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Chronic pain, depression, fibromyalgia and chronic fatigue all seem to feed off each other but which came first? What is the root of this debilitation?

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This is a difficult question to answer. The etiology of each of these chronic illnesses remains, alas, a mystery that we have yet to conclusively solve.

That being said, it is very important that we solve them. Why? Because baby-boomers (a very large portion of the American population) are headed into geriatric conditions. Among the most common of these is fibromyaligia. It is to pain management, what alzheimer’s and frontotemporal dementia are to neurology.

What we do know is that pain, fibromyalgia, depression and chronic fatigue syndrome often share common symptoms:

  • sleep disturbance (usually long-term)
  • excessive stress levels
  • psychological repercussions/detriments from sleep loss, excessive stress, and other factors
  • reduced capacity for activities of daily living (ADLs), resulting in reduced cardiovascular exercise and resultant hypofitness

All these factors result in:

Fibromyalgia domains[1]

We also know that although the above symptoms seem to correlate with inflammation, research has shown a demonstrated lack of local inflammation in these shared co-morbidities (common co-occurences). In addition, as inflammation does not occur, anti-inflammatories do not help.

Further answers to this question have filled many textbooks (and been part of ongoing debate in pain management) due to unexplained etiology: if we could figure out the biological pathways that develop the disease, we would at least be closer to a definitive understanding of the commonalities between these diseases. We could then address and treat them definitively.

To my knowledge, the closest we have come to a definitive etiology of fibromyalgia is as follows (if someone knows differently, PLEASE correct me):

  • Fibromyalgia can be considered a discrete condition, as well as a construct. This helps explain how/why individuals have multifocal pain and other somatic symptoms in spite of the lack of nociceptive input (i.e., peripheral damage/inflammation) that adequately accounts for the pain.
  • The primary abnormality, identified to date in fibromyalgia and related pain syndromes, is an increased gain (as in a volume control turned up) in central nervous system pain processing (i.e., secondary hyperalgesia/allodynia).
  • It is likely that this “turning up the volume” on pain and sensory processing is in part due to increased levels of excitatory neurotransmitters (e.g., glutamate, substance P), and/or low levels of inhibitory neurotransmitters (serotonin, norepinephrine, GABA, cannabinoids).
  • Analgesics that work well for “peripheral/nociceptive” pain syndromes (e.g., NSAIDS, opioids), are largely ineffective in fibromyalgia.
  • The most effective classes of drugs in fibromyalgia are centrally acting analgesics (e.g., triciyclics, serotonin re-uptake inhibitors, “SNRI”s, and anticonvulsants (calcium channel blockers).
  • Nonpharmacologic therapies such as education, exercise, manual therapy, and cognitive behavioral therapy are very effective in fibromyalgia and are typically underutilized in routine clinical practices. [2]

Diffuse pain (11/18 points on the body) [3]

Diffuse pain (11/18 points on the body – see diagram above) is the hallmark of fibromyalgia, and this is notably absent in depression and chronic fatigue syndrome. It is also absent, in this pattern, in myofascial pain syndrome (MPS), which tends to be more localised, and also tends to be more functionally oriented. In the fibromyalgia patient, the common complaint is that, “I hurt all over.” The tissue feels very soft and broken-down, versus taut bands and knots of MPS. However, they do sometimes coincide. (See Devin Starlanyle and Mary Ellen Copeland’s “Fibromyalgia & Chronic Myofascial Pain.”)

"Fibromyalgia & Chronic Myofascial Pain: A Survival Manual."

As to how this has been established in case studies, please see the below table:

Frequency of Comorbidity in Fibromyaliga[4]

So, what does this all mean?

  • Sleep quality/quantity is interrupted.
  • There is usually a level of sustained stress and psychological distress.
  • There is a discrepancy of diagnostic criteria: pain with fatigue and psychological distress, versus fatigue and psychological distress, versus psychological distress alone. Granted, cases may change over time (see above diagragm) but the primary characteristics of each individual’s case remain unique in these criteria.

