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Wednesday, February 24, 2016

Muscle Pain treatment

Bismillahirahmanirahim and this is one of the common problem that always appears in our human body are call myofascial pain syndrome or in other name myalgia pain. For info and guideline I would like to prescribe It is a syndrome characterized by chronic pain caused by multiple trigger points and myofascial tightening.  For the term fascial pertains to the muscle, and it is a lining composed of the connective tissue that covers, connects and supports muscles.

Myofascial Tissue in close up 

My patient always show this sign
- Tenderness during palpation with referred pain to the other muscles of the body or joints
- It will show a limited ROM and difficulty to relax or fully lengthen the muscle
-  some of them associate with longer lasting muscle pain, weakness and stiffness
- Sleep disturbance
Other than that  this syndrome can include many more symptoms, which are related to the area of the body where the trigger points are present.

As we know the myofascia is composed of connective tissue, which contains: cells, ground substance and fibers and the ground substance and the fibers, which are outside of the cells, make up the matrix, which can be solid and gelatinous with a web-like shape.
In common problem happen, when myofascia becomes tight and thick it is
difficult to get it back to the gel-like flexible state without intervention.
So this reaction cause the muscle and the fascia can essentially be “trapped” together causing inflammation and pain.
The symptom will present a Muscular dysfunction  that can lead to movement limitation, which can cause a cycle of pain that must be broken. The worse thing to the patient is  This tightening of myofascia will also affect the neurotransmitter’s ability to send and receive neural information, whichwill further distress the muscle

The research show the exact cause of myofacia syndrome is unknown.
However, many factors such as bad posture, injury, leg length discrepancy, emotional stress, whiplash accidents, surgery, overuse, inactivity will affect myofascia
tissues, and cause changes such as:
1.      diminished elasticity of myofascia
2.      thickening and tightening of myofascia preventing muscle to fully relax
I always explain to my patient to let them understand ,If the body creates enough sites where the myofascia has changed then this will affect the quality of movement, making one muscle work harder to pull against the restriction present in the opposite muscle so this causes more tension in the muscle and discomfort, which will cause neuromuscular response known as “guarding” of the painful area. (The reason there always pain on other area)
We also need to understand  that a muscle becomes in a constant tension that
needs more nutrition and oxygen, and starts to produce more waste. This creates an area in the
myofascia starving for food and oxygen and loaded with toxic wastes. Such an area is a trigger point.

As my understanding as a physiotherapist I would like to say ,trigger point is a sore point that not only hurts where it is pressed, but it also “ triggers” a referred pain to the different area of the body. Have you feel this type of experience ? , when you press some of the part of muscle another place also feel the pain.

Center of muscle shows tender spot in a palpable tight band and refers
pain to a distance. The tight band extends the length of the muscle fibers
to its attachments, where the sustained tension of the tight band produces
an attachment trigger point on both sides of the muscle.

The trigger point will restrict movement, cause weakens and
prevents full lengthening of the affected muscle A nerve entrapped between trigger point and the bone, which can produce numbness in the area of compression.

Most of the time when my patient is come because of this problem a Simple test can be done to distinguish between trigger point with nerve entrapment and trigger point
without one.

·         If ice makes it feel better that is a sign of nerve entrapment
·         If ice makes it worse and heat reliefs the pain, then there is no nerve entrapment
It easy right to differentiate of this problem , Pain from trigger point is usually steady, dull, and deep but If there is nerve entrapment the pain can be burning, sharp, and lightening-like.
The Trigger point may develop secondary and satellite trigger points.
·         Secondary trigger point is develop when a muscle is subject to stress because another muscle with trigger point not properly function or  isn’t doing it’s job so Another muscle compensates for the muscle that is not working and the overworked muscle can develop a secondary trigerpoint.
·         Satellite trigger point  is develop when a muscle is in a referred pain zone of another Trigger point.

