Treating Muscular Targets and Nerve Interaction

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses key research supporting using dry needling with electrical stimulation to target peripheral nerves to reduce pain and improve muscular function.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog

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PAUL KILLOREN Good morning team. We've got YouTube up. We've got Instagram live. Happy to kick off the PT on ICEDaily Show this morning. If we've never met, my name is Paul Killoren. I'm the current division lead for the dry needling division with ice. And this week you actually have a dry needling double header coming at you. On Thursday, our lead faculty, Ellie Melrose, is going to dive into technique Thursday. with some subscap tips. Zach Long, barbell physio, hit subscap pretty hard last week. So we want to bring you the dry needling tips for subscap on Thursday. That's with Ellie. Catch it live in the morning or catch the recording. Today is clinical Tuesday, and we're actually going to kick off a topic that really celebrates our advanced dry needling course. As a division, we have two courses going down this weekend. One of them is myself hitting the advanced dry needling course in Bellingham, which is really cool for all of the reasons. It's an advanced course, it's kind of the last part of our dry needling trilogy, our three course series, which will build out our dry needling cert with ice. It's really cool in Washington that that third course is what gives our kind of our inaugural group the 75 hours, which as of last week, the word is that in Washington, PTs will be able to dry needle patients as early as July. So really cool stuff happening this weekend. And the advanced course is really my direct segue into the topic this morning. PERIPHERAL NERVE STIMULATION If you saw the teaser yesterday, we're going to talk peripheral nerve stim. And I guess first to qualify our advanced course, the first half of the course is treating more technical or slightly higher risk targets. Muscles around the scapula, around the thorax, we treat the suboccipitals, we treat some more technical muscular targets. That's the first half of the advanced course. But the second half of the advanced course, we stop having intramuscular interactions with our needles and e-stim. And what I mean by that is we do tendon needling, we do scar needling, but we do peripheral nerve stim techniques. So I figured it'd be worth at least having a little teaser topic on the podcast to discuss What are we doing with all that? And really, this is a short format this morning. So what I'm not going to do is dive deep into all of the things and all of the reasons and all of the research as to why we might intentionally, directly interact with a peripheral nerve with our needling and e-stem. But I wanted to give you some research teasers, kind of a little sampler platter, a little charcuterie board of research when it comes to peripheral nerve stem. And again, without getting into all of the reasons we might do it, it might be obvious for me to say that there's actually some pretty sound research that says if we have a true nerve injury, it was injured in surgery or there's a degeneration or a palsy or a tractioning, but if there's a direct trauma to a nerve and we're trying to regenerate or we're trying to improve the nerve health, It might sound kind of obvious that there's quite a bit of research that says if we can directly stimulate that nerve with our needle and e-stim, that there's great benefit there. I mean, that's obvious, that's a home run. Treat the tissue that was injured, all of that stuff. What you might not necessarily immediately assume is that there's actually pretty solid research when it comes to direct nerve stim being the sciatic nerve for low back pain or for improving muscular performance. even some neuropopulation stuff. That might not be the immediate thought when we talk about influencing a nerve with e-stim. And again, what I'm not going to get into today is all of the stratifying, the decision-making process of when we might stim a nerve versus when we do our intramuscular stuff. I really just want to tease you with some research because these techniques are out there. These percutaneous neuromodulation therapies are actually becoming much more popular. whether it's for pain relief as an alternative to pharmaceuticals, whether it's post-surgical pain modulation or improving muscular performance. These techniques are growing in the rehab realm, in the sports medicine realm. So I want to tease you with some research. THE RESEARCH BEHIND PERIPHERAL NERVE STIMULATION The first one, it's kind of a pilot research study from 2019. The author is Alvarez-Pretz. That's a hyphenated last name. And what they did was basically did one bout, it was 10 trains of 10 hertz frequency, but one session of femoral nerve stim. And what they looked at, these are patients with unilateral knee pain, they looked at immediately before and immediately after strength output. So max isometric strength for the quads before and after femoral nerve stim. And it improved. Not only did it improve statistically significantly from pre to post, but it outperformed a healthy control. So pretty cool stuff. Again, I'm just giving