  1. After confirmed pregnancy:

Quchi(LI11), Zusanli(St36), Neiguan(PC6), Yinlingquan(Sp9), Taixi(Kid3), Taicong(Liv3), Ear Shenmen, Ear Neifenmi, Ear Stomach, until six weeks of pregnancy.

Some important acupuncture points:

AbdomenBack Points

 

Amy was scheduled to have hormone regulation (hormone treatment) for a month before trying to become pregnant again, and to have acupuncture treatments with me three times a week during that month.

After four weeks of treatment, Amy underwent the IVF procedure and was kept on the acupuncture treatment twice a week. Amy reported to me that she had eight eggs mature, a much improvement compared with  the first IVF treatment which had produced only three mature eggs.

After a 48 to 72 hour culture, six of her eggs were fertilized and Amy’s doctor implanted four into the uterus. The doctor told her she should have bed rest overnight and that she could return to work the next day; however, I told her to have bed rest for two days, because Amy’s job is more stressful than most people’s, and she has to bend forward in her work to deliver babies.

A month after insemination Amy told me she was pregnant. She was very excited about her condition and eight months later delivered twins, a boy and a girl. She was thrilled with the results, as was her husband.

In my personal experience:

  1. In unexplained infertility, most of the cases are stress related. As an OB-GYN doctor, Amy worked very hard, as did her husband, and they had little time to be together. They are both under constant stress, their bodies always tight, in particular Amy’s uterus muscles. These factors made it very difficult for the fertilized eggs to attach themselves to the uterus. Some patients may be lucky enough to be pregnant; however, they may not retain their baby in the uterus because of the stress and tightness of their uteruses. They may have frequent miscarriages. My treatment is mainly for stress-reduction.
  2. Many unexplained infertility patients have irregular hormone environments in their bodies because of their high stress levels. These will affect the patient’s entire reproductive system, such as Oocyte maturation, delivery, fertilization, implantation, etc. My acupuncture points are selected to adjust the hormone environment and make the different hormones harmony.
  3. Each patient should have about one month of acupuncture treatment before starting the IVF procedure to prepare the patient’s hormonal system and to have her relax psychologically.
  4. It is extremely important for the patient to have 48 hours of bed rest after insemination before taking up normal activities, because at this time the fertilized eggs are very weakly bound to the uterus. Any inappropriate movement during these first 48 hours might cause an early miscarriage.
  5. For the key acupuncture points, you may do the acupressure by yourself as indicated above.

 

 

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News Letter, Vol. 8 (2), March, 2017, © Copyright

Jun Xu, M.D., Hong Su, C.M.D., Lic. Acup. http://www.rmac.yourmd.comwww.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

How Can Acupuncture treat Occipital Neuralgia?

后头痛

 

 

Linda, a 45-year-old female dental assistant, came to me complaining of severe headaches that started at the back of her head and continued down a portion of her neck.  The pain also radiated up to her scalp, around her ears and sometimes into the bilateral temporal area.  The pain was off-and-on, but occurred every day.  The pain ranged from dull to sharp, and was sometimes located directly behind the right eye.  As a dental assistant, she constantly turned her head to the right when dealing with patients.  This caused the headache to become more severe, and she was frustrated that it interfered with her daily work.  She had consulted several doctors about her condition, and had been prescribed Naprosyn, Percocet and Neurotin, but none of them alleviated her condition.

These headaches intensified when Linda was under stress, which was often because of her job: if she had many patients waiting for her and felt under pressure, the headaches worsened.

When I examined Linda, I discovered that when I pressed her scalp at the base of the skull and suboccipital area, the pain radiated to the back, front and side of her head, and also to the right side of the eye.  When I pressed hard on the suboccipital area (the base of the skull) the pain was exacerbated and I could feel the bilateral temporal artery palpating.

The patient probably suffers from occipital neuralgia, which is a cycle of pain spasms originating in the suboccipital area, caused by an inflammation of the occipital nerves.  The two pairs of occipital nerves (each nerve contains a greater and lesser occipital nerve) originate in the second and third vertebrae of the neck.  These nerves supply areas of the skin along the base of the skull and behind the ear, but are not always connected directly with the structures inside the skull. However, they do interconnect with other nerves outside the skull and continue into the neuro-network.  Eventually they can affect any given area along the scalp, mainly on the bilateral temporal area behind the ear and sometimes connect to the nerve branch on either side of both eyes.

Occipital neuralgia may occur continuously, often as the result of the nerve impingement, especially from arthritis, muscle spasm, or as the result of a prior injury or surgery.  Sometimes these conditions will impinge the occipital nerve root, leading to severe headaches at the back of the head, leading to muscle spasm.  Linda exhibits the severe form of occipitical neuralgia, most likely because her profession causes her to tilt her head in the same manner for a good part of her day. This stress causes the occipital nerve to be impinged, sending a constant signal to the nerve network in her scalp, leading to headaches and the pain behind her right eye.

The clinical diagnosis of this condition is based on palpation by the doctor of the bilateral occipital nerve root, which will induce or trigger the headache. Doctors currently use various treatments.  One option is to inject 1% lidocaine 5cc into the occipital nerve root, which decreases or relieves the pain, confirming the diagnosis.  A second option is to use surgery to cut or burn the nerve with a radial wave probe.  A third option is to use a small injection of Botox or a similar medication.  Western medicines include anti-inflammatory or narcotics such as Percocet or Darvocet, Naurontin, anti-epilepsy medication, etc.  For the majority, these medications do not work well, though occasionally they can reduce the occurrence and frequency of the occipital neuralgia.

Some patients respond to physical therapy and massages to decrease the spasm of the neck muscle, which might temporarily relieve the occipital neuralgia.  Though doctors may recommend surgery, many patients resist this type of treatment.

According to Traditional Chinese Medicine, occipital neuralgia belongs in the category of the side headache, i.e. the Shao Yang Gallbladder meridian headache.  Gallbladder meridians are distributed around the sides of the head, and excessive heat in the gallbladder can lead to headaches.  The gallbladder meridian originates from the outside of the eye, and continues up the temporal nerve area, around the lateral skull area, down the occipital nerve area, down through the trunk and to the outside of the leg.  If there is excessive heat along this meridian, there will be an imbalance of yin and yang.  For example, if the patient undergoes stress, muscle spasm or arthritis, the nerve and the gallbladder meridian will be impinged.  This, in turn, will cause the gallbladder to heat up, leading to excessive heat, an imbalance of yin and yang and a severe headache.

Another meridian identified in occipital neuralgia by Traditional Chinese Medicine is the urinary bladder meridian, which starts from the inside corner of the eye, continues through the middle and the top of the scalp, and follows down the back of the trunk and into the back of the leg.  Due to the connection between the gallbladder and urinary bladder meridians, heat in one will cause heat in the other to rise, generating pain around the eye, the temporal area and the scalp, and making the ensuing headache severe and highly unbearable.  Therefore, the principal acupuncture treatment is to relieve this excessive heat in the gall bladder and urinary tract.

穴位

表格

The main acupuncture points used for treatment are: Du 20 Bai Hui, GB 20 Feng Chi, GB1 Tong Zi Liao, GB 8 Shuai Gu, Extra point Tai Yang, GB 34 Yang Ling Quan, SI 3 Hou Xi, Lu 7 Lie Que, Kid 6  Zhao Hai, Li 3 Tai Chong.

Linda underwent my treatment three times a week for one month, resulting in immediate, short-term relief of her headaches.  However, the headaches continued to plague her because of her strenuous work.  In addition, her irregular menstrual cycle and hormonal changes led to more severe headaches.  Thus, I also treated her for hormonal changes by utilizing a Chinese herb Da Zhi Xiao Yao San.  The combination of acupuncture and herbal therapy seemed to be effective and, after about two months of treatment, Linda reported that her headaches occurred only infrequently and were very mild, and that she was satisfied with her treatments.

