CURRENT THOUGHT ON PAIN REDUCTION IN MYOFASCIAL PAIN SYNDROMES (Part 1)

Myofascial Pain Syndromes
Have you found making it through the day seems to be harder and harder because of muscle stiffness, soreness and pain? You may be suffering from a myofascial pain syndrome. Myofascial pain syndromes (MPS) are a growing problem in the United States and beyond. There are quite a few variations of this malady; nearly as many as there are people who suffer from the symptoms. A general presentation might (but, then again, might not) include an inflammation of the thin covering over a muscle or muscles (fascia), muscle pain, joint pain, focal tenderness and muscle tension. These are frequently made worse by stress (physical, emotional or spiritual), weather changes, physical activity, injury to an internal structure or organ, repetitive motion and/or inactivity.

One Important Form of MPS
One feature frequently found in MPS is the existence of trigger points (TP).
These small, tender nodules can be found by palpating (touching) the skin with a firm pressure. They often occur in predictable locations and have the ability to create pain patterns that have little to do with the location of the trigger point. For example, a trigger point found near the place where your neck connects to your body can create pain in your forearm. A trigger point in a low back muscle is quite capable of creating pain that seems to be coming from your foot.

A number of techniques have been developed over the years to treat trigger points. These include a variety that run from gentle non-invasive through aggressive non-invasive to frankly invasive procedures. Gentle non-invasive techniques might include electrical muscle stimulation and moist heat. More aggressively, therapeutic massage that focuses on trigger points has been shown to relieve pain and dissipate trigger points. A more invasive technique is trigger point injections to help break up tenacious TPs that refuse to dissolve as described by Dr. Janet Travell in her book, “Myofascial Pain and Dysfunction: The Trigger Point Manual”.

What is a trigger point?
Trigger points are frequently created as a result of the natural activities of your own body. During normal muscle activity, waste products are created (lactic acid and other materials). Your body wants to rid itself of this noxious waste and usually does so by having it removed by the blood and lymphatic systems. But if, for example, tight muscles prevent normal blood and lymphatic flow, the waste can accumulate in small pools near the muscles. These are trigger points.

Treatment expectations
Pain referral patterns of trigger points can sometimes mimic other conditions. I have treated patients with diagnoses of carpal tunnel syndrome and sciatica who were concerned about recommended surgeries. Using trigger point therapy those symptoms were frequently resolved without surgical intervention. This is no guarantee that your symptoms will respond in a like manner, but it is usually a good idea to treat from least invasive to most invasive one step at a time. As you progress through your program, the specifics of treatment will change based upon your progress. This takes time so you should have patience and stick to the treatment instructions to move from elimination of the trigger point to rehabilitation of the muscles.

Treatment results are less predictable than we’d like and they must be created for each individual patient and change as you move through the healing process.. It is a “hit-and-miss” situation while looking for the ideal strategy. Currently, the “Best Guess” method in determining an appropriate treatment protocol is our only option. I have found that a large majority of patients respond well to a combination of chiropractic adjusting and therapeutic massage. If the symptoms and findings don’t resolve completely, referral to a pain management physician for injections is appropriate. Manipulation under anesthesia can also be beneficial in treating MPS. Finally, a surgical consultation is available if all else fails.

Some forms of MPS do not involve trigger points. I will explore some of these in the next part of our discussion.

A FEW THOUGHTS ON THE SIGNIFICANCE OF PAIN

Pain is one of your brain’s interpretations of information received through your nervous system and is the result of some sort of stimulus from outside or from within your body. Most of us have a variety of interpretations available to us, including pain, pleasure, irritation, vibration and others. Pain is the way your brain tells you that something isn’t right and you need to find the cause.

The brain is also frequently capable of discerning the general location of this noxious stimulus. For example, if you feel a pain in your left leg, you initially look at your left leg to see if something from outside your body (exogenous) is causing this pain. If you find the cause, you remove it; a thorn, splinter, bee sting, etc.

Pain from an internal cause (endogenous) is more difficult to identify. But the solution is the same. Identify the cause and remove it. This is best done using approaches starting with the least invasive and moving one step at a time toward most invasive.

There are many possible causes of internally generated pain but it can be classified into two main categories: Acute and Chronic. Pain can also have a number of different descriptors like sharp, electric, stabbing, burning, throbbing, achy, etc. Each gives us information useful in determining the real cause and location of the pain causing lesion.

Acute pain is frequently exogenous but can also be endogenous. This is usually more severe and immediate in the sense that it often appears quickly and demands immediate attention because it instantly alters your daily activities. Chronic pain can also be severe but is longer term. It doesn’t come as a surprise because the sufferer has had this condition for an extended period. Chronic pain can also interfere with your daily activities but many patients have worked out a way to do at least some of their activities by changing how they accomplish these.

The brain can sometimes be fooled, especially by endogenous pain. Pain can be generated by problems with the bones, joints, muscles, ligaments, tendons, blood vessels, lymphatic vessels or the nerves themselves. The situation can be complicated by pain perceived by the brain as occurring in one location but the cause may be in a completely different one. For example, a tear in one of the muscles may cause that left leg pain but it may also be caused by pressure on the nerve that runs to that region suffering interference at a different location.

