Acupuncture and Endurance?

We were treating patient that with low back pain that had decreased lumbar endurance the other day (you should be able to hold a "superman" post with your arms at your sides for 150 seconds. He has been continuing to improve and is now virtually pain free.

many folks don't realize a nice side effect of acupuncture is increased increased endurance, among other things. How about trying this on other muscles as well? We ran across this article you may find interesting

"Acupuncture therapy is able to eliminate free radicals, resist lipid peroxidation, prevent dysfunction of the motor hypothalamus-pituitary-gonadal axis, reduce the creatine kinase content, and lower lactic acid concentration, so as to play an important role in the elimination of sports fatigue and improvement of athletic ability of the body. "

link to free full text:

https://link.springer.com/article/10.1007/s11726-009-0123-7

An often overlooked culprit in hip pain...

We often find clinically that the quadratus femoris as becoming the 1st dysfunctional muscle of the deep 6 external rotators (1) and its pain referral pattern can mimic the piriformis (2) and piriformis syndrome (3) as well as hamstring insertional tendinitis.  It has also been implicated in some cases of femoroacetabular impingement (4)  as well as ishiofemoral impingement (5). It is active during walking stance phase, and moreso during stance while running as well as with a clamshell exercise with external rotation (6). It appears to be maximally lengthened with flexion and adduction or abduction, with internal rotation ( a great position of you need to stretch this muscle), and is deducted to be strongest going from a 60-90 degree flexed position into extension (ie: it has the with the largest moment arms observed for extension in the deduced force-length efficient range of 60-90° flexion)(7).

Needling this muscle can sometimes pose a challenge. Here is a demo of one way to accomplish it I often employ while needling some of the other surrounding hip musculature.

Consider the QF the next time you have someone with hamstring insertional pain, or diffuse hip pain that you are having a difficult time localizing.

1. Personal observation
2. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities vol. 2 (Baltimore: Williams & Wilkins, 1992) pp. 186-193.

3. Dalmau-Carolà J Myofascial pain syndrome affecting the quadratus femoris Pain Pract. 2010 May-Jun;10(3):257-60. doi: 10.1111/j.1533-2500.2009.00347.x. Epub 2010 Feb 11

4.  Diamond LE, Van den Hoorn W, Bennell KL, Wrigley TV, Hinman RS, O'Donnell J, Hodges PW. Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement.  J Orthop Res. 2016 Aug 11. doi: 10.1002/jor.23391. [Epub ahead of print]

5. http://radsource.us/ischiofemoral-impingement-syndrome/

6. Semciw, Adam I. et al. Quadratus femoris: An EMG investigation during walking and running Journal of Biomechanics , Volume 48 , Issue 12 , 3433 - 3439

7. Vaarbakken K, Steen H, Samuelsen G, Dahl HA, Leergaard TB, Stuge B .Primary functions of the quadratus femoris and obturator externus muscles indicated from lengths and moment arms measured in mobilized cadavers. Clin Biomech (Bristol, Avon). 2015 Mar;30(3):231-7. doi: 10.1016/j.clinbiomech.2015.02.004. Epub 2015 Feb 11.

Something a little different for a change: Case Management of a Post Surgical Foot

In this series, we will follow the progress of a post surgical, post rehab foot. These are the actual case notes and you can follow our thought process as we move along. 

History:

JM presented with left-sided content foot pain. On July 24 she broke her left navicular and cuboid (pretty unusual, as these fractures are rare. Navicular fractures are usually stress fractures (1), occurring in about .6% of fractures in one study (2).  Cuboid fractures are also rare and occur in less than 1.8 per 100,000 (3) ) She also tore the reticular ligaments. this happened when she fell down the stairs, inverting and plantar flexing the foot.

She has had extensive physical therapy as well as plate fixation of the navicular but is still having constant discomfort; she feels a pinching and shock like sensation in the right arch, particularly when loading the foot (whenever you hear about a "shock like pain, begin thinking about nerve related pain). She has been on gabapentin in the past which helped but she stopped it 3 weeks ago with no regression of her symptoms. She feels frustrated.

