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March 2018 Newsletter

Posted on March 2, 2018 at 10:20 AM

What is Musculoskeletal Ultrasound?

Ultrasound imaging uses sound waves to produce pictures of muscles, tendons, ligaments and joints throughout the body. It is used to help diagnose sprains, strains, tears, and other soft tissue conditions. Ultrasound is safe, noninvasive, and does not use ionizing radiation.

 

What is Ultrasound Imaging of the Musculoskeletal System?

Ultrasound is safe and painless, and produces pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or sonography, involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin. High-frequency sound waves are transmitted from the probe through the gel into the body. The transducer collects the sounds that bounce back and a computer then uses those sound waves to create an image. Ultrasound examinations do not use ionizing radiation (as used in x-rays), thus there is no radiation exposure to the patient. Because ultrasound images are captured in real-time, they can show structures under the stresses they endure with normal movement. It is this unique property that allows us to see compromises of ligaments and tendons quite easily.

 

 

What are some common uses of the procedure?

Ultrasound images are typically used to help diagnose:

• Tendon tears, or tendinitis of the rotator cuff in the shoulder, Achilles tendon in the ankle and other tendons throughout the body.

• Muscle tears, masses or fluid collections.

• Ligament sprains or tears.

• Inflammation or fluid (effusions) within the bursae and joints.

• Early changes of rheumatoid arthritis.

• Nerve entrapments such as carpal tunnel syndrome.

• Benign and malignant soft tissue tumors.

• Ganglion cysts.

• Hernias.

• Foreign bodies in the soft tissues (such as splinters or glass).

• Dislocations of the hip in infants.

• Fluid in a painful hip joint in children.

• Neck muscle abnormalities in infants with torticollis (neck twisting).

• Soft tissue masses (lumps/bumps) in children.



 

Mindful Observation

This exercise can be simple but powerful by helping you start to appreciate seemingly simple elements of your environment.

 

The exercise is designed to connect us with the beauty of the natural environment, something that is easily missed when we are rushing around in the car or hopping on and off trains on the way to work.

 

1 Choose a natural object from within your immediate environment and focus on watching it for a minute or two. This could be a flower or an insect, or even the clouds or the moon.

2 Don’t do anything except notice the thing you are looking at. Simply relax into watching for as long as your concentration allows.

3 Look at this object as if you are seeing it for the first time.

4 Visually explore every aspect of its formation, and allow yourself to be consumed by its presence. Notice the color, shapes, textures, movements, and sounds.

5 Allow yourself to connect with its energy and its purpose within the natural world.

Throughout the month of March give your mindful observation a try. When waiting for a friend or family member practice this observation. Don’t forget about your breathing and continue to practice the mindful breathing you practiced last month.




 

 

Feb 2018 Newsletter

Posted on February 13, 2018 at 1:50 PM

What is Central Sensitization?

Central sensitization syndrome (CSS) is a condition of the nervous system that is associated with the development and maintenance of chronic pain. When central sensitization occurs, the nervous system goes through a process called wind-up and gets regulated in a persistent state of high reactivity. This persistent, or regulated, state of reactivity lowers the threshold for what causes pain and subsequently comes to maintain pain even after the initial injury might have healed.


Central sensitization has two main characteristics. Although these are not essential to diagnose CSS, both involve a heightened sensitivity to pain and the sensation of touch. They are called allodynia and hyperalgesia. Allodynia occurs when a person experiences pain with things that are normally not painful. For example, chronic pain patients often experience pain even with things as simple as touch or massage. In such cases, nerves (called interneurons which are not normally turned on but are on high alert in patients with CSS) in the area that was touched sends signals through the nervous system to the brain. Because the nervous system is in a persistent state of heightened reactivity, the brain doesn't produce a mild sensation of touch as it should. Rather, the brain produces a sensation of pain and discomfort. Hyperalgesia occurs when a stimulus that is typically painful is perceived as more painful than it should. An example might be when a simple bump, which ordinarily might be mildly painful, sends the chronic pain patient through the roof with pain. Again, when the nervous system is in a persistent state of high reactivity, it produces pain that is amplified.



Mindful Breathing

This exercise can be done standing up or sitting down, and pretty much anywhere at any time. If you can sit down in the meditation (lotus) position, that's great, if not, no worries.

Either way, all you have to do is be still and focus on your breath for just one minute.

