Definition of acupuncture, its role and place in modern medicine. The main components of puncture reflexology. Location of the main components of puncture reflexology. Reception and the moment of action.
Health – a state of balance and harmony of vital forces of the body, and illness is the result of discord or disorder of vital functions. Hence the basic principle of Chinese medicine: do not treat individual organs and whole body. Chinese believe that the disease – is the imbalance of vital energy.
In Chinese medicine, the concept of organ of the body has a very distant relationship with the anatomy. It refers to the whole organism functional systems, provided the heart, lungs, etc. (In the contemporary literature they are called orbs). Some of the bodies that recognize Chinese medicine – for example, the “triple heater” – have no anatomical prototype. In Chinese medicine, the symbolic topography of the human body, consisting of “energy”, indistinguishable on the material level officials.
Such, for example, three cinnabar fields (Tian Dian), the relevant public places of vital energy, the gate of life (minutes less), is in the kidneys, etc.
In addition to the functional systems Chinese medicine attaches great importance to the joints, joints, and particularly the channels of circulation of energy “chi”, the so-called meridians (Ising-man), which only partially coincide with the circulatory system and lymphatic drainage (the latter considered the material analogous “these”). “Great Dictionary of Chinese Characters” offers about 30 different values of the character “these”.
In general, “these” – is the fundamental substance, which underlies the structure of the Universe, where everything exists because of its change and movement.
The physical structure of the nervous system are considered together with the muscles and tendons, which also have their own energy channels. In general, tissues and internal structure of the body in Chinese medicine is given far less attention than the process of metabolism and interaction of bodies.
In ancient times there were various arrangements of energy channels in the body eventually was worked out their common classification. Distinguished 12 main channels and 12 branches from them, 8 so-called miraculous vessels, 15 collaterals, 12 myshechnosuhozhilnyh channels and 12 skin zones. The system of 12 main channels (meridians) reflects the interaction of 12 internal organs and creates a cycle of energy and blood, which begin with a channel of light and returns to him.
Needle is in the hands of a dentist usually means an anesthetic. Acupuncture – the ancient healing method, which has at its core the idea that the introduction of a specific point is very thin, sharp needles among other things can help alleviate pain.
The principle underlying reflexology is that imposed on certain points of special needles stimulate nerve fibers in the muscles. Then the pulse is sent to the central nervous system which in turn stimulates the release of chemicals that dull the pain. Clinical studies have shown that acupuncture is effective in treating contracture jaws, as well as helping to control pain after dental procedures. Reflexology can be used in conjunction with the classical treatment, for example, to accelerate the onset of anesthesia.
Acupuncture is one of the most fundamental and ancient methods of influencing the circulation of energy in the body. Any disease or pathological process in the human body can be regarded as violation of energy transfer: a violation of the circulation of “chi, blood, lymph, mucus, etc.
Correction, or treatment is carried out using needles, which are introduced into the human body (in certain points located on the meridian, as mentioned above).
Set of needles for acupuncture
Insert the needle into the human body can either stimulate or inhibit the action of a specific functional system of rights. Thus, we have a kind of “tells” the body, where there are certain “problems”, including the mechanisms of self-regulation and recovery.
Stage of twisting the needle
Indications for acupuncture:
• heart and vascular diseases (coronary heart disease, hypertension, syndrome of vegetative-vascular dystonia).
• Diseases of the respiratory system (tracheitis, acute and chronic bronchitis, bronchial asthma in children).
• Diseases of the ear, nose and throat (otitis media, chronic rhinitis, chronic tonsillitis, pharyngitis, sinusitis).
• Diseases of the digestive system (chronic gastritis, gastric ulcer and duodenal ulcer, chronic cholecystitis, chronic pancreatitis, chronic enteritis, chronic colitis, irritable bowel syndrome, constipation, functional disorders of the digestive system).
• Diseases of the nervous system (vertebral lesions of the peripheral nervous system: sciatica, radikuloishemiya etc., migraine, trigeminal neuralgia, the state arose as a result of acute cerebral circulatory disorders, encephalopathies of different origins, depression, sleep disorders, chronic fatigue syndrome, etc. etc.).
• Diseases of the kidney, urinary tract and genital organs of men.
• Gynecology (neurogenic bladder dysfunction, cystitis, impotence, menstrual dysfunction, inflammatory diseases of female genitalia of nonspecific etiology; restoration of woman in the postpartum period).
• Diseases of the skin (dermatitis of various etiologies, psoriasis, trophic ulcers, pustular skin diseases, etc.).
• Endocrine diseases (obesity, thyroid disease, diabetes).
• Diseases of the spine and joints (osteochondrosis, scoliosis, arthritis, torticollis, etc.).
• Rehabilitation of patients after trauma of the locomotor apparatus.
Contraindications to acupuncture:
• Neoplasms (malignant and benign).
• Acute infectious diseases, chronic infectious disease in the acute stage (tuberculosis, brucellosis).
• Fever of unknown etiology.
• Systemic diseases and blood-forming organs.
• Diseases of the cardiovascular system and other internal organs in a stage of decompensation.
Certain health problems, which are included as indications for acupuncture, very often result as a consequence, the problems in the mouth. For example, periodontal disease may be due to diseases of various organs and systems, such as: the endocrine system, skeletal system, digestive system, etc.
Acupuncture treatments
Therefore, knowing that to achieve a result, all means are good, the use of techniques of Oriental Medicine can be a good complement to traditional treatments.
MODERN PRINCIPLES OF SELECTION IN ZONES OF INFLUENCE PHYSIOPUNCTURE
In the recent literature on the puncture physiotherapy (PT) focuses on the mechanism of action of physical factors, their parameters and various theoretical aspects of the problem.
No doubt about the importance of these issues, but without adequate attention of researchers is the choice of zones, the specificity of response with stimulation of a site, the adequacy of the parameters and factor in the impact zone.
Chinese physical therapy (PT) (physiopuncture) – Zhen-chiu therapy more than 3 thousand years ago raised questions (and successfully solves them) on the site of action (choice of points, areas of acupuncture), duration (the optimal time of procedure, that is, taking into account daily, monthly, seasonal and other biological rhythms) and the method of exposure, providing a method and effect of stimulation, physical factor (acupuncture, acupressure, moxibustion, or heating, etc.). All these questions are relevant for modern physiotherapy. Let us consider in more detail at possible options for the choice of areas for the FT.
One of the simplest and effective ways to select bands in the FT – impact directly on the lesion site, such as lumbalgia – in the zone of pain, pathological broncho-pulmonary system – inhalation, in diseases of the hepatobiliary system – in the liver and gall bladder , for any changes in the knee joint (gonarthrosis) – on the knee joints, etc. This approach is widely used in the FT, but it does not take into account the pathogenic mechanisms of disease, and consequently does not enable a more effective influence on the course of the pathological process. For example, in gonarthrosis importance to its development should be autonomic segmental education (L1-L3), which are trophic centers with respect to the knee. Of course, the additional impact on the required segmental education, but little direct effect on the pathological focus will be more effective. This principle is the choice of areas in the practice of RT is called metameric or segmental (metameric, segmental), and is one of the most widely used.
Virtually on this principle holds classical FT, which includes the use of three main zones, the three whales; cervical collar and lumbar regions and zones Zakharyin-Geda. The selection of these areas is not random and is supported by numerous clinical results and substantiated theoretically.
Zone Zakharyin-Ged and metameric segmental-selection principle zones physiopuncture
Priority in the description of special zones on the human body belongs to one of the founders of
Subsequently, the English neurologist G. Ged developed and theoretically proved the doctrine of the zones with altered cutaneous pain sensitivity.
He drew attention to the fact that in the presence of a pathological process in the internal organs of pain, which they arise, often projected in some areas of the skin. The author gave a description of the phenomenon of pain, which is determined by palpation pressing and frequent presence of hyperalgesia in these areas.
