Rapid Differential Diagnosis of Pain Generators

1. Rapid Differential Diagnosis of Pain Generators in Physical Medicine Dr. T.W. Brown, ND Vancouver, B.C. October 2009

2. 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

3. 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.

4. 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….

5. 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

6. 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…?

7. 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

8. 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

9. 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

10. 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

11. 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).

12. 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

13. 1. Myofascial Pain • But worse with quick stretching – excess movement, stretching so that pain increases 1-2 hours after activity.

14. 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

15. 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

16. 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

17. 2. Neuropathic Pain • This is Cord mediated and central pain

18. 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

19. 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

20. 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!!!

21. 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***

22. 3. Joint/Facet Generated Pain • Synovial Joints/Facets – are complex structures with bones, joint capsules, ligament, cartilage, synovial fluid, neurovascular & autonomic components.

23. 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.

24. 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.

25. 4. Disc Generated Pain

26. 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.

27. 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

28. 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

29. 5. Ligament Generated Pain

30. 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

31. 5. Fibro-osseous Junctions

32. 5. Ligaments • Have their own pain referral patterns – not the same as dermatomal, myofascial, or myotomal patterns. (e.g. Hackett charts)

33. 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….

34. 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.

35. 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.

36. 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.

37. 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.

38. 6. Tendons

39. 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)

40. 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

41. 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

42. 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

43. 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.

44. 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

45. 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.

46. 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

47. 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.

48. 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)

49. 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

50. 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….