Breaking the cycle of chronic pain. What is chronic pain?
Upto one in five Canadian adults suffer from chronic pain. It affects one in five people globally and is the primary reason people seek medical treatment. In most cases, chronic pain starts with an acute injury or illness. Sometimes, what can happen, is that even after you’ve healed from an injury, surgery or other conditions, the pain continues. If the pain lasts longer than 3 months it’s then considered chronic pain.
Chronic pain syndrome can then be considered short term pain, or acute pain, that doesn’t go away and has a physical and psychological impact on a person’s life. Chronic pain syndrome often creates secondary complications such as sleep deprivation, depression, irritability and fatigue, affecting a person’s personal and social relationships.
What is Pain?
Pain functions as a warning signal. The nervous system senses danger and responds to it with actions called guarding responses, designed to protect and defend us from further injury or harm.
Muscle tension, decreased range of motion, anxiety, fear of movement, increased sympathetic responses (raised heart rate, increased blood pressure, change in respiration) and a mechanism called low pain threshold (becoming excessively sensitive to pain and minor impulse or stress to the body region cause pain) are all consequences of the guarding response. This is the way the body protects itself from future painful incidents.
In chronic pain, even after the injury has healed, this mechanism remains and continues to affect the body creating a vicious cycle of real pain.
Your Brain and Pain
When we adopt this instinct to guard ourselves against future pain, it actually does the opposite and keeps feeding your pain cycle and increasing symptoms including pain (scientific research “Pain Processing in the Human Nervous System: A Selective Review of Nociceptive and behavioral Pathways). This guarding mechanism is most likely to occur to those people that view their pain or condition as a threat, rather than something that just is and that in all likelihood can be overcome or at worst worked through towards acceptance and continuing on with life in as normal or your new normal way as possible.
Being extremely apprehensive about your injury and symptoms, avoiding activities believing that that may be harmful, stress and negative emotions are coupled with autonomic, endocrine, and immune responses which may amplify pain through a number of psychophysiological pathways prolonging your “fight or flight” response to the original injury. This will lead to a downward cycle of deconditioning, weakness, muscle spasms and/or tension, increased anxiety and depression.
What can Saanich Physiotherapy and Sports Clinic do to help reverse pain?
Part of our job as physiotherapists and massage therapists is to help you and guide you, our patients, to overcome any fear avoidance behaviour (learned fear), such as fear of movement, by using not only hands-on treatment, dry needling or exercises, to target your injury or pain, but to talk to, explain and assist you in understanding the way that pain and our brain works. We can help you to overcome or negate some of these non-helpful brain responses. By doing this we help you to down-regulate your brains protective response in order to minimise your pain experience.
Working with you in this 1:1 way, taps into your brain and nervous system. Your brain and nervous system is complex. We can work with you to change your neural pathways and learned patterns of thinking and beliefs that in turn produces more of your own natural brain chemicals like endorphins. This resetting and rebalancing, forming positive neural/brain connections, plays a large part in you overcoming your injury or pain experience.
Of course, each individual person is unique and we all come with our own history and life story that also plays a major part in how we experience pain and how we as therapists target your particular treatment. The way we think about our pain and ourselves, how we act and what kind of self-talk we undertake can all play a major role in the way that our Physiotherapists work with you, our patients who suffer from injury, pain, chronic pain, pain sensitivity, learned fear, anxiety, and depression.
What is Dry Needling?
Dry Needling is a specialised form of treatment that we use for reducing your pain and inflammation. Your trigger points are targeted with acupuncture needles to treat your pain, muscle tension, injury, and dysfunction. Dry Needling treatment is highly effective and you will often feel immediate pain relief as your muscles relax.
Common injuries treated with Dry Needling
Headaches & Migraine
Carpal Tunnel Syndrome
Hip & Knee Pain
How does Dry Needling work?
Needles are usually used to target painful trigger points in muscles. The penetration of the needle causes a micro-trauma that increases blood flow and alters the chemical balance in the muscle, assisting with muscle relaxation and healing.
