Pain Care General Pain Topics

Anatomical and physiological approach for understanding trigger points, chronic pain, massage, excercise, twitch, whiplash and tingling and numbness.

Categories: Trigger Points Chronic Pain Massage Exercise Twitch Whiplash Tingling Numbness

Myofascial Pain| Trigger Points

Sunday, October 21, 2007

Myofascial trigger point as defined by Travell and Simons includes “a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle fascia which is painful on compression and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena”.

The autonomic phenomenon on palpation of the trigger point consist of skin redness (vasomotor response), sweating (sudomotor response due to pain is characteristically hot and sticky sweat as opposed to thin sweat from nervousness or just being cold ) and goose pimpling (pilomotor response). Usually with pain due to trigger point palpation, the goose pimples do not cross the midline.

When the trigger point is pressed, there is an area of referred pain. This is the feature that differentiates myofascial pain syndrome from fibromyalgia. The tender spots in fibromyalgia do not produce referred pain.This pain is reproduced reliably on palpation of the trigger point in myofascial pain. The referred pain does not coincide with dermatologic or neuronal distributions, but follows a consistent pattern.

Trigger points may develop after an initial injury to muscle fibers. This injury may include a noticeable traumatic event or repetitive microtrauma to the muscles. The trigger point causes pain and stress in the muscle or muscle fiber. As the stress increases, the muscles become fatigued and more susceptible to activation of additional trigger points. When predisposing factors combine with a triggering stress event, activation of a trigger point occurs. This theory is known as the “injury pool theory”.

Gunn’s theory for myofascial pain is that of shortened muscle fibers due to injury to nerve roots leading to denervation of muscle fibers. The denervation is related to aging, blunt trauma insidiously or acutely from whiplash injuries, sports, work and repetitive injuries. The shortened muscle fibers produce pain from compression of intramuscular nerve terminals and small blood vessels. There is also a tugging effect of the tight muscles on its own tendon with a pulling or tugging effect on ligaments, bones and joints. The covering of the bones called periosteum or the annulus fibrosus of the intervertebral discs is painful since they are richly innervated with pain fibers.

Electromyography at the trigger point shows spontaneous electrical activity with presence of endplate potential, and the active loci probably are related closely to motor endplates.

Treatments used traditionally include spray (freeze) and stretch, physical therapy, transcutaneous electrical stimulation, ultrasound, massage , ichemic compression therapy, trigger point injections with local anesthetics, corticosteroids, botulinum toxin, dry needling and/or acupuncture.

The most effective treatment for myofascial pain syndrome is Electrical Twitch Obtaining Intramuscular Stimulation (eToims®). The trigger points have to be systematically searched for and electrically stimulated. The characteristic forceful twitch on trigger point stimulation is strong enough to effect movements of the joint over which the treated muscle crosses. When such twitch forces are elicited, it treats the root cause of the pain which is the shortened muscle. The skin resistance to electrical stimulation is lowest at the trigger point allowing effective stimulation of the intramuscular terminal nerves using the least current. However, the stimulus strength has to be supramaximal to ensure effective stimulation of the trigger point (s).

Sports Injuries| Chronic Pain

Friday, December 15, 2006

Sports injuries that result in chronic pain is due to injuries to the neuromuscular system from excessive and repetitive use of muscles during training and performing in the game. Muscles which are exposed to excessive lengthening contractions and muscles which cross multiple joints are those which are prone to sports injuries.

If you have healthy muscles and nerves as a baseline, these tissues can heal very easily even when subjected to repeated trauma. Genetic factors play the most major role in ability to withstand trauma and ability for tissues to heal, differentiating the common person from the elite athlete. Even the elite athlete can withstand only so much cumulative trauma and once their reserves disappear and also as they age, the tissues have more difficulty in healing and they also suffer from chronic nerve related muscle and joint pain.

The ordinary person however may just have one episode of sports injury such as a fall or lifting injury and they may progress into chronic pain. If they have been injured before they are prime candidates for nerve related muscle pain that can become long-standing. Sports and other trauma related chronic muscle pain can begin even in childhood. Indeed many children as young as 7-8 years old may suffer from sports initiated chronic disabling muscle pain.

Chronic pain is known as pain that will not go away. The person who develops chronic pain may have pre-existent nerve related muscle discomfort or pain. Since this type of person has little to no reserves in the nerve and muscle tissues to heal promptly, additional trauma leads to permanent nerve injury with resultant chronic pain.

