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IMS: The missing link?

IMS: The missing link?

A blog by Amy Mathews Amos- See below

My symptoms started in January 2008, with deep pain in my bladder and the sense that I had to urinate constantly. I was given a diagnosis of interstitial cystitis, a chronic bladder condition with no known cure. But in the following months, pain spread to my thighs, knees, hips, buttocks, abdomen and back. By the time my condition was properly diagnosed three years later, I had seen two urogynecologists, three orthopedists, six physical therapists, two manual therapists, a rheumatologist, a neurologist, a chiropractor and a homeopath.

What was wrong? Something completely unexpected, given my symptoms: myofascial pain syndrome, a condition caused by muscle fibers that contract but don’t release. That constant contraction creates knots of taut muscle, or trigger points, that send pain throughout the body, even to parts that are perfectly healthy. Most doctors have never heard of myofascial pain syndrome and few know how to treat it.

In my case, trigger points in my pelvic floor — the bowl of muscle on the bottom of the pelvis — referred pain to my bladder. Points along my thighs pulled on my knee joints, creating sharp pain when I walked. Points in my hips, buttocks and abdomen threw my pelvis and lower spine out of alignment, pushing even more pain up my back. The pain was so severe at times that I could sit for only brief periods.

“Why didn’t anybody know this?” I asked my doctor, Timothy Taylor, soon after he correctly diagnosed the reason for my pain. “Because doctors don’t specialize in muscles,” he said. “It’s the forgotten organ.”

‘There’s no wire’

Most medical schools and physical therapy programs lack instruction in myofascial pain, in part because it involves referred pain, according to Robert Gerwin, an associate professor of neurology at Johns Hopkins University. Gerwin, who is also president of Pain and Rehabilitation Medicine in Bethesda, says that medicine has only recently come to understand this type of pain.

 

“I remember a long conversation with a neurosurgeon saying that [referred] pain is impossible because there’s no connection, there’s no wire, no string, no blood vessel, there’s no nerve, there’s no nothing connecting these two places,” Gerwin said. Of course, the surgeon was “not realizing that the mechanism of spread is through the spinal cord.”

Pain signals from taut muscle fibers travel to specific locations on the spinal cord that also receive signals from other parts of the body. Referred pain occurs when pain signals from muscles register in the nervous system as if they came from elsewhere.

Although physicians increasingly recognize referred pain today, diagnosis and treatment of myofascial pain often takes more time than most physicians can provide, according to Taylor. Practitioners need specific training to recognize trigger points. And they must examine and palpate patients carefully to identify and locate these taut bands of muscle fiber.

 

In a 2000 survey, more than 88 percent of pain specialists agreed that myofascial pain syndrome was a legitimate diagnosis, but they differed over the criteria for diagnosing it.

Norman Harden, the medical director of the Center for Pain Studies at the Rehabilitation Institute of Chicago, conducted that survey. He believes that practitioners need clear, validated criteria for diagnosing myofascial pain and identifying effective treatments. He recently conducted another survey to determine if the level of recognition among pain specialists has changed. Preliminary results suggest it has not.

According to Gerwin, myofascial trigger points often cause or contribute to problems such as chronic back pain, headaches and pelvic pain. Trigger points can form anywhere in the body after an injury or if muscles brace against pain or trauma for a long period. They also can result from chronic overuse of muscles due to stress or to poor posture that puts constant pressure on muscles not designed to withstand it.

Taylor understands this as both a physician and a patient. His myofascial pain started in 2003 during his daily run. “I felt a sharp pain in my rear that felt just like when my brothers used to shoot me with our BB gun,” he recalled. He checked himself for signs of injury but found none, then limped home, assuming it was a strained muscle that would heal after a few days. It didn’t.

 

He sought treatment first from his general practitioner. He then went to a battery of specialists: neurologists, rheumatologists, orthopedic surgeons, osteopathic physicians, physical medicine and rehabilitation specialists, and physical therapists.

Found it on the Internet

After three years, a physical medicine and rehabilitation specialist told him the source of his pain was his piriformis muscle, a pear-shaped muscle that runs diagonally across the buttocks. The doctor prescribed stretching and strengthening exercises to resolve it, but they only made things worse. Eventually, the pain reached down to Taylor’s knees, up to his head and out to his fingers on both sides of his body.

But he finally had a useful piece of information. He did an Internet search for “piriformis muscle” — a common spot for trigger points — and “myofascial pain syndrome” popped up. “I had been to the bone doctor and the joint doctor and the nerve doctor and the rehab doctor, and none of them had really examined my muscles in great detail,” he said. And none of them identified trigger points. Taylor has since changed his focus from radiology to working toward understanding, diagnosing and treating the condition. When I met him in 2011 he had established a practice that specializes in pain syndromes.

