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?

Posted on December 14, 2015 by Kate Simmons

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.”)

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.

Essentials of Pain Medicine, 3d Edition; 2011; Benson, Raja, et al.; pg. 346
Ibid., pg.350
fibromyalgia points of pain diagram
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
Essentials of Pain Medicine, pg.347
What can neuroscience conclude about acupuncture? by Adriano Stephan on CogSci

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

Posted on February 11, 2014 by Kate Simmons

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.

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

Posted on January 6, 2014 by Kate Simmons

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:

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.
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:

Use a tennis ball or other compression ball (not too small or hard!) to roll the foot and heel on, to massage it.
Take the foot, ankle and calf through a more challenging series of motions, such as “drawing the alphabet, A-Z” with the foot.
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):

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 can cause muscles to be sore for weeks to the point that they’re painful when used?

Posted on October 1, 2013 by Kate Simmons

Unfortunately, there are quite a few diagnoses that are relevant to muscle soreness and weakness beyond a week’s span. Be sure to have a physician examine you to at least rule out some of the more basic physiological diseases.

Once those are cleared satisfactorily, ask yourself the following questions:

Was there a precipitating event? That is, did it happen all of a sudden? If so, how?
Where in the body did the pain originate? What was the quality of the pain (sharp/burning/dull & aching/sore/tingling/numbness)?
How long did the pain last?

If the pain began with a precipitating event (e.g. “I lifted something;” “I slept funny;” “I twisted in the shower;” “I leapt to catch a ball;” etc.), it usually indicates a sprain or strain to muscle, tendon, or ligament. If you hear a “pop” or “crack” in a joint, it is most likely a connective tissue rupture. If this is the case, you will need a good interview by a sports medicine physician (MD/DO) and probably a scan of some kind (x-ray or CAT scan for bony/cartilage tissues; MRI for muscle/tendon/ligament tissues). This will help to determine what damage, if any, has been done, and if the issue warrants surgery and/or therapeutic intervention. This needs to be your first port-of-call for pain lasting longer than 1-2 weeks.

Once you have determined that there is minimal damage, and therefore, that surgery is unwarranted, you can determine that the cause is one of the following:

Not normal delayed onset muscle soreness (lasting 24-72 hours): See my answer to What causes delayed onset muscle soreness?
A sprain or strain: See Sprains, Strains and Other Soft-Tissue Injuries
If there are multiple areas around the initial location of pain and injury, you may have developed myofascial pain syndrome: “Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension. While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens.”

Myofascial pain syndrome (Mayo Clinic)

As a bit of an aside, sub-acute (1-6 months) and chronic (more than 6 months) of myofascial pain are treated thus:

“A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 1–3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.” (Wiki: Trigger point)

(PS – I’m really proud of the Wiki on this. They nailed it, spot on.)

In a standard clinical interview, you have to go over all the aforementioned patient history, physicians’ reports, scans and anything else you can tell or show the practitioner about what may be the cause of the pain. Your practitioner can then figure out what muscles do the motion that produced the injury & other perpetuating factors, which allows the practitioner to decide what to treat first. This is the general clinical starting point for therapeutic focus.

What is the difference between kneading, rolling, percussion, and vibration?

Posted on August 20, 2013 by Kate Simmons

All the different useful procedures of massage can be classified under eight main categories.

Passive Touch is passive (still). It consists of lightly touching the body with one or more fingers, the whole hand or both hands. This technique is used in Swedish massage, Myofascial Release and Craniosacral therapy, to name a few. Physiological effects include elevation of temperature via heat from the hand, and sensory influence on the cutaneous nerves, often associated with comfort.

Simple touch can be remarkably effective in relieving hypersensitivities, especially in the head and joints. Nervous irritability can be quieted sometimes by simple touch of the hand on the head.

Compression consists of making light or heavy pressure with the whole hand or one or more fingers. This is used in manual deactivation of a myofascial trigger point or to temporarily numb an irritated nerve such as in trigeminal neuralgia or sciatica. When administered correctly, the effect of compression is to diminish swelling and circulatory congestion, and to slightly numb the nerves pressed upon.

Stroking is simply light touch combined with motion. The tips of two to five fingers or the entire palmar surface of one or both hands are moved slowly and gently over the skin with minimal contact at a rate of 1-2 inches per second in the direction of arterial (heart-outward) flow only.

There are many different techniques and reasons for stroking, both direct and reflex. The main effect of stroking is a decided sedative effect. However, very light stroking may produce a very powerful reflex effect, like a tickle or stimulant to spinal nerve roots. This can be very useful to alleviate sleeplessness or hypersensitivity such as a nervous headache (very useful with upset babies and children). Neuralgic pain and numbness may also be somewhat abated with this technique. It can be used abdominally to reflexively stimulate digestion: think of how you gently rub your stomach when you have overeaten or have indigestion.

