Archive for February, 2014

Low-Level Laser Therapy

One lesser-known but valuable tool for multiple painful conditions is the low-level laser.  The laser is a source of extremely pure, organized light, as opposed to something like a regular light bulb, which emits a scattered, disorganized light.  We can liken organized light to the sound of a flute playing a single note, and disorganized light to the sound of a stone rolling around in a tin can.  The laser is a non-painful treatment option that affects the local (near the area being treated) immune system, blood circulation, and the release of different chemicals that affect how we experience pain.

While it isn’t clear exactly how the laser helps a variety of painful conditions, there are two proposed means by which the laser improves pain:

  1. The light energy (called photons) is absorbed in the injured area and stimulates the production of Cytochrome C.  Cytochrome C is a protein involved in cell metabolism and energy.  When Cytochrome C is stimulated, it revs up the cell’s metabolism, and gives the cells more energy to heal the injured area.
  2. The light energy from the laser leads to the production of small amounts of singlet oxygen.  Singlet oxygen is a reactive form of oxygen, which means that it is very easy for this type of oxygen to take part in chemical reactions.  At high doses, singlet oxygen can be destructive, and has been used in cancer treatment to destroy cancerous cells.  At very low doses, singlet oxygen can increase the number of cells.  This may be one way the laser helps promote tissue repair.

The laser in a non-invasive, non-painful treatment option that can, in some cases, produce results immediately.  For pain that has been around for a long time, more than one treatment session is usually needed for best results.

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Statins may cause muscle pain

Do you have or used to have high cholesterol? Statins are a class of drug used to lower the amount of cholesterol produced by the liver.  You might recognize some of the more common brands like Lipitor (Atorvastatin Calcium) or Crestor (Rosuvastatin Calcium).  They are commonly used for patients with high cholesterol, diabetes, or those with a family history of heart attacks.  Recent data shows that approximately 5% of patients maintained on statins experience muscle pain and weakness.  Muscle pain is one of the top reasons patients choose to stop taking statins[1].  If you are taking a statin and are experiencing muscle pain or weakness, you may want to talk with your doctor about adjusting your dose or finding an alternative treatment.



[1] Jacobson, Terry A. “Toward “Pain-Free” Statin Prescribing: Clinical Algorithm for Diagnosis and Management of Myalgia.” Mayo Clinic Proceedings 83.6 (2008): 687-700. Science Direct. Web.

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Hypothyroidism and muscle pain – are they related?

You can experience muscle pain for many reasons. We discussed trigger points in an earlier blog (see www.normanmarcuspaininstitute.com/what-are-trigger-points/ to recap your memories).  A common medical problem, abnormal activity of the thyroid gland, can cause muscle pain.

Hypothyroidism is a condition in which your thyroid gland doesn’t make enough hormone.  (Hyperthyroidism, which is not as common, is when the thyroid gland produces too much hormone and that can also produce muscle pain.)  When you don’t have enough thyroid hormone, many systems in your body are affected and you may notice the following signs and symptoms:

-brittle nails

-hair loss

-fatigue (feeling tired)

-dry skin

-memory problems

-having trouble thinking clearly

-weight gain

Muscle symptoms associated with hypothyroidism are often described as a cramping, stiffness or weakness.

Hypothyroidism is generally treated with hormone replacement therapy, which means you’re taking synthetic (man-made) hormones to replace the ones that the body isn’t producing.  In one study, almost 20% of patients complained of joint and/or muscle pain, of which 50% had relief in symptoms after starting thyroid replacement therapy[1].

So if you have been diagnosed with hypothyroidism or have symptoms of hypothyroidism and also complain of muscle pain, it’s very possible that the two are related. Ask your doctor to check it out.



[1] Carette, S., Lefrancois, L. Fibrositis and primary hypothyroidism. J Rheumatol. 1988; 15(9):1418-21.

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Treating trigger points in muscles

The most common method in treating trigger points is with trigger point injections. Simply put, trigger point injections are needles being placed into the taut, tender points of the muscle. However, there are different techniques in injecting the muscle fibers.