One area where this interference frequently occurs is in the spine. There are a number of structures near that nerve where it exits the spine that can put pressure on it. The brain interprets the input as coming from where that nerve terminates rather than at the point of interference. So, leg pain may actually have little or nothing to do with the leg. Physical examination, nerve testing and imaging with x-ray, MRI and CT are invaluable in making the correct diagnosis.

Medications can help with some pain in the sense that the nerve impulses can be interrupted or altered so that the brain no longer interprets pain messages. But these medications are for temporary pain relief only. They do not indentify or eliminate the cause of the pain.

Medications should only be used as a Band-Aid, not as a cure. Hiding your pain with pain relievers, muscle relaxants and anti-inflammatory medications can help you feel better for a little while, but before too long, the continuing damage will worsen to a point that the medications are no longer able mask the pain. Remember that your pain is not caused by a steroid deficiency and that the medications should be used to make you feel more comfortable while you and your physician look for the real cause of the pain.

Horse and Human: Two Members of One Team

Equestrian activities are among the very few sports with teams made up of members from two different species. Top efficiency of both team members promotes better enjoyment of recreational rides, a higher level of competition and a safer ride for both. Most experienced riders assume that if the team turns in a bad performance, it is never your horse’s fault and always the rider’s responsibility. But it is your horse, alone, that receives the best possible care; some of you even providing equine chiropractic for them. But your horse is only half the team. You need and deserve to be in top form, also. Ultimately, the entire riding experience; enjoyment, performance and safety are dependent upon you and your horse both being at your best.

This partnership requires precise contributions from both team members. Your ability to maintain the most effective seat is as important as your horse’s preparation in both recreational riding and in competition. Critical communication between horse and rider is enhanced when you are structurally aligned and balanced; sending clear messages to your partner rather than ambiguous or contradictory ones. The strength and balance of your abdomen and back and your ability to exert fine control over your thigh’s adductor muscles and buttock muscles intensifies the accuracy of the message you send to your teammate. This enhances your ability to maintain a deep seat and yet with your knees relaxed but flat on the saddle. This communication ultimately frees your horse increasing both performance levels and longevity.

Top athletes, including Olympians and professionals, use chiropractic treatments to amplify the effects of training and improve competitive status. Your goals may include a more enjoyable trail ride, assistance in moving to the next level of competition or even more focus and energy in your ride. Whatever it may be, we can help you with this goal.

Getting Beyond the Pain

No doctor ever cured anyone of anything. The most we can hope for is to put your body into the best possible position to heal itself.
Having said that, health care in general and chiropractic specifically are replete with stories of “miracle cures” but the most remarkable miracle cures are those that result from long, patient work. Most chiropractic patients arrive with complaints that have been present, in varying intensities, for many years. Typically, they have tried a bewildering number of treatment approaches and enjoyed some success in reducing symptoms. But the symptoms, pain, numbness, tingling, weak muscles, etc., never completely resolve. Many decide to try chiropractic as a last resort.

This puts the chiropractic approach at a disadvantage because of having to address abnormal chronic changes that have established over time. For example, “With soft tissue injuries there is frequently tearing and stretching of the involved soft-tissues as well as damage produced from local micro-hemorrhage and inflammation. The reaction is the usual bodily response to such trauma and its inevitable sequelae commonly known as “scar tissue”. Scar tissue forms not only on the skin, but on all internal lesions as well; such as muscle tears, sprains, strains, or where internal surgery has been performed. As damaged tissues heal, local areas of inflammation remain chronic sources of irritation because the body repairs a wound, ulcer, or other lesions by increasing its production of the tough, fibrous protein, collagen, at the site of damage. The collagen helps form new connective tissue that covers the area to the lesion. Adhesions are areas of scar tissue that form between internal organs and are a potential complication of not only internal surgeries, such as intestinal operations, but also of sprains, strains, and other soft tissue lesions. This results in area tissues that retain fluid from the inflamed state. This further creates a weakening of the fibers, as well as creating a rigid and fibrotic state due to “healed” but damaged tissue.” (Reference: The American Medical Association Encyclopedia of Medicine, Random House, New York, 1989).

The first step in working with your chronic complaints is to “back out” some of the results and sequelae of previous treatments and the chronic changes inherent in longer-term injuries. This requires commitment, compliance and patience on your part and that of the doctor. Recognizing that the fibrotic tissue of a scar tends to develop in a disorganized ball rather than along organized planes the body needs, the first task is to re-organize that tissue so it works with you rather than presenting an obstacle to normal function.

This is not to say that you will not see benefits fairly quickly because you probably will. But you should keep in mind that to achieve as close to 100% as possible will take time. You do not notice pain until your body reaches a pain threshold. Your chiropractor can often help you back across that pain threshold fairly quickly but that is nowhere near 100%. You are just on the other side of that threshold and the least stress can send you back into pain. The goal is to move you as far from pain as possible and this takes time and treatment. Much of your chiropractic treatment will occur while you are not suffering from acute pain.

Remember, your body didn’t get this way overnight and is not going to achieve repair quickly. However, the goal of achieving and exceeding a pain-free life is well worth the commitment.