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Pain Management

Perth Natural Medical Cinic's Dr David Main explains:

Pain Management

Dr David Main offers assessment and treatment services for both acute pain problems such as sports injuries, accident and occupational injuries, and more long-standing and difficult pain problems such as chronic injury pain, degenerative pain, headache, and muscular and ligamentous pain.

Dr Main has 14 years experience in treating pain disorders using myofascial trigger point therapy and prolotherapy.

Myofascial therapy

Introduction

The concept of muscular pain and dysfunction arising from trigger points is something that seems self evident to sufferers, but is a concept the medical community has been slow to accept.

A myofascial trigger point is a localised area of muscular contraction. This may be felt as a nodule within the muscle tissue. Microscopically, this nodule is made up of a collection of smaller knots within the muscle fibres. These fibres are locked in the contracted state, and may stay like this for extended periods (Figure 1). This concept is at odds with common impressions that muscle tissue is self-healing and regenerative.

How Trigger Points Arise

Trigger points arise with overloading or injury to the muscle, and occur in typical anatomical locations. The injury of course, can arise suddenly, as is the case with a whiplash injury, or a sporting injury, or can arise slowly, in situations of repetitive strain or long-standing overloading of the muscle. This is commonly seen in the stressed white collar worker slaving away at the computer.

Exactly what happens in the muscle when a TrP develops is not clear. One description is that they are a localised neuromuscular disorder. In a normal muscle, contraction of muscle fibres is set off by an electrical impulse. When the muscle is relaxed, no electrical activity is seen. In a TrP, constant electrical activity is present and can be measured by accurately placed electrodes.

Muscle contraction then causes tissue hypoxia (oxygen lack), and the release of chemicals in the area which sensitize pain nerves. Contraction also results in a taut band through the muscle leading to shortening.Clinically therefore, TrPs are perceived as tender nodules in a stiff muscle. Pain is not well localised, and commonly refers into another zone. Neck and shoulder TrPs commonly refer to the arm and hand for example. Tenderness and pain over the bony attachment of the muscle is also common, and tendonitis may result. Myofascial pain is usually worst after waking in the morning, and improves after moving and with heat and massage.

Frequently, sensitisation of the autonomic nervous system results in other symptoms. It is very common to notice skin wheals to light pressure - this indicates ready release of histamine in the skin. TrPs in low back and pelvic musculature may result in irritability of the bowel or period pain, and in the neck can cause tinnitus, vertigo and sinus problems; Secondary problems may arise due to pain. It is very common to see sleep disturbances, fatigue and depression. Fibromyalgia may arise from muscular trigger points.

Myofascial pain problems are extremely common. In one study of patients attending a pain clinic, in 74% of the group, myofascial trigger points were considered by a neurologist to be the primary source of pain. In a similar study of 283 patients, a primary diagnosis of myofascial pain was made in 85% of patients.

Trigger Point Treatment

Trigger Point Injection Trigger point injection (TPI) is the needling of trigger points and is the most effective method of eliminating TrPs in the long term. TPI introduces a small amount of local anaesthetic such as procaine or lignocaine into the trigger point. TPI is the method of choice for both recent and long-standing myofascial pain disorders. Injection therapy is appropriate for localised injury, for example a hamstring strain in a sportsperson, and for widespread pain conditions such as neck and back injury or headaches.

Needling of the contracted knots within the trigger point complex clears the localised spasm and resets the muscle to its normal state.

How this occurs has not yet been defined. It may be that introducing a needle into the contraction knot disrupts the motor end-plate (where the nerve touches the muscle) to defuse the spasm, or that the needle allows magnesium to enter the area and allow muscle relaxation. In either case, it is the accurate introduction of the needle tip into the area that produces good results. The use of local anaesthetic in the injection is not essential, although it does produce faster and more reliable results.

Prolotherapy

Prolotherapy is a treatment technique which addresses the _ pain inputs arising from tendons and ligaments. Very commonly, quite exquisite pain may arise at the points of attachment of tendon and ligament to bone. These points may develop fibrous trigger points and inflammatory reactions and refer pain into distant locations. For example, in the cervical spine, ligament insertion pain refers to the upper arm, hand and fingers. In the occipital bone of the skull, pain is referred forward to above the ear, temple, forehead and eye (see Figure 2).

Treatment of the trigger point complex in the belly of the muscle will reduce tension on the insertion point and often relieve pain. In some cases though, more complete results are obtained by needling of the fibrous components. In some cases, simply needling or infiltration with local anaesthetic and/or steroid will achieve good results. In other cases, the use of a more specific solution is necessary. Prolotherapy involves the injection of a glucose solution into affected ligaments. This is mildly irritant to the tissue and sets up a proliferative reaction in the area, stimulating a healing response. Good pain relief is often obtained after a series of three to five injections. Authors such as Hackett (1958) felt that pain relief follows from tightening of the ligamentous structure by this proliferative response. It is also possible that pain relief follows from the effects of the glucose solution on pain nerves in the area. Prolotherapy may be useful for the treatment of pain arising from many areas. For example, Hackett published the results of a research involving 656 patients with chronic low back pain treated with prolotherapy. The average duration of pain before treatment was 4.5 years, with some patients suffering much longer. Almost half of the cases had failed to improve with surgery. Excellent long term results were reported: twelve years after treatment with prolotherapy, 82 percent of patients considered themselves cured.

