an example of neuromodulation...

[nari]

This is purely empirical, and I may cop flack from purists, but thought I would post anyway.

65 yo male (friend)
History of (R) knee pain for 10-12 years, geting worse over last 2-3 years.
Imaging: Well defined loss of joint space, medially.
Diagnosis: loss of medial cartilage, OA, etc etc
Did not accept offer of arthroscopy. Takes glucosamine, effect unknown.
Pain mostly central knee, some occasional oedema, mild.
Walking limited by pain, sometimes at 1 km or earlier.
Orthoses prescribed, some help but increase in SIJ area pain. (Expected)
Two weeks ago, I stuck a small strip of tape above the patella, and another strip arbitrarily over the patellar ligament.
No pain, at rest (previously woken by pain at night)
No pain on walking up to 4 km. After that, some mild diffuse pain.

Owner of knee most impressed.:D

Rationale:
Neuromodulation through the skin. Tape lightly applied, no chance of any 'support' factor.

Comments?


Nari

[OaksPT]

Nari,
Is he wearing the tape during gait? Are you having to still tape him? Do you think you would have similar results if the taping had been done away from the site of pain, say in the popliteal fossa?
Great insight,
Scott

[Synergy]

Nari,

So the tape was 'lightly applied', but in what fashion? I'm assuming horizontally over the patella and across the patellar tendon? You said "no chance of any 'support' factor". Do you mean the tape was not pulled taut in any given direction? Regardless, his decreased s/s are very interesting given what appears to be an arbitrary placement of tape.

[nari]

Hi Scott

He wore it 24/7 and when one strip fell off, he just replaced it.

I don't know about other sites - pop fossa sounds a good possibility, to experiment with...

It is just ordinary elastoplast - cheap stuff.

I remember years ago when I taped painful hemiplegic shoulders thinking: This works so well for pain and it has nothing to do with support, so...?

The same n/m theory seems to hold good for PF pain, whatever the reason for it. I think McConnell has agreed that support and realignment of patella is not the full answer to pain resolution...but am not up to date on that.

Thinking about it, maybe that is why taping the Lx spine into extension worked....

Ain't the brain a marvellous thing, and it is fun talking to it...

Nari


PS Crossed posts again..! No, just applied with NO tautness, simply placed over the skin. I figured horizontally, because the pain is centrally experienced. No criteria - just talking to the mechanoreceptors.

[Diane]

Nari, I've started digging in (at long last) To The Brain's Sense of Movement by Alain Berthoz, recommended ages ago by Matthias. (Takes me awhile but I eventually do get around to things.)

In it, he says,I will define all the sensory receptors that enable us to analyze movement in space. These receptors are collectively responsible for what is called the sense of movement, or kinesthesia. Kinesthesia is the result of cooperation among several sensors, and it requires the brain to coherently reconstruct movement in the body and in the environment. When this coherence cannot be achieved, perceptual and motor disturbances result, as well as illusions, which are actually solutions the brain devises to deal with discrepancies between sensory information and its internal perceptions.

So, the tape gives the brain an added layer of movement meaning.. Via the skin proprioceptors? I would lay odds on that.

[nari]

Diane,

Am not sure of the reason behind it all, but it happens frequently. Anticipation of pain relief is one potential explanation, but this guy is as cynical as I am and did not expect the tape to do anything. (He thought it was a joke and he would just humour me). Anticipation has to be the reason why kids react so rapidly and effectively to the BandAid Rx...but not in this case, I suspect.

A search for possible reasons, such as the one you gave above, didn't come to much, for me. Taping certainly assists proprioception, as in the case of sub-acute ankle dysfunction. Next time I see him I will do what Chris A suggested and tape away from the anterior aspect of the knee.

What is interesting are the hemi shoulders..no movement present of any functional value, or even movement full stop. Yet pain relief is there...


