A typical scenario in the so-called pain management field is a patient seeking relief after injury to a skeletal joint, most often the cervical or lumbar region of the spine. The skeletal structure becomes misaligned by select myofibril shortening in prime mover and auxiliary muscles that excessively attempt to offer support. The pain of radiating tonic muscle spasms becomes greater in intensity than that of the original injury.
Chronic pain is almost always a combination of nerve irritation (usually by scar tissue), inflammation (that produces scar tissue to irritate nerves in a vicious circle), mechanical and environmental insult, muscle spasm secondary to habituated muscular bracing, antalgic posturing, and a host of other contributing factors, such as attitude toward the attention-seeking pain. A pie chart of the pain components is always possible.
Once pain is chronic, pain-perceiving centers in the brain can magnify the condition; and when the suffering patient’s scans show that the verbal complaint appears to outweigh the pathology, the additional stress of the doctor’s failure to appreciate the complaint further amplifies the perception of pain. Being told “It’s all in your head” is a profound insult to the one suffering.
Compounding the problem is long-term use of narcotic medication. For instance, if the pain is a combination of neuritis, active triggers points and inflammation, high doses of central nervous system depressant medications are required; and the higher the doses, the greater the side effects of mental dullness, constipation, loss of libido, lowered immunity, and gradually lowered pain threshold that only helps perpetuate the debilitating condition and fuels associated depression. In time, due to liver enzyme induction, the chronic pain sufferer ends up dependent on narcotics, believing that any increase in discomfort is related to the somatic condition and not withdrawal from drugs of the opiate type. The number of iatrogenic cases of pain disorders cannot be measured.
The best authorities, those that write the text books for pain specialists, agree that all pain patients are capable of lowering their pain to a tolerable level, if not totally extinguish it.
Below is a treatment plan for the neuromuscular component that is almost always the major part of chronic pain.
Muscle spasms (trigger points) can be caused by injury, such as to the piriformis muscle when one of your legs skids out to the side on a wet surface, and you react to avoid a fall. But most trigger points are the result of excessive use of a muscle or muscle group, which we label as a Repetitive Strain Injury (RSI). Muscle that are too weak for a task are especially prone to entering spasm. Trigger points can be so severe and chronic as to render the individual disabled.
My experience has been that many therapists--chiefly physical therapists--are erroneously trained to engage the patient in a muscle-strengthening exercise, before the spasm is released. The
practice almost always aggravates the myopathy, and the patient goes home in more pain than before the "treatment." Moreover, if the therapist is not talented--I say talented because palpating
and identifying the character of a trigger point is an art form--he or she may treat a satellite point instead. Trigger points refer pain. For example, it is not uncommon for a spasm in one
paraspinal to express pain contralaterally.
First and foremost, passive stretching. The addition of vapocoolant spray, or even ice-massage gives relief and helps re-educate the muscles (Simons & Travel). Concomitantly, ischemic pressure is applied to release tonic or clonic spasm--e.g. myofascial release.
Neuromuscular re-education of the myofibrils is a matter of the central nervous system accepting a longer (stretched) muscle length as the norm. Having the patient attempt to contract the affected muscle against resistance provided by the therapist for a few seconds and then suddenly relaxing the muscle. two or three times, can prolong the relief. But in most cases follow-up therapy
After the patient gains relief, compliance with instruction to avoid performing any activities that require contraction of the problematic muscle is critical. Even the simple task of picking up
a cup of coffee can resurrect a dying trigger point in a neck muscle. In such case, the patient is wise to drag the cup as closely as possible to self before lifting it up to drink, even though the practice seems excessively guarded.
Trigger points in the process of being totally extinguished are easily activated. A good analogy is the dropping of a penny into a paper bag with a wet bottom. The last penny (activity) is no greater than the first forty, but it is enough to cause the bottom of the bag to break, the proverbial last straw that broke the camel's back. Without some ergonomic education, the patient is at high risk to suffer recurrence of the presenting problem.
The LAST stage in treating painful muscle spasm is muscle strengthening, chiefly for the purpose of avoiding recurrence. A strong, conditioned muscle is capable of heavy or repetitive work. sEMG monitoring is useful in determining when and how much exercise the patient can perform without risk of resurrecting trigger points. A gradual increase in resistance exercises followed by a variety of full weighted flex-relax rotations will serve as a prophylactic against future RSI.
Doctors and therapists of every kind must recognize that efficiency in performing activities of daily living (ADL) is indispensable to resolution of chronic pain. The science of lifting and moving without aggravating a pain condition should be the main feature in patient education as since stress is cumulative: one can suffer a “bad day” without any apparent cause. But feeding a trigger point is like tossing a penny in a paper bag. One penny is no heavier than the previous one; but, like the last straw that broke the camel’s back, the last penny (last ADL) can tighten a muscle fiber like piano wire.
I train my patients to stand up, sit down, pick up objects, even do some household chores without taxing muscle groups that are myopathic. Instead of registering 25 uV to 75 uV on the surface electromyogram (sEMG), they record 5 uV to 10 uV, a huge difference at the end of the day.
The last step is almost routinely taken firstly by physical therapists. I refer to all these people as “physical terrorists.” Of course, not all PTs are so ignorant as to have the patient contract a muscle in spasm; but, in my experience, most do. So I have stopped referring my patients for PT. Muscle strengthening is very important because it serves as a prophylactic against reviving the pain condition. I perform a sEMG on the patient before prescribing a flex-relax exercise to gradually build a resistance to future trigger point activity. If the muscle at rest registers < 2 uV, and good recovery is observed in the post flexion state–especially if hyperactivity is absent in the waveform–I proceed with confidence in adding resistance to exerice. sEMG monitoring removes any guess-work and ensures the condition will not be exacerbated and eventually resolved.