The Influence of Alternative Therapeutic Techniques on Managing Pain: Evidence for Novel Therapeutic Techniques

Brian Hortz, PhD, AT, SFDN, ITAT

Director of Research & Education

Structure and Function

Disclosure

The opinions presented are those of

the presenter and do not necessarily

reflect the opinions of Structure and

Function Edcuation.

The presenter is employed by

Structure and Function Education

which provides continuing education in

Dry Needling and Stecco’s fascial

manipulation.

GoalsPresenting evidence of pain management via 4 Interventions:

Cupping, IASTM, Fascial Manipulation, Dry Needling

-Discuss Pain:

-Pain theories

-Pain management

-Discuss 4 therapeutic Techniques

-Examine the evidence for pain management

One Major Challenge to our

Athletes/ Patients

Pain

Pain

• Pain is a vital function of the nervous system in providing the body with a warning of potential or actual injury.

• It is both a sensory and emotional experience, affected by psychological factors such as past experiences, beliefs about pain, fear or anxiety.

Pain

• Inflammatory• Pain associated with active inflammation

• Nocioceptive• Generated by activation of nociceptors in

peripheral tissues by an actual or potentially tissue damaging event

• Neuropathic• Pain caused by a lesion of the

somatosensory nervous system

• Nociplastic• Change in function of nociceptive pathways

• Central sensitization may be the underlying mechanism

Hainline, BJSM, 2017

Pain vs Nocioception

• Nocioception- the sensory nervous system’s response to a harmful or potentially harmful stimulus

• Pain is a symptom

• Nocioception stimulus and pain sensations DO NOT go hand in hand

• Chronic pain (CRPS/ Phantom Limb/ Fibro) is pain without nocioception

Basbaum et al, 2009

Nociceptors

• Inflammatory mediators (egbradykinin, serotonin, prostaglandins, cytokines, and H+) are released from damaged tissue and can stimulate nociceptors directly.

Hendelman W, Humphreys P, 1942, Skinner C. The Integrated Nervous System:

A Systematic Diagnostic Approach. Boca Raton: CRC Press/Taylor & Francis;

2010.

Melzack and Wall, 1965

Moayedi and Davis, 2013

Milan, 1999

Nociception- Ascending Pathways

Neuroscience Online-

https://nba.uth.tmc.edu/neuroscience/m/index.htm

Melzack and Wall, 1965

Moayedi and Davis, 2013

Milan, 1999

https://www.earthslab.com/anatomy/tracts-of-the-spinal-cord/

Theories of Pain

• Gate control- Most commonly associated with all of the techniques we will review.

• Kennedy, Donna L et al. “Reliability of conditioned pain modulation: a systematic review.” Pain vol. 157,11 (2016).

• Melzack R. Pain and the Neuromatrix in the brain. J Dent Educ 2001

• Moayedi M, Davis KD. Theories of Pain: from Specificity to Gate Control. J Neurophysiol. 2013

• Neuromatrix theory - Pain is

produced in the brain and

spinal cord, not peripherally

• CPM is a “pain- inhibits

pain” theory

• Two noxious stimuli

are applied

So what evidence do we have that novel therapeutic techniques decrease pain?

How do we evaluate evidence?

Vacuum CuppingEvidence of Pain control

CUPPING

BACKGROUND

-Dates Back 3000 BC, exact origin is unknown

-Ebers papyrus (1550 BC) from Ancient Egypt is one of the oldest medical

texts to mention cupping therapy.

-Hippocrates wrote extensive descriptions of the cupping applications

-Described different types of cups

-Narrow with long handle

-Other with a wide opening

-During the Renaissance, cupping was popular in the treatment of gout

and arthritis in Italy

Aboushanab,Tanner, AlSanad, Saud. Cupping Therapy An Overview from a Modern Medicine Perspective. Jnl of Acupuncture and Meridian Studies.2018; 11(3) 83-87

What do the RCT’s say about effectiveness of treating

pain?

What do the Systematic Reviews say about effectiveness of treating

pain?

But you see equivocation in conclusions….

So why is everyone so skeptical?

So how do YOU evaluate the evidence?

Myo-Fascial ManipulationMyofascial Release, Fascial Manipulation, etc.

References

FASCIAL MANIPULATION

“ THE TRADITIONAL APPROACH THAT STUDIES THE

MUSCLES AS INDEPENDENT UNITS, HAS BEEN A

BARRIER TO UNDERSTANDING THE BIGGER PICTURE

OF FASCIAL FUNCTION.”

THOMAS MYERS

BACKGROUND

• Myofascial Techniques are widely employed manual therapy

treatment that involves mechanical forces to manipulate

the myofascial complex, intended to restore optimal

length, decrease pain, and improve function.

• Myofascial practitioners claim that by restoring the length

and health of restricted connective tissue, pressure can be

relieved on pain sensitive structures such as nerves and

blood vessels.

Evidence of Fascial Manipulation for Managing Pain

What do the RCT’s say about effectiveness of treating

pain?

What do the Systematic Reviews say about effectiveness of treating

pain?

Again you see equivocation….

So why is everyone so skeptical?

INSTRUMENT-ASSISTED SOFT-TISSUE

MOBILIZATIONEffects on Pain

Theory, Mechanisms, Evidence

Background

• Instrument assisted soft-tissue mobilization (IASTM) has become a popular myofascial intervention for sports medicine professionals.

• There are various IASTM companies such as RockTape®, HawkGrips®, Graston®, Te cnica Gavilan®, Functional and Kinetic Treatment with Rehab (FAKTR)®, Adhesion Breakers®, augmented soft-tissue mobilization or ASTYM®, and Fascial Abrasion TechniqueTM that each teach their own treatment approach and design their own instruments (e.g., specific material, instrument shape).

• The popularity of IASTM has also prompted an emerging body of research on the efficacy of IASTM.

What do the RCT’s say about effectiveness of treating

pain?

What do the Systematic Reviews say about effectiveness of treating

pain?

Again you see equivocation….

So why is everyone so skeptical?

Dry Needling

Dry Needling

• Dry needling is a treatment performed by skilled, trained therapists, certified in the procedure.

• A thin monofilament needle penetrates the skin and treats underlying muscular trigger points for the management of neuromusculoskeletal pain.

• Dry needling has been used for a wide variety of musculoskeletal issues, such as shoulder, neck, heel, hip and back pain.

What do the RCT’s say about effectiveness of treating

pain?

What do the Systematic Reviews say about effectiveness of treating

pain?

Again you see equivocation….

The Caveat

More rigorous randomized controlled trials are clearly needed to more fully elucidate the effectiveness of dry needling

So why is everyone so skeptical?

So let’s make sense of this…..

• Quality of studies: RCT’s and reviews included here

• Equivocation on these due to methods of RCT’s

• Blinding is the most consistent factor

• Should we be blind to the results due to insufficient blinding?

• Let’s look at quantity and consistency as well…

So let’s make sense of this…..

Dry Needling

IASTM MF Techniques Cupping

SO….. If I’m using these to treat pain….

IASTM < MF Techniques < Cupping < Dry Needling

We all need to understand the issues surrounding

these studies and consistency of evidence for each

of these in treating pain.

If you aren’t convinced that this accumulation of

evidence is sufficient, don’t use the technique.

Comparisons To Long Held Therapies

“

”

Questions?

Absence of evidence is not evidence of absence. — Sir Martin Rees

Thank You!

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