Areas of the body and the zone of innervation of cutaneous nerves
Although to this day much of the mechanism of zones Zakharyin-Ged still not entirely clarified, still in the pathogenesis of their formation established anatomical and functional (metameric) connection between the skin and internal organs through the segmental apparatus of the spinal cord. In the process of their particular role is played by the functional state of CNS.
According to modern views, the zone Zakharyin-Ged can be interpreted as a zone with an altered sensitivity of the skin and other tissues (muscles, bones), that is certain metameric, with a complex vasomotor and motor-trophic reflex, which is like a metameric cutaneous projection of the internal organs, which ill. In areas Zakharyin-Ged palpation revealed tenderness, trophic changes, skin conductivity, there is excessive sweating, skin temperature and surface sensitivity in the form of hyper-or gipoalgezii.
Parasympathetic innervation by the vagus nerve (organs of thoracic and abdominal cavity) and the sacral spinal cord segments (genito-urinary organs and rectum) are in parentheses segments that could be partly involved in the innervation of an organ. In fact, GA Zakhar’in and G. Ged confirmed the data of folk doctors East of the possibility of special zones in diseases of internal organs, but whatever, nor was the initial mechanism of physical therapy, the following reaction develops with the inclusion of the nervous, endocrine and other humoral systems. In the primary physical factor aktseptsii difference of range, which determines the specificity of the specificity of response, and the latter link these areas with the organs and body systems. It is clear that for a particular response (non-stress reaction) to be adequately matched the stimulus (its power, frequency, wavelength of electromagnetic radiation, etc.), time and duration of action, the state system in which the action is directed. With thin, but adequate incentives they play mostly the role of information and reference.
At the same time zone sizes, their stability, the nature of the changes susceptibility and electrical can be important clinical signs of disease dynamics.
However, the value of these areas is important not only for diagnosis but also for different variants of physiotherapy. Effect of physical factors on a particular zone Zakharyin-Ged allows purposefully influence the functional status of a particular organ. In fact, we have the opportunity to direct stimulation of “beaten” disease of ways, it is noted peculiar principle of feedback: an inner body – a certain area of the skin and vice versa. Such feedback, no doubt, realized through the segmental apparatus of the spinal cord.
It is known that the human body to some extent preserves the principle of metameric structure, which is important to select areas of action and understanding the mechanisms of FT.
The universality of autonomic-segmental innervation of internal organs and certain metameric (ie, when the source of innervation of any internal organ and metamers serve the same segments, or the same vegetative creation) is the basis of metameric, segmental principle FT.
Close relationship of somatic and autonomic formations at the level of the spinal cord allow switching pulses from the somatic division in vegetative and vice versa. For example, the impact on metamers D10-L1 (segments of the spinal cord D10-D12) may affect all the main parameters of the functioning kidney and adrenal gland (see Table 1).
Such metameric principle of “small” FT has been described yet, MN Lapinsky and discovered the classics FT AE Shcherbakov and AR Kirichinskim. He found its application in the practice of acupuncture in the form of recommendations of national doctors East on the use of so-called signaling points.
With the strong power of physical factors, first the response of an organism is determined by the neuro-reflex and humoral mechanisms. In these cases, the threshold or type-threshold stimulus to the corresponding reaction involves the segmental apparatus of the inclusion of the autonomic nervous system, ANS, and through the last – the internal organs, blood vessels and other likely impacts on the curative effect zone Zakharyin-Ged, point-criers (signal) trigger points, just sore points is based on a similar mechanism, ie, metameric-setmentarny principle.
However, the convergence of somatic and visceral afferent occurs not only on spinal cord neurons, as well as on the neurons of the reticular formation, brain stem, hypothalamus and cerebral cortex These facts are the physiological basis for explaining the effectiveness of FT in vistsiralnoy pain and other pathologies. In these cases, if we are talking about multi-level neural regulation of functions, ie, the systemic principle.
Systemic principle of organization functions and the choice of zones, based on this principle
In the process of evolution has developed a multi-level security regulation of the same functional-dynamic system, a kind of safety margin of the system to the presence of 3.5 or more levels of regulation. These facts formed the basis of the teachings of Anokhin and his disciples on the functional systems. Under the functional systems of these authors imply a dynamic, self-regulatory organization, which selectively integrates various bodies and levels of neural and humoral regulation in order to achieve some useful results for the organism. An example of a multi-level organization of the system can serve as a breathing system in which there are:
1) motor cortex, ensuring a conscious (any) to perform respiratory movements, coughing;
2) the respiratory center of the medulla oblongata, which regulates unconscious (automatic) breathing;
3) segmental apparatus of the spinal cord, which provides vegetative-trophic functions of both the light and appropriate nerves and muscles;
4) the respiratory muscles and nerves that innervate them;
5) own lungs and airways.
It is clear that the treatment of respiratory diseases important influence on the different levels (not one!) Respiratory system with possible focus on a particular level depending on the causes of the disease. System principle forms the basis of FT sanogenesis, explains the possibility of compensatory reactions of the organism in various pathological conditions.
It also gives the physician reason for choosing the optimal areas of action: in some cases enough influence on the segmental apparatus and the affected organ, in others – need to connect the stem or cortical regions of the brain, or a combination thereof.
A similar approach can be called multi-level or system, providing exposure to different levels of functional systems and contributes to “unite disparate functions.” Such an approach could be achieved by methods of physiotherapy and physiopuncture it is virtually impossible to use drug therapy.
Analyzing the current approaches in the selection of areas for action FT, must take into account the dualistic (system-antisystemic) the principle of regulation of any function, then there are many phenomena in biology are twofold: compensation, decompensation, assimilation, dissimilation, stress protection, adaptation, maladjustment, the advantage of tone sympathetic or parasympathetic of VNS; pain system – Pain, dysphoria, euphoria, etc.
In many cases, the impact is not on pathologically changed system, and the physiologically stored antisystems.
Special or specific zones of influence and their choice to practice fiziopunkturnoy
As noted above, along with the impact on local areas or lesions using a choice of zones, based on system, systemic anti-systemic and metameric, segmental principles. Are also used, known and continues to develop new methods of CFT with the use of special or specific areas of influence.
For example, has already been mentioned on the neck-neck and lumbar regions, the effect of which was the most widely used in the FT.
Lumbar region
Effect on the lumbar region is recommended for the treatment of many diseases. The main action of the majority of physical factors is the effect on kidney function and adrenal gland, which in part reflects the possible reactions of certain organs, in response to their stimulation or stimulation of segmental zones of innervation. Becomes clear why the lumbar region – one of the whales FT.
Cervical-collar region
Impact on cervical-collar region and neck pretty chain, primarily in verhnesheyny sympathetic ganglion (VSHSG) is shown in various diseases of the brain. This is because the nature of these zones relative to the function of the brain, its metabolism, CSF and hemodynamics. In classical neuroscience is known that the autonomic centers spinal cord segments (C8-Th2) are the main source of autonomic (sympathetic) to ensure the head in general and in particular the brain, including blood vessels, choroid plexus of brain ventricles, and others peculiar coordinator of innervation in humans is VSHSG, the fibers which come from the vegetative segments (C8-Th2) spinal cord. From the spinal cord autonomic sympathetic afferent conductors, lying around blood vessels in the plexus of the external and internal carotid arteries, in contact with the vegetative nodes of the face (pterygopalatine, ear, ciliated and submandibular), are sent to the face and brain structures. The individual autonomic fibers from the site come into dorsal root segments C1-C4, and through the neck mezhganglionarnuyu branch go to segments of Thl-Th4. Formed a kind of feedback: segments C8-Th2 VSHSG form, and from him on these fibers is feedback to virtually the same segments. Indeed, the cervical-collar region – is a unified whole. It should also be noted that other means of vegetative sympathetic support of the head and brain is an autonomic perivascular plexus of vertebral artery.
It follows that the only source of sympathetic innervation of the head is lower cervical and verhnegrudnye spinal cord segments, their lateral vegetative horns, which are specified by the path followed by the brain and other anatomical structures of the head. This explains the importance of the effects on cervical neck area.
