Cross House Hospital Lecture 2007

8/14/2019 Cross House Hospital Lecture 2007

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An Alternative Approach to

Musculoskeletal pain

Marcus WebbOsteopath

Medical Acupuncturist


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Dont give up


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Osteopathy

Andrew Taylor Still(1828-1917)

Surgeon in the UnionArmy during the Civil

WarConcepts developed

by 1874First school of

osteopathic medicinein Kirksville, Missouriopened in 1892.


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Osteopathy a definition

Osteopathy is a primary healthcare system that

work through the neuro-musculoskeletal system,

and accepts that the internal organs affect, and

are affected by that system.Relevant psychological and social factors also

form part of the diagnosis. Another important

principle of osteopathy is that the body has itsown self-healing mechanisms, which can

be utilised as part of the treatment.


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Chiropractic

Daniel David Palmer

(1845 - 1913)

Canadian-born teacherand healer

Palmer School of

Chiropractic opened in

1897


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Chiropractic a definition

Chiropractic is concerned with the diagnosis,

treatment and prevention of mechanical

disorders of the musculoskeletal system and the

effects of these disorders on the function of the

nervous system and general health. There is an

emphasis on manual treatments including spinal

manipulation or adjustment.


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Traditional Acupuncture

Yellow Emperor

Huang Di

Nei Jing (Su Wen)

2500 BC5000 years of known

history

Yin Yang & vitalenergy (Qi)

Meridians


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Acupuncture a definition

Traditional acupuncture can be defined as

the insertion of solid needles into the bodyalong traditional "meridians" for therapeutic

purposes in accordance with traditional

Chinese concepts of diagnosis.


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Historically pain was painful!


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Non-traditional Acupuncture

Dry needling

Trigger point Acupuncture

Medical Acupuncture

Ah Shi Technique

One in the same!


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Dry needling a definition

Dry needling or non-traditional acupuncture

ignores or radically reinterprets the traditional

apparatus of "meridians" and "points" and is

based on the modern understanding of anatomy,physiology, and pathology. This form of

acupuncture has also been called medical

Acupuncture. Dry needling and medicalacupuncture are therefore different names for

the same thing.


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Needle therapy is not new


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Pain

Nociception

The immediate response conveyed to the brain.

InflammationA local response to cellular injury.

Neuropathy

Ongoing pain often with no obvious signs.

Super sensitivityA result of malfunctioning nerves.


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Super sensitivity

Adverse change in local neuronal environment e.g. Spasm, injury

Damage or destruction to axonal microtubules

Nerve still functional but axoplasm flow reduced

Function of nerve affected

Tissue innovated by this nerve becomes super sensitive

Myofascial trigger point generation

Adapted from: The Gunn Approach to the treatment of chronic pain


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Features of Tissue Super Sensitivity

There is pain in the absence of ongoing tissue damage.

There is a delay in the onset of pain after a precipitating injury.

Mild stimuli are very painful.

There may be a stabbing component to the pain.

Pronounced summation and after-reaction from stimuli.

Activation or generation of Myofascial trigger points

Adapted from: The Gunn Approach to the treatment of chronic pain


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Features of Myofascial Pain

Continuous, deep, dull aching pain.

Tender spots (trigger points) in muscles.

Relief by deactivating trigger points.

Restricted range of motion in muscles.

Muscle twitch with trigger point stimulation.

Patient is startled or jumps with trigger point pressure.


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Neck-head pain

Classic upper trapezuis trigger points with typical referral pattern

Taken from: Myofascial pain and dysfunction. The trigger point manual. Travell & Simons


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Shoulder pain

Example of trigger points associated with

true frozen shoulder or pseudo capsulitis


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Functional Disability

Muscle

Spasm

Physical

traumaEmotional

tensionDisease

Ischemia

Pain

Metabolites

Disability

Limited Muscle Elongation

Myofascial Trigger Points

Restricted Joint Motion

Facial Contracture

Oedema

AtrophyFibrous

Reaction

Functional

Disability


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Case 1 Lumbar Spinal Stenosis

William, 67 year old

Retired gas fitter

No medical history of note No prescribed medication

Enjoys a game of golf

Easy going personality


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History Insidious onset in January 2006

Bi-lateral sciatica often to ankles but residing daily in

his buttocks, thighs and back of knees. Positive neurological claudication with activity (Golf)

No active low back pain

Side effects from analgesia and ineffective

Neurosurgeon told William to live with it after viewing

his MRI.


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MRI Report

Taken in April 2006 demonstrated wide spread disc

degeneration and hypertrophic changes causing central

stenosis from L3-4 and a significantly narrowed

intervertabral foramen on the left at the L5-S1 level.


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Physical examination

Stood with flat back

Mottled, non-blanchingrash-like appearance dueto chronic use of hotpack!

Limited lumber extension

Full SLR and strong EHL Prominent paravertebral

tension and tenderness


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Case 1


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Any Volunteers ?


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Disease & Functional Disability

Local skeletal disease irritate tissue

Visceral disease may activate reflex spasm Viscero-Somatic reflex via autonomic system


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Physical Trauma


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Emotional Tension

Anxiety & stress cause muscular tension

Anxiety will amplify existing pain

Amplified pain lowers the threshold for pain tolerance

Chronic pain induces emotional tension


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Ischemia

Healthy muscle requires good circulation

Spasm acts as a tourniquet

Muscular ischemia impairs oxygenation Retained by-products of muscle metabolism

Irritation of local tissue

Reflex contracture

Activation of trigger points


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Pain

Pain will cause a spinal reflex commonly resulting in protective spasm

of muscles innovated by that segment and associated levels


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Metabolites


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Disability

Altered posture and function

The 5-Ds of chronic pain

Disability

Disuse

Depression & loss of motivation

Drug dependence

Degeneration


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Autonomic nervous system


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Stress-Pain-Spasm Cycle


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Cross House Hospital Lecture 2007

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