A popular treatment is dry needling, which sounds like exactly what it is: Tiny needles are inserted into the skin to stimulate a twitch response in the heart of a trigger point, releasing it. Although similar to acupuncture, dry needling focuses directly on trigger points rather than on the meridians, or energy fields, recognized by Chinese medicine. Usually, each trigger point requires several treatments before it relaxes substantially. Between sessions, patients treat themselves each day by pressing the points against a hard surface with simple tools such as tennis balls and holding for a minute or two. Treatment also addresses posture-related strains on muscles and metabolic factors such as vitamin and mineral deficiencies, low thyroid and hormonal imbalances that can contribute to trigger points.

Though a few studies have been done, they have not adequately demonstrated the effectiveness of treatments for trigger points, according to a 2009 review published in the European Journal of Pain. Researchers at the Universities of Exeter and Plymouth and the British Medical Acupuncture Society reported that only one of the seven studies they reviewed found dry needling to be effective in reducing pain. Four other studies found no difference between dry needling and placebo treatment, and the two remaining studies had contradictory results.

 

The American Academy of Orthopaedic Manual Physical Therapists recognizes dry needling as a legitimate treatment. The group maintains that research shows that dry needling reduces pain and muscle tension and helps muscles with trigger points return to normal. Other studies are underway. Jay Shah of the National Institutes of Health and Lynn Gerber and Siddartha Sikdar of George Mason University are using ultrasound imaging to examine how dry needling changes the physiology of trigger points after treatment.

Diagnostic guidance

Gerwin says that proper training in finding the trigger points can lead to consistency in diagnosing them. He and physical therapist Jan Dommerholt of Bethesda Physiocare run Myopain Seminars, which help physicians and physical therapists learn how to diagnose and treat trigger points.

According to Harden at the Rehabilitation Institute of Chicago, without clearer diagnostic criteria accessible to general practitioners, experiences like mine will continue. “As awareness grows and doctors feel empowered to understand and make this diagnosis, then that endless and frustrating round of trying to find what I’ve got and what the answer is will stop,” he said.

Gerwin agrees that more research will help, but already he sees greater acceptance of trigger points in the medical community.

“I think the bottom line is simply that the
underlying pain physiology is understood now to explain why referred pain occurs, to understand why tenderness occurs,” he said. “And that explains a lot of what muscle pain is all about.”

In my case, through a combination of therapies, including dry needling, compression, stretching, postural changes and relaxation techniques, I feel much better. I no longer need dry needling, but I do need to practice the other techniques myself, regularly, to prevent trigger points from reforming or to release them myself when they do form.

 

Amy Mathews Amos, a science writer in Shepherdstown, W.V., blogs at amymathewsamos.com.

 

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Tension Headache? Learn more

Tension Headache? Learn more

“Tension headaches” are often talked about and we see a lot of patients with these headaches. In our diagnosis of these conditions, about eighty five percent of all headaches arise from the neck, or cervical spine, which refers pain into the head through the nerves which go to both areas. Neck problems cause head pain because some of the nerves which come from the spinal cord have branches which go to the upper neck joints and other branches which spread over the back of the head, with still others going to the front of the head. When one area is sore the brain interprets the pain as coming from all the areas the nerve branches go to.

CAUSES OF TENSION HEADACHES

Patients who have “Tension Headaches” or “stress headaches’’, are often very busy and have work related problems, a tough boss, urgent deadlines, problems with managing work flow and they often have trouble sleeping because of work problems and their worries. This causes the patient to be mentally and emotionally stressed and their relationships at work and with their families suffer.
They develop a headache which they cannot shake and they feel helpless, tired, tense, anxious and in pain. We have seen many cases where the headaches have continued for weeks and frequently kept recurring, sometimes over many years.

It is important to understand that a Tension Headache is due to “physical tension” in the tissues, often from a poor working position and the damage it has caused, not the other mental “tensions” listed above. Once full neck movement has been restored with treatment, the tissues have healed and the postural strains have been removed, patients often cope better with the other aspects of their lives. This is where Physiotherapy can help by breaking the vicious “Physical Tension” cycle. It is better to think of these as “structural headaches”.

Our neck is made of seven vertebrae stacked one above another. They support the head and they are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints which join the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. The junction of the first vertebra and the head does not have a disc and the joints there are particularly susceptible to leaning forward which causes the weight of the head to strain the joints, ligaments and muscles as gravity causes a shearing force as the head slides downward.

The neck muscles are often blamed as the cause of pain but this is rarely the whole story. Muscle pain often develops as the muscles contract to prevent further damage, as they protect the primary underlying structures. This pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture, etc, there is temporary relief but the pain will always comes back as the muscles resume their protective bracing. The most common sources of primary pain are the facet joints and their ligaments in the upper neck and the discs in the lower levels of the neck.

