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Pain Treatment Options

By Jeff Lutz, CMTPT September 17, 2014 No comments

There are, without a doubt, many ways to address any condition - treating pain is no different. There are conservative approaches along with invasive procedures.

When treating trigger points and Myofascial Pain it is generally in the best interest of the patient to exhaust the conservative treatments before beginning the invasive ones. Many times invasive procedures do not resolve the condition and sometimes make it more difficult to treat later.

Granted, this is why it is of utmost importance to educate yourself, as you are doing now, about your condition so you can make an informed decision. Whatever decision you make -- stick with it -- treatment, no matter what it is, does not work if you do not follow the direction of the practitioner.

Conservative Approaches

A conservative approach is any type of therapy that is not adding foreign materials to the body or invasively piercing the skin.

 

Myofascial Trigger Point Therapy

Myofascial Trigger Point Therapy was pioneered by Janet Travell, MD who was the White House Physician during Kennedy and Johnson's term in office. This therapy employs the use of manual therapy techniques to deactivate trigger points and restore normal range of motion. Once normal range of motion has been achieved a person may return to a pain free lifestyle. Modification of habit, which is generally simple and practical, is usually required to keep the pain from returning. Types of modalities a therapist may use, but not limited to:

Trigger Point Pressure Release - a therapist will locate and compress a trigger point until it refers its pain. The patient will let the therapist know when the pain begins to dissipate at which time the therapist will slightly increase pressure and repeat until the pain is no longer referred. The muscle is then stretched to its normal range.

Active Myofascial Release Techniques - this manual therapy technique is designed to break through adhesions which form in the fascia (connective tissue) of the body. This is usually performed on patients who have had their pain for long periods of time where this physical change has taken place.

Vapocoolant Spray and Stretch - spray and stretch is applied to encourage relaxation of a muscle by essentially distracting the central nervous system and allowing the targeted muscle to relax. A cold spray is applied over the area of the muscle and through its pain pattern while at the same time the practitioner is moving the muscle into a stretch.

Post Isometric Relaxation (PIR) - this manual therapy technique is used to facilitate more range of motion from a group of muscles. The patient will be placed into a position where they will be asked to exert low level force against the practitioner for about 5 seconds. The practitioner will then tell the patient to relax and will move the body part into the stretch position for the muscle group for which they are applying the PIR.

Heat - heat is applied to relax muscle and help with restoring range of motion.

 

 

Massage Therapy

Massage therapy is growing faster and faster all the time because many people are finding relief without having to use as much medication to control conditions such as pain and anxiety. The effect massage has on the body is stress reduction which in turn can translate into less pain in the body. Other physical benefits can be achieved depending on the type of technique utilized. In my opinion people do not look to massage for pain relief because of the mentality behind it. Massage is still looked upon as a 'pampering' or 'luxury' service. All I can say is that you do not know until you give it a try -- if you get the right therapist you may be very happy with the results.

 

Chiropractic

Last, but certainly not least, is chiropractic care. From being in this field for 7 years, I have noticed a very important thing about chiropractors. They can do what I cannot. Chiropractic care is designed to manipulate joints, primarily in the spine, although some chiropractors will manipulate other joints as well. Chronic myofascial pain patients many times need manipulations after trigger point therapy to restore the motion of the joint itself. This sometimes must be done by what is called a HVLA adjustment, which stands for High Velocity Low Amplitude. The response I usually get from chiropractors is their patients adjust much easier after having muscle work performed.

Other devices are used in the chiropractic community such as activators and various electromechanical devices. Once again, it is important to find a chiropractor who fits your needs, and more importantly, keeps your best interests in mind. I like chiropractors who encourage their patients to keep themselves healthy so they do not need constant care and tend to refer to those types of chiropractors.

 

Moderately Invasive Techniques

Dry Needling and Trigger Point Injections (TPI's)

While these techniques are a part of trigger point therapy, they need to be separated because they may only be performed by properly trained and licensed health care practitioners. Types of practitioners who perform these techniques are MD's, DO's, PT's*, Nurses (RN's)*, and acupuncturists (AP). The practitioners with the * beside their credential are not licensed in all 50 states to perform this technique, but the others are.

