Original research
Clinical Validation of Pain Management Manipulative Therapy for Knee Osteoarthritis With the Squeeze-Hold Technique: A Case Series

https://doi.org/10.1016/j.jcm.2016.12.005Get rights and content

Abstract

Objective

The purpose of this case series was to describe the short-term and long-term clinical effects of a manual technique for treating osteoarthritis (OA) knee pain.

Methods

This study measured of the immediate effect and long-term effect by using a case series of different groups of subjects. Knee OA and activity restriction in patients were evaluated by using the Kellgren-Lawrence (K/L) Grading Scale and the Japanese Knee Osteoarthritis Measure (JKOM) index. In the intervention, lower limb muscles were squeezed by hand for 20 seconds. Each squeeze was performed for both lower limbs. Passive range-of-motion (ROM) exercise was performed on the knee joint. In one set of cases, immediate effects were measured after a one-time treatment with pretreatment and posttreatment outcome measures. Eleven people with knee OA participated in the study. On a visual analogue scale (VAS) for pain, muscle stiffness, and muscular hemodynamics for estimation of muscle blood flow were recorded before and after the squeeze-hold treatment. In another set of cases, the treatment was given to all patients once a week for 6 months, and long-term effects were measured. Data on 5 subjects with knee OA were collected for 6 months after initial treatment. The VAS for pain and JKOM were recorded every month for 6 months.

Results

For immediate effects, the VAS was 69 ± 21 mm before treatment and 26 ± 22 mm after treatment. Muscle stiffness was 8.8 ± 3.6 (absolute number) before treatment and 3.5 ± 2.1 after treatment. Tissue (muscle) oxygen saturation was 60.1 ± 5.7% before treatment and 65.3 ± 4.8% after treatment. Total hemoglobin was 24.3 ± 3.3 (absolute number) before treatment and 25 ± 2.3 after treatment. A tendency for reduction in OA knee pain and muscle stiffness was observed, and a tendency for increase was observed in the blood flow in the muscle. For long-term effects in all 5 participants (any K/L grade, any JKOM score), OA knee pain and JKOM score improved gradually through 6 months.

Conclusions

The participants in this case series showed improvement in pain and function. These findings indicate the feasibility of a larger study on the squeeze-hold intervention for OA knee pain.

Introduction

Knee osteoarthritis (OA), a degenerative joint disease and a major cause of locomotor disability, is likely to affect over 250 million people worldwide.1 Knee OA limits the movement of 80% of affected individuals, and 25% of affected individuals are unable to perform their major activities of daily living. Moreover, 11% of individuals with knee OA require personal care.2 The prevalence of radiographic knee OA is approximately 37.4% among Americans 60 years or older.3 In developed countries, the incidence of knee OA is rising as the population ages. The increasing number of older people with functional impairments is dramatically affecting the medical economy.4 For example, 9.3 million people in the United States have symptomatic knee OA, and the average discounted lifetime costs for people with a diagnosis of knee OA are estimated at $140,300.5 Despite the high prevalence and the significant economic burden, OA of the knee remains incurable.6, 7

The main problem with OA of the knee, and the biggest factor in the disability of patients, is pain.8, 9 Pain renders patients inactive, and decreased joint movement disturbs the repair capacity of the articular cartilage. Moreover, inactivity weakens the lower extremity muscles, and this accelerates the progression of OA.10 Thus, pain exacerbates the disease pathology of OA in the knee. Pain relief is, thus, a key component of effective treatment.

Medication brings only temporary pain relief.11 In conservative therapy, therapeutic exercises are considered an effective treatment for OA knee pain.12, 13 However, sustained effort is required for the analgesic effect to be obtained, and patients find it difficult to remain motivated. Therefore, such treatments have not yet become a solution.14 More immediate and effective measures for OA knee pain are eagerly anticipated. Osteoarthritis knee pain is mostly associated with motion, not with rest. Many patients experience strong pain when they start to walk, but the pain subsides as they continue walking.15 In other words, pain develops when the periarticular muscles of the knee joint contract and is reduced by repeated contraction and relaxation. This gave rise to the idea that the muscles attached to the knee joint may be largely responsible for the development of pain. The hypothesis is that the pain is caused by muscle spasms and the retention of pain-producing and pain-enhancing substances caused by poor blood flow in these muscles. The poor blood flow leads to local acidosis, and the acidosis produces pain-producing bradykinin and pain-enhancing prostaglandin.16 To flush the pain-causing substances out of the muscles, it is necessary to facilitate blood flow through the capillaries. Blood perfusion to capillaries is controlled by the smooth muscle precapillary sphincter. For this reason, to flush out the bradykinin and prostaglandin, it is necessary to dilate the precapillary sphincter. These precapillary sphincters dilate when there is an increase in carbon dioxide (CO2) and a decrease in pH.17 CO2 is increased, and pH is decreased by “squeezing and holding blood in the muscles” as the muscular cells metabolize. Squeezing and holding the leg muscles could theoretically relieve pain for people with knee OA.

Therefore, the purpose of this case series was to describe the squeeze-hold technique applied to people with knee OA and measure the immediate and long-term effects on pain and activities of daily living.

Section snippets

Methods

This case series consisted of 2 groups of patients: 1 group to measure immediate effects and another to measure long-term effects. Each group included different types of subjects. All participants gave written informed consent, and the study was approved by the institutional review board of the Kibi International University research ethics committee.

Immediate Effects

The VAS for pain was 69.2 ± 20.9 mm before treatment and 25.8 ± 21.5 mm after treatment. Muscle stiffness was 8.8 ± 3.6 (absolute number) before treatment and 3.5 ± 2.1 after treatment. StO2 was 60.1 ± 5.7 % before treatment and 65.3 ± 4.8 % after treatment. Total Hb was 24.3 ± 3.3 (absolute number) before treatment and 25 ± 2.3 after treatment. Regardless of the condition of the knee OA (K/L grading, JKOM), these effects were similar (Table 1). The VAS scores for pain rose gradually day by day

Discussion

This is the first study to assess the effects of the squeeze-hold technique on patients with knee OA. The preliminary results showed that muscle stiffness was reduced, and StO2 increased on the unchanging total Hb before and after the squeeze-hold treatment. Increased StO2 on the unchanging total Hb indicated improvement of blood flow. Osteoarthritis knee pain gradually improved and diminished substantially in several months by sustained, once-a-week treatment regardless of the OA condition

Conclusions

This study has provided preliminary evidence on the clinical effects of the squeeze-hold technique for treating OA knee pain and indicates the feasibility of a large-scale study.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

  • Concept development (provided idea for the research): M.N.

  • Design (planned the methods to generate the results): M.N.

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.N.

  • Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.N.

  • Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): M.N.

  • Literature search (performed the

Acknowledgment

The author thanks the following for their cooperation: Mr. Yasushi Sanenobu, Physiotherapist, Dr. Yasuji Tabe, and Dr. Yoshihiko Kisaka of Kisaka Hospital, Hiroshima, Japan; Dr. Keiji Egusa, Dr. Shuji Tanimoto, and Dr. Makoto Egusa of Bicchu Orthopaedic Hospital, Okayama, Japan.

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    Paper submitted October 26, 2014; in revised form November 25, 2016; accepted December 29, 2016.

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