Part 1: Treatment Modalities
At the Pole Physio we focus on delivering patient centred evidence-based practice. But what does this actually mean?
Patient centred evidence-based practice is the balance of best evidence available, clinical expertise of the therapist and patient goals and values (Engle et al., 2021). Sometimes:
the evidence does not always match what we see in clinic
the quality of studies available can be poor
the population in the studies does not match what we treat
the best evidence may not align with what a patient wants
As pole dancers – we know we move our bodies in unique ways and there is minimal research in our population!
It is important that when seeking a medical assessment – whether it be with a Physiotherapist, Chiropractor, Osteopath etc - that they are focusing on YOU – the patient – and your goals - not the profits of the business or for clinicians to get incentives.
So how does that relate to this blog? We wanted to talk about some treatment modalities that may be recommended as management of sports or musculoskeletal injuries. We will not be taking a deep dive into every aspect of it – but we are going to look briefly at the current evidence and providing YOU the information.
As we are looking at evidence and studies – the picture below provides a quick snapshot of the different levels – our focus is on Level 1 and 2 studies.
We make no apologies – this IS a long blog, but it is going to give you a lot of information. Let's get started!
Treatment Modality
So what is a treatment (or therapeutic) modality? A modality refers to the administration of thermal, mechanical, electromagnetic or light energies through an external agent for therapeutic purposes (Bellow 2016). If you are ONLY receiving a therapeutic modality and nothing else during your consult – this is NOT evidence-based practice…
And yes.. a lot of capitals may be used today – this is something we are passionate about!
Thermal Modalities
Hot or cold therapy?
Hot or cold therapy can include ice baths (also known as cryotherapy), localised icing with a bag of frozen peas, heat packs and sauna. But when should we use it? And what for?
Regarding cold therapy, the evidence is conflicting and inconclusive and depends on HOW and WHEN you use it (Wang et al., 2022). Recent evidence suggests it has a positive effect on muscle power, soreness and perceived recovery when used after high intensity exercise, however it is also reported that exercise has a similar effect (Moore et al., 2022). This study emphasises that it is focused on perceived recovery aka how YOU feel it helps you. So, if you think it’s going to help you, it likely will help. If you are sceptical (like us), it probably won’t.
When it comes to management of acute soft tissue injuries, guidance has changed over the years regarding appropriate management to optimise recovery. From the acronyms PRICE to POLICE, and now – PEACE & LOVE (Dubois & Esculier, 2020). PEACE – for acute injuries, LOVE for subacute injuries. (we do not apologise for the ongoing acronym changes – as we know more through research, things change; the challenge as a health professional is to stay on top of it!).
In saying this, at times using ice for a short period can be useful. If an injury is particularly painful, the use of ice for a short period can help numb the area, thus temporarily reducing pain levels.
How about heat? Heat therapy may include warm bath, sauna, ultrasound and the good old hot pack. But why use a hot pack? It aids in increasing skin temperature, increasing blood flow to the area and can help management of inflammation. HOWEVER – it only goes to a depth of 1-2 cm below the surface of the skin, so provides very short term relief, and has demonstrated some short term effects for pain relief from Delayed Onset Muscle Soreness (DOMS) in the first 48 hours (Wang et al., 2022).
What about a sauna? As someone who lived in Finland – I LOVED a good sauna – but that was to warm up after being outside. Hussain & Cohen, (2018) looked into 40 different articles, with a lot of different outcomes assessed.
The conclusion was the use of sauna in athletes MAY improve athletic performance but the studies included were of a small sample size.
Key take away message When should we use hot or cold? It depends on what works for you. If the idea of submerging in an ice bath fills you with dread – then skip it and focus on an appropriate cool down. If you love to snuggle up to a heat pack after a session – then do it. But DO NOT forget your active recovery
Want to know more about when you should use heat or ice? Then click on the link here to read our heat vs ice blog!
Red light/infrared therapy
Red light saunas and targeted infrared therapy are a hot topic at the moment (pun intended…). The concept is the use of light and thermal energy in management of certain conditions and promote musculoskeletal recovery.
There is very low level evidence to support its use as an adjunct in management of knee osteoarthritis, tendinopathy and some chronic inflammatory conditions (Tripodi, Feehan, Husaric, Sidiroglou, & Apostolopoulos, 2021; Tsagkaris et al., 2022) From a musculoskeletal recovery and injury management perspective – there is no evidence.
