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Interventions for Recovery, Regeneration and Pain Relief

Sue Falsone PT,MS,SCS,ATC,CSCS,COMT,RYT®Associate Professor, Athletic Training, A.T. Still University

Owner, Structure & Function Education@suefalsone / @sfdryneedling

Disclosures

• Owner, Structure & Function Education, PLLC–Teaches dry needling and cupping

• Educational Advisor–Meyer PT

• Safer Pain Relief Committee Member–Performance Health

Complimentary and Alternative Therapies

• Relaxation• Meditation

• Chakras• TCM• Manual

Medicine

• Homeopathy• Dietary• Herbal

As Classified by the National Center for Complementary and Alternative Medicine (NCCAM)

Statistical Significance

Clinical Significance

The probability that the null hypothesis is correctly rejected

“Yes” or “No”

The minimal change that’s important or worthwhile to patient or clinician

Magnitude of Change

EVIDENCESomething that furnishes proof

SCIENCEThe state of knowing : knowledge as

distinguished from ignorance or misunderstanding

Webster’s

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Patient Assessment Treatment Outcomes

Science Research

Evidence

Mindset

Emotional Response to Injury

Emotional Response to Injury

Changes in Social

Behavior

Irritability

Changes in Appetite

Feelings of Isolation

AngerLack of Motivation

Sadness

Changes in Sleep

Fear

Psychosocial aspects of rehabilitation in sports. Covassin et al, 2015. The Meaning of Pain:

Lorimer Moseleyhttp://www.otpbooks.com/product/lorimer-moseley-pain-research/

Pain is….

• Conscious• Subjective• Peripheral • Central• Emotional• Situational–Movement and task

• Cultural• Personal–Past experience

Kinesiology Tape

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How Does Kinesiology Tape Work?

• Sensory theory–Gate Control theory

• Circulatory theory–Convolutions lift skin, creates channels, promotes

blood flow and reduces pressure• Muscle activation theory–Based on the different directions and tensions

Bottom Line: We really don’t know

Proposed Mechanism

• Stimulation of receptors in skin and superficial fascia–Affects muscles /

tissues under skin–Neurological

mechanism• Potential Placebo Effect

Mega Review: Kinesiology Taping (Page et al. 2015)

Study PAIN STRENGTH ROM PROPRIO SWELLING FUNCTION

Bassett 2010 +

Csapo 2014 +

Drouin 2013 + + + +

Kalron 2013 + 0 0 ? 0

Lim 2015 ++ 0

Montalvo 2014 +

Morris 2013 + +

Mostavifar 2012 + ? ?

Parriera 2014 + +

Taylor 2014 + 0 +

Williams 2012 + + ? ?

+ Trivial benefit; as effective - Harmful

++ Clinically beneficial ? Unclear/ inconclusive

0 No benefit

Kinesiology Tape and Blood Flow

• Increases cutaneous microvascular blood flow• Kinesiology Tape increases skin

blood flow regardless of tension, and continued for 3 days of wear – (Craighead et al. 2015)

• Mechanism unknown

Specified Kinesiology Tape Tensions with Positive, Significant Outcomes

(Page et al. 2015)

0

5

10

15

20

25

30

35

0% 0-25% 25-50% 50-75% 100%

Number of Studies with Significant Outcome, by Tension

In well-controlled studies with significant outcomes:• 86% of studies

utilized tension <50%

• The most common tension used was <25%

Kinesiology Tape

• What do we know?–It helps with pain–It improves cutaneous blood flow for 3 days of wear–The most common tension associate with positive

outcomes is 25%

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Dry Needling Tools in the Tool Box

• No one discipline owns a specific technique–Homeopathic and Naturopathic physicians and

acupuncturists all prescribe herbs–Physical Therapists, Chiropractors, Athletic

Trainers and Osteopaths all perform manipulation–Athletic Trainers, Physical Therapists, and

Chiropractors all use manual therapy, tape, exercise and modalities

The Dry Needling Issue, Dommerholt, 2008

Acu--Puncture

• Acu = sharp, needle• Puncture- to pierce a surface

Traditional Acupuncture

Western Medical

Acupuncture

Trigger Point DN

Peripheral NeuromodulationIMS Dry Needling

Superficial Deep

Auricular TCM

Dry Needling vs. Acupuncture: the Ongoing Debate; Zhou 2015

PAIN AND DRY NEEDLING MECHANISMS

Pain

• Cell damage and pain sensation–Releases bradykinin, CGRP, histamine,

substance P, nerve growth factor, etc. –These can cause pain and inflammation,

vasodilation • Needle insertion stimulates A Beta, A Delta

and C Fibers–CGRP, NO, Adenosine locally• Vasodilators and pain modulators

Physiological Effects of Dry Needling, Cagnie, 2013

Dry Needling for Manual Therapists, Gyer, 2016

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Pain Pathway- Ascending

• A Beta, A delta and C fibers go to the dorsal horn and connect to secondary neurons– Glutamate and substance P are

released here

• Segmental effect

Physiological Effects of Dry Needling, Cagnie, 2013Dry Needling for Manual Therapists, Gyer, 2016