To show this in another way, here’s a current diagram for commonalities that would produce these common symptoms:

Neural Influences on Pain and Sensory Processing[5]

This would help to explain the commonalities of:

  • sleep disturbance ~/= fatigue
  • depression
  • low pain threshold (easily triggered pain)
  • functional compromise

In addition, it may explain why:

  • Amitryptaline/Nortryptaline (SSRI) are helpful in treating many of these common symptoms, via increased levels of available serotonin and norepinephrine/noradrenaline levels in overall tissue.
  • Lyrica/Neurontin (Ca Channel blockers) are helpful to treat many of these common symptoms, via reduced central excitability in signal (especially pain signal) processing.

It is agreed, though, in interdisciplinary pain management, that effective therapy for ALL of these conditions MUST include:

  • Appropriate pharmacologic prescriptions, and
  • Cognitive Behavioral Therapy, to learn triggering deactivation and new coping mechanisms: to mediate pain perception and subsequent neuromodulation.

The following is further noted as helpful:

  • Physical therapy: Begin an appropriate “start low, go slow” low-impact cardiovascular exercise program, such as aquatic therapy or other low-impact mechanisms. This maximises tissue metabolism and ultimate tone.
  • Massage therapy: This modality maximises efficiency of circulatory return and tissue metabolism, in order to enable the tissue to respond to functional demands and short/long-term capabilities (much like physical therapy).
  • Acupuncture: This modality reduces overall CNS (central nervous system) hyperactivation and restores CNS stability. Some studies vary as to the effectiveness of this modality, but observed results are more consistent. In practice, it has shown to help with patient’s ability to comply with functional demands, perhaps due to lowering levels of CNS hyperalgesia. [6]

I wish I had more definitive information to convey. In pain management circles, this is what we’ve got so far. Know, however, that we’re working on it, ardently.

I’ll update as I’m able to.

 

  1. Essentials of Pain Medicine, 3d Edition; 2011; Benson, Raja, et al.; pg. 346
  2. Ibid., pg.350
  3. fibromyalgia points of pain diagram
  4. Weiner’s Pain Management: A Practical Guide for Clinicians (American Academy of Pain Management), 7th edition; 2007; Mark V. Boswell, B. Eliot Cole; pg. 497
  5. Essentials of Pain Medicine, pg.347
  6. What can neuroscience conclude about acupuncture? by Adriano Stephan on CogSci

What is the purpose of the navel in the human body, beyond birth?

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As Lou Davis says, there is no function of the navel for autonomic function past birth. But it can be argued that there is a musculoskeletal / myofascial function to the navel as it relates to deeper muscular and connective tissue structures in relation to anatomical development and subsequent physiological functional capacity.

The navel is a connective tissue (fascia) locus[1] that is centered around our physical center of gravity, which is why physiotherapists make such a fuss about “core” strengthening. The abdominal muscles and associated connective tissue (including in the area of the navel) constitute a center of support for the viscera and the musculoskeletal (including Lumbar) structures surrounding and supporting it.

This becomes important, in physiotherapy, when the “core abdominal support” has been anatomically or physiologically / functionally compromised. The navel itself doesn’t have muscular components, such as contractive sarcomeres, but it affects the sarcomeres of the surrounding myofascia, including rectus abdominus and external obliques,etc. The navel itself is not the issue, but its location at our center of gravity and the functionality that extends from that center of gravity is the issue.

[1] Fascia: The Tensional Network Of the Human Body; 2012, Elsevier; Robert Schleip, Thomas Findley, Leon Chaitow, Peter Huijing; pgs. 50-52

What does where the pain lies tell you about the nature of a headache?

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Most headaches around the eyes, cheeks, temples, and top, back or base of the skull involve the muscles, connective tissue (myofascia), nerves or structures around the joints of the jaw, ear, and/or sinuses. These headaches can be primarily caused by a direct strain or sprain, or secondarily caused by drug side effects or other conditions that precipitate inflammation in those areas. The brain tissue itself does not have nerve endings that perceive pain, but the tissue surrounding it certainly does!

There are many muscles in the neck and head. I’ll primarily address the myofascial pain pattern of each one, since their are too many related conditions and drug effects to list in a single answer. In any case, a thorough examination by a physician to determine the cause of the pain would still be called for.Areas of pain in muscles (from Travell and Simons’ Myofascial Pain and Dysfunction, volume I) are grouped into the following areas:

Varieties of headache (from Travell and Simons' "Myofascial Pain and Dysfunction," volume I)

(Ch.5, pg.167)

The muscles that create the referred pain in these areas are grouped here, in the same text:

Travell and Simons' "Myofascial Pain and Dysfunction," volume I

If you are curious about the specific pain pattern of a particular muscle, you can visit this site (or other similar accredited sites) to find out: National Association of Myofascial Trigger Point Therapists.

