Transcript Conservative Management of Joint Pain

Conservative Management of Joint Pain
John C. Hughes, D.O.
Aspen Integrated Medicine
Overview: Osteopathic Treatment of Joint
Pain
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Osteopathic Medicine: DO defined, Principles
DO techniques for knee, back, hip, shoulder pain:
 Direct versus Indirect
 Focus: Counterstrain
Injectional Therapy for joint pain
 Pathophysiology of Joint injury
 Proliferative Therapy
Medications/ Supplementation for Pain
Osteopathic Medicine: DO history
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Developed in the late 1800’s alongside allopathic
(M.D.) medicine
Founded by A.T. Still, M.D., who rejected the harsh
drug treatments used then for manual medicine
Still was accepted by the medical community but chose
to start his own schools because his holistic philosophy
was fundamentally different
Osteopathic Medicine: DO Defined
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Many D.O.’s practice in typical allopathic settings as
surgeons, internists, or primary care settings
Traditional osteopathic doctors make up about 10% of
all those trained and are those who continue to utilize
their hands to manually treat patients.
Osteopathic Medicine: DO Defined
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A D.O. is different than the other therapists because, in
the U.S., a D.O. is a medical physician
Traditional osteopathic doctors use very specific forms
of manual medicine, unlike any other manual therapist.
An important note: A D.O. is not a therapist. When an
osteopathic doctor places his or her hands on a patient,
he or she is practicing medicine.
Insurance companies reimburse D.O.’s at a higher rate
for osteopathic manual medicine than any other manual
therapies
Osteopathic Medicine: DO Principles
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1) The body is a unit; one cannot treat a part of the
body without consider its entirety.
2) Structure and function are reciprocally interrelated.
3) The body is capable of self-regulation, self-healing,
and health maintenance.
4) The nervous system controls, influences, and
integrates all bodily functions.
5) Rational treatment is based on an understanding of
these principles.
Osteopathic Techniques for Joint Pain
counterstrain
 indirect balancing
 myofacial release
 cranial therapy
 lymphatic drainage
 facilitated positional release
 HVLA, muscle energy
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Osteopathic Techniques: Direct
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Direct: Attempt to direct body parts into and often
through their physiological and anatomical barrier
Examples: Muscle Energy, HVLA (High Amplitude, Low
Velocity), Stretching, ROM exercises
Demo
Great for Cervical, Mid-Back, Low back somatic
dysfunctions (facet joints, intercostal areas, some tight
muscles, “frozen” shoulders) in young, healthy patients
Used by Chiropractors, Physical Therapists frequently
Osteopathic Techniques: Direct
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Pros: Often provides quick relief for patients, can
encourage healthy physiology
Cons: Rarely provides permanent changes to the
tissue, patient has to return frequently to find relief
 Rationale: The body cannot adapt and hold to the
often abrupt changes created by these often rapid
lengthening therapies (that go beyond the
physiologic barrier)
Dangers: Can be damaging to body tissues, joints
Osteopathic Techniques: Indirect
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Indirect: Attempt to direct body tissues (muscle,
bone, fascia, tendons) away from their anatomic or
physiological barrier
Examples:
 counterstrain
 indirect balancing
 myofacial release
 cranial therapy
Osteopathic Techniques: Indirect
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Pros: More sophisticated techniques as they work
with the body’s own physiology; great for older, postsurgical patients, after trauma; very effective and
calming to the body; provide lasting, often permanent
changes; not forceful--minimal risk of damaging tissue
 Rationale: The body can adapt to the physiological
changes fostered by indirect techniques
Cons: Require more patience and more time to do
techniques; difficult for patients to do own their own;
do not provide immediate “popping” sounds
Indirect Techniques: Counterstrain
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Used mostly by traditional osteopathic doctors, some
chiropractors, and a few physical therapists
Counterstrain:
 Developed by Laurence Jones, D.O.
 Definition: “a passive positional technique that
places the body in the position of greatest comfort,
thereby relieving pain by reduction and arrest of
inappropriate proprioceptor activity that maintains
somatic dysfunction”
Counterstrain: How does it help?
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A “somatic dysfunction” might be defined as any body part
dysfunction that presents itself with a restriction of motion,
tissue texture changes, asymmetry, or temperature changes
For example: A knee joint sprain presents with restriction of
motion
 The knee joint motion is most restricted at one point
 Likewise, the knee joint is also least restricted at one
point
Demo
Counterstrain: How Does It Work?
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Technique: Could be thought of as the opposite of
stretching (as the goal is to find the greatest position of
ease)
Directed not at tissue damage itself but to the “aberrant
neuromuscular reflexes within the tissue”
In particular, counterstrain is directed at muscle spindles
within the extrafusal fibers of muscles
Muscle spindles are highly specialized sensory receptors
which consist of a connective tissue sheath holding 5-12
intrafusal fibers (about 3mm long each)
Counterstrain: How Does It Work for Pain?
