The most powerful tool in my practice
Soon after I began practicing medicine, I noticed an odd phenomenon. Despite my best efforts some patients were NOT getting better. And other patients who I would normally expect to have difficulty in getting better were actually improving. The patients who were not improving had an odd array of symptoms and didn’t fit in any traditional category. They had unexplainable aches, pains, stiffness, fatigue and emotional problems that were not responding to treatment. My inability to help these patients was frustrating for both of us.
The other category of patients whose symptoms, I would normally have expected to resist treatment but were actually improving was exemplified by an early patient of mine with fibromyalgia. Fibromyalgia patients usually have a complex array of physical, mental and emotional symptoms. These symptoms test the ability of most providers to provide therapeutic relief. Because of the difficulty in diagnosing Fibromyalgia, having no definitive blood test, both the patient and the physician often experience major frustration. At the time, my patient was also getting regular acupuncture treatments. Because acupuncture was not in my arsenal of therapies, I had no idea what this treatment involved. But because it was obviously providing relief for my patient, I enrolled in an acupuncture course offered by UCLA to help my understanding and see if this knowledge could be applied to help my patients.
The Acupuncture course was founded by Joseph Helms, MD. The first Medical Acupuncture for Physicians course was held in 1980 under the sponsorship of the American Holistic Medical Association. From 1982 through 2008 HMI offered the course in collaboration with the continuing medical education offices of UCLA and Stanford Schools of Medicine. The Medical Acupuncture course opened the door to a whole new approach to medicine. The lecturers and attendees were excited by this new approach to healing. I began incorporating some of the treatments into my practice. But after months of effort, and treatment with individual patients, I was dissatisfied with the results. Fortunately the Medical Acupuncture course offered more options for using acupuncture in pain therapy. Two practitioners who had done significant research in the field were mentioned, specifically, C. Chan Gunn, MD and Janet G. Travell, MD .
The key component to most chronic pain issues are trigger points that develop in stressed muscle fibers. TPs are discrete, focal, hyper-irritable spots located in skeletal muscle. Muscles are engines of movement and when infected with TPs became shorter, tighter, stiffer and denser. These infected muscles altered the natural functioning of the muscles. Muscles function in locomotion and are made up of the fibers of movement, the coverings, the transition to a ligament and then the attachment to the bone. This muscular unit is call Myofascial Tissue and is the focus of therapy.
These short , stiff myofascial tissue irritate and compress associated nerve fibers, pain fibers, joints, lymphatics, arteries and veins. A shortened muscle will alter the alignment of a joint and cause premature wear and tear. If this alter alignment if left for decades, it can destroy the natural design of a joint and increase degeneration. The compressed nerve fibers will switch on pain alerts, alarms and alter normal sensations called neuropathy. The broken pain signals will be oppressive and unrelenting as would happen after Shingles. Alter sensory fibers will cause a slight innocent pressure to be interpreted as scalding hot or burning. Compressed arteries will choke off nourishment to limbs leading to cold fingers and toes and could lead to ulcers. Compressed veins which bring blood back to the heart will cause swelling and another type of ulcer. Myofascial disease will lead to fear, anxiety, insomnia and worry. Even suicides.
Some providers think that myofascial tissue will masquerade as a number of maladies that will delay therapy for weeks, months and even years. The triggers will growing in numbers per muscle as in density and spreading to others areas of the body. Most provider do not know that myofascial tissues infected with trigger points will have a local pain clinical finding and in a referred pain pattern that may be a joint segments away.
The technique to relieve this stressed muscle tissues is now called myofascial release therapy (MRT) and is focused on these “trigger points” that develop in muscles. MRT is already in use today in regular physical therapy, massage therapy, sports medicine and in chiropractic medicine. Myofascial Release Therapy, when used correctly can begin the healing process for patients with complex muscle and skeletal and/or neuropathic pain issues. MFRT or MRT is as simple as a stretch to as complex as using a thick needles to breakup the muscle fibers. Once can use leverage to unwind the muscles floor exercising, stretching and yoga. Hands-on therapies like deep tissue massage, a light touch release and chiropractic adjustments.
Some myofascial tissues can not be effectively released just with leverage and powerful hands. The muscles require an electrical depolarization by using a stainless steel or metal tool. A solid needle as an acupuncture needle or a sharp cutting tipped hypodermic needle. I imagine myofascial tissue as different grades of beef from Filet Mignon to a tough leathery hunk of meat. Take a sewing needles and push it through the filet, easy. Now try to push a sewing needle through a belt, almost impossible with a sewing needle. But if you take a needle with a knife like tip and you can penetrate the belt. If you tried to bend or twist or pierce a leather belt with a sewing needles.
Traditional Chinese Acupuncture was know to be highly effective at muscular and ligamentous type medical problems but the myth was a mystery to modern doctors had not incorporated it into routine care. TC Acupuncture is a powerful therapeutic modality but somehow it is lost due to the ancient foreign language and tradition.