She was in physical therapy until the end of December. She has continued with exercises consisting of plantar flexion/toe raises, mobilization and inversion/eversion, squats/lunges as well as massage. She has improved but not completely better. She is able to hike 4-5 miles with little pain (boy, those Colorado women are tough!). The foot generally feels better with non weight bearing and rest as well as avoiding impact. The foot feels stiff in the morning and  she limps for the first 10 minutes after getting out of bed. Most recently she has had x-rays at VSO with Dr. X.

What did we find?

There was swelling noted over the extensor digitorum brevis with significant weakness of it as well as the extensor longus. No sensory deficits, reflexes intact. She had an anatomically short left short leg which appeared to be functional. There was a scar visible over the dorsum of the foot approximately 2 inches in length (see photos) and some discoloration lateral just anterior to the lateral malleolus. palpation along the medial plantar nerve revealed increased sensitivity below the navicular and into the medial heel. 

She has external tibial torsion bilaterally and limited eversion of the forefoot on the right. Her cuboid was moving appropriately but talonavicular articulation was not. She has adequate hip extension, 15+ degrees and ankle dorsiflexion bilaterally in excess of 15 degrees.

One leg standing with eyes open was less than 10 seconds. Loss of flexion and extension about the L SI joint. 

no x rays available for this visit

What we think was wrong:

Left foot pathomechanics (talonavicular) secondary to surgery and fracture. She has significant weakness of the short and long extensors as well as limited eversion and proprioceptive difficulties.

Discussion:

The talonavicular articulation is one of the key joints in mid foot pronation. Pathomechanics appear to be compromising the medial plantar nerve. This is exacerbated by her inability to fully evert the forefoot and pronate through the mid and forefoot (pronation is dorsiflexion, eversion and abduction). 

What We did:

We manipulated the sacroiliac joint and metatarsophalangeal articulations. We held off on any mobilization of the foot until we see her x-rays, hopefully available next visit.

We treated with neuromuscular acupuncture at the origin/insertion of the long extensors as well about the short extensor mass where the swelling was located. She was given the tripod standing, lift spread reach, toes up walking, and tiptoe waiting exercises to perform 2-3 times daily. She is scheduled for followup next week with x-ray review.

1. http://emedicine.medscape.com/article/85973-overview

2. http://journals.sagepub.com/doi/pdf/10.1177/2473011416S00299

3. http://www.uptodate.com/contents/cuboid-and-cuneiform-fractures

Dry Needling and Muscle Activation Patterns

A nice study looking at how sequential muscle activation patterns can change with dry needling. Think about the applications for gait?

"Removing LTrPs changes the order of muscle recruitment to a more sequential, stable pattern that is not significantly different to that displayed by the control group prior to fatiguing exercise. This suggests that removing LTrPs may allow subjects to better cope with the effects of fatigue, as evidenced by the reduced variability in activation times and the reduced co-activation of the muscles investigated. "

FREE FULL TEXT here: https://isbweb.org/images/conf/2003/longAbstracts/LUCAS_198-208_SB_LONGE.pdf

3 points to use with ankle instability

In this study they stimulated 3 points: ST41, BL60 and GB40. Take a look at their locations (above). ST41 is at the base of the long extensor tendons; gee, we never emphasize long extensor function, do we? GB 40 is at the lateral malleolus between the peroneus longus/brevis and peroneus tertius; how important are these for coronal plane stability, not to mention the ability to descend the 1st ray. BL60 is just anterior to the lateral malleolus, right by the peroneus longus and brevis (again). Could they have included K6, under the medial malleolus and near the long flexors? Sure. How about SP4 or 4, in the substance of the flexor hallucis brevis and anterior to the extensor hallucis longus. Of course. You can probably think of other points to include as well.

Do you think it was by accident that their muscle selection included dorsiflexors (excepting the peroneus longus) and everters? How about a muscle that would help descend the 1st ray and complete the medial tripod? Hmmm... There is always a reason and a rationale....

"CONCLUSION: Electroacupuncture can effectively improve the proprioception of athletes with FAI and achieves a superior efficacy as compared with the conventional physiotherapy."...or in this case, low level e stim to the medial and lateral malleolus.

How about adding these points, no matter how you would like to stimulate them, to your CAI toolkit?

