The use of topicals, ointments, pastes, emollients and creams, which we will refer to as agents from here, to treat skin and other conditions dates back several thousands of years.1
We have come a long way since then, understanding the barrier (skin or integument), compounds and chemical composition of the agents.
Also, the intent on use of the agents needs to be carefully considered when choosing an agent.
Despite the long history of these methods, the more recent times in the past decade or two have provided us with a great deal more knowledge on how to capitalize on agents to enhance and benefit the clientele with which we serve. Although there are many choices, this discussion will focus on the main purpose of transdermal application.
The Barrier to the Inside World: Skin
The integumentary system is most commonly known as the skin but does include other structures beyond our discussion here. More important is to understand how we can use the skin to our advantage, after all being our contact point in much of manual therapy. Although it may appear as though it keeps everything together inside the body, we do have other structures for that purpose.
The skin’s main purpose is protection from negative forms of light, chemicals, disease and physical harm, in addition to assisting in body temperature regulation and vitamin D synthesis. To accomplish all of this, the skin contains many structures and cells as well as other body systems, including nervous and cardiovascular.
Layers of skin encompass both free nerve endings and blood vessels. Some of these nerves are very sensitive to various stimuli including chemical.2 However, because it is so thin (just millimeters in layers) we can also influence structures below the level of the skin, hence various manual techniques for the myriad of conditions with which we work.
As all systems have a purpose in the function of the body, we have learned to take advantage of the processes of most systems to change the internal environment, to heal or improve a function. For example, ingestion, injection or intravenous introduction of a chemical to make its way into the body to treat a disease process.
We have also learned we can use the skin as a delivery system; however, because its main purpose is to essentially keep what’s in inside and what’s out outside, there is more science to making that transition in one direction or the other.
Ingredients Matter: Menthol
Ingredients, or the chemical composition, of an agent determine its ability to make its way through the barrier, known as transdermal.
Some chemicals may have the ability to move across the dermal layers on their own; others may require some assistance from these. This is an important concept because it is a pathway that can provide both local and systemic introduction into the body, conservatively and with low risk compared to the other methods such as ingestion or injection, minimizing risk of infection, gastrointestinal disturbances or reduction of potency.
One of the most popular and common transdermal ingredients is menthol. Although menthol has been used for millennia in treating pain, it is its current understanding of its interaction with the human body that lends itself to be a very important component to transdermal agents.3 Menthol interacts with the receptors (free nerve endings) in the skin and can cause an analgesic effect.4 This interaction is so powerful that the receptor is also nicknamed the “menthol receptor.”4 This is not only important for the local stimulation but this signal makes its way to the brain for further processing. This can make the pain modulation now central.
Although menthol falls in a class of chemicals called counter irritants, it is different. It has similar characteristics as cold reception or cold therapy in pain modulation but has been shown to be more comfortable than ice application.4 It has also been shown to improve performance over ice application and is likely more easily available and simpler to apply.5
Menthol’s complete set of interactions is beyond our scope here, but two other areas of interest for us include potential neuromuscular influence and ability to help deliver other chemicals.6 Menthol has been shown to inhibit muscle activity, especially in subconscious, overactive muscles including reflexive muscles such as spinal stabilizers. This is a matter in cervicogenic headaches.
An agent that can create a decrease in muscle tonicity through inhibition may not only be good in preparation for the manual therapy one is about to impart, but also consider the implications with additional clinical use of devices that can benefit from abnormal tone including exercise therapy.
Menthol also assists in the delivery of other substances. Being able to target an area for concentrated influence may not only reduce the negative effects of other ways to intake symptom-relieving substances but also enhancing concentrations of the body’s healing processes.
One must also consider the relative concentration of menthol in the application. Too little and the effects will be minimal and possibly not clinically relevant and too much could have the opposite effect. The optimal dosage falls within the 10% active ingredient concentration. This may optimize the benefits associated with reducing pain, enhancing healing and maximizing delivery of additional ingredients.
Additional Clinical Ingredients
As previously mentioned, menthol is a good delivery method for other ingredients. This is an opportunity to introduce further enhancing agents to promote healing and management of conditions. Chronic pain is a public health problem, causing significant disability among individuals, loss of occupational productivity, and high rates of health care costs in most nations.7
In addition, this has led to an opioid crisis as more drugs have become available and challenges in monitoring their dissemination and influence have led to abuse. To counteract this situation, manufacturers and practitioners have directed focus on methods to address some of the more pronounced causes of chronic pain such as osteoarthritis (OA) and degenerative joint disorders. Additional ingredients include dimethylsulfone/methylsulfonylmethane (also known as MSM) and glucosamine.