Many people will willingly admit that they have been tight in their muscles and joints for as long as they can remember and some will state that they have been tight since childhood. When there is no pain, people usually do not seek medical help for discomfort related to tight muscles or joints. They continue to perform competitive training for sports in addition to performing usual work, recreational, social or home related activities. They live with some degree of discomfort or minor pain related to the muscle tightness but seldom seek help for muscle discomfort until it becomes significant pain.

All movements associated with daily activities tend to injure nerves close to the spine known as spinal nerve roots and also the nerves within the tight muscles. However, low grade injuries related to cumulative slow and insiduous trauma or aging are better tolerated and can heal better. However, when many nerves are injured simultaneously at multiple levels on both sides of the spine as that occurs with sudden blunt trauma as with a whiplash injury healing to obtain a complete cure of the pain or discomfort is difficult.

Due to the force of the sudden trauma, the spinal nerves are acutely and violently stretched, kinked or bruised against the spinal joints, bones or intervertebral discs. The injured and irritated nerves then signal the muscles to go into spasm. The resultant significant muscle spasms will have a vice-like effect on the nerves and blood vessels within them causing more nerves to be injured. This self perpetuating cycle of spinal nerve root injury as well as the intramuscular nerves causing muscle spasms which in turn cause more nerve injury maintains the patient in the state of continued chronic pain.

© 2007 copyright www.stopmusclepain.com

Massage

Sunday, December 3, 2006

The beauty of massage is that you can do it yourself and you can do it multiple times every day and that's how massage is best done.

Always feel around in the muscles for points or places that make you feel good and relaxed. Massage is a mechanical stimulant for the muscles and though it moves the muscles passively, it can be quite effective because it helps to keep the muscles soft and pliable.

Massage movements can help the muscles to twitch if the motor point (nerve muscle meeting point) of the muscle can be found and stimulated mechanically through manual movements. If you can find pleasurable and relaxing points within the muscle, then the massage is able to twitch (contract) these points which are the motor points and the massage will be even more effective in relaxing the muscles.

If some places in the muscle are too tender, do not use strong pressure in those areas because it can irritate and make the muscle spasm in these areas even more intense. Therefore massage can induce pain or aggravate pain instead of relaxing the muscle.

Pounding the muscles with your hand or using an electric massager can be very effective in massaging large muscles.

Briefly squeezing the muscle with your hand and immediately letting it go can be quite useful especially in the neck or on small to medium size muscles. Also, an effective way for massaging the forearm and arm muscles is to twist the muscles in clockwise and anti-clockwise motion across the shaft of the bone.

For massaging the small muscles of the hand and feet use two fingers, press or roll the muscle with one finger on the top of the hand or foot and the other finger on the palm of the hand or sole of the foot.

The most important areas to massage are the muscles along the side of the spine from the base of the skull to the base of the lower spine. Massage also the slopes the shoulder for the trapezius muscles and muscles over the shoulder blade and along the inner border of the shoulder blade and between the shoulder blades. Include also the latissimus dorsi muscle that runs from the back of the armpit along the back of the chest to the lower back. Massage horizontally also along the lower angle of the shoulder blade wrapping to the side and front of the chest. There are motor points along the upper border of the latissimus dorsi muscle and massage can help twitch to induce relaxation of the muscle.

You can effectively massage the muscles of the back by yourself by leaning against a 1-2 pound plastic coated barbell. This will help to also stretch the back muscles. If you have too much pain, you may wrap the barbell in a small towel or just use a soft rubber ball or a tennis ball to lean against.

You may find it useful also to lean the spine muscles against the edge or corner of a table, door, cabinet or wall. You can slide yourself sideways across that corner to get a better massage effect.

Massage to include as many muscles as you can. These muscles lie on the back and front of the body, the outer and inner aspect of the limbs. Massage to include the lower limb muscles, the gluteus maximus (buttocks), hip, thigh and calf muscles. Include the scalp muscles as well as the facial muscles.

The pressure of the massage should vary according to the tenderness felt during massage. If it is too tender, do not use too much pressure to avoid inducing or aggravating pain. If you should find points that are relaxing and pleasurable, you may massage these areas longer and also find more of these relaxing points.

© 2007 copyright www.stopmusclepain.com

Post Exercise Soreness

Tuesday, December 12, 2006

Post exercise soreness

After exercise or unusual activities, we often feel stiff, sore, achy and tight in our muscles. The muscles are also tender to touch. Generally, we do nothing about it and wait for the symptoms to subside. After two to three days, we may recover from the symptoms without any residual problems.

