Chronic Low Back Pain MDNT An

… Chronic Low Back Pain … MDNT; An Adjunctive Therapy for Musculoskeletal and Remedial Therapists Jim Olds BHSc Dip RM Dip CN • Fellow ANTA • National Vice President ANTA • National Director CPE ANTA • Associate Member Sports Medicine Australia • QLD Manager Faculty of Remedial Therapies Australian College of Natural Medicine

Evidence Based Medicine and Back Pain • The Biomechanics of Back Pain is written by four of the leading researchers in the field with an up-to-date detailed analysis of the latest spinal research • The book emphasizes the relevance of research to clinical practice in the understanding and treatment of back pain

The Researchers … • Michael A Adams BSc Ph. D University of Bristol UK • Nikolai Bogduk BSc Med MB BS MD Ph. D Dip. Anat Dip. Pain. Med FAFRM FAFMM FFPM(ANZCA) Prof Pain Medicine NU NSW • Kim Burton DO Ph. D UK • Patricia Dolan BSc Ph. D UK • Brian J C Freeman MB BCh BAO DM FRCS UK

Prevalence of Low Back Pain • Low back pain (LBP) affects approximately 80% of the population • Approximately 18% develop protracted pain • Around 8% develop chronic low back pain The Biomechanics of Back Pain 2 nd ed Adams Bogduk Burton Dolan and Freeman Elsevier Ltd 2006

Effects on Activities of Daily Living • LBP is rarely self-limiting and should no longer be considered as transient in nature • Rather it manifests as a periodic attack usually followed by a temporary remission – “attack/remitting” cycles • Adams et al suggest that the approach to understanding chronic LBP should be reconsidered. The Biomechanics of Back Pain 2 nd ed Adams Bogduk Burton Dolan and Freeman, Elsevier Ltd 2006

The Cochrane Collaboration and Evidence Based Medicine • The Cochrane Collaboration, a well-respected web based reference service for scientific research, made the following contribution: • … low back pain is usually a self-limiting and benign disease that tends to improve over time … www. cochrane. org

What does EBM mean to MSTs? Do you think we need to review all the research and develop our own opinions? Research Experience Knowledge

Components of Back Pain • Adams et al in their latest contribution to the understanding of the biomechanics of back pain concluded there are … some difficulties faced when discussing … how diseases occur in different groups of people • Considering the multifactorial nature of back pain, Adams and colleagues coined the term low back trouble

Common Causes of Low Back Trouble • LIGAMENT SPRAINS • FRACTURES • • wedge flexion/distraction burst compression • DISC INJURIES • • • prolapse extrusion sequestration • • zygapophyseal joints facet joints • MUSCLE STRAINS • active trigger points • GENETIC PREDISPOSITION and AGING • • degenerative disc disease facet incompetence osteoarthritis osteoporosis

Specific Risk Factors • Societies: western etc • Age: disc injury or DDD • Gender: should be only two • Genetic: the things your parents gave you • Environmental: workplace, sports, hobbies • Psychosocial: risk-takers, depression etc • Diseases: osteoporosis, arthritides

Sciatica…poetry and politics… Thou cold sciatica, cripple our senators, that their limbs may halt as lamely as their manners William Shakespeare 1564

Sciatica • In 24% of confirmed cases of disc prolapse these individuals remained asymptomatic • When disc prolapse does become symptomatic, it does so by compromising a spinal nerve or its roots • The classic symptom of this type of pain is radicular pain or sciatica; radiculopathy

Disc Prolapse and LBT • While there is a positive correlation between low back pain and disc prolapse there are many arguments about its influence • Most people with back pain do not have disc prolapses • The pain arising around a discogenic pattern can be attributed to inflammation, oedema and stimulation of nociceptive fibres in the dura mater

Myofascial Injuries • Muscle Strain • Muscle Spasm • Active trigger points

Muscle Strain - According to EBM The International Association for the Study of Pain (IASP) criteria for muscle strain require … • the muscle be specified • the strain be diagnosed by valid and reliable tests Tenderness over the site or motion tests are deemed not valid or reliable by the IASP

Muscle Spasm • The IASP rules that a muscle spasm is a diagnosis that is not valid or reliable: • Studies have failed to demonstrate electromyographic or other features that correlate with pain from the allegedly affected muscle

Myofascial Trigger Points • Myofascial pain is an attractive explanation that is widely entertained according to the IASP • Inter-observer agreement about the presence of Tr. Ps in the quadratus lumborum and gluteus maximus muscles was poor … Perhaps they did not know where to look?

Myofascial Pain and Trigger Point Therapy • Any musculoskeletal therapist who has received training in the identification, location and treatment of MTr. Ps will have experienced, in the majority of cases, the reward of lowering the pain levels of the client in treatment

Travell and Simons • What did they really do? • Dr Janet Travell classified the locations and referral patterns of most of the common Tr. Ps • Dr David Simons collaborated with her to catalogue the details of her work and together they pioneered and refined the medical injection of local anaesthetic to deactivate trigger points and resolve referred pain

Trigger Point Manual The reasons for Travell and Simons’ success within the medical profession … Ø The exhaustive classification of trigger points on the body Ø The production of a comprehensive manual of instruction to demonstrate the points and methods which could be utilised in pain therapy

Wet Needle Therapy • Travell and Simons categorised the Tr. P and the pattern related to it • They detailed the results of injecting a substance into the Tr. P to bring relief to the sufferer of acute or chronic pain • For Drs Travell and Simons this became a life work • Their work has provided many practitioners with an effective modality for the resolution of pain

