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Non - Pharmacologic Options for Managing Chronic Pain.

üEssential oilsüCBD oils

üMyofascial pain treatment

Christopher Cecil, DC, FNPMelissa Rietz, FNP

HeadacheUpper extremity painLower extremity pain

Christopher Cecil, DC, FNPFamily Nurse PractitionerChiropractic orthopedist

chriscecil@live.com

OBJECTIVES� What is Myofascial pain syndrome?� Understanding what a Trigger point is� How to identify trigger points� How trigger points refer and cause pain� How to treat specific trigger points effectively

Disclosure:I have no personal or professional affiliation with any of the resources listed in this presentation, that would allow me to have any monetary gain or professional advancement from this lecture.

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3 simple areas/muscles� Upper trapezius muscles (headache)

� Infraspinatus muscle (Upper Ext. Pain)

� Gluteus medius and minimus muscles (Lower Extremity Pain)

Myofascial pain syndromeWhat is it?� A muscular condition that causes referred or local pain

from the muscles or fascia.� It's hallmark is a trigger point� Focal, nodule, muscle spasm or tender point within a

taught band in a muscle� The nodule produces pain locally or distally with

pressure or independent of pressure

Red BiblesMyofascial Pain and Dysfunction Janet Travell and

David Simons

� Explain and instruct most everything regarding MPS

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Trigger point

� The nodule is within a tight band

Trp under ultrasound

What causes a trigger point?What is it?

� Endplate damage at nerve endplate of the muscle� Acetylcholine spillover� Some sympathetic nervous system innervation� Trigger point is active, apart from the regular muscle

fibers� A bunching up of the small fibrils around the

neuromuscular endplate

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Neuro endplate dysfunction

Myofascial painspecific to muscles� Not to be confused with fibromyalgia� Fibromyalgia is a global pain disorder� 9 pairs of tender points etc.…

� Myofascial pain syndrome is specific to muscles and fascia, and their referred pain patterns

Trigger points refer pain to distal areas or locally

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Referred Pain

Refered pain Neuro

Causes of trigger points� Stress (anxiety), sympathetic nervous system

Berkoff and Hubbard� Mechanical muscle problems causing an plate disruption� Joint dysfunction, proprioceptive issues afferents/efferents� Trauma� Posture, overuse stress� Nutrition ie. Magnesium

Travell was big on this

�Tension headache� Caused by one or all of these

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Types of trigger points�Active Refers pain without pressure

�Latent No symptoms unless pressed

� satellite� attachment

Case� Patient presents with a frontal headache which is intermittent for three

weeks.� Headache occurs daily and last three hours per day.� It's a pressure type pain in the temporal and frontal aspect of the head.� Sometimes it is constant.� The patient usually feels it at the end of the day after work or when on

the computer.� They have had headaches like this in the past but never for three

weeks.� Ibuprofen helps.� There is no other significant past medical history.

� What might be the cause?

Upper Trapezius

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Trapezius muscle

Occiput superiorly to T-12 inferiorlyLateral one third of the clavicle laterally including the achromiumThe entire length of the spine of the scapula3 Parts to the Trapezius

Upper Trapezius muscle� Upper trapezius� Medial third of the superior

nuchal line at the occiput

� From the ligamentum nuchaeextending from C1 to C5 spinous processes

� laterally to the lateral third of the clavicle

� Middle trapezius� C6 to T-3 extending laterally to

achromium and superior lip of spine of scapula

Upper Trapezius referral

OcciputTempleFrontal

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Palpate a trigger point

� Palpate a trigger point� in upper trapezius

� Pincer grip� The upper portion

of the shoulder� Squeeze, feel nodule� Ask, where does the pain go or is this a familiar pain?

Treatment for upper trapezius trigger points� NSAIDs (temporary)� Massage- deep massage seems to work best to patient's tolerance

- theracane auto trigger point work� Stretching- stretch and spray (diagnosis and treatment)

- or home stretching� Manipulation- moving the attachments of the muscle

- normalizing joint and muscular function- affecting afferents and efferents (joint capsules)- scleratogenous pain and myofascial pain

� Trigger point injections/dry needling- lidocaine decreases sensation, patient perceives less

pain with more improvement

Stretching

� Separate attachments by depressing achromium and clavicle (sit on hand), lateral bending of neck to the opposite side and rotation of head towards the shoulder in question.

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Stretch and Spray Upper Trap

Direct pressure/massage

� Massage therapy/Trigger point pressure

� Auto trigger point pressure

� Theracane� Tennis ball

Manipulation

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Trigger point needling/injection� Dry needling- acupuncture needle

� Trigger point injections- lidocaine or nonirritating fluid � 27 Gage needle, .5 or 1% lidocaine� Find the trigger point� Local twitch response� Move needle/ multiple points� Reduplication of pain or headache� Inform patient pain usually means success

� Very effective

Upper extremity pain

� Several muscles� infraspinatus� scalenes� pectoralis minor and major

Upper extremity referrals/other muscles

Scalenes Pectoralis Minor

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Infraspinatus Muscle

Anatomy

Infraspinatus fossa and spine of the scapula (medially)Posterior aspect of the greater tubercle of humerus(laterally)Main Function- Lateral rotation of the humerus

