Chronic pain is at epidemic levels and has become the highest-cost condition in health care. This course uses evidence-based science with creative and experiential learning to better understand chronic pain conditions and how they can be prevented through self-management in our cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms. The goal of this course is to blend creative, experiential, and evidence-based teaching strategies to help participants understand chronic pain conditions and how a human systems approach can be applied to self-management strategies to reduce risk factors, enhance protective factors, and prevent chronic pain. There are four major objectives to the course; 1. Describe the prevalence, personal impact, and health care dilemma associated with chronic pain. 2. Recognize the clinical characteristics and underlying etiology of several common pain conditions and the peripheral, central, and genetic mechanisms of chronic pain 3. Based on the literature associated with risk and protective factors in the seven realms of our lives, learn specific strategies in each realm that can be employed daily to prevent chronic pain and enhance wellness. 4. Appreciate the value of a human systems approach to health care and how it can provide a basis for integrative, interdisciplinary, and individualized care to preventing pain and enhancing wellness. CONTINUING EDUCATION CREDIT OPTION Accreditation Statement: University of Minnesota, Interprofessional Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. American Medical Association (AMA) The University of Minnesota, Interprofessional Continuing Education designates this enduring material for a maximum of 24.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. American Nurses Credentialing Center (ANCC) This activity is awarded up to 24.0 ANCC contact hours. Other Health Care Professionals Other health care professionals who participate in this CE activity may submit this certificate statement of participation to their appropriate accrediting organizations or state boards for consideration of credit. The participant is responsible for determining whether this activity meets the requirements for acceptable continuing education. Registration and disclosure information is available here at http://z.umn.edu/chronicpain and pay the additional fee. Then, email your Coursera certificate statement of completion to cme@umn.edu.
3 Myofascial Pain: Perpetuating factors
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Preventing Chronic Pain: A Human Systems Approach
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Common Pain Conditions and their Mechanisms (Week 3)
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Dr. James Fricton, DDS, MSProfessor and Pain Specialist
University of Minnesota, HealthPartners Institute, and Minnesota Head and Neck Pain Clinic
Acute myofascial pain that involves only one or two muscles can be treated.
You can use various stretching techniques, trigger point injections,
deep tissue massage, and stretch, and typically the patient will respond.
For example, here we have a trigger point in the masseter muscle.
And if this trigger point developed acutely after a long dental appointment,
or after a chronic dental infection, and no other secondary muscles have
developed trigger points, simple jaw stretching should take care of the pain.
Early or acute myofascial pain has the following characteristics.
It's typically pain of fairly short duration.
It has a fairly clear onset.
Patients can identify, yeah, it happened right after that dental appointment where
I had my mouth open for three hours.
Very few muscles are involved, maybe one or two trigger points, three at most.
And there are few perpetuating factors.
And there's no behavioral or psychological problems, that's key.
If, however, you have somebody who has a much more complex pain presentation,
the pain's been there a very long time and there are more muscles involved,
then there's really sort of more of a chronic situation.
For example, here we have an upper trapezius trigger point.
As we know, this can cause secondary trigger point development in the muscle
that receives the referred pain, in this example here, the masseter muscle.
So the key trigger point is in the upper trapezius.
The satellite trigger point is in the masseter.
Now if the masseter muscle also develops trigger points, and
we have trigger points in the masseter muscle in two or
three different sites, and we get the temporalis muscle involved as well,
we now have a much more complicated myofascial pain problem, and
probably also a much more complicated patient.
Chronic myofascial pain problems usually have a fairly long and complex history.
I've had headaches for 11 years, I've been to see 22 different specialists,
nobody's been able to help me,
I've had lots of different treatments, and on and on and on.
So we have multiple diagnoses.
There's usually many associated symptoms.
There's often multiple muscles that have myofascial trigger points.
There's also multiple perpetuating factors that have accumulated.
And there are typically also multiple behavioral and
psychological issues that go along with a chronic pain condition.
Well, let's talk about the perpetuating factors to these chronic
myofascial pain problems.
Perpetuating factors include muscle overload.
The most important aspect of managing chronic myofascial pain is
the identification and control of the perpetuating factors.
