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Lee, Yoon, Shin, Ahn, Lee, Won, and Jang: Three cases meniscus injury treated with Shinbaro pharmacopuncture therapy

Abstract

Objectives

The purpose of this report was to show that oriental therapy, specifically Shinbaro pharmacopuncture is effective for improvement of symptoms and and range of motion (ROM) in patients diagnosed with meniscus tears in the knee.

Methods

Three patients were treated with herbal medicine, acupuncture, cupping, Shinbaro pharmacopuncture. The efficacies of the treatments in the three cases were assessed and the progress of the three cases were measured Numerical Rating Scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), European Quality of Life five dimensions dimensions (EQ-5D), and range of motion (ROM) measurements.

Results

After all the treatments, NRS, WOMAC, and EQ-5D decreased. Active and passive ROM of the knee increased.

Conclusion

These reports show the effect of Shinbaro pharmacopucture on a meniscus tear. Due to the small number of cases in this study, further case reports are needed.

초록

목적

신바로 약침 치료가 반월상 연골 파열 환자에게 호전을 보인 예가 있어 이를 보고하고자 한다.

방법

이 환자들은 한약, 침치료, 부항과 함께 신바로 약침 치료를 받았다. NRS, WOMAC, EQ-5D와 ROM이 치료 평가 도구로 활용되었다.

결과

치료 이후 NRS, WOMAC, EQ-5D는 감소하였다. 슬관절의 능동 수동 ROM은 모두 증가하였다.

결론

이번 치험례는 반월상 연골 파열 환자에게 신바로 약침 치료 후 유의한 효과가 있음을 시사한다. 다만 증례수가 적기 때문에 앞으로 더 많은 케이스 보고가 필요하다.

I. Introduction

During the exercise, the knee joint undergoes stress in two different places. In the sagittal plane, it undergoes flexion and extension. In the horizontal plane, it experiences internal and external rotation1). The stability of the knee joints is controlled by the ligaments, joints, and surrounding muscles2). Damage to the ligaments and cartilage is commonly seen as a result of a large functional demand imposed on the knee joints1).
The function of the meniscus is to reduce the load on the joint. It also contributes to joint stability, lubrication, and the reduction of friction during exercise. The inner meniscus and outer meniscus are fibrous cartilage discs located in the knee1). The medial meniscus (MM) is attached to the medial collateral ligament (MCL) and coronary ligament. The coronary ligament is 4–5 mm in length. The lateral meniscus is divided by the lateral collateral ligament (LCL) and popliteal tendon; the coronary ligament is 13–20mm in length. The differences in these the coronary ligament is 13–20mm in length. The differences in these structures is the reason why the medial meniscus is more likely to rupture3). The medial meniscus tends to be damaged by twisting forces2). If meniscus tear occurs, immediate and acute pain occurs, and all activities are stopped4).
In the past, meniscus tear surgery was considered as the first option for such cases. However, the meniscus was recently found to be crucial for maintaining knee function. Therefore, it is important to preserve as much of the meniscus as possible5).
Shinbaro pharmacopuncture consists of Acanthopanacis Cortex, Achyranthis Radix, nikoviae Radix, Cibotii Rhizoma, Glycine Semen Germinatum, Eucommiae Cortex. Shinbaro pharmacopuncture uses an extract that is especially effective for anti-inflammation6) and nerve regeneration7). It is also effective for cartilage protection in degenerative arthritis8). There are case reports showing Shinbaro pharmacopuncture was as effective as bee-venom pharmacopuncture for a herniated lumbar intervertebral disc, but without the side effects9).
There are some reports describing Korean medicine therapy for meniscus tears1013). However, there are few reports of the use of Shinbaro pharmacopuncture for meniscus tears. We observed the outstanding therapeutic effects of Korean medicine in 3 patients who were treated at Buchoeon Jaseng Korean medicine hospital for meniscus injuries therefore, we present these 3 case reports.

II. Treatment and evaluation methods

1. Treatment methods

1) Pharmacopuncture therapy

Shinbaro pharmacopuncture was performed at Jaseng Wonoe Tangjunwon, Namyangju, Korea. Using a disposable insulin syringe, 1.0 cc of Shinbaro was injected at Hyeolhae (血海, SP10), Eumsi (陰市, ST33), Yanggu (染丘, ST34), and Dokbi (犢鼻, ST35). The needle depth was 0.5 mm. This was performed twice a day.

