Conservative Management of Joint Pain

John C. Hughes, D.O.

Aspen Integrated Medicine

Overview: Osteopathic Treatment of Joint Pain

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

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

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

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

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

Osteopathic Techniques: Direct

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

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

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

Pros: More sophisticated techniques as they work

with the body’s own physiology; great for older, post-

surgical 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

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?

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?

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?

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?

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?

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

“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

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

“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

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

33

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

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

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?

“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?

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?

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

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

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

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

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

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

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

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 cross-

sectional area of MCLs compared with saline-injected and

uninjured controls. Dextrose injections did not alter other

measured properties in this model.

Prolotherapy: Clinical Evidence

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

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

Topical Medications:

Lidocaine cream (post-

operative neuralgia)

Topical Supplements:

DMSO

Traumeel

Capsaicin

Other Supplements/ Medications:

Glucosamine

Hyaluronic Acid (Injections): occasional