Acupuncture Pain Relief After Knee Surgery Lowers Morphine Use

ST34 Liangqiu

Researchers conclude that acupuncture improves pain relief outcomes in patients receiving pain-relieving drugs after total knee arthroplasty (TKA). Researchers from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine combined acupuncture with standard drug therapy. Patients receiving both pain-relieving drugs and acupuncture in a combined treatment protocol had superior patient outcomes compared with patients receiving only pain-relieving drugs. The researchers conclude that the addition of acupuncture to a traditional drug treatment regimen significantly reduces pain intensity and frequency, the total dosage requirements for pain-relieving drugs, and mitigates relevant complications. [1]

 

Electroacupuncture
The researchers cited independent scientific research documenting electroacupuncture’s pain-relieving effects. Fang et al. note that electroacupuncture “relieves pain by inhibiting the production of endogenous algesic substances.” [2] Han et al. demonstrate that “Low-frequency electroacupuncture increases the release of enkephalin, β-endorphin, endomorphin in the central nervous system, while high-frequency electroacupuncture increases the release of dynorphin in the spinal cord.” [3] Enkephalin, β-endorphin, endomorphin, and dynorphin are endogenous opioid peptides that play an important role in pain modulation. Han et al. add, “A disperse-dense wave of low frequency and high frequency stimulates the release of all four types of endogenous pain modulators, maximizing the pain-relieving effect of electroacupuncture.” [4]

Another study conducted by Han et al. shows that “low-intensity electroacupuncture is more effective for relieving local pain, while high-intensity electroacupuncture is effective for relieving both local and distant pain.” [5] In this study, a disperse-dense wave of 2 Hz/100 Hz was used. The intensity of electroacupuncture was adjusted to patient tolerance levels (2–5 mA). The researchers note, “Considering the human body has limited tolerance to electric stimulation, we keep the electric intensity between a patient’s sensory threshold and pain threshold.” [6]

 

Design
Guangzhou University of Traditional Chinese Medicine researchers (Chen et al.) used the following study design. A total of 40 patients that received TKA due to severe knee osteoarthritis were treated and evaluated in this study. The patients received TKA between May 2017 and February 2018. They were randomly divided into an electroacupuncture (EA) treatment group and a control group, with 20 patients in each group. For the control group patients, patient controlled epidural analgesia (PCEA) was provided. PCEA is a way to deliver pain-relieving drugs to the epidural space through a pump. Patients may push the pump if they need more medicine during PCEA. The treatment group received electroacupuncture in addition to the identical PCEA treatment administered to the drug control group.

The statistical breakdown for each randomized group was as follows. The treatment group consisted of 2 males and 18 females. The average age in the treatment group was 67.1 ±7.0 years. The control group consisted of 0 males and 20 females. The average age in the control group was 66.7 ±6.3 years. There were no significant statistical differences in gender and age relevant to patient outcome measures for patients initially admitted to the study.

 

Treatment
Before the end of the operation, both groups received a single dose of 1–2 mg of morphine through an epidural injection. Immediately after the operation, all patients were given PCEA. The analgesic medicine for PCEA included morphine, ropivacaine, droperidol, and sodium chloride solution. Morphine is a narcotic opioid drug used to treat pain. Ropivacaine is an amide anesthetic drug used for epidural anesthesia. Droperidol is an antidopaminergic drug used to prevent nausea.

The automatic drug delivery rate was 2 mL/h. The patient control rate was 0.5 mL/15 min. The PCEA treatment lasted 48 hours. In addition, patients received oral administration of 200mg of celecoxib, twice per day. Celecoxib is a nonsteroidal anti-inflammatory drug used for the treatment of pain and inflammation. When pain is severe and affects sleep and functional rehabilitation, patients received parecoxib sodium, tramadol, and NSAID drugs to control pain either through intramuscular injections or oral administration. These drugs have powerful analgesic effects. Dosage, administration, and the frequency of drug use was recorded. The acupoints used for the treatment group included the following:

  • ST34 (Liangqiu)
  • SP10 (Xuehai)
  • SP9 (Yinlingquan)
  • ST36 (Zusanli)
  • ST40 (Fenglong)
  • GB40 (Qiuxu)

Upon disinfection of the acupoint sites, a 0.25 mm × 25 mm or 0.25 mm × 40 mm filiform acupuncture needle was inserted into the acupoints, reaching a standard depth. After elicitation of a deqi sensation, the acupuncture needles were connected to an electroacupuncture device. The needles on the following acupoint combinations were connected to the same pair of electrodes: Liangqiu and Xuehai, Yinlingquan and Zusanli, Fenglong and Qiuxu. A disperse-dense wave (2 Hz/100 Hz, 2–5 mA) was applied with an intensity level set to patient tolerance levels. The needles were retained for thirty minutes, timed from the initiation of electroacupuncture current. Treatments were applied every day for seven consecutive days.

 

Acupoint Selection
The acupoint prescription used in the study is based on historical TCM (Traditional Chinese Medicine) indications and proven modern applications. Liangqiu is the Xi-cleft point of the Foot Yangming Stomach meridian. According to TCM principles, the Xi-cleft points, one for each meridian, are points where qi has accumulated. The Xi-cleft points are mainly used for acute diseases. The acupoint Liangqiu is indicated for lower-limb paralysis and knee pain or swelling. The researchers note, “Patients after TKA usually have decreased muscle strength and knee stability.” Thus, “Liangqiu is selected to increase the muscle strength and relieve pain.” [7]

Xuehai is located on the Foot Taiyin Spleen meridian. Needling this point transforms qi into blood and strengthens the spleen and stomach, which is helpful for “relieving relevant complications such as nausea, vomiting, and poor appetite.” [8] Zhao et al. treated patients with knee pain by acupuncture at Liangqiu and Xuehai and confirm that these two points are effective for relieving pain and strengthening the muscle. [9] In the experiment, needling at the two points achieved a 65.5% recovery rate.