2) Acupuncture treatment

The needles were disposable stainless steel needles 0.25 mm in diameter and 30 mm in length (The Eastern acupuncture equipment manufacturer, Boryung, Korea). The needles were inserted at Hyeolhae (血海, SP10), Wijung (委中, BL40), Eumsi (陰市, ST33), Yanggu (燥丘, ST34), Dokbi (備鼻, ST35), and Eumgok (陰谷, KI10) for 15 minutes twice a day.

3) Cupping

The cups were sterilized and disposable. Cupping was performed for 4 minutes, twice a day at 血海 (SP10), 染丘(ST34), and 陰谷 (KI10).

4) Herbal medicine treatment

Mabalgwanjeol decoction (馬勃關節湯) was prescribed for case 1, cheongpajeonsinbang 2 decoction (靑波煎新方2號) for case 2, and keoseuphwalhyoljitong decoction (祛濕活血止痛湯) for case 3. The patients took the medicine 3 times a day (3 packets 3 times a day) (Table 1).

5) Physiotherapy

All cases underwent interferential current therapy (I.C.T) once a day and received hot compresses with medicinal herbs over the painful knee for 20 minutes once a day.

2. Methods of Evaluation

1) Numerical Rating Scale (NRS)

The NRS is an instrument for measuring the subjective level of pain and is good for evaluating the degree of pain. The patient subjectively assesses their degree of pain from 0 to 1014). This assessment was performed twice; once on the first day of hospitalization and again on the last day of hospitalization.

2) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is a new elective health status instrument for patients with osteoarthritis. It is composed of 24 questions about pain, stiffness, and physical function15). This assessment was performed twice, once on the first day of hospitalization and again on the last day of hospitalization.

3) European quality of life 5 dimension (EQ-5D)

The EQ-5D is an instrument for describing and evaluating that status of one’s health. It defines health status using the following 5 dimensions: Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression15). EQ-5D was evaluated twice, once on the first day of hospitalization and again on the last day of hospitalization.

4) Range of motion (ROM) and special tests

Active and passive range of motion (ROM) for flexion, extension, and other special tests of the knee were performed at 7:00 am every day. However it was not assessed when the pain was severe.

III. Cases

1. Case 1

1) Patient

Yim OO; Female, 61 years old

2) Chief complaint

Left knee pain.

3) Date of onset

End of November 2016

4) Past medical history

Hypertension and hepatitis B.

5) Present illness

Left knee pain developed while practicing yoga at the end of November 2016. Meniscus tear was diagnosed using radiographic image, and the results from magnetic resonance imaging (MRI) performed at a local clinic. The patient was prescribed medicine and received physical therapy.

6) General condition

  1. Sleep pattern: Slept well without pain

  2. Diet: Normal appetite (one bowl of rice per meal). Occasionally, the patient experienced gas in the bowels

  3. Urination: Favorable

  4. Bowel movements: Once a day with loose stools

  5. Thirst: Usually drank a less than the average amount of warm water

  6. Sweating: Usually had less sweat than average

  7. Tongue assessment: Red tongue

  8. Radial pulse assessment: Relaxed pulse (緩脈)

7) Duration of treatment

February 9, 2017 to February 23, 2017 (15 days of hospitalization)

8) Radiology

Results of the knee MRI (02/09/2017)
  • MM: transverse mild tear of the posterior horn

  • MCL: Partial tear and sprain of the proximal portion.

Anterior cruciate ligament (ACL), posterior cruciate ligament (PCL),LCL, lateral meniscus: Not remarkable.
A small fluid collection was seen in the suprapatellar bursa, knee joint, and posterior recess of the distal femur and proximal tibia.
Conclusions:
  1. MM: transverse mild tear of the posterior horn.

  2. MCL: Partial tear and sprain of the proximal portion.

9) Progress after treatments

  1. Change in the NRS (Table 2)

  2. Change in the WOMAC (Table 2)

  3. Change in the EQ-5D (Table 3)

  4. Change in the ROM and results from special tests (Table 4)

2. Case 2

1) Patient

Joe OO, Female, 58 years old

2) Chief complaint

Right knee pain.

3) Date of onset

Middle of June 2016

4) Past medical history

Hypertension.

5) Present illness

Right knee pain developed in the middle of June 2016 for no specific reason. The patient was initially only prescribed medicine by the local clinic. She had a radiograph taken and was not diagnosed with any particular disease. She took the medicine and received physical therapy.