Usually, acupuncture, with or without the addition of herbal supplements, can alleviate the problems and pain associated with these headaches.  However, sometimes it is best to combine acupuncture with a nerve block (utilizing 4cc of 1% lidocaine plus 10 mg Kenalog mixed together) injected into both sides of the occipital nerve origin.  One month of this combined treatment should give the patient 95% relief from his/her symptoms.

Tips for acupuncturists:

  1. You should identify the location of the pain and tenderness, and treat the headache accordingly.  For example, the frontal headache belongs to the Yang Ming meridian; the temporal side headache belongs to the Shao Yang meridian; the top scalp headache belongs to the Jue Ying meridian.
  2. Always use Du 20 Bai Hui for all the different types of headaches. This is based on my personal experience over 20 years of practice.

Tips for patients:

  1. You should be very specific when describing the tender points on your head because each tender-point location belongs to a different meridian, and treatment varies based on each location.
  2. Massaging the Tai Yang and UB 20 Feng Chi points for 20 minutes, 2 to 3 times a day, will greatly decrease the headache.

 

News Letter, Vol. 8 (1), March, 2017, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Cervical Dystonia

Cervical dystonia woman

Lisa L. is an 18-year-old female, who had been complaining of neck pain for the past six years.  The patient reports that, six years ago, when she woke up, she suddenly realized that her neck jerked to the left. The jerk happened very often; her neck would jerk two or three times every 5-10 minutes.  The jerk was involuntary and occurred more frequently especially when she was tired or under stress. However, if she had a good night’s rest, felt energized, and focused on something (e.g. her favorite sports), she would not experience the sudden, involuntary neck movements. Only when she sat still, did her neck start to jerk.

Lisa’s neck muscle always feels very tight, and the tightness can be very painful. She has been to many doctors and has tried everything, such as physical therapy and multiple medications, without any improvement. She therefore came to me for evaluation and treatment. Upon physical examination, I noted that the left side of the patient’s sternocleidomastoid muscle had hypertrophied. It felt like a thick rope on the left side of her neck. I also noted that other muscles had undergone hypertrophy: the levator scapular and splenius capitis at the cervicals. Throughout the entire physical examination, there was no jerk or involuntary contraction on the left side of the patient’s neck.

What Lisa is suffering from is called cervical dystonia, which is the most common form of focal dystonia.  Cervical dystonia is characterized by abnormal and spasmodic squeezing of the muscle that leads to muscle contractions in the head and neck area. The movements are involuntary and are sometimes very painful, causing the neck to twist repetitively, resulting in abnormal posture.  Overall, this may affect a single muscle, a group of muscles, such as those in the arms, neck, and legs, or even the entire body.  Patients with dystonia often have normal intelligence and no associated psychiatric disorders.

The causes of cervical dystonia are currently unknown.  There are two types of cervical dystonia:

Primary cervical dystonia: This type of cervical dystonia is not related
to any identifiable, acquired disorders affecting the brain or spinal cord such
as stroke, infection, tumor, or trauma. In some cases, primary cervical dystonia
is genetic, caused by abnormal genes such as dystonia DYT1. However,
because not all carriers of the DYT1 gene develop cervical dystonia, it
is likely that other genes or environmental factors may play a role in the
development of cervical dystonia.

Secondary cervical dystonia: Unlike primary cervical dystonia, secondary
cervical dystonia has obvious causes such as stroke, tumor, infection in the
brain or spinal cord, traumatic brain injury, toxins, birth defect, etc.  There
may be a period of months between the injury and the onset of the dystonia.

Tests and diagnosis:

The first step when diagnosing cervical dystonia is to determine if any of the causes that may lead to secondary dystonia are evident.  The following tests may be used to screen and/or diagnose for secondary cervical dystonia:

1.Toxins and infections screening: blood or urine samples will confirm the presence of toxins and infections.

2.Tumor screening: an MRI will identify and visualize tumors of the brain or spinal
cord.

3.Genetic testing: can be used to identify DYT1, which is critical to the diagnosis
of primary cervical dystonia.

4.Electromyography (EMG) testing: measures electrical activity of muscles.  An EMG can help diagnose muscle or nerve disorders.

Medications:

Many different medications have been used to treat cervical dystonia but most are not effective:

1.Cogentin and Kemadrin are examples of drugs that decrease the level of acetylcholine. These have helped some patients but have sedating side effects.

2.Valium, Ativan, Klonopin, etc., regulate the neurotransmitter GABA.

3.Sinemet, Laridopa, etc. either increase or decrease dopamine levels.

4.Carbamazepine is an anticonvulsant.

Botox injections:

Botox injections can usually stop the muscle spasms by blocking acetylcholine, relieving the symptoms for approximately three months. Very experienced doctors should administer the Botox injections. If Botox is used for more than a one-year period, it will gradually become less effective because the patient’s body will begin producing auto-antibodies against it.

Other treatments:

In some severe cases, surgery may be an option.  Surgery is the last resort and is used to selectively denervate the nerve supplying the muscle.

Another treatment option is deep brain stimulation.  This involves implanting an electrode in the brain connected to a stimulated device in the chest that generates an electrical pulse.  These electrodes will temporarily disable nerve activities by damaging
small areas of the brain.

Chinese medicine:

According to traditional Chinese medicine, cervical dystonia is caused by excessive liver wind. The liver controls the movement of all tendons, muscles and joints in the human body. Excessive liver wind overstimulates the tendons, muscles and joints, constantly activating the muscles. We use the following methods to treat our cervical dystonia patients.

  1. Acupuncture

The principle acupuncture treatment used to treat cervical dystonia reduces the excessive liver wind and thereby decreases the activities of the tendons, muscles and joints. The acupuncture points are along the meridians of the liver and gall bladder, such as the Feng Chi and Tai Chong points.

In addition, because patients with cervical dystonia have abnormal head and neck movements, acupuncture must also be used along the Du meridian, which controls head movement. The Du meridian supplies the entire brain. If the energy of the Du meridian is excessive, the entire head will move abnormally. Therefore, the acupuncture treatment should also include the Da Zhui and Hou Ding points from the Du meridian.  These points will adjust and regulate the Du meridian, the yang, activate the tendon function, and balance the input and output of the energy of the Du meridian.

The acupuncture treatment should also include the Xin Shu, a direct outlet acupuncture point from the heart and the Shen Shu, a connecting point from the kidney. Sheng MenTai Xi and the points listed above are involved in the circuitry of the heart and kidney, and will decrease the fire surrounding these organs, keeping the yin and yang in harmonious balance. Some local points in the neck and head such as Tian ChuangTian RongTian Ding, and Fu Tu, should also be used for their localized calming functions.

This combination of local and distal acupuncture points will greatly decrease the symptoms associated with cervical dystonia.

  1. Moxibustion:

艾灸

Moxa is a Chinese herb similar to cigarette to warm certain points in the human body. We suggest to use the following device to moxa the neck sternocleidomastoid muscle for 30 minutes. Patients should learn how to use it before you use for yourself.

  1. Guasha (Scrape) :

刮痧

Following  the length of  sternocleidomastoid muscle, use the Guasha plate to scrape down 30 times then up 30 times, 5 sessions per day.

 
The patient was treated with acupuncture at the above points for approximately two months, three times a week. After the last treatment, the number of neck contractions had significantly decreased. Now, she only experiences mild neck jerks and contractions, allowing her to perform her daily activities in a normal manner.

Tips for acupuncturists:

  1. Acupuncture cannot treat all forms of cervical dystonia. The milder the disease, the better the treatment results. Physicians should find the cause if the patient is suffering secondary cervical dystonia.
  2. Using heating pads and massages after the acupuncture treatment increases its effectiveness.

Tips for patients:

1.The earlier the treatment, the better the treatment results.