For the temporalis muscle, a sample pattern might look like this:

Temporalis muscle

Muscles of the neck can refer pain locally or up into areas of the head, including the face and jaw. Most facial muscles (including muscles of the eye, ear and jaw) tend to refer pain very locally; they very rarely refer down to the neck.

Pain in the face and jaw, especially, tend to indicate problems with the sinuses, eyes, muscles of mastication (chewing), dental problems (such as malocclusion or infection), or some other local infection (such as a cold or flu). Pain can be triggered by any recurrent infection or source of inflammation, even cancer. This essentially means that therapy for the muscles may provide temporary relief, but since the primary trigger has not been resolved, it will keep recurring.

If the problem is primarily myofascial, correction of any source of mechanical strain (including postural or ergonomic strain) must be removed or at least reduced for the therapy to be effective and lasting.  

The first 3 books on this list are my favorites on non-migraine headaches for the layperson: Amazon.com: trigger points and headache: Books

BUT, of course, if a headache is especially severe, has lasted for longer than three days, happens repeatedly, is interfering with your functioning significantly, is affecting your eyesight, hearing, balance, cognitive function, or is doing anything other than just making your head hurt, please go see a doctor right away!

What do you do to stay productive all day?

What do you do to stay productive all day?

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The answers to this will be a bit subjective, due to the demands and personal makeup of our different lives. As a 46yo woman, wife, mother, business owner, muscle therapist, etc., here are some things that help keep me on track.

  1. Good sleep. This cannot be overstated, and I am fierce about not only the quantity (min. 6 hours, 8 best), but the quality. I spend an hour with a hot bath and soothing music and meditation to calm my body and mind down before going to bed. I have a great bed and pillow, and I make sure that I am warm and comfortable during sleep. Consequently, I fall deeply asleep about 2 minutes after hitting the pillow, and I wake up when the alarm goes off, refreshed and ready for the day. Well, after one cup of coffee.
  2. Morning exercise. I have a pretty rigid schedule, but I find that 30 minutes of morning exercise (minimum) in a natural setting, such as a walk on the beach (or somewhere similarly enjoyable) clears away the “cobwebs” physically and mentally, and I feel like it gives me a jump-start on increased energy for the rest of the day. It clears my mind of clutter and makes me feel ready to face the day’s challenges calmly. It works better for me first thing in the morning, because I tend to be too busy or tired later in the day, when it’s easier to blow off.
  3. Good nutrition. I have high physical and mental demands on me during my workday, and I am sensitive to drops in blood glucose levels (runs in my family). I try to get good quality food (nutritious, moderate fat/sugar/salt intake) at even 2-4 hour intervals throughout the day. Low-fat protein sources, such as soy milk or miso, tend to help me stay awake and alert.
  4. Productive use of downtime. I have been trying to make a habit of meditating for up to 15-minute intervals through the day during “waiting” periods. These can include the time between appointments, end of the workday, during a bath, etc. Allowing myself to try to “drain of thought” is like a deep breath of refreshing air for my whole self. Which leads me to:
  5. Take notes. I have always found it difficult to give myself permission to jot down a note (on paper, Post-its, Evernote, my wrist, etc.) to remember something trivial (calling a friend, picking up something at the store, etc). I do not remember these things well while working. When I’ve written the note, I no longer feel the weight of trying to remember, and I can concentrate better on the moment at hand.
  6. Regular time with family and friends. We make a family habit of eating together and watching a movie together every night. Yes, every night. This requires a fair bit of compromise on all our parts. We have never regretted it, and you don’t ever get the time with your kids back to do over. It makes for a grateful, peaceful evening. As regularly as possible, we try to get together with friends about whom we care deeply.  Scheduling ahead helps. Again, we’re never sorry we did, and good times and lasting friendships are shared by all.

Rinse, repeat.

How do sports medicine physicians (MD or DO) and physiotherapists view chiropractic?

How do sports medicine physicians (MD or DO) and physiotherapists view chiropractic?

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My perspective on chiropractic, outlined below in 3 parts, is that of an advanced muscle therapy practitioner who has worked with many wonderful DCs in the Bay Area. We’re lucky to have them and their services.