Dry needling is performed by inserting a dry needle (a needle that will not be injecting any medication) into a trigger point. The practitioner is looking for a local twitch response (LTR), which is a clinical sign of a trigger point. The practitioner will then move the needle around while staying within the same injection site to penetrate and deactivated all trigger points in the area. A patient will then be stretched and given specific range of motion exercises to perform before returning for another round of therapy. Many times, because of this technique, a patient is sore from the needle being used to perform the technique. The pain does however go away and usually leaves the patient pain free.

Trigger Point Injections (TPI's) are essentially the same as dry needling except a medication or mix of medications are injected into the region of the trigger point. The injection will help with the post needling soreness along with making the actual therapy more tolerable to those with low thresholds for pain. Keep in mind, it is the needle that does the job, not the medication being injected.

 

Invasive Approaches

Invasive techniques are ones which pierce the body and remove tissue/bone and leave scars. Most surgeries are considered invasive procedures. Do not let surgeries scare you as they are sometimes necessary to alleviate pain, but many times can be avoided if a person pays careful attention to themselves and addresses conditions that come up in a prompt manner.

There are many different types of surgeries used for pain, so rather than talking about all of them, I will mention that it is far better to keep a certain mentality when considering surgery.

When considering surgery:

Try to make it a last resort. Most surgeons will agree with this statement and will order therapy for a specified time period before considering a procedure especially with 'borderline' patients.
Get a second opinion. You cannot undo a surgery so it is always good practice to have another specialist look at your case and give their opinion. The opinion may not have to do with getting surgery or not, but perhaps the approach or procedure itself could be different allowing a better chance for resolution and faster recovery time.

Stop Smoking.

If you smoke - stop. Most surgeons will not operate on a smoker especially if a bone fusion is being performed. The body will not fuse properly, and sometimes not at all, which is called a non-union.

 

Referrals

Ask for referrals for a surgeon from a practitioner who works with cases like yours as they know who can provide the best resolution for you. The surgeons I recommend in this area I believe are top notch and always on the cutting edge of their field. Furthermore, they treat their patients with respect and allow a person to feel comfortable in making this important decision for themselves.

 

This article was written by Jeff Lutz, CMTPT of The Pain Treatment and Wellness Center, 245 Humphrey Rd., Suite 2, Greensburg, PA 15601, 724-853-2353, http://musclepainhelp.com/index.html

Solved Mysteries

By Jeff Lutz, CMTPT September 15, 2014 No comments

Myofascial Trigger Points

For those of you who have been treating patients and addressing myofascial trigger points (MTrPs) for 20 years or longer, you may remember a day when a diagnosis of trigger points were considered to be "alternative" or "hippie" medicine. "You think my patient has what?" was a common response from many physicians when told about trigger points. Getting health care providers to understand the concept of referred pain with relation to the muscular system was like trying to teach a lion to hate steak.

Current Research

In recent times, however, there have been some interesting discoveries that are actually backed by good, solid science. Shah et al showed myofascial trigger points by using ultrasound vibration sonoelastography (VSE) which uses an external vibration source in conjunction with Doppler techniques. MTrPs vibrated at a different resonance than the surrounding "normal" tissue making trigger points appear as focal, hypoechoic regions on 2D ultrasound. This imaging technique helped the researchers determine that MTrPs are elliptical in shape, with a size of 0.16 ± 0.11 cm2.1

"But what is happening inside the purported myofascial trigger point?" you may ask. Shah et al gives us an understanding about this. In their paper, the researchers were able to gather extremely small amounts of fluid and determined that concentrations of protons, bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-alpha, interleukin-1beta, serotonin and norepinephrine were significantly elevated in active myofascial trigger points compared to controls.

Archive Image

We can image trigger points. We know they are different internally. How do we assess? Trigger points are best identified and treated when a practitioner follows a specific protocol that not only takes trigger points into consideration as a pain generator, but also other medical conditions that may be responsible for the pain complaint. In other words, they should be included in your differential diagnosis/assessment. Remember that trigger points can be a primary source of pain or secondary due to visceral disease, joint dysfunction, parasitic infection, systemic disorders and others, which is generally more apparent when response to therapy is negligible or transient.

