Posts tagged pain
How Does Needle Depth Impact Treatment Effects From Dry Needling?

Dry needling is a treatment provided by Physical Therapists to relieve a patient’s muscular pain and associated symptoms. This intervention can be performed in both extremity and spinal regions within the body. Current research continues to investigate the mechanisms behind its’ effectiveness, as well as, the most appropriate patient populations and diagnoses for its’ utilization. In addition, authors are trying to determine which parameters of the treatment such as needle placement, needle number, duration of treatment, utilization of electrical stimulation and needle depth may be modified for optimal treatment effects.

Griswold and colleagues reviewed the available evidence behind needle interventions for spinal pain to determine if depth of needle placement influences treatment effects (JMMT. 2019). Authors included 12 studies in the systematic review and 10 studies in the meta analysis. They reported both superficial and deep dry needling improved pain but significantly better outcomes on pain were found for utilization of deep dry needling. In addition, there was a greater effect when needles were placed in the area of pain compared to a distal site on the body.

Contact the experts at MEND to learn more on how dry needling can improve your current symptoms

Kettle Bell Impact on Muscle Recruitment and Posterior Chain Function

The majority of people with lower quarter pain or symptoms will demonstrate altered coordination and communication between the nervous system and muscles.  This leads to altered movement patterns which may perpetuate symptoms and lead to more chronic pain and muscle imbalances.  Primary movers for our movement patterns (example: gluts) may be substituted for weaker, less tolerant muscle groups (lumbar extensors) leading to a greater loss of performance, strength, agility, coordination, and balance.  

boulder physical therapy posterior chain strengthening

One of the most common areas of coordination or strength impairments includes the muscles of the posterior chain shown above.  This chain of muscles involving the same side hamstring and glut works with the opposite side latissimus dorsi to produce athletic and functional movements each day.  Impairments within this chain of muscles, in particular weakness or inhibition of the gluteus maximus, leads to poor movement patterns, chronic symptoms, and loss of performance in tasks involving this chain.  Examples would include most throwing movements and your golf, baseball, or hockey swing.  Conversely, strengthening this chain of muscles leads to improvements in strength and performance.  

kettlebell swing strengthening louisville physical therapy

The kettle bell is an excellent piece of strength training equipment to develop coordination, power, and strength.  Two common swings with this piece of equipment include single and double hand swings.  This back to front movement is an excellent way to target the posterior chain and incorporate a movement patterns from your foot through your hand as you accelerate the weight.  Different phases of the swing, located below, incorporate different muscles at different degrees of recruitment.   

boulder physical therapy strengthening sports performance

A recent article by Van Gelder et al. examined the muscle activity of the hamstrings and gluts during the kettle bell swing in 23 healthy young adults (IJSPT. 2015). The authors noted significant recruitment of all muscles in the leg reaching a threshold of activity needed for strengthening.  Thus, the kettle bell swing is an excellent alternative to replace single muscle or joint strengthening exercises.  The authors also noted hip extension range of motion was associated with the ability of the participants to recruit the gluteal muscles.  Thus, athletes and clients utilizing kettle bell swings should ensure they have proper mobility in their hips before adding resistance in this movement pattern.  

To evaluate your movement patterns and learn how to improve your performance contact your local Physical Therapist. 

How Does Stretching Improve Flexibility?

here are not many more controversial topics in the exercise science literature than stretching.  While most believe stretching is an important component of a fitness or rehabilitation program the debate occurs on the timing, frequency, duration, type, direction, and intensity of the stretching program.  Recently, a large push in corrective exercise programs involves mobilizing joints and body regions most prone to limitations in range of motion including the ankles, hips, and thoracic spine.  In our practice, we often prescribe these self mobilizations to patients to complete at home in order to reinforce manual physical therapy treatments (mobilizations, manipulations, soft tissue treatments) provided in clinic.  

These self mobilizations or static stretches have an positive impact on the available range of motion in an individual joint or functional movement (squatting, turning your head to the left).  Static stretches held for 15-30 seconds at the point of stretch have been shown to improve ROM when applied for 2-4 repetitions.  These stretches should be held until after exercise and sports due to their negative impact on performance.  Previously explanations behind the improved range of motion after stretching described improvements in the extensibility of the muscle and tendon.  These explanations have been disproven in the recent literature and seem less probable given the amount the intensity, duration, and frequency needed to make a true structural change in muscle after stretching. 

In our body, we do not have receptors specific to the feeling of pain, rather we have thresholds for information regarding temperature, chemical irritation, and mechanical loading like stretching.  Once the stimulation reaches a high enough level a signal is transmitted to the spinal cord and brain before processing this stimulation as pain.  These thresholds for mechanical information are responsible for making injured areas more tender or sensitive and may explain some of the benefits behind stretching.   

A recent article by Konrad et al. (Clinical Biomechanics, 2014) examined the impact of a 6 week static stretching program on 49 healthy volunteers.  The authors of the study were interested in the mechanisms behind the stretching program and what was responsible for the improvement in ROM.  Not surprisingly, the volunteers improved their ankle ROM but consistent with the prior literature the increases were not due to changes in extensibility.  Using medical and biomechanical engineering instruments the authors did not note any improvements in functional (passive torque) or structural (muscle or tendon changes) indices.  Conversely, the authors believe that changes in ROM are due to improvements in the volunteers' tolerance to stretch.  The mechanical stimuli of stretching was improved allowing them to move further into the range of motion before a "stop" signal was sent through the nervous system.  