Key take away message: We are yet to see evidence in athletes regarding the use of red light/infrared therapy. Remembering that with patient centred evidence-based practice – YOUR beliefs are important. If you are finding that red light sauna is working for you as a recovery strategy – go for it – but do not forget your active recovery.
Electrotherapy/Electromagnetic modality
Transcutaneous Electrical Nerve Stimulation (TENS)
Current evidence suggests that TENS may be used to help reduce pain levels in chronic pain conditions when used in conjunction with exercise, psychological interventions, pain and lifestyle education (Johnson, Paley, Jones, Mulvey, & Wittkopf, 2022). For those who use TENS for acute lower back pain – the evidence is very clear in stating it will not be of benefit (Binny et al, 2019)!
Key take away message: TENS can be useful in helping ‘dampen down’ that feeling of pain, but should not be the first thing you go for when we know the right exercises can help in reducing pain.
Interferential
Similar to TENS, interferential current can be used to help dampen down those pain receptors. A systematic review published in 2022 by Hussein et al reported when used in isolation it can aid in providing pain relief. But aware of the placebo effect – where an individual perceives an effect, but it actually has no therapeutic benefit. Why do we consider this? Because when interferential is compared to exercise and education or when used in ADDITION to exercise and education – there is no change (Hussein et al., 2022).
Key take away message: Exercise, education and activity modification are going to have a better effect on managing your pain than interferential. So, skip the buzz and get moving (how’s that for a double pun?)
Ultrasound
The use of ultrasound in soft tissue injuries was thought to aid in management of tendon, ligament and muscle injuries. But where has the evidence come from for its use? Studies on animal models, and where the use of ultrasound is in comparison to no treatment (Best, Wilk, Moorman, & Draper, 2018). Regarding chronic injuries – there is NO evidence supporting the use of ultrasound in management of osteoarthritis in isolation, but it MAY be beneficial in addition to other treatments (Aiyer et al., 2020). And for soft tissue injuries? The evidence is inconclusive regarding effectiveness (Papadopoulos & Mani, 2020).
Key Take away message: Simple – there is no evidence for the use of ultrasound in management of musculoskeletal and sports injuries, or in the prevention.
Extracorporeal Shock Wave Therapy (ESWT)
ESWT was initially used in clinical practice for the management of urinary stones, and over the years has been promoted as treatment modality for improving blood supply to tendons and aid in healing. In comparison to ultrasound, ESWT uses lower frequency waves and does not have a thermal effect. Recent research has evaluated the role of ESWT in chronic tendon related injuries (Al-Abbad et al., 2020), however ESWT is reported to be JUST as effective as exercise, especially around tendon pain. And for acute tendon or muscle injuries? There is no evidence supporting ESWT.
Key take away message: ESWT may be used as an adjunct in management of chronic tendon related injuries in certain populations. But like all things – make sure it is balance with exercise and appropriate management strategies!
So what about some other modalities that are not electromagnetic?
Exercise
I know some of you might be confused – but YES - exercise is a treatment modality. You may have noticed with the modalities we are mentioning, the studies compare them with the effectiveness of exercise. This is because exercise is the most effective therapy and foundation of injury management! Exercise promotes movement, improves strength, proprioceptive awareness and flexibility.
Key take away message: SIMPLE – you should have exercises in your management plan, and most of your time with your treating therapist should be around exercises or activity modification. Take a moment to reflect if exercise is the main focus of your injury management strategy?
Cupping
Have you seen some people wandering around the studio with circle shaped bruises on their body? It is likely that they have had cupping. Cupping involves using a negative pressure (through sucking) to traction the skin. What does it do? We actually do not know! Studies available are of low quality and difficult to prove its effectiveness (Cramer et al., 2020).
Key take away message? It is not a supported intervention – it may feel good, but it does nothing. And there are some significant side effects that are worth considering – scars, burns, infection and persistent skin conditions (National Institute of Health).
Dry Needling/Acupuncture
Dry needling and acupuncture – what is the difference? Dry needling involves inserting fine needles into the specific myofascial trigger points of a muscle to induce a localised and central response to the stimulus. Acupuncture is where those fine needles are inserted along lines of energy (known meridian lines in Chinese medicine).
Hot off the press! Chys et al., (2023) has just published an umbrella review looking into the clinical effectiveness of dry needling. Whilst it has some short-term effect in reducing pain and when used in conjunction with other interventions (are you sensing a theme here?), in isolation there is minimal evidence available to support its use.
Key take away message: The use of dry needling and acupuncture may help reduce pain short term – but make sure you have appropriate exercises as well!