6) General condition

  1. Sleep pattern: Awoken by pain once a day

  2. Diet: normal appetite (one bowl of rice per meal)

  3. Urination: favorable

  4. Bowel movements: Once a day, normal stools

  5. Thirst: Usually drank more than the average amount of cold water

  6. Sweating: Usually had a little more than the average amount of sweat

  7. Tongue assessment: Red tongue

  8. Radial pulse assessment: Relaxed pulse (緩脈)

7) Duration of treatment

December 26, 2016 to February 11, 2016
(48 days of hospitalization)

8) Radiology

Results of the right knee MRI (12/26/2016):
  • MM: Degenerative tear of anterior horn with a perimeniscal cyst.

  • Degenerative transverse tear of the posterior horn.

  • ACL,PCL,MCL,LCL, lateral meniscus: Not remarkable.

  • Medial condyle of the distal femur: Chondromalacia grade 2.

  • Small amount of fluid collection in the suprapatellar bursa, knee joint, and posterior recess of the distal femur and proximal tibia.

  • Focal subchondral bone erosion in the lateral tibial plateau and proximal tibia.

Conclusion:
  1. MM: Degenerative tear of the anterior horn with a perimeniscal cyst with a degenerative transverse tear of the posterior horn.

  2. Mild degenerative arthritis in the medial compartment of the right knee joint.

9) Progress after treatments

  1. Change in the NRS (Table 2)

  2. Change in the WOMAC (Table 2)

  3. Change in the EQ-5D (Table 3)

  4. Change in the ROM and results from special tests (Table 5)

3. Case 3

1) Patient

Kang O O’Male 52 years old

2) Chief complaint

Left knee pain

3) Date of onset

End of October, 2016

4) Past Medical History

Hyperlipidemia, hypertension and diabetes.

5) Present Illness

Left knee pain developed at the end of the October 2016 for no specific reason. The patient had a radiograph taken and was diagnosed with no specific disease. The patient only received injection therapy at the clinic.

6) General condition

  1. Sleep pattern∷Light sleep because of pain.

  2. Dietary state: Less appetite (half bowl of rice per meal).

  3. Urination: Favorable

  4. Bowel movements: Once a day, normal stools.

  5. Thirst: Usually drinking a less than average amount of warm water

  6. Sweating: Hardly any sweating during the day.

  7. Tongue assessment: Red tongue

  8. Radial pulse assessment: Relaxed pulse (緩脈)

7) Duration of treatment

December 24 2016 to January 4, 2017 (12 days)

8) Radiology

Lt Knee MRI (2016/12/24)
  • MM: Degenerative wear and tear of the posterior horn with extrusion

  • ACL,PCL,MCL,LCL, and lateral meniscus: Unremarkable.

  • Trochlear groove of the distal femur: Multifocal chondral defect and subchondral bone erosion and chondromalacia grade 3.

  • Inner facet of the patella: chondromalacia grade 2 and subchondral bone erosion.

  • Medial condyle of the distal femur: Diffuse chondral defect, chondromalacia grade 3, subchondral bone erosion, and diffuse bone marrow edema.

  • Medial tibia plateau: Chondromalacia and diffuse bone marrow edema.

  • Moderate amount of fluid collection in the suprapatellar bursa, knee joint, and posterior recess of the distal femur and proximal tibia.

  • Diffuse bone marrow edema in the intercondylar notchy area and proximal tibia.

  • Tendinosis of the distal semimembranous tendon, and popliteal fossa(medial aspect).

Conclusion
  1. Severe degenerative arthritis in the medial compartment and left knee joint.