Zusanli a the He-sea point of the Foot Yangming Stomach meridian. The He-sea points are points where qi comes together and collects on the corresponding meridian. This point is indicated for lower limb paralysis. Modern research confirms that Zusanli “inhibits the destruction of articular cartilage induced by IL-1β and TNF-α.” [10]

Yinlingquan is located on the Foot Taiyin Spleen meridian. This point is indicated for abdominal pain, knee pain, and soft tissue pain around the knee. Fenglong is located on the Foot Yangming Stomach meridian. The researchers note, “Needling Fenglong improves muscle atrophy, limb weakness and other symptoms after TKA, and reduces gastrointestinal discomfort.” [11] Qiuxu is the Yuan-source point of the Foot Shaoyang Gallbladder meridian. The Yuan-source points are where the body’s primordial qi collects. Needling this point smooths the joint and regulates qi and blood. This point is indicated for lower limb paralysis and ankle pain. The researchers also note that Qiuxu “alleviates joint discomfort and joint pain after TKA and helps to generate gastric qi and blood to improve gastrointestinal symptoms caused by TKA.” [12]

 

Evaluations
Multiple subjective and objective instruments were used to measure patient outcomes at several data points: 1 day (T1), 3 days (T2), 5 days (T3), and 7 days (T4) after completion of the operation. First, visual analogue scale (VAS) scores at rest and upon movement were measured. VAS is a measurement tool used for assessment of pain intensity or frequency.

Second, active and passive knee flexion range of motion (ROM) was tested. Third, the frequency of pushing a PCEA pump and the dosage as well as frequency of pain drug use was recorded. Fourth, patient safety was evaluated by observing whether there is swelling of the affected limb, redness of the wound, skin irritation, etc. Fifth, complications were measured by monitoring blood pressure and heart rate and also by recording the incidence rate of respiratory depression, nausea and vomiting, and urinary retention. Sixth, infection risks were evaluated through monitoring plasma white blood cell and C-reactive protein levels.

After treatment, the VAS scores at rest and upon movement in the EA (electroacupuncture) group were both significantly lower than that in the control group on T2, T3, and T4. There were no significant differences between the two groups regarding active and passive knee flexion ROM. The frequency of pushing a PCEA pump in the EA group was significantly lower than that in the control group. There was one patient that used extra pain drugs two times of in the EA group, with a total drug use rate of 5%. By comparison, there were three patients that used extra pain drugs eight times in the control group, with a total drug use rate of 15%.

Regarding complications, the EA group had two cases of nausea and vomiting, one case of dizziness and headache, and one case of chest tightness, while the control group had three cases of nausea and vomiting, two cases of dizziness and headaches, and two cases of chest tightness. Plasma white blood cell and C-reactive protein levels in both groups decreased after treatment, and there were no significant differences between two groups, indicating that “EA doesn’t increase infection risks for patients after TKA.” [13]

 

Results
The results indicate that electroacupuncture combined with pain-relieving drugs into an integrated treatment protocol is more effective than pain-relieving drugs as a monotherapy. Zhou et al. conclude that acupuncture is safe and effective for the relief of postoperative pain after TKA. Taking a broader view, the results of this study suggest that acupuncture may reduce addiction to pain medications after surgery by reducing pain levels and the need for medications.

 

References
[1] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.
[2] Fang JQ, Liu F, Shao XM, et al. Effect of Electroacupuncture on Carrageenan-induced Inflammation Interleukin-1β and Tumor Necrosis Factor-α Concentrations and mRNA Expressions in Toe Tissue in Rats [J]. Acupuncture Research, 2007, 32(4): 224-228.
[3] Han JS. Further Evidence of Acupuncture’S Frequency Specificity Analgesic Effect [J]. Acupuncture Research, 2001, 26(3): 224-227.
[4] Han JS. Further Evidence of Acupuncture’S Frequency Specificity Analgesic Effect [J]. Acupuncture Research, 2001, 26(3): 224-227.
[5] Han JS. Study of Factors That Affect the Analgesic Effect of Acupuncture [J]. Acupuncture Research, 1994, 19(Z1): 1-3
[6] Han JS. Further Evidence of Acupuncture’S Frequency Specificity Analgesic Effect [J]. Acupuncture Research, 2001, 26(3): 224-227.
[7] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.
[8] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.
[9] Wang XQ, Jiang YF, Qin KF. 282 Cases of Knee Joint Pain Treated by Oblique Acupuncture at Xuehai and Liangqiu [J]. Chinese Acupuncture, 2003, 23(5): 311
[10] Zhou JZ, Wang CF, Ma Y, Hu YH. Effect of Intra-articular Injection with Paeonol and Acupuncture at Zusanli on Serum Interleukin 1-beta and Tumor Necrosis Factor-alpha Contents in a Rabbit Model of Knee Osteoarthritis [J]. Chinese Journal of Tissue Engineering Research, 2012, 16 (22): 4096-4099.
[11] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.
[12] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.
[13] Chen D, Sheng D, Xu JL, Zhang YY, Lin TY, Zhang QW. Electroacupuncture Intervention Reduces Post-Surgical Pain of Patients Undergoing Total Knee Arthroplasty [J]. Acupuncture Research, 2018, 43 (10):616-621.

Source: HealthCMi