Controversial Topics in Treatment Techniques

Controversial Topics in Treatment Techniques

Updated: This post was originally published on May 12, 2017 and has been refreshed as of March 2, 2020.

In physical therapy, there are a number of different treatment techniques—many of which vary from therapist to therapist. However, many treatment techniques are controversial in nature. Sue Falsone, the first female head athletic trainer in any of the four major sports in the U.S. (MLB, NFL, NHL, NBA), shares her experiences with five controversial treatment techniques. 

Controversial Topic #1: Icing

It’s a tried and true treatment, right? I pull a hammy . . . ice it. I sprain my ankle . . . ice it. Any type of injury occurs and I need immediate treatment . . . ice it. But is ice really the way we should be going? I learned long ago in grad school, from the one and only Bill Prentice, how to manage the acute ankle sprain. We didn’t ice it—we compressed it. 

We did an open basket weave tape job and wrapped it with an ace wrap or elastikon on top of that, telling the athlete that the only reason to take that compression wrap off was if his/her toes were going numb.  

The inevitable response to our instructions was “what about icing?” Our response was “If you put ice on and can feel it through the tape, great. If not, I am not worried about you icing.” EVERY TIME . . . and I mean EVERY time, the athlete got better very quickly. Swelling was minimal, movement was initiated very soon in the rehab process, and they returned to the field.

I didn’t know why we did this. I was a young grad student learning so many things and was in absorption mode, not question mode. All I knew was that it worked and the women’s basketball players I worked with never missed much time, pleasing both our coach and head AT, thus making me a happy GA.

Now, I am learning why.

I encourage you to read “RICE: The End of an Ice Age.” Dr. Gabe Mirkin coined the term RICE in 1978. Now, he believes this:

“Coaches have used my ‘RICE’ guideline for decades, but now it appears that both ice and complete rest may delay healing, instead of helping.” – Gabe Mirkin, MD, March 2014.

When we look at the physiology of an acute injury, and then look at the physiology behind what ice does, the mechanism by which we thought ice might work no longer matches up as it relates to tissue healing and swelling. Where it does continue to match up is with pain relief. Ice can be an extremely effective form of pain relief, especially in the acute stages of an injury. If pain is the overriding issue, ice may be a great consideration. If swelling and inflammation control are the main concern, ice may not be the best choice.  

In the blog mentioned above, Josh Stone does a great job of summarizing the research and recent comments from Dr. Mirkin. It will make you reconsider your current immediate treatment intervention, if nothing else.

Controversial Topic #2: Dry Needling

OK—you guys knew this was a shoe in, and I have changed my thought process on this topic over the years. Acupuncture is the overarching umbrella for which all needling therapies fall under. Dry needling is one very specific technique used to target neuromusculoskeletal injuries.  Acupuncture is such a huge topic, supported by a very specific and complex medical model. We only begin to touch the surface of this model with dry needling.  

Acupuncture is largely rooted in eastern medicine, while dry needling is largely rooted in western medicine. While of course there is overlap between the two, and there are plenty of eastern medicine practitioners who subscribe to western medicine philosophies and vice versa, I believe these two approaches can and should co-exist. While we may use the same tool, this does not mean the application of this tool makes the practitioner. Meaning, just because I manipulate someone’s lumbar spine, I don’t magically become a chiropractor, and just because I use a fine filiform needle, I don’t magically become an acupuncturist.  

The western medical education I have more than prepares me to use this tool in my practice. Athletic trainers, physical therapists, chiropractors, and other health care professionals are well trained in anatomy, physiology, patho-physiology, and emergency care. This more than prepares these professionals to deal with neuromusculoskeletal injuries. In my personal practice, I refer to acupuncturists often, specifically when more systemic issues pervade my patient. I advocate for continued inter-professional collaboration and understanding in the best interest of the patient. 

Controversial Topic # 3: Self Myofascial Techniques

As I reflect over my personal practice the last several years, I realized I can over-foam roll a patient in a heartbeat! Why would I do that? There is nothing else in my practice, from manual therapy to exercise, that I do Every. Single. Day. Why do I do that with foam rolling

There are multiple studies that show the positive effects of foam rolling on arterial function (Okamoto, 2014), increase in range of motion (MacDonald, 2013), and attenuating muscle soreness (MacDonald, 2014). We know foam rolling seems to decrease DOMS (Pearcey et al., 2015). We know that increasing the tissue temperature and stimulating an inflammatory response may change the viscosity of hyaluronan within the layers of the deep fascia (Stecco, 2013). Foam rolling remains a large part of my practice, but it is periodized in a much better fashion, and used for different reasons beyond “rolling out tissue” the way it was years ago.  

Controversial Topic #4: Use of Ultrasound as a Diagnostic Tool

MRIs and CT scans are the gold standard for many suspected diagnoses. But let’s consider some less expensive, more portable, more functional types of diagnostic testing—for example, sonography. Chang (2009) does a very nice job of discussing the use of sonography vs. MRI. Sonography has become a more utilized and accepted diagnostic tool in the United States over the years. The ultrasound (US) is extremely user dependent and requires a significant amount of skill in order to be used as a reliable diagnostic tool. We need more comparison studies to MRI for accuracy in diagnosis, as well as moving assessments of tissues. 

De Jesus et al (American Journal of Roentgenology. 2009;192: 1701-1707) did a great meta-analysis of MRI, MRI arthrography, and Diagnostic US to detect rotator cuff tears. MRI and US were comparable in this analysis in detection of rotator cuff tears. More comparison studies need to be done on different areas of the body, but the thought of having a more portable, less expensive, less claustrophobic, just-as-reliable-diagnostic seems pretty appealing in this day and age of our country’s health care system.

Controversial Topic #5: Hemp-Derived CBD

CBD has quickly become a hot topic among physical therapists and the world of professional sports. Since the federal legalization of hemp-derived CBD products in 2018, many have started to question its potential in soothing sore muscles and joints. Despite the growing number of research being conducted to understand CBD, it’s still new—and controversial.

There are many topical analgesics on the market that are formulated with hemp-derived CBD, which begs the question: Can they be used in conjunction with other treatment methods? Topical analgesics are formulated to absorb directly into the treatment area where applied. So, could a hemp-derived CBD product formulated with analgesics offer soothing relief for acute injuries? Time will tell, but incorporating hemp-derived CBD products formulated with analgesics into your treatment methods could offer an alternative form of relief to patients looking for a more holistic approach to their wellness. 


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