So the importance of identifying and
controlling perpetuating factors is greatly underestimated.
For example, chronic muscle overload will over time
result in the development of trigger points.
And continued muscle overload will cause the trigger points to redevelop or
reactivate over and over again, even if they have been treated with
excellent spray and stretch or perfect trigger point injections.
Psychological factors was shown,
psychological stress was shown to experimentally
increase spontaneous electrical activity found in the trigger points.
And increased spontaneous electrical activity means increased referred pain.
Therefore, understanding the stresses that a person is under and teaching or
learning healthier techniques of coping with stress will help reduce
trigger point activity, and therefore also the referred pain associated with that
trigger point activity.
Underlying disease or inflammation is not only a causative factor but,
obviously, if left untreated or poorly managed,
this will cause the perennial reactivation of associated trigger points.
Lastly, any compromise in the energy metabolism of muscles appears
to aggravate and perpetuate myofascial trigger points as well.
We need adequate hormone and vitamin levels in order to
treat the increased irritability of the muscles and poor response to therapy.
So first, let's look at posture.
There are many, many different types of posture that people engage in.
Here's the example of good posture, somebody standing fairly straight.
The hips are in line with the shoulders are in line with the ears, and
everything is in normal balance.
Forward head posture is very, very common.
The shoulders collapse forward, the neck comes forward, and the head has to go into
extension in order for the person to be able to see where they're going.
This is also typical of what we called thoracic kyphosis,
where the back rounds down.
Swayback and lumbar lordosis problems are less involved in the head but
more involved with lower back issues and
other muscle problems in the lower part of the body.
Now, how heavy is your head?
For every inch the head comes forward of where it should be,
the ear should be in line with the shoulders, but for every
inch that it comes forward, the muscles have to do an extra ten pounds of work.
So if your head is two inches forward of where it should be,
it's doing 20 pounds of extra work.
And if it's four inches forward of where it should be,
it's doing 40 pounds of extra work.
That's a lot of extra work on a chronic basis all day long,
those muscles just working to keep your head up.
Here's an example of poor posture at the computer.
And this causes extension of the head in order to see the screen.
We see rounding of the shoulder and the low back, loss of lumbar lordosis,
collapse in the chest, and we have here under thigh compression.
The other thing that happens is that the keyboard is on a desk and
the arms need to be elevated in order to use the keyboard.
What we want to do in that situation is educate the patient about
correcting their work station.
Most people work at a computer during the day, or if not,
if it's not part of their job, they often spend hours In the evening perhaps
sitting on the computer, returning emails, playing on Facebook, or whatever.
So we want to make sure that whatever amount of time they spend
at the computer is in good posture.
So contrast this picture here with this other one.
Now we have a chair that has better support.
And we have provided a foot rest, so
that the individual has a right angle and
no under thigh compression with sitting at the computer.
The height of the monitor has been adjusted so that
the person can see the monitor without tilting their head up or collapsing down.
And we have here a table specifically for
the keyboard, so that the arms can be at a right angles and
there's no odd angle of the wrist, and the shoulders can be relaxed.
Here's an example of driving.
In Los Angeles in particular, there's a lot of time spent in cars.
And if you lose your lumbar support in your car and you collapse forward,
then you spend the entire time that you're in the car
driving with your head in extension, and again, activating all these These
muscles overloading everything while you're driving.
If however, you use a lumbar support and
you put that lumbar support in where between the seat and
your back where the belt goes, you can now restore the lumbar lordosis.
And you can get back the normal posture orientation of the head and neck and
shoulders, and you can drive without aggravating all of these head,
and neck muscles.
Here's a very common problem of the heavy shoulder bag and the problem it causes
the elevation of the levator scap, the trapezius muscle, angulation of the body.
It's much better to take A, either abackpack over both shoulders.
Or if you have a long enough strap on your bag to bring it over and
to put the purse across the body and the strap on the acromioclavicular joint,
as opposed to on the shoulder itself.
TV, a lot of people like to watch TV.
What is the posture of your patient when he or she is watching TV?
Is the television directly in front of them?
Or are they sitting in some kind of sofa or chair and the television is over there?
And for an hour or two, whenever they watch TV,
they are actually looking the wrong direction.
