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?

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 science behind Trigger Point deep muscle massage? Does it work? How many sessions does it take before you feel relief?

The answer to this question will include current, state-of-the-art research, as well as my and my colleagues’ clinical experience over several decades. I will address each of the three questions in sequence.

 

1) What is the science behind trigger point deep muscle massage?

There are several theories for the etiology/pathophysiology of trigger points and myofascial pain syndrome. Research continues on each, as none have yet been decisively proven.[1][2] Massage therapy (MT) has been studied extensively, and has been shown to produce objective effects most notably in those bodily systems which interact locally with the myofascial (muscle and connective tissue) systems.[3] These include the local circulatory systems, local and central nervous systems, and the lymphatic system within the immediate vicinity of the area worked on. It should be noted that the fascial structures, which encapsulate the contractile structures and tissues, exert mechanical forces upon the other associated structures, thus affecting their physiological function. MT (specifically ischemic compression and friction massage) has been shown to be effective in releasing myofascial trigger points.[5] MT also has minimal side effects, no drug interactions, is low cost, and often includes positive patient-practitioner relations (which lead to a positive and productive mentality during therapeutic treatment and rehabilitation).

 

2)  It does work. But how?

MT that successfully releases trigger points includes ischemic compression and friction massage. Ischemic compression involves holding pressure steadily on a trigger point until it softens/releases. Friction massage involves sliding the finger/hand/etc. along a (usually) venous direction of a muscle. This creates a vacuum/suction effect upon the circulation which quickly introduces freshened circulatory fluids to the area, and moves inflammatory chemicals present back into general circulation.[6] The freshened circulatory fluids include blood and lymph, which carry pain-relieving endorphins, as well as energy constituents for metabolic recovery for both the myofascial tissue and the neuromuscular junctions. Inflammatory chemicals removed include substance P, prostaglandins, bradykinin, etc.[7]

Dry Needling & Manual Trigger Point Therapy Courses and Training )

(image: Dry Needling & Manual Trigger Point Therapy Courses and Training)

If you’d like to see some of this for yourself, try this: locate the blue (venous) lines on the underside of your wrist. Press, then rub, slowly along the blue line toward the elbow. The blue line will go clear for a moment, then the blue, or venous, blood will return in a second or two. You have just performed friction massage to the veins which will drain blood and lymph from the tissues it serves. These tissues may contain nociceptive (pain inducing) and/or inflammatory biochemicals. If you flush the tissue of venous blood/lymph, creating a “quick-refresh” of arterial blood, the tissue will be flushed of painful biochemicals, while receiving pain-relieving biochemicals. This is the function of ischemic compression and friction massage for painful areas, including tissue with active trigger points.

3) How many sessions does it take before you feel relief?

If you have been properly diagnosed with MPS, and your practitioner is well-trained and experienced, you should feel immediate relief. Ischemic compression and/or friction massage releases a trigger point (and the attendant pain and tension) within a minute or two. If trigger points are extremely active, it may take several passes over an area to treat it completely.

There is a clinical understanding in our profession: the complex part of therapy is not releasing the patient’s pain (if you know what you are doing), but rather keeping them out of pain.

If your therapist is good, you will feel better, at least significantly, for a while. The task for you then is to:

  1. learn to do effective self-care to release the trigger points,
  2. stretch/strengthen the tissue, and
  3. track when the pain recurs, so that your practitioner can superimpose the timeline of recurrence with functional tasks, to possibly trace those tasks that need to be modified or eliminated (which will remove the trigger point’s perpetuating factor).

When these have been accomplished, you should be solidly on the road to recovery. Progress often follows a “two steps forward, one step back” pattern, as perpetuating factors are gradually eliminated and the tissue rehabilitates successfully. How long that will take depends on many factors: your age, general health, metabolic factors, stress levels, fitness, ergonomic factors, daily functional tasks, diet, sleep, emotional state, etc. Your doctor and therapist should help you to minimize the impact of triggers, and also to bolster those areas of overall healthy living that need help. If symptoms don’t improve noticeably within several weeks, you should seek other opinions and help.

————————————

[1] “Etiology of Myofascial Trigger Points,” article on the National Center for Biotechnology Information, U.S. National Library of Medicine website.

 

[2] “Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome,” article on the Science Direct website.

 

[3] “Physiological and clinical changes after therapeutic massage of the neck and shoulders,” Article on the Science Direct website.

 

[4] “The Effects of Pressure Release, Phonophoresis of Hydrocortisone, and Ultrasound on Upper Trapezius Latent Myofascial Trigger Point,” article on the Science Direct website.

 

[5] “The muscular force transmission system: Role of the intramuscular connective tissue,” article on the Science Direct website.

 

[6] Myofascial Pain and Dysfunction: the Trigger Point Manual, pg. 86.

