The Semblance of Dry Needling using FIDN process on Knee Retinaculum for pain in Osteoarthritis

Dr. Mihir Somaiya
Founder and President – FIDN Institute UK

The Epidemiology

“A wise and salutary neglect.”

― Edmund Burke

Of course  osteoarthritis forms the major epidemiology in the modern world which is often neglected and underrated. Epidemiologic principles can be used to describe the distribution of osteoarthritis in the population and to examine risk factors for its occurrence and progression. For the purpose of epidemiologic investigation, osteoarthritis can be defined pathologically, radiographically, or clinically. However the early diagnosis is often attributed with the increase in physical examination and the restriction in activity of daily living. Studies of osteoarthritis in people who have joint symptoms may be more clinically relevant, because not all persons who have radiographic osteoarthritis have clinical disease, and not all persons who have joint symptoms demonstrate radiographic.

Osteoarthritis is the most common joint disorder in the United States and a  serious chronic disease that affects 1 in 7 US adults—32.5 million people. Symptomatic knee osteoarthritis occurs in 10% men and 13% in women aged 60 years or older. It is the most common form of arthritis and a leading cause of disability worldwide, largely due to pain, the primary symptom of the disease. The pain experience in knee is well-recognized as typically transitioning from intermittent weight-bearing pain to a more persistent, chronic pain. The most recent update of the Global Burden of Disease figures (2013) estimated that nearly 242 million people were living with symptomatic and activity-limiting osteoarthritis of the hip and/or knee. In the US, it is predicted that by 2030 an estimated 67 million adults will have doctor-diagnosed arthritis, compared with 52.5 million adults in 2010–2012.By 2030, the number of US adults with arthritis is projected to reach 67 million. The Framingham Osteoarthritis Study found that prevalence of knee pain and symptomatic osteoarthritis in the United States roughly doubled in women and tripled in men during the 20 years of the study after adjusting for age and body mass index. In Finland and Sweden, incidence rates for OA have increased almost tenfold from 1986 to 2003. Pain is the defining clinical presentation with inadequate pain relief is a major reason of impaired mobility in older adults in the US and is considered a key factor in onset of frailty in the elderly.

Tibiofemoral joint osteoarthritis is characterized by joint effusion, osteophytes, diminished flexion range, mediolateral instability and varus deformity. On the other hand in patellofemoral osteoarthritis, valgus deformity, grossly reduced quadriceps strength, pain on patellofemoral joint compression difficulty descending stairs. Primary osteoarthritis develops in a slow, progressive fashion and can affect 1 or all 3 major joint compartments of the knee. The risk of getting knee osteoarthritis is a multifactorial, complex interplay of constitutional and mechanical factors. Osteoarthritis is directly linked to an increase in water content of the articular cartilage with a decrease in proteoglycan content. As collagenase levels increase, maintained collagen becomes severely disrupted. The vicious cycle continues with elevated levels of proteolytic enzymes and inflammatory cytokines and the joint becomes more arthritic and painful.

The Paradigm shift from Biomechanics to Neurophysiology structure of Fascial therapies.

“To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science.”

― Albert Einstein

Knee alignment which includes (hip, knee & ankle angle) is a key determinant of load distribution. Any shift from a neutral or collinear alignment of the hip, knee and ankle affects load distribution at the knee. Therefore, one would speculate that malaligned knees may have a higher risk of developing osteoarthritis and a higher subsequent risk of progression than knees with neutral alignment. In a prospective cohort study, Sharma et al demonstrated that in the presence of existing knee osteoarthritis abnormal anatomic alignment was strongly associated with accelerated structural deterioration in the compartment under greatest compressive stress. Knees with varus alignment at baseline had a fourfold increase in the risk of medial progression of knee osteoarthritis, and those with valgus alignment at baseline had a nearly fivefold increase in the risk of lateral progression. The same study also found that the impact of varus or valgus malalignment on the risk of osteoarthritis progression was greater in knees with more severe baseline radiographic disease than knees with mild or moderate disease. Another study found that knee malalignment was associated with the size and progression of bone marrow lesions as well as with rapid cartilage loss on MRI.