  1. Help yourself with Guasha, Moxa, massage and heating pad.

 

West Africa’s Calling for Dr. Jun Xu, Report one—His

team work in leprosy village of Senegal

Dr. Jun Xu went to Leprosy village in 2013, 2014 and 2016, soon he will go to the leprosy village on March 31, 2017.

jim-africa10

In 2013, there was no a single room being used for treatment in the leprosy village, Dr. Xu and his team had to use a tent. The temperature was around 125 Fahrenheit degrees.

tent-inside-tent

The leprosy patients were waiting for their turn to be attended. Dr. Jun Xu saw about 200 patients a day.

laprosy-pt-2

 

Typical leprosy patient:

 Early Stages

Spots of hypopigmented skin- discolored spots which develop on the skin. Anaesthesia(loss of sensation) in hypthese opigmented spots can occur as well as hair loss.

“Skin lesions that do not heal within several weeks of and injury are a typical sign of leprosy.” (Sehgal 24)

Progression of disease

“Enlarged peripheral nerves, usually near joints, such as the wrist, elbow and knees.”(Sehgal 24)

Nerves in the body can be affected causing numbess and muscle paralysis

Claw hand- the curling of the fingers and thumb caused by muscle paralysis

Blinking reflex lost due to leprosy’s affect on one’s facial nerves; loss of blinking reflex can eventually lead to dryness, ulceration, and blindness

“Bacilli entering the mucous lining of the nose can lead to internal damage and scarring that, in time, causes the nose to collapse.”(Sehgal 27)

“Muscles get weaker, resulting in signs such as foot drop (the toe drags when the foot is lifted to take a step)”(Sehgal 27)

Long-term Effects

“If left untreated, leprosy can cause deformity, crippling, and blindness. Because the bacteria attack nerve ending, the terminal body parts (hands and feet) lose all sensations and cannot feel heat, touch, or pain, and can be easily injured…. Left unattended, these wounds can then get further infected and cause tissue damage.” (Sehgal 27)

As a result to the tissue damage, “fingers and toes can become shortened, as the cartilage is absorbed into the body…Contrary to popular belief, the disease does not cause body parts to ‘fall off’.” (Sehgal 27)

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Every year, Dr. Jun Xu and his team bring around $300,000 worth of medicine donated from his team members and Americares in Stamford, CT to treat the leprosy and other patients in Senegal and Guinea Bissau. http://www.americares.org/, in 2017, his team also received medicine donation from Direct Relief in California, https://www.directrelief.org/.

medicine

Dr. Jun Xu and his team finally established a clinic in the leprosy village, one building for the clinic, and another building for the living of doctors and nurses.

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Leprosy village people were celebrating the opening of the clinic.

africa-1137

There are 8 wards, which could hospitalize the patients if it is medically necessary.

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Dr. Jun Xu’s team usually stay in Senegal for 10 to 14 days every year, these are the foods his team brought from US in order to keep them health and safe. They do not dare to eat street food.

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The above are the coolants Dr. Jun Xu’s team to carry their food from US.

africa-106

 

Dr. Jun Xu and his team from US in 2006.

If you are interested in joining Dr. Jun Xu’s team or donating to his work in Senegal, please address your check payable to AGWV, and send to

Jun Xu, MD, 1171 E Putnam Avenue, Riverside, CT 06878, USA.

Dr. Xu promises that all your donation 100% will go to Senegal and his team will nerve use a penny from your donation. You will receive the tax deductible receipt. Any amount is a great help for Africa patients.

for more info, please visit our website:

http://www.drxuacupuncture.co and http://www.africacriesout.org

 

 

 

 

 Dear Friends:

You are cordially invited by Jun Xu, M.D. to talk and signing of his new book: “Magic Needles, Feel Younger and Live Longer with Acupuncture”

at Auditorium of Christ Church, 254 East Putnam Avenue, Greenwich, CT on Sunday, June 26, 2011 at 10:30 AM. Dr. Xu will also present lecture of ” Neck Pain after Computer Use, Allergy and Sinusitis, How May Acupuncture and Chinese Herbs Help You?” Please join this exciting event.

Jun Xu, M.D. and Staff

News Letter, Vol. 3 (6), June, 2011, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720 begin_of_the_skype_highlighting            (203) 637-7720      end_of_the_skype_highlighting

 

 

 

 

     Burning sensation at right lateral thigh                

 

Fig 6.1

Janina S., a 54-year-old female, has been experiencing a tingling sensation and numbness on the outside of her right thigh for six months.  The pain sometimes burned, sometimes was dull and extended to the groin area and the buttock.  It often became worse when Janina did much walking or standing and she felt altered sensation in the front and lateral of thigh.  Sometimes she woke up in the night feeling pain on the lateral front of the thigh.  She consulted her primary care physician who told her she probably had a pinched nerve on her lower back and was given physical therapy, which did not help her at all.  She had an X-ray and an MRI which showed negative findings, so she was frustrated at not getting to the cause of her problem or given any treatment for it.

She was then referred to me for examination and treatment.  I found no tenderness on the lower back or lateral side of the thigh, and no decreased range of motion of the lower back, hip or knee, except that there was slightly  decreased sensation of the anterior and lateral thigh.  I concurred with her regular physician that she probably had a pinched nerve, but need further explanation to the patient.

This nerve is called the lateral femoral cutaneous nerve, which passes underneath the inguinal ligament and might be compressed, thus causing the numbness, tingling and burning sensation in the lateral and anterior thigh.  In most people this nerve passes through the groin to the upper thigh without any compression, but there is a condition, named as meralgia paresthetica, i.e. the lateral femoral cutaneous nerve is trapped and becomes pinched under inguinal ligament.

Fig. 6.2 Anatomy of the lateral femoral cutaneous nerve.

http://emedicine.medscape.com/article/1141848-overview

Fig. 6.3 Sensory distribution of the lateral femoral cutaneous nerve.

Common causes of this compression include the following:

  1. Tight clothing.
  2. Obesity
  3. Pregnancy
  4. Scar tissue around the inguinal ligament
  5. Walking, cycling or standing for long periods of time.
  6. Other conditions such as diabetes, alcoholism and thyroid disorder.

The diagnosis of meralgia paresthetica is based mainly on physical examination and patients’ complaints, especially as laboratory studies such as blood tests and imaging studies – MRI’s, X-rays – are not very specific, though an EMG and nerve conduction studies may be helpful in making a diagnosis.

History

  • When the LFCN is entrapped, patients usually feel pins, needles, numbness, tingling, sometimes burning, sharp pain sensation at the lateral thigh. Because individual LFCN distribution might be different, some patients may have the above symptoms, i.e.paresthesias at frontal and/or back of the thigh, or groin area.
  • Symptoms are typically unilateral.  However, they may be bilateral in up to 20% of cases.
  • Biking, Swimming, walking, standing, running  may aggravate the symptoms; sitting tends to relieve them.

Physical Examination:

  • Numbness, tingling sensation, i.e. paresthesias, can be revealed  at frontal and lateral thigh.
  • Occasionally, patients are very sensitive to touch, and feels burning, and sharp pain with palpation, i.s. hyperesthetic in this area.
  • Tapping over the upper and lateral aspects of the inguinal ligament or slightly over extending the thigh backward, which stretches the nerve, may reproduce or worsen the paresthesias.
  • Pelvic compression testing is positive. By deep palpation just below the anterior superior iliac spine at the groin area may reproduce the symptom.
  • Motor strength in the involved leg most likely is normal.

Treatment with western medicine:

  1. Lifestyle and home remedies such as avoidance of tight clothes, weight loss, maintaining a steady low weight and avoiding standing or walking for long periods can be helpful.
  2. Medications.  There are many helpful medications for this condition, including corticosteroid injections which can reduce inflammation and temporary relief of pain, also tricyclic antidepressants and Neurotin.
  3. Physical therapy
  4. When the pain is severe, a focal nerve block can be done at the inguinal ligament with a combination of lidocaine and corticosteroids. This should temporarily relieve the symptoms for several days to weeks. Ultrasound guidance for the blockade may be beneficial in patients with regional anatomical variations.