Acupuncture cervical-collar zone
However, greater detail on the functions VSHSG and possible mechanisms of influence of physical factors in its stimulation.
In 1930 p. E. A. Asatryan said modified production of food conditioned reflexes in the extirpation VSHSG in dogs. Later these results were confirmed by other researchers. A number of experimental studies and clinical observations reflect the role of the sympathetic nervous system, and in particular VSHSG in autoregulation of cerebral circulation.
It is known that the mechanisms of regulation of cerebral circulation, including venous, the leading role played by neurogenic, myogenic and metabolic factors. In the neurogenic regulation of the principal value belongs intracerebral noradrenergic system (brainstem structures, the blue stain, etc.), which is significantly affected by VSHSG. With the change in blood flow in the vascular plexus of ventricles of the brain associated hypo-or hyperproduction (secretion) of cerebrospinal fluid pathology VSHSG.
These findings were confirmed by long experience with electrical stimulation VSHSG. There is work, indicating a change in the amount of RNA, RNA-ase activity in subcellular structures of the brain and the disappearance of norepinephrine in the pineal gland after the removal of VSHSG.
In the experimental paper by Sokolova et al. The role of VSHSG in the specialized regulation of energy metabolism of the brain and its cortex. Only with continuous energy supply, the authors point out, at the synapse may occur intense protein synthesis, polypeptides, neurotransmitters and other metabolites in conducting nerve impulses.
The above examples to a certain extent explain the importance of using a FT segments C8-Th2 and VSHSG area through which you can actively influence the circulation of the brain and its energetic processes. It should be noted that the cervical neck area and these segments are the source of sympathetic innervation (via the star-shaped node) of the chest, including the heart. Not surprisingly, the impact on cervical-collar region is one of the most popular in the FT, that is one of its whales.
Transcerebral method
Impact on the area of scalp and face a variety of physical factors commonly used in FT. Some of them (electrosleep, central elektroanalgeziya, endonasal electrophoresis and electrophoresis for Burginyonom) have become classics, while others (action for specific zones of the scalp) is actively being developed.
Impact on the area of the scalp is different both in terms of choice of the adequacy of physical factors and its parameters, and in terms of choice of range.
Particular attention should be given technique transcerebral impact when, depending on the physical factor, which is used and its settings can be different therapeutic effects: analgesic, sosudistoreguliruyuschy, immunoregulatory, gormonoreguliruyuschy, antidepressant, etc.
Перспективні трансцеребральні методики фізіопунктури з “прицільною” дією на необхідні зони кори головного мозку (рухову, чутливу та ін.) або інші функціонально важливі структури, наприклад дія на парасагітальну ділянку та проекцію цистерни мозку. Prospective transcerebral techniques physiopuncture with “sighting” action on the necessary areas of the cerebral cortex (motor, sensitive, etc.) or other functionally important structures, such as effects on the parasagittal area of the brain and the projection of the tank.
The choice of these zones is explained by the following factors. Parasagittal area of the projection corresponds to the superior sagittal sinus, and there is a significant concentration of arachnoid villi, localized upper (large) anastomotichnaya
That field is also important in other aspects. So, according to Eastern medicine, are located (the epicenter of the parasagittal area) an important energy zone – the point T (XIII) of 20 or a specific chakra in Indian medicine.
The functional significance of this plot confirms contemporary research. The literature on melatonin and its role ieuroimmunology, draws attention to the fact that the embryology of this area is laid so-called fourth (parietal) eye, which is directly related to the pineal gland (epiphysis). The role of this cancer are studied in detail by many scholars. However, now we know that iron out two important hormones – epitalamin and melatonin. Education is the source of melatonin, serotonin pinealocytes, which is constantly and in greater numbers than in other organs, is contained in the pineal gland of mammals. Melatonin at pharmacological properties is no less potent than serotonin, but its sedative effect on the CNS is more pronounced. Activating effect of serotonin due to the excitation serotoninreaktivnyh systems of the reticular formation of the caudal portion of the midbrain and the bridge. These cores, in turn, send long descending axons in the spinal cord. Probably, this serotonergic system plays the biggest role in the modulation of nociception, and in conjunction with the pineal gland hormone – a person’s mood. Depression is largely related to its dysfunction.
These facts also explain the results of the high efficiency of phototherapy with white light at many depressive states.
Epiphysis actively influences the biorhythms of the organism, immune status and pituitary function. Interestingly, the known fact that the effect of light on the synthesis of melatonin and serotonin in the pineal gland depends on the condition of the peripheral sympathetic innervation. At the bilateral removal of superior cervical sympathetic ganglia of these light effects are not observed.
The dependence of the functional activity of the pineal gland of light is an important reason for the purposeful use of light to the normalization of its functions. In addition, if direct photostimulation epiphysis is difficult, due to its deep location in the brain (pineal gland anatomically is located in the rear of the III ventricle), the effect on him may be oposredstvenno – through the zone, embryology associated with it, that is in the parasagittal area. Perhaps the laser pulse infrared radiation in some cases can directly affect the pineal gland (the penetration depth of more than
Consequently, the impact on the parasagittal area in the treatment of many diseases, especially depression, is quite justified.
The choice of the projection area of the brain for a big tank lazerostimulyatsii, microwave therapy, etc. also associated with the role of the site. It is known that a large tank of the brain is an important regulator of the movement of cerebrospinal fluid, however, for example, marked a kind of synergistic therapeutic effects: electrical stimulation of the upper cervical sympathetic nodes and lazerostimulyatsiya parasagittal area has always been more effective in combination than when using them.
The zone of large tanks skull brain trauma often involved in the pathological process. Normalization of its function, a decrease of reactive (inflammatory) changes is an important precondition for the normalization liquorodynamics. It should also be borne in mind that in the tank located brainstem structures, including the reticular formation. Stimulation of these structures is directly related to the processes sanogenesis.
Speaking about the specificity of the zones of influence, we should note the high sensitivity to physical factors, palms, feet, ear, etc.
Particularly sensitive to EMF carotid sinus area, the effect of which could cause significant therapeutic effects.
Perspective in the choice of zones of influence in the FT are hardware methods – identifying areas of low electrocutaneous resistance or high potential, “interested” vascular pool or REG Dopplerograms etc.
Helpful in this regard, there are options acupuncture (system, meridian) Diagnostics (Methods Nakatani, Akabane, Foll, hardware pulse diagnosis, etc.), allowing to detect not only the pathological system and thus the zone of influence, but do it often at the preclinical level. This last fact is particularly important in preventing relapse of disease and to monitor the effectiveness of treatment.
Thus, a modern FT has a great range of possibilities in the choice of zones of influence. It is important that every medical specialist has learned the most important of them, and skillfully used them in clinical practice, mindful of the fact that each zone of the “individual” and requires adequate physical factor.
Physiopuncture: trends, problems and prospects
Millennium humanity sums up over time and outlines the plans for the future, trying to identify prospects. This also applies to medicine, particularly physiotherapy – the science of therapeutic and prophylactic use of energy of physical factors, both natural and artificial.
It is worth noting that
Given the achievements in studying the mechanisms of action on the body of physical factors, the experience gained by practitioners, it is possible to identify such opportunities physiotherapy:
1. expansion of the indications for the use of physical factors in the treatment of immune deficiency of different origin, cancer, blood disorders (anemia), eye disease, severe diseases of the peripheral nervous system during acute course of myocardial infarction, pancreatitis, etc.;
2. the use of physical factors to stimulate the physiological mechanisms for the protection of the organism, the mechanisms sanogenesis (restitution, recovery, compensation, immunity), especially in patients with chronic, recurrent course of disease;
3. purpose of physical and medical or medication and physical treatment systems, given that this combination potentiates the therapeutic effect of complex components, reduces the side effects of drugs, prolongs the time of exposure to the pathological process;
4. wider use of information and the resonance effect of physical factors in small and very small amounts of energy (magnetic fields, millimeter wave, low-intensity laser radiation, the effects of aromatic substances, etc.);
5. expanding opportunities puncture physiotherapy, considering obtaining a desired manifestations and overall effect on the whole body;
6. the use of purposeful actions of certain physical factors on certain pathogenic manifestations of diseases or disorders. Refers to inflammation and its components, dystrophic-degenerativnyezabolevaniya, changes in immune homeostasis, correction of catabolic or anabolic conditions, pain of acute, subacute or chronic pain syndrome;
8) in the last decade have begun to actively use the energy of physical factors for diagnostic purposes. This method of thermal imaging, ultrasound, laser diagnostics, electrodiagnostics.
