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.
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.
Sports Injury Prevention for Baby Boomers
While there may be no single fountain of youth, you can slow down the aging process by staying physically active. Regular exercise enhances muscle and joint function, keeps bones strong, and decreases your risk of heart attack and stroke.
Here are some tips developed by the American Orthopaedic Society for Sports Medicine and American Academy of Orthopaedic Surgeons that can help you exercise safely.
Always take time to warm up and stretch before physical activity. Research studies have shown that cold muscles are more prone to injury. Warm up with jumping jacks, stationary cycling or running or walking in place for 3 to 5 minutes. Then slowly and gently stretch, holding each stretch for 30 seconds. Do not stretch cold muscles.
Just like warming up, it is important to cool down. Gentle stretching after physical activity is very important to prepare your body for the next time you exercise. It will make recovery from exercise easier.
Consistent Exercise Program
Avoid the “weekend warrior” syndrome. Compressing your exercise into 2 days sets you up for trouble and does not increase your fitness level. Try to get at least 30 minutes of moderate physical activity every day. If you are truly pressed for time, you can break it up into 10-minute chunks. Remember that moderate physical activity can include walking the dog, working in the garden, playing with the kids and taking the stairs instead of an elevator. Parking on the far end of a parking lot will increase the distance you have to walk between your car and your destination.
Take sports lessons. Whether you are a beginner or have been playing a sport for a long time, lessons are a worthwhile investment. Proper form and instruction reduce the chance of developing an “overuse” injury like tendinitis or a stress fracture.
Lessons at varying levels of play for many sports are offered by local park districts and athletic clubs.
Invest in good equipment. Select the proper shoes for your sport and use them only for that sport. When the treads start to look worn or the shoes are no longer as supportive, it is time to replace them.
Listen to Your Body
As you age, you may find that you are not as flexible as you once were or that you cannot tolerate the same types of activities that you did years ago. While no one is happy about getting older, you will be able to prevent injury by modifying your activity to accommodate your body’s needs.
Use the Ten Percent Rule
When changing your activity level, increase it in increments of no more than 10% per week. If you normally walk 2 miles a day and want to increase your fitness level, do not try to suddenly walk 4 miles. Slowly build up to more miles each week until you reach your higher goal. When strength training, use the 10% rule as your guide and increase your weights gradually.
Develop a balanced fitness program that incorporates cardiovascular exercise, strength training, and flexibility. In addition to providing a total body workout, a balanced program will keep you from getting bored and lessen your chances of injury.
Add activities and new exercises cautiously. Whether you have been sedentary or are in good physical shape, do not try to take on too many activities at one time. It is best to add no more than one or two new activities per workout.
If you have or have had a sports or orthopaedic injury like tendinitis, arthritis, a stress fracture, or low back pain, consult your Physiotherapist who can help design a fitness routine to promote wellness and minimize the chance of injury.
Some reflections on concussion from the author below. We can help if you do have concussion.
A Carolina Panthers player left the Super Bowl and was found to have a concussion.
By David L. Katz
Fortunately for me and the others gathered at the Katz home, we enjoyed a fabulous, Cuisinicity.com meal for the Big Game. No surprise there; my wife is the culinary genius behind the site.
Thank goodness for the wonderful dinner, because the game itself was rather disappointing. There was, I trust my fellow spectators will agree, an unusual bumper crop of penalties, some egregiously bad calls by the referees, some truly strange mistakes by players and a disquieting bounty of poor sportsmanship into the bargain. Congratulations to the Broncos and Peyton just the same, but seriously, weird game.
Alas, it also featured an announcement all fans of the game should now know is a reason for a collective wince: concussion protocol. Corey Brown, of the Carolina Panthers, left the game after a head injury, underwent neurological evaluation and was found to have a concussion.
I trust everyone now knows the ominous implications of that kind of injury if repeated periodically over the course of a career. The media attention to Chronic Traumatic Encephalopathy, or CTE, is considerable and rising. The movie “Concussion,” starring Will Smith, raises the profile further. I highly recommend the movie if you haven’t seen it, by the way. It is very well done, and beautifully acted, and entertaining even as it educates.