Trigger Point and Prolotherapy - What to Expect

Successful trigger point therapy unlocks a large number of the contracted muscles of the neck and shoulders. In addition to eliminating headache, shoulder and neck pain and range-of-movement benefit greatly. To achieve this, careful coverage of the involved muscles is performed over the treatment sessions. Average treatment time for headache totals 3 - 3.5 hours. This is usually broken into 1 - 2 one-hour treatments, and 2 - 5 half hour sessions.

The needling itself is mildly to moderately painful, although most find it less painful than they imagined. Entonox (nitrous oxide) gas is available and often makes the procedure virtually pain-free. The effects of Entonox wear off within minutes.

Trigger point therapy has few side-effects. Some swelling or bruising of the area is common and harmless. This may be reduced by taking Vitamin C 500 mg twice daily during treatment. Post-injection soreness lasts two to three days. Any pain left after five days is due to continued muscular trigger points.

For post-injection soreness, application of heat packs, warm baths and gentle stretching are effective. The use of ice is to be avoided. Never ice muscular injuries. Ice makes the taut bands in muscles more active and locks in any bleeding. Scarring may result making treatment more difficult. Anti-inflammatory medication such as Nurofen or analgesics such as paracetamol may also help. Blood thinners such as aspirin increase bruising and should be discontinued one week before treatment. Warfarin and other medications should be continued as normal. Please have normal meals before attending to avoid hypoglycaemia. Treatment should be deferred if you have a flu or infection, particularly if a fever is present.

Many patients can have treatment and attend work on the same day, although in some cases, particularly at the beginning of treatment, a short time off work may be needed. It is recommended that you do not drive immediately after treatment, and that particularly for the first session, you bring a friend or family member to take you home.

Myofascial treatment and prolotherapy are very safe treatments with low complication rates.

Mild treatment effects are common:

• some bruising or swelling of the treated areas
• post-injection soreness or headache lasting up to one week

More serious effects are uncommon:

Reactions to Entonox gas: Entonox gas can occasionally produce anxiety and/or a depersonalisation reaction; this wears off rapidly once the gas is ceased, but has a very slight potential for injury.

Side effects of local anaesthetic (lignocaine or procaine) are described, for example central nervous system (most commonly short-lived tingling or numbness of the tongue and mouth) or cardiovascular effects; these medicines are in wide use in everyday medical practice with few problems.

Injection into a blood vessel or nerve. Minor bruising of tingling is in most cases the only side-effect. Very occasionally, tingling can persist for longer.

Injection into lung tissue: injection around the upper shoulders is routine in treatment of headache. Misplaced injections can result in lung puncture (pneumothorax) requiring further treatment and hospitalisation. Dr Main has had no cases of pneumothorax in 14 years of muscle pain and headache treatment.

Infection in skin or muscle is very uncommon

Severe side effects are rare and unusual

Injection into the spinal cord or brain: this is the most dangerous of side effects and carries the risk of permanent brain damage or death. I know of no cases where this has occurred in Perth practice, although it has been described as an extremely rare consequence of acupuncture.

Improving the Results of Treatment

Some pain problems whilst primarily muscular in nature are refractory tonormaltreatment techniques including TPI.

Clues to these more difficult cases include:

Repetitive work-related activities hamper recovery, for example, constant computer work ("Mouse Arm")

Poor control of background factors including hormonal fluctuations in women or deficiency in men, ongoing depression or pain sensitisation (eg, excessive consumption of analgesic medications, or fibromyalgia)

Poor nutrition and vitamin or mineral deficiency

Biomechanical instability (eg, short leg) or previous surgery

A second problem, for example, degenerative joint disease.

The treatment protocols at the Clinic aim to address these difficult factors by identifying them at the outset and correcting reversible problems.

The results of treatment may be improved by supplementing with the following nutrients: Magnesium - use magnesium chelate 500 - 1000 mg twice daily to aid muscle relaxation.

Vitamin C - use 500 mg twice daily to improve muscle healing and reduce bruising A multivitamin complex to provide broad-spectrum nutrient support - one daily.

If arthritis or degenerative joint disease is present add: Glucosamine sulphate 1500 mg daily Fish oil 1 g twice daily

Further Reading:

http://www.medicineau.net.au/clinical/musculoskeletal/Myofascial.html

http://en.wikipedia.org/wiki/Trigger_point
An excellent overview of the current thinking on Myofascial Trigger Points

http://scholar.google.com.au/scholar?hl=en&lr=&cites=4220654213280795893
A selection of scholarly articles citing trigger point therapy.