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On the polar, contractile ends of these intrafusal fibers,
there are gamma motor neurons that terminate there after
originating on the ventral horn
The contractile ends of the intrafusal fibers are sensitive
to changes in length (that occurs with muscle stretching)
When the extrafusal fibers of the muscle are stretched,
the intrafusal fibers are activated to resist the stretch
through an efferent neurofeedback to the gamma motor
neurons
Counterstrain: How does it Work for pain?
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The gamma motor neurons thus provide a necessary
CNS control to allow appropriate stretching and
resistance
With more stretching of the large extrafusal muscle fibers
(as often occurs with trauma, aka somatic dysfunction),
there is more gamma motor stimulation so there is a
greater reflexive resistance to the stretch created by
feedback from the intrafusal muscle fibers
Counterstrain: How does it Work for pain?
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In short, the greater the trauma/ the greater the stretch,
the more gamma excitement is present in the CNS
Counterstrain works by approximating the muscle by
passive shortening in order to decrease gamma gain
(aka gamma excitement) to turn off the reflexive
contraction by initiated by the intrafusal fibers of the
muscle spindles
A muscle that has been approximated can then return to
its lengthened form allowing increased range of motion,
less spasm, and ultimately less pain
Counterstrain: How does it Work?
Counterstrain: Figures
Counterstrain: Figures
Clinical Data: Counterstrain
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“Effect of Counterstrain on Stretch Reflexes, Hoffmann
Reflexes, and Clinical Outcomes in Subjects With Plantar
Fasciitis” JAOA • Vol 106 • No 9 • September 2006 • 547-
556
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Conclusions: Clinical improvement occurs in subjects with
plantar fasciitis in response to counterstrain treatment. The
clinical response is accompanied by mechanical, but not
electrical, changes in the reflex responses of the calf
muscles.
http://www.jaoa.org/cgi/content/full/106/9/547
Clinical Data: Counterstrain
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“Stretch Reflex and Hoffmann Reflex Responses to Osteopathic
Manipulative Treatment in Subjects With Achilles Tendinitis” JAOA •
Vol 106 • No 9 • September 2006 • 537-545
Conclusion: The reduction of stretch reflex amplitude with OMT,
together with no change in H-reflex amplitude, is consistent with Korr's
proprioceptive hypothesis for somatic dys-function and patient
treatment. Because subjects' soreness ratings also declined
immediately after treatment, decreased nociceptor activity may play an
additional role in somatic dysfunction, perhaps by altering stretch
reflex amplitude.
http://www.jaoa.org/cgi/content/full/106/9/537
Counterstrain: Further References
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Korr’s Theory http://www.jiscs.com/PDFs/CH13SCS.pdf
“Immediate effects of the strain/counterstrain technique in local
pain evoked by tender points in the upper trapezius muscle”
Clinical Chiropractic, Volume 9, Issue 3, Pages 112-118
http://linkinghub.elsevier.com/retrieve/pii/S14792354060007
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osteopathic treatment when compared to standard medical
treatment helped patients with chronic injuries find pain relief in
less visits and less medication
http://content.nejm.org/cgi/content/abstract/341/19/1426
Injectional Therapy for joint pain:
Physiology of Acute Sprains
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Inflammation phase--damaged cells release cytokines and
other mediators that cause vascular dialation and
permeability
PMLs, followed by macrophages enter the scene and along
with other cells, stimulate the migration and proliferation of
fibroblasts
Proliferative phase of connective tissue healing--fibroblasts
encourage synthesis of procollagen matrix (2-3 days after
injury)
Vascular buds form increasing blood supply (3-4 days) and
new tissue forms
Injectional Therapy for joint pain:
Physiology of Acute Sprains
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Remodeling phase: Collagen type I changes to collagen type
III and fibrils increase along lines of stress to become tightly
packed (2-3 weeks)
Collagen thickens and increases to preinjury length but with
only 50 to 70 % tensile strength (without additional injury to
stimulate fibroblasts)
With severe injury, the healing process may stop before the
tissue is sufficiently competent for everyday use
The term “degenerative” is often used to describe this
inadequate healing and resulting body structure (other terms
include chronic tendonitis, DDD, OA, etc.)
Injectional Therapy for joint pain:
Degenerative, Chronic Tissue-Why painful?
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“Nerve density at periosteum and periosteal attachments
of tendons and ligaments is 2nd only to skin”
Without functional sufficiency, pain mechanoreceptors
function as chronic nociceptors
Injectional Therapy for Joint Pain: Is blocking
inflammation the answer?