I have no particular expertise in CTE beyond any doctor’s basic understanding of it, and others have said plenty already. If you are interested, as every football fan should be, and certainly as every parent of a child inclined to play football must be, the relevant information is readily available. I will take the opportunity to make a different point, about the cultural malleability of “normal,” and thus, “acceptable.”
While I have no claim to the football-fan hall of fame, I like the game as much as the next guy. I am wondering more and more, though, if my entertainment is worth the price the players are paying.
Football is part of our culture, and thus normal. We might thus think that if it has occasional consequences, those, too, are normal. That may make them seem acceptable. But that’s the real danger here: complacency. We can perhaps only see it looking across cultures, rather than from corner to corner within the box that is our own.
Consider, for instance, the Gladiatorial Games of Roman times. Those were, infamously, contests to the death, whether between people, or people and wild, half-starved animals. The only vague approximations of any such barbaric entertainment in the modern world are, so far as I know, bull fighting, and the generally illegal contests between fighting dogs or roosters. There is no longer any mainstream interest in watching bloody death for entertainment.
But that’s simply because sensibilities and culture have evolved. The Romans were people just like us. Their society, too, was made up of mothers and fathers, aunts and uncles. They, too, knew love and compassion. But they cheered while watching young men, literally, kill one another. In their culture, it was normal, and thus acceptable; but I trust we agree history has reached a different verdict.
I happen to be a fan of both the late Heath Ledger, and Paul Bettany, and was thus predisposed to love the movie “A Knight’s Tale.” I’m no movie critic – I can’t say whether or not it’s a great movie – I can only say I like it.
The movie is especially noteworthy for how it handles anachronism. More than once, it features period elements, like music, and then transitions them to the modern analog, such as a rousing rendition of “The Boys Are Back in Town” by Thin Lizzy. More memorable still is a scene at a dance. Heath Ledger’s character is dancing with his love interest in the stylized manner of medieval folk dance. The music then transitions to the late, great David Bowie – “Golden Years,” to be exact – and the dancing keeps pace, morphing into what one would expect, more or less, in any given club on any given Saturday.
The director, I think, was telling us something important: The old-fashioned music and dance of medieval times would not have felt old-fashioned then. It was, simply, the music and dance of its day. It was normal. Showing medieval folk dancing to a modern audience says: this was an old-fashioned party. The director substituted “current” music and dance to show us how it felt to the participants. It was current and normal then, and no matter how it feels to us now, that’s how it would have felt to them.
That’s relevant to football. We are not willing to entertain ourselves by watching young men bash one another’s heads in with maces, as the Romans did. But we do entertain ourselves as young men bash their helmeted heads into one another repeatedly over a span of years, with all-too-often calamitous consequences.
Our gridiron heroes are latter-day gladiators. And their house – the house of football – inspires almost religious devotion in our culture. But that may be only because it is part of our culture. Imagine if football did not yet exist, and we were thinking of introducing it, and knew about CTE from the start. Would we add such a game and such a liability to our cultural entertainments?
The one-time editor of the Journal of the American Medical Association, and later Medscape, Dr. George Lundberg, reflected along similar lines in the New York Times recently. He discusses cultural evolution over a much shorter period than the Middle Ages to now, noting a marked change in his personal – and our societal – enthusiasm for the brutalities of boxing. Both the sport and its following have changed dramatically in recent years, and he conjectures that football is in that same queue.
My principal mission here is to point out the inevitability of culturally induced blindness to the unacceptable elements of what is currently normal. We live in a time of epidemic obesity and its complications in our children, yet continue to market multicolored marshmallows to them as “part of a complete breakfast.” This is absurd, and history will judge us accordingly, but it’s normal now – and so we overlook the hypocrisy. Cultures around the world justify practices as heinous as female genital mutilation. What passes for “normal” is self-defining, and to some extent, self-perpetuating.
Until, that is, we evolve beyond it. Looking back, what was normal yesterday often proves repulsive and contemptible today.
We speak routinely about “thinking outside the box,” but when the box is culture, that is much easier said than done. Everything we know is inside the box, as are we. The contents of the box at any given time are normal.
