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
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.
James Dunning, DPT, MSc (Manip Ther), FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Raymond Butts, PhD, DPT, MSc (NeuroSci), Cert. DN, Dip. Osteopractic
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
- Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-265.
- Corbett MS, Rice SJ, Madurasinghe V, et al. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013;21(9):1290-1298.
- Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan S. The Effects of Acupuncture on Chronic Knee Pain Due to Osteoarthritis: A Meta-Analysis. J Bone Joint Surg Am. 2016;98(18):1578-1585.
- Mavrommatis CI, Argyra E, Vadalouka A, Vasilakos DG. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: a 3-armed, randomized, placebo-controlled trial. Pain. 2012;153(8):1720-1726.
- Vas J, Mendez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. Bmj. 2004;329(7476):1216.
- White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford). 2007;46(3):384-390.
- Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet. 2005;366(9480):136-143.
- Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18(4):476-499.
- Chen N, Wang J, Mucelli A, Zhang X, Wang C. Electro-Acupuncture is Beneficial for Knee Osteoarthritis: The Evidence from Meta-Analysis of Randomized Controlled Trials. Am J Chin Med. 2017;45(5):965-985.
- Manheimer E, Cheng K, Linde K, et al. Acupuncture for peripheral joint osteoarthritis. The Cochrane database of systematic reviews. 2010(1):CD001977.
- Langevin HM, Schnyer R, MacPherson H, et al. Manual and electrical needle stimulation in acupuncture research: pitfalls and challenges of heterogeneity. J Altern Complement Med. 2015;21(3):113-128.
- Foster NE, Thomas E, Barlas P, et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. Bmj. 2007;335(7617):436.
- Chen LX, Mao JJ, Fernandes S, et al. Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: a randomized controlled trial. J Clin Rheumatol. 2013;19(6):308-316.
- Weiner DK, Moore CG, Morone NE, Lee ES, Kent Kwoh C. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clin Ther. 2013;35(11):1703-1720 e1705.
- Weiner DK, Rudy TE, Morone N, Glick R, Kwoh CK. Efficacy of periosteal stimulation therapy for the treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial. J Am Geriatr Soc. 2007;55(10):1541-1547.
- Mcindoe A. A comparison of acupunture with intra-articular steroids injection as analgesia for osteoarthritis of the hip. Acupuncture in Medicine. 1995;13(2).
- Mann F. Reinventing Acupuncture: A new Concept of Ancient Medicine. Butterworth-Heinemann, 2nd Ed. Cambridge MA 2000.
- Zhang Y, Bao F, Wang Y, Wu Z. Influence of acupuncture in treatment of knee osteoarthritis and cartilage repairing. Am J Transl Res. 2016;8(9):3995-4002.
- Scharf HP, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med. 2006;145(1):12-20.
- Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013;17(8):348.
- Guo ZL, Longhurst JC. Activation of reciprocal pathways between arcuate nucleus and ventrolateral periaqueductal gray during electroacupuncture: involvement of VGLUT3. Brain Res. 2010;1360:77-88.
- Zhang Y, Zhang RX, Zhang M, et al. Electroacupuncture inhibition of hyperalgesia in an inflammatory pain rat model: involvement of distinct spinal serotonin and norepinephrine receptor subtypes. Br J Anaesth. 2012;109(2):245-252.
- Zhang R, Lao L, Ren K, Berman BM. Mechanisms of acupuncture-electroacupuncture on persistent pain. Anesthesiology. 2014;120(2):482-503.
- Su TF, Zhang LH, Peng M, et al. Cannabinoid CB2 receptors contribute to upregulation of beta-endorphin in inflamed skin tissues by electroacupuncture. Mol Pain. 2011;7:98.
- Erin N, Ulusoy O. Differentiation of neuronal from non-neuronal Substance P. Regul Pept. 2009;152(1-3):108-113.
- Zhang ZJ, Wang XM, McAlonan GM. Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture. Evid Based Complement Alternat Med. 2012;2012:429412.
- Bullock CM, Kelly S. Calcitonin gene-related peptide receptor antagonists: beyond migraine pain–a possible analgesic strategy for osteoarthritis? Curr Pain Headache Rep. 2013;17(11):375.
- Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J. Anti-inflammatory actions of acupuncture. Mediators Inflamm. 2003;12(2):59-69.
- Raud J, Lundeberg T, Brodda-Jansen G, Theodorsson E, Hedqvist P. Potent anti-inflammatory action of calcitonin gene-related peptide. Biochem Biophys Res Commun. 1991;180(3):1429-1435.
- Butts R, Dunning J, Perreault T, Maurad F, Grubb M. Peripheral and Spinal Mechanisms of Pain and Dry Needling Mediated Analgesia: A Clinical Resource Guide for Health Care Professionals. International Journal of Physical Medicine and Rehabilitation. 2016;216(4:2).
- Lundeberg T. Acupuncture mechanisms in tissue healing: contribution of NO and CGRP. Acupunct Med. 2013;31(1):7-8.
- Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain. 2009;147(1-3):60-66.
- Huang J, Zhuo LS, Wang YY, et al. [Effects of electroacupuncture on synovia IL-1beta and TNF-alpha contents in the rabbit with knee osteoarthritis]. Zhen Ci Yan Jiu. 2007;32(2):115-118.
- Li ZD, Cao LH, Wang SC. [Effect of moxibustion in treating knee joint osteoarthritis and its relation with contents of hyaluronic acid in serum and synovial fluid]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2009;29(10):883-885.
- Liu X, Shen L, Wu M, et al. Effects of acupuncture on myelogenic osteoclastogenesis and IL-6 mRNA expression. J Tradit Chin Med. 2004;24(2):144-148.