The development of these areas is promising, especially because it ofteon-invasive methods of investigation.
Myofascial Pain Syndrome. Manual methods of muscle correction. Manual therapy (chiropractic).
Principles of modern reflexology.
Myofascial Pain Syndrome
Myofascial Pain Syndrome (or MPS) is a term used to describe one of the conditions characterized by chronic, and in some cases, severe, pain. It is associated with and caused by “trigger points” (TrPs), which are localized and sometimes extremely painful contractures (‘knots’) found in any skeletal muscle of the body. The symptoms can range from referred pain through myofascial trigger points to specific pains in other areas of the body.
MPS may be related to a closer-studied complex condition known as fibromyalgia. By accepted definition, the pain of fibromyalgia is generalized, occurring above and below the waist and on both sides of the body. On the other hand, myofascial pain is more often described as occurring in a more limited area of the body, for example, only around the shoulder and neck, and on only one side of the body.
Neither MPS or FMS is thought to be an inflammatory or degenerative condition, and the best evidence suggests that the problem is one of an altered pain threshold, with more pain reported for a given amount of painful stimuli. This altered pain threshold can be manifest as increased muscle tenderness, especially in the certain areas, e.g., the trapezius muscle. These syndromes tend to occur more often in women than in men, and the pain may be associated with fatigue and sleep disturbances.
The precise cause of MPS is not fully understood and is undergoing research in several medical fields but there are some systemic disorders, such as connective tissue disease, that can cause MPS. Unfortunately, many practitioners consider it too generalized and, since physicians’ specializations have become so narrow, they do not want, nor have the necessary current information, to treat the condition.
A fairly new form of therapy called Myofascial Release, using gentle fascia manipulation and massage, is believed by some to be beneficial and pain-relieving.
Myofascial pain syndromes can arise of distinct, isolated areas of the body, an example being Urologic Chronic Pelvic Pain Syndromes. (UCPPS).
People who suffer from this syndrome are many times in “unbearable” pain which moves at will from one point in the body to the next. It has been found that mild pressure on “trigger point” areas may relieve some of the discomfort by calming down the nerve pain. (UCPPS).
Myofascial Pain. The Symptoms and Causes
Myofascial pain syndrome is a chronic local or regional musculoskeletal pain disorder that may involve either a single muscle or a muscle group. The pain may be of a burning, stabbing, aching or nagging quality. Importantly, where the patient experiences the pain may not be where the myofascial pain generator is located. This is known as referred pain. The pathophysiology of myofascial pain remains somewhat of a mystery due to limited clinical research; however, based on case reports and medical observation, investigators think it may develop from a muscle lesion or excessive strain on a particular muscle or muscle group, ligament or tendon. It is thought that the lesion or the strain prompts the development of a “trigger point” that, in turn, causes pain.
In addition to the local or regional pain, people with myofascial pain syndrome also can suffer from depression, fatigue and behavioral disturbances, as with all chronic pain conditions.
How to Diagnose and Treat Myofascial Pain Syndrome
Myofascial pain syndrome can be considered, at least partially, a side effect of our modern lifestyles. It is caused by numerous factors: trauma, tension, inflammation, overuse, overload, poor posture, stress, repetitive strain, poor sleep, emotional stress, or other medical conditions, such as nerve entrapment, thyroid dysfunction, vitamin insufficiencies, metabolic dysfunctions. Myofascial pain is pain localized in the muscles and surrounding tissues. The constellation of symptoms includes achiness, fatigue, poor sleep, chronic muscle tightness, and limited range of motion. Sometimes, myofascial pain can produce numbness and sensory disturbances. If myofascial pain occurs in the neck, it can cause ringing in the ears, loss of balance, or chronic headaches.
Trigger points:
Trigger points are commonly associated with myofascial pain. In a study of 200 asymptomatic young adults, 54% of females and 44 % of males had latent trigger points. Latent trigger points are not painful unless they are pressed. In adult populations with complaints of pain, 86-93% of people had active trigger points. Active trigger points cause pain with or without applied pressure. Trigger points are hypersensitive, painful “knots” in taut muscle bands. When pressed, the trigger point often causes localized or referred pain. The trigger point may cause numbness, tingling, increased sweating, muscle spasms, or radiating pain to other areas. Infact, the trigger point can mimic nerve related (neuropathic) pain.
Ergonomics and Posture:
Because this is often a chronic condition, treatment requires multiple repeated therapies. Because of our sedentary lifestyles and numerous hours seated at a desk, the small muscles of the neck and upper back are under considerable strain. Being cognizant of one’s posture as well as ergonomic considerations may be helpful in decreasing the intensity and frequency of painful episodes. Intermittent stretching and regular relaxation techniques can help quell the pain, improve range of motion, and promote more restful sleep.
Therapeutic options:
Passive therapeutic options include physical therapy which includes, application of deep heating modalities such as ultrasound, electrical stimulation, and ice or hot packs. Other physical therapy techniques include range of motion, stretching, and, after the pain has subsided, strengthening exercises. Massage therapy helps to manually break up the muscle “knots” and relax the muscle fibers. Massage therapy also causes release of local endorphins into the bloodstream to create a relaxed mood. Chiropractic care and acupuncture may be also be used for treatment.
Trigger point injections:
Another important therapeutic treatment option includes trigger point injections. Trigger point injections employ small needles and local anesthetic ( lidocaine) to mechanically break up the muscle “knots”. The procedure takes less than 5 minutes. Side effects may include mild soreness during the first 24 hours, followed by a sense of openness and looseness in the muscle group. Possible side effects of any injection include a risk for bleeding or infection. Lidocaine is an anesthetic which can stop cardiac arrhythmias, but can also cause them if injected intravenously. Because the injection site is the muscle and the syringe is pulled back to make sure we are not in a blood vessel the risk is extremely low. Lidocaine is metabolized in the liver. Lidocaine leaves the body within 4-6 hours. Aside from lidocaine, traumeel, a blend of several herbal medications, can be injected into the trigger points.
Contraindications to trigger point injections:
People who should not get trigger point injections include pregnant or nursing women. Anyone on blood thinners (325mg of aspirin, coumadin, plavix or someone who has a problem with clotting). Anyone with a rash or skin infection, or anyone who has an allergy to lidocaine.
Dry needling:
For those with an allergy to lidocaine or those who prefer not to inject any medications, trigger point injections can be done with out lidocaine. This is referred to as “dry needling.” Dry needling can also cause release of trigger points and the sensation of openness, but may be accompanied with more soreness than when lidocaine is injected.
Medications:
Sometimes medications can be prescribed, such as anti-inflammatories or muscle relaxants. These are not without their side effects and risks. Anti-inflammatories can erode gastric lining, impair renal function, and alter clotting mechanisms. Muscle relaxants can cause sedation, grogginess, and decreased ability to focus. Other medications may also be used. Alternatively, an anti-inflammatory diet can be incorporated to help decrease inflammation in the body.
Recognition of this syndrome is difficult and requires the physician to have a precise understanding of the body’s anatomy. Trigger points can be identified by pain produced upon digital palpation (applying pressure with one to three fingers and the thumb). In diagnosing myofascial pain syndrome, four types of trigger points can be distinguished:
active trigger point — an area of exquisite tenderness that is usually located in a skeletal muscle and is associated with local or regional pain;
latent trigger point — a dormant area that can potentially behave like an active trigger point;
secondary trigger point — a hyperirritable spot in a muscle that becomes active as a result of a trigger point and muscular overload in another muscle;
satellite myofascial point — a hyperirritable spot in a muscle that becomes active because the muscle is located within the region of another trigger point.