Nari

[Synergy]

1: J Athl Train. (http://javascript%3Cb%3E%3C/b%3E:AL_get%28this,%20%27jour%27,%20%27J%20Athl%20Train.%27%29;) 2002 Mar;37(1):19-24. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=12937439) Links (http://javascript%3Cb%3E%3C/b%3E:PopUpMenu2_Set%28Menu12937439%29;) http://www.ncbi.nlm.nih.gov/entrez/query/egifs/http:--www.ncbi.nlm.nih.gov-corehtml-query-pubmed-pmc.gif (http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3494&uid=12937439&db=pubmed&url=http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=12937439)
The Effects of Patellar Taping on Knee Joint Proprioception.

Callaghan MJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Callaghan+MJ%22%5BAuthor%5D), Selfe J (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Selfe+J%22%5BAuthor%5D), Bagley PJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Bagley+PJ%22%5BAuthor%5D), Oldham JA (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Oldham+JA%22%5BAuthor%5D).

University of Manchester, Manchester, UK.

OBJECTIVE: To evaluate the effects of patellar taping on knee joint proprioception. DESIGN AND SETTING: In a research unit, 3 proprioceptive tests were performed. For each of the tests, a standardized patellar taping technique was applied in random order. SUBJECTS: Fifty-two healthy volunteers (27 women, 25 men; age, 23.2 +/- 4.6 years; body mass index, 23.3 +/- 3.7). MEASUREMENTS: We measured active angle reproduction, passive angle reproduction, and threshold to detection of passive movement on an isokinetic dynamometer. RESULTS: We found no significant differences between the tape and no-tape conditions in any of the 3 proprioceptive tests (P >.05). However, when the subjects' results for active angle reproduction and passive angle reproduction were graded as good (</=5 degrees ) and poor (>5 degrees ), taping was found to improve significantly those with poor proprioceptive ability (P <.01). CONCLUSIONS: Subjects with good proprioception did not benefit from patellar taping. However, in those healthy subjects with poor proprioceptive ability as measured by active and passive ankle reproduction, patellar taping provided proprioceptive enhancement. Further studies are needed to investigate the effect of patellar taping on the proprioceptive status of patients with patellofemoral pain syndrome.

PMID: 12937439 [PubMed - as supplied by publisher]

Thought this link may be of some interest. Within the article, I found the following relevant:

Interestingly, Prymka et al13 (http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=12937439#B13) showed that an elastic knee bandage improved patients' proprioceptive status significantly. A proposed mechanism for this finding was that the bandage stimulated rapidly adapting superficial receptors in the skin during joint motion and increased pressure on the underlying muscles and joint capsule.
The proprioceptive enhancement demonstrated in that study indicated that such deficits could be rectified by stimulating skin during motion and by pressure on underlying muscles and the joint capsule.
We hypothesize that subjects with poor proprioceptive ability (ie, >5° accuracy from the target angle) may have received improved afferent feedback via cutaneous receptor stimulation from the patellar tape, thereby improving joint reposition accuracy. This, however, was not the case in subjects classified as having good proprioception. Another explanation might be that those with good proprioception were good enough not to need any influence from external aids such as taping; the poor group, on the other hand, was more amenable to any external help given to them by taping. Birmingham et al21 (http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=12937439#B21) also noted that the poorer the inherent proprioceptive ability, the greater the improvement after application of an external device.
A few of the articles the researches were referencing involved the use of an elastic bandage, i,e. the external device. It seems as though anything providing some type of compression, be it a small amount (tape simply applied without force) or a larger amount (bandage/compression sleeve=greater constriction) would increase proprioceptive awareness and potentially decrease pain. Maybe a good study would be to compare patellar taping versus the store bought compression sleeve (http://www.bd.com/elastics/displayProduct.asp?path=0&bid=11&lid=0&tid=0&pid=70).

[nari]

Thanks, Chris...

[bernard]

Thanks Chris.
Here is the full text paper.