you these little nuggets today. But here's the first citation that says femoral nerve stem improved quad performance. And these are knee pain patients. So again, you can get deeper into the inhibition mechanisms and why that might be, but immediate change in max strength output of the quads with femoral nerve stem. Since I brought up the femoral nerve stem, let me tease you with one more. It's a 2020 publication by Paola Garcia Barmejo. Again, she's looking at anterior knee pain. One bout of ultrasound guided femoral nerve stem improved knee pain, but also range of motion, functionality, and there was a crossover. So they did it on one side, and they saw changes on both. So again, femoral nerve stim, we have changes in not just quad strength, but knee pain, functionality, range of motion, all the things. But let's talk back pain. Or let's frame it this way. Let's talk sciatic nerve stim for a moment. Because the first research publication, 2008, it's by an O, Fascinating stuff. Because again, it might be kind of obvious for me to say if we wanted to improve blood flow to the sciatic nerve, if we wanted to send blood into the vasonevorum, like engorge the vessels to the nerve, improve blood flow to that nerve tissue, it might be pretty obvious for me to say that doing direct sciatic stim does that. And it does. But here's a research article that's fascinating and gives context as to other interactions. Because for this research, they're looking at blood flow to the sciatic nerve, and they had three groups. Group one, they actually did lumbar muscle pumping e-stim. So they didn't necessarily say multifidus, but they did that muscular motor response e-stim to the lumbar paraspinals, and then they looked at blood flow to the sciatic nerve. Group two, they did the sciatic nerve stim. They put a peripheral nerve stem directly on the sciatic nerve and they looked at blood flow. Group three, they actually did e-stem to the pudendal nerve. So a separate nerve, but again, they're looking at blood flow to the sciatic nerve. Here are the fascinating findings. 57% of the folks in that lumbar paraspinal group saw improved blood flow to the nerve. So whether you want to say that that pushes us kind of towards the the changan, the radiculopathic influence, or like the segmental influence of nerves, the myotomal influence you could say, 57% of the folks that got lumbar paraspinal e-stim saw improved blood flow to the sciatic nerve. But here's the rest of the fascinating findings. 100% of the folks that received sciatic nerve stim saw improved blood flow to the sciatic nerve. That was almost their control and it worked. But the last piece here is that 100% of the folks that received e-stim to the pudendal nerve, also 100% of them saw increased blood flow to the sciatic nerve. Fascinating. So we do have an influence approximately from that muscle pump of the lumbar paraspinals, but it's almost like we don't have to be nerve specific because we can put some e-stim on the pudendal nerve and we saw improved blood flow in the sciatic nerve. Again, I'm just going to tease you with more research. The next publication by San Mitro Iglesia in 2021. Love these names. I mean, I will say most of the research being done right now is overseas, international. For this research, they had folks with low back pain and they had three groups. Those three groups all received sciatic nerve e-stem. but they were in three separate anatomical locations. So group A, they put e-stim on the sciatic nerve proximally, so near the issue of tuberosity. Group B, they put e-stim mid-hamstring, so mid-thigh, just a different anatomical location for a sciatic nerve. And then the last one was actually the popliteal fossa, so you wanna call that tibial nerve, whatever. But they're stimming the sciatic nerve or sciatic components in three separate anatomical locations. Fascinating outcomes, these are folks with low back pain. Every single group that received eSTIM to a nerve improved in low back pain, in range of motion, actually in their balance tests, and in their functional scales. And there was no difference between these three groups. So with those last two kind of research nuggets, I'm calling them, it almost seems like we can have a profound impact with nerve stem, peripheral nerve stem, and maybe we don't need to be nerve specific and we certainly don't need to be location specific, meaning we're having a global impact here. And if you've, and if you're out there and you've taken one of our upper or lower courses already, hopefully you gathered that the nervous system influence is really the driver of our contemporary understanding for the therapeutic benefit, the therapeutic mechanisms of dry needling. Now that we're interacting with a nerve, a peripheral nerve, early indications are that we're having a very similar, but maybe a more profound, more substantial nervous system interaction. Maybe it's everything we talk about, muscle spindle and motor unit loop interactions up to the dorsal horn and then, you know, supraspinal centers going to the cortex and somatosensory, all of that stuff. We're now interacting with a much more sensitive much more nervous peripheral nerve structure, and that nervous system influence has to be times 10. So again, today I really just wanted to tease