The association between malalignment and risk of incident knee osteoarthritis is less clear. In the Framingham Study, however, Hunter and colleagues using four measures of knee joint alignment (i.e., the anatomic axis, the condylar angle, the tibial plateau angle, and the condylar tibial plateau angle) found none of these measures to be associated with an increased risk of incident radiographic knee osteoarthritis. The authors speculated that malalignment may not be a primary risk factor for the occurrence of radiographic knee osteoarthritis but rather a marker of disease severity and/or its progression. The retinaculum, part of the fascial system, is strong connective tissue found only in certain parts of the body. The retinaculum exists to provide stability and protection for tendons and nerves as they cross important joints. Fascia is a protective webbing that wraps the entire body. It works in different ways, connecting some things together, allowing others to glide around each other. Fascia is not dissimilar to tendons and ligaments in their physical make-up but they all have different roles to play. The retinacula, found in the hand, foot and knee, are covering muscle tendons and nerves as they cross vulnerable joints.

The retinacula of the knee are way more complex because of the structure of the knee itself. There are two retinacula of the knee, the medial and lateral and they sort of act ligamentously to balance and stabilize the kneecap, ideally sustaining an equal pull to the inside and outside. They relate as well to the IT band and patella ligament and can all be seen to be of one piece if you want to stretch things a little. Excessive or prolonged loading or direct trauma to fascial tissues initiates micro and macro changes necessary for tissue repair. These effects may also contribute to pathological changes that modify tissue function and mechanics, leading to compromised function of the healthy tissue. Effects may become systemic, and thus not limited to the injured/loaded tissues.

Following an acute injury from overload or anoxia in fascial tissues, the immune response aims to phagocytose injured cells. An acute inflammatory response is typically short-lived and reversible and involves the release of a range of molecules, including pro inflammatory cytokines from injured cells and macrophages, along with other substances (eg, bradykinin, substance P and proteases) that sensitize nociceptive afferents and promote immune cell infiltration. If loading is prolonged or repetitive, persistent inflammation may develop, leading to the prolonged presence of macrophages and cytotoxic levels of cytokines in and around tissues, ultimately resulting in ongoing tissue damage. Some tissue cytokines (eg, interleukin-1β, tumour necrosis factor (TNF) and transforming growth factor beta (TGFβ-1)) are fibrogenic cytokines that can promote fibrosis via excessive fibroblast proliferation and collagen matrix deposition.

Overproduction of cytokines also maintains sensitization of nociceptive afferents a change that would increase production and release of substance P (a known nociceptor neuropeptide). Recent studies show that substance P can stimulate TGFβ-1 production by tendon fibroblasts, and that both substance P and TGFβ-1 can induce fibrogenic processes independently of each other. Taken together, these findings suggest that both neurogenic processes (nerves are the primary source of substance P) and loading/repair processes (TGFβ-1 is produced by fibroblasts in response to mechanical loading and during repair) can contribute to increased collagen in fascial tissues. Fibrosis (eg, collagen deposition) around the tendon, nerve and myofascial tissues influences dynamic biomechanical properties secondary to tissue adherence or induce chronic compression. 

Increased collagenous tissues surrounding the nerves can cause the nerves to be fixed and also enhance pain behaviours. Furthermore, inflammatory cytokines can ‘spill over’ into the bloodstream, leading to widespread secondary tissue damage and central nociceptor wind-up. Circulating TNF is elevated in chronic lower back pain, and recent data highlight a relationship between elevated TNF and greater risk for progression to chronic pain in some individuals of overuse. Adipose tissue is a potential source of pro inflammatory cytokines and has been implicated in a range of musculoskeletal conditions, including osteoarthritis. Regardless of the underlying mechanism, fibrotic changes in the muscle have a substantial potential impact on tissue dynamics and force generation capacity.

The key infrastructure for developing Myofascial Pain Syndrome.

“Failure is not fatal, but failure to change might be.”

― John Wooden

The fashionable content which attracted discussion in all the therapy clinics from 2010 formed the key to my therapy puzzle although the primitive perception of fascia which I received in my physical therapy school was of a continuous piece of fibrous sheet that wraps the body just underlying the skin. However, the detailed analysis in the year 2011 revealed to me that it is much more than superficial fascia which fabricates its way in to deep structures and forms the architecture of body structures. Irrespective of the structures, fascia forms a continuum between muscles to bone and bones to bones by way of tendons & ligaments with forming anchors to the bones of your spine and also your viscera to support organs. The associated concept of trigger points was always accompanied with myofascia which illuminate the abstraction of fascia as a science.