  2. Degenerative wear and tear of the posterior horn and extrusion status of the MM.

  3. Degenerative arthritis in the patellofemoral knee joint.

9) Progress after treatments

  1. Change in the NRS (Table 2)

  2. Change in the WOMAC (Table 2)

  3. Change in the EQ-5D (Table 3)

  4. Change in the ROM and results from special tests (Table 6)

IV. Discussion

The knee is the largest joint in the human body. The muscles surrounding the knee are large and strong. The ligaments have complex forms that maintain the stability of the joint16). Knee perform crucial biomechanical functions during walking and running. The stability of knees is achieved mainly by the cartilage rather than the structural arrangement of the bone. Damage to the ligaments and cartilage is commonly seen as a result of large functional demands imposed on the knees1).
The meniscus is fibrous cartilage that distributes stress between the femur and tibia17). It is also very important safety devices on knee because they helps reconcile and guide your knees. The shape of the meniscus resembles a half-moon with a triangular cross-section. The upper and lower sides are close to the femur and tibia3). Damage to the meniscus can also be accompanied by a single burst or ligament damage. Ruptures in the meniscus cause the mechanism of the knee to malfunction, contributing to degenerative arthritis17). A small tear in the meniscus can also cause instability; therefore, knee surgery will often negatively affect future knee stability, even if it is performed for therapeutic purposes. Since the most common complication of surgery is degenerative arthritis, conservative and non-invasive methods are preferred for the treatment of meniscus tears18).
In Korean medicine, the knee is referred to as “膝 者筋之府, 屈伸不能, 行則僂附, 筋將憊矣” which means the knee is where the muscles gather, and damage to the knee is seen as a sign of a dysfunctional liver19). Knee pain is expressed as 鶴膝風, 歷節風, 膝腫痛20).
The extracts for Shinbaro pharmacopuncture are obtained by distillation. The extracts are used after filtration and freezing. They are sterilized at 121°C for 15 minutes21). These effects of these components include anti-inflammation, anti-arthritis, antioxidant activity, bone-regeneration, and pain reduction22). Shinbaro treatment on monosodium iodoacetate-induced osteoarthritis caused the trabecular bone to increase by approximately 40% and reduced the inflammation-inducing element, such as prostaglandin and anti-collagen antibody, by about 60% when compared to that of the control group23).
Because conservative therapy for meniscus tears is important, a variety of treatments from oriental medicine are needed. There are reports of motion style treatment by Choi et al.10), the effects of bee venom pharmacopuncture by Kim et al.11) and Lee et al.12), the effects of treatment with general Korean medicine by Woo et al.13), and the effects of miniscalpel acupucture therapy by Jung et al.5) However, there are few case reports about Shinbaro pharmacopuncture, so we decided to report the findings in these three cases.
Three patients were diagnosed with meniscus tears and preferred conservative approach to treatment. Shinbaro pharmacopuncture was the main method of treatment. The extract was injected at Hyeolhae (血海, SP10), Eumsi (陰市, ST33), Yanggu (染丘, ST34), Dokbi (犢鼻, ST35). Standards for the treatment of the knee by acupuncture have been implemented. Treatment with herbal medicine has been used to improve knee injuries. Within each case, the prescription was unchanged. In case 1, the patient complained of knee pain associated with a heaviness of the body and fatigue, so a Mabalgwanjeol decoction (馬 勃關節湯) was administered. In case 2, the patient was administered a Cheongpajeonsinbang 2 decoction (靑波煎幸斤方2號) because the chief complain was acute pain during all types of movement. In case 3, a Keoseuphwalhyoljitong decoction (祛濕活血止痛 湯) was administered, for a feeling of heaviness in the knee.
The NRS score decreased in all cases: from 7 to 3 in case 1, 7 to 2 in case 2, and 7 to 3 in case 3. The WOMAC also decreased in all cases: from 75 to 21 in case 1, 72 to 11 in case 2, and 73 to 16 in case 3. EQ-5D improved in all 3 cases. In case 1, the ROM during active flexion increased from 100 to 130, from 110 to 120 during passive flexion, and from − 10 to 0 during active extension, and on the day of discharge, from −5 to 0 during passive extension ROM. Severe pain during the McMurray and Apley compression tests resolved. In case 2, after treatment was completed, the ROM changed from 110 to 135 during active flexion, from 115 to 135 during passive flexion, and from −20 to 0 during active extension, and from −1 to 0 during passive extension. During the McMurray and Apley compression tests, the response changed from positive to negative. In case 3, the ROM changed from 100 to 135 during active flexion, from 105 to 135 during passive flexion, and from −10 to 0 during active extension, and from −5 to 0 during passive extension.
All three reduced acute pain during routine motion. After the therapy, results from the special tests also improved. These cases show the strong effect of Shinbaro on tears of the meniscus. However, treatment with Shinbaro was coupled with acupuncture, herbal medicine, cupping, and physiotherapy. In addition, since there were only a small number of cases, the results cannot be generalized. Shinbaro pharmacopuncture has many effects on musculoskeletal disorders and cartilage disorders21,22). Since conservative treatment for meniscus injuries is important, more case reports of treatment with Shinbaro pharmacopuncture or any other methods of Korean medicine for meniscus injuries are needed. Further reports describing a larger number of cases with objective evaluation methods for meniscus tear are necessary.