The best treatments for myofascial pain syndrome are active and passive physical therapy methods. There is also the “stretch and spray” technique, in which the muscle with the trigger point is sprayed along its length with a coolant such as fluorimethane, and then stretched slowly.
Trigger point injection, whereby local anesthesia is injected directly into the trigger point, also is used. At times, corticosteroids and botulinum toxin can be injected. Massage therapy also can be of significant benefit in some patients. Often a combination of physical therapy, trigger point injections and massage are needed in refractory chronic cases.
Myofascial pain (MP) is a common, painful disorder that is responsible for many pain clinic visits. MP can affect any skeletal muscles in the body. Skeletal muscle accounts for approximately 50% of body weight, and approximately 400 muscles make up the body. MP is responsible for many cases of chronic musculoskeletal pain.
MP can cause local or referred pain, tightness, tenderness, popping and clicking, stiffness and limitation of movement, autonomic phenomena, local twitch response (LTR) in the affected muscle, and muscle weakness without atrophy. Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles, restricted range of motion (ROM), and a visible or palpable LTR to local stimulation, are classic signs of MP. Over 70% of TrPs correspond to acupuncture points used to treat pain.
An active TrP is an area that refers pain to a remote area in a defined pattern when local stimulation is applied. Satellite TrPs appear in response to a primary, active TrP and usually disappear after the primary TrP has been inactivated. Latent TrPs cause stiffness and limitation of ROM but no pain. Frequently, they are found in asymptomatic individuals.
Although MP and fibromyalgia have some overlapping features, they are separate entities; fibromyalgia is a widespread pain problem, not a regional condition caused by specific TrPs.
Pathophysiology
A taut band in a muscle may be necessary as a precursor to the development of a trigger point (TrP). Taut bands are common in asymptomatic individuals, but patients with them are more likely to develop a TrP. A latent TrP can develop into an active TrP for a number of reasons. Psychological stress, muscle tension, and physical factors, such as poor posture, can cause a latent TrP to become active.
The pathophysiology of myofascial pain is not well understood. Current research supports sensitization of low-threshold, mechanosensitive afferents associated with dysfunctional motor endplates in the area of the TrPs projecting to sensitized dorsal horeurons in the spinal cord. Pain referred from TrPs, as well as LTRs, may be mediated through the spinal cord after stimulation of a sensitive locus.
Possible factors that lead to myofascial pain syndromes.
Tendonitis presents as local pain, inflammation, dysfunction, and degeneration. It can be associated with overuse, infection, systemic rheumatic disease, or metabolic disturbance such as calcium apatite or pyrophosphate deposition. Fluoroquinolone antibiotic use can be associated with tendonitis and rupture. Inflammation can cause “triggering,” in which the digit locks and a snapping sensation is felt upon release.
The spectrum of nonarticular myofascial pain syndromes.
Bursitis presents as local pain and inflammation of the synovial fluid filled saclike structures that protect soft tissues from underlying bone. Overuse, infection, systemic rheumatic disease, and metabolic disturbance such as calcium apatite and pyrophosphate deposition can also cause bursitis. Gout often causes olecranon bursitis and prepatellar bursitis.
Structural disorders such as scoliosis, lateral patellar subluxation, and flatfoot can cause local pain but are not always a source of pain or dysfunction. The hypermobility syndrome presents with arthralgias due to increased joint laxity in the face of muscle disuse.
Neurovascular entrapment can occur centrally (eg, in spinal stenosis), in deep tissues (eg, thoracic outlet syndrome), or peripherally (eg, carpal or tarsal tunnel syndromes). Bone enlargement due to osteophytes, muscular tension, and inflammation can contribute to narrowing of a neurovascular passage. Pain and paresthesia usually occur distal to the site of entrapment.
Regional myofascial pain syndromes, such as temporomandibular joint syndrome, may represent a pain-spasm pain cycle triggered by mechanical injury, such as strain or overuse.
Multiple bursitis and tendonitis syndrome present with anatomically localized areas of pain and dysfunction. Pain can be widespread, but the muscle tender points observed in fibromyalgia are absent. Usually, much less fatigue occurs, and responses to local therapies are better than in fibromyalgia.
Fibromyalgia, in many cases, presents as a form of allodynia, in which usually painless stimuli are perceived as painful, and hyperalgesia, in which normally painful stimuli is amplified. Cerebrospinal fluid levels of substance P are elevated, and additional abnormalities in the serotonin system and in the regulation of cortisol exist. Fibromyalgia can also coexist with various autoimmune diseases and often presents after a severe flulike syndrome, a defined infection (eg, Lyme disease), or trauma. Sleep is often disturbed, and nonrestorative sleep is associated with increased pain. The increased prevalence in females may point to a hormonal influence. Few abnormalities occur in the peripheral musculature. Studies that show abnormalities of cerebral blood flow in the thalamus and caudate nucleus help support the likelihood that pain processing in the central nervous system behaves abnormally.
A recent study found that patients with fibromyalgia have an increased expression of sensory, adrenergic, and immune genes during moderate exercise.5 Abnormalities of the neuroendocrine immune system are well documented, but none has yet been proven to be sensitive and specific enough to be used as a criterion for diagnosis.
Psychological, personality, and social factors may play important roles in many chronic cases of local and generalized pain syndromes. The image below depicts possible factors that contribute to the generation of these syndromes.
Clinical
History
Patients with myofascial pain usually report regionalized aching and poorly localized pain in the muscles and joints. They also may report sensory disturbances, such as numbness in a characteristic of distribution. The type of pain felt is characteristic of the muscle involved. An acute onset may occur after a specific event or trauma (eg, moving quickly in an awkward position), while chronic pain may result from poor posture or overuse.4 Patients may note disturbed sleep. Persons with cervical and periscapular myofascial pain may have difficulty finding a comfortable sleeping position. They may or may not be aware of muscle weakness in the affected muscles and may have a tendency to drop things.
Physical
A skilled examiner can provide accurate diagnosis of myofascial pain (MP). Unfortunately, most medical school and residency training programs do not adequately cover this common condition. Locating trigger points (TrPs) is the most important part of the physical examination. TrPs tend to occur in characteristic locations in individual muscles. The book Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual is considered the criterion standard reference on locating and treating TrPs.
When the TrP is located, the patient typically has a positive jump sign when local pressure is applied over the area; the jump sign should not be confused with an LTR. The jump sign simply means that the patient jumps from pain or discomfort in the area that has been palpated. Apply a consistent amount of pressure to the area, because applying too much pressure can elicit pain iearly all individuals. A pressure algometer (ie, pressure threshold meter) or palpatometer can be used to standardize the amount of pressure applied.
A taut band is found in the muscle, either by palpation or by needle penetration. It can be distinguished by palpating or by dragging the fingers perpendicular to the muscle fibers. A localized knot or a tight, ropy area is noted. Patients report that the area is extremely tender when palpated. A localized flinching in the area of the muscle being palpated or an LTR may be noted in active TrPs, as well as in latent ones. Palpation or insertion of a needle into the TrP causes reproduction of the patient’s pain and, frequently, sensory complaints. Palpation of either an active or a latent TrP causes referred pain in a characteristic area for each muscle, a phenomenon described in the above-mentioned TrP manual. Sensory disturbance (eg, paresthesias, dysesthesias, localized skin tenderness) may be noted in the same area where pain may be referred. Autonomic phenomena also may be elicited (eg, sweating, piloerection, temperature changes).