Zhu Y, Qiu ML, Ding Y, Qiang Y, Qin BY. [Effects of electroacupuncture on the proprioception of athletes with functional ankle instability]. Zhongguo Zhen Jiu. 2012 Jun;32(6):503-6.

Acupuncture/Dry Needling and Proprioception. A Winning combination.

What a great combination of therapies for folks with chronic ankle instability, or almost any injury for that matter! Taking 2 modalities that emphasize afferent input from the peripheral mechanoreceptor system, which has such a large influence on the cerebellum as well as the segmental and descending pain inhibition pathways.

Did you notice they used the trigger points in the peroneus longs muscle to needle? Though they didn't say it, did you remember that that the point correlates to a great point: Gallbladder 34, which is an empirical point for musculoskeletal pain? Interesting how this muscle influences both frontal and saggital plan stability. 

Though the techniques of exercise could use some refinement (check out the gents posture in the photo, sure looks like he could use some gluteus medius work!), this is a good overview that provides evidence that utilizing spacial summation (combining multiple techniques that provide afferent input to more than one modality to cause an effect) has better outcomes than one alone. Put this one on your reading list : )

Salom-Moreno J, Ayuso-Casado B, Tamaral-Costa B, Sánchez-Milá Z, Fernández-de-Las-Peñas C, Alburquerque-Sendín F.Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial. Evid Based Complement Alternat Med. 2015;2015:790209. doi: 10.1155/2015/790209. Epub 2015 Apr 30.

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

Those Multifidi

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:
“Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.”

see also our post here.

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print]
The immediate effect of dry needling on multifidus muscles’ function in healthy individuals. Dar G1,2, Hicks GE3.

One point and 1 treatment can profoundly influence gait

When talking about the lower extremity and gait (as I have been know to do at more that one seminar), I often talk about the “reverse engineering” principle. This is looking at a muscle or muscle group from a “ground up” perspective, as it would be functioning during the gait cycle. This, along with knowing when a muscle should be firing in the gait cycle, can provide clues to what may be going on and how you may be able to help.

When discussing the quads, we often employ this principle. It can be a little difficult to think of the vastus medialis as a lateral rotator of the thigh and the rectus femoris as a flexor (anterior nutator) of the pelvis, but if you put your foot on the ground and think about it, you will see what I mean.

The VMO is often implicated in patello femoral syndromes but cannot be selectively activated. The ratio between vastus medialis and vastus lateralis does seem to be alterable and perhaps is a siginificant factor.

How about if we look at the vastus lateralis instead?

The vastus lateralis is the largest and most powerful portion of the quadriceps. One paper reports that the muscle volume of the the vastus lateralis was 674 cm3 followed by the vastus intermedius at 580 cm3, vastus medialis 461 cm3 and lowest in the rectus femoris 339 cm3.  This makes the vastus lateralis is twice the volume of the rectus femoris!

Studies of muscle fiber orientation show that VL force component is directed approximately 12-15° laterally with respect to the longitudinal axis of the femoral shaft. This would mean it has a tremendous mechanical advantage and could (should?) pull the patella directly laterally compared to the VMO force, whose component is directed approximately 55 ° medially.   The muscle “balance” between the VMO and the VL, along with the periarticular soft tissue structures acting on the patella, is considered major component in the control of normal patellar alignment and function. The VL is often considered to be the “overactive” one by many clinicians, particularly in cases of patellofemoral dysfunction. It turns out that from an EMG standpoint, they may be correct. 

The vastus lateralis arises posteriorly from the femur along the linea aspera and circumnavigates the thigh in a counterclockwise fashion to attach laterally to the patellar tendon.   Because of its size and fiber orientation, it would stand to reason that needling it would have more cortical representation than say the vastus medialis.

There is an interesting paper where they needled a single acupuncture point: Stomach 34. For those who haven’t studied acupuncture (or don’t remember) this point is located on the thigh, in a small depression about 2.5 inches (63 mm for the metric folks) lateral to and above lateral border of the patella. In other words, it is in the vastus lateralis (see above).

The results showed statistically significant improvement in velocity, cadence, stride length, cycle time, step time and single/double leg support after treatment. The effect was small, but positive.