Traditional Chinese medicine:

  1. Acupuncture body acupuncture:

The acupuncture points usually I choose are: Sp 12 Chong Men, Sp 13 Fu She, GB 29 Ju Liao, GB 31 Feng Shi, GB 32 Zhong Du, Arshi, GB 34 Yang Ling Quan, Sp 10 Xue Hai and Liv 3 Tai Chong.

These insertions are combined with electrical stimulation for 30 minutes three times a week for about four weeks.

Points Meridan/No. Location Function/Indication
1. Chong Men Sp 12 Superior to the lateral end of inguinal groove, on the lateral side of the femoral artery, at the level of the upper border of symphysis pubis Abdominal pain, hernia, dysuria, local groin pain
2. Fu She Sp 13 0.7 inch laterosuperir to Chong Men, 4 inch laeral to the midline of the body Lower abdominal pain, hernia, local groin pain
3. Ju Liao GB 29 In the depression of the midpoint between the anterosuperior iliac spine and the great trochanter Pain and numbness in the thigh and lumbar region, paralysis, muscular atrophy of the lower limbs
4. Feng Shi GB 31  On the midline of the lateral aspect of the thigh, 7 inch above the transverse politeal crease. When the patient is standing erect with the hands clse to the sides, the point is where the tip of the middle finger touches Pian and soreness in the thigh and lumbar region, paralysis of the lower limbs, beriberi, gereral prutitus
5. Zhong Du GB 32 On the lateral aspect of the thigh, 5 inches above the transverse popi\liteal crease, between vastus lateralis and biceps femoris muscles Pain and soreness of the thigh and knee, numbness and weakness of the lower limbs, hemiplegia
6. Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
7. Xue Hai Sp 10 When the knee is flexed, 2 inch above the medial edge of patella. Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
8. Tai Chong Liv 3 On the dorsum of the foot, in the depression distal to the junction of the first and second metatarsal bones. Headache, dizziness and vertigo, insomnia, congestion, swelling and pain of the eye, depression,, infantile convulsion, deviation of the mouth, pain in the hypochondriac region, uterine bleeding, hernia, enuresis, retention of urine, epilepsy, pain the anterior aspect of the medial malleolus

Fig 6.4

Fig 6.5

  1. Blossom needles should tap the front and lateral of the thigh skin, allowing the lateral femoral cutaneous nerve distribution.

Fig. 6.6

Janina underwent treatment with both acupuncture and blossom needle tapping and was much improved after five visits.

Tips for patients:

  1. You have to talk to an MD physician to find out other possible diagnosis, such as Lumbar Sacral radiculopathy, Sciatica and peripheral polyneuropathy, etc.
  2. Check if you are wearing a tight cloth, sometimes, you only need wear a loose cloth.
  3. If you are overweight, you may have to lose weight.
  4. If you like bike or other repetitive exercise, please pay attention to the inguinal area, you have to rest a while then restart your exercise.

Tips for Acupuncture practitioners:

  1. Make sure you have a clear diagnosis, if the patient has other illness instead of lateral femoral cutenous neuropathy, the above treatment will not work.
  2. You may have to use both body and blossom needles to treat your patients.

News Letter, Vol. 3 (5), May, 2011, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720 begin_of_the_skype_highlighting            (203) 637-7720      end_of_the_skype_highlighting

Knee Pain – Meniscus Tear


 

www.iidperformancept.com

Robert J is a 45 year-old male who loves sports, especially skiing, snowboarding and tennis. He came to me one day and complained of right knee pain on and off for about one week. He reports skiing one week ago while accelerating downhill while suddenly trying to make a left turn, when he fell in the snow. He felt immediately pain at right medial knee. However, he managed to walk down the slope. When he arrived at the base of the slope, he put ice right away on the right knee. His knee had mild swelling, but was not so painful. He thought his knee pain would gradually subside; he might not need to see a physician. However, for last the two days, he felt his right knee pain was getting worse, he had difficulty bending his right knee, and sometimes had his knee “locked” in certain position. He took Tylenol and Advil but did not feel any improvement. Therefore, he came to me for evaluation and treatment.

Based on his history, especially that he twisted his right knee during skiing; I suspected he might have either knee sprain or meniscus tear:

  1. Knee sprain : A knee sprain means that you have injured one of the four major ligaments around the knee joint. The most common symptom of knee sprain is knee pain, swelling and sometimes you may feel pop sound at the knee. Among the four ligaments, ACL is the most common form of injury.
    1. ACL: The anterior cruciate ligament is a ligament located at frontal knee. ACL prevents your lower leg, the tibia, from sliding too far forward,  and is critical to knee stability, and people who injure their ACL often complain of symptoms of their knee giving-out if you have complete or partial tear of ACL, or  frontal knee pain and swelling if you have just sprain of ACL.

Fig 5.1

Photo © A.D.A.M.

    1. The PCL, posterior cruciate ligament,  is the ligament located at back of the knee, which prevents your lower leg,  the tibia (shin bone) from sliding too far backwards. Along with the ACL, the PCL helps to maintain the tibia in position below the femur (thigh bone). The PCL injury is the so-called “dashboard injury,” when the knee is bent, and an object forcefully strikes your tibia backwards, like happened in the car or ski accident.
    2. The MCL, medial collateral ligaments, and the LCL, lateral collateral ligaments,  located inside of the knee, connects the end of the femur (thigh bone)  with the top of the tibia. The MCL and the LCL resists widening of the inside of the joint, or prevents “opening-up” of the knee. Impact force to lateral knee usually causes the MCL injury, and to medial knee, the LCL injury.

Fig 5.2

aclsolutions.com

Pain and Swelling of the knee are common with Knee sprain, i.e. the tears of ACL, PCL, LCL and MCL.  When there is an effusion immediately after a knee injury, a possible cause is severe injury to a knee structure. The clinical differentiation of which ligament injured depends on the location of the knee pain, for  example, the  pain located at median knee might be MCL tear,  in the frontal knee, possible ACL tear. The main difference between tears of ligament and meniscus is that there is swelling right away after ligament injury, for meniscus tear, the swelling usually comes in slowly after a few hours.  However, a MRI is an absolutely necessary to identify the injured structure and guide the next step for the treatment strategically.

  1. Meniscus Tear:

There are two types of meniscus tears: medial and lateral meniscus tear.

The meniscuses  are two wedge-shaped pieces of cartilage act as “shock absorbers” between your femoral and tibial bones. The one located in the medial side of the knee is called medial meniscus, the one in the lateral side called lateral meniscus. They are designed to cushion the joint and keep it stable.

Meniscus injuries are associated with cutting injuries. They occur with tibial (shin bone) rotation while the knee is partially flexed during weight bearing (football, soccer, ski, etc.)

The most common symptoms of meniscal tear are:

  • Pain, you may feel “pop” sound at the accident
  • Stiffness and slowly swelling with decreased knee range of motion
  • Catching or locking of your knee
  • Tenderness of the medial joint line indicates medial meniscus damage, pain in the lateral joint line may mean lateral meniscus injury.

There are three types of meniscus tears. Each has its own set of symptoms and the treatments are different.

A. Minor tear, you may have slight pain and swelling. It does not interfere your daily activities, but you do feel some slight pain and minimum swelling. This usually goes away in 2 or 3 weeks.

B.  Moderate tear can cause pain at the side or center of your knee. Swelling slowly gets worse over 2 or 3 days with limited range of motion and moderate, tolerable pain, you may walk with mild or moderate pain.  You might feel a sharp pain when you twist your knee or squat. The pain may come and go for years if the tear is not treated.

C.  Severe tears, pieces of the torn meniscus can move into the joint space. You may feel severe pain and difficulty walking. The meniscus chips  can make your knee catch, pop, or lock. You may not be able to straighten it. Your knee may feel “wobbly” or give way without warning. It may swell and become stiff right after the injury or within 2 or 3 days.