Essential criteria for identifying an active or latent TrP include the following:
Palpable taut band if the muscle is accessible
Exquisite spot tenderness of a nodule in a taut band
Patient’s recognition of current pain complaint by pressure on the tender nodule
Painful limit to full ROM stretch of the involved muscle
Confirmatory observations include the following:
Visual or tactile identification of an LTR
Imaging of an LTR induced by needle penetration of a tender nodule
Pain or altered sensation on compression of a tender nodule, in the distribution expected from a TrP in that muscle
Electromyographic demonstration of spontaneous electrical activity (SEA) that is characteristic of active loci in the tender nodule of a taut band
Lowered skin resistance to electrical current – This has been found over active TrPs when compared with surrounding tissue and may be useful in localizing TrPs. Skin resistance normalizes after the treatment of TrPs.
Causes
Several factors contribute to myofascial pain (MP). Abnormal stresses on the muscles from sudden stress on shortened muscles, leg-length discrepancies, or skeletal asymmetry are thought to be common causes of MP. Poor posture also may cause MP. In addition, the assumption of a static position for a prolonged period of time has been implicated in the condition. Anemia and low levels of calcium, potassium, iron, and vitamins C, B-1, B-6, and B-12 are believed to play a role. Chronic infections and sleep deprivation have been cited as causative factors, as have radiculopathy, visceral diseases, and depression. Hypothyroidism, hyperuricemia, and hypoglycemia also have been implicated in MP. The pathogenesis likely has a central mechanism, with peripheral clinical manifestations.
Other Problems to Be Considered
Articular dysfunction requiring manual mobilization
Nonmyofascial trigger points
Radiculopathy
Workup
Laboratory Studies
No specific lab tests confirm a diagnosis of myofascial pain (MP), but lab tests can be helpful in looking for predisposing conditions, such as hypothyroidism, hypoglycemia, and vitamin deficiencies. Specific tests that may be helpful include complete blood count (CBC), chemistry profile, erythrocyte sedimentation rate (ESR), and levels of vitamins C, B-1, B-6, B-12, and folic acid. A thyrotropin level may be helpful if clinical features of thyroid disease are present.
Imaging Studies
Infrared or liquid crystal thermography can show increased blood flow, which is sometimes noted at trigger points. Other imaging studies are useful only to rule out other sources of pain generation.
Other Tests
Needle electromyography (EMG) examination of trigger points (TrPs) in humans and rabbits has shown high-voltage spike activity and spontaneous, low-voltage endplate noise, which is considered characteristic but not pathognomonic. Surface EMG has been used in experiment protocols to monitor muscle activity in TrPs. Ultrasonography has been used to visualize the LTR elicited by needle penetration.
Procedures
Trigger point (TrP) injections sometimes are performed with bupivacaine, etidocaine, lidocaine, saline, or sterile water. Dry needling is occasionally performed, without the injection of any substance.
Steroids may be used in areas possibly associated with inflammation, as in frozen shoulder. Botulinum toxin shows promise as a substance that can provide long-lasting relief. Its mechanism of action may be related to the blocking of acetylcholine release at the neuromuscular junction of the dysfunctional motor endplates.
A report by Affaitati et al indicated that a topical anesthetic patch can also relieve myofascial pain, without the discomfort that can result from TrP injections. Patients in the study were separated into groups of 20, one of which was treated for 4 days with a lidocaine patch applied to each patient’s trigger point (with patients receiving a total daily dose of 350 mg). The second group received a placebo patch, and the third group was treated with injections of 0.5% bupivacaine hydrochloride.
In members of the lidocaine patch and bupivacaine injection groups, the investigators found significant decreases and increases in, respectively, subjective symptoms and pain thresholds. Although the effects at muscle TrPs and target areas were more pronounced in the injected patients, the lidocaine patients experienced less therapy-related discomfort. Subjective symptoms and pain thresholds did not improve in the placebo group.
Treatment
Rehabilitation Program
Physical Therapy
Physical therapy for patients with myofascial pain focuses on correction of muscle shortening by targeted stretching, strengthening of affected muscles, and correction of aggravating postural and biomechanical factors. Modalities can be useful in decreasing pain, allowing the patient to participate in an active exercise program.
Corrections of leg-length discrepancies with a heel lift or the use of dynamic insoles also may be helpful. Various other techniques and procedures, including the following, have been demonstrated to be effective in some patients:
Indomethacin phonophoresis
Massage and exercise
Stretching
Electrical muscle stimulation (
Deep Muscle Stimulator
Ultrasonography
EMG biofeedback
Occupational Therapy
Occupational therapy can be helpful in assessing and setting up ergonomically correct workstations for patients with myofascial pain. Properly set up work sites can help to decrease aggravating postural factors.
Medical Issues/Complications
Trigger points (TrPs) can result from noxious stimuli, such as a herniated disc. Inquire about such precipitating factors in the patient’s environment.
The treatment of TrPs can provide temporary relief of visceral pain referred from other organs and can mask the pain of serious conditions (eg, appendicitis, myocardial infarction).
Complications of TrP injections are rare and depend on the area being injected. They include local pain, bleeding, bruising, intramuscular hematoma formation, infection, and, more rarely, neural or vascular injury, or penetration of an underlying organ (which could lead to pneumothorax).
Consultations
Consultation with a specialist in physical medicine and rehabilitation may be indicated and should be arranged as needed.
Other Treatment
Acupuncture may be helpful.
Osteopathic manipulation techniques may include integrated neuromusculoskeletal release, myofascial release, strain-counterstrain, muscle energy, and high-velocity/low-amplitude manipulation.
Medication
Muscle relaxant medications23 and nonsteroidal anti-inflammatory drugs (NSAIDs) can at times be a useful adjunct to active, exercise-based treatment for myofascial pain, but they are helpful only rarely on their own. Medications such as low-dose amitriptyline may help to improve the patient’s sleep cycle. Botulinum toxin type A injected into trigger points can reduce muscular contractions through the inhibition of acetylcholine release at the neuromuscular junction and appears to have an antinociceptive effect. Current research suggests that peripheral sensitization is blocked, which indirectly reduces central sensitization.
Myofascial pain syndrome. Manual methods of muscle correction
INTRODUCTION
The first description of myofascail pain syndrome was published in the german literature in 1843.
Myofascial pain is probably the most common cause of musculoskeletal pain in medical practice (Imamura, Fischer, Imamura et al.1997).
Myofascial pain is caused by hyper- irritable spots called trigger points that develop in skeletal muscle or its surrounding fascia.
Despite the fact that an estimated 44 million Americans struggle with the condition, myofascial pain is arguably one of the better kept Secrets of modern medicine. Relatively little is known about it in the medical community which makes it difficult for medical professionals to distinguish it from other forms of soft tissue disorders Or to understand how it can undermine for interact with other illnesses. Also unfortunate is that the practical experience required to accurately diagnose myofascial pain are simply not available in many medical schools.
It is not difficult, however, to realize potential the devastation caused by myofascial pain once one realizes how prevalent it can be in the human body.
In 1987, David Simons, MD, a pioneer in the field of myofascial pain, wrote skeletal muscle is the largest organ of the body makes up nearly half of body weight. Muscles are the motors of the body. They work with and against the ubiquitous spring of gravity together with cartilage, ligaments, and intervertebral discs as the bodies mechanical shock absorbers. Each of the approximately 500 skeletal muscles subject to acute and chronic strain. Each muscle can develop myofascial trigger points and has its own characteristic pattern of referred pain.
An
WHEN FASCIA IS INJURED
Because fascia permeates all regions of the body and is all interconnected, when it scars and hardens in one area (following injury, inflammation, disease, surgery, etc.), it can put tension on adjacent pain-sensitive structures as well as on structures in far-away areas. Some patients have bizarre pain symptoms that appear to be unrelated to the original or primary complaint. These bizarre symptoms caow often be understood in relationship to our understanding of the fascial system.
UNDERSTANDING FASCIA SYSTEM
Fascia is a three dimensional web of connective tissue which runs continuously throughout the body from head to foot and superficial to deep without interruption. It does not have origins or insertions, as do muscles. Rather it runs continuously throughout the body lending support and separation to all systems.
Fascia is composed of an elastocollagenous complex with elastin fibers which lend elasticity and tissue memory), and collagen fibers (which lend strength), embedded in a gelatinous ground substance which allows fiber mobility, as well as cellular circulation.