Dry Needle Therapy • Over time, dry needle therapy arose as a result of various researchers finding that the insertion of a needle into a point had the same effect as wet needling • They found that the insertion of the needle into the trigger point deactivated the referred pain before they injected anything into the point

Review of Wet and Dry Needling Trials • Cummings and White (2001) carried out a review which led them to state: the principal findings are that, when treating Tr. Ps with injections, the nature of the injected substance makes no difference to the outcome, and that wet needling is not therapeutically superior to dry needling • This confirmed what Sir William Osler (1909) stated: that in order to alleviate myofascial pain it is necessary to do no more than simply stimulate nerve endings at points of maximum tenderness with a needle Acupuncture, Trigger Points and Musculoskeletal Pain 3 rd ed Peter E Baldry Elsevier Ltd 2005

Dry Needling Tr. Ps • Myofascial dry needle therapy (MDNT) is commonly used today as a treatment based on deactivation of Tr. Ps • The greatest difference between MDNT and acupuncture is that therapist is not trained in Traditional Chinese Medicine • This obviated the need for training in acupuncture diagnostics, and the understanding of the acupuncture points and meridians, which has been described as mysticism by the medical profession of the day (19 th Century)

Remember the Cochrane Collaboration? • The website produced an article which states: dry needling may be a useful adjunct to otherapies for (treatment of) chronic low back pain • The statement noted that: dry needle therapy. . . is more effective than no treatment or sham treatment … there is evidence of pain relief and functional improvement … immediately after treatment in the short term …

Peter E Baldry MBBS FRCP • Baldry explains…although Melzack et al (1977) showed that…TC acupuncture points (TCAPs) and MTr. Ps have an undifferentiated morphology … the important difference is that a TCAP is only slightly tender due to the nerve endings being in a quiescent state Acupuncture, Trigger Points and Musculoskeletal Pain 3 rd edition PE Baldry JW Thompson 2005 Elsevier

Differentation of APs and MTr. Ps • … a MTr. P is exquisitely tender because of the nerve endings having become activated and sensitized … • The most common cause of sensitisation is trauma to the muscle containing the MTr. P

Specificity of Treatment • … when employing ‘manual’ acupuncture (MDNT) to a specific site to suppress chronic pain, the manipulation is invariably a strong one … an acute episode requires only a light stimulation • … superficial techniques will stimulate the A-delta afferents … Bowsher’s review (1998) has given a detailed account of the effects of treating back pain utilising the A-delta afferent nerve fibres

Why A-delta Afferents? • Gobel et al (1980) found that A-delta fibres cause a direct input into the stalked cells of the dorsal horn • The effect of this stimulation resulted in the release of the inhibitory endogenous opioid peptide enkephalin (EOP) response (Ruda et al 1984)

Inhibitory Effects • The overall effect of enkephalin is to block the generation of noxious information in a MTr. Ps group IV nociceptors • The additional affect of SDN has an inhibitory effect on the wide dynamic range transmission neurons (Hashimoto & Aikawa 1993)

The Case for SDN • Baldry concluded that in cases where pain exists as a result of an active primary MTr. P, needling to a depth of 5 -10 mm into the MTr. P is prescribed to deactivate an acute pain pattern where radiculopathy is absent

Deep Dry Needling (DDN) • Baldry states … when MTr. P activity arises secondary to the development of a radiculopathy, DDN should be employed • During this process A-delta nerve stimulation must take place as a result of the needle passing through the skin, the subcutaneous tissue … and rapidly into the MTr. P itself, evoking a local twitch response (LTR)

Training in MDNT • Private colleges have increased the hours of study for musculoskeletal therapists with regard to infection control and hygiene around invasive therapy delivery • Modality training is based on a comprehensive program covering anatomy, neurovascular anatomy, functional anatomy and neurophysiology

Practitioner Recognition • Professional associations have developed pathways for recognition of suitably trained practitioners • Professional practitioner insurers have added MDNT to their scope of cover • Clinics will need to comply with the Skin Penetration Act relevant to specific locations

The Legality of Practice in MDNT • This has been addressed in Victoria between the Chiropractic Board and the CMRB • MDNT training providers do not pretend to be training anyone in acupuncture therapy • Myotherapists and musculoskeletal therapists completing MDNT training are precluded under the Chinese Medical Registration Act (CMRA) 2000 in Victoria to hold themselves out to be acupuncture practitioners

Registration and Protection of Title • Under the CMRA, the title and practice of acupuncture is protected by state legislation • Some practitioners had claimed to practice acupuncture as an adjunctive therapy, when in fact, they had not trained in acupuncture • This is now regulated in line with the legislation in Victoria • Only registered acupuncture practitioners are legally allowed to use the title • All other practitioners are now correctly calling their practice dry needling Guidelines for practice of dry needling by chiropractors April 2005

References Ø http: //www. cochrane. org Ø The Biomechanics of Back Pain Adams, Bogduk, Burton, Dolan Ø Myofascial Pain and Dysfunction The Trigger Point Manual Janet G Travell MD David G Simons MD Ø Acupuncture, Trigger Points and Musculoskeletal Pain 3 rd Ed Peter E Baldry John W Thompson

Thank you Jim Olds BHSc Silkwood Natural Therapies 79 Silkwood St Algester 4115 Phone: 0432 949 422 www. growthedges. com. au