The stimulation of pain receptors also causes the body to release opioids (e.g. endorphins). These are natural pain relievers in your brain. Their release provides further pain relief to you.
Your muscle may respond with a twitch response to the needle stimulation. This is a highly effective form of dry needling treatment and you often feel immediate benefits from this form of release. Your muscle releases tension and lengthens. Substance p, a pain chemical in your body, as well as inflammatory chemicals are eliminated around your trigger point. Flushing out these nasty chemicals can provide a longer lasting pain relief.
How is Dry Needling different to Acupuncture?
Acupuncture generally refers to the traditional Chinese medicine which is based on stimulating the flow of Chi (energy) through the meridians of the body, whereas Dry Needling is based on anatomical and neurophysiological principles. While the dry needles are the same and many of the ideas behind acupuncture are still applicable, the principles behind the use of Needling are very different.
Often people may use the term acupuncture when referring to Dry Needling so if you have had acupuncture in the past it could have been Dry Needles.
Is Dry Needling Physiotherapy safe?
Dry Needling Physio is very safe. There are certain factors that may make you unsuitable for Needling or that require extra care to be taken (e.g. Diabetes) but your Physio will consider these. All dry needles are sterile and used once before being disposed of safely in a sharps container.
Will Dry Needling Hurt?
One of the great advantages of Dry Needles over deep tissue massage for muscle release is that there is generally less pain both during and after treatment.
Most people don’t feel the insertion of the dry needle. When the needle penetrates the trigger point, you may feel an initial twitch or deep ache that quickly settles to become a light dull ache, warmth, heaviness or nothing at all. This is far better than the constant feeling associated with a firm massage that would be required to achieve an equal effect.
After Dry Needling Physio treatment there is often no or little soreness. Sometimes you may feel slightly tight, sore or an ache for a short time (up to 1-2 days). This again is invariably much less that than felt after massage and soft tissues techniques.
Are our devices giving us neck pain?
There are millions of people right now looking down at their smartphone or tablet. Do you ever stop to think about what this might be doing to your neck and upper back?
At Saanich Physiotherapy and Sports Clinic, we are seeing a huge increase in the amount of neck, upper back, shoulder and arm pain which is all related to posture when using devices. From texting on the smartphone to watching TV on the tablet in bed, we are all guilty in some way. And sadly, we are seeing more and more children coming in with these issues too.
Consider how much your head actually weighs. On average, it weighs 4.5-5kg. When sitting or standing upright, this weight is supported by the lower neck vertebrae, intervertebral discs, muscles and ligaments. When you then lean your head forward when looking at your smartphone, the relative weight of your head on your neck muscles can increase up to 27kg! Just by looking down at your phone, you can increase the force on your lower neck by 5 times!
When maintaining this position for a period of time, the muscles will fatigue and stop working, meaning that the force of your head is now being held up by small ligaments, the neck joints and the discs in the neck. It is no wonder people are having more and more neck pain.
The term “Text Neck” is becoming more commonly accepted as a diagnosis for neck pain caused by prolonged use of smartphones and tablets. If left untreated, this massive increase in force in the lower neck and lead to headaches, increased arching of the spine, general pain and tightness and arm pain from irritating nerves in the neck. It can also cause weakening of the muscles in the neck which can lead to ongoing pain, stiffness, headaches or arm pain in the future.
With the increase in children having smartphones and even the use of tablets in school, there are becoming more and more postural issues arising which is definitely a concern for ongoing and long term neck and upper back problems later in life.
Text Neck can be treated. Your Physiotherapist may use joint mobilizations, soft tissue massage, taping or even dry needling to help restore normal movement within the joints and muscles.
However, it is imperative that you strengthen the muscles in the neck and upper back to prevent long term issues. Your Physiotherapist will tailor a program for you to complete at home or might even recommend core conditioning or yoga classes for a supervised strengthening program.
If you, your children or another family member or friend are guilty of using their smartphone or tablet too much and are noticing pain or discomfort in their neck, upper back or arm make sure you book an assessment with your Physiotherapist sooner rather than later!
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.