1 Start by breathing in and out slowly. One breath cycle should last for approximately 6 seconds.

2 Breathe in through your nose and out through your mouth, letting your breath flow effortlessly in and out of your body.

3 Let go of your thoughts. Let go of things you have to do later today or pending projects that need your attention. Simply let thoughts rise and fall of their own accord and be at one with your breath.

4 Purposefully watch your breath, focusing your sense of awareness on its pathway as it enters your body and fills you with life.

5 Then watch with your awareness as it works work its way up and out of your mouth and its energy dissipates into the world.


Throughout the month of February give your mindful breathing a try. Schedule yourself time or on the fly. It may be difficult at first to let go of wandering thoughts and focus on one thing your breath. Try not to get frustrated just relax and try again later or the next day. The more you practice the easier it will become.


CoQ10 and Migraines

Posted on January 31, 2018 at 9:10 AM

An article appearing on January 3, 2018 in Nutritional Neuroscience describes a randomized, double-blind, placebo-controlled trial that resulted in a reduction in migraine duration, frequency and severity, as well as a lower levels of calcitonin gene-related peptide (CGRP) and tumor necrosis factor-alpha (a marker of inflammation) among participants who received daily supplements of coenzyme Q10 (CoQ10)


The trial included 45 women aged 18 to 50 years diagnosed with episodic migraine. In addition to migraine prophylactic medication, 23 participants received 400 milligrams CoQ10 per day and 22 participants received a placebo for three months. Serum CoQ10, CGRP, tumor necrosis factor-alpha (TNF-a), and other factors were measured at the beginning and end of the study.


Migraine severity, duration, and frequency per month were lower at the end of the study among those who were given CoQ10 compared to the placebo. In addition to a rise in serum CoQ10 levels, women who received CoQ10 experienced a reduction in TNF-a and CGRP at the end of the treatment period. “There is a correlation between neurologic inflammation and CGRP release in migraine,” Monireh Dahri and colleagues explain. "Likewise, CGRP transcription can be stimulated by endogenous inflammatory molecules, such as TNF-a, which increases the CGRP promoter activity and actuates MAPK pathway. In our study, reduction of TNF-a in CoQ10 treated group was accompanied with CGRP decrease, which can be explained by the above-mentioned mechanism."


"As migraine patients have higher level of inflammation and have been reported to have CoQ10 deficiency, CoQ10 supplementation may be a beneficial complementary treatment in migraineurs," they suggest.

Reciprocating Gifts.

Posted on September 15, 2017 at 10:00 AM

Great Tumblers a patient made us. We are so fortunate to work with such a great group of people!

TMJ the hard case!

Posted on August 24, 2017 at 10:15 AM

Temporomandibular joint dysfunction

 

 

Introduction

The temporomandibular joints (TMJ) connect your lower jaw to your skull. There are two matching joints, one on each side of your head, just in front of your ears. They let your jaw move up and down and from side to side.

The abbreviation "TMJ" refers to the joint but is often used to refer to any problems with the joints. Such problems include:

Popping sounds in your jaw

Not being able to completely open your mouth

Jaw pain

Headaches

Earaches

Toothaches

Other types of facial pain

Most people with TMJ problems have pain that comes and goes, but some have chronic (long-term) pain.

 

Signs and Symptoms

TMJ problems often cause the following symptoms:

Pain, particularly in the chewing muscles or jaw joint or an ache around your ear

Limited movement or locking of the jaw

Pain in the face, neck, or shoulders, or near the ear

Clicking, popping, or grating sounds when opening your mouth

Trouble chewing

Headache

A sudden change in the way your upper and lower teeth fit together

Also, sometimes earaches, dizziness, and hearing problems

 

What Causes It?

Sometimes TMJ dysfunction can be caused by an injury, such as a heavy blow, to the jaw or temporomandibular joint. But in other cases there may not be a clear cause. Other possible causes include:

A bad bite, called malocclusion

Orthodontic treatment, such as braces and the use of headgear

Wearing away of the disk or cartilage in the joint

Stress or anxiety. People with TMJ problems often clench or grind their teeth at night, which can tire the jaw muscles and lead to pain.

 

Who is Most At Risk?

