| Author: | Pang, Chun Yiu |
| Title: | Short-term effects of ultrasound-guided dry needling on pain and functional disability for knee osteoarthritis : a double-blind, randomized and controlled study |
| Advisors: | Fu, Amy (RS) |
| Degree: | DHSc |
| Year: | 2022 |
| Subject: | Osteoarthritis -- Treatment Acupuncture Hong Kong Polytechnic University -- Dissertations |
| Department: | Faculty of Health and Social Sciences |
| Pages: | xxiii, 143 pages : color illustrations |
| Language: | English |
| Abstract: | Purpose The application of dry needling (DN) to treat knee osteoarthritis (KOA) that is one of the most prevalent forms of arthritis. The efficacy of DN in patients with KOA has not yet been proven yet. Recognizing that ultrasound-guided (US) DN has demonstrated favorable outcomes in the treatment of other painful musculoskeletal conditions, the purpose of this study was to investigate the effects of DN and US-guided DN in the treatment of knee pain and dysfunction secondary to KOA. Method Ninety subjects (25 males and 65 females) aged between 50 and 80 (61.26±5.57) with radiological KOA were recruited and randomly assigned into three groups with a computer programme (Group 1 [G1]: US-guided DN, Group 2 [G2]: Placebo US-guided DN and Group 3 [G3]: control). Inclusion criteria were: 1) aged 50 to 80 years old, 2) referred with a diagnosis of KOA included X-rays in grade I-III of Kellgren and Lawrence (KL) scale (i.e., primary KOA fulfilling the American College of Rheumatology criteria, at least three out of six, for clinical and radiographical diagnostic KOA), 3) presenting with an episode of anterior and/or medial knee pain with 2-3 local tender spots (for selecting the locations of DN). Exclusion criteria were: 1) having other musculoskeletal diseases associated with knee pain e.g. referred pain from the low back or posterior or lateral knee pain or co-existing pain over the other limb; 2) suffering from acute inflammation, diffuse tenderness upon palpation test, bone marrow lesion, severe joint deformity or valgus angle of tibiofemoral joint equal to or more than 150 with X-rays revealing a grade IV in the KL scale, coagulation disorders, metabolic, or neuropathic arthropathies, immunosuppressed or systematic disease; 3) having severe concomitant illness (e.g. sprain ankle, OA hip, etc.) that might affect the clinical outcomes of this study (e.g. functional mobility), 4) contraindications to DN including pregnancy, malignancy, menstruating at the time of study, fear of DN; 5) having recent treatment involving acupuncture or DN therapy within a month prior to the start of the study; 6) inability to answer questionnaires and non-responsiveness towards the assessor; 7) having a wound or pressure sore or skin problems or skin allergy, including an allergy to iodine; 8) having a history of injecting steroid or other drugs. The intervention for G1 was real US-guided DN that was applied to the tender spots at the ligamentous structures (medial patellofemoral ligament, medial patellotibial ligament and medial collateral ligament), where showed abnormal sonographic findings (i.e., hypoechogenicity, hyperechogenicity and mucoid degeneration). The intervention for G2 was placebo US-guided DN that was applied DN under a placebo US guidance with off-monitor to the tender spots around medial knee joint. The intervention for G3 was routine exercise and education. The interventions for the G1, G2 and G3 were delivered once weekly for four weeks. In addition, all subjects received standardized exercises and patient education video of knee care. Outcome measures included Visual Analogue Scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales of pain, symptoms and quality of life (QOL) were collected at baseline, 4-week and 8-week follow-ups. A mixed design consisted a between effect and a repeated measure effect. Once the interaction effect was observed, the between effect by comparing the three groups: G1 (real ultrasound-guided dry needling with exercise and education), G2 (placebo ultrasound-guided dry needling with exercise and education) and G3 (exercise with education). Additionally, a repeated measure for the time effects including three time points (baseline, 4-week follow-up and 8-week follow-up) was assessed. The