1. How do sports medicine physicians (MD or DO) and physiotherapists view chiropractic?

This will depend heavily on which MD/DO you ask, their professional training, and the focus of their practice. Those that specialize in pain medicine are often acquainted with experienced DCs that are very skilled in helping people get out of pain very quickly. Chiropractors have a very in-depth training in musculoskeletal anatomy and physiology that enables them to understand and enlist effective therapeutic techniques that can achieve speedy relief from symptoms. The proof is in the result: does the patient feel better, or not? Although no technique is a panacea, a DC’s techniques often yield an answer of “yes.”

In my 24 years of experience, I’ve found that sometimes you need someone skilled to cavitate a joint (therapeutically manipulate the alignment of the bony tissue), or series of joints, if they are “stuck.” You have to take into account the tension and function of soft tissue as well (perhaps even primarily), but if the joint is “stuck,” it needs to be mobilized, softly and mindfully. It won’t be functional otherwise, and therapeutically, that’s the bottom line.

2. Has chiropractic managed to shake itself loose from the old Palmerian dogma of “subluxations” and the notion that “adjustments” can cure all manner of illnesses?

As far as I know, DC curriculum still includes such dogma. However, any responsible practitioner knows that no technique is a panacea, and answering on behalf of those DCs who no longer subscribe to such notions, and whom I respect, the answer is “Yes.”

Good DCs have many therapeutic techniques besides “adjustments.” When used well, they get great results in pain management.

There are many symptoms and conditions where cavitation can help provide comfort. See also this entry on Quora.com: Human Physiology: Is it okay to pop/crack your joints (knuckles/back/neck/etc.) daily?

3. How prevalent are chiropractors in sports medicine?

Again, this will depend on the area of practice and training standards. If someone is good at what they do (getting people out of pain and back to functional levels), they could be an MD, DO, PT, DC, or MT. “Therapy” is a very divergent and fluctuating field, one that has only one goal: Get Someone Better, ASAP. The trick is, the modality must be consistently effective and reproducible. As in any therapeutic field, great DCs are well-educated healers. They will most probably be at the forefront of challenging cases, providing pretty astonishing results. I’m honored to be working with some of the best of them. They continually, delightfully, surprise me and my patients with results that we can’t get from soft-tissue therapy or medications alone.

Why am I getting headaches when I make long phone calls?

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From a reader:

Why am I getting headaches when I make long phone calls? Why do they last up to a week before the pain starts to go away? It’s hard to get to sleep with such pain, and even when I do sleep, the pain is still there when I wake up. Is this dangerous for me? Are there any health concerns?

My answer:

First, you should definitely see a physician. Make that appointment ASAP! 😉

That being said, a likely scenario is activated trigger points in the muscles of the neck and shoulder (most likely the upper trapezius, splenius capitus, splenius cervicis, and suboccipitals). These are the muscles that produce this very familiar posture:

Headaches from long phone calls

How often do we see and DO this on any given day? This action strains the muscles and the connective tissue (myofascia) mentioned above because they are probably not used to, and are definitely not “designed for,” the sustained contraction shown above.

Let’s go through the pain patterns that emerge when these various muscles undergo repetitive strain (which leads to active trigger point referral patterns):

1) Upper trapezius:

Pain in the upper trapezius muscle

2) Splenius capitus:

Splenius capitis

3) Splenius cervicis:

Splenius cervicis

4) Suboccipitals:

Suboccipitals

(Credit for all of these medical illustrations belongs to Barbara D. Cummings, the illustrator for Travell and Simons’ “Trigger Point Manual.” She had an extraordinary gift for giving the viewer an accurate, literal view of subjective pain.)

ALL of these muscles are engaged in the posture in the first picture, where someone is holding a phone between their head/ear and their shoulder. You have to hold it there somehow, right? Well, these are the muscles that do it for you, and they are most probably strained and activated through prolonged, static holding of this posture.

The most obvious way to help prevent this from happening again is by correcting the problematic posture that strains these muscles:

  1. Keep your head upright and your neck straight on prolonged conversations.

  2. Switch which hand holds the phone, so that you are not constantly loading the same muscles on the same side (thereby straining them). Give them a rest by using the similar muscles on the opposite side, then switch again when they get tired.