The risk for TMJ problems may be higher with these factors:

Gender: more women than men seek treatment

Age: people ages 30 to 50 have the most problems

Children and adolescents with arthritis

Grinding teeth, clenching jaw

Malocclusion (bad bite)

High stress levels

 

What to Expect at Your Provider's Office

 

Your health care provider will check muscles in the area of the TMJ, and will:

Look for asymmetry or inflammation in your face

Listen for joint clicking or scraping sounds

Test the range of motion in your jaw

Look at your teeth for evidence of jaw clenching or teeth grinding

If you are having any neurological symptoms, such as numbness, your provider will give you a neurological exam. Your provider may also order imaging tests, such as an x-ray, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) scan to look for degenerative disease or disk problems.

 

Treatment Options

 

Prevention

Reducing stress and keeping yourself from grinding your teeth or clenching your jaw may help prevent TMJ problems or lessen the symptoms.

 

Treatment Plan

In many cases, you can treat TMJ dysfunction at home. Your doctor may:

Ask you to change your eating habits: cut food into small pieces, avoid too much chewing, and stop chewing gum.

Give you exercises that stretch the muscles around your jaw.

Your doctor may also recommend:

If your bite is out of alignment, your dentist may suggest you wear a biteplate over your teeth to help bring your upper and lower jaw into alignment.

If you grind your teeth in your sleep, you may be asked to wear a night guard over your teeth.

If stress is causing you to clench your jaw, your doctor may suggest stress reduction techniques or cognitive behavioral therapy to help you manage anxiety and tension.

 

Drug Therapies

Your doctor may recommend the following medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs): to relieve pain. These drugs include ibuprofen (Advil, Motrin) and naproxen (Aleve).

Minor tranquilizers or muscle relaxants at bedtime to reduce spasms and pain.

Injections of a local anesthetic.

Corticosteroid injections, for severe cases.

Botox (botulinum toxin A) injections: can reduce muscle spasms

 

Surgical and Other Procedures

In some cases, removing fluid from the joint may help reduce pain, especially for people whose jaws lock. When other measures have failed, surgery may be needed to repair or take out the disk between the temporal bone and the jaw.

 

Complementary and Alternative Therapies

A comprehensive treatment plan for TMJ dysfunction may include a range of complementary and alternative therapies (CAM). Work with a health care provider who has experience treating TMJ and be sure to tell all of your doctors about any medications, herbs, and supplements you are taking. Treatments, including physical medicine, may help.

 

Nutrition and Supplements

The following nutritional tips may help prevent or reduce symptoms of TMJ dysfunction:

Eat soft foods high in flavonoids, such as cooked fruits and vegetables. Flavonoids are plant-based antioxidants that may help decrease joint pain.

Avoid saturated fats, fried foods, and caffeine. These foods may increase inflammation.

DO NOT chew gum.

 

Some supplements that may help:

Glucosamine: may reduce pain and help rebuild cartilage in the joint, which helps improve range of motion. Some studies show that glucosamine helps reduce pain in people with arthritis, which involves painful joints. One study found that glucosamine worked as well as ibuprofen (Advil, Motrin) for relieving pain and other TMJ symptoms. Glucosamine is often combined with chondroitin sulfate. Glucosamine may increase the risk of bleeding, especially if you also take blood thinners like warfarin (Coumadin), clopidogrel (Plavix), or aspirin. Some doctors think glucosamine might interfere with medications used to treat cancer. Ask your doctor before taking glucosamine and chondroitin.

Vitamin C: is also used by the body to make cartilage. It may improve range of motion in your joints, including your jaw, although there are no scientific studies investigating vitamin C for TMJ problems. Vitamin C supplements may interact with other medications, including chemotherapy drugs, estrogen, warfarin (Coumadin), and others.

Calcium and magnesium: may help the jaw muscle relax, although there are no scientific studies using them for TMJ problems. Magnesium and calcium interact with several medications, herbs, and supplements. They can also affect your heart and blood pressure, so be sure to tell your doctor before you take them.

 

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects, and can interact with other herbs, supplements, or medications. For this reasons, take herbs with care, under the supervision of a health care provider.

Cramp bark (Viburnum opulus) and lobelia (Lobelia inflata) may help reduce muscle spasms, although there are no scientific studies to support using them for TMJ problems. Rub 5 drops tincture of each herb into joint. Use on the skin only and do not apply to broken skin. DO NOT take these herbs by mouth (orally).

