Tag: Pain

“They” say it’s not accupuncture

DRY NEEDLING? WHAT’S OUT THERE?

 

  1. “Myofascial pain syndrome is characterized by the presence of one or more symptomatic myofascial trigger points (MTrPs) located in skeletal muscle. Myofascial trigger points are palpable, localized areas of hyperalgesic muscle tissue typically located in a taught band of fibers”

Myofascial pain syndrome is pain believed to be originating from the myofascia. I feel like Webster’s dictionary at this point. You know what I mean? For instance when you look up a word such as ambulation and the first definition is: The act of ambulating. Thanks wise guy!

Let’s start with myofascial. There are two types of fascia spoken of in the research. The first is superficial (superficialis) fascia and the second is deep (profundus) fascia. There is this awesomely boring book to read about fascia if you are ever having trouble falling asleep (Fascia: The Tensional Network of the Human Body: The science and clinical applications in manual and movement therapy). I only recommend it if you are really interested because it is very long and very boring. I guess that we also have to start with “What is fascia?” In school we didn’t learn much about this tissue. For those that graduated before 2012, we were only taught that it is the white stuff that we have to cut through in order to see the muscles. It was more of a nuisance than an actual tissue to pay attention to. Boy, have things changed! If you have watched any of Kelly Starrett’s videos or read the book: Supple Leopard (which I highly recommend to most of my athletic patients), then you will see many ways in which the fascia can be moved and “loosened”. Fascia is a very tough tissue that helps to give us shape and encompasses the entire body. It covers our muscles and even covers the small structures that make up an entire muscle. Big picture: it’s everywhere. The research on it is still young and we don’t know its full purpose yet, but are starting to understand that when it is angry…it let’s us know.

These MTrPs are palpable, meaning that we can feel them if we attempt to feel you up. They are the “knots” that most people complain about. Some of these “knots” are like small marbles and others are like small sausage links. Either way, they are hyperalgesic, which means…for a lack of a better term…angry.

 

  1. “In addition, research indicates active MTrPs have greater concentrations of inflammatory and nociceptive agents, as well as a lower pH, compared to non-pathologic muscle fibers”

There are some details hidden this sentence. The first is the description of “active” trigger points. If some are active, then others are inactive. These are historically called latent trigger points. This type of trigger point has the same palpable nature of a trigger point, but doesn’t cause pain. I don’t know of any research that looks at the pH of latent trigger points. Think about it though. The only way that we can really know if a trigger point is active or inactive is to play with it and see if it hurts.

 

  1. “It has been suggested that TDN (trigger point dry needling) hyperstimulates the pain-generating area and thereby normalizes the local sensory inputs. Another hypothesis suggests that TDN causes natural opioid-mediated pain suppression by stimulating local alpha-delta nerve fibers.”

The take home point from this is that we have no idea how this may work! There are theories as to the why it works, but there are articles showing that it works. Put this in perspective…I consistently say that our profession is in its infancy regarding research, but I really should say that we are in our toddler stage. I have a young daughter and am just waiting for her “Why” stage. As a curious father myself, I always want to answer the question when I can, but at the same time I know that I will (through no fault of my own, as it appears to be a genetic trait of parents) answer her question with “because I said so”.

 

  1. “Trigger point dry needling is administered by inserting a thin, solid filiform needle directly into the palpable trigger point…then incrementally manipulated within the tissue in order to elicit a localized twitch response (LTR) and removed once the MTrP has been released”

Picture a pincushion…enough said! I like why’s, but there aren’t many with this regards. I can remember during a clinical, the clinical instructor was teaching me acupressure techniques in which you hold a force downward onto the knot and wait for the patient’s pain response to change or hold for 90 seconds, whichever comes first. This just seemed so arbitrary to me. What I saw was that I was going to dig my thumb into a patient and wait for them to tell me that it doesn’t hurt as much. People aren’t dumb. In the words of Dr. House… all people lie. If I tell you that I will push into your skull with enough force to cause you pain and that I will stop when your symptoms are better…what will you do? I think I’d be fixed.

There are too many vague descriptions for me with regards to this technique. “Incrementally manipulated”? What does this even mean? I can see a session lasting for hours and coming into the room every 10 minutes to “release the muscle”. This technique may work, but we still don’t have enough information to make this type of treatment standard yet.

 

  1. “Moderate to severe adverse events causing significant distress or further medical treatment (e.g., fainting, headache, nausea) occurred at a rate of <0.04%”

This means that 4 in 10,000 will have an adverse reaction. Hypersensitivy to aspirin is between 1-2 in 100. Overall, this appears to be a safe intervention, but we still have yet to see if it is effective.