Fig. 1
Left knee MRI from case 1 (2/9/2017)
acup-34-3-109f1.tif
Fig. 2
Right knee MRI of case 2 (12/26/2016)
acup-34-3-109f2.tif
Fig. 3
Left knee MRI of case 3 (12/24/2016)
acup-34-3-109f3.tif
Table 1
Prescription of Herbal Medicines
Prescription Composition of medicinal herbs
Mabalgwanjeol Decoction (馬朝關節湯) Lasiosphaera Seu Calvatia 12g, Achyranthis Radix 8g, Ginseng Radix 8g, Glycyrrhizae Radix 4g, Osterici Radix 4g, Testudinis Plastrum 4g, Angelicae Pubescentis Radix 4g, Hordei Fuctus Germinatus 4g, Saposhnikoviae Radix 4g, Amomi Fructus 4g, Astragali Radix 4g, Aconiti Tuber 2.8g
Cheongpajeonsinbang2 Decoction (靑波煎新方2號) Chelidonium majus Linne var. asiaticum Ohwi, Achyranthes japonica Nakai, Chaenomeles sinensis Koehne, Acanthopanacis Cortex, Corydalis Tuber, Osterici Radix, Atractylodis Rhizoma, Angelicae Gigantis Radix, Rehmanniae Radix, Paeoniae Radix Rubra, Clematidis Radix, Araliae Continentalis Radix, Citri Unshii Pericarpium, Carthami Flos, Amomi Fructus, Giycyrrhizae Radix et Rhizoma, Zingiberis Rhizoma Cudus, Zizyphi Fructus
Keoseuphwalhyoljitong Decoction (祛濕活血止痛湯) Lonicerae Flos 8g, Akebiae Caulis 8g, Coicis Semen 8g, Atractylodis Rhizoma 8g, Cinnamomi Ramulus 4g, Dianthi Herba 4g, Angelicae Gigantis Radix 4g, Persicae Semen 4g, Saposhnikoviae Radix 4g, Angelicae Dahuricae Radix 4g, Rehmanniae Radix Crudus 4g, Linderae Radix 4g, Achyranthis Radix 4g, Clematidis Radix 4g, Hoelen 4g, Paeoniae Radix 4g, Citri Unshii Pericarpium 4g, Cnidii Rhizoma 4g, Gentianae scabrae Radix 4g, Polygoni Avicularis Herba 4g, Caesaipiniae Lignum 2g, Carthami Flos 2g
Table 2
Change in the Numerical Rating Scale(NRS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
Admission day Discharge day
NRS of case 1 7 3
NRS of case 2 7 2
NRS of case 2 7 3
WOMAC of case 1 75 21
WOMAC of case 2 72 11
WOMAC of case 3 73 16
Table 3
Change in the European Quality of Life-5Dimensions (EQ-5D)
EQ-5D Admission day Discharge day
Mobility case 1,2,3: severe case 1, 2, 3: slight problems
case 1, 2: slight problems
Self-care case 1,2,3: severe case 3: no problem
Usual activities case 1,2,3: severe case 1, 2, 3: slight problems
Pain/Discomfort case 1,2,3: severe case 1, 2, 3: no problem
Anxiety/Depression case 1,2,3: severe case 1, 2, 3: no problem
Table 4
Change in the ROM and results from special tests
Admission day after 7 days Discharge day
active flexion 100 110 130
passive flexion 110 115 120
active extension −10 −5 0
passive extension −5 0 0
Apley compression test UC* +
Apley distraction test UC* UC*
McMurray test UC* +
Valgus stress test UC*
Varus stress test UC*
Drawer’s sign UC* UC*

* UC: Uncheckable.

Table 5
Change in the ROM and results from special tests
Admission day after 16 days after 32 days Discharge day
active flexion 110 115 120 135
passive flexion 115 120 125 135
active extension −20 −20 −10 0
passive extension −10 −10 −5 0
Apley compression test UC* + +
Apley distraction test UC*
Mcmurray test UC* + +
Valgus stress test UC*
Varus stress test UC*
Drawer’s sign UC*

* UC: Uncheckable.

Table 6
Change in the ROM and results from special tests
Admission day after 7 days Discharge day
active flexion 100 115 135
passive flexion 105 120 135
active extension −10 −10 0
passive extension −5 −5 0
Apley compression test UC* + +
Apley distraction test UC*
Mcmurray test UC* +
Valgus stress test UC*
Varus stress test UC*
Drawer s sign UC*

* UC: Uncheckable.

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22. Kim SH, Lee CH, Lee JS et al. Anti-Inflammatory Activities of a Herbal Preparation GCSB-5 on Acute and Chronic Inflammation. Korean Journal of Pharmacognosy. 2005 ; 36(4) : 311–7.

23. Kim WK, Chung HJ, Pyee Y et al. Effects of intra-articular Shinbaro treatment on monosodium iodoacetateinduced osteoarthritis in rats. Chin Med. 2016 ; 11 : 17.
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