 

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of TMJ dysfunction based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Causticum: for burning pains

Hypericum perforatum: for sharp, shooting pains

Ignatia: for tension in the jaw

Kalmia: for face pain, especially with other joint pains or arthritis

Magnesia phosphorica: for muscle cramps

Rhus toxicodendron: for pains that feel better in the morning and in dry weather, and worse after movement or in wet weather

Ruta graveolens: for pains from overuse or injury

Physical Medicine

Contrast hydrotherapy, which is alternating hot- and cold-water applications, may:

Lower inflammation

Provide pain relief

Speed healing

Use hot packs and ice wrapped in a clean, soft cloth and apply to area. Alternate 3 minutes hot with 1 minute cold. Repeat 3 times for 1 set. Do 2 to 5 sets per day.

 

Acupuncture

Very good evidence suggests dry needling can treat TMJ dysfunction. Several well-designed studies found that needling therapies can relieve pain long term for TMJ problems.

 

Manipulation

There is some Evidence that Cervical manipulation as well as manipulation to the TMJ as well can help with TMJ dysfunction and restore range of motion

 

Craniosacral Therapy

This therapy is a very gentle form of body work. Practitioners use their hands to get rid of restrictions in the craniosacral system, the fluid and membranes surrounding the spine and brain. Although there are not many studies, some people say they feel better after craniosacral therapy. Find a practitioner who has training and experience with TMJ problems. You can interview several practitioners before deciding which one is right for you.

 

Massage

Some types of massage and chiropractic manipulation may help:

Reduce muscle spasms

Provide pain relief

Prevent symptoms from coming back

 

 

Biofeedback

Biofeedback teaches you how to reduce muscle tension through relaxation and visualization techniques. At first, sensors are placed on your jaw, and a machine shows the amount of tension in your muscles. Using relaxation and visualization techniques, you learn to reduce the amount of tension around your jaw while the machine provides instant feedback so you can see how you are doing. Once you have mastered the technique, you can do the relaxation and visualization techniques anywhere, without the machine.

Improving posture

Two types of movement therapy can sometimes help treat TMJ problems: the Alexander technique and the Feldenkrais method.

The Alexander technique teaches you how to properly align your head, neck, and spine, and move your body. It can help relieve tension in your head and jaw muscles, which may reduce the symptoms of TMJ dysfunction.

The Feldenkrais method teaches you to recognize bad posture habits and movements that cause your body to tense. It is a gentle therapy aimed at making you more aware of how your body moves, and helping you develop an inner awareness of your body. Feldenkrais is popular with dancers and musicians, who often do repetitive motions that can lead to overuse injuries.

 

Prognosis and Possible Complications

About 75% of people with TMJ problems who follow a treatment plan with more than one treatment find relief. In rare cases, long-term teeth clenching or grinding, injury, infection, or connective tissue disease may cause degenerative joint disease or arthritis. If you have severe grinding, a nighttime bite guard worn inside your mouth may help.

 

Following Up

You may need to see your health care provider regularly to make sure your treatment plan is working for you.

 

Headache Behind the Ear? Don't forget the SCM!

Posted on May 16, 2017 at 7:40 AM

What does a headache behind the ear mean? Signs, causes, and treatments


There are several causes of headaches behind the ear. With proper medical treatment, these headaches can be relieved.

A headache behind the ear refers to any pain that originates from that specific area of the head. Though headaches themselves are very common, headaches that occur exclusively behind the ear are fairly unusual.

 

This type of headache pain can have several causes. The cause of the headache behind the ear will determine symptoms and treatment.

 

This article explores the signs and symptoms of headaches behind the ear and details what causes them. It also discusses how they can be treated to relieve pain and the associated symptoms.


Causes

There are several possible causes of a headache behind the ear. These include the following:

 

Occipital neuralgia[woman with a headache behind her ears]

Occipital neuralgia can cause pain behind the ears.

One of the most common causes of a headache behind the ear is a condition called occipital neuralgia.

 

Occipital neuralgia occurs when the occipital nerves, or the nerves that run from the top of the spinal cord up through the scalp, are injured or inflamed.

 

People often mistake sharp pain behind the ear to be the result of a migraine or similar types of headaches, as symptoms can be similar.

 

People who suffer with occipital neuralgia describe the chronic pain as piercing and throbbing. They also describe it as similar to the feeling of receiving an electric shock in the following places:

 

upper neck

back of the head

behind the ears

Occipital neuralgia happens as a result of pressure or irritation to the occipital nerves. It typically only appears on one side of the head.