We want to make sure that when we are watching TV that were well
supported that the TV is in front of us and we are comfortable,
and we're not in awkward postures for a long time.
This is also common, people like to read in bed, but where's the light source.
Typically, the light source is to one side.
And then what happens is you can see in this diagram,
we tend to bring the book over and have the light shining on it and
we're in very awkward posture for however long we're reading.
Much better if we like to read in bed is to get a wedge,
have the light source directly from behind and
have the book supported on a pillow.
Here's an example of sleeping posture.
We want to make sure that the pillow fills in the space between the head and
the neck, and the bed for side sleeping.
And so, we want to have a pillow that allows some modification of its
shape in order to support the head and
neck appropriately when we're sleeping on the side.
If we're back sleepers, then we would want to put again, the pillow
under the head and the neck and the shoulders on the bed and we can butterfly.
In this picture, you can see the pillow is kind of butterflied up over the shoulders.
So the pillow provides reasonable support for the head and
the neck, and the shoulders, and the rest of the body are on the bed.
I personally prefer to use a body pillow,
because that allows the arm to be well-supported.
Many trigger points in the scalene muscles and also in the shoulder girdle
our aggravated, and activated by collapse of this arm during side sleeping.
So body pillows are very,
very useful to support the body very well during sleeping time.
Lets talk a little bit about psychological factors.
Psychological factors include stress, depression, anxiety and
behavioral problems.
And we already know that psychological problems
will complicate chronic pain issues.
Studies have shown that the electrical activity
in myofascial trigger points goes up with stress.
This is a study that was done by McNulty et al in 1994 that
looked at the activity of
the spontaneous electrical activity in the trigger point in response to stress.
Here, we have the recording of the trigger point itself over time.
And here, we have a recording from a needle that was placed
in the normal muscle next to the trigger point.
On the x-axis, we have the time in various tasks
that were done during the different time periods.
And on the y-axis,
we have the microvolt amperage of the electrical activity in the muscle.
As we can see, there was a baseline period.
A period of forward counting, one, two, three, four, five and
we also have a little rest period and then we had the stressful situation,
which was believe subtracting serial sevens from a hundred and
that was considered a stressful activity.
If we look at the electrical activity of the normal
muscle it's stayed the same throughout the entire experiment.
If we look at the spontaneous electrical activity in the trigger point,
we can see that during the stressful activity, the electrical activity,
the amplitude went way up.
And when there was a rest period, recovery period, relaxation period.
The amplitude in the muscles went back down.
So this correlates very nicely with the clinical experience that
people have more people when they're stressed.
So here we have, for example, a very stressed individual and
their trigger points are getting more and more active.
The amplitude is going up higher and higher, and higher.
And eventually, they're going to have their headache.
Another psychological factor that effects myofascial pain complaints is depression.
Depression tends to lower pain threshold.
It intensifies pain.
It impairs the response to myofascial therapy.
It causes sleep disturbance.
People who are depressed tend to have less activity and
do less exercise, which aggravates myofascial pain,
because then the muscles that are already tight and short and irritable get more so.
And [COUGH] everything about depression will aggravate trigger points and
should be identified, and treated.
People who are depressed can't distinguish whether or not something is helpful.
Treatments are difficult and motivation in terms of getting them activated,
and exercising and out, and doing the things that they need to do in order to
treat their myofascial pain are very difficult.
So, depression really needs to be identified and treated.
Another factor that often complicates chronic pain
conditions is behavioral problems and there are many,
many situations where the only recognition and
attention somebody gets is from their pain.
So for example, in this cartoon, a husband or a boyfriend is walking in and
he says, are you being discharged today?
I just spent $8 on these flowers.
What? She wasn't going to get flowers unless she
was sick?
So, that is a complicating factor to all chronic pain and also needs to
be addressed in the management of a chronic myofascial pain disorder.
The third perpetuating factor that needs to be address,
this underlying disease or inflammation.
So visceral disease such as migraine or
irritable bowel, or arthritis.
For example, here we have somebody who has a knee problem or
joint dysfunction, which is really not an inflammation, but
a stiffness or a reduction in the normal movement of a particular joint.
It can be cervical.