[nari]

Interestingly, I understand he tried out one of those neoprene roll-on roll-off braces earlier, and found them intolerable, due to what I can only think of as increased sensitivity to the compression. (He was vague, saying it 'drove him crazy') As you say, Chris, a study comparing tape and full compression would be interesting.

But the bits of text you quoted seem to fit, and the point remains that it doesn't seem to matter where the tape is placed, from my previous trials with taping over / around whingeing joints.

I guess it could be argued that removing all pain experience puts the knee at risk of over-use and worsening long term. Not sure about that one, but at present, without the pain, he can increase CV fitness with walking.

The fact that the pain used to wake him up at nights suggests the typical chronic pain response..rather than the traditional "OA" pain of the past due to inflammation or whatever.

More down the track after experimenting with tape placement/s.

Nari

[emad]

hi Nari :

Interesting case study trial , we meet lots of patients with the same complaints , I tried to apply ,the same , since 2years for an adult 35 years , I gained very fast results like what you mentioned.

The strange aspect here is the anticipation /expectation factor of the patient has direct effect on the cortex organisation ,postive anticipation has positive effect ,which is on the contrary to what you said with your consumer .

Regards
Emad

[nari]

True, emad. Which is why something else is going on...perhaps it is not really known yet.

Nari

[cedric]

many sportsmen can't play without a small strap... i didi sometimes strap them exoticaly (i mean with no effect, with lightly)
i believe this more about emotions or psychology

[nari]

cedric

I have often wondered about those little straps...rather like copper bangles and things like that?

What do you think about acupunture/acupressure points? They seem to work for quite a few people but it has been demonstrated that light pressure works just as well as sticking needles in. Might check out my little compendium of "acupressure points".........

Probably another thread, but I wouldn't, myself, introduce another 'hot thread' at present.....


Nari

[cedric]

what do i thing about acupuncture/acupressure point?

i don't really have an idea about it as far i only know a few aboutthe theory and almost nothing about the practise ;)
do you mean that there would be an acupuncture point just over the knee and the strapp may have an action on that point?

[nari]

cedric

I really don't know, as I looked up the point and it is halfway up the thigh. I don't know anything about acupuncture but acupressure seems to work.

I heard from him today..tape still sticking on, and no pain whatsoever, for the first time in many years....

???

Nari

[cedric]

seems to be a great result but you don't know exactly why? (or did i missed something somewhere?)

acupuncture and acupressure uses the same "point" but it is a different way to stimulate them (needles or soft finger pressure) am i right?

[nari]

I think they share the same point...

I think I know why he got pain relief, but the fact that it is long lasting is curious. The skin is full of mechanoreceptors (ask Diane!) and it is a very strong neuromodulatory medium, convincing the brain that there is no threat...but I am not sure why it acts so quickly and lasts so long.
My next plan is to remove the strips for a week and see what happens.....


Nari

[cedric]

i'm curius to see hat is going to happen then

[nari]

OK, he removed the strips 2 days ago (as a mutual experiment) and no other factors have radically altered as far as weight bearing and sleeping activities go.
Mild aching at night has returned, but only mild. No pain on walking 3.5 km.

I am suggesting another few days without the strips and then try posterior 'modulation'.

Nari

[Synergy]

If I may ask Nari, why posterior? It appears as though the anterior 'modulation' was effective enough to reduce his symptoms. Are you just experimenting now or are you suggesting that his pain will return in a few days?

[nari]

Chris, this fellow is very obliging and only too happy to be an experiment.

Some night pain had returned, though very mild, and the posterior taping is to see if it changes anything....it was something that Scott suggested earlier in the thread.
The advantage of using friends is that one can play around with them!

Nari

[Synergy]

Oops...must've missed Scott's post above. Well, it will be interesting to see if that position reduces his pain or provides no help at all.

[nari]

Chris

If the pain is resolved again with posterior (pop fossa area) taping- what are your ideas on what is going on? I suspect it will resolve - but that is purely my neuromatrical take on pain anywhere.