 

In some cases, the pressure or irritation maybe because of inflammation, overly tight muscles, or an injury. Often, doctors cannot find a cause for occipital neuralgia.

 



Mastoiditis

Mastoiditis is an infection of the mastoid bone, which is the bone directly behind the ear.

 

This infection is much more common in children than adults and generally responds to treatment with no complications.

 

Mastoiditis causes a headache behind the ear as well as fever, discharge from the ear, tiredness, and hearing loss in the affected ear.

 



TMJ

The temporomandibular joints (TMJ) are the ball and socket joints of the jaw. These joints can become inflamed and painful.

 

[pointing out the symptoms of tmj on a model skull]

TMJ can cause aching behind the ear and it usually accompanied by jaw pain.

While most people with TMJ inflammation feel the pain in the jaw and behind the ear, others may just experience a headache behind the ear.

 

TMJ can be caused by:

 

stress

teeth grinding

arthritis

injury

jaw alignment

Symptoms

Symptoms of headaches behind the ear can vary based on the causes.

 

Occipital neuralgia may cause intense pain to the back of the head and/or upper neck. Often, it can start in the neck and work its way up to the back of the head. The episodic pain is like an electric shock to the back of the head and/or neck.

 

Signs of an infection, such as fever or tiredness, often accompany mastoiditis.

 

People experiencing TMJ may sense jaw tightness and pain in addition to a headache behind the ear.

 

Additional symptoms that people who suffer from headaches behind the ear may experience include:

 

pain on one or both sides of the head

sensitivity to light

aching, burning, and throbbing pain

pain behind the eyes

tender scalp

pain with neck movement



Diagnosis

The main causes of headache behind the ear often overlap. It is crucial to get a proper diagnosis so the condition can be treated appropriately.

 

For diagnosis, a doctor will ask a person questions about medical history. Information about any recent head, neck, or spine injuries should be included.

 

After asking questions, a doctor will probably do a physical examination. For this, the doctor will press firmly around the back of the head and base of the skull in an attempt to reproduce the pain through touch. This examination checks for occipital neuralgia, as this condition is sensitive to the touch in most cases.

 

Some additional steps in diagnosis may include a shot to numb the nerve. If a person experiences relief then occipital neuralgia is likely to be the cause of the pain.

 

In more atypical cases, a doctor may order an MRI or blood test to further confirm or rule out other causes of the pain.

 

If occipital neuralgia is ruled out as a possible cause of pain in the initial visit, the doctor will probably check for signs of mastoiditis, including fever and discharge from the ear.

 

For further diagnosis, a doctor may examine the jaw or recommend a visit to a dentist to check for TMJ.

 

Home treatments

Treating the pain is the primary method of dealing with a headache behind the ear, unless a root cause can be determined.

 

There are some at home treatment options for people to try before or in addition to a doctor's care.

 

[woman in yellow sweater sleeping on the couch]

A common way to manage headaches at home is to rest or nap in a quiet room.

Some at home treatments include:

 

rest in a quiet room

over-the-counter anti-inflammatory drugs, such as ibuprofen

massage of neck muscles

apply heat to back of neck

reduce stress

stop teeth grinding

As with any treatment options, a doctor should be consulted before adding medications.

 



Treatment of headaches behind the ear

When under a doctor's care, someone will have a treatment plan for headaches behind the ear that will include managing the pain and treating underlying causes of the pain.

 

Depending on the exact cause of headaches behind the ear, a doctor may prescribe medications, including:

 

prescription muscle relaxants

nerve blocks and steroid shots

physical therapy

antidepressants

antiseizure drugs, such as carbamazepine and gabapentin

antibiotics if mastoiditis is suspected

a night-guard for TMJ

Nerve blocks and steroid shots are often temporary and necessitate repeat visits to the doctor to be reinjected. Furthermore, it may be necessary to administer several shots before the pain is manageable.

 

In rare cases, an operation may be required. Typically, operations are used if pain does not get better with other treatments or keeps recurring.

 


Operations may include:

 

Microvascular decompression: This procedure involves the doctor finding and repositioning the blood vessels that are compressing the nerves.

Occipital nerve stimulation: A neurostimulator delivers several electrical pulses to the occipital nerves. In this case, the electric pulses may help block pain messages to the brain.