Known as a dietary intake supplement, MSM has great transdermal capability as a stable compound (an important component to any delivery route). MSM is also another ingredient that is known to be an anti-inflammatory and specifically impactful on osteoarthritis (OA).8,9 Although OA is considered a chronic condition, it is a vicious and continues cycle of inflammation, like an autoimmune condition. Reducing this cycle can play a crucial role in any regimen attempting to manage this condition. Inflammation must be addressed to move to any sort of tissue healing.
The glucosamine derivative also has a long history as a dietary supplement. It is a compound that is found in the human body, especially in joint structures that are part of the cartilage matrix. It can be constituted from shells of shellfish or manufactured.
Cartilage in the joints is important for maintaining joint space and cushioning, but also assists in fluid consistency. Although studies have had variable outcomes for ingestion, topical glucosamine may provide more influence on the area being treated. 10
An important detail is in the delivery method, combined approach and individual profile. Remember an earlier point: Reducing inflammation is a key component prior to tissue healing.
Other ingredients may also include additional stimulants and aromas to enhance the application experience. This can be considered an additional feature as satisfaction of clientele is generally considered a good business goal, but can also influence actual outcomes as well as return and compliance.11
If you are a manual therapist or work with other applications or modalities, there are also chemicals that will assist or complement your approach.
Having the appropriate viscosity and molecular size consistency of the topical or transdermal agent can be beneficial as it may also be used in your soft tissue manual technique or other energy modalities that require a medium such as therapeutic ultrasound or a more modern technology in extracorporeal pulsed activation technology (EPAT).
Making Your Choice in an Agent
There are several factors in determining what is best for you and your clientele/patients. Success in massage therapy practice is multifaceted and addressing as many components with crossover approaches can help to predict success.12
First, let’s consider one of the most common clinical presentations, disability as a result pain. It is always best to address mechanisms that cause a problem, because management not only results in decreased pain, but also improvement in performance and even some restoration.
For example, decreasing pain through decreasing the cause, inflammatory mediators in the body, allows for nearly immediate improvement in performance such as movement. Another example would be headaches that have a cervicogenic relationship where decreasing the muscle tension causing the headache will have a more profound effect than just tricking the brain into not feeling the pain. This is an important role in health care and may also result in lower costs associated with chronic conditions that require more invasive procedures such as surgeries.
From a clinical and clientele perspective, using an agent that is pharmaceutical-grade has several implications, including outcomes higher than standard over-the-counter.
As consumerism in conservative health and self-care is at one of its highest levels, you must consider the perception of value in your approach and the tools you use. If you are using and doing what otherwise can easily be replaced or purchased at the local store or online, it can devalue your services. If you are not using a transdermal agent for clients or patients who have a clinical condition, you might want to consider this approach.
From a clinical-grade product, the effects can be very long-lasting and have a very positive outcome on the client or patient experience. You may also find that a quality transdermal agent can be used in some of your manual techniques and other modality approaches such as pre- and post-exercise therapy, therapeutic taping, and as a medium for physical agents such as IASTM, therapeutic ultrasound and EPAT.
Lastly, it would be an appropriate consideration to look at the supplemental goods and services you offer your clientele. Pain relief topicals and ointments are very popular and well-known in the consumer market, which was estimated to be $2.612 million in 2019.13
People are seeking out these products and should come from a professional they trust. Some of the manufacturers and suppliers have sales control to provide the clinician an opportunity to generate some profit by providing their clientele with a high-quality clinical product that cannot be purchased online or at the local store.
Finding a clinical-grade product that you can supply to your clientele will allow them to continue to experience benefit from a non-opioid pain management and healing program. This generates additional revenue and is a constant reminder of your valued services.
About the Author:
Christopher Proulx, DC, PhD(abd), CSCS, is the founder of Effective Motion Strategies, and is in private practice and a consultant for individuals and athletic teams, as well as a guest lecturer and researcher at colleges and universities. He has over 25 years of experience in sport and clinical sciences in higher education and practice, including massage and bodywork education. He wrote this article on behalf of Stopain Clinical Pain Relieving Products.
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