 

[7] “Changes in Blood Flow and Cellular Metabolism at a Myofascial Trigger Point With Trigger Point Release (Ischemic Compression): A Proof-of-Principle Pilot Study,” article on the Science Direct website.

 

What kind of doctor should I see if I have myofascial pain syndrome?

What kind of doctor should I see if I have myofascial pain syndrome?

This answer is based on my 25 years of teaming up with Bay Area physicians to help patients with myofascial pain syndrome.

To see the most effective and well-educated physician for myofascial pain syndrome, you should see a physiatrist, especially one specializing in pain management. Some other options include:

  • Physicians who specialize in occupational injury, as they seem to have greater training and understanding of myofascial pain syndrome, and
  • An increasing number of neurologists and orthopedists who specialize in pain management.

The first step to finding the right medical professional will be to do your own research on your condition, and thereby make sure that you actually have symptoms that fit the profile of MPS. While an official diagnosis will need to be done by a physician, your self-education will (or should) be welcomed by the physician, as it will save them time.

Next, you will want to do a cursory search on Google and Yelp to determine which physicians state a specialty in MPS. There may be many, as physicians seem to be racing to learn proper protocol for MPS treatment right now. The primary physiatrist I knew at Stanford Pain Management Clinic spends about 65% of his time traveling to educate physiatrists in MPS. Once you’ve decided a doctor might be right for you, you can always call their office, and ask the staff if they treat myofascial pain syndrome. You can even ask how they do it; or you can ask the physician at the appointment.

If they reply, “We inject cortisone into the sore/tender area,” they are probably not well-trained, as this doesn’t address the taut band and trigger point.

As part of a team with the well-trained physician, my job is to get rid of as much of the active/latent trigger points as possible. If there’s something I can’t address (too deep, too active, etc.), they inject it, because IT WORKS. However, they also realize that you can’t do more than 4 or 5 at a go, because they are painful.

The internet and the phone are your friends. Don’t be afraid to use them in order to find the best doctor to help you. Good luck!

 

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

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 is the best thing to do if you burn your hand?

What is the best thing to do if you burn your hand?

Any burn that is 2nd or 3rd degree (puckering or blistering/charring of the skin) needs to be seen to by a physician asap. Otherwise, you risk serious, possibly life-threatening, infection and loss of bodily tissue.

In cases of a simple first-degree burn or scald (quick touch to a heated surface or liquid), you have to cool the skin temperature to normalize it as quickly as possible. This is best-done by running the burned/scalded skin under cold running (clean) water until the first “burning” sensation has reduced or passed (at least for one minute). This will also hopefully clean the wound of any foreign substance, such as charred material or chemical irritants.  

Next, you want to disinfect and numb the tissue, both to prevent infection from the compromised area (cohesive skin is the most powerful exterior barrier to infection our body has) and to numb the area’s nerves that perceive burning pain. This helps to abate the hyper-inflammatory process that can result from sudden tissue insult, such as a burn.  

This can be achieved in several ways. The easiest is to apply a combination disinfectant/numbing ointment such as Neosporin “with Pain Relief” (lidocaine). The disinfectants, combined with the topical numbing agent lidocaine, help the metabolism of the tissue resist infection until the skin (dermis layers affected) has healed sufficiently to do so unaided. Aloe Vera gel has also been used as a demulcent (skin-soother) since antiquity, and you can add this after the disinfectant/numbing agents.

There have been many herbal agents throughout history that have been utilized to provide the disinfectant, numbing, and demulcent (skin-soother) properties described above. However, any encompassing list and history of these agents would make this answer far too long, especially when there are cheap and effective alternatives available at the supermarkets and corner stores.

Once you have treated the wound with good cooling, disinfecting, numbing, and demulcent agents, you need to cover the wound with some sort of sterile dressing. Usually this means – Yes! – a Band-Aid. Think of the Band-Aid dressing as a kind of “temporary non-adhesive synthetic skin” that will serve as a protective barrier while your actual skin is vulnerable and healing. Make sure that the adhesive doesn’t touch the wounded skin, or it will abrade the skin further. You will want to repeat this treatment every 4-6 hours as needed, for at least 24 hours: rinsing, applying “ointment” and covering with a bandage. If there is ANY indication of excessive reddening, swelling, or sensations of itching, burning, etc., see a doctor (emergency, if necessary) immediately. This is no joke – burns can be very dangerous!  

If no adverse effects are noted, a kiss to the (bandaged) boo-boo may help too!

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

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?

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?

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?

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 can I reduce knots in my shoulders (trapezius muscles)?

From a reader:

How can I reduce knots in my shoulders (trapezius muscles)? I work at a computer most of the day, and have tight knots in my shoulders; specifically, in my trapezius muscles. How can I reduce the tension in these muscles, without having someone else massage them? Are there self-massage techniques I can use? What are appropriate stretches?