I always give the explaination to my patient to be understand if there is without proper intervention the trigger point can lead to severe and widespread chronic
Myofascial Pain Syndrome, which is defined as condition of multiple trigger points
present in all four quadrants of the body for at least 6 months (remember that 6 months )

·         Grinding the teeth
·         Clenching the jaw
·         Thumb sucking
·         Chewing gum
·         Loss of wisdom tooth
·         Oral surgery
·         Mouth breathing
·         Extreme emotional tension
·         Smoking-causes the blood vessels to constrict and decreases blood flow, which limits the amount of oxygen and nutrients
·         Poor posture, overuse muscles, immobility, exercising only one side of the body and promoting muscular asymmetry will cause additional tightening and stress applied to the muscles. (Common happen in most of my patient)

·         Sternocleidomastoid
·         Upper Trapezius
·         Suboccipital muscles
·         Splenius Capitis and Splenius Cervicis
·         Masseter
·         Temporalis

Most of the problem sometime the trigger points in the muscles mentioned above can cause headache, toothache, blurred vision and balance problems, eye, ear, sinus, jaw, and neck pain.

Here I want to share the type of the treatment designed to relief pain caused by trigger points are:
1.      Trigger point injection(info from My orthopaedic surgeon )- directly injecting the mild dose of procaine (local anesthetic) into the trigger point. It is difficult to accurately stick the trigger pointwith the hypodermic needle.

2.      Spray and Stretch (Applying by me almost)- the therapist needs to be absolutely sure that is stretching the muscle containing the Trigerpoint that is referring the pain, and just before stretching it is important to chill the skin around the Trigger point and the area where pain is referred with ice of refrigerant spray to distract the Central nerve system. It is also important to work quickly so that the cooling agent won’t cool the underlying muscle. In affected of this technique , Cooling the muscle will inhibit the stretch rather than facilitating it. After stretch the skin should be rewarmed with hot pack. If a patient had a limited movement before treatment I would like perform passive range of motion to improve their range.

3.      Deep stroking massage (One of My favourite treatment )-it is safe and effective method applied directly to the Trigger point . Success with trigger point massage depends ultimately on your ability to recognize referred pain and to trace it back to the trigger point that is causing it. Trigger points are not usually found at the place that hurts. Massage in the wrong place can feel good but doesn’t resolve the problem.  I like to say that the physiotherapist’s hands are a great tool in searching for the tenderness spots. Try to Use deep stroking massage with slow, rhythmic, repeated strokes in one direction. Performing a series of deep strokes across the trigger point will move the blood and lymph fluid with accumulated wastes from the painful areas. A deep stroking massage is also bringing relief by activating release of painkilling endorphins. (one of natural pain relief created in human body)

4.      Ischemic compression-is one of  the traditional practice regarding trigger points dictates that a therapist must press and hold them until they release, which is squeezing the blood out of the trigger point.

5.      Trigger Point Release- Heat up the tissue with  using the electrotherapy such as the ultrasound or hot pack. Apply direct pressure with your thumb to the trigger point for 60-90 seconds and then stretch. Repeat 3 times, and apply ice. (Ultrasound parameters will depend on how deep the muscle with Trigger point  is located. If it is a superficial muscles the parameters will be frequency at 3 MHz, transducer size 5 cm2, duty factor 50%, 2 min. intensity for example on 0.5 depends on how deep is the Trigger point.

            If you use the Ultrasound as one of the modalities please remember this Contraindications of               Ultrasound therapy :
·         directly on pregnancy,
·         metastasis,
·         lack of sensation,
·         thrombus,
·         pacemaker,
·         psoriasis.

6.      Posture Re-training:  My advice the key and the easiest way is to Learning and applying principles of correct posture and body mechanics can help relieve stress and tension on the affected muscles.
7.      Electrical stimulation- other alternative is using Transverse electrical nerve stimulation , triggers points have a decreased resistance to electrical energy so TENS can be beneficial in treating the pain coming from trigger point

For my advice to people who have this problem is
·         Trigger points do not respond to positive thinking, biofeedback, meditation, and progressive relaxation.
·          Patient with Myofascial pain syndrome should avoid weight training, swimming in the cold water, and muscle overuse.
·         Using Tennis ball or back knoober  are examples of tools that can be used by patients at home to relief pain caused by typical nodules or active trigger points. Wallahuaklam.


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