The review of the available literature advances in fascia research within the field of biomechanics, gross anatomy, histology & clinical relevance. The theory features fascia as an uninterrupted viscoelastic tissue which forms a functional 3- dimensional collagen matrix. The key characteristic component which was described is the the biomechanical force transmission & influence on length of sarcomeres to improve force production. The role of myofascial pain is largely appreciated as many encapsulated nerve endings found in fascia are mechanoreceptors that respond to mechanical pressure or deformation, and include Golgi receptors, Pacinian corpuscles & Ruffinis corpuscles. The different techniques of tissue manipulation may stimulate the above receptors knowing what receptors are more significantly concentrated in a particular target tissue, which can help a manual practitioner choose the method of stimulus and technique (For e.g. deep pressure, light stroke, stretch, tension or vibration). The fascial science & the assimilation of paradigm shift from biomechanics to neurophysiology encouraged me to disdain from pseudo trigger point dry needling application to main stream fascial dry needling perspective.

The formulation

“Sometimes a clearly defined error is the only way to discover the truth.”

― Benjamin Wiker

Multiple studies have used dry needling of the knee joint without targeting specific trigger points to treat pain and disability in patients with knee osteoarthritis.Recent systematic reviews and meta-analyses provide strong and overwhelming evidence for the effectiveness of acupuncture in the treatment of knee osteoarthritis.

According to the Cochrane Database systematic review on acupuncture for peripheral joint osteoarthritis, Manheimer et al. found acupuncture to be associated with a statistically significant and clinically meaningful short term improvement in osteoarthritis pain when compared to a wait list control. Additionally, this systematic review, which included 12 RCTs of patients with knee osteoarthritis and 4 trials of patients with knee pain, reported statistically significant reductions in pain following acupuncture in patients with knee osteoarthritis at 6 months when compared with sham acupuncture. Moreover, in an individual patient data meta-analysis of 9 RCTs comparing real, sham and no acupuncture for chronic pain conditions, Vickers et al. reported superior outcomes using real acupuncture in the treatment of knee osteoarthritis. Additionally, a very recent meta-analysis of 11 high-quality RCTs concluded that real acupuncture provides a significant reduction in pain immediately following treatment compared to other physical treatment methods, including sham acupuncture. In contrast to the findings of the Cochrane Database systematic review and two recent meta analyses, it is noteworthy that an earlier trial found the addition of real acupuncture to a course of advice and exercise for the treatment of knee osteoarthritis provided no additional improvement in the WOMAC pain sub-scale at 6 months when compared to sham acupuncture. The data from Foster et al also failed to demonstrate a significant relationship between patient treatment preferences and clinical outcomes or patient expectations and pain at 6 and 12 months. However, the results of Foster et al. should be viewed cautiously due to the limited number of treatment sessions in the acupuncture protocol compared to other studies which may have rendered the true acupuncture intervention suboptimal, a concession that the authors independently made. More importantly, unlike other trials the subjects in the Foster et al trial did not have radiographically confirmed knee osteoarthritis.

Nevertheless, despite the methodological differences of the Foster et al trial, a cost-utility analysis of the Foster et al data by Whitehurst et al concluded that advice and exercise plus real acupuncture delivered by physical therapists still provided a cost effective use of health care resources.

Likewise, there is robust evidence that peri-neural needling of non-trigger point structures helps reduce pain and disability while improving sensory and motor nerve conduction velocities. Such findings suggest that organizations that teach physical therapists a TrP ‘search and destroy’ method of dry needling may not be evidence based. Rather, therapists may be much more effective treating conditions such as osteoarthritis by focusing on non-TrP locations such as neural, connective(Retinacula), and muscle tissue.

Conclusion

The biomechanical, chemical, & vascular effects of needling either superficial, subcutaneous tissue (non-muscular) or deep intramuscular tissue without injecting any substance have been well documented.

Improved microcirculation around the knee joint for osteoarthritis has been demonstrated following dry needling into non-TrP locations such as neural, connective(Retinacula) and improved muscle blood flow has been found following ‘manual acupuncture’ in the lower extremities. Furthermore, low blood flow seemed to correlate with pain intensity, suggesting that reduced microcirculation plays a role in the pathophysiology of myofascial pain syndrome. Electrical dry needling in patients with knee osteoarthritis has also resulted in endocrinological changes, including increases in beta-endorphins and decreases in cortisol.

Disclaimer : The suggestions from readers are welcome at support@fidninstitute.com and this blog is my opinion and should not necessarily be of others. Any views or opinions represented in this blog are personal and belong solely to the blog owner and do not represent those of people, institutions or organizations that the owner may or may not be associated with in professional or personal capacity unless explicitly stated.

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