Think about where the trigger points are for this muscle (see above) ; fairly close to this point, sometimes (depending on the trigger point), even directly over this point. Needling has many effects on muscle and its trigger points and we like to think that needling “normalizes” function of a muscle; perhaps it influences the apparent “dominance” of this muscle and allows the patella to track more medially?

So, in this popultion of patients of elderly individuals, 1 acupuncture (needling) treatment  had a positive influence on their gait. Perhaps if the folks in the knee study were treated a few more times, we would have seen a change. Imagine what could have happened if aditional treatment modalities, like exercise, proprioceptive work and gait retraining were added! 

What a great, cost effective alternative or addition to your rehabilitation this could be. Consider adding this modality (and point!) to your current clinical toolbox, not only for older patients but for any patients that may have a gait abnormality.

https://tmblr.co/ZrRYjx24ecKUx

Boucher JP, King MA, Lefebvre R, Pépin A. “Quadriceps femoris muscle activity in patellofemoral pain syndrome.” Am J Sports Med. 1992 Sep-Oct;20(5):527-32. Web. 17 Nov 2012.

Souza DR, Gross MT. “Comparison of vastus medialis obliquus: vastus lateralis muscle integrated electromyographic ratios between healthy subjects and patients with patellofemoral pain.” Phys Ther. 1991 Apr;71(4):310-6. Web. 25 Nov 2012.

Cowan SM, Bennell KL, Crossley KM, Hodges PW, McConnell J. “Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome.” Med Sci Sports Exerc. 2002 Dec;34(12):1879-85. Web. 26 Nov 2012.

Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG. “Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome.” Arch Phys Med Rehabil. 2006 Nov;87(11):1428-35

Kim, H. H., & Song, C. H. (2010). Effects of knee and foot position on EMGactivity and ratio of the vastus medialis oblique and vastus lateralis during squatexercise. Journal of Muscle and Joint Health, 17(2), 142-150.

Lam, P. L., & Ng, G. Y. (2001). Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain. American Journal of Physical Medicine & Rehabilitation, 80(11), 804-808.

Erskine, R. M., Jones, D. A., Maganaris, C. N., & Degens, H. (2009). In vivo specific tension of the human quadriceps muscle. European journal of applied physiology, 106(6), 827-838. [PubMed]

Grabiner MD: Current Issues in Biomechanics (9th ed). Champaign, Human Kinetics Publishers, 1993.

http://www.orthobullets.com/anatomy/10058/vastus-lateralis

Hauer K, Wendt I, Schwenk M, Rohr C, Oster P, Greten J. Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial. Arch Phys Med Rehabil. 2011 Jan;92(1):7-14. doi: 10.1016/j.apmr.2010.09.023.

Peter Deadman, Mazin Al-Khafaji, Kevin Baker: A Manual of Acupuncture (2nd Edition) Journal of Chinese Medicine Esat Sussex, England 2007

Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual: The Lower Extremities. Vol.2 . Baltimore, Md: Williams & Wilkins;1992

 http://www.medscape.org/viewarticle/521494_3

One way to correct an dysfunctional Extensor Hallucis Brevis

The Extensor Hallicus Brevis, or EHB  (beautifully pictured above causing the  extension (dorsiflexion) of the proximal big to is an important muscle for descending the distal aspect of the 1st ray complex (1st metatarsal and medial cunieform) as well as extending the 1st metatarsophalangeal joint.

Since this muscle is frequently dysfunctional, and is one of THE muscles than can lower the head of the 1st metatarsal, along with the peroneus longus and most likely the tibialis posterior (through its attachment to the 1st or medial cunieform), needling can often assist in normalizing function and works especially well, when coupled with an appropriate rehab program. Here is one way to needle it effectively. 

Treat the paraspinals in addition to the peripheral muscle

As people who treat a wide variety of gait related disorders we often emphasize needling the paraspinal muscles associated with the segemental innervation of the peripheral muscle you are treating. For example, you may facilitate or needle the L2-L4 paraspinals (ie: femoral nerve distribution) along with the quads, or perhaps the C5-C6 PPD’s along with the shoulder muscles for the deltiods or rotator cuff for arm swiing. We do this to get more temporal and spacial summation at a spinal cord level, to hopefully get better clinical results.