But if you already have muscle pain and discomfort prior to the exercise, any exercise or unusual activities will aggravate the underlying pain. Muscle spasms associated with unusual activity can irritate or compress the small nerve fibers and blood vessels within the muscles. The muscle spasms can also have a traction effect on bones and joints.

To effectively relax the muscle spasms, the treatments should start immediately after the exercise. Return of blood flow to the nerve and muscles will prevent the nerve irritation from progressing into permanent nerve damage. Rest, ice, compression and elevation in various combinations as well as stretching and massaging the muscles are the usual measures of treatment.

Manual massage to the muscles is essential to relax some of the more superficial muscle spasms but the best way to relax deep muscle spasms is to use electrical stimulation of motor points to obtain strong force twitches. Twitch contractions associated with electrical stimulation of motor points can produce a deep internal muscle stretch not possible with voluntary stretching exercises or massage since the latter can stretch only the more superficial muscle fibers.

Voluntary exercises usually involve movements of multiple muscles and multiple joints. On the contrary, twitch contractions from motor point stimulation with electricity can be elicited in a single muscle thus moving only the joints associated with that muscle’s contraction. The twitch contractions are the most effective way to perform no-impact aerobic exercises. These twitch contractions also promote stretching and aids to increase circulation to the muscle area in spasm allowing the entrapped nerves to be released and allow healing to occur immediately curing the post exercise soreness.

© 2007 copyright www.stopmusclepain.com

Spontaneous Twitches

Saturday, December 2, 2006

If one feels twitching in the muscles usually it is a sign of presence of nerve irritation. Consult your doctor to determine the diagnosis especially if the twitching continues nonstop or lasts longer than 2-3 days.

The lower eyelid is a common area to twitch. Check your face in the mirror to see if the twitching also involves the upper lip of the mouth. This is a sign of facial nerve irritation and is more significant when many more muscles of the face are involved.

Check to see if you have been biting into too many solid and hard foods like nuts or ice, or too much repetitive motion activities of the jaws as in chewing gum or biting frequently into crunchy foods and snacks. Immediately avoid chewing or biting down on anything hard and crunchy.

Feel around in the muscles of the cheeks and jaws to determine if there is any tenderness in these muscles. Massage the tender areas. Additionally, feel for tender areas in the neck especially on the side where the facial twitching is present. Massage your neck muscles frequently every day especially the portion of the neck muscles close to the mastoid bone. The mastoid bone is a protrusion of the skull bone just behind the ear. These muscles close to the mastoid bone when too tight can pull on or irritate the facial nerve which is right by that bone as it exits the skull.

The optimal way to relax the muscles of the neck in order to reduce the traction effect on the facial nerve is to selectively contract them using Electrical Twitch Obtaining Intramuscular Stimulation. Treatments to electrically induce twitches have to be applied to splenius cervicis and longissimus, sternocleidomastoid and trapezius muscles, the entire spinal muscles from the base of the skull to the base of the spine. Treatments also have to be applied to the facial muscles especially the masseter muscle.

© 2007 copyright www.stopmusclepain.com

Car Accidents| Blunt Trauma| Whiplash of the Spine

Wednesday, December 27, 2006

Rear-ended car accidents are common and the incidence of whiplash injuries is in the range of one million annually in the United States1. Due to the backward movement of the head upon the neck followed by a forward movement of the head, a whiplash injury often results in nerve related myofascial pain.

Patients may suffer from neck, mid-back, and lower back pain and pain down the upper and lower limbs in various combinations. Often, these patients with whiplash injuries sure to car accidents and other trauma also suffer from muscle contraction headaches, temporomandibular joint pain and a clicking noise in the jaw joint with jaw movements, dizziness, unsteadiness, tingling and numbness and coldness in the fingers. Patients can also suffer from post-traumatic fibromyalgia resulting in total body pain. Soft tissue trauma to the neck can result in an increased incidence of fibromyalgia compared with other injuries. There may also be a post-concussion syndrome leading to memory deficits and concentration problems.

Although symptoms may dissipate within three months of the car accident, 30% of the patients may continue with chronic neck symptoms and 10% of the patients may have chronic headaches. 6% of the patients may not be able to return to work even after one year post car accident.

Although patients may complain of pain predominantly on one side, careful neuromusculoskeletal examination will reveal tenderness in many muscles on both sides of the spine, and in both upper and lower limbs with accompanied restriction in range of motion in many joints. Sluggish tendon reflexes may be present.

