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6 Articles in Volume 1, Issue #6
Accurate Diagnosis
Getting Off the Pain Roller Coaster
Getting to the Point
Opioid Rotation: Mechanisms, Concepts, and Benefits
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 4
The Pain and Sleep Relationship

Getting to the Point

Myofascial soft-tissue techniques can release trigger points and help patients better manage their pain.

Chronic pain disorders are not always well understood by the medical or psychological community. In an effort to understand, extensive physical examinations, CAT, MRI, X-ray, and laboratory tests are completed in order to find concrete evidence that a real problem exists. Even when the results of these examinations are found to be within normal limits, many patients continue to complain about their pain problems well beyond what most health care providers consider would be appropriate for a particular injury or related problem.

When the Medical Examination Shows No Specific Problem

The focus of medical science and practice has been directed at understanding and treating acute life and death problems. Little attention has been focused on how to handle the long-term chronic problems that people are expected to live with. When patients present with chronic pain, it is easy for many medical practitioners to assign them to the category of psychological overlay since no observable cause can be found for the lingering pain problem. Additionally, by the time chronic pain patients ask for help they are frustrated, angry, depressed, feeling overwhelmed, fatigued, and have poor sleep patterns. Even those patients with identified chronic pain pathology have additional problems, which can be amplified by myofascial soft-tissue problems. These are often caused by how patients stand, brace, and protect their bodies from pain, and from underlying structural irritations that cause muscles to tighten and become tense. This causes much frustration and confusion for patients and providers.

Crisis intervention theory suggests that when people are under stress they tend to psychologically regress thus resulting in the person looking sicker than may be the actual case. Such regressions make it easier for medical professionals to also feel frustrated by not knowing how to provide curative services to this difficult population of patients. This creates a unique tension between providers and patients, each searching for an answer that will resolve the problem.

Mental health professionals are frequently enlisted to search for the psychological causes, which allow for the chronic patient to be dismissed and discredited. This leads to a mistaken belief that chronic pain/problem patients are difficult, if not impossible, to treat. There is also a belief that such patients are only trying to milk the system of compensation in some way and, therefore, every effort must be made to find reasons to avoid dealing with such patients as soon as possible. This belief also extends to the idea that once the patient is diagnosed as having a functional (psychological) overlay, he or she will magically resolve the pain problem once the case is closed. Though there are some patients for whom this may be true, this approach tends to complicate the issues of how to provide an effective pain management treatment approach, which allows patients to start to feel in control of their lives again through an active self-care approach.

Pain management psychologists have long been active in developing such approaches that can be quite effective. A cognitive behavioral pain management approach, which helps to educate the patient about active skills, offers some of these alternatives. However, to be fully effective, health care professionals need to consider the importance of helping patients with a myofascial soft-tissue approach to self-care.

Myofascial Disorders as the Underlying Cause

In their book, Myofascial Pain Dysfunction: A Trigger Point Therapy Manual (Vol. 1 & 2), Janet Travell, MD, and David Simons, MD, were some of the first clinicians to utilize information that was first understood in osteopathic medicine approaches emphasizing the importance of the muscle system to body balance. More recently, Davin Starlanyl, MD, and Mary Ellen Copeland, MS, MA, published Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual (New Harbinger Publications, Inc., 1996), offering more research. Both books describe muscle “trigger points" as tender points that form in the muscles for any reason — injuries, stress, chronic pressure, accidents, etc. Trigger points are also known as jump points because when pressure is applied to them the person wants to jump. As trigger points are formed they cause other muscles to compensate thereby creating additional trigger points. These trigger points are not permanent and can be reversed with proper trigger point therapy. However, this requires active participation of the patient. Patients also need to be taught how to do their own trigger point therapy because their muscles will have developed habits and want to return to being tight and tender. Patients have to do regular trigger point therapy at home on a frequent basis until they have knocked out the trigger points, stretched their muscles to their normal length and flexibility, and a new habit pattern is formed for the muscles.

Pain management psychologists have long been active in developing such approaches that can be quite effective.