In short, we will continue to utilize both static and dynamic stretching in our practice but emphasis should be placed on the influence of these exercise programs on the nervous system not the extensibility of the muscle.   

How Does Exercise Heal Injured Tissues?

Each day we meet with athletes, clients, and patients who present with an injury or condition involving an injury to a muscle, nerve, ligament, tendon, or bone.  One of the most powerful tools we have to accelerate the healing of this injury is exercise.  A previous post discussed the impact of Physical Therapy exercises on Achilles Tendinopathy.  This post described the impact on exercise on achilles tendinopathy and how exercise improves injured tissue a process called mechanotransduction.  Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses (Khan Br J Sp Med 2015).  

Khan et al. in a recent article used the term "mechanotherapy" to describe the benefits of Physical Therapy exercises on injured tissues in the body (Br J Sp Med. 2015).  These authors updated the definition of this term to include "the employment of mechanotransduction for the stimulation of tissue repair and remodeling".  Each day we utilize exercise parameters including direction of force, speed, intensity, frequency, duration, and others to optimally impact a patient's injured tissue in order to promote healing and restoration of function.  Each tissue in the body seems to have unique responses to loading from Physical Therapy exercise.

A common example of this phenomenon occurs in our bones.  Gradual loading of the bones through exercise improves bone density, but aging and a lack of weight bearing exercise can lead to osteoporosis.  Bone cells (osteocytes) are stimulated through loading in weight bearing and exercise to promote fracture healing in injured bones.  Research by Challis et al. examined the impact on loading in addition to standard fracture care in patients with forearm fractures (Aust J Phys 2007, J Bone Joint Surg Br 2006, Clin Orthop Relat Res. 2005).  The authors noted improved fracture healing, strength, and range of motion when fractures were exposed to low load, cyclical pressures from a pneumatic cuff wore under the cast.  This suggest gentle, controlled loading in addition to immobilization may accelerate fracture healing. 

Muscle and tendon offer us some of the best examples of exercise's impact on tissue.  The benefits of exercise on muscle are clearly known including increased size (hypertrophy) due to loading (weight training) and the loss of muscle size due to disuse or immobilization (cast).  After a brief period of controlled rest after a muscular injury (strain) exercise has been shown to positively effect the cellular healing and repair of these injured tissues (Jarvinen et al. Best Pract Res Clin Rheumatol. 2007).  Without proper loading these injured muscles may remain in a weakened state making them more prone to subsequent injury.  We often see this in recurrent injuries such as hamstring strains.

Ohberg et al. examined the impact of achilles tendon exercises on achilles tendinopathy.  These patients demonstrated quick improvements in pain and function, but they were also followed over the coming years to determine how their tendons healed from this exercise (Br J Sp Med 2004).  The authors noted improved tendon structure with 19/26 tendons returning to "normal" quality on ultrasound imaging.  As described in our previous blog post early pain relief and restoration of function is likely due to a different mechanism than tendon restructuring since these changes often take years to develop. 

In short, Physical Therapy exercise will always be a hallmark conservative treatment for the regeneration of injured tissues.  Utilize a Physical Therapist to learn how to best manage your injury and how to utilize specific exercise parameters in get back to life and sports. 



The University of Google and Sports Injuries

Physical Therapists’ education, training, and skill set allows our profession to uniquely evaluate and treat the needs of both acute and chronic musculoskeletal conditions.  In this role we have consistently demonstrated great patient outcomes at a lower cost than others members of the healthcare team.   Education is one of the most important interventions we can provide to patients.  Spending up to an hour with patients allows us to educate them on their condition, how to avoid unnecessary imaging, medication, or surgery, and how to properly manage their unique symptoms.  Unfortunately, many patients are without a local PT and are utilizing the Internet prior to seeing a Physical Therapist in attempt to find some of the same information.  

A recent study by Bisson et al. set out to find how accurate patients are at self diagnosis after using the internet (Ortho J Sp Med, 2015).  The authors created a web based program to collect patient information on their injury and then generate a list of potential diagnoses to explain their symptoms.  The web system had the ability to generate a list of over 20 knee diagnoses based on the the entered information.  After each patient selected the diagnosis they felt was most consistent with their symptoms they were examined and diagnosed by an orthopedic surgeon.  The patient's list of probable diagnoses was incorrect 42% of the time, but 58% of the 200 patients had the diagnosis in their list of choices from the web based system.  

Clearly, a web based system cannot replace the expertise of an orthopedic specialist but may assist a patient with determining a diagnosis based off their symptoms up to 60% of the time.  One limitation of any web based system is the inability to recognize the individual symptoms and factors which create the unique presentation of their case.  Only a trained clinician can recognize these individual differences and change the diagnosis or plan of care accordingly.

Patient's are using the internet with mixed results to determine the cause of their symptoms, remedies for recovery, and the prognosis.  In our practice, our phone and email lines of communication are always open for past patients to use us as a resource and many take advantage allowing us to remain an educator for pain and sports injuries.  Find a local, knowledgeable PT and use them as a resource for your pains.  The information you receive is likely more accurate than anything you can obtain through a web based search.