For age 65 or above,  you may not remember the history of knee injury.  You may only notice feeling pain after you got up from a squatting position, for example. Pain and slight swelling are often the only symptoms.

Clinically, it is rarely seen a single structure injury in severe cases, very often there are mixed injuries of meniscus  and ligaments. The classic O’Donoghue triad (or unhappy triad) is characterized by an injury to three knee structures:

Other knee injuries that may mimic knee ligament and meniscus tears:

1. Patellofemoral pain syndrome (PFPS):  is a syndrome characterized by pain or discomfort seemingly originating from the contact of the posterior surface of the patella (back of the knee cap) with the femur (thigh bone). Runners, basketball players, young athletes and females especially those who have an increased angle of genu valgus (knock knees) are highly risk for PFPS. Typically localized anterior knee pain behind your knee cap is exacerbated by sports, walking, sitting for a long time, or stair climbing. Descending stairs may be worse than ascending.

2. Backer’s cyst: is an accumulation of joint fluid (synovial fluid) that forms behind the knee. A large cyst may cause some discomfort or stiffness but generally has no symptoms. There may be a painless or painful swelling behind the knee.

3. Pes anserine bursitis (often coupled with tendonitis): is a painful, inflammatory condition affecting the pes anserine bursa (and pes anserine tendon) between your shinbone (tibia) and the hamstring tendons at the inside of your knee; typically caused by stress to the area.

The following physical examination will help us differentiate the above diagnoses.

  • Anterior draw test: this test is used to exam ACL injury. With the patient lying supine, the knee flexed to 90 degree, the examiner grasps the patient’s knee and pull lower leg forward, if an anterior motion and distinct endpoint felt, ACL tear could be clinically diagnosed.

Fig 5.3

http://www.cobrabrigade.com

  • Posterior draw test: this test is used to exam PCL injury. As like ACL test, if a posterior motion and distinct endpoint felt, PCL tear is clinically indicated.

Fig 5.4

bestpractice.bmj.com

*    Collateral ligament test:  With the patient lying supine, the lower leg flatted without bending, the examiner apply force at medial knee with one hand and another hand on with opposite force at the ankle of same knee, if the patient feels pain at medial knee, that indicates the patient has possible medial collateral ligament injury, if the pain is on the lateral side, then it might indicate lateral collateral ligament injury.

Fig 5.5

http://www.vidrec.com

  • Apley’s grind test: The patient lies prone with the knee flexed to 90 degree, the examiner places force downward on the heel compressing the menisci between the femur and tibia bones.  In the mean time rotate the tibia while asking the patient report which portion of the knee is tender; the examiner could make a diagnosis of either medial or lateral meniscus tear.

Fig 5.6

netterimages.com

McMurray Test: The patient lies on their back, knee flexed to 90 degrees, as the examiner holds around the knee with their thumb and index finger on the joint lines.   The knee is then extended as either internal or external rotation is applied by the examiners other hand at the ankle.  If a click is heard or felt at the knee, the test is positive for a meniscus tear.

Fig 5.7

http://thesteadmanclinic.com/meniscus/diag.asp

By physical examination, Robert showed vague positive on medial collateral ligament test, and positive test of Apley’s Grind test. Because of the positive findings for both tests, therefore, it is medically necessary to have X-ray and MRI of the left knee.

  • X-ray and MRI:

X-rays and MRIs are the two tests commonly used in patients who have meniscus tears. An x-ray can be used to determine if there is evidence of degenerative or arthritic changes to the knee joint. The x-ray of Robert’s left knee showed no narrow space, nor osteophysites, which guides me go ahead to order MRI.

The MRI is helpful at actually visualizing the meniscus.

Fig 5.8  Normal meniscus

www.EMEDx.com

Fig 5.9

www.EMEDx.com

 

Fig 5.10


 

www.EMEDx.com

 

Normal knee under MRI shows smooth edge without interruption as you may see from above, however, if there is meniscus tear,  you may see the interrupted meniscus line and non lineated edge of the meniscus. Robert’s MRI showed left medial knee meniscus tear.

Treatment for Meniscus  and ligament tears

Clinically, it is difficult to differentiate meniscus from ligament tears. However, in the early stage with mild to moderate cases of all the above diagnoses, the treatment is about same:

  1. Acute stage.  In this stage the patient suffered a trauma or injury with acute pain, so it is necessary to use acronym PRICE measures for  this stage.
  2. Protection.  Use or crutches or a brace is necessary to help stabilize the joint to avoid weight bearing and prevent further damage.
  3. Rest.  Reduce or stop the activities that caused the pain, which will help reduce the pain and improve the injury.
  4. Ice.  In the acute stage, there is pain and acute inflammation. Ice will decrease this inflammation and should be applied to the injured knee three or four times a day for 20 minutes at a time.  It also helps to rub the ice pack around the knee to protect the knee and decrease the pressure of the inflammation.
  5. Compression.  Use of a compression bandage and massaging the damaged tissue helps to prevent fluid build up edema, and hard rubbing of the knee helps to strengthen it.
  6. Elevation.  Elevate your leg with help of gravity will facilitate the fluid return from the swelling knee to your heart, which will decrease the knee swelling.
    1. Postacute Stage.  For mild to moderate knee pain, the following can help:
    2. Anti-inflammatory medication. Non-steroid anti-inflammatory medication such as NSAID’s, including asperin, nanproxen and ibuprofen help decrease the inflammation and decrease the pain.
    3. Physical therapy.  The proper exercises will strengthen the muscles around the knee and help to regain the knee stability.  Samples of great non-weight bearing from non-weight bearing (NWB) movements to strengthen and stretch the muscles of the leg to weight bearing (WB) movements are described in detail in the previous newsletter concerning knee pain.  The exercises below demonstrate a progression from NWB (straight leg raises, stretches) to WB with added resistance (knee stabilization exercises A-D, Wall Squats, Step-Ups)

Balance training, or proprioception, is critical to re-train the stabilizing muscles of the ankle, knee and hip.  As demonstrated below a wobble board can be used once balance in a tandem stance, one foot in front of other, on a flat surface is mastered.

Fig 5.11

http://www.personallyfitonline.com/tandem-stance

Fig 5.12

http://www.summitmedicalgroup.com/library/sports_health/meniscal_tear_exercises/

Fig 5.13

http://www.summitmedicalgroup.com/library/sports_health/meniscal_tear_exercises/

  1. Acupuncture:

The acupuncture treatment for knee sprain and meniscus tear are about same. There are two major types of knee osteoarthritis based on Traditional Chinese Medicine:

  1. Wind hot: the knee is mild to moderate swollen, warm, or hot with severe tenderness
  2. Wind cold: the knee is very stiff, cold and heaviness, the pain is worse in the morning, difficulty moving, getting in or out of car, mild to moderate pain.

I choose the following acupuncture points for both type: LI 4 He Gu, LI 11 Quchi, St 35 Du Bi, Nei Xi Yan, Xue Hai, Liang Qiu, He Ding, Wei Zhong, I add Ying Ling Quan, Wei Yang for Wind hot, and Yang Ling Quan, Zhu San Li for Wind cold.