Treatment Options Acupressure/Trigger Point Self-Care Therapy

Acupressure techniques can be used to unblock oxygen and blood flow until the trigger point releases and the muscle can be stretched to its normal length again. Pressure is placed on the trigger point causing pain that is usually intense in nature. Pressure is maintained (up to minute or more) until the trigger point can let go. Patients can find their trigger points when they hit a tender point and feel pain. When a tender point has pressure applied to it and the pain radiates to another area, a myofascial trigger point is found. When pressure is applied to a tender point and the pain does not radiate to another area a tight muscle is found. Though the initial response by the patient is to feel intense pain, this quickly subsides as the patient feels the trigger point releasing. The patient also ultimately feels an improvement in muscle flexibility, length, and a reduction of pain.

Tennis Balls and Trigger Point Therapy

Once patients have been shown how to release trigger points with acupressure techniques, they must also be instructed how to do this at home on a regular basis. One of the reasons many patients become discouraged is that they expect a permanent fix and become frustrated when they go home and find muscles tightening with trigger points again forming within a few hours of being treated. Patients need to know they have to become active in helping their bodies develop new habits over time. The problem is that it can be difficult for patients to reach certain areas of their bodies in order to apply effective acupressure techniques. One technique patients can utilize is to place two tennis balls in a sock, tie the end, place it on their neck, and slowly move it down the spine. The balls come to replace the pressure applied by the hands in these areas. Another method is to put one tennis ball in a long sock. The ball can then be moved into a position on a distant part of the body. Again the patient can lie on it, sit in a chair on it, etc., for effective acupressure techniques. Other patients have used “S” hooks (back knobbers) that go around the trunk or shoulders and position a wooden ball in the appropriate place to apply pressure to release a trigger point.

Ice/Cold/Heat as a Distraction Technique

The nerves for muscles in the neck, shoulders, and back are mediated by the spinal cord reflex, which often develops a tight memory for the muscles. Cold or heat applied slowly over an area just treated by acupressure can help to distract the spinal cord synapse reflex to help the muscle further increase in length and flexibility. The idea is not to freeze the muscle, but use briefly to distract it. Ice in a Ziplock® bag, blue ice, etc., can be used for this purpose. Using a hair dryer moving quickly over the affected muscle area can help with the distraction technique in the same way as using cold techniques.

Relapse Prevention and Flare-Up Planning

One of the frustrating issues in dealing with chronic illness and pain problems is the fact that just as patients are starting to show improvement, they experience regressions and flare-ups of pain. This can be very discouraging to patients unless they understand the issues of relapse prevention and the various techniques necessary to maintain their gains. Acupressure, pacing themselves, taking frequent breaks, not trying to do everything when feeling good, relaxation techniques, and other techniques must be employed regularly to help reverse any regression. Recovery from many problems has shown that for the ego to integrate it must regress. If the patient is able to understand that regression is in the service of the ego then they can understand the cyclic nature of any healing process. Regressions and relapses need to be seen not as failures, but rather as learning experiences that can help them learn to manage these problems better over time.

Relapses can be predicted and tend to be related to emotional pressures, physiological changes, interpersonal conflicts, depression, anger, and lack of sun light and exercise. It is often helpful for chronic pain patients to set a timer to go off every 20 minutes so they can stop, change positions, and move. Many patients tend to stay in one position for hours without even realizing it and then wonder why it is hard for them to move later. Some patients, as they recover, find that they can be very active one day only to pay the price for it the next few days. Such patients need to learn the value of not rushing to do everything when feeling good. If patients expect regressions, they also are less likely to panic and then explore the issues that might have set off the setback in progress. Unless the patient becomes an active partner in the treatment process, little will be of long-term help to the patient. Relying on professionals to resolve things will not work long term. The patient needs to learn techniques that can be done on a regular basis at home, at work, and on a daily basis, as part of being active in managing these problems.

Additional Techniques To Enhance Responses

Myofascial techniques are best integrated into a broad based, skill-developing, behavioral pain management approach to therapy where the patient feels empowered with a variety of knowledge skills. Relaxation techniques are central for the patient to learn in the first therapy session following the initial evaluation interview. Active biofeedback techniques where patients learn what muscles, stretches, and techniques can help reduce tight muscles is also helpful. Passive-relaxing biofeedback techniques have a limited place in treatment beyond the initial sessions because patients need to learn what they have to specifically do with their bodies. Many chronic pain patients are alexithymic, having a poor understanding of internal bodily feelings, sensations, or emotions. At the same time, most pain/illness patients internalize many of their emotions onto their bodies. Learning how to move and experience their body differently helps them to reduce the muscular tensions in active ways. Cognitive behavioral psychotherapy discussions are critical to learning a new somatic/emotional vocabulary and in coming to understand how related issues can impact their present chronic pain situation. Fear, anxiety, post traumatic stress disorder responding issues, depression, family co-dependency issues, etc., all are important helping the patient make a longer-term change.