No matter the treatments decided upon, it is important to relay to a doctor whether or not they are effective.

 

In some cases, continued pain may indicate that it is the result of another condition, which needs to be treated differently.

 



Outlook

Generally, headaches behind the ear are not the result of a life-threatening condition.

 

In many cases, people experience pain relief when resting and taking medication as prescribed or directed.

 

In most cases, people with a headache behind the ear should see full or nearly full symptom relief with proper diagnosis and treatment.

Do not reuse needles!!!!!!

Posted on April 5, 2017 at 10:15 AM

Here is a microspcopic view of a filament needle at various stages of "use". Many people "re-use" their needles to save money. Needles are Cheap (relatively speaking)...people aren't. Get a NEW NEEDLE. 




Quick Blog about working out....AT WORK!

Posted on February 7, 2017 at 7:55 AM



 

Mini Workouts You Can Do At Work!

What does exercise have to do with running a successful healthcare business?

More than you think. Everyone knows exercise has significant health benefits, but what about its cognitive benefits?

Research shows that regular exercise dramatically improves job performance and productivity. According to a study cited in Harvard Business Review, it "enables us to soak in more information, work more efficiently, and be more productive." Here are some of the perks:

Improved concentration

Sharper memory

Faster learning

Prolonged mental stamina

Enhanced creativity

Lower stress

Although many healthcare professionals know and preach the benefits of exercise, finding the extra time to do it themselves can be a challenge. They're already overstretched and overworked as it is, running a successful healthcare business and taking care of family responsibilities. But, there is a solution!

Make short bursts of exercise part of your daily routine. A few minutes every couple of hours isn't going to sabotage your schedule or quality of patient care. In fact, it will increase your energy and focus, so you can deliver the level of care and service your patients and customers deserve.

 



Other Ways To Sneak In Exercise At Work

 

Do a set of 20 push-ups every morning when you wake up.

While you’re waiting to use the bathroom at work, do 30 squats.

Set your timer to go off every 30 minutes to an hour. Then, run up and down the stairs or do push-ups for 1 minute.

Ride your bike to work.

Grab a fellow employee and take a walk around the block or the parking lot.

Park farther away, so you increase the number of steps you walk.

Take the stairs instead of the elevator.

For your next meeting, have a walk-and-talk around the block or parking lot.

Have a daily or weekly push-up challenge with everyone at the office.

Before each meeting, have everyone do 30 squats or 30 push-ups.

Run up and down the stairs for 3 minutes 3 times a day.

Switch out your office chair for a stability ball.

All It Takes Is A Few Minutes A Day

 

Research shows it can take as little as 10 minutes a day to see results. You may not become the next Ironman, but you and your medical team will be in better shape to deliver quality care and superior service.




Updated evidence on Fibromyalgia

Posted on December 17, 2016 at 9:05 AM

The global burden of chronic pain has reached epidemic proportions; furthermore, it is estimated that 136 million Americans are currently suffering with chronic pain.1 Despite this large number, the diagnosis and management of conditions such as Fibromyalgia Syndrome (FMS) remains poorly understood, widely criticized, and routinely mistreated by physical therapists and medical physicians alike. The use of dry needling is described in the literature as a novel and potentially effective intervention for treating FMS. Despite the evidence supporting neuronal plasticity and centrally-mediated changes in chronic pain, the traditional conservative interventions for FMS have exhausted light exercise, gentle mobilization, and/or electro-thermal modalities, with little more than poor patient outcomes. Perhaps it is time to change the way we treat chronic pain and utilize the best possible evidence to guide us in delivering the highest quality of care for conditions such as FMS.

A large body of evidence supports that exercise has little to no benefit in patients with FMS, and further, that chronic muscle pain appears to worsen with exercise.2,3 McVeigh et al found 85% of patients with FMS reported increased fatigue and pain following exercise.4 Therefore, perhaps the repetitive movement or “more exercise for everyone” model does not fit all categories or patient conditions.

