Discussion
The number of knee surgeries being performed has increased and the use of Korean medicinal approach for the control and management of pain after various surgeries has been increasing. However, only a few studies have investigated the patient’s pain control and management after soft tissue reconstruction. We reported a case in which Korean medicinal treatment was applied after knee surgery and conducted a literature review on this subject.
Our literature search yielded six reference articles, including Liang’s article
15) from 2006, which was a randomized controlled trial, and five other case reports. Among them, they included a maximum of two cases per study except Silvia’s research that included 20 cases. Further studies should include many more cases to draw more solid conclusions.
In each study, several instruments were used as an index to evaluate the recovery of patients. VAS, which is an objective pain index, and ROM were the most commonly used indexex, as in the current study.
In addition, studies by Oh et al.
11) (2010) and Park et al.
12) (2016) used the Lysholm score to assess knee ligament function. The Lysholm score consists of eight questions on pain, swelling, limpness, squatting, instability, support, stair-climbing and locking. Of the total score of 100, pain and instability account for 25 points each
16). EMGs were performed in a study by Silvia et al.
13) (2016) to evaluate the strength of the weakened quadriceps muscle after ACL reconstruction. In our case, the VAS, ROM, and KOOS were used as the indexes to evaluate the recovery of the patient.
The patient in this study was treated for 7 days after the arthroscopic right ACL reconstruction on June 27, 2014, and was treated after discharge. However, he continued to experience pain, and his ROM did not recover. He visited the departments of acupuncture and moxibustion because he was unable to walk independently. Afterwards, he was admitted to the hospital and received Korean medical treatment from July 10, 2014 to August 2, 2014.
The knee is referred to “肝之合, 膝也”, “腎主骨” and is closely related to the liver and kidney in Korean medicine theory. According to the theory, the river is responsible for/connected to the muscle and the kidney is responsible for/connected to the bone. When the two organs weaken, pathogenic qi[邪氣] of wind-cold-dampness[風寒濕] invades in the weakened state of the bone and muscle or blood stasis because of injury, and this results in disturbances in the circulation of qi and blood. Thus, knee diseases such as 膝痛, 膝中痛, 膝重, 膝外 廉通, 鶴膝風, and 膝痺 occur. These cases are accompanied by symptoms, such as pain[疼痛], swelling[腫脹], numbness[痲木], joint swelling[關節 腫大] and difficulty in flexion or extension[屈伸不 利], and they are recommended 淸熱, 散寒濕, 强筋骨, 滋陰養血, 補氣血, 補肝腎, 活血去瘀, 補腎將陽, 消腫止 痛 and 溫經通絡 as treatment methods
11)
In this case, the patient was diagnosed with and treated for damp-heat[濕熱] based on severe knee edema and pain at the time of admission, difficulty in flexion or extension, knee joint fixation, and systemic conditions such as heaviness of the body.
Acupuncture was the main treatment method in this case and was performed twice a day, once in the morning and again in the afternoon. In the morning, Dadu (大都, SP02), Shaofu (少府, HT08), Jiexi (解谿, ST41), Qulinqi (足臨泣, GB41), Xiaxi (俠 谿, GB43) and Zutonggu (足通谷, BL66) were selected to help improve the circulation of the meridians. In the afternoon, Weizhong (委中, BL40), Liangqiu (梁丘, ST34), Xuehai (血海, SP10), Yinshi (陰市, ST33), Jimen (箕門, SP11) and Biguan (脾關, ST31) were selected as local acupoints and stimulated via electroacupuncture.
In various studies, acupuncture has been known to induce the release of neuropeptides at the nerve endings, thus dilating blood vessels and exerting anti-inflammatory effects
17)18). The effect of acupuncture on the proliferation of collagen in the ligament has also been reported
19), and we presumed that it was effective in improving the strength of the weakened cruciate ligament.
Danggwijeomtong-Tang, used in this patient, is a prescription in the Oehyeong chapter of Donguibogam. It is known to cure swelling and pain caused by beriberi resulting from damp-heat. In this case, the patient had a well-built physique and usually experienced heaviness of the body and sweating more than average. Furthermore, he had severe swelling and a feeling of heat at the knee at the time of admission; thus, he was diagnosed as having damp-heat[濕熱]. We tried to remove the damp-heat to improve the knee symptoms. In addition, the long-term use of Danggwijeomtong- Tang has been reported to reduce anti-collagen antibody levels and to decrease CRP levels and the ESR
20). Therefore, the decreased CRP and ESR and increased collagen level of the patient were expected.
QSE was performed voluntarily for the rapid recovery of the weakened muscle strength after surgery. QSE is an isometric exercise to enhance the strength of the quadriceps muscle, and it is a method to induce isometric contraction by pushing a towel under the knee in a sitting position with the knee extended
21). The results of the study showed that the peak torque, peak torque per body weight, maximum repetition total work, average power, and total work showed a statistically significant increase in patients with ACL reconstruction who underwent QSE of the extensor muscle
22).
The patient could not perform active movement of the right knee joint and could not walk independently. In the first week of treatment, active flexion of the right knee joint was possible up to 30–40°, and in the second week, it was restored to 85° and independent walking was possible. The ROM recovered up to 90° of active flexion in the third week of hospitalization.
Pain at the time of admission decreased from VAS score 6 to VAS score 2 in the first week of admission. Thereafter, it decrease steadily, and there was little pain at the time of discharge. Moreover, the flare at the time of admission completely disappeared, and the heat sensation decreased by 90%. The KOOS showed a total score of 99 at the time of admission, but improved to 142 at the time of discharge, showing improvements in the evaluation of stiffness, activities of daily living, sports and recreation function as well as pain. With respect to progression, the pain was rapidly recovered from the first week, and other subscales related to function improved by the third week of treatment.
Thus, acupuncture combined with herbal medication and physiotherapy was effective in improving the clinical symptoms of ACL reconstruction. Although many studies have investigated acupuncture treatments for ligament injuries, only few cases involved the use of Korean medical treatment for post-operative symptoms. Even in those cases, most of the patients experienced symptoms immediately after the surgery. Therefore, the fact that the current patient develped symptoms 1 month after the surgery it is a differentiating factor.
In addition, it is significant that the degree of improvement of knee joint function can be assessed using the KOOS, which is an instrument for evaluating knee joint function similar to the ROM and VAS. The KOOS is better for prolonged monitoring than is the Lysholm score, which is usually used in domestic research. Future studies should apply the KOOS in young and active patients and verify its reliability and validity. Furthermore, another strength of the KOOS is that it entails a lower possibility of observer bias than does the Lysholm score.
8)
A limitation of this study was that only one case was evaluated, and there was no follow-up after discharge. In addition, acupuncture, the main treatment in this case, as well as herbal medication and physiotherapy were combined; therefore, it is difficult to identify the individual effect of acupuncture. Moreover, there is a lack of imaging results such as MRI or plain radiography at discharge. Since just one case was reviewed, the possibility of natural progression cannot be excluded. Accordingly, further studies are warranted on Korean medical treatment for postoperative symptoms in patients undergoing surgery, in order to develop a suitable postoperative treatment protocol.