Bonferroni correction is a multiple-comparison correction. The outcomes were analyzed by a two-way design of mixed effects that an analysis of covariance (ANCOVA) (two-tailed) was perfromed for time effect and group effects. Post hoc test was conducted when there was interaction between time and group effects. Baseline of age, gender, body mass index (BMI), severity of disease and duration of pain were entered as covarites. The missing data was analyzed with the Intention-to-treat (ITT) approach if more than 5% missing data. Results Significant reduction in VAS with interactions between the time and group effects in repeated-measure ANCOVA [F(4,158)=6.92, p<0.001, partial η2=0.149] were observed. Post hoc pairwise comparisons with the Bonferroni correction revealed that the participants with G1 had significantly higher pain reduction than G2 and G3 at 8-week (both p<0.05). There was no significant difference between G2 and G3 in pain reduction at 8-week follow-up (p=0.91). For group effects, G1 achieved significant improvement in VAS at 8-week follow-up (G1 vs. G2, p=0.002; G1 vs. G3: p< 0.001). There was no significant difference between G2 and G3 (p= 0.912). For the time effects, G1 achieved significant improvement in VAS at the 4-week follow-up (p< 0.001) and on 8-week follow-up (p< 0.001). In addition, G1 also showed a significant pain reduction between 4-week and 8-week follow-ups (p<0.001). G2 and G3 did not show the significant pain reduction between 4-week and 8-week follow-ups (both p>0.05). Moreover, significant improvement of KOOS-pain showed with interactions between the time and group effects [F(4,158)=5.94, p<0.001, partial η2=0.131]. Post hoc pairwise comparisons with the Bonferroni correction revealed that G1 had significant improvement in KOOS-pain than G2 and G3 at 8-week follow-up (both p<0.05). For group effects, G1 achieved significant improvement in KOOS-pain at 8-week follow-up (G1 vs. G2: p=0.009; G1 vs. G3: p=0.010). However, there was no significant difference between G2 and G3 (p=1.000). For time effects, G1 achieved significant improvement in KOOS-pain at 4-week follow-up (p=0.011) and at 8-week follow-up (p<0.001). In addition, the improvement in KOOS-pain was also significant between 4-week and 8-week follow-ups (p<0.001). G2 and G3 did not show the significant pain reduction between 4-week and 8-week follow-ups (both p>0.05). However, interactions between the time and group effects were not significant in KOOS-symptoms with repeated-measure ANCOVA (p=0.082) and in KOOS-QOL (p=0.202). Similarly, no significant main effect was found in exercise compliance or pharmacological consumptions among the three groups as measured by repeated-measure ANCOVA (p=0.077). In G1, the needles were applied to the medial patellofemoral ligament (MPFL) (n=17), medial patellotibial ligament (MPTL) (n=16) and medial collateral ligament (MCL) (n=11) to patients with hypoechogenicity (n=2), hyperechogenicity (n=4) and mucoid degeneration (n=24). In G2, the needles were applied to the MPFL (n=19), MPTL (n=15) and MCL (n=7) to patients with hypoechogenicity (n=3), hyperechogenicity (n=1) and mucoid degeneration (n=26). There were no occurrences of infection or adverse effects on during the interventions. Conclusion Patients with KOA who received US guided-DN plus exercise therapy demonstrated significant improvement in knee pain. Besides, the patients received placebo US-guided DN plus exercise therapy who also demonstrated improvement in pain reduction. However, the improvement was less than US guided-DN. These results also shed light on the application of DN to ligamentous structure to patients with KOA in an effective and safe manner. DN may induce remodeling of the ligament and promote cellular proliferation and matrix synthesis of the treated ligament. Clinically, physiotherapists can apply US-guided DN in helping to provide an accurate puncturing stimulation to the target ligament in KOA to promote tissue healing, leading pain reduction. Further studies examining the long-term effects of US-guided DN and expanding to a wider range of KOA severities are recommended. |
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| Access: | restricted access |
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