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Understand and treat common musculoskeletal problems related to dysfunction and pain by identifying and addressing pain generators with Naturopathic Principles of Practice. Learn about key pain generator types and the healing cycle for effective assessment and treatment.
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Rapid Differential Diagnosis of Pain Generators in Physical Medicine Dr. T.W. Brown, ND Vancouver, B.C. October 2009
Examination & Assessment: Common Musculoskeletal Problems • Patients commonly seek help for two main reasons 1. Dysfunction 2. Pain Dysfunction = Difficult functioning Pain = comes from one or more PainGenerators within the body’s systems • It therefore becomes our job as doctors to identify and eliminate the dysfunction & pain generators – at their source- using Naturopathic Principles of Practice
Pain Generators/Reflexes • Reflexes that are firing at the wrong time or with inappropriate stimulation are “misfiring” • This is the source of Pain generators • By remodeling the tissues and changing the firing of the pain generators we can eliminate the source of the pain – without poisoning the system with drugs that attempt to block the pain pathways but fail to correct the underlying physiology.
The Main Pain Generators in Clinical Practice • 1. Myofascial Pain • 2. Neuropathic Pain • 3. Facet (Joint) Pain • 4. Disc/Ligament Pain • 5. Ligament/Fibro-osseous Junctions • 6. Tendons • 7. Craniosacral dysfunction • 8. Visceral Referred Pain • 9. Other….
INJURY-SPASM-PAIN GENERATORS& Healing Cycle INJURY Inflammation – PG2 Release, Cytokines Spasm – Splinting Actions Deposition – Stabilization/Patching with GAG’s, minerals, Remove wastes - Enzymes Remodeling Fibrosis or Hypermobility Loss of Elasticity Loss of Elasticity Loss of Flexibility Loss of Strength Pain Generator Pain Generator
Assess: With Knowledge • What is the probable mechanism of injury? • What phase of injury/repair is the tissue in… Acute Subacute Chronic? • What are perpetuating factors? • Deficiencies, infection, toxicity, other…?
History Taking: Injury Mechanisms • Forces go through tissues and the tensile strength is relative to each tissue, the body position, and the preparation of the body for the impacts. • Think of tissues from surface to deep for outside to inside forces • Skin, Fascia-Muscle-Tendon, Ligament, Joint/Facet, Bone, Disc, Cord- Brain • Think in reverse for inside out forces
INJURY HIERARCHY #1 – Priority Central Nerve Peripheral Nerve IN ANY TYPICAL JOINT OR TISSUE INJURY 3 2 #2 Priority Bone – Periosteum 4 #3 Priority Ligaments Fibro-osseous Joint Capsule #4 Priority Muscles Fascia Skin 1
Assess with Knowledge:(cont’d) • What is the likely tissue involvement? • Based on understanding the characteristicsof the different tissues/pain generators • Based on autonomic response-challenge findings
1. Myofascial Pain • Myofascial components include: Skin& Fascia layers that connect and separate different compartments and organs / tissues, including muscles, tendons, and meninges. • It also includes the Muscles themselves
1. Myofascial Pain • Mechanism of injury is from… • Chronic overuse of muscle making it exhausted then injuring some of its fibres, • Or a one time trauma, severe chill • Resulting in…Taut bands with a palpable grain of rice embedded inside … a “trigger point” • Pain scale 3-5 / 10 • Unless patient on Statin drugs like Lipitor or Red rice yeast – which make golf ball trigger points and need lots of Co-Q-10 & magnesium (pain 5-7/10).
1. Myofascial Pain • Overlaps neuropathic pain patterns • Characteristic trigger point referral pattern charts • Stiff, feels as if it should be numb but isn’t, • Better with warmth, heat, some movement
1. Myofascial Pain • But worse with quick stretching – excess movement, stretching so that pain increases 1-2 hours after activity.