Trazpezius


My answer:

EVERYBODY gets tension (and sometimes, pain) in the neck and shoulders as well as in between the shoulder blades. This has, of course, increased in these times when we’re all looking down and hunching up at our phones and laptops. Here’s how to get rid of it. Based on the reader’s questions, I’ve broken up my answer into 3 sections below.

 

How do I reduce tension in these muscles?

This is the most important question. You could have the best therapist to resolve the tension for a time, but if you continue to do the actions that result in the tension and pain, they will just keep coming back and probably keep getting worse.

The most common problem that exacerbates tension and pain in the neck and shoulders is holding the neck in an unnatural position. The two most common are looking down for extended periods and craning the neck and head forward (most probably to focus on miniscule print on a device such as a smartphone or laptop). The answer is to figure out how to keep the head as upright and without rotation as possible, while you relax your shoulders and arms at your sides.

The trapezius itself is, ironically, not the most common cause of neck/shoulder pain in the curve of the shoulder (the levator scapula is). However, TrP1 (Trigger Point 1) at the curve of the neck/shoulder is one of the myofascial TrPs observed the most often [1]:

Trigger Point 1

There are about seven common trigger points located in the upper, middle and lower portions of the trapezius muscle:

Trigger points located in the trapezius muscle

Point 7 (x) produces pilomtor activity or “gooseflesh” to the upper extremity [2]

Trapezius trigger point 7

“In study of static loading, Bearns (1961) discovered that the upper fibers of trapezius, contrary to universal teaching, ‘play no active part in the support of the shoulder girdle in the relaxed upright posture.” [3]

 

Are there self-massage techniques I can use?

ABSOLUTELY.

FIRST, you must have been assured by a proper diagnostician (MD/DO) that there are no problems (such as a herniated disc, bone spurs, etc.) that will constantly madden the nerves that feed the musculature of the neck and shoulder. If there is such an inflammatory component, anything I write here will be transitory because the true cause has not been addressed. My suggestions below can temporarily interrupt the pain signal, which has benefit, but ALL pieces of the problem must be addressed to have lasting comfort.

First, it is very helpful to heat the area first. This will dilate blood and lymph vessels, bringing an influx of fresh blood into the area. It will also soften the connective tissue (fascia) that surrounds and binds the muscle fibers and heads, which will make the whole area more amenable to stretching. This step also prepares the tissue for massage (flushing) of the inflammatory chemicals that are making it hurt.

You can use a couple Swedish massage techniques to soften and relax the tissue. These are friction (rubbing along the fiber) and kneading (like with bread dough). For more information, see my blog entry What is the difference between kneading, rolling, percussion, and vibration?

For trigger point deactivation, you can use point-compression with fingertip(s) or a pressure tool (such as a backnobber or theracane):

Using a backnobber

You can also use a tennis or pinky ball against a wall, but they are notoriously difficult to use on the curve of the shoulder. I’ve found the backnobber to be the most useful. It’s only $30, and the product and subsequent comfort can last the rest of your life (no affiliation, just a big, big fan of one of the coolest designs EVER!) [4]

Here’s what you do:

  1. Find the trigger point (any “x” in the above diagrams) that produces the pain pattern that you have, or alternately find a knot in a band of muscle in the curve of the neck/shoulder.

  2. Heat first!

  3. Apply pressure with a fingertip or tool, just enough to “feel it,” and HOLD for 15-60 seconds, until it feels like it is “dissolving/softening,” or until it feels “done.”

  4. Apply the same technique to adjacent and associated trigger points

  5. At this point, you MUST take the muscles released through their normal resting range of motion!

 

What are appropriate stretches?

This is a tricky one for the neck and shoulder, which have an astonishing array of motion capabilities.

PLEASE NOTE: The exercises below will NOT help and will probably be painful and/or harmful if the tissue is not softened first. Before doing any of the below stretches, follow steps 1 and 2 above. Take it slow and EASY, and remember to breathe. Do NOT make it hurt, just stop at the first point of stretch and relax into it.

Stretches that are most helpful for neck/shoulder pain are as follows:

Stretches helpful for neck and shoulder pain (points 4-7)

(points 4-7)

Stretches helpful for neck and shoulder pain (points 5-7)

(points 5-7)

Stretches helpful for neck and shoulder pain

If you follow the steps above, you should get immediate, long-lasting relief from neck/shoulder pain from computer use. If you do not, it’s time to see a pain-management doctor. Don’t wait. The longer these muscles go on in an inflamed, irritated, shortened state, the longer it takes to deactivate and rehabilitate them.

Ultimately, the triggers must be eliminated, the tissue must be softened/relaxed/deactivated, and then it must be strengthened within its current capability.


[1] Myofascial Pain and Dysfunction; the Trigger Point Manual, Travell and Simons, pg.184

[2] Ibid., pg.186

[3] Muscles Alive; Their Functions Revealed by Electromyography, John V. Basmajian, Carlo J. DeLuca, pg.266

[4] The Pressure Positive Company