Periosteal Electric Dry Needling for Knee Osteoarthritis: Effectiveness & Mechanisms

The current body of evidence strongly supports the use of needling therapy, i.e. acupuncture for treating the pain, stiffness and related-disability associated with knee OA.^1-7 Zhang et al⁸ cited a 69% consensus following a Delphi study recommending the use of acupuncture for the symptomatic treatment of OA and reported a moderate effect size for this needling modality (i.e. acupuncture).

ELECTRICAL DRY NEEDLING FOR KNEE OSTEOARTHRITIS

However, does stimulating a needle manually cause the same, or different, physiological effects than stimulating it electrically in patients with knee OA? A recent meta-analysis concluded electroacupuncture is superior to manual acupuncture for improving pain and function in patients with knee OA.⁹ Eleven RCTs with 695 participants were included. The meta-analysis indicated that electroacupuncture was more effective than pharmacological treatment (RR = 1.14; P=0.03) and manual acupuncture (RR = 1.12; P=0.02) for pain reduction and functional improvement in patients with knee OA. Likewise, in a secondary analysis that pooled data from the Manheimer et al Cochrane review,¹⁰ Langevin et al¹¹ concluded that electroacupuncture was superior to manual acupuncture (pooled effect of 5 knee OA trials; n=1215; p=0.042).¹¹ Notably, this may be one reason why the Foster et al¹² and Chen et al¹³ studies found unfavorable results when investigating the effects of manual acupuncture in knee OA.

PERIOSTEAL NEEDLING FOR KNEE OSTEOARTHRITIS

Appropriate needle depth may also be an important component to consider when using dry needling therapies for joint OA. More specifically, a number of studies have demonstrated that periosteal needling (i.e. getting the needle close to the bone, or tapping the needle repeatedly on to the bone) leads to significant and clinically meaningful improvements in pain and disability in patients with hip and knee osteoarthritis.^14-16 Periosteal needling is a technique originally described by Felix Mann that targets the richly innervated periosteum of bone, typically with electric stimulation.¹⁷

Although the mechanisms by which electroacupuncture favorably affects pain and physical function in patients with knee OA remains unclear, Zhang et al¹⁸ recently found significantly lower T2 values on MRI at the anteromedial and anterolateral tibial sub-regions of 100 knees following 20 minute sessions over 4 weeks of 7-point, low frequency electroacupuncture; that is, electroacupuncture appears to play a role in cartilage repair in individuals with knee osteoarthritis.¹⁸ Similarly, 10 sessions of periosteal electric stimulation (i.e. 4 acupuncture needles touching the bone of the tibiofemoral joint) with monthly “booster” sessions have been found in the medium and long term (9 months post treatment initiation) to significantly decrease WOMAC pain, stiffness and function scores in patients with severe (i.e. Kellgren-Lawrence grade 3 or 4) knee OA.¹⁴

Notably, three studies found unfavorable results when adding acupuncture as an adjunct therapy to exercise-based physical therapy in patients with knee OA. Nevertheless, considering the recent findings regarding the influence of acupuncture on cartilage repair¹⁸ and the efficacy of periosteal stimulation¹⁴ in patients with knee OA, it is possible that the needles in the Foster et al (0.5 cm to 2.5 cm¹²), Chen et al (0.2 cm to 3.0 cm¹³) and Scharf et al (0.5 to 3.5cm¹⁹) trials were not inserted deep enough.

PHYSIOLOGY OF PERIOSTEAL ELECTRIC DRY NEEDLING

According to Weiner et al, periosteal stimulation with needles inhibits peripheral pain processing, stimulates local vasodilation and alters vascular sympathetics.¹⁴ More specifically, electroacupuncture has been shown to activate Aδ, C and Aβ pain fibers, facilitating diffuse noxious inhibitory control and gate control within the dorsal horn of the spine.^20-22 Electroacupuncture has also been shown to facilitate endogenous anandamide, increasing local opioid production while decreasing pro-inflammatory factors such as TNF-α, IL-4, IL-6, IL-8 and IL-10.^23,24

Electroacupuncture causes the release of substance-P and CGRG predominantly from non-neural structures, facilitating a negative feedback loop to neural and neuroactive components of the target tissue.^25,26 In the case of periosteal needling, this may lead to decreased inflammation of the densely innervated periosteum. Notably, CGRP in high quantities causes inflammation, but the concurrent release of substance-P combined with electric stimulation in the vicinity of the periosteum may provide sustained, low levels of CGRP required for a potent anti-inflammatory effect.^27-30 CGRP also initiates a cascade of events mediated by protein kinase A (PKA) in vascular smooth muscle, leading to vasodilation.³¹ Moreover, PKA stimulates nitric oxide synthase, increasing the production of nitric oxide, thereby exaggerating the vasodilation effect.³¹ The improved vasodilation enhances the microcirculation of degenerative joints, resulting in increased opioid delivery and decreased inflammatory factors in the synovia.^32,33

Limited evidence also suggests that acupuncture may stimulate an increase in hyaluronic acid, allowing the synovial fluid to better lubricate the joint.³⁴ Mechanical and electric needle stimulation at, or close to, the periosteum may be particularly advantageous in joint osteoarthritis, as acupuncture has been shown to reduce IL-6 mRNA expression in bone marrow, thereby limiting inflammation and inhibiting myelogenic osteoclast activity driving degeneration.³⁵

CONCLUSION

In order to maximize the physiologic effects of dry needling in patients with knee OA, electric stimulation and needle placement on to, or near, the bone, cartilage or joint line should likely be considered.

AUTHORS

James Dunning, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Montgomery, AL

Raymond Butts, PhD, DPT, MSc (NeuroSci), Cert. DN, Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Atlanta, GA

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