Pain Pathway- Ascending

• Ascend via the contralateral lateral spinothalamic tract to the thalamus and PAG

• Third order neurons go to the somtaosensory cortex

• Spinoreticular tract goes to the brainstem before the thalamus and hypothalamus, with further projections into the cortex. – This is the emotional aspects of

pain

Physiological Effects of Dry Needling, Cagnie, 2013

Pain Pathway- Descending

• PAG is high in concentration of opioid receptors and opioids causing analgesia–Descending pathways go to dorsal horn and

inhibit pain transmission•Glycine and GABA are inhibitory neurotransmitters

–Noradrenaline and serotonin as well as dopamine are released• Electroacupuncture specifically (Chou, 2012)

–Enkephlins and Beta-endorphins are released

Physiological Effects of Dry Needling, Cagnie, 2013Dry Needling for Manual Therapists, Gyer, 2016

Gate Control Theory

Pain Stimulus

C-Fiber

Strong Signal to Brain

Pain Stimulus

C-Fiber

Weak Signal to Brain Inhibitory

Interneuron

Touch from skin(A Beta Fiber)

OPEN GATE CLOSED GATE

Theories of pain: from specificity to gate control, Moayedi, 2013

Neuromatrix Theory of Pain

• Pain is produced in the brain and spinal cord, not peripheral tissue• Several parts of the central nervous system work

together to produce pain• Shifts focus from peripheral tissue and peripheral

nervous system to the central nervous system• Explains things such as phantom limb pain,

fibromylagia, NSLBP, etc.

Pain and the neuromatrix in the brain, Melzack 2001Conditioned Pain Modulation

• CPM is a “pain- inhibits pain” theory–Two noxious stimuli are applied at the same time–The second in the area, but not in the same spot as the

first–The second stimulus gets processed by the dorsal horn

and can inhibit the first noxious stimuli• Could be why dry needling near the area is helpful• Give cause to why we do not have to be in an exact

location to see good results

Physiologic Effects of Dry Needling, Cagnie, 2013

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What Does the Literature Say?

• Collagen, elastic fibers, fibroblast, adipocytes, and mast cells, CGRP + nerve fibers have all been found histologically on the needle after removal – (Kimura et al, 1992)

• When A Delta and C fibers are stimulated, CGRP, NO and SP are released– Associated with inflammation– Also vasodilators (Sato, 2000)– Increased blood flow locally

• Improved microcirculation and blood flow around the knee and lower extremities – (Loaiza 2002, Larsson 1999, Shinbara 2008)

What Does the Literature Say?• Dry needling with e-stim in knee OA shows endocrinological

changes, including increase in beta-endorphin and decrease in cortisol (Ahsin et al, 2009)

• Periosteal pecking resulted in significantly reduced pain in OA of the knee when used with e-stim in a study with 88 people who were in pain for longer than 3 months (Weiner et al, 2007) – Stimulated with 100 Hz for 30 minutes

• Positively influence tendon healing by increasing blood flow and local vasodilation and collagen proliferation (Kubo 2010, Sandberg 2003, Shinbara 2008, James 2007)

TMJ DysfunctionPre Treatment Post Treatment

Dry NeedlingPeripheral and Spinal Mechanisms…Butts, 2016

• What do we know?– It helps improve pain via Gate Control Theory, Neuromatrix

Theory or Conditioned Pain Modulation Theory– Evidence to show it improves blood flow locally in the tissues– Evidence of several biochemical, mechanical and neural

physiological processes occurring• Exact mechanisms unknown

– There is histological evidence of inflammatory cells, collagen and elastin, and nervous tissue on the needle after removal (Kimura, 1992)

Dry Needling

• What do we know?–Every technique is not for every patient or pathology–Every technique is not for every clinician

Cupping/ Vacuum Therapy/ MFD

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History• Dates back to 3000 BC however exact origin is

unknown• Much literature is Russian, Chinese, and Korean• Wet Cupping- small incision is made in the skin to

cause bleeding• Dry Cupping- non-invasive (if performed

correctly)–Use of fire or hand pump to create negative

pressure under the cup

Three Techniques

1. Static cup/ Static Body2. Dynamic Cup/ Static Body3. Static Cup/ Dynamic Body

Three Techniques- 1

1) Static Cup/ Static Body• Physiological healing concerns• Leave the cups where they are for 5 -10 minutes •Watching closely so as to not pull blood or

interstitial fluid out

Physiology• Theory!–We have a non-functioning

microcirculatory system– Blood is brought to the area via artificial

measures (negative pressure)– The body can either dissipate this influx

of fluid once the negative pressure is removed or it cannot• Through the processes of angiogenesis

and autolysis, the body will build a new microcirculatory network, and break down the old, non-functioning structures

Diagnostic and Prognostic

• Diagnostic–Discoloration• Is the area under the cup white?• Is the area under the cup red• Is the area dark purple

–Blisters–Swelling

• Prognostic–How long does blood take to dissipate?