White and Panjabi described clinical instability as the loss of the ability of the spine, under physiologic loads, to maintain relationships between vertebrae in such a way that there is neither damage nor subsequent irritation to the spinal cord or nerve roots, and, in addition there is no development of incapacitating deformity or pain due to structural changes.

Increased movement between vertebrae (antero or retrolisthesis) of > 3.5 mm (or 25% of the saggital body diameter) during flexion and/or extension suggests clinical instability. This often leads to intersegmental dysfunction and subsequent neurological sequelae which could be explained through the following mechanisms:

Recall that the spinal nerve, formed from the union of the ventral (motor) and dorsal (sensory) rami, when exiting the IVF splits into an anterior and posterior division, supplying the structures anterior and posterior to the IVF respectively. The posterior division has 3 branches: a lateral branch that supplies the axial muscles such as the iliocostalis and quadratus; an intermediate branch, which innervates the medial muscles, such as the longissimus, spinalis and semispinalis; and a medial branch, which innervates the segmental muscles, (multifidus and rotatores) as well as the joint capsule. Inappropriate intersegmental motion has 2 probable neurological sequelae: I) alteration of afferentation from that level having segmental (reflexogenic muscle spasm or vasoconstrictive/vasodilatory changes from excitation of primary afferents and gamma motoneurons) and suprasegmental (less cerebellar afferentation, less cortical stimulation) effects and II) compression or traction of the medial branch of the PPD, causing,  over time, demyelination and resultant denervation, of the intrinsic muscles, resulting in impaired motor control both segmentally and suprasegmentally. The segmental effects are directly measurable with needle EMG. This is a form of paraspinal mapping, which has also been explored by Haig et al. So, in short, instability can lead to denervation and denervation can lead to instability.

We often see clinically that treating a trigger point (needling, dry needling, acupuncture, manual pressure) can alter the function of the associated muscle . Improvements in muscle strength and changes in proprioception are not uncommon. Needling also seems to increase fibroblastic activty through the local inflammation it causes. Wouldn’t better muscle function and some scar tissue be a beneficial thing to someone with instability?

The next time you have a patient with instability, make sure to include the paraspinals in your quest for better outcomes.

The Vasti

Do you treat runners? Do you treat folks with knee pain? Patellar tracking issues? Do you treat the quadriceps? Do you realize that the vastus lateralis, in closed chain, is actually an INTERNAL rotator of the thigh (not a typo), and many folks have a loss of internal rotation of the hip? Do you give them “IT band stretches” to perform?

In this short video, Dr Ivo demonstrates some needling techniques for the quads and offers some (entertaining) clinical commentary on the IT band. A definite view for those of you who have needling in their clinical tool box.

Dry Needling and Proprioception. What a great combination.

Since dry needling and proprioception both have such profound effects on muscle tone, why not combine them to treat chronic ankle instability? We do all the time and here is a FREE FULL TEXT article that ties the two together nicely!

And what better to muscle to use than the peroneii? These babies help control valgus/varus motions of the foot and influence plantar and dorsiflexion AND the longus descends the 1st ray. We call that a triple win!

“This study provides evidence that the inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the end of the therapy in individuals with ankle instability. Our results may anticipate that the benefits of adding TrP-DN in the lateral peroneus muscle for the management of ankle instability are clinically relevant as large between-groups effect sizes were observed in all the outcomes.”

link to full text
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

photo from this past weekends Dry Needling Seminar: working on the dorsal interossei

Podcast 68: Gait , Arm Swing, Neuro-developmental Windows

A. Link to our server:

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_68ffinal.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-68

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1.Brain implant helps paralysed man move his hand
http://realitysandwich.com/220399/brain-implant-helps-paralysed-man-move-his-hand-wired-uk/?u=95820

2. Has Science Finally Confirmed the Existence of Acupuncture Points, Validating Chinese Medicine?

http://themindunleashed.org/2014/03/science-finally-confirmed-existence-acupuncture-points-validating-chinese-medicine.html

