When using Medical Acupuncture in the treatment of musculoskeletal pain, I find myself in the main selecting either segmental points or trigger points if present, sometimes both.
Segmental points are basically those where tissue, preferably muscle, which shares the same segmental innervation as the structure likely to be responsible for nociceptive input, is stimulated. Trigger points must meet with the relevant diagnostic criteria and when using Medical Acupuncture to deactivate may be referred to as dry needling. These terms are often used interchangeably however, at least in Europe.
One of the conditions for which I find segmental Acupuncture particularly useful is that of knee osteoarthrosis and associated pain symptoms. The evidence would generally support using more local to the knee joint (White, 2007) and I would select points within muscles which act on the knee joint as well as sharing the same segental innervation. That said, so called sham Acupuncture can also be beneficial in providing pain relief and often extra-segmental points, those outside the segment, are used to augment the effects of segmental points.
Speaking of augmentation, Electro-Acupuncture (EA) is often used to potentiate pain neuro-modulatory effects to a level assumed to be beyond that of Manual Acupuncture (MA). Low frequency EA (2 Hz) has been shown to increase the release of enkephalins and B-endorphins, whereas high frequency EA (80-100 Hz) has been shown to increase the release of dynorphins (Ulett et al, 1998). High frequency EA if often used to give more immediate but shorter lasting pain relief, low frequency longer lasting. For this reasons EA is often given at a mixed frequency.
Just how beneficial the the use of EA over MA is in the providing pain relief in knee osteorathrosis was considered in a recent study by Plaster et al, 2014 who found no significant differences in two arm RCT, however pain levels did reduce by 52% and 42% respectively. Neither was there a difference in strength and mobility measures. However only a single session of either MA or EA was given, the dose/intensity level in the EA group was not clearly described and it would appear that the number of local segmental points used was limited. My experience with EA in the treatment of knee osteoarthrosis has been very positive, but would allow at least 4-6 sessions for the cummulative effects.
When treating this condition, I am also always on the lookout for active and/or latent myofascial trigger points which could be impairing muscle function and contributing by referral to the knee pain symptoms. The vastus medialis, lateralis, upper rectus femoris, hamstrings and gluteal muscles would be important to consider, as well as the calf muscles.
After needling I like to get the knee moving, graded therapeutic exercise is important to help maintain or restore range of movement and well as improve muscle function and stability of the knee joint. I prefer graded isometric and closed chain exercises to begin with.
Does manual therapy have role to play?
Mulligans techniques have been very good to me over the years, in particular for those mechanically restricted knees which are not inflamed nor too irritable. For more graded mechanical input, Maitlands techniques can be used.
As with most conditions I treat, an integrated approach works best from a clinical point of view and since including Medical Acupuncture as a basis of treatment, my results have been generally very satisfying both for me and my patients.