A facet joint strain is much like an ankle sprain, strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged.

In the upper neck, facet joint strains typically occur during excessive bending or twisting movements and may follow trauma such as a car accident causing whiplash but generally, Tension Headaches occur with prolonged forces such as slouching, keying and reading.

There is often a previous history of pain coming and going as the damaged area became inflamed, was treated and settled for a while but as the underlying problem still remained, the pain flared up repeatedly every time it was strained. This type of injury, although often chronic, responds very well to specific Physiotherapy treatment.

OTHER CONDITIONS

There are many other sources of headaches and neck pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will advise you should a more serious condition be suspected.

SYMPTOMS OF TENSION HEADACHES

Symptoms of “Tension Headaches” arising in the neck, are always affected by movement of the head and neck. This is important to understand. Symptoms are sometimes severe and may be sudden in onset but also may be mild and of gradual onset. There are other serious conditions which can produce headaches. If you have severe headache symptoms which are not affected by movement and a recent history of fever or nausea, you must consult a doctor urgently.
Facet joints, discs, muscles and other structures are affected by our neck positions and movements and when damaged, will respond very well to Physiotherapy treatment.

DIAGNOSIS OF TENSION HEADACHES

“Tension Headaches” often appear complex and require a full understanding of the history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues and these coexisting pathologies are treated individually as each is identified. Where the Physiotherapist requires further information or management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.

TENSION HEADACHE RELIEF

Some of these cases will temporarily respond to a general non-specific treatment such as bed rest, ice and anti-inflammatories, however Musculoskeletal Physiotherapists have developed diagnostic skills and treatment techniques, targeted to stopping “Tension Headaches”. We will identify the reasons for the development of the pain and advise strategies to promote healing and to prevent further damage.

Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education.

When normal function has been achieved, the inflammation and pain has settled and the structures have healed, using your new strategies will reduce the possibility of the headaches ever recurring. We use this approach to reduce or stop chronic pain. While we have the choice to manipulate or “click” joints, those with ongoing pain will seldom benefit from repeated “adjustment”. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost as the tissues tighten up again. Potentially dangerous “adjustments” of this type have little long term benefit and can lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safe and appropriate treatment for you.

PROGNOSIS OF TENSION HEADACHES

Physiotherapy for “Tension Headaches” can provide outstanding results but it is a process, not magic. The damage which produces “Tension Headaches” takes time to develop and time to repair and heal. You will understand there are often several interacting factors to deal with and your compliance is necessary.

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Low back pain? Remember this: Arch is good, flat is bad!

Low back pain? Remember this: Arch is good, flat is bad!

If you want to steer clear of lower back pain, remember this: Arch is good, flat is bad.

Back pain is anything but rare; only headaches and colds are more common. According to the National Institute of Neurological Diseases and Stroke, Americans spend more than $50 billion each year on lower back pain, which is the No. 1 cause of job-related disability in the country and one of the leading contributors to missed time from work.

There’s acute lower back pain, sometimes intense but generally short-lived discomfort resulting from injury to the lower back incurred during sustained physical activity (playing sports, doing yard work) or by a sudden jolt (being in a vehicle collision). But it’s chronic lower back pain, the kind that lasts for more than three months, that is more debilitating and more difficult to treat.

Much of that chronic pain is caused by damage to the discs — the spongy, multi-function structures that lie between the spine’s vertebrae — in the lower part of the back right above the pelvis known as the lumbar region. And much of that damage is caused by poor body mechanics — the way people stand, walk, lift, carry, reach, bend, sit and sleep — in which the back is too often flat, not arched.

“The key to avoiding lower back pain is keeping pressure off your lower lumbar discs,” said Tadhg O’Gara, M.D., an orthopaedic surgeon at Wake Forest Baptist Medical Center in Winston-Salem, N.C. “That means keeping an arch to your lower back.”

The intervertebral discs, essentially the spine’s shock absorbers, are under constant pressure, especially in the lower back, which supports the weight of the upper body. The five vertebrae in the lumbar region are naturally arched toward the front of the body, so bending forward compresses the front of these disks, which over time can force them out of position to press on one or more of the nerves emanating from the spinal cord. This condition — known as a bulging, herniated or ruptured disc — can cause pain in the lower back and elsewhere, especially the buttocks, thighs and even below the knee (sciatica). And that pain can be severe.
“People who haven’t had lower back pain don’t re alize how painful it is,” O’Gara said. “And many health care providers don’t realize how painful it is.”
So how is chronic lower back pain treated?

“The first thing to figure out is what exactly is causing the pain, because that determines what approach to take with treatment,” said Kristopher Karvelas, M.D., assistant professor of physical medicine and rehabilitation at Wake Forest Baptist. “That’s not always easy. Pain is usually related to the discs, but other causes of low back pain have overlapping symptoms and pain patterns.”