Muscles do not exist in isolation. Muscles are actually groups of myofibrils/myofibers/myofascicles which are bound together by fascial envelopes. The muscular fascia (perimysium) runs continuously into the osseous fascia (periosteum) which joins the periarticular tissue as well.
The vertebral column is supported in space by the myofascial system, just as a tent pole is supported by the guide wires. The system was designed to work in a balanced, symmetrical position. When using myofascial release techniques, a primary goal is to improve structural alignment and reduce abnormal pressure on pain sensitive structures that may be producing the symptoms of pain, spasm or abnormal tone.
Fascia reorganizes itself along the lines of tension imposed upon it in order to support the structure. Where there is excess stress, fascia will thicken to add strength and support. Although connective tissue functions to support our posture and motion, it does not evaluate how we can equally reinforce poor posture and motion, as it does efficient movement the body fascia may be regarded as a continuous laminated sheet of connective tissue that extends without interruption from the top of the head to the tip of the toes. It surrounds and invades every other tissue and organ of the body, including nerves, vessels, muscle and bone. Fascia is more dense in some areas than others. Dense fascia is easily recognizable (for example, the tough white membrane that we often find surrounding butchered meat).
Myofascial restrictions:
A small change in the myofascia can cause great stress to the body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40 %; (Greenman, 1996). If two major joints are restricted in the same extremity, it can increase by as much as 300 %;. Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function.
In “Principles of Manual Medicine” (ibid), the author finds it convenient to separate fascia into three layers, but it is continuous and three dimensional, so please visualize it as such.
Superficial fascia is attached to the underside of the skin. Capillary channels and lymph vessels run through this layer, as do many nerves, and subcutaneous fat is attached to it. If the superficial fascia is healthy, skin moves easily over the surface of the muscles. In FMS and CMP, it can get stuck. There is also a great potential to store excess fluid and metabolites in the superficial fascia. This fascia is often the easiest to palpate, but palpation may be hampered by the presence of excess fluid. The presence of this fluid is a clue that there is something wrong and may also give clues as to the location of the problem.
Deep fascia is tougher and denser, and is used to separate large sections of the body. It covers some areas like huge sheets, protecting them and giving them shape, and separates muscles and organs. The pericardium, the pleura and the perineum are all made up of specialized deep fascia. The dural tube is also fascial, and this fascia is connected to the membranes surrounding the brain. Together, they hold and protect the craniosacral system, and changes in the craniosacral fascia can affect what it contains. Sheets of fibrous myofascial adhesion can form anywhere along nerves and block normal healthy function.
The subserous fascia is loose tissue covering the internal organs and holding the network of blood and lymph vessels that keep them moist.
Myofascia is fascia related to muscle tissue. Healthy myofascia allows for compression and tension, as well as relaxation. It is the fascia that forms adhesions and scar tissue. Healthy ground substance making up part of the myofascia has a gelatinous consistency so that it can better absorb the forces that are created during movement. Ground substance maintains the distance between connective tissue fibers. This prevents microadhesions from forming and keeps tissues supple and elastic. When the critical distance is not maintained, the fibers become cross-linked by newly synthesized collagen fibers, which are also part of the fascia. Collagen crosslinks are arranged haphazardly, unlike healthy linkages, and are harder and more painful to break up. The state of the ground substance can profoundly affect the state of health. Muscles and tendons join bones and ligaments and come together at attachment areas. The cellular membranes in these areas can become extremely convoluted, which increases the surface area and changes the angle of force. This increases the potential for tissues to stick together and causes tissues near attachment areas to become more easily torn (Simons, Travell and Simons, 1999). Attachment TrPs can become fibrotic or calcified with time. The sooner they are appropriately treated, the easier it will be to return the myofascia to a healthy state. Chronicity can often be prevented by prompt and through acute care.
PHYSICAL FINDINGS AND CHARACTERISTICS
Any muscle with a painfully restricted range of motion and a tender spot that reproduces the patient’s pain when compressed likely has a myofascial trigger point.
A number of important physical findings have been reported in muscle that pl plays host to trigger points for example, the is usually limited range of motion in the muscle which is caused by pain. Loss of strengths and stamina frequently of course as well. During clinical examination, the actual trigger point can be recognized as a localised spot of tenderness which occurs in a nodule or a palpable taught band. Of muscle fibres. These changes can be caused by a massive increase of the neurotransmitter acetylcholine.
Gently rubbing across the direction of the muscle fibres of superficial muscle, the examiner can feel a nodule at the trigger point and a rope like induration that extends from this nodule to the attachment at each end of the involved muscle fibres. The taut band can be snapped or rolled under the finger in accessible muscles. snapping palpation Of the trigger point frequently evokes a transient twitch response of the taut band fibers. This is often referred to as a local twitch responce or LTR.
In 1981, One hypothesis explained how the taut band muscle fibers contracted in the absence of propagated electrical activity, and why stretching the muscle could produce rapid resolution of the tenderness of the nodule and the tautness of the band. The hypothesis focused on excessive calcium release from the sarcoplasmic reticulum as a cause of local muscle fiber contracture. The contracture, in turn, causes local ischemia that limits energy replacement and consumes more adenosine triphosphate (ATP), depleting the energy source. These events leave insufficient ATP for adequate return of calcium from the contractile elements to the sarcoplasmic reticulum by the calcium pump. Stretching the muscle reduces the overlap between actin and myosin, thereby reducing energy demand and breaking the cycle.
TISSUES SUSCEPTIBLE TO REPETITIVE STRAIN INJURIES
Chronic myofascial pain is a neuromusculoskeletal condition. It is nonprogressive, nondegenerative, and noninflammatory. It is composed of myofascial trigger points (TrPs) which refer pain and other symptoms in very precise patterns in specific regions of the body. It seems progressive because each TrP can develop satellite and secondary TrPs, which can form secondaries and satellites of their own. With treatment of TrPs and the underlying perpetuating factors, however, the TrPs can be “reversed” and minimized or eliminated. A small change in the myofascia can cause great stress to other parts of your body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40%, and, if two major joints are restricted in the same extremity, it can increase by as much as 300% (Greenman 1996). Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function. A myofascial TrP is always found in a taut band, which is structurally related to contraction knots caused by a thousand-fold increase in the release of acetylcholine, an important neurotransmitter. This action takes place in an area of the muscle where nerves end, which is called a motor endplate (Gerwin 1999). The cause of TrPs appears to involve serious disturbances of the nerve ending, and dysfunction of the contractile mechanism of the muscles.
One of the most common perpetuating factors of myofascial trigger points is inappropriate therapy. You cannot strengthen a muscle with a TrP because it is already physiologically contractured. The TrP must be gone before the muscle can be strengthened. The patient usually presents with complaints from the most recently activated TrP. When this is eliminated, the pain pattern may shift to an earlier TrP, which also must be inactivated. Trigger points are directly activated by acute overload, overwork fatigue, direct trauma, and chilling. They are also activated indirectly by other TrPs, visceral disease, arthritic joints, and emotional distress. Active TrPs vary from hour to hour and day to day. The signs and symptoms of TrP activity long outlast the precipitating event.
Inflammation
It is important to keep in mind that neither FMS nor CMP is inflammatory, although secondary inflammation of the joints may sometimes occur in long-standing untreated TrPs. This occurs because contracted muscles harboring trigger points (TrPs) can pull bones slightly out of alignment. “Inactivating the related myofascial TrPs and the elimination of their perpetuating factors appear to be important parts of early therapy to delay or abort the progression of some kinds of osteoarthritis
Change in the Fascia
A muscle with active trigger points cannot be strengthened. The TrPs must be deactivated first. This can be accomplished by careful galvanic electrical stimulation, spray and stretch techniques, trigger point therapy, Myofascial therapy and other modalities. These therapies often work well in concert. Work hardening and weight training will do nothing but create more pain and disability.