3.This Tiny, Whip-Tailed Robot Can Administer Meds Anywhere In the Body

http://www.entrepreneur.com/article/235007

4. It matters what you put on your kids feet
“Shoes affect the gait of children. With shoes, children walk faster by…

 http://www.ncbi.nlm.nih.gov/pubmed/21244647

5. Normal gait development.

http://www.oandp.org/jpo/library/1993_02_035.asp

6. Myelination

http://cogweb.ucla.edu/CogSci/Myelinate.html

7. Arm swing in kids.

http://www.ncbi.nlm.nih.gov/pubmed/21531534

8. Arm swing and gait speed.

http://www.ncbi.nlm.nih.gov/pubmed/24396216   and

http://tmblr.co/ZrRYjx1JVgmv_

acupuncture and muscle strength

“The present study shows that a single acupuncture treatment was efficacious for improving isometric quadriceps strength in recreational athletes. These results might have implications not only for athletic performance enhancement, but also for rehabilitation programs aimed at restoring neuromuscular function."  

Wow. What a statement! If you read the abstract, you will also read this ”The difference in the mean change in MIVF from baseline between acupuncture (46.6 N) and sham laser acupuncture (19.6 N) was statistically significant (p < 0.05), but no significant difference was found between acupuncture (46.6 N) and sham acupuncture (28.8 N)“  

So what was "sham acupuncture”? Simply put, acupuncture to non acupuncture meridian points. In other words, they put needles in muscles, just not on established meridians. Hmmm…Sounds alot like a form of dry needling. When you place a needle in a muscle, there is a good chance you will stimulate (or change function) of a muscle spindle or golgi tendon organ (length and tension receptors we have talked about before. see here, here, here, here, and here. guess we wrote about them a bit, eh?). Sham acupuncture still showed a positive result.                                                                  

                                                                                                                             

The bottom line? Needling the muscle changes how it contracts. It can be a useful tool for improving performance and rehabilitation.                                                                                                                                                                    

The Gait Guys. Geeks to the core. Bringing you the information to help you make better decisions with every post.  

European Journal of Applied Physiology

September 2010, Volume 110, Issue 2, pp 353-358

Immediate effects of acupuncture on strength performance: a randomized, controlled crossover trial

• Markus Hübscher,
• Lutz Vogt,
• Thomas Ziebart,
• Winfried Banzer

Download PDF (205 KB) View Article

Abstract

The present study investigated the immediate efficacy of acupuncture compared to sham acupuncture and placebo laser acupuncture on strength performance. A total of 33 recreational athletes (25.2 ± 2.8 years; 13 women) were randomized to receive acupuncture, sham acupuncture (needling at non-acupuncture points) and placebo laser acupuncture (deactivated laser device) in a double-blind crossover fashion with 1 week between trials. Assessment included bipedal drop jumps for maximum rebound height and quadriceps maximum isometric voluntary force (MIVF). Furthermore, surface electromyography (EMG) was used to measure the EMG activity of the rectus femoris muscle during a 30-s sustained MIVF of the knee extensors. Mean power frequency (MPF) analysis was applied to characterize muscular endurance. Measurements were performed at baseline and immediately after treatment by a blinded investigator. Repeated measures ANOVA and post hoc paired-sample t test with Bonferroni–Holm correction were used for statistical analysis. The difference in the mean change in MIVF from baseline between acupuncture (46.6 N) and sham laser acupuncture (19.6 N) was statistically significant (p < 0.05), but no significant difference was found between acupuncture (46.6 N) and sham acupuncture (28.8 N). ANOVA did not show statistically significant treatment effects for drop jump height or MPF. The present study shows that a single acupuncture treatment was efficacious for improving isometric quadriceps strength in recreational athletes. These results might have implications not only for athletic performance enhancement, but also for rehabilitation programs aimed at restoring neuromuscular function.

http://link.springer.com/article/10.1007%2Fs00421-010-1510-y

all material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.

Understanding Neuroreceptors: Movement Concepts

For all you inquiring minds out there, here is a question on one of our YOUTUBE videos we though was worth making into a post.

Question: “Dr Waerlop says that GTO’s (golgi tendon organs) inhibit muscle tension and muscle spindle apparatuses (MSAs) increase muscle tension. But then he says to treat the attachments (GTOs) to increase the tension and the bellies (MSA’s) to decrease. Seems counterintuitive. What is the modality of tx, acupuncture? Massage?…..What is your modailty for treating these? And does that modality inhibit those neurosensors or stimulate them?”

