Lecture #7 06/27/2019 Update on the Evidence: Modalities Linsey Hamilton, PT, DPT, SCS Sports & Orthopaedic Specialists Allina Health Allina Health Sports Medicine Conference 2019 Objectives ◻ To highlight the current evidence regarding the efficacy of: Therapeutic ultrasound Instrument assisted soft tissue mobilization Cupping therapy Dry Needling Kinesiology taping ◻ To consider athlete preferences regarding recovery modalities ● Describes conclusiveness of evidence from CRs regarding PT ● 283 reviews from 2008-2017 ○ 88 relating to MSK ● 5.7% provided conclusive findings ● Need for further research of high methodological quality ©AllinaHealthSystems 1 Lecture #7 06/27/2019 Therapeutic Ultrasound ● Over 20 years of randomized controlled trials ● Multitude of musculoskeletal conditions ● Strong evidence of no benefit Alyer 2019, Balci 2018, Katzap 2018, Desmueles 2015, Ebadi 2014, Page 2013, van den Bekerom 2011, Shanks 2010, Rutjes 2010, Ho 2007, Buchbinder 2006, Baker 2001, Robertson 2001, van der Windt 1999, Instrument Assisted Soft Tissue Mobilization (IASTM) ● Popular intervention for myofascial pain ● STM using specifically designed instruments ○ Varied materials & shapes ● Graston®, Hawk grips®, Functional and Kinetic Treatment and Rehab®, Adhesion Breakers®, Fascial Abrasion Technique ™ ● Proposed mechanism: Stimulation of connective tissue remodeling via increased fibroblast recruitment ● 5 RCT’s MSK conditions ● 2 RCT’s joint ROM in healthy subjects ● Current evidence does not support IASTM for treating MSK conditions ● Weak evidence supporting IASTM for increasing LE joint ROM ©AllinaHealthSystems 2 Lecture #7 06/27/2019 ● 9 RCT’s MSK conditions & healthy participants ● Current evidence does not support use of IASTM to improve pain, ROM, or function in healthy individuals or those with varied pathologies Cupping Therapy ● Traditional Chinese Medicine: 3300 BC ● Varied techniques ○ Dry vs wet ○ Glass, bamboo, silicone, plastic ○ Heat, mechanical, electrical ○ Retained, moving ● Create vacuum effect ● Proposed mechanism: Create short term localized hypoxia to improve microcirculation and transport of metabolic by- products ● 135 trials ● RCT’s on cupping for herpes zoster, Bell’s palsy, acne, lumbar disc herniation, cervical spondylosis ● Wet cupping (in the majority of trials) ● All trials were of low methodological quality ● Wet cupping may be effective for some conditions ● Lack of reporting on adverse events ©AllinaHealthSystems 3 Lecture #7 06/27/2019 ● 11 trials with 498 subjects from China, USA, other ● Soccer, football, handball, swimming, gymnastics, track & field ● Cupping 1-20 times @ daily or weekly intervals ● Cupping alone or combined ● Unclear or high risk of bias in majority of trials ● No explicit recommendation for or against cupping for athletes Dry Needling ● Use of thin filiform needle to mechanically influence myofascial trigger points and connective tissues ● Based in Western neuroanatomy and modern scientific study of the musculoskeletal and nervous systems ● Requires additional/specialized training ● Proposed mechanism: Increased fibroblast activity, collagen remodeling, activating of descending pain inhibitory pathways Dry Needling: Systematic Reviews ● Very low to moderate quality evidence ● At immediate and 12 week f/u, DN was superior to no treatment, sham, placebo for: ○ Pain reduction ○ Pain pressure threshold ○ ROM ○ QOL ● Insufficient evidence re: functional outcomes, disability, sleep quality, medication intake ● Evidence for long term benefits is lacking ● Further high quality RCTs with standardized procedures are needed ©AllinaHealthSystems 4 Lecture #7 06/27/2019 Kinesiology/Tension Taping ◻ Application of tape with elastic core ◻ Developed in the 1970s ◻ KT Tape, Kinesio Tape, RockTape, SpiderTech ◻ Proposed mechanism: Enhances lymphatic return Muscle facilitation or inhibition ◻ 6 RCTs comparing KT to sham taping ◻ Methodological quality: Low ◻ No significant difference in pain or disability scores between groups KT in Soccer Players: Muscle Performance Dos Santos J Back Musculoskelet Rehabil 2017 KT vs no tape on VM & VL Serra Braz J Phys Ther 2015 KT vs micropore on quadriceps Espi-Lopez J Sport Rehabil 2019 KT vs sham KT on rectus femoris *Muscle performance of the quadriceps is not altered by KT ©AllinaHealthSystems 5 Lecture #7 06/27/2019 Ankle balance taping results in significantly greater gait velocity, step length, and stride length as compared to sham tape and no tape in amateur soccer players with lateral ankle sprain. No tape ● Perceptions of elite athletes regarding recovery modalities ● 32 physiological, psychological, social, & complementary methods ● ALL Sleep, fluid replacement, socializing with friends ● MEN Ice bath, supplements ● WOMEN Discussions with teammates/coaches after training/matches ● SOCCER Active cool down, massage, prayer Summary ● Strong evidence for no benefit: US ● Weak evidence or small effect: IASTM, Cupping, DN, KT ● Consider patient/athlete perceptions & beliefs ● Engage patient/athlete in active rehabilitation ©AllinaHealthSystems 6 Lecture #7 06/27/2019 Thank You! Linsey Hamilton, PT, DPT, SCS [email protected] 952.914.8631 ©AllinaHealthSystems 7.