Myofascial techniques are best integrated into a broad based, skill-developing, behavioral pain management approach to therapy...

It is critical for patients to learn that it is not just one technique that will be helpful to them in the end. What works best is for patients to learn and utilize a variety of active cognitive-behavioral pain management techniques on a regular basis over time. Follow-up of patients after the active phase of treatment is critical to helping patients maintain their gains. However, once active therapy has been completed in the first few months, appointments can be spread out in order to help patients deal with things more on their own in home and work environments.

Magical Words: Cure Versus Management

It is important to remember that the most important thing to know in pain management techniques is that management is the magic word. Chronic pains are managed rather than cured. This requires knowledge and the development of self-care skills. However, the use of myofascial techniques offers patients the opportunity to reverse soft-tissue injury and related problems that previously had been not understood as contributing to the chronic nature of the problem.

Conditions Responsive to Myofascial Techniques Headache Pain Problems

Though it is recognized that muscular tension headaches might respond to myofascial techniques, migraine and vascular headaches may also be triggered by muscular tension issues. It becomes critical with headache patients to work in teaching them how to use myofascial acupressure techniques to stop or reduce headache problems.

Motor Vehicle/On-the-Job Injuries

Many health care providers, and patients, do not realize that myofascial soft tissue problems can cause pain that is experienced as something deep in the bones. The use of myofascial trigger point acupressure techniques can be considered a viable treatment option. The normal course of recovery may involve physical therapy involving isometric, exercise therapy, conditioning, or passive techniques such as heat and ultrasound techniques. Though these can be helpful in many cases, patients with myofascial disorders may experience themselves getting worse with such approaches to rehabilitation. Before these can be employed, myofascial manual (hands on) trigger point acupressure therapy should be performed. Oftentimes, isometric exercises tend to tighten already shortened muscles.

Home Treatment Program
In order for any myofascial soft-tissue trigger point therapy to be effective and curative, it requires the following:

Stretch every hour.
Heat every two hours.
Drink at least 6-8 glasses of water per day.
Relax. Don’t overuse or abuse the treated muscle just because you feel better.
Follow this for the next 48 hours during your waking hours.
If you are successful in keeping the muscle in a relaxed and stretched out position, there is a good chance the trigger point will not return.

Post-Surgery Continuing Pain Problems

Many patients having undergone surgery for spinal disc problems, including fusions, continue to experience pain problems post-surgically often leaving them feeling discouraged and defeated. Other surgical patients often find they now have pain problems they never experienced previously. Many of these problems are related to the traumas of surgery on the body where a muscle tightens to protect itself and scar tissue problems that can further be complicated by the development of scar tissue around nerves. Myofascial, and its related scar tissue release, therapy can greatly help to reverse these problems.

Aftercare Instructions for Trigger Point Therapy

Releasing trigger points with acupressure may cause soreness and bruising afterward. Heat (like a heading pad) can help relax the muscle further post release. The use of pain relief ointments (like Aspercreme) can be helpful reducing the pain and soreness that results from trigger point therapy. Gently stretching the muscle frequently throughout the day so that the muscle gets used to being in a normal relaxed position is another way for patients to deal with the pain. Using trigger point therapy may result in some mild bruising and soreness. There also may be some itching around the pressure site. Advise patients to try to avoid scratching these areas. It may be advisable to recommend patients take an antihistamine (like Benadryl), which may help with any allergic response from the release of histamine from trigger point therapy. Over-the-counter pain medications are also helpful for soreness and pain after trigger point therapy to reduce soreness. Figure 1 demonstrates a home program patients can utilize.

Summary

The more patients know about their condition, along with feeling they are partners in finding multiple solutions to their illness/pain problems, the more empowered and comfortable they feel. This knowledge allows them to feel that they are not helpless. As they feel empowered, there is a corresponding reduction in anxiety, panic, depression, and anger. Though limitations from the illness/ problem/injury may continue, such patients have learned that they can do things to control what is happening to them. Taking extra time to help patients learn home techniques helps them to feel there is hope and something they can do themselves. The result is a patient who becomes more of an active participant in managing his or her pain. n

Last updated on: May 16, 2011
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