There has to be something other than skin mechanoreceptors over the quad tendon area and patellar tendon, which I understand is approximately the standard area for proprioceptive effect on the knee. Which is why I want to tape away from the 'standard'.

Nari

[Diane]

I will lay odds that taping the posterior knee (flexor surface) will be less effective.. the skin is more sensitive and the brain will find it irritating rather than helpful. Just an observation from one who has played with taping for a few years now.

[JaneS]

Hi Nari,
Did you have another chance to consider sensory habituation to the pain which I mentioned.
Let's tentatively postulate (as per Diane's post & quote of 10/1) that the tape has 'given the brain an added layer of movement meaning'. To go a step further, say that the tape has modulated (but definitely not masked) the orginal pain to some extent; The level of pain of which the patient is now aware is less than the original pain perception. If that pain is now perceived as more tolerable, perhaps the patient's process of habituation has started to take effect.

If my parallel with TRT is relevant, it seems a bit quick to me. However, your post to-day mentions that on removing the straps, he continues to feel pain - but mild pain. (It is important to know that I am not speaking from clinical experience, only considerable reading from recent study).

That the original strap caused the patient to report 'no pain' is a bit of a puzzle. It doesn't seem that you set out to mask pain - but that seems to have occurred. Usually when masking (eg total analgesia) is removed, the pain is perceived to be strong, as beforehand. I suspect quite a significant psych effect - is he having any psych treatment or informal psychosocial support from you?

The idea of posterior taping is interesting. Again working on the logic of sensory habituation with practical tinnitus but not pain knowledge here is an idea.
If you think that your patient is becoming used to the tape on the anterior of the knee and it is not as effective in modulation, I can see the reason for some variation. However, Diane suggests, posterior taping often causes more irritation. Reinforcement of a negative sensory perception may result in a backward step towards sensitisation. From a sensory and psychological perspective this would appear to be counterproductive.

What I am suggesting about the adaptation of sensory habituation from TRT to pain has no precedent, as far as I know. What I have hypothesised above is just the bare bones. It is an idea I have been nursing ever since I learnt a bit about the similarities (prior to my pain management study). When I went back to upgrade from Grad Dip to M.Sc.Med (pain mgt), I chose as an elective a self-directed subject which would allow me to see if there was any substance to the idea. It seems that there could be but needs much more work. If you would like me to provide more references as I go, please let me know.

Jane

[nari]

Jane

Thanks for your input but it was way beyond anything I expected. This is just a fun trial, with some interesting possibilities.
This fellow is not a patient and is not receiving any kind of psychosocial support from me...he is a friend, that's all! he thought it would fail anyway, in a joking way.
I seriously doubt a masking effect..unless that resulted in some permanent modulation.
I can see no reason why NOT to change to posterior placement...as my last post suggested, this is experimental, so why wouldn't I change where I put the strips...?

Sorry to be picky but this is not a full blown case study - some fun with pain modulation, that's all.
Will let you know what eventuates.

Nari

[nari]

Three days ago I taped the posterior aspect of his knee above the joint and repeated the patellar tendon tape. During the 'tapeless' period, the night pain was reported to have increased, but daytime walking etc was OK.
Sound familiar?
Night pain?
Chronic pain?
Increased sensitivity?

There has been no significant change in two days, but he thought the night pain was less.
Why tape above the posterior aspect of the joint? Thought it was a good idea to vary one factor arbitrarily and continue with the sub-patellar tape.


Nari

[nari]

For anyone who is still interested:

A month ago I put some tape on this fellow, above and below the patella.
Pain relief was remarkable (his words) and when it was removed, some night pain returned, though less. Some days later, I put some tape posteriorly (above the joint) and across the patellar tendon anteriorly. Night pain has not been a problem, (as before with anterior tape) and with orthoses, he can walk up to 4 km with no symptoms.
More than that, and the (R) great toe complains, but I blame that on the orthoses.

It's not a study, but a whimsical experiment which I suspect has some support for the effectiveness of simple taping for pain relief.


Nari