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.
Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. 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 at 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. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each vertebra, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset 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 known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.
Wearing a knee brace has been shown to “significantly improve the pain and symptoms” of a type of osteoarthritis affecting the kneecap, according to a new study.
Arthritis Research UK-funded researchers at The University of Manchester claim their findings, presented at the Osteoarthritis Research Society International meeting in Philadelphia have enormous potential for treating this common joint condition effectively — as well as providing a simple and cheap alternative to painkillers.
Osteoarthritis of the knee affects around six million people in the UK and is increasing as the population ages and becomes more obese. Current treatments are limited to pain relief and joint replacement.
Osteoarthritis of the knee affecting the kneecap (patellofemoral osteoarthritis) accounts for about 20% of patients with knee pain. They typically experience pain that is made worse by going up and down stairs, kneeling, squatting and prolonged sitting.
“There’s a pressing need for non-surgical interventions for knee osteoarthritis, and little attention has been paid to treatments particularly aimed at the kneecap (the patellofemoral joint), a major source of knee pain,” explained Dr Michael Callaghan, research associate in rehabilitation science at the University of Manchester.
“We’ve shown that something as simple as a lightweight knee brace can dramatically improve the symptoms and function for people with this particular type of knee osteoarthritis.”
The research team conducted a randomised controlled trial of a lightweight lycra flexible knee brace fitted around the knee with a support strap for the kneecap. One hundred and 26 patients between the ages of 40 and 70 were treated over a 12-week period. All had suffered from arthritic knee pain for the previous three months.
They were randomly allocated to either immediate brace treatment or delayed treatment (i.e. after six weeks.) Both groups of patients eventually wore the brace for a period of 12 weeks and averaged roughly seven hours a day.
After six weeks of brace wearing there were significant improvements between the brace wearing group and the no treatment group in scores for pain, symptoms, knee stiffness, muscle strength and function. After 12 weeks there were significant improvements in these scores for all patients compared to when they started.
“Patients repeatedly told us that wearing the brace made their knee feel more secure, stable, and supported,” Dr Callaghan added. “Our theory is that these sensations gave the patient confidence to move the knee more normally and this helped in improving muscle strength, knee function and symptoms.”
Professor Alan Silman, medical director of Arthritis Research UK, which funded the trial, said: “Osteoarthritis of the knee is a painful disorder that affects millions of people in the UK, causing pain and reducing activities. We know that in patients with arthritis, the knee joint is frequently out of normal alignment, which might be an underlying cause of the problem, as well as making it worse.
“By using a simple brace, the researchers have been able not only to correct the alignment but achieve a very worthwhile benefit in terms of reducing pain and function. This approach is a real advance over relying on pain killers and has the potential to reduce the end for joint surgery and replacement, procedures often employed when the symptoms become uncontrollable.”
The ROAM (Research into Osteoarthritis in Manchester) project has run three trials at The University of Manchester and the University of Salford.
HIP AND KNEE PAIN
Spacing exercise-based physical therapy sessions over a 12-month period while using three additional “booster” sessions periodically has been shown to be more cost effective than alternative physical therapy strategies in the treatment of knee osteoarthritis, according to research presented this week at the American College of Rheumatology Annual Meeting in San Francisco.
Osteoarthritis, sometimes called degenerative joint disease, is a slowly progressive disease in which joint cartilage breaks down. Normally, cartilage on the ends of bones allows smooth, pain-free joint movements. In OA, cartilage becomes thin and irregular, resulting in symptoms of joint pain and stiffness. Grinding or cracking sensations may occur. Joints that are under high stress due to repeated activity or weight bearing are most susceptible to OA. The hips, knees, hands and spine are commonly affected. OA becomes more common with aging.
Common pharmacologic treatments for OA include nonsteroidal anti-inflammatory drugs (called NSAIDs) and analgesics (e.g., acetaminophen and ibuprofen), and exercise is considered an excellent first line, conservative, treatment for the disease. Researchers recently compared the cost-effectiveness of four different physical therapy strategies among 300 people with knee OA participating in a two-year study across several different institutions.
Strategy one included 12 visits of exercise therapy alone over a nine-week period; strategy two included eight initial visits of exercise therapy within a nine-week period plus four booster sessions at 3 time points (two boosters at month five and one at months eight and 11) spaced across a 12-month period; strategy three included 12 visits of exercise therapy plus manual therapy; and strategy four included eight initial visits of exercise therapy plus manual therapy and four booster sessions. Total health care costs were estimated using patient-reported outcomes as well as data from the Healthcare Utilization Project and the Medicare physician fee schedule.
“We believed there was a need to improve both the magnitude and sustainability of treatment effects of exercise therapy for improving pain and function in people with knee OA,” explains G. Kelley Fitzgerald, PT, PhD, FAPTA; professor and associate dean of graduate studies, University of Pittsburgh School of Health and Rehabilitation Sciences and the principal investigator in the study.
“Previous research indicated that using manual therapy might be a way of improving the magnitude of treatment effects, and booster sessions might be a way of ensuring sustainability of treatment effects. We also believed it would be important to determine the impact on health care costs to inform best-practice approaches with regard to using manual therapy and/or booster sessions, should they prove to be clinically effective.”
The researchers noted that the booster strategies (strategies two and four) significantly lowered health care costs and showed greater effectiveness in the treatment of knee OA. Between those two strategies, strategy two cost $1,061 more, but gained .082 more quality-adjusted life years, which looks at the burden of the disease in comparison with the quality and quantity of life.
Overall, the study showed that, while exercise therapy remains effective in treating people with knee OA, it might be more effective to supplement exercise with manual therapy and space physical therapy visits over a longer period of time to maximize long-term benefits.
“These results indicate that supplementing exercise with manual therapy and spacing physical therapy sessions across a longer period of time may provide greater benefit to individuals with knee osteoarthritis, while simultaneously reducing downstream health care utilization,” explains lead investigator in the study, Allyn Bove, PT, DPT; assistant professor, Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences.
Based on these findings, Dr. Bove believes patients should consider consulting a physical therapist to treat the pain and disability caused by knee OA and notes they should be willing to potentially commit to re-visiting their physical therapist every few months to reinforce the benefits. Additionally, Dr. Bove says these findings may encourage physical therapists to add more manual therapy techniques, as well as booster sessions to their plans of care for these patients.
Materials provided by American College of Rheumatology (ACR).