History turns the years into a ladder. Out of the box we all climb, into a bigger box presumably, as we gain the perspective of altitude, and roll our eyes at the mess we’ve left behind.
I love watching football. The Romans presumably loved their gladiatorial games. Both are normal in context. That doesn’t guarantee that either is right.
For the sake of today’s players, and our sons inclined to take their places, I hope we reform the game of football sooner than later. It’s a great game, but not when paid for with brains scrambled, and lives cut short.
In general, we need to recognize how readily we follow the gospel of any given culture telling us what’s normal. We need to recognize that normal is simply what we do now, and that it isn’t necessarily right. Perhaps the true measure of cultural enlightenment is how ably we judge ourselves in real time as history is sure to do in the fullness of time.
Some common spinal injuries and conditions we treat:
Acute lower back (lumbar) pain due to spinal disc and/or facet joint injuries
Chronic low back (lumbar) pain
Sciatica – referred pain and symptoms into the lower limb
Pelvic dysfunction syndromes . Often diagnosed in patients who feel ‘out’.
Childbirth related instability and acute pain syndromes of the lower back and pelvis.
Spondylolisthesis (forward slip of one vertebrae on the vertebrae directly below it)
Spondylosis (disc space narrowing combined with degenerative changes in the facet joints common with age)
Acute neck pain due to facet joint and/or spinal disc injury
Chronic neck pain
Brachialgia-referred pain and symptoms into the arm, ‘pinched nerve’ pain and/or pins and needles/numbness (known as paraesthesia)
Mid-back (thoracic) and rib (costovertebral joint) pain (which, in some cases, refer pain around the chest wall)
Acute/chronic (myofascial) trigger point conditions. (These are tender and hypersensitive coin sized zones within the muscle tissue that can cause local pain and tightness and can also refer to distant sites.)
Muscle and joint stiffness
Causes of Spinal Pain
Acute and chronic spinal pain is experienced due to the stimulation, via mechanical or chemical irritation, of small nerve endings, nerve root or spinal cord sheaths, nerve cords, complex pain mechanisms in the central nervous system or a combination of the above.
Acute Spinal Pain
This can involve findings of bulging disc, disc protrusion or disc prolapse/rupture. Disc problems are very common in the lower back (lumbar spine). They are often associated with episodes of bending, bend with twist or prolonged sitting /driving which distorts the rim of the disc causing acute pain. In addition it can produce pressure on the spinal nerves in the lower back which produce symptoms known as sciatica. This is felt as pain, pins and needles sensation, numbness and/or weakness in the leg(s). In the neck (cervical spine), disc injuries can cause debilitating pain into the neck and commonly severe pain into the arm called brachialgia due to compression of the spinal nerves in the neck. This is commonly referred to as ‘pinched nerve’.
These joints are small joints which flank the disc on either side and behind the spinal discs. They are like a finger joint in their structure and when injured swell and inflame and cause acute pain and restriction of movement. They can be sprained in an injury or activities involving twisting, arching and reaching upward movements. In the neck they can become overstrained by an awkward night’s sleep leading to a condition known as ‘Acute Wry Neck’. They can cause local pain and also refer pain to neighbouring and even distant sites.
The joints of the pelvis can suffer acute injuries through high force trauma such as motor vehicle/bicycle accidents, contact sports, slips and falls on to the ground/floor, landing from a height, or when the female pelvis is vulnerable before and after childbirth. Injury and acute instability syndromes can occur which involve the sacroiliac and pubic joints. Lumbo-pelvic dysfunction conditions are common in the sporting population. Muscle imbalance, asymmetrical posture and structural alignment, as well as poor activation and stabilising strength (core control) can create syndromes such as chronic back pain, Osteitis Pubis (OP), recurrent hamstring strains, and contribute to a range of soft tissue injuries/conditions in the lower body.
This refers to the soft tissue layer involving the muscles, tendons and fascial tissues. This can be injured acutely and cause local pain at the site of injury but can also be responsible for ache and pain at distant sites. Myofascial pain is often associated with damage to deeper joint structures, namely disc and facet joints as either a primary (injured tissue) and/or secondary (protective spasm) component of the acute injury.