Braces
No doubt at some stage in the studio we have seen aerialists wearing a brace of some sort, but should we be using them? From a research perspective, it is helpful to look at a comparative sport where there are similar loading patterns – like gymnastics.
A recent study looked into the use of wrist guards to reduced pain and injury prevention in gymnasts, and whilst they proved effective, they reduced proprioception (awareness of body in space and time) and performance (Choo, Smith, & Cook, 2021). Interestingly – the studies used braces and rigid tape for management of chronic injuries, and for an aerial population the use of tape may be more appropriate.
Key take away message: The use of a brace during pole activities is not the best modality as it affects our grip points and body awareness. ALSO - you should have exercises to address the reasons why you are wearing a brace!!
So if braces may not be appropriate – what about taping?
Taping
Rigid tape, rocktape, k-tape, stretchy tape and the tape that hurts so much coming off. What is the evidence around the effectiveness of its use??
Rarely is taping use in isolation as a management strategy. Cupler, Alrwaily, Polakowski, Mathers, & Schneider (2020) reviewed the literature across musculoskeletal injuries and where there is evidence stands on what tape. End result? There is NO high-quality evidence supporting the effectiveness of kinesio tape across the spectrum of injuries. None. Zero. Zilch.
But there is higher evidence for the use of rigid tape.
Let’s look at ankles for example. Bellows and Wong (2018) investigated research into the effect of balance training and bracing on ankle injuries amongst athletes. When we think about how much load goes through our ankles (especially in heels), the use of a bracing strategy (taping) may be considered. The outcome? The use of taping may reduce the incidence of ankle injuries, but there is the increased risk of injuries to the knee (Bellows & Wong, 2018). There is always a trade-off.
Key take away message: The use of tape may play a role in injury management – so have the discussion around what works best for you. As for K-tape? Apart from the pretty colours, you are better off spending your money on good old rigid tape.
Foam rolling
Ahhh.. the good old foam roller. We either love it, or hate it. Most people commonly associate a foam roller with the key role of myofascial release (application of pressure on muscle and fascia). What does the evidence say regarding performance and recovery?
Hendricks, Hill, Hollander, Lombard, & Parker, (2020) looked into this! The key outcomes were that the use of foam rolling does not improve athletic performance, BUT it does not impede force or power outcome. It can be effective in the reduction of DOMS and have some short-term changes in flexibility due to changes in neural inhibition (allowing for an improved tolerance for the muscle to stretch).
Key take away message: The use of a foam roller may help in the management of DOMS and short-term improvements in flexibility – however if the idea of spending a good 30-60 seconds on a foam roller isn’t your idea of recovery – that is ok!
Massage
Massage or trigger point release is considered to be a mechanical pressure (through a therapist’s hand or the use of a theragun) provided to an area with the intention of providing a downregulatory response to the nervous system (reduction in pain). Often when you are having a massage you may be told ‘I am releasing this muscle’ ‘your fascia is tight’ ‘This will improve your flexibility’.
We cannot release or stretch fascia. PERIOD.
When you have a massage, it is reducing YOUR pain levels through localised pressure changing the input to your nervous system (that downregulation response), which in turn allows a specific area to move more freely without a pain protective response (Crawford et al., 2016).
What about around performance? The evidence does not suggest that massage is beneficial to enhance performance (Davis, Alabed, & Chico, 2020). There is a small number of studies that suggest that there can be a slight improvement in flexibility and DOMS (similar to foam rolling!). However, it is important to note that most studies investigating effect of an intervention on DOMS are subjective – meaning it is based on how YOU feel it influences your symptoms
Key take away: A massage is not releasing muscle or fascia. It is providing a localised pressure to aid in reducing YOUR perception of pain. It does not actually manually change the ‘tightness’ of the muscle but it may help your perceived pain/tightness temporarily. If you feel better after a massage – great! Remember it is not your only form of recovery and it should not be your first line of intervention for injury treatment.
In summary:
WOW. That was A LOT of information (and capital letters…) – if your head is spinning faster than a vomitron trick - take a break and come back to this later. We have tried our best to keep in simple and digestible – but as you can see there is a lot of information, and individual biases that come into play.
The biggest take away from this blog? There are a lot of treatment modalities that are not evidence-based practice! A good clinician will be able to help incorporate appropriate modalities in addition to exercises that are effective for you into a longer-term treatment plan.
If you have a current injury that is annoying you, or do not feel your current injury management plan working for you – book in now with The Pole Physio!
Online telehealth appointments can be booked via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'pole-tential'.
Until next time, train safe.
The Pole Physio
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References
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