First, a thorough history should be taken. Travell emphasized the importance of this step by saying, "The mystery is in the history." Patients should be instructed to provide a chronology of events that led up to the onset of their condition being sure to include all previous medical diagnoses (regardless of perceived relevance), a listing of all medications, nutritional supplements and any current lab and diagnostic imaging studies.

She said patients should provide dates and places of residence, education, marriages, children living (ages and where they live), sports, travel and employment (what kind, where, for whom). Chronology of medical events should include all illnesses, infections, accidents (e.g., fractures, falls), surgical procedures, pregnancies and miscarriages, allergies (tests and hyposensitizations) and vaccinations.3 She mentions that trigger points are aggravated by elevated histamine levels and active allergies. Testing the skin for dermatographia by marking it is a simple way to identify high histamine levels, according to Travell.

Patient Interview (The History)

When talking to patients about their pain, the practitioner should do two things. First, the patient should be instructed to use one finger and outline the areas of pain while the practitioner documents the described pain on a pain map. Secondly the practitioner should ask specific questions about the other areas of the body that the patient did not mention. This will help determine if there was ever pain in other places, which could indicate a myofascial condition that preceded the complaint with which the patient is presenting.

Discussing the patient's dietary intake is also of importance. Simply asking patients if they eat a "balanced diet" is not always a good practice. Many times patients will state that they are eating well despite having serious diet restrictions, most often vegetarianism. When a patient is not consuming meats, fowl, fish or dairy products, they are at high risk for vitamin deficiencies, including but not limited to deficiencies in iron, vitamin D, B12, etc. Many times the onset of pain can be related to a time that is soon after a dietary change where these types of restrictions are initiated.

Discuss the profession of the patient to determine the types of muscle strain that may occur. Have patients snap a picture of their workstation and include it with their history information. Some practitioners may ask for patients to get a picture taken while they are working. A picture can immediately identify a situation that can cause muscular strain and essentially explain the condition. Use similar techniques when looking at any activity with which the patient spends considerable time, including sports and hobbies.

Describing Pain

Although it is possible for trigger points to cause constant pain, more often than not the pain is intermittent and aggravated by specific movements. Many people have found that certain positions can alleviate their trigger-point pain and unknowingly avoid certain movement due to the pain produced while moving through range of motion. Generally, pain from trigger points is described as steady, deep, dull and aching, and rarely as burning or throbbing. Occasionally, trigger-point pain is described as sharp or "lightning-like" stabs of pain.3 Referred tenderness is also a symptom where the area that is sensitized is extremely painful to the lightest palpation, especially when multiple trigger points refer to one area or in a naturally sensitive zone of the body.

Be as specific as possible in questioning. I can recall a situation where I noticed fasciculation of muscle as I was working with a client and also noticed that he was extremely fidgety and talked fast. I looked at the intake form I used at the time that asked about caffeine intake, and the client checked the box next to coffee and listed "one cup." I asked again about coffee, and he confirmed his "one cup" as on the form. Because it really wasn't relevant to me at that time, I let it go. When he came in the next time presenting as even more fidgety, I laughed and asked, "How BIG is that cup?" The client went out to his vehicle and brought in what looked like the coffee dispenser in a convenience store! I immediately changed the "how much" part of my intake to ask for ounces consumed.

This article is the first of three. The next two will discuss medical perpetuating factors for myofascial pain due to trigger points, and useful treatment techniques and self-treatment. 

References

1. Sikdar, S., Shah, J., et al. (2009). Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of Physical Medicine and Rehabilitation, 11(90), 1829-1838.

2. Shah, J., Phillips, T., Danoff, J., & Gerber, L. (2005). An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology, 5(99), 1977-1984.

3. Simons, D., Travell, J., & Simons, P. (1999). Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. Upper Half of Body. 2nd ed. Baltimore: Williams and Wilkins.

Jeffrey A. Lutz is board certified in myofascial trigger-point therapy and has two offices in western Pennsylvania. He is president-elect of the National Association of Myofascial Trigger Point Therapists, an organization of therapists who specialize in trigger-point therapy (www.MyofascialTherapy.org) and is the technical writer for www.TriggerPointProducts.com. This article was reviewed by Timothy Taylor, MD, CMTPT, director of Pain Relief Home, a practice specializing in the treatment of myofascial pain located in Richmond, VA (www.PainReliefHome.net).