2/4/18 1 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 EVIDENCE Something that furnishes proof SCIENCE The state of knowing : knowledge as distinguished from ignorance or misunderstanding Webster’s
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Footbal Chiro Meeting 2018 · Asanas •The poses and postures Pranayama •The breath •Breathing exercises The Bandhas “To hold, tighten or lock” 1.MulaBandha(root lock) Draw
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2/4/18
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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:
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
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