There are two major types of needles used in injecting the muscle. With dry needling, it is common to use acupuncture needles[1], which are small, thin and flexible. When a liquid is injected in the muscle (such as saline or lidocaine), hypodermic needles are used, which is a hollow needle that is generally thicker and is not flexible.

Different fluids (injectates) can be used in trigger point injections. Lidocaine or bupivacaine are commonly used, which are numbing agents. Corticosteroids and botulinum toxin (better known as Botox) are also used, in hopes that the injectate would reverse the changes in the trigger point rather than just the needle causing minor damage and inflammation which is thought to lead to regrowth of normal muscle fibers. Still others have used saline. Studies have shown that it didn’t matter what was injected into the muscle[2]; there was not a noticeable difference in pain relief between the different injected substances. Also, dry needling injections seem to be just as effective as injections with any substance, suggesting that what is injected is not what causes relief but rather the physical needling of the muscle.

Other treatments used for trigger points include:

-TENS (transcutaneous electrical stimulation) – electrodes are applied to the skin, sending an electric current to the nerves in the skin. The nerves then transmit a signal to the brain. This signal is competing with the signal coming from your painful area. So, instead of feeling your normal pain, you’ll feel a buzzing sensation where the electrodes are attached.

-“spray and stretch” – a technique in which ethyl chloride spray (or a comparable cold) is used to numb a painful area, followed by gentle stretching

-ultrasound

-low level laser

The fact that so many different approaches claim to be effective indicates that there is confusion concerning the understanding and treatment of pain thought to be coming from trigger points.  All muscle pain is not caused by trigger points.  My associates and I discuss the need for a comprehensive approach to muscle pain in a study published in Pain Medicine[3]. (This article can be accessed here.

 


 


[1] Mense, Siegfried, and Robert Gerwin. Muscle Pain: Diagnosis and Treatment. Heidelberg: Springer, 2010

[2] Cummings, T.Michael, and Adrian R. White. “Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review.” Archives of Physical Medicine and Rehabilitation 82.7 (2001): 986-92.

[3] Marcus, Norman J., Edward J. Gracely, and Kelly O. Keefe. “A Comprehensive Protocol to Diagnose and Treat Pain of Muscular Origin May Successfully and Reliably Decrease or Eliminate Pain in a Chronic Pain Population.” Pain Medicine 11.1 (2010): 25-34.

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What are trigger points?

Have you ever felt a painful tightness that just won’t go away no matter how much you stretch? Even if the pain subsides or goes away temporarily, when it recurs you still feel a tender knot that’s always in the same area. This may be due to trigger points (TrPs).  TrPs are tender nodules which can cause pain and are found in a taut band of muscle tissue.  This taut band is formed from a small group of contracted muscle fibers which will make that region of your muscle feel hard and tender.  TrPs are sensitive to pressure and movement. Pressing on a trigger point will cause pain.

Muscle Fiber

TrPs can be classified as either active or latent.  A latent TrP is one that causes pain when palpated, or pressed on, but not spontaneously while resting.  An active TrP can cause spontaneous pain – either at rest, in use, or while being pressed.  If there is enough stress – for example, from too much exercise, a latent TrP can transform into an active TrP.

The cause of TrPs is still being studied, however, there is speculation that the taut band appears in the muscle first without any tenderness or irritation.  With additional stress, the hardened area becomes tender to the touch (a latent TrP), and finally, may progress to producing spontaneous pain as an active TrP.  The initial hardness in a band of muscle fibers can be caused my multiple factors:  injury, overstretching, or over-exercising.

TrPs can be a debilitating source of pain. They can cause weakness and lack of coordination in the muscles where they are found. Next blog, we will discuss common treatment options for trigger points.

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One way in which muscles can cause pain

Nerves connect muscles to the spinal cord.  When something stimulates your muscles, for example, if someone were to press on your arm, the muscle sends a message via the nerves first into the spinal cord, and then up to the brain.  Once the brain receives the message (in this case, that there is pressure on your arm), then your body is able to perceive sensation.  This all happens in a split second, so that your brain receives the message immediately after the stimulus appears.  When the sensation is strong enough it no longer feels like pressure or a simple touch; it is experienced, rather, as pain.    Once the brain processes the message, then you become aware of pain in your muscle.