  3. Give yourself a few moments to slowly take your head and shoulders through their comfortable range-of-motion, in order to restore circulation and re-establish normal resting length for the muscles. This involves making SLOW circles, or moving the head in opposing directions (i.e., up/down & right/left).

Also, if the calls tend to be especially stressful, give yourself “breaks” every 5-10 minutes to disengage for at least 60 seconds. If needed, perhaps mention that you must take a moment to attend to something personal (letting the cat in, a call on the other line, etc.), then take that moment to:

  1. Consciously relax any tension you feel. For example, try tensing your muscles for 5 seconds while holding your breath, then exhale while relaxing those muscles (2-3 times in a row). This is a simple biofeedback technique.

  2. Imagine the tension as something physical (smoke, dirty water, etc.) draining out of your feet into the floor/ground. This is a simple meditative/visualisation technique.

  3. Give yourself permission to drop as much tension as you can, and to breathe as slowly, deeply, and as relaxed as you can manage. This is a simple cognitive behavioral therapy technique.

When ready, resume conversation. 🙂

If you would like to know some relatively easy ways to relax your muscles and stop the pain, and your physician has cleared you to do such exercises as the above (no contraindications), see my blog post How can I reduce knots in my shoulders (trapezius muscles)?

Good luck, truly. I think a great deal of people are struggling with this right now.

How long does the pain last once you start walking again after foot surgery?

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From a reader:

“I fractured my fifth metatarsal and, after attempting to heal naturally for a couple weeks, I ended up getting it fixed surgically, with a titanium plate. Ten weeks after the injury occurred, I finally was able to walk again, using a cam boot and cane. I have no balance issues, but the pain was pretty severe.  I’d say it ranged from 7 or 8/10 at first, and now, a week later, it’s around 5-6.

I’m wondering if you have a sense of when my foot will feel normal again? As in being able to maybe take a jog, or chase my cat?”

My answer:

How long the pain lasts can differ from case to case, but from these descriptions, several ideas come to mind. However, anything I say here is obviously trumped by your podiatrist, who has seen you and directed your care.

You say that you are now at 11 weeks post-op, and you only began mobilizing the foot/ankle last week. My guess is that the area of the heel, where the achilles tendon anchors, has become tight and somewhat adhesed. This creates inflammation in the area. Also, I would bet that the soleus muscle has an active trigger point which needs to be deactivated, and that the muscle needs to be mobilized and rehabilitated.

The reason that I say the soleus muscle, in particular, is that the referral zone for the soleus is nearly unique to that muscle. It looks like this (see TrP1 in the diagram):

Soleus muscle

Keep in mind, 10 weeks (2.5 months, roughly) is a LONG time for your foot to be immobilized. Muscle / connective tissue that has been damaged begins to heal, literally, overnight. Unfortunately, when there is bony tissue fracture or damage that requires immobilization, the soft-tissue takes a backseat to healing the bones completely, which results in the soft-tissue being pretty darned stiff and sore when you begin to re-mobilize.

Here’s what I recommend to those who present with this type of complaint:

  1. Heat the foot and calf with a hot water/epsom salt soak for 10-15 minutes to dilate the blood/lymph vessels and reduce swelling in the joints.
  2. Use a rolling pin (yes, that’s right, like for pastry) to roll across the soleus muscle and compress the trigger point (“X”, above, for TrP1). You can also use the Tiger Tail, a cool new tool I learned about:

Tiger Tail

  1. Use a tennis ball or other compression ball (not too small or hard!) to roll the foot and heel on, to massage it.
  2. Take the foot, ankle and calf through a more challenging series of motions, such as “drawing the alphabet, A-Z” with the foot.
  3. If still sore, either use an ice pack or a lidocaine cream on the heel (only, not the ankle or calf, and please clear with your podiatrist first):

Lidocaine

The ice or 4% lidocaine will temporarily deaden the superficial sensory nerves, and hopefully lessen the soreness.

I also recommend walking on a soft surface (such as sand or with your body supported in water) very slowly and barefoot to maximize mobility and minimize impact and weight-bearing to the heel.

Good luck!

What does scapular retraction do?