Fortunately for us, C. Chan Gunn, MD who studied TCA uncovered an article published in the 30’s that sheds light on the ancient discipline. This article noted that a muscle could be stimulated to twitch with a stainless steel probe. Gunn used this idea to offers a parallel theory of “Traditional Acupuncture.” Gunn uses the tool or acupuncture needles to unlock these TPs. He called his technique Intramuscular Stimulation or IMS. He stated in his textbook the differences in IMS and traditional acupuncture as: 1. IMS requires a medical diagnosis. 2. A medical examination is imperative. 3. The placement of the needles is indicated by the examination. 4. Knowledge of modern anatomy is essential. 5. An immediate positive change in the subjective and objective finding is expected.
Gunn’s philosophy went beyond traditional acupuncture for a new vision of what was truly happening within the muscle tissues. Gunn believed that using the acupuncture needles in IMS created the following benefits:
1. Inserting the thin flexible solid stainless steel needle into the skin and muscle caused microscopic tissue injury. That injury triggered a healing cascade of repair which repaired the tissue injury and any local secondary injury. Muscle stem cells proliferate to restore muscle health and power.
2. The stainless steel needle, once it entered the muscle, triggered a muscular re-polarization creating a muscle twitch. After the twitch, the muscle would relax. The relaxed muscle would be a little longer, less tense and tight. Better able to fit and correctly realign a joint.
Gunn’s IMS is a powerful technique that allows one the freedom to use the needles in places that were disregarded by all other authors. and wisdom of Gunn is at the core of all successful needle myofascial therapy. The down side of Gunn is that it is time consuming, labor intensive and for some patients can be painful and intolerable.
Janet G. Travell, MD, who’s worked extensively on Myofascial Pain Therapy, was an orthopedic doctor in the 1950s-60s. She realized that focused therapy at the joints was less successful that focusing the therapy on the muscles. Many physicians saw musculoskeletal pain issues as originating in joints or static structures; she understood that many of these pain and disability issues originated in the muscles. She also discovered that treating the muscles would also alleviate a lot of movement disorders and pain syndromes. She noted that if the muscles were treated then the ligaments, nerves and circulatory dysfunctions would naturally resolve. She called her therapy Trigger Point Injections.
Travell, MD injected lidocaine into a trigger before activating the release which is less painful, but take even more time that Gunn. In the world of Travell you compliment the trigger points with some hands-on therapy. Still both of these authors techniques can be painful so a lot of patient would simply suffer with the pain than the injections.
These intensely miserable patient had nowhere to turn until Edward S. Rachlin, MD. modified both techniques. Rachlin, MD. is an orthopedic surgeon who has written a text on Myofascial pain issues. He was able to see the benefits of the disciplines proposed by Gunn and Travell and blend them into an integrated package. His therapeutic package is also focused on the muscular trigger points. The Rachlin injection procedure does not require the twitching-response as Gunn/Travell taught in schools of MRT. Plus Rachlin would perform a pre-trigger point anesthesia injections to soothe the trigger before the release. Much less pain and much more tolerable to already depleted miserable patients.
During this evolution of myofascial release therapy a provider focused his injections at the junction between the tendon/ligaments and the bone. This procedure is now called Prolotherapy introduced by George Hackett, MD. His contribution is now global and in essence, it too involves injections and needles, but the focus is on the tendons and ligaments. I contend that this is a valid procedure just as the others but due to some misunderstanding due to the substance being injected. A very mild caustic agent is injected in an attempt to stimulate fibroblastic cell to renew and thicken thus strengthening the joint.
In 15 years of treating complex pain in my patients I have used these therapies extensively. With all these options, all patients can receive the benefits of less pain and misery. Each patient’s overall well being and the fortitude determine whether the necessary work can be completed in one visit. In others, the pain tolerance is a limiting factor and may require a series of visits.
I believe, MRT can revolutionize our healthcare system. MRT is already in use today in regular physical therapy, massage therapy, sports medicine and in chiropractic medicine. It can become the treatment of choice for hundreds of medical ailments. Medical Benefits of MRT:
- Remarkably effective
- Can decrease the need for back, knee, or hip surgery
- Can decrease the need for some medications
- Can eliminate the need for medications in some ailments
- It has minimal side effects
- No drug interactions
- No contraindications
- Few precautions
- Help contain the rising cost of healthcare.
- Simplify care so these procedure can be put into the hands of NP. PA. PT and even the patients themselves. Sort of like a DIY needle therapy at home.
- Empowering patient to help in their own care.
Disadvantages:
The downside of MRT is that it is time consuming, labor intensive, can be painful and requires a team of additional helpers to assist the patients and the administer the wellness program. As with most medical illnesses preventive care is valued and early therapy can avert some of the intensity. But nothing that could not be dealt with in the global scheme of medical care.
Recommended reading on pain therapy:Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathy Origin, C. Chan Gunn MD, PhD Click to order on Amazon
Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set) David G. Simons, MD Janet G. Travell, MD Click to Order on Amazon
Myofascial Pain and Fibromyalgia: Trigger Point Management Edward S. Rachlin, MD Click to order on Amazon
Ligament and Tendon Relaxation (Skeletal Disability: Treated By Prolotherapy) George S. Hackett, MDAcupuncture Energetics: A Clinical Approach for Physicians [Hardcover] Joseph M. Helms (Author) Click to Order on Amazon