Myofascial Pain is Nerve Derived Pain • Is caused by, perpetuated by or stimulated by nerve irritation. • Nerve injuries can masquerade as myofascial pain or joint pain
Myofascial Pain is Nerve Derived Pain • All myofascial pain has some component of neural and spinal cord inflammation • In some case the nerve is the primary problem
1. Myofascial Pain-Treatment • Always treat the nerve first • Frequency Specific Microcurrent – is 100% effective in treating myofascial pain if the tissues are properly hydrated. (See effective treatments) • Therefore it can be diagnostic as well as therapeutic – especially good for large areas • Localized area: Neural therapy works well
2. Neuropathic Pain • This is Cord mediated and central pain
2. Neuropathic Pain • Pain scale is 5-7 / 10 unless on Neurotin, Gabapentin, or Narcotics • Typical symptoms – cervical pain, burning midscapular pain, shoulder-arm-hand, or back-leg-foot pain, headaches, aching, burning, tingling, stabbing pain. • Typical symptoms after a cervical/spinal trauma
2. Neuropathic Pain • Widespread upper and lower body muscles extremely sore, tender to touch, history of cervical trauma. • Fibromyalgia is 13x more common following cervical injuries- generalizes after 1-3 months and symptoms persist. • Hypertonic deep tendon reflexes - due to upper motor neuron interference from injured spinal levels above site
2. Neuropathic Pain • Muscles are hypertonic or exquisitely sensitive to touch • Numb or hypersensitive areas – test sensation with pinwheel or pin • Narcotics are generally not effective, or become non-responsive • Patient will rub at area below the site to try and relieve discomfort • *Pain gets worse with other treatments!!!
2. Neuropathic Pain- Treatment • Typically difficult to treat unless you… • Treat injury and spinal – concussion components (thalamic and brain stem) • Injury is to cord but without paralysis • = Hypersensitive nerve/cord • Treatment of choice – • Frequency Specific Microcurrent – Neuropathic Pain Protocol – very effective • Also –Learn to Reset …. • The Craniosacral System***
3. Joint/Facet Generated Pain • Synovial Joints/Facets – are complex structures with bones, joint capsules, ligament, cartilage, synovial fluid, neurovascular & autonomic components.
3. Joints/ Facets • Bending joint into compression aggravates • Muscles around joint will spasm/splint when joint is moved – palpate gently to feel for splinting. • Distraction usually relieves • Not a dermatomal pattern • In spine – sitting & extension causes back or spine pain – flexion relieves.
3. Joint/Facet Pain- Treatment • Localize facet/joint and treat it • Responds to appropriate treatment • Manipulation • Facet/joint block – Neural therapy • Other components – • Use Frequency Specific Microcurrent – • Facet Joints Protocol treats - bone, synovial membranes, ligaments, neurovascular components etc. • Acute, Subacute or Chronic Phases.
4. Disc Generated Pain • Mechanism from a bend or lift with a twist component • As from many sporting injuries • In the thoracic spine this can be very minimal (usually missed) • In the cervical spine – very likely if there was rotation or the head was turned on impact. • Most common C4/5, C5/6, but may be higher • Compression of disc generally makes pain worse, distraction feels better.
4. Discogenic Pain • The gel of the disc is like battery acid to the nerves and tissues • 80% of the pain is dematomal, 20% is back pain – sometimes no back pain • Pain scale 3-8 / 10. • Pain changes with position and activity. • Can be bulging, herniated, sequestered, dessicated. • May take 3-4 months to heal
4. Discogenic Pain - Treatment • Sometimes surgery is indicated however… • Most diagnosis is made by CT Scan or MRI after a lot of time and …. • Disc may repair – shrink over time • May not be the actual cause of pain …. So treat keeping in mind…. • The need to prevent further injury & • Treatment of other components such as *ligament instability, *facet joints, *myofascial & neurovascular elements for long term success • Frequency Specific Microcurrent Protocols helpful
5. Ligament Generated Pain • Ligaments are like hinges that hold bones together • Give a “spring-like” rebound effect to make muscles and mechanical energy system efficient – (puts bounce in your step) • Join at fibro-osseous junctions – exquisitely sensitive areas on the periosteal membrane of bone
5. Ligaments • Have their own pain referral patterns – not the same as dermatomal, myofascial, or myotomal patterns. (e.g. Hackett charts)
5. Ligaments • Research shows – stretched 5-7% a ligament can tear – and lose 30% of its strength. • Suseptible to further tearing/ weakening • General concept – ligament injury is like tearing the elastic in your underwear….
5. Ligament Laxity • Repair – laxity/weakness of fibres causes tissues to come apart and become unstable • Major cause of chronic back pain/joint weakness • This may be due to loss of cross-linking or longitudinal structure, and poor blood supply into ligament structures • New research indicates that matrix metallo proteinases (MMP’s) can be released to cause breakdown of collagen structures in acute injuries.