Friction is where the whole or part of the hand is moved steadily over the surface of the skin following venous flow (toward the heart) with a varying but significant degree of pressure according to the “thickness” of the area being worked on. There are many different techniques for friction depending on the influence you want on the tissue. As a rule, some lubricant such as oil, lotion or powder should be utilized to avoid overstimulation, abrasion and irritation of the skin.

The principal objective of friction is to encourage better circulation, thus emptying the veins and lymphatic spaces and channels of waste matter and painful chemicals. It is probably the most valuable of the various massage procedures.

Swedish massage, Cross-Fiber massage and Active Release Technique use deep friction to break up scar tissue in different structures such as skin, muscle, tendon or ligament. Manual Lymphatic Drainage uses very light friction to clear swelling and congestion from joints and lymphatic outlets.

Friction and kneading are probably the most widely used massage techniques worldwide.

Kneading is probably the best known massage procedure, as familiar as kneading dough. It essentially consists of alternating and intermittent compression and squeezing of the tissue, either by grasping it or compressing it against underlying bony surfaces. Kneading differs from friction in that the skin is held in firm contact with the surface of the hand.

Kneading techniques can either be superficial or deep, and can be further delineated by specific techniques. These include superficial/deep kneading (like a baker kneads dough), skin rolling, wringing, and palm/fist/finger kneading, to name a few. Swedish massage and Deep Tissue Massage utilize these heavily. The main goal of kneading is to stimulate all the vital activities of the body part being worked on, including the nerves, blood vessels, glands and cellular exchanges of the tissue. Deep kneading assists muscles to increase in size and function through better circulatory exchange, and assists in the removal of painful chemicals and connective tissue adhesion. Superficial kneading is especially indicated for swelling and any other condition where the skin and superficial circulatory channels need to be more active.

Vibration consists of fine vibratory or shaking movements from the therapist’s hands to the area worked on. This can be subdivided into lateral, knuckle, superficial, deep, shaking and digital vibration, depending on how the therapist uses his or her hands to address the patient’s needs.

Vibration primarily stimulates. It can cause muscle contraction, a pleasant tingling sensation due to stimulation of sensory nerves, and increased blood flow and subsequent temperature rise of the region. It is valuable in cases of paralysis, neuralgia or neurological weakness or fatigue, where stimulation of the area’s function is needed. I have found it to be especially helpful in cases where the patient is unable to relax a muscle or has trouble with neurologic dysfunction and spasm (such as with Cerebral Palsy).

Percussion consists of blows to the tissue using the hands or fingers with varying degrees of technique and force. The movement is always elastic and from the wrist, which penetrates deeply without bruising superficial structures. As a rule, the hand should strike the body transversely across the muscle’s fibers. Different techniques include tapping strike w/ finger’s ends, spatting (strike w/ fingertips), clapping (strike w/ whole palm), hacking (strike w/ pinky side of hand) and beating (strike with palmar side of a closed fist).

Percussion is a powerful stimulant for both the skin and underlying structures. A short, light application produces a momentary spasm, and thus blanching, of the superficial vessels. Strong percussion dilates the vessels a great deal, as evidenced by the reddening which follows. If very strong, percussion can produce nerve paralysis, as any martial artist knows. Other effects include stimulation of the organs through reflex centers and the spinal cord, and assisting with dislodging mucus congestion in the lungs.

Joint Movement obviously consists of the therapist moving the patient’s joint through a range of motion. This can be combined with other techniques such as deep friction (as in Active Release technique) or touch (as in Myofascial Release and Unwinding). It may be either passive (no effort from the patient) or resistive (as in Proprioceptive Neuromuscular Facilitation, Lewit technique, etc.). Joint Movement strongly affects fluid flow through both the joint and the joint’s connective and adjacent structures. It is useful in cases where there is stiffness, pain, swelling and hyperstimulation. Think of how you shake your hand when it feels tired or stiff.

All this being said, reading this or any other blog does not make one a massage therapist. If you want to truly learn these techniques, whether to give a better backrub or to become a licensed therapist, check out good schools nearby and take an appropriate class. The internet and certifying massage school associations, such as AMTA (American Massage Therapy Association), can help with this. The skills gained will benefit you and your loved ones throughout your lives.

There are many wonderful books about massage, but my favorite one on basic technique is “Art of Massage” (John Harvey Kellogg, MD, reprint 1975 by Health Research, CA), which was our main textbook in 1988. Most of the information on our Medical Board exam for licensure was taken from this text.

Joint Movement