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Cortisone injections: block inflammation, stop the healing
cascade, decrease immune function (risking microbial
infection), cause tendon weakening, atrophy, or ruptures
Antinflammatory medications: block healing cascade
Injectional Therapy for joint pain: What is
Proliferative Therapy?
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Prololiferative therapy (or Prolotherapy) is defined as the
injection of irritant or proliferant solutions into the affected
ligaments, tendons, and/or joints.
This type of injection leads to local inflammation in the
injected area.
The localized inflammation triggers a wound healing
cascade, resulting in the deposition of new collagen,
New collagen shrinks as it matures. The shrinking collagen
tightens the ligament that was injected and makes it
stronger
Injectional Therapy: History of Prolotherapy
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The concept of Prolotherapy originated in the non-surgical
treatment of hernias, varicose veins, and hemorrhoids,
If the connective tissue in the veins becomes weakened,
hemorrhoids and varicose veins form.
Weakness in the collagen, of course, causes ligament laxity
and tendon degeneration with resultant chronic pain.
Most of the early innovators in injection treatment method were
surgeons who were looking for methods to improve surgical
outcomes or replace surgery with more conservative methods.
Injectional Therapy: History of Prolotherapy
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The injection of hernias, varicose veins, and hemorrhoids was
called Sclerotherapy, because the injection "sclerosed," or
scarred, the area.
Hippocrates, the father of Western medicine, introduced heated
metal probes into the dislocated and painful shoulders of javelin
throwers. He believed that this would tightened the shoulder
capsule by creating tough scar tissue and that the scar tissue
would keep the shoulder in place.
Dr. George S. Hackett developed modern prolotherpy
beginning in 1939; Unlike the sclerotherapists, Hackett
used an irritant that helped proliferate healthy collagen
Prolotherapy: Solutions, Technique
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Proliferative substances have varied over the decades but
have included phenol, glycerin, sodium bicarbonate,
dextrose, sodium morruhate, hypertonic saline
Dextrose is commonly used as a proliferant today
These substances are injected at the bony attachments of
tendons and ligaments to improve their integrity
Prolotherapy: Explained
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Dextrose is thought to "dehydrate" the injected tissues,
causing an injury signal for the body, and initiating the
healing process. Dextrose has been shown to be a growth
stimulant on it's own as well.
This healing process is one of inflammation restarts the
normal healing cascade that would occur with an acute
injury
Prolotherapy: Clinical Evidence
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1800 patients followed for 2 years; 80% showed marked
improvement in upper and lower body pain; Hackett GS:
Prolotherapy in whiplash and low back pain. Postgrad Med
27:214-219, 1960
Two RCTs (160 participants) found that prolotherapy
injections, given with spinal manipulation, exercise, and
other therapies, are more effective than control injections
for chronic low-back pain and disability.
http://www.cochrane.org/reviews/en/ab004059.html
Prolotherapy: Clinical Evidence
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60% increase in collagen fibril diameter measured at 3
months after 6 weekly injections in patients with low back
pain; Klein RG, Dorman TA, Johnson CE: Proliferant
Injections for Low Back Pain: Histological Changes of
Injected Ligagments and Objective Measurements of
Lumbar Spine Mobility Before and After Treatment J
Neurol Orthop Med Surg 10: 141-144, 1989
Osmolarity studies: Elevation osmolarity by as little as 50
mOsm has been found to activate multiple growth factors
including PDGF
Prolotherapy: Clinical Evidence
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Response of Knee Ligaments to Prolotherapy in a Rat
Injury Model; Am J Sports Med July 2008 vol. 36 no. 7
1347-1357
Conclusion: Dextrose injections increased the crosssectional area of MCLs compared with saline-injected and
uninjured controls. Dextrose injections did not alter other
measured properties in this model.
Prolotherapy: Clinical Evidence
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A systematic review of four injection therapies for lateral
epicondylosis: prolotherapy, polidocanol, whole blood and
platelet-rich plasma; British Journal of Sports Medicine
2009;43:471-481
Conclusions: There is strong pilot-level evidence
supporting the use of prolotherapy, polidocanol,
autologous whole blood and platelet-rich plasma injections
in the treatment of LE.
Medications/ Supplementation for Pain
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Oral Supplements:
 Traumeel
 Systemic Enzymes
 Curcumin
 SOD
Oral Medications:
 1st choice: Ultram
 2nd choice: Percocet or Tylenol
 Not recommended: Ibruprofen, other Cox 2, steroids
Medications/ Supplementation for Pain
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Topical Medications:
 Lidocaine cream (postoperative neuralgia)
Topical Supplements:
 DMSO
 Traumeel
 Capsaicin
Other Supplements/ Medications:
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Glucosamine
Hyaluronic Acid (Injections): occasional