you with that. We do cover peripheral nerve stim techniques on our advanced course. Again, the first half of the course, we keep doing muscular interactions. We do the rest of the muscles that you didn't get in upper and lower, the more advanced, the higher technical muscles. But then the second half of our advanced course, we do peripheral nerve stem, tendon needling, and scar needling. And maybe we can grab a few more of these podcast spots throughout the rest of this year to say, why would we interact with a peripheral nerve? Today, I just set for you a little charcuterie board of research that says we can change, not just nerve health, not just nerve blood flow or neuro regeneration, but we can improve muscle function. We can change strength. We can change pain. And maybe there are patients like low back pain where the initial strategies of conservative therapy, maybe even our, our typical paraspinal or multifidus estim isn't working. We now have one more strategy, one more tissue interaction to consider. But again, that's all I wanted to jump on today was to give you a quick snapshot of nerve stim research. Not gonna give away all of our secrets on how we stim nerves. It's probably fair to say or fair to acknowledge that all of the research I just went through, almost all of the percutaneous neuromodulation, so peripheral nerve stim with needles, fair to say that almost all of that research is done under ultrasound. And that's to ensure safety kind of, but also ensure that it is a direct peripheral nerve interaction. We're not going to use ultrasound on the course. So really the beauty of the technique is how do we interact with it safely again, for sure, but consistently and effectively. So peripheral nerve stim is a big topic on our advanced course. We have a couple that will be popping up. Again, the first one is this weekend in Bellingham. If we're not sold out, we're nearly sold out. We have one in December in Colorado, and there'll probably be one or two more that pop up Q2 and Q3. Hopefully we're targeting the Midwest. We are probably going to be back here in Washington, because again, we need that for our 75 hours to treat patients. But peripheral nerve stim, if anything, I wanted to put that in your mind today. And I mean, big picture before we continue this podcast series about why and how and when for peripheral nerve stim. At the very least, I want to keep throwing out this topic because on the ground floor, if nothing else changes in your mind, I'd like to kind of decrease the paranoia or the concern of needling near a peripheral nerve. Or if you use eSTIM, I'm sure you've had that interaction where the needle goes in, all of the words from the patient are normal, achy, crampy, sore, no nerve words. But then you add yeast into the equation and clearly you're near a peripheral nerve and you generate a different response. At the very least, I'd like to turn off some of the alarm bells that we're so paranoid of interacting with a peripheral nerve that we don't acknowledge there's benefit there. Again, upper and lower, our goal is just to treat muscular targets. We're not intentionally trying to interact with a nerve, but advanced we will. So on the ground floor, I'd love for just The, we always respect nerves for sure, but we don't want to respect them so much that we don't see that there's benefit there. Again, you should be trained in a technique. We're not trying to intentionally or accidentally interact with the nerve. We need to know where they live. If you took a level one or a level two course from somewhere else, I'm sure they mapped the large vessels, the large nerves, and we want to avoid them at all costs. And you should do that to start with. I mean, there's, There's something very precise and very safe about knowing how to not interact with it directly with the needle. But then there is another layer on top of that, that eventually, especially when we use e-stim, so we're going to piston much less, we're going to use e-stim, there's value to knowing where these tissues live and interacting with them directly. So for now, I just want to put that thought in your mind. I want to decrease some of the paranoia, some of the nervousness of being around a nerve, and hopefully I can keep teasing you with certain research. We'll throw some stuff up on Instagram. If you've taken upper or lower through us, you can look for the advanced courses popping up. To complete the CERT for ice, it is upper, lower, and advanced, but you only need to take one of them to show up on the advanced course. So let me know what you think. I mean, do you have questions on peripheral nerve stem? Throw them on Instagram. Hit me up directly on Instagram if you'd like, at dptwithneedles. Otherwise, stay tuned for Thursday. Ellie is going to jump on and show you some subscap tips. Such a key muscle for your shoulder, folks. Again, go back and listen to Zach Long's episode from last week. and how he assesses it and how important it is to treat and how he loads it because Thursday Ellie's just going to bring the dry needling smoke. She's going to teach you how to get in there safely, consistently and effectively. It's a key target. So that's what we got coming at you. Thanks for joining.

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