Basic diagnostic methods include physical examination, review of the patient’s medical history and patient descriptions of the onset, location, severity and duration of the pain and of any limitations in movement. Imaging techniques such as X-rays, MRI and CT scans also can be employed to pinpoint the source of pain.

Once the reason behind the pain is determined, the most frequently prescribed treatment is physical therapy, not surgery.

“I typically reserve surgery for patients who have a medical need other than pain,” Karvelas said. “There’s a large toolbox that we can go to for patients, and surgery is the last tool.”

Depending on the individual patient’s condition, physical therapy programs usually include exercises designed to strengthen back and abdominal muscles and to promote proper posture and balance. These can include stretching, swimming, walking and even yoga. But education also is a key element.

“Patients need to recognize that posture and activity are crucial in relieving and preventing back pain,” Karvelas said. “They need to learn what exercises to do on their own and how to do them properly to prevent future flare-ups.

“We can help resolve acute back pain episodes, but when we are talking about chronic back pain, the pain may never resolve completely. However, we do use a team approach to treat patients and teach people how to cope with their pain effectively.

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Shoulder Pain for Freestyle Swimmers. Yikes

Shoulder Pain for Freestyle Swimmers. Yikes

 

Elite and competitive swimmers log between 60,000 and 80,000 meters weekly — swimming the length of an Olympic-sized pool 1,200 times — which places significant stress on their shoulder joints. “The upper body provides 90 percent of the propulsive force to move through the water. Due to the amount of force generated and the range of motion required to swim efficiently, the shoulder needs to have perfect mechanics to avoid injury,” says Dr. Elizabeth Matzkin, lead study author of a literature review in the August issue of Journal of the American Academy of Orthopaedic Surgeons and assistant professor of orthopaedic surgery at Harvard Medical School.

Swimming is an endurance sport but “swimmer’s shoulder” — a broad non-medical term often used to describe a variety of shoulder injuries — can affect swimmers at all levels. According to the literature review authors, many shoulder injuries are preventable with proper technique, training, stretching, and strengthening.

Shoulder pain affects 40 to 91 percent of competitive swimmers. Overuse and poor shoulder mechanics can cause muscle imbalances, decreased range of motion of the shoulder, and less efficient swim strokes, all placing athletes at greater risk for further injury. The most common swimming-related injuries include:

Impingement — As swimmers becomes fatigued, the pectoralis muscles (commonly known as “pecs”) compensate for tired muscles, which can cause the peak of the shoulder blade to rub (impinge) against the rotator cuff (tendon and bursa), stress the anterior (front of the body) ligaments, and create tears in the tissue that holds the top of the arm bone in place.

Scapular dyskinesis — Intense, repetitive rotation of the shoulder blade over the chest wall can overstretch and loosen the upper back muscles that keep the shoulder bones in a healthy position. Abnormal shoulder mechanics (scapula dyskinesis) can cause pain near the collarbone when the upper chest muscles tighten to compensate for the loosened upper back muscles.

Glenohumeral internal rotation deficit (GIRD) — Intense, repetitive rotation of the shoulder blade can cause the front shoulder ligaments to overstretch and loosen. This can cause the soft tissues and muscles in the back to tighten to compensate for the loosened front shoulder muscles while limiting the internal rotation of the shoulders, which puts swimmers at greater risk for rotator cuff tears. Swimmers must maintain some shoulder looseness to remain competitive. However, about 20 percent of competitive swimmers have hyperlaxity — the ability of joints to move beyond the normal range of motion — which increases the likelihood of greater shoulder instability and susceptibility to pain.

Possible and often subtle signs of shoulder injuries among swimmers may include:

A dropped elbow during the recovery phase of the freestyle stroke.
Excessive body roll, which may signify shoulder pain.
Drooping of the affected shoulder.

“Injury prevention is best accomplished by proper training. Most importantly, swimmers need to stretch, especially the posterior shoulder capsule, and avoid muscle imbalance by strengthening both the rotator cuff and the scapular stabilizer muscle groups,” says Dr. Matzkin. When a swimmer experiences shoulder pain, a thorough physical examination is important to diagnose the source of the pain, whether there is atrophy in the shoulder or reduced strength in the shoulder joint.
Treatment may include nonsurgical (e.g., a combination of ice, stretching, and anti-inflammatory medication, focused rehabilitation to reduce pain) or surgical (e.g., for structural injuries to manage pain rather than to enhance athletic performance) options to potentially prevent future injuries.

Journal Reference:
Elizabeth Matzkin, Kaytelin Suslavich, David Wes. Swimmer’s Shoulder. Journal of the American Academy of Orthopaedic Surgeons, 2016; 24 (8): 527 DOI: 10.5435/JAAOS-D-15-00313

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