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Scapular retraction is movement of the scapula (shoulder blade) backwards and inwards towards the spine. It is mainly produced by the rhomboids (M/m) and medial / lower trapezius in this isolated movement:

Movements of the upper limbMovements of the Upper Limb

Keeping these muscles toned is important in order to support functionally healthy placement of the scapula in static postures and to have good shoulder girdle strength. This strength is balanced with those muscles that pull the scapula forward, which can be overly tight and weak with extended slouching.

A simple isolation exercise to strengthen these muscles of scapular retraction involves squeezing the muscles backwards against resistance. Such resistance can be accomplished by using simple arm weights, or by using an added weight or resistance device, such as free weights (or even a soup can), strengthening bands, pulleys, etc.

"Such resistance can be accomplished by using simple arm weights, or by using an added weight or resistance device, such as free weights (or even a soup can), strengthening bands, pulleys, etc."

Any of these variations of this exercise will be more effective in isolating these muscles if you bend your torso forward 90′, which prevents primary loading of supporting muscles.

Here’s a video which shows such an exercise (credit: WellCor):

CAUTION

If you have ANY neck problems or discomfort, support the head with a towel and relax it (do NOT lift up head or tuck the neck). Remember to breathe in a relaxed manner during the exercise: breathe IN through the nose during the contraction, then EXHALE through the mouth when you relax the contraction.

If you experience any discomfort during or following the exercise, alert your therapist or doctor immediately.  Good luck!

 

Are dental guards and occlusal splints really effective to treat Bruxism (teeth grinding)?

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As long as the guards / splints are well designed and worn consistently, they can be effective for those people who grind so badly that they damage their teeth. Ill-fitting splints, however, can create more problems than they solve (besides which, they are rarely worn because they are uncomfortable).

In my practice, the most common problems I’ve seen with splints is that they are too big. This throws off the placement of the temporomandibular joint (TMJ) which then makes the muscles of the jaw (most notably the masseter and pterygoid muscles) painful and tight. Very often, the tension in these muscles feeds into the grinding through muscle tension and heightened activation.

In the below diagrams, the red areas indicate the primary patterns of pain associated with bruxism. In the first diagram, the muscle drawn at the back of the jaw is the masseter, which is the main chewing muscle. You can easily feel this muscle when clenching your jaw:

Masseter muscle

Bruxism also affects the medial and lateral pterygoid muscles:

The medial and lateral pterygoid muscles

which are very difficult to reach, but important to treat for TMJ pain and bruxism.

There is a good product out now for self-treatment of the muscles of the jaw, called The MyoFree Solution:

The MyoFree Solution

Very often, if you deactivate trigger points in the jaw and restore normal tone and resting length, the bruxism reduces or is eliminated entirely.

In the meantime, though, let your dentist know that the splint is uncomfortable, and ask them to reexamine the fitting. Good luck!

Why do we get knots in our back muscles, but not in other areas (e.g. arms or legs)?

Why do we get knots in our back muscles, but not in other areas (e.g. arms or legs)?

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“Muscle knots,” otherwise known as trigger points, can occur in any muscle of the body when that muscle is used improperly or damaged. With repeated misuse or damage, the affected sarcomeres (contracting fibers) can “lock” into immobility and inflammation of varying levels. Online research of any skeletal muscle of the body reveals images of trigger point pain patterns for that muscle. (Various muscles associated with locations of pain throughout the body are shown here too: National Association of Myofascial Trigger Point Therapists | Symptom Checker)

Current wisdom on this subject is as follows: “The presence of CGRP (calcitonin gene-related peptide) drives the system to become chronic, potentiating the motor endplate response and potentiating, with SubstanceP, activation of muscle nociceptors. The combination of acidic myofascial pH and proinflammatory mediators at the active trigger point contributes to segmental spread of nociceptive input into the dorsal horn of the spinal cord and leads to the activation of multiple receptive fields. Neuroplastic changes in dorsal horn neurons occur in response to constant nociceptive barrage, causing further activation of neighboring and regional dorsal horn neurons that now have lowered thresholds. This results in the observed phenomena of hypersensitivity, allodynia, and referred pain that is characteristic of the active myofascial trigger point.” 1

To put it in simpler clinical terms, an active trigger point that is referring pain will activate (as a result of tissue metabolism and biochemistry altering the nociceptive threshold) associated soft tissue and neural regions through neuroplasticity.

1. An expansion of Simons’ integrated hypothesis of trigger point formation (pg. 474, 1st P.)