Perpetuating Factors of Myofascial Trigger Points
Common MTrP perpetuating factors are:
• skeletal asymmetry and disproportion
• nutritional inadequacies
• reactive hypoglycemia or insulin resistance
• paradoxical breathing
• pain
• impaired sleep
• conditions impairing muscle metabolism
• head-forward posture
• chronic infections
• bad habits such as chronic gum chewing
• other TrPs
• visceral disease
• arthritic joints
• FMS and other chronic illnesses
• vitamin and mineral insufficiency
• adhesions
• previous surgeries
• previous traumas
• allergies
• poor posture
• poor body mechanics
• poor coping behaviors
• lifestyle
• smoking
• alcohol consumption
• stress
• Morton’s foot
• thyroid resistance
• short upper arms
• short lower legs
• unequal leg length
• hypothyroid
• psychological stress
• ill-fitting shoes
• ill-fitting furniture and car seats
• hypermobility
• repetitious exercise and work
• overwork
• immobility
Autonomic Reactions and TrPs
Some trigger points may produce autonomic reactions, such as sweating, blanching, dizziness, and nausea. These autonomic responses may be relieved by treating the trigger point. Many muscles have multiple TrP locations. The major factor in TrP pain is always mechanical, even if it was triggered by stress.
Myofascial Trigger Points (MTrPs)
Trigger points are extremely sore points occurring in ropy bands throughout the body. To more easily palpate TrPs in the arm or leg muscles, stretch the involved muscle about 2/3 of the way out. If there is pain at the end of a restricted range of motion, there is probably a TrP involved. TrPs cause muscle weakness and other dysfunction before they cause pain. Much of the restricted range of motion and dysfunction often attributed to old age may be due to myofascial TrPs and thus can be successfully treated. Travell and Simons have carefully documented and detailed the maps and common associated proprioceptive and autonomic concomitants.
Myofascial Trigger Points
A latent MTrP doesn’t hurt unless you press it. Your patient might not even know it’s there, but his or her body does. It weakens the affected muscle, restricting movement and preventing its full lengthening. If you press on the TrP it refers pain in its characteristic pattern. Latent TrPs may be activated by overstretching, overuse, or chilling the muscle. People who get little exercise have a greater chance of developing latent TrPs. Some people believe that by restricting their range of motion they are getting rid of their TrPs. Nothing can be farther from the truth. When someone with multiple latent TrPs falls, develops an infection, or is affected by any other stressor, all of the latent TrPs can activate simultaneously. Physical stress isn’t the only thing that can cause TrPs. Tension TrPs can occur. These are not the psychological result of tension, but they are physiological biological effects of long-term emotional abuse, mental trauma or other stressor. Constantly holding muscles tight in a “fight-or-flight” stress response changes biomechanics. It will take both patient and care provider effort, time and persistence to change them back. Bodywork and exercise can activate TrPs, and so can a TrP examination.
An active TrP not only hurts when it is pressed, like an FMS tender point, but it “triggers” a referred pain pattern somewhere else in the body. This pain pattern is similar from patient to patient and may include spillover pain areas. These TrPs often produce symptoms other than pain. Active TrPs hurt when the muscle is in use. When the TrP becomes very active, pain and other symptoms occur even when the muscle is resting. The fact that these pain patterns are very much similar from patient to patient helps if the diagnostician is familiar with the patterns so well described by Travell and Simons. A comprehensive history will tell you where to look for TrPs and may help prevent needless pain. If your patient has a stiff neck, for example, you can check for TrPs in the levator scapulae, and if there is a problem with incontinence, there are TrPs that can affect that too. Some other TrP associated symptoms include localized sweating, tearing, poor balance, nausea, tinnitus, goosebumps, runny nose, buckling knees, weak ankles, illegible handwriting, headaches, and muscle cramps.
Myofascial Trigger Point Therapy (MTPT) is a unique treatment protocol for the treatment of myofascial pain and dysfunction.
The protocol is based on the seminal works of Janet G. Travell, MD and David G. Simons, MD and integrates current scientific concepts and research. This protocol includes the following: differential diagnosis, comprehensive patient history, pain mapping, range of motion evaluation, postural analysis, identification of perpetuating factors, correction of perpetuating factors by working with an interdisciplinary team, manual techniques like Advanced Myofascial release to treat myofascial pain and dysfunction, personalized patient stretch and exercise rehabilitation program, patient education.
STAGES OF REHABILITATION PROCESS
Stage 1 -Recovery
Stage 2- Stabilization
Stage 3-Follow up, To enhance recovery and reduce risk of relapse.
TREATMENT METHODS
Neuro-Myofascial system
Myofascial therapy
Manual trigger point therapy
Neuromuscular techniques
Muscle release techniques
Muscle energy techniques
spray and stretch therapy
MTP injections with stretching (dry needling)
Galvanic stimulation
Joints, ligaments and tendons
orthopedic medicine
Transverse frictions
Injections
Mobilizations ( Muscular, soft tissue, nervous and articular )
Manipulation of the Soft tissues and Joints.
Advanced and Specific Exercise Program.
Functional Restoration
Relaxation techniques
Clinical ergonomics
Postural advice and correction (using adhesive Tapes Etc.)
Nutrition – health diet
Nutritional supplements.
Managing psychosocial risk factors.
Manual therapy (chiropractic).
Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system. Chiropractic is controversial, and it is generally considered to be complementary and alternative medicine, a characterization that many chiropractors reject. The main treatment involves manual therapy, including manipulation of the spine, other joints, and soft tissues; treatment also includes exercises and health and lifestyle counseling. Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body’s function and its innate intelligence, a notion that brings ridicule from mainstream science and medicine.
D.D. Palmer founded chiropractic in the 1890s and his son B.J. Palmer helped to expand it in the early 20th century. It has two main groups: “straights”, now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider subluxations to be the leading cause of all disease; “mixers” are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture. Chiropractic is well established in the
For most of its existence, chiropractic has battled with mainstream medicine, sustained by ideas such as subluxation that are not based on solid science. Vaccination remains controversial among chiropractors. The American Medical Association called chiropractic an “unscientific cult” and boycotted it until losing a 1987 antitrust case. Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians and health plans in the
Treatment techniques
Picture 1. Doctor applies a caudad pressure to the dorsum of the hand bilaterally. Normally, the patient maintains strong wrist extension. A hidden cervical disc may be present when the patient exhibits a weakness with wrist extension.
Picture 2: Doctor applies anterior-superior pressure to the transverse processes of the cervical spine, to detect the level of involvement.
Picture 3: When the vertebra above the level of the disc involvement is challenged, the wrist extensor muscle will test weak.
Picture 4: Supine correction for a hidden cervical disc is displayed. Note that the Index Finger DIP contact is on the spinous process inferior to the involved disc level. (This is the segment below the challenged vertebra that produced weakness in the extensor muscle test.)
Spinal manipulation, which chiropractors call “spinal adjustment” or “chiropractic adjustment”, is the most common treatment used in chiropractic care; in the
There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, Applied Kinesiology (which emphasises “muscle testing” as a diagnostic tool), and cranial. Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.
Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than 1/3 of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.
Principles of modern reflexology
1. Consistency – methods punkturnoyi refleksooterapiyi be appointed on the basis of previous treatment.
2. Early use – justified the appointment of private medical factors in the early stages of pathological process significantly improves results and reduces the time complex therapy.
3. Adequacy of influence – the choice of physical factors, methods of procedure should adaptive capacities of the patient or organ system.
4. Optimal dose – should try to pursue the best treatment options physical factors.
5. Specificity of action – the choice and differential use of physical factors is to maximize the use of features of their mechanism of action and relevance of the pathogenesis of specific diseases.
6. Dynamism of use – during the course of treatment should be messing with the recipe physiotherapy procedures, depending on the reaction of the patient to avoid habituation to the effects.
7. Complexity and systematic physical therapy – medical complex should consist of methods of influence on different body systems, provide basic treatment and concomitant diseases.
8. Individual approach – the appointment of physiotherapeutic procedures should take into account biological rhythms, sex and age characteristics.