Read the rest of this entry

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How we perceive pain – nociceptors

We generally don’t think of muscles as a cause of pain. Sure, we know that after exercise or playing ball we can have muscle soreness, but when pain persists we often think it is coming from nerves, joints or the spine.  Believe it or not, muscles (and other soft tissue) are the most common reason for pains such as lower back pain, neck pain and shoulder pain.  The brain gets information from the body about pain from specialized nerves called nociceptors that respond to tissue damage. Trauma, overwork, and over-exercising cause low oxygen and too much acidity in the muscle. These changes, along with other chemicals that are produced when the muscle is damaged in any way, stimulate the nociceptor.  When a stimulus as strong enough it causes the nerve cell to produce an electrical impulse that is sent into the spinal cord and then up to the cortex, the part of the brain where we perceive pain.

There are actually more nociceptors in the muscle attachment sites (the ends of the muscle where it attaches to the tendon and the tendon attaches to the bone) than in the muscle tissue. That is why if you have pain originating in muscles you may be more aware of the pain close to a bone than in the middle of the muscle.

Any kind of injury releases substances from damaged muscle and surrounding tissue that stimulates the nociceptor. If the nociceptor gets enough stimulation it creates an electrical discharge which travels down the nerve and ends up in the spinal cord. Muscle nerves that have been stimulated repeatedly become more sensitive to additional stimulation. They are called sensitized nerves and they will more easily produce electrical activity with even non painful events such as any contraction to move the muscle. That is why when an injured muscle is used it may cause pain.  That is why if you have strained muscles for any reason you may feel pain from every day movement.  Nociceptors are key structures in the perception of pain.

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Muscles as the source of pain

Muscles are the largest organ system in the body, accounting for approximately 50% of our body weight.  We have different ways of categorizing muscles: how they look, how they move, and where they’re located. We are going to focus on muscles that move voluntarily, which means we tell the muscles to move, as opposed to involuntary muscles, which automatically move on their own (like our heart and blood vessels). There are 641 muscles in the body – 340 pairs (meaning we have one on the right, and one on the left), and one unpaired (which is the transverse arytenoid for those who must know).

Back Pain

70% of lower back pain is diagnosed as idiopathic or non-specific[1], which means we are not sure what caused the pain. However, most investigators believe that sprains and strains of the soft tissue are the source of pain. Soft tissue refers to muscles, tendons, and ligaments. So it may be surprising that the emphasis in evaluating and treating lower back pain, neck pain, and shoulder pain, is on the spine and the nerves coming out of the spine. In fact, from 1997 to 2005, the prevalence of the diagnosis of spine-related issues has increased 100% while the diagnosis of strains and sprains of soft tissue has gone down by 40%[2].

This is generally attributed to the increase in the use of high-tech imaging studies, such as MRI and CT scans.  However, just because we have a clearer image of what’s going on inside of your body doesn’t mean that we have a clearer understanding of what’s causing your pain. More than 90% of lower spine MRIs exams in adults are abnormal[3]. Studies have found that up to 40% of people have herniated discs and as many as 70% have degenerated discs with no pain. If people can walk around with abnormal spines without pain, then this means that abnormalities in the spine aren’t always the cause of pain. Your diagnosis of a herniated disc, spinal stenosis, or spondylosisthesis may actually be unrelated to your source of pain.

Muscles are often ignored when it comes to diagnosing pain. I believe the reason is that we rarely evaluate muscles as a source of pain. We generally don’t learn about or understand how they work, what chemical changes take place inside, and how they produce pain (the pathophysiology). I would like to take the next few blogs to discuss how muscles contribute to your chronic pain.



[1] Deyo, RA., et al. Low Back Pain. NEJM. 2001; 344(5):363-370

[2] Martin, B., et al. Expenditures and health status among adults with back and neck problems. JAMA. 299(6):656-64, Feb 2008.

[3] Zimmerman, Robert D. “A Review of Utilization of Diagnostic Imaging in the Evaluation of Patients with Back Pain: The When and What of Back Pain Imaging.” Journal of Back and Musculoskeletal Rehabilitation 8 (1997): 125-33.

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