National Fibromyalgia Association FAME Conference Orange, CA - PowerPoint PPT Presentation

National Fibromyalgia Association FAME Conference Orange, CA March 17, 2006 Treating Myofascial Pain Hal Blatman, MD Medical Director Blatman Pain Clinic Holistic Comprehensive Pain Care www.blatmanpainclinic.com

PAIN THEORY • In school, we are taught theories regarding pain – Mechanisms of causation – Treatment protocols and procedures – Medications

WE’RE TAUGHT IS FIRST THEORY INFLAMMATION

• Inflammation words Pain Theory – Tendonitis – Arthritis – Bursitis

Has had shoulder pain for TEN years! Uncle George

Have Turned Into All of His Friends Doctors

Eventually, George Hurts Badly Enough To See Doctor Jones

Doctor Jones • X-ray of the shoulder • MRI scan of the shoulder – Spurs – Bones too close together

George Has ARTHRITIS Therefore

George Goes Home with a Bottle of Arthritis Pills • He is a happy camper – Not because he gets any better – But because he knows what he’s got

Doctor Jones Took a Leap of Faith • He was taught when he went to school: – If he could demonstrate an abnormality on x-ray… – Close to where George had pain… • He could tell George that the pain comes from what is seen on the X-ray.

That Requires a “Leap of Faith” We Have No Right to Make

Second Theory: PINCHED NERVE, HERNIATED DISC • If pain goes from the neck down the arm… • Or from the lower back down the leg…

PINCHED NERVE, HERNIATED DISC • We know how to find that disc • And we know how to fix it!

Pain can Come Third Theory: Nerves From

Neuropathic Pain Theory • Peripheral nerve disorders • Peripheral neuropathies • Causalgia, Reflex Sympathetic Dystrophy • Pain after amputation – Phantom Limb and Stump Pain

Fourth Theory: DEPRESSION

Middle Age Depressed Woman Theory of Pain • If you’re 40 years old and a woman – And you’ve hurt for a couple of years • You must be depressed – And your depression causes your pain

Causes the Depression In Actuality This Pain

If you get Bummed Out on a bad pain day, your body can do it to your head, even if your life is perfect, and your childhood was normal.

SUPRA-TENTORIAL PAIN THEORY Fifth Theory:

If all our Tests ARE NORMAL And you still think you hurt…. You must be making it up! You must be making it up!

Theories Correct? Are These

People With FMS/CFS Go to The Doctor, And What They’ve Got Doesn’t Fit Anything We’re Taught

Many Fibromyalgia Patients are among the most Medically Educated People I see in my Office

Much of The Pain of Fibromyalgia

MYOFASCIAL MYOFASCIAL PAIN PAIN

A Different Theory Myofascial Pain • Much of This Pain is Caused by: – Myofascial Trigger Points In Muscle and Fascia

MYOFASCIAL PAIN • Referred from T.P.’s in specific and consistent patterns, characteristic of each muscle • Patient usually presents with symptoms related to the most recently activated T.P.’s

Myofascial pain can cause: • Numbness and tingling • Burning pain • Radiating pain – neck, face, teeth, head – neck, shoulder, arm, hand – low back, buttocks, thigh, leg, foot

AUTONOMIC PHENOMENA • Localized vasoconstriction • Sweating • Salivation • Proprioceptive disturbance – imbalance – dizziness, vertigo – tinnitus

THERE IS LIFE AFTER A NEGATIVE EMG

THERE IS LIFE AFTER A NEGATIVE MRI

ALL THAT RADIATES IS NOT RADICULAR

Myofascial Trigger Points • Generate TWO Pain Patterns – Localized and Referred • Quality of Pain – Pain – Numbness – Tingling – Burning

Treasure Map

AND NECK AND NECK HEAD HEAD PAIN PAIN

Look at These Pain Patterns Think about Headache… Migraine Tension TMJ

Sternocleidomastoid

Temporalis

Masseter

Lateral pterygoid

Trapezius

Trapezius

Suboccipital

Semispinalis

Palpation Exercise • Be GENTLE!! • This can cause a headache • This can also relieve a headache

PALPATION • Grasp muscle between thumb and fingers • Cross palpate -- roll the muscle between the thumb and fingers • Taut band twitches as the active trigger point passes between the thumb and fingers

Pinch Grasp and Palpate

Palpating Sternocleidomastoid Muscle Trigger Points

Palpating Sternocleidomastoid Muscle Trigger Points

EXTREMITY EXTREMITY UPPER UPPER PAIN PAIN

Scalene

Infraspinatus

Subscapularis

Biceps

Latissimus

Pectoralis

Triceps

Tennis Elbow

Hand

Pinch Grasp and Palpate

Palpating Tennis Elbow Trigger Points

and BODY and BODY TRUNK TRUNK PAIN PAIN

Paraspinal Thoracic

BACK BACK PAIN LOW PAIN LOW

Quadratus lumborum

Rectus abdominus

Piriformis Gluteus Minimus

Gluteus maximus

Piriformis

PELVIC PELVIC PAIN PAIN

Pelvic pain

EXTREMITY EXTREMITY LOWER LOWER PAIN PAIN

Quadraceps

Hip Adductor

Hip adductor

Hamstring

Tibialis posterior

Gastrocnemius Tibialis anterior

Pinch Grasp and Palpate

Palpating Gastrocnemius Trigger Points

Ipsilateral Soleus

T REATMENT T REATMENT • Inactivate the trigger points • Stretch the involved musculature • Opioid pain medication

Inactivating Trigger Points • Needle/injection • Acupressure • Fascial stretching/Rolfing • Compounding pharmacy • Decrease sympathetic tone

Case Report • Medical Information is not shown here. • Pain diagrams follow this slide showing improvement over a few months for this patient. • All she did between the first and second visits was change her diet, stretch, and use a small rubber ball.

Body work Thyroid Diet

Side Effect of Cortisone Injection

Case Report • Medical Information is not shown here. • Pain diagrams follow this slide showing improvement over a few months for this patient. • All she did between the first and second visits was change her diet, stretch, and use a small rubber ball.

People With MPS/FMS/CFS Go to The Doctor, And What They’ve Got Doesn’t Fit Anything We’re Traditionally Taught