Points Meridan/No. Location Function/Indication
1 Du Bi Stomach 35 When the knee is flexed, the point is at the lower border of the patella, in the depression lateral to the patellar ligament Pain, numbness and motor impairment of the knee, beriberi
2. Nei Xi Yan Extraordinarypoint When the knee is flexed, the point is at the lower border of the patella, in the depression medial to the patellar ligament Knee pain, weakness of the lower extremities
3. Xue Hai Sp 10 When the knee is flexed, 2 inch above the medial edge of patella. Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
4. Liang Qiu Stomach 34 When the knee is flexed, the point is 2 inch above the laterosuperior border of the patella Pain and numbness of the knee, gastric  pain, mastitis, motor impairment of the lower extremities
5. He Ding Extraordinarypoint In the depression of the midpoint of the superior patellar border Knee pain, weakness of the foot and leg, paralysis
6. Wei Zhong UB 40 Midpoint of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosus Low back  pain, motor impairment of the hip joint, lower extremities, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness of leg,  hemiplegia, abdominal pain, vomiting, diarrhea, erysipelas.
7. Ying LingQuan Sp 9 On the lower border of the medial condyle of the tibia, in the depression on the medial border of the tibia Abdominal pian and distension, diarrhea, dysentery, edema, jaundice, dysuria, enuresis, incontinence of urine, pain in the external genitalia, dysmenorrheal, pain in the knee
8. Wei Yang UB 39 Lateral to UB40, on the medial border of the tendon of biceps femoris Stiffness and pain of the lower back, distension and fullness of the lower abdomen, edema, dysuria, cramp of the leg and foot
9. Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
10. Zu San Li Stomach 36 3 inch below St. 35 Du Bi, one finger below the anterior crest of the tibia, in the muscle of tibialis anterior Gastric pain, vomiting hiccup, abdominal distension, borborygmus, diarrhea, dysentery, constipation, mastitis, enteritis, aching of the knee joint and leg, beriberi, edema, cough, asthma, emaciation due to general deficiency, indigestion, apoplexy, hemiplegia, dizziness, insomnia,
11. LI 4 He Gu On the dorsum of the hand between th e1st and 2nd metacarpal bones, approximately in the middle of the 2nd metacarpal bone on the radial side. Headache, pain in the neck, redness swelling and pain of the eye, epistaxis, nasal obstruction , rhinorrhea, toothache, deafness, swelling of the face, sore throat, arotitis, trismus, facial paralysis, febrile die\seases with anhidrosis, hidrosis, abdominal pain, dysentery, constipation, amenorrhea, delayed labour, infantile convulsion, pain, weakness and motor impairment of the upper limbs.
12 LI 11 Qu Chi Flex the elbow, the point is in the depression of the lateral end of the transverse cubital crease. Sore throat, toothache, redness and pain of the eye, scrofula, urticaria, motor impairment of the upper extremities,abdominal pain, vomiting, diarrhea, febrile disease.

Fig 5.14

Fig 5.15

Fig 5.16

Fig 5.17

  1. Corticosteroid injections:  steroid injection can quickly decrease the inflammation and decrease the pain, however, it is not possible to use this treatment more than three times a year because there are too many side effects.  These include risk of infection, water retention and elevated blood sugar levels.

Treatment for Robert:       Robert was treated with both physical therapy for about 12 visits. Because it is a moderate left medial meniscus tear, he did not go through the arthroscopic surgery. After about 2 to 3 treatments, his knee swelling was subsided, about 6 visits, his pain was gradually decreased. He was discharged from my clinic after 12 visits, he was given home exercise program to strengthen his quadriceps at home.

Tips for patients:

  1. Always apply ice to your knee, if you have knee injury after any accident. You’d better use the PRICE procedure as I mentioned above.
  2. Always exercise your quadriceps muscle, this group muscle can protect your knee structures, even you do not have any knee injury now.
  3. You must have a clear diagnosis, if your diagnosis is severe knee meniscus or knee ligament tear, I do not recommend conservative treatment.

Tips for acupuncture practitioners:

  1. Acupuncture and physical therapy only can treat mild to moderate knee sprain and meniscus tears. For severe knee sprain and meniscus tears, you have to wait until the patients have arothscopic surgery done.  You may then start acupuncture and physical therapy treatments.
  2. Bike and swimming exercises should be encouraged as long as the patients are out of acute stage.
  3. Always encourage your patients use ice after exercise for their knees.

News Letter, Vol. 3 (4), April, 2011, © Copyright

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.com

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720 begin_of_the_skype_highlighting (203) 637-7720 end_of_the_skype_highlighting

 

Knee Pain and Knee Osteoarthritis

 

thisdayinquotes.com

 

Jonathan S. a 44-year-old man has experienced knee pain on and off for two years.  He played varsity football while in college and after graduation took up tennis which he played often over the years, four or more times a week, and never had a physical problem.  However, the knee pain developed two years ago and the symptoms become worse with weather changes.  His pain has been getting worse, even when he is only walking and he has stiffness and swelling, with decreased range of motion when he wakes up in the morning.  He experiences difficulty bending or extending his knee and when he goes up or downstairs, he feels as his right knee is giving out.  He has severe tenderness along the joint, so he consulted his primary care physician who suspected osteoarthritis of the right knee. When an X-ray was done it showed his right knee cartilage was worn out and the knee joint had a very narrow space.  Jonathan was told osteoarthritis of the knee and it was a very serious condition and the best way to treat it would be with a total knee replacement, which he refused to do.

He then consulted me and I noted his knee was moderately swollen and when I checked the range of motion there was limited knee flexion (about 0-70 degrees) . When I moved the knee I heard clicking and cracking noises, which indicated crepitation of the right knee.  I also checked the knee X-ray which showed the knee space narrowing and also noted some bony spurs along the tibia and fibula bones, all of which confirmed the diagnosis of knee osteoarthritis.

What is Knee osteoarthritis?

Knee Osteoarthritis is caused by the breakdown and eventual loss of the cartilage of knee joint.  Cartilage is a protein substance that serves as a “cushion” between the bones of the joints. Osteoarthritis is also known as degenerative arthritis, i.e. the wearing out of joints during aging process, the older, the worse the arthritis. Before age 45, osteoarthritis occurs more frequently in males. After 55 years of age, it occurs more frequently in females.

As we look at the following picture, the left side knee joint revealed severe OA with narrow space, in the following picture of the knees, the right one is a normal X-ray with plenty of knee space. The left one is a typical osteoarthritis knee. You will see the detail analysis or illustration  of the left knee of the x-ray afterwards.

Fig. 4.1

 

https://sites.google.com/a/bishopfoley.org/anatomy-bfc/

 

Causes of Knee Osteoarthritis

As we mentioned above, deterioration of articular cartilage is the main problem associated with knee osteoarthritis. The condition can be caused by:

  1. Previous knee injury:   Injuries contribute to the development of osteoarthritis. Fractures, ligament tear, and meniscal injury which can affect alignment and promote wear and tear. For   example, athletes who have right  knee-related injuries may try to avoid right knee pain by leaning to the left side, then he will be at higher risk of developing osteoarthritis of left knee.
  2. Repetitive strain on the knee: Overuse of certain joints increases the risk of developing osteoarthritis. For example, marathon runners, tennis players and football players are at increased risk for developing osteoarthritis of the knee.
  3. Genetics: Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine and knee because of the change of dynamic chain in entire body.
  4. Obesity: Overweight increases the risk for osteoarthritis of the knee and hip by addition of stress and impact on the joint surface during weight bearing mobility.   Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of the knee and hip or decrease the rate of progression once osteoarthritis is established.

How Is Osteoarthritis Diagnosed?

The diagnosis of knee osteoarthritis is based on a combination of the following factors:

1.   Your description of symptoms includes: older than 40 years, knee Pain,  Stiffness Decreasing range of motion,  Muscle weakness and atrophy due to inactivity or stiffness,  Baker’s cyst (a harmless fluid collection in the back of knee)

2.   The location and pattern of pain: the pain located at the midline of the knee, morning stiffness, the pain follows weather changes sometimes

3.   Certain findings of a physical exam: Crepitus,  Effusion,  Deformity, etc.

4.   X-ray of the knee osteoarthritis includes the following characters:

*          Joint Space Narrowing: Joint space loss is usually not uniform within the joint, the weight bearing part of the knee joint usually wear out more,  “Bone-on-bone” suggests there is no joint space left.

*          Development of Osteophytes: also called bone spurs, are protrusions of bone and cartilage, which typically develop as a reparative response by remaining cartilage, cause pain and limited range of motion in the affected joint.