The most motion in a whiplash injury from a car accident occurs at the C5-C6 vertebra level following 5g acceleration but force is also distributed to the C4-C5 to C7-T1 levels depending on the intensity of acceleration2. Cervical spine x-rays may show straightening of the cervical spine due to paraspinal spasm. CAT scan and MRI scan are often performed to rule out presence of herniated cervical disk and nerve root impingement. Commonly the facet joints are involved. These tests may be normal since in a whiplash, the injury is to multiple level bilateral spinal nerve roots.

The nerve roots in trauma induced whiplash injuries become irritated from being stretched, distorted, kinked or transiently compressed against bone either at the level of the disc or more outward away from the center of the spinal canal in the region of the foramen through where the nerve roots exit. Whiplash type injuries of the nerve roots can occur also with falls, sudden recoil type movements from lifting injuries or with any sudden jerky and forceful movements to the head, neck and lower back.

Quantitative electrodiagnostic studies which reveal the extent of the nerve damage is most useful for determining the outcome for recovery. The prognosis for recovery is dependent on the number and extent of nerve roots involved, presence of nerve root impingement, age of the patient, associated degree of underlying degenerative spine disease, multiplicity and diffuseness of symptoms and the initial high pain levels on presentation, etc. These nerve related factors are more important than the speed or severity of collision or the extent of damage to the vehicle but these factors do contribute to the amount of nerve damage induced.

Routine treatments include physical therapy with use of cold modalities in the acute condition and heat modalities such as hot packs after the first 24-48 hours. Medications will include anti-inflammatory medications, pain pills and muscle relaxants. Mobilization of the tissues using massage, TENS unit and gentle active range of motion can be useful. If cervical collars are used, the narrow portion of the collar must be kept in the front. As a general principle, the use of the cervical collar should be limited to two hours on and two hours off. A good cervical pillow that supports the neck well during sleep is essential. Patients must lie on their back to sleep. They must not sleep on their sides or on the abdomen. They must not place pressure on their arms and must avoid sleeping with their arms under the pillow or head.

Acute nerve related muscle pain is most responsive to eToims® Twitch Relief Method with treatment directed towards muscles supplied C2 through C8 nerve roots with emphasis on muscles supplied by the C6 and C7 nerve roots and the trapezius muscles supplied by the C4 nerve root. The entire spine from neck to the lower back needs to be treated. After controlling the neck pain, treatments also have to be directed to the muscles supplied by the lumbosacral nerve roots.

1. Evans RW. Some observations on whiplash injuries. Neurologic Clinics. 10(4):975-97, 1992 Nov.

2. Ito S. Ivancic PC. Panjabi MM. Cunningham BW. Soft tissue injury threshold during simulated whiplash: a biomechanical investigation. Spine. 29(9):979-87, 2004

© 2007 copyright www.stopmusclepain.com

New Onset (Acute) Tingling and Numbness and Twitching

Friday, December 8, 2006

If you have new onset (acute) tingling and numbness in your hands on waking up, this may be from improper positioning during sleep and putting pressure on the nerves to the hand. This can occur at the elbow, wrist or hand. If you have pain in the elbow, you will think that you have the symptoms of tennis elbow and if you have pain in the wrist and hand, you may wonder if you have carpal tunnel syndrome.

Depending on which fingers are having the symptoms, it is always a good idea to immediately massage the muscles. Commonly, the ring finger and the little finger are having the symptoms. There may also be twitching in the muscle in the first web space (between the thumb and index finger) or the little finger may be seen to be twitching. This is a sign of ulnar nerve irritation and the nerve may be irritated at the elbow or just above the elbow underneath the triceps.

You must massage the triceps muscle, forearm muscles especially the ones on the back of the forearm (these are the most common muscles for giving rise to symptoms of tennis elbow) and the hand muscles. It is a good idea to also massage the neck, the muscle at the slope of the shoulder called the trapezius, shoulder blade muscles and those between the shoulder blades, the muscles of the upper arm and the latissimus dorsi. This huge muscle runs from the arm pit to the lower back. The same muscles should be included for massage if the tingling and numbness is in the thumb, index and middle fingers.

If the tingling and numbness is in the big toe or the little toe, or if there is twitching in the calf muscles, massage muscles at the back and front of the leg, especially the calf muscles. Also circumferentially include the muscles at the front, back and sides of the thigh, buttock and the lower back muscles.