Posture

� stresses pectoralis minor along with scalene muscles� Shoulder internal rotation stresses infraspinatus

Infraspinatus injury� Trauma to shoulder � Rotator cuff injury (One of the 4 rotator cuff muscles)� External rotation injury

-putting seatbelt on, tennis backhand, pulling across body

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Infraspinatus referred pain

� Mimics C-5 or C-6 nerve root symptoms

Treatment of infraspinatus� Massage or deep myofascial work� auto massage with theracane or tennis balls� Stretching, internal rotation shoulder� Posture, stretching pectoralis major, retraction of

scapula and external rotation � Normalize shoulder joint movement/scapular humeral

rhythm� Trigger point needling/injection

Infraspinatus self care

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Massage Therapy

Infraspinatus stretching� Stretching� Stretch and spray

Trigger point injection/needling

� Safe, scapular fossa� Palpate and find several trigger points� Try to reduplicate upper extremity symptoms

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Infraspinatus Injection

Glut Med/Min referral patterns

Gluteus medius and minimus(one area)

� Pseudo-sciatica, more common than true sciatica� Referred pain and tingling to posterior thigh or lateral

thigh to leg� DDX low back issues/nerve related symptoms

Mimics S-1 and or L-5 Nerve Root symptoms� Press trigger points with elbow reduplicate symptoms

helps DDX (deep pressure)

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Gluteus medius and minimusmuscles

AnatomyGlut MediusAnterior and PosteriorGluteal lines of IlliumTo Greater TrochanterGlut MinInferior to andterior and Posterior gluteal lines To the greater Trochanter

Palpate Triggerpointin glut med/min

� Deep Pressure often use elbow� Will reduplicate patients pain if in the right spot� Patient lies on side with affected side up� Bend both knees� Explore several areas in glut med/min

Glut Med/Min Function

� Abduct the Femur (Abductors)� Slight internal rotation of the Femur� Stabilize the Pelvis especially during gait (Level)

Trendelenberg

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Treatment of Glut Med/Min

Stretching (all hip movements)Massage (Deep)Auto massage with tennis ball, Foam roller or PVC pipeCheck for excessive Pronation of feet (Fallen Arches)Pelvic dysfunction correction (Hip and Sacroillic joint)Trigger point injections

Stretching Glut Med/Min

� Affected side leg and foot away from wall

� Lean greater trochantertoward wall

Massage and Trp Pressure� Massage/ self care � Tennis ball (Wall)� Foam Roller

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Hip Dysfuncion and Arthritis

� Hip Dysfuncion and Pelvic dysfuncion stress the pelvic stabalizers.

� Gluteus Medius and Minimus are main pelvic stabilizers

Limited Hip ROM puts much stress on the abductors

Glut Med/Min Trp injections

-2 inch spinal needle(Increased tissue in area)

-Multiple trigger points-Injection 2 muscles-Superior to trochanter-Inferior to illiac crest in the

Gluteal fossa of pelvis

Pronation of foot/Flat feet

� Pronation adds significant stress to the abductors

� Need to correct each step with Glut/Med contraction in stance phase

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Trochanteric or Gluteal Bursitis

� Stress due to the abductors at the Greater Trochanterthe attachments of the Glut Med/Min

� Condition often comes back unless the function is addressed

Summery

� Myofascial trigger points are extremely common� Often they are over looked � Trps refer pain that can mimic Nerve Root symptoms� One of the most common causes of Headache� They are relatively easy to treat� Nurse practitioners can treat trigger points multiple ways� First step is recognition and diagnosis

(If you don’t look for the trigger points, you wont find them)

Christopher Cecil, DC, FNP

� Albuquerque Neck and Back Pain Center� Contact me at: chriscecil@live.com

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References� Simons DG, Travell JG, Simons LS. Travell & Simons' myofascial pain and

dysfunction : the trigger point manual. 2nd ed. Williams & Wilkins; Baltimore: 1999.

� Travell JG, Simons DG. Myofascial pain and dysfunction : the trigger point manual. Williams & Wilkins; Baltimore: 1983.

� Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle EMG activity. Spine (Phila Pa 1976) 1993 Oct 1;18(13):1803–1807. [PubMed]

� Dommerholt J, Huijbregts P. Myofascial trigger points : pathophysiologyand evidence- informed diagnosis and management. Jones and Bartlett Publishers; Sudbury, Mass: 2011.

� Wolfe F Clauw DJ Fitzcharles M et al. The american college of rheumatology preliminary diagnostic criteria for

� fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62:600–10.

References� Gerwin RD. Classification, epidemiology, and natural history of myofascial

pain syndrome. Curr Pain Headache Rep. 2001 Oct;5(5):412–420. [PubMed]� Myofascial pain associated to trigger points: A literature Review� https://core.ac.uk/download/pdf/19525579.pdf

� The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature

� LD Rickards - International journal of osteopathic medicine, 2006 - Elsevier� Chiropractic management of myofascial trigger points and myofascial pain

syndrome: a systematic review of the literature� H Vernon, M Schneider - Journal of manipulative and physiological …, 2009 -

Elsevier

References� salusmt.com� deeprecovery.com� epainassist.comorthobullets.com� researchgate.net� myemail.constantcontact.com� aneskey.com� liftbigeatbig.com� practicalpainmanagement.com� correctposturebrace.com