*          Subchondral Sclerosis: subchondral bone is the layer of bone just below the cartilage. Sclerosis means that there is hardening of tissue. Subchondral sclerosis is seen on x-ray as increased bone density, frequently found adjacent to joint space narrowing. The degeneration of bone which occurs in osteoarthritis causes bone to turn into a dense mass at the articular surfaces of bone.

*          Subchondral Cyst Formation: are fluid-filled sacs which extrude from the joint. The cysts contain thickened joint material, mostly hyaluronic acid. Traumatized subchondral bone undergoes cystic degeneration.

5.  Sometimes blood tests will be given to determine if you have a different type of arthritis.

6. If fluid has accumulated in the joints, your doctor may remove some of the fluid (called joint aspiration) for examination under a microscope to rule out other diseases.

 

Treatment of the knee by western medicine.

For all knee pain, the most important thing is to divide the pain into two types:

  1. Acute stage.  In this stage the patient suffered a trauma or injury with acute pain, so it is necessary to use acronym PRICE measures for  this stage.
  2. Protection.  Use or crutches or a brace is necessary to help stabilize the joint to avoid weight bearing and prevent further damage.
  3. Rest.  Reduce or stop the activities that caused the pain, which will help reduce the pain and improve the injury.
  4. Ice.  In the acute stage, there is pain and acute inflammation. Ice will decrease this inflammation and should be applied to the injured knee three or four times a day for 20 minutes at a time.  It also helps to rub the ice pack around the knee to protect the knee and decrease the pressure of the inflammation.
  5. Compression.  Use of a compression bandage and massaging the damaged tissue helps to prevent fluid build up edema, and hard rubbing of the knee helps to strengthen it.
  6. Elevation.  Elevate your leg with help of gravity will facilitate the fluid return from the swelling knee to your heart, which will decrease the knee swelling.
    1. Postacute Stage.  For mild to moderate knee pain, the following can help:
    2. Anti-inflammatory medication. Non-steroid anti-inflammatory medication such as NSAID’s, including asperin, nanproxen and ibuprofen help decrease the inflammation and decrease the pain.
    3. Physical therapy.  The proper exercises will strengthen the muscles around the knee and help to regain the knee stability.

A Foam Roller, Hand Held Marathon Massage Stick, or other types of Soft Tissue Work will assist in loosening adhesions and imbalances that may place greater stress through the joints of the knee and limit full range of motion of the muscles.

 

 

 

 

 

Fig. 4.2

 

 

http://www.sideofsneakers.com/2010/09/01/foam-roller-vs-the-stick/

Fig 4.3

 

http://zealousvitality.wordpress.com/tag/quads/

 

 

 

 

 

Fig. 4.4

 

http://www.h3daily.com/fitness/roll-it-out/

 

 

The muscles of the hip and knee must be strengthened with exercises placing less stress through the arthritic joint with Non-Weight Bearing (NWB) Exercises.  4-Way Hip Exercises on a mat will strengthen muscles surrounding the hip and knee.  These should be progressed from 3 sets of 10, to 2 sets of 15 to 1 set of 30 then repeated with ankle weights.

 

Hip Flexion involves lying on your back with one knee bent and the working leg straight being lifted up to the height of the opposite knee than down slowly.

 

Hip Extension involves lying on your stomach and lifting one leg up about 10-12” then down slowly.

 

Hip Abduction and Hip Adduction both involve lying on your side.  Hip Abduction involves the top leg being lifted up around 20” then down slowly.  Hip Adduction involves crossing the top leg over the bottom leg and performing the exercise by lifting the bottom leg off the table about 10” then down slowly.

 

4-Way Hip Exercises on Mat

 

 

Fig. 4.5

 

 

http://www.sportsinjuryclinic.net/cybertherapist/corestability.php

http://www.best-leg-exercises.com/ankle-weights.html

 

 

 

Clam Shells are NWB and can be performed in a seated position or lying on your side to strengthening the muscles of the outer and inner thigh. Increased tension of the band will make the movement more challenging, select a band resistance to make the last few reps more difficult to achieve 2 sets of 10, then once able to complete a 3rd set, increase resistance.

 

Clam Shells Seated

 

Fig. 4.6

 

 

 

http://www.exercise.com/exercise/band-assisted-seated-hip-abduction

Fig. 4.7

Clam Shells Side Lying

 

http://www.active.com/cycling/Articles/Tight-IT-Band-3-Simple-Exercises-to-Fix-it-Now.htm?page=2

 

 

 

 

Utilizing a Stretch-Out Strap Routine following strengthening exercises will improve mobility in the muscles.  Each stretch should be held from 30-60 seconds and repeated on both legs.  This routine flows easy from one move to another and is NWB so less stress is placed through the knee joint compared to if these exercises were performed in standing.

 

 

Stretch-Out Strap Calves – place band around ball of foot and pull band back keeping knee straight till a strong but comfortable stretch is felt in the calves

Fig. 4.8

 

http://sicksport.com/fitness-stretching-c-86_111/stretch-out-strap-with-book-p-1361

 

Stretch-Out Strap Hamstrings – lie back and lift leg up keeping straight at knee till a strong but comfortable stretch is felt in hamstrings

Fig. 4.9

 

 

http://www.procombinetraining.com/pct_store.htm

 

Stretch-Out Strap Glutes – place band around shin and pull up towards chest till a strong but comfortable stretch is felt in the glute

Fig. 4.10

 

 

http://www.exf-fitness.com/en/products/10/90/Stretch_Out_Strap.aspx

Fig. 4.11

 

Stretch-Out Strap Inner Thigh – bring leg out to the side, keeping it off the ground till a strong but comfortable stretch is felt in the inner thigh

 

http://jones-strength.blogspot.com/

Fig. 4.12

http://jones-strength.blogspot.com/

 

Stretch-Out Strap Outer Thigh – bring leg across the body, keeping if off the ground till a strong but comfortable stretch is felt in the outer thigh

 

 

 

 

Stretch-Out Strap Quadriceps – lying on stomach with band around ankle, pull strap over shoulder till a strong but comfortable stretch is felt in the quadriceps

Fig. 4.13

 

http://www.simplefitnesssolutions.com/stretch.htm

 

 

Manual PT with supervised exercise has been shown beneficial with OA of knee and may prevent and delay surgical intervention

 

Recent research studies have shown benefits with Kinesio Taping to help reduce knee pain and improve quadriceps strength.  The tape will assist in correcting imbalances at the knee to reduce stress on joints and recruit greater muscle activation.

 

Fig. 4.14

 

 

 

http://www.theratape.com/spidertech-precut-upper-knee-tape.html

 

 

Walking when pain free is a great form of exercise.  Avoid high impact activities such as jogging and running and opt for walking, elliptical, exercise bike, swimming to improve the strength and range of motion of the leg muscles.

 

Fig. 4.15

 

 

http://www.healthcentral.com/chronic-pain/h/what-causes-knee-pain-when-walking.html

 

 

  1. Corticosteroid injections:  steroid injection can quickly decrease the inflammation and decrease the pain, however, it is not possible to use this treatment more than three times a year because there are too many side effects.  These include risk of infection, water retention and elevated blood sugar levels, etc.
  2. Hyaluronic injections. Hyaluronic acid is a substance that is naturally present in the human body. It is found in the highest concentrations in fluids in the eyes and joints.

 

As we all understand, Osteoarthritis is characterized by a loss of articular cartilage and a reduction in the elastic and viscous properties of the synovial fluid occurs. The molecular weight and concentration of the naturally occurring hyaluronic acid decreases, which lead to decreases the lubrication and protection of the joint tissues of the knee.

The above theory raised the concept of viscosupplementation, i.e. injection of hyaluronic acid into the osteoarthritic knees.

 

One study from Canada showed that 80 percent of 458 knees injected with hylan had a positive response, and the average duration of efficacy was 8.2 months. (Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85.)