The concept of neuroplasticity, or the structural and functional cortical changes related to chronic pain states, has been described by multiple sources.7,8 Neurophysiologic changes have been identified at multiple levels of the central nervous system including the spinal cord, brainstem, and cortex.9,10,11,12 Coghill et al found specific brain areas of increased activation in chronic pain states including the anterior cingulate cortex, primary somatosensory cortex and prefrontal cortex.9 Yu et al reported specific disruptions in functional connectivity at enkephalin producing pain control centers of the periaqueductal gray in chronic pain conditions.13 Moreover, the mechanism of hypersensitivity has been found to largely occur at the dorsal horn involving wide-dynamic-range neurons (WDR).14 WDR neurons are regulated by diffuse noxious inhibitory controls (DNIC) via the subnucleus reticularis dorsalis in the caudal medulla.14

Patients with FMS are thought to have defective DNIC systems; that is, the WDR neurons, which are responsible for innocuous and noxious stimuli, develop increased receptive fields, thus increasing the region of perceived pain.14 Disrupted brain circuitry has been described by Loggia et al who articulates that decreased activation of the periaqueductal gray area in the midbrain accounts for decreased descending pain modulation in patients with FMS.15 Two studies reported augmented pain processing in patients with FMS via disruptions of cortical areas responsible for the anticipation, attention, and emotional manifestation of pain.16, 17

The role of myofascial trigger points in FMS has been largely utilized in identifying the diagnosis. The biochemical properties of myofascial trigger points, including localized acidity and the increase in inflammatory mediators, may contribute to peripheral changes in patients with FMS.18 That is, sustained peripheral nociceptive input may sensitize dorsal horn neurons and supraspinal structures leading to hyperalgesia, allodynia, and referred pain.19

Peripheral and centrally-mediated changes associated with dry needling have been described in the literature; furthermore, dry needling to specific distal points in the upper or lower extremities has been found to activate sensorimotor cortical networks and deactivate limbic-paralimbic areas.20, 21 Deactivation of limbic areas following dry needling is thought to affect the sensory, cognitive, and affective dimensions of pain.20 Studies utilizing fMRI have demonstrated that dry needling at specific distal points activates the descending pain centers including the PAG.22 Moreover, dry needling with electric stimulation has been shown to activate enkephalinergic inhibitory interneurons, thereby modulating central pain.19 In addition, dry needling has also been found to reduce pain by peripheral mechanisms. One recent study found peripheral opioid receptors contribute to the anti-nociceptive effects of electrical dry needling via activation of cannabinoid CB2R receptors.23 Moreover, the stimulation of ATP release and the subsequent activation of adenosine A1 receptors via electrical dry needling is thought to sharply reduce inflammatory and neurogenic pain.24

The use of dry needling to target solely trigger points within muscles has been challenged.25 Several authors have articulated that the effectiveness of dry needling lies in the mechanical disruption of the integrity of dysfunctional endplate at the neuromuscular junction.19 That is, dry needling to the endplate region is thought to cause increased discharges, decrease acetylcholine stores, and thus reduce spontaneous electrical activity.19 However and importantly, not all patients with fibromyalgia have trigger points, and not all patients with trigger points develop FMS.26 Some investigators have distinguished the “tender points” associated with fibromyalgia from trigger points—i.e. tender points may lack taught bands.27 Given that skeletal muscle in patients with FMS has been shown to have altered oxygen utilization,28 perhaps dry needling can be useful to help improve muscle vascularity and oxygenation, and hence reduce sustained peripheral nociception.29,30

Nevertheless, the efficacy for the use of dry needling in patients with FMS is limited; that is, to date, there are few high methodologic quality studies on the topic. Two recent systematic reviews provide conflicting evidence for the use of acupuncture (i.e. the insertion of needles without injectate without the intent of moving qi along traditional Chinese meridians) in FMS—i.e. both concluding further high quality research is needed before definitive conclusions can be made in regards to efficacy.31,32 In a randomized controlled trial, Deluze et al found electroacupuncture provided significant improvements in pain perception and sleep quality (limbic system) in patients with FMS.33 Additionally, a recent systematic review and meta-analysis found that dry needling may be effective in the immediate and short-term in patients with upper quarter myofascial pain syndrome.34

 

 

 

 

 

 

 

 

REFERENCES

1 Tsang A , Von Korff M, Lee S, Alonso J, Karam J. Common Chronic Pain Conditions in Developed and Developing Countries: Gender and Age Differences and Comorbidity With Depression-Anxiety Disorders. Pain. 2009;10(5): 553.

2 Fricton J. Myofascial pain. Baillière’s Clinical Rheumatology. 1994;8(4): 857-880.

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Bluegrass Doctors of Physical Therapy Picked as Top 16 Providers in Louisville

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