 

  1. “TDN is more effective than stretching and percutaneus electric nerve stimulation, and at least equally as clinically effective as manual MTrP release and other needling treatments”

This means that dry needling has more promise than basic stretching, but is no better than many other techniques to reduce pain.

 

  1. “It appears that TDN, as performed and measured in each study, does not influence strength, variably improves ROM and function and frequently decreases pain”

We know that it helps pain. We don’t know how it helps pain. There are two major theories for affecting pain: the bottom-up theory and the top-down theory. The bottom-up theory is using an external stimulus to reduce your painful complaint. Again, if I put an ice pack on your painful area or hit a separate area with a hammer, your initial pain will reduce. The top down theory is not spoken of in the research very often. This is using your brain to reduce your pain, such as with meditation. It is also called the endogenous (internal) opioid (cocaine) theory. Aside from pain relief, there appears to be little evidence that it helps any other complaints. Since a majority of patients are coming to therapy for pain complaints, this could be used as an adjunct to mechanical (movement based) therapy in order to reduce pain complaints. (As of today’s date, I have absolutely no training in this treatment).

 

  1. “TDN treatment may allow for improved tolerance to other interventions, such as manual therapy and therapeutic exercise, with potential for overall accelerated progression and more lasting positive results”

This statement sums up my thoughts on this type of treatment approach. It can be used as an adjunct to get the patient back to where the research is strong…exercise. I will have to look into the legalities of performing this type of intervention in our state, as each state has it’s own rules regarding invasive procedures for PT’s.

 

MORAL: Using dry needling techniques can be useful for pain reduction, but has no other effects. This could be an intervention in order to return the patient back to functional activities assuming the patient has demonstrated that he/she will be a non-responder to a mechanical (movement based) intervention program.

 Functional Therapy and Rehabilitation 

(Now part of Goodlife PT)

903 N 129th Infantry Dr

Joliet IL

8154832440

EXCERPTS TAKEN FROM:

Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. JMMT.2015;23(5):276-293.

 

Do you run loudly?

Shhhhhh…quiet. Tread lightly and land softly. May your joints forever feel young.

  1. “Several of these programs instruct participants to land softly in an attempt to teach proper landing technique and reduce impact forces. Mandelbaum et al reported an 88% decrease in anterior cruciate ligament injuries in 1041 female subjects using soft landing cues”

Are you thinking what I’m thinking? Seinfeld? Mandelbaum seriously?! This was the family of old guys in the hospital with Jerry that kept hurting themselves trying to lift the t.v. I thought it was funny.

What the above is saying is that the sound of your landing can directly indicate your injury risk. Don’t go jumping off buildings to test this theory! I won’t be held liable.

 

  1. “13% decrease in peak vGRF during a drop-landing task when 80 adult recreational athletes were instructed to listen to the sound of their landing…reduced by 24% in a stud in which 12 female recreational athletes were asked to land softly…”

What this means is that the softer you land the quieter you land. vGRF is vertical Ground Force Reaction (some people really hate it when I mix up the letters, but oh well…You know who you are!). This is it this way. For every action, there is an equal and opposite reactions. This means that if you land with a heavy load, the ground pushes back up at you with an equal load. If you absorb some of the load with your joints by bending, then the ground doesn’t push back as hard. Think of dropping a stick vertically from a specific height. The stick will actually bounce a little after it hits the ground, because the ground pushes back. Now do the same experiment with a wet noodle and you will get a totally different result. This may not be an exact science, but at least it makes sense to me. When you land quietly (wet noodle), you don’t get the jarring force from the ground as when you land loudly.

  1. “Initially, the participants were instructed to perform drop landings (with no instruction) to obtain a baseline, normal sound amplitude of landing…then instructed to …create a quieter or louder sound from this normal landing condition”

For those of you that perform high-intensity exercise of varying modes under time domains-based exercises, (I am unsure that if I use the word crossfit that I may be sued like those before me) such as box jumps, that this study will apply to you.

  1. “quiet-landing instruction results in significantly greater joint excursion at the ankle and knee when compared to a normal landing sound instruction”

Essentially, the quieter that you try to land, the more that you perform a squatting based movement on the land. The stiffer you land, the louder you are. The louder you are, the more force (think jarring) that your joints have to endure.

MORAL: Be quiet! Tread lightly!

Excerpts taken from: Wernli K, NG L, Phan X, et al. The Relationship Between Landing Sound, Vertical Ground REaction Force, and Kinematics of the Lower Limb During Drop Landings in Healthy Men. J Orthop Sports Phys Ther. 2016;46(3):1945-199.