 

Hyaluronic acid injection at your knee will provide lubrication for knee,   acting as a lubricant and shock absorbent. The hyaluronic acid that is used as medicine is extracted from rooster combs or made by bacteria in the laboratory and similar to gelatinous material in the tissue spaces and generally throughout the body.

 

Side Effects of Hyaluronic Acid injection: No systemic reactions were attributed to hyaluronic acid. Most of the reported adverse reactions consisted of minor localized pain or effusion, which was almost always resolved within one to three days.

 

Indications of intra-articular hyaluronic acid injections:

  1. Significantly symptomatic osteoarthritis who have not responded adequately to standard nonpharmacologic and pharmacologic treatments.
  2. Intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications).
  3. Patients who are not candidates for total knee replacement or who have failed previous knee surgery for their arthritis, such as arthroscopic debridement, may also be candidates for viscosupplementation.
  4. Total knee replacement in younger patients may be delayed with the use of hyaluronic acid. As per current studies, the metal knee joint after total knee  replacement may last 10 to 15 years, we usually recommend patients to  have the total knee replacement in a older age, such as age of 65 or above to avoid two surgeries for total knee replacement in their life time. Therefore, by injection of hyaluronic acid into the knee joints, patient’s pain might decrease and the surgery might be delayed for a while.

Injection Technique

Hyalgan is supplied in 2-mL prefilled syringes.  The recommended injection schedule is one injection per week for five weeks for Hyalgan. Repeat courses of Hyalgan can be performed after six months.

A knee joint can be injected several ways. One approach is to have the patient lie supine on the examination table with the knee flexed 60 to 90 degrees (Figure ). In this position, the anterior portions of the medial and lateral joint lines can easily be palpated as dimples just medial or lateral to the inferior pole of the patella. Often, the medial joint line is easier to palpate and define and can be chosen as the site of injection.

In my office, I routinely use ultrasound image to guide the knee injection, with this method, the injection is much more accurate and much less painful.  If you would like to have knee injection, the ultrasound guided injection might give you a better result.

 

Fig. 4.16

 

 

www.wn.com

Fig. 4.17

 

 

drericchan.wordpress.com

Fig. 4.18

 

http://www.myorthosports.com

  1. Surgery.  There are two types of surgery:
  2. Arthroscopic surgery.   This type will repair the torn meniscus, ligament and tendon.
  3. Total knee replacement.  This operation is usually performed on people 65 and over, because the prosthetics of an artificial joint usually lasts only 15 to 20 years.  If the replacement is performed too early, the patient might have to undergo another one at a later time.

 

 

Treatment by traditional Chinese medicine:

Traditional Chinese medicine has a long history of using acupuncture to treat knee arthritis. In western countries, acupuncture treatment of knee osteoarthritis has been intensively studied. Selfe TK, Taylor AG. Of University of Virginia collected ten trials representing 1456 participants met the inclusion criteria and were analyzed. These studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee. (Selfe TK, Taylor AG, Fam Community Health. 2008 Jul-Sep;31(3):247-54. Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials. School of Nursing and the Center for the Study of Complementary and Alternative Therapies, University of Virginia Health System, Charlottesville, VA 22908, USA.)

 

 

There are two major types of knee osteoarthritis:

  1. Wind hot: the knee is mild to moderate swollen, warm, or hot with severe tenderness
  2. Wind cold: the knee is very stiff, cold and heaviness, the pain is worse in the morning, difficulty moving, getting in or out of car, mild to moderate pain.

 

I choose the following acupuncture points for both type: St 35 Du Bi, Nei Xi Yan, Xue Hai, Liang Qiu, He Ding, Wei Zhong, I add Ying Ling Quan, Wei Yang for Wind hot, and Yang Ling Quan, Zhu San Li for Wind cold.

 

  Points Meridan/No. Location Function/Indication
1 Du Bi Stomach 35 When the knee is flexed, the point is at the lower border of the patella, in the depression lateral to the patellar ligament Pain, numbness and motor impairment of the knee, beriberi
2. Nei Xi Yan Extraordinary

point

When the knee is flexed, the point is at the lower border of the patella, in the depression medial to the patellar ligament Knee pain, weakness of the lower extremities
3. Xue Hai Sp 10 When the knee is flexed, 2 inch above the medial edge of patella. Irregular menstruation, dysmenorrheal, uterine bleeding, amenorrhea, urticaria, eczema, erysipelas, pain in the medial aspect of the thigh
4. Liang Qiu Stomach 34 When the knee is flexed, the point is 2 inch above the laterosuperior border of the patella Pain and numbness of the knee, gastric  pain, mastitis, motor impairment of the lower extremities
5. He Ding Extraordinary

point

In the depression of the midpoint of the superior patellar border Knee pain, weakness of the foot and leg, paralysis
6. Wei Zhong UB 40 Midpoint of the transverse crease of the popliteal fossa, between the tendons of biceps femoris and semitendinosus Low back  pain, motor impairment of the hip joint, lower extremities, contracture of the tendons in the popliteal fossa, muscular atrophy, pain, numbness of leg,  hemiplegia, abdominal pain, vomiting, diarrhea, erysipelas.
7. Ying Ling

Quan

Sp 9 On the lower border of the medial condyle of the tibia, in the depression on the medial border of the tibia Abdominal pian and distension, diarrhea, dysentery, edema, jaundice, dysuria, enuresis, incontinence of urine, pain in the external genitalia, dysmenorrheal, pain in the knee
8. Wei Yang UB 39 Lateral to UB40, on the medial border of the tendon of biceps femoris Stiffness and pain of the lower back, distension and fullness of the lower abdomen, edema, dysuria, cramp of the leg and foot
9. Yang Ling Quan GB 34 In the depression anterior and inferior to the head of the fibula Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion
10. Zu San Li Stomach 36 3 inch below St. 35 Du Bi, one finger below the anterior crest of the tibia, in the muscle of tibialis anterior Gastric pain, vomiting hiccup, abdominal distension, borborygmus, diarrhea, dysentery, constipation, mastitis, enteritis, aching of the knee joint and leg, beriberi, edema, cough, asthma, emaciation due to general deficiencyk, indigestion, apoplexy, hemiplegia, dizziness, insomnia, mi\a

 

 

 

 

 

 

Fig. 4.19

 

Fig. 4.20


 

 

Fig. 4.21

 

 

 

Jonathan underwent treatment with acupuncture, and his acute pain subsided and the swelling returned to normal after five sessions of acupuncture.  I also injected Hyalgan once a week for five weeks.  After the acupuncture treatments and injections, the patient reported that the pain was much subsided, and for almost a year he was pain free.

Tips for patients:

  1. Acupuncture and all other treatments besides surgery would buy you time if you have severe knee osteoarthritis. As I mentioned above, we recommended you have your total knee replacement as late as  possible, the mechanical knee joint lasts only 10 to 15 years, you would not be happy during your life to have two times of total knee replacement.
  2. If you have mild to moderate knee osteoarthritis, acupuncture should be the first choice because of its effectiveness and no side effects.
  3. If  you would like to consider Hyalgan or other Hyuaric Acid injection, you should ask your physician if they use ultrasound guided injection and if they inject your knee once a week for at least three weeks in your knee. I prefer to inject once a week for 5 weeks, which could guarantee you have enough Hyuaric Acid injected in your knee.

Tips for Acupuncturist:

  1. In the acute stage of any knee pain, the patient should be treated by old fashioned methods: protection, rest, ice, compression and elevation.
  2. If an acute ligament or meniscus injury is suspected, the patient should be referred to an orthopedic or rehabilitation physician and have a MRI for the knee.
  3. A recent study by the NIH showed acupuncture can significantly decrease the pain of knee osteoarthritis.
  4. After the acute phase subsides, acupuncture with Moxa is extremely effective for Wind cold type, acupuncture with ice at the knee is a very useful method for wind hot type.