Answer: GTO’s are high threshold receptors that actually modulate muscle activity through inhibition  (Ib afferents) and Spindles are lower threshold receptors receptors that modulate overall activity, particualrly length. Think of the GTO’s as responding to tension and the spindles as responding to muscle length. Spindles are more in the belly of the muscle and GTO’s at the musculo tendonous junctions. By treating the origin and insertion of the muscles, you can modulate both, whereas treating the belly of the muscles, seems to affect the spindles more.

By treating the origin and insertion of the muscles, you can modulate both, whereas treating the belly of the muscles, seems to affect the spindles more.

The modality can be manual or acupuncture stimulation of the origin/ insertion of the muscle that tests weak.We find that acupuncture seems to work bestbut manual methods work just fine as well. We believe we are normalizing function, rather than specifically inhibiting or exciting. Like Chinese medicine, we are balancing the Yin and the Yang, creating homeostasis.

The Gait Guys: Making it real. Making it understandable. Making it happen : )

A Great Reference Text:

Biomedical Acupuncture for Sports and Trauma Rehabilitation
Dry Needling Techniques,
Yun-tao Ma, Elsevier, 2010

Both Dr Allen and Dr Waerlop have studied under Dr Ma and Dr Waerlop has had the privilege of teaching with Dr Ma (Dr Waerlop is one of the leading acupuncture instructors in the US and one of the few Dry Needling Instructors)

This book is a follow up to Dr Ma’s 1st book: Biomedical Acupuncture for Pain Management.

They are both great resources for the Western approach to needling for pain management and dry needling, explaining the physiological mechanisms behind both.

Dr Waerlop uses acupuncture extensively for muscle stimulation and facilitation in many gait related disorders, and finds it a valuable adjunct to therapeutic exercise.

The Gait Guys

You can download many lectures on acupuncture by Dr Waerlop and many videos by Drs Allen and Waerlop on rehabilitation and gait, as well as basic science here.

Acupuncture can be effective for many types of sports injuries and rehabilitation of gait related disorders. One such study can be found here.

The effect of needling is though to be 3 fold: local, segmental and cortical.

The local effect of needling occurs at the site of the needle insertion. Local tissue damage causes cytokines to be released and this stimulates both the inflammatory and healing process, as well as increasing local circulation.

The segmental affect is thought to be at the spinal cord level (the dermatome or sclerotome) where inhibition of pain impulses occur (pre synaptic inhibition for you neuro nerds out there)

The cortical or “long loop” effect is thought to be due to activation of higher brain centers which cause descending inhibition of pain and activation of the hypothalamic-pituitary axis (which appears to be one of the reasons acupuncture can be effective for colds and other problems).

You can view many of our posts on pain and its physiology here to gain a better understanding of the pain pathway and pain modulation.

The Gait Guys: yes, sometimes we are a pain, but we offer solutions to help and give you the research to back it up

Injury and Repair?

It appears injury and repair are the yin and yang of healing. Injury may be necessary for nerve regeneration to occur, at least in mice. Talk about neural learning! So injuries (from a neurological perspective) may be a good thing!  Perhaps this is why acupuncture, dry needling and intramuscular therapy work so well for these conditions. ( Watch for a Live Gait Guys course in dry needling and intramuscular stimulation this fall in Chicago and Denver!)    

A protein abbreviated DLK (which stands for dual leucine zipper kinase) apparently is necessary to activate nerve regeneration after an injury.    

“DLK is a key molecule linking an injury to the nerve’s response to that injury, allowing the nerve to regenerate,” says Aaron DiAntonio, MD, PhD, professor of developmental biology. “How does an injured nerve know that it is injured? How does it take that information and turn on a regenerative program and regrow connections? And why does only the peripheral nervous system respond this way, while the central nervous system does not? We think DLK is part of the answer.”    

Most injuries have a neurological component, whether it be the inflammatory process, a change in muscle tone or activity, the perception of pain or proprioceptive abnormality. If this mechanism is not triggered, the nervous system may not heal. This may provide clues as to why nerve injuries heal so slowly or are less responsive. Learning more about this protein may provide clues and answers to this commonly encountered dilemma.    

The original paper was published in Neuron and a nice summary can be found here.    

The Gait Guys: sorting out the literature and giving you the latest information so you can make more informed clinical decisions.