Three Techniques- 22) Dynamic Cup/ Static Body• Opposite of foam rolling• They have more of a fascial

restriction versus a physiological healing issue• Sometimes the tissue needs

distraction, not compression• Periodizing tissue work

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Three Techniques- 3

3) Static Cup/ Dynamic Body• Opposite of ART• ROM restrictions are

present

What Does the Literature Say?

• Static/ static technique x 10 minutes on 17 LBP patients (symptomatic for at least 8 weeks) demonstrated–Immediate improved significant differences

in VAS scores, SLR, trunk flexion and statistically significant reduction in PPT in 4 places

• Need more evidence!

Cupping

•What do we know?–It picks up a lot of skin and tissue–It brings blood and inflammatory markers to

the area

VISCERAL

Visceral Manipulation• Assists functional and structural imbalances

throughout the body• Evaluates and treats the dynamics of motion

and suspension in relation to organs, membranes, fascia and ligaments• Increases proprioceptive communication within

the body– Relieving symptoms of pain, dysfunction, and

poor posture

Structure

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Ligament of Treitz Low Back Pain and Kidney MobilityTozzi et al, 2012

• 101 asymptomatic people• 140 subjects complaining of NSLBP• Measured distance: superior pole of the right

kidney to ipsilateral diaphragmatic pillar during maximal inhalation and exhalation• Calculated the excursion of movement

People with NSLBP present with a reduced range of kidney mobility compared to that found in

asymptomatic subjects

Visceral Manipulation

•What do you we know?–Organs are attached to the body by fascia–Viscera have a somatic connection

Yoga

Gandhi Goes to Yoga

• https://www.youtube.com/watch?v=hBMc9s8oDWE

Reduce Stress

Improve Balance

Improve Functional Outcomes

Improve Social

Outcomes

Improve Energy Levels

Decrease Menopausal Symptoms

Improve Strength

Improve Flexibility

Decrease Pain

The Health Benefits of Yoga and Exercise, Ross, 2010

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Concepts- The 8 limbs Yamas

•Moral restraint• Rule for living virtuously• Universal morality• The “Do Not’s”

Niyamas

• Recommended habits and activities for healthy living• Personal

observances• The “Do’s”

Asanas

• The poses and postures

Pranayama

• The breath• Breathing exercises

The Bandhas“To hold, tighten or lock”1. Mula Bandha (root lock)

Draw energy through perineal and kegelmuscles

2. Uddiyana Bandha (abdominal lock)Draw energy through the abdominals

3. Jalandhara Bandha (chin lock)Draw energy through the deep neck flexors

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Uttkatasana(Fierce Pose)

Virabhadrasana III(Warrior C)

Utthita Hasta Padangushthasana(Standing Big Toe Pose)

Garudasana(Eagle Pose)

Chaturanga Dandasana(Four Limb Staff Pose)

Adho Mukha Shvanasana(Downward Dog)

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Ūrdhva Mukha Shvānāsana(Upward Dog) Yoga

•What do we know?–We are already using elements of yoga in our

current practice–Multiple health benefits have been linked to

yoga practice

Meditation Meditation

• “Persistent lack of consensus in the literature” on what meditation is and how it should be defined – Defining a complex intervention: the development of demarcation criteria for

“meditation.” (Bond et al 2009)

• Physiological and psychological changes occur with breath-based meditation–Specifically the yogic breath – Breath-based meditation: a mechanism to restore the physiological and cognitive

reserves for optimal human performance. (Carter et al 2016)

Meditation

• Deep, rhythmic breathing can result in a state of relaxation that reduces depression and anxiety• Breath-based meditation has also been shown to

balance the autonomic nervous system, decreasing the “fight or flight” response that can often be associated with stress. – Brown, RP, and Gerbarg, PL. Sudarshan Kriya yogic breathing in the treatment

of stress, anxiety, and depression: part I-neurophysiologic model. J AlternComplement Med 11:189 - 201, 2005.

Imagery

Visualimages of what

you want to happen

Kinesthetichow the body feels during movement

Auditorythe roar of the

crowd

Olfactorythe smell of

the gym

Gustatorythe taste of

gum you chew when hitting

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Goal setting Goal Setting

Overall Conclusions on Alternative Interventions

• Adjunct and alternative treatments are limited by their evidence–However often have a lot of science

• Often marred as ‘pseudoscience’• Need research on combining adjuncts with

conventional (not stand-alone)• Above all ‘do no harm’• Remain critical, but open-minded