It can be lumbar.
It can be the temporomandibular joint.
All of these ongoing sort of painful conditions can
cause the perpetuation of trigger points.
So the muscle tightens up in response to the painful disorder or
the dysfunction and continues to redevelop, reactivate the trigger points.
Metabolic endocrine inadequacies and
nutritional inadequacies are also something that needs to be considered and
managed in a chronic myofascial pain condition.
Nutritional inadequacies affect muscle metabolism.
Any compromise of the energy metabolism of the muscle appears to aggravate and
perpetuate trigger points.
So patients really should be screened for general good health and nutrition.
And they should be referred to their physician for
management of any systemic abnormalities.
If we look at metabolic or endocrine inadequacies, for example, hypometabolism,
or thyroid inadequacy, doesn't have to be frankly hypothyroid it can be just
low normal thyroid, this means that the thyroid levels are borderline low or
low normal but, not frankly deficient.
These people only have mild symptoms of low thyroid and they're typically not
treated, they respond to myofascial therapies but only temporarily.
The response to treatments improves tremendously with supplemental thyroid.
Hypoglycemia also aggravates trigger point activity, and
it also reduces the response to therapy.
This is because hypoglycemia symptoms are primarily due to increased
levels of stress hormones in the blood and as we discussed previously,
stress increases the spontaneous electrical activity and
trigger points and also the attendant symptoms.
Nutritional inadequacies are also very important.
The nutrients of most concern in people with myofascial pain are the water soluble
vitamins, B1, B6, B12, folic acid and vitamin C.
There are also certain elements, calcium, iron, and potassium that are important.
Deficiencies in the water soluble vitamins is common
in people with poor dietary habits.
Also in people who drink excessive alcohol or have chronic comorbid diseases.
Nearly half of all people with chronic myofascial pain
require resolution of vitamin inadequacies for lasting relief.
Several factors may cause vitamin insufficiency,
these include inadequate ingestion and impaired absorption.
This is also a very common with people that have had bariatric procedures.
Elderly people, pregnant women, substance abusers, crash dieters,
the economically disadvantaged, the emotionally distressed and depressed, and
the seriously ill, are specially vulnerable.
So we want to make sure that we get adequate fruits and
vegetables and a decent diet going with all of our myofascial pain patients.
Several minerals especially iron, calcium, potassium and magnesium are needed for
normal muscle function.
Iron, calcium and
potassium deficiency lead to increase irritability of the muscle.
Iron is essential for hemo and myoglobin,
which transport oxygen to and from the muscle fibers.
Calcium is essential to the muscle for the release of acetylcholine at the nerve
terminal and, for the contraction mechanism within the muscle.
And potassium is needed for the rapid repolarization of the nerve and
muscle cell membranes.
So all of these things are very important.
So what is the take away message for all of these perpetuating factors?
We really, if we want to properly manage myofascial pain,
we really have to identify and control the perpetuating factors first.
Then we can apply specific myofascial trigger point therapies.
In the absence of controlling the perpetuating factors,
you can perform the most perfect spray and
stretch, you can do the most perfect trigger point injections.
And if you haven't controlled the perpetuating factors,
the myofascial pain is going to return.
And that is very, very frustrating.
So really, in summary, the management and
prevention of myofascial pain is like teaching people healthy living.
We need to have good posture and body mechanics, we need to take care of
ourselves and manage our stress, maybe we want to learn some meditation techniques,
some simple time managing techniques that will allow us to relax during the day and
no get so whined up that we end up having pain.
We need to eat nutritious and regular meals so
that we take care of the nutrient needs of our body and our muscles and
also prevent the onset of hypoglycemia when the blood sugar drops so
low because we haven't eaten for a while.
We need to make sure that we sleep regular hours and we get a good amount of sleep,
that prevents depression and makes us feel better.
There are many, many reasons to have a regular sleep schedule,
not just for myofascial pain problems.
And we also need to get regular exercise.
For myofascial pain we need to do stretching exercises of the muscles that
have the trigger points.
But we also need to get out and walk and get fresh air so that we get
the endorphin's going and we feel better overall and we're not so deconditioned.
So the management and
prevention of myofascial pain is really all about healthy living.
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