Ligaments • Inflammation and repair cycle for ligaments is much slower and different than for myofascial components • Involves inflammation, repair, remodeling over a number of weeks – typically 8-12. • Cortisone and NSAID’s stop repair of ligaments – if used too much or too soon repair is arrested.
Ligaments • Consider ligament instability with chronic joint subluxation patterns, chronic sprains etc • Trauma that doesn’t break bone almost always causes joint/ ligament injury. • Eg – seated car accident = sacroiliac or hip joint injury especially on brake pedal side • Seat belt injury – will likely cause ribcage and acromio-clavicular injury, and pelvic injury.
Ligament Injury • Most always overlooked as cause – • Doesn’t x-ray except for motion studies • Harder to palpate – Specific • Overlooked in anatomy classes • Everyone tends to focus on bones and muscles without thinking about mechanisms of injuries, connective tissue components, and tensegrity issues. • Ligament is #3 priority of structure.
6. Tendons • Are linked to myofascial components – muscle proprioception and fibro-osseous/ligament junctions. • Like white nylon rope – very flexible and strong with little stretch. • Vulnerable areas are at transition zones or over boney protuberances, and bend zones (eg-Achilles-calcaneus/talus)
6. Tendons • Injury = tendonosis (not tendonitis) – fibres separate but no white blood cells etc. • Painful to stretch, pull and palpation especially squeezing • Show separation and disruption of fibres on ultrasound when injured • Healing = collagen remodelling, junctional repair mechanisms – to muscle, to bone • Slow response healing time- similar to ligaments
7. Visceral Referred Pain • Achey and deep, • Pain scale 3-5 / 10 • Time frame and location vary with organ • Pain under right shoulder, 30-60 minutes after meal – Gallbladder • Pain 11-12 Rib – Kidney? • Prostate – Sacral/Low Back pain
7. Visceral Referred Pain • Area is too tender to be muscle pain • Sensory exam is normal • Tissues in the back don’t respond to challenges- turn them over • Pain/reaction with abdominal palpation • Something just isn’t right – history of some infection – overload of toxins – think visceral
9. Other… • Dermatomal pain • Cervical, thoracic, lumbar dermatomes • Shingles, post herpetic neuralgia • Compression neuropathies • Carpal tunnel, thoracic outlet, Morton’s neuroma • Peripheral neuropathies • Diabetic, Chemo, Toxicity • Reflex Sympathetic Dystrophy.
Other… • Emotional Energetic Pain • Rule out everything else first • Because patient is neurotic doesn’t mean that nothing is wrong • Their pain is real – the reaction to the pain is how much they mind it/ how much it affects them • Studies show early pain, injury, trauma from 2-5 years of age gets hard wired into response pattern – later on they melt down under stress/pain. They mind it more – or it affects them at survival program level. • The problem came on with some emotional trauma or energetic experience. • Look out for multiple personality disorders
Differential Diagnosis Principles of Identifying Pain Generators • Find the pain generator by provoking it- • Stress it by compressing it, stretching it, palpating or stimulating it in such a way that it hurts…or creates an autonomic reaction!!! • Eliminate mechanical causes by diagnosis or treatment to arrive at visceral, emotional, or central mechanism.
General Principles of Identifying Pain Generators • This is where autonomic response testing – especially manual muscle testing procedures are rapid and effective when done skillfully • Autonomic Response Testing – uses the body’s automatic alert response and control system –(the autonomic or “vegetative” nervous system)- to help identify and locate problem areas
Autonomic Response Testing • Autonomics innervate all joints and extracellular connective tissues… • Different types of proprioceptors and neurological pathways….all connect via autonomic and afferent/efferent pathways.
Autonomic Nervous System • Innervates everything – including all joints, viscera (guts), and extracellular tissue (outside the cell) • Operates entirely at the subconscious levels of the nervous system (Limbic and Reptilian Levels)
Types of Autonomic Responses Testing Methods • E.A.V. Polygraph testing • Thermography Galvanic Skin Response • Heart Rate Variability • Nogier Pulse Testing (Auriculocardiac Reflex) • Arm/Leg Length Reflexes • Manual Muscle Testing Procedures They all involve baseline testing, various challenges, and retesting to identify response pattern
Muscle Response Testing • Response patterns of autonomic testing…. • Is very suited for musculoskeletal problems….. • Its quick… • Its always present… • Its adaptable… • It is inexpensive… • Its response is…in real time….