If you would like a running assessment or are experiencing pain during running, come see me at:

Functional Therapy and Rehabilitation

(Now part of the Goodlife family)

903 N 129th Infantry Dr

Joliet IL

8154832440

If it hurts it must be bad, or good, or whatever.

Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-134.

  1. “Pain is a normal human experience and essential to survival”

This portion is rarely spoken of in PT school and we spend our time in school learning how to shut down the pain, either in an ideal way of dealing with a mechanical problem or in a way in which we “trick” the brain of not seeing the pain for a short period of time. When working with patients, I often describe the gate control theory as the “Three Stooges” way of treating pain. For instance, if you have a headache and I hit your foot with a hammer, what happened to your headache. I stole the example from my dad, because this is how he would always respond if I told him my arm was sore after baseball practice. This was way back in the 1980’s and he was a laborer by trade. The gate control theory makes sense to most people, but we can also see the example and understand that it is probably not the best way to fix a problem, as we end up with a broken foot from the hammer.

  1. “The pain neuromatrix explained our knowledge and understanding of the functional and structural changes in the brains of people suffering from chronic pain”

To simplify, we have pain because our brains tell us that something is painful. This could be due to past experiences, actual painful stimuli eliciting Nociception, super excited nerves , so on and so forth.

  1. “biomedical models may induce fear and anxiety, which may further fuel fear avoidance and pain catastrophization”

It is very common for a patient to come into the clinic and say that he/she is avoiding a particular activity because of a history of a herniated disc. There is research that shows that a herniated disc can become “unherniated” (for a lack of a more layman’s term) over the course of 6 months. The patients are never educated regarding this point. Once a herniation, always a herniation is just not true. This biomedical or pathoanatomical (patho=bad and anatomical = body parts) model of health care is outdated and simply is not as useful to use with the general public because research demonstrates that the patient may become “sick listed” and from there stop participating in previously enjoyable activities.

  1. “a plethora of papers have been dedicated to a mere 20-millisecond delay of abdominal muscle contraction, yet despite the enormous amount of time, money and energy spent on this science, clinically it has yet to provide results superior to those of any other form of exercise for low back pain”

Doing the vacuum pose while lying down is no better than doing a general squat or learning how to utilize your diaphragm during breathing mechanics. As the layperson, there are many people that want to take your money in the health care industry. (I hate to say it like this, but healthcare is a huge business and the public needs to see it as so.) When the new fad comes out to solve back pain, don’t buy into the infomercial and as a matter of fact, turn off the t.v. and go get a book from the local library. You will spend hundreds of dollars less than what is proposed on the infomercial and be better off after having read the book. Nothing beats knowledge and the smarter you are at taking care of yourself, the better armed you are when you actually get in front of a health care practitioner. Remember, it is a business and we all want your money if you will give it to us. A better use of your time is to come educated so that I don’t have to teach you the basics of posture for 30 minutes, but can instead can teach you how to perform more high level movement patterns instead of sitting properly to reduce your pain. Oh wait, pain is normal. I’d lose my job if I sold this to all of my patients, but instead the patients need to be educated between hurt and harm.

  1. “In all health care education, be it smoking cessation, weight loss, or breaking addiction, the ultimate goal is behavior change.”

Speaking as a physical therapist, I can’t stress to the patients enough how the therapy experience is a team. Smart people call it therapeutic alliance, but I’ll settle for team. My part is to educate the patient and attempt to solve the puzzle of the patient’s pain, but it is the patient’s job to take the information that they have gained during the session and go home and apply it to their daily lives. For a patient to do nothing at home, AKA make no changes in behavior, and come to the following session thinking that the pain will go away is similar to :

https://spencergarnold.files.wordpress.com/2013/01/snatch-miracle.jpg

Patients may come hoping for a miracle, but it is not to be. The patient and therapist have to work together to attempt to solve the pain problem. If one side of the team is not doing their part, then the PT has to be willing to discharge the patient or the patient has to be willing to fire the PT.

  1. “…when PNE (Pain Nueroscience Education [pain is a normal human response]) is paired combined with either exercise or manual therapy, it is far superior in reducing pain compared to education alone”

From this I take that teaching the patient and then moving the patient is better than just teaching the patient. We can all agree that low level exercise is good for people. If we don’t agree with this, then we are saying that it is safer long term to live like a slug then to get up and walk around the living room. It just isn’t so. People will refuse to get up and walk around the living room when they start experiencing low back tightness, leg fatigue, or the dreaded “Fran cough” (look it up and btw I am an advocate professionally speaking). We as a society have to start moving more and learn about how our body is supposed to work. This can not be done from infomercials that have pictures of pulsating backs or frowning stomach fat.