Soft Tissue Dysfunction Stephen M. Perle, DC, MS Professor of Clinical Sciences University of Bridgeport College of Chiropractic No competing interests No association with providers of commercial products and/or devices discussed in this presentation and/or with any commercial supporters of these activities. 2 Primary Spine Practitioner Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiropr Man Therap. 2011;19(1):17. MCA - NCMIC Stephen M. Perle, DC, MS 2017 3 Stephen M. Perle, DC, MS 2012 1
A Diagnosis-Based Clinical Decision Rule Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskelet Disord. 2007;8:75. Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropr Osteopat. 2008;16:7. Murphy DR, Hurwitz EL, McGovern EE. Outcome of pregnancy-related lumbopelvic pain treated according to a diagnosis-based decision rule: a prospective observational cohort study. JMPT. 2009;32(8):616-24. Murphy DR, Hurwitz EL, McGovern EE. A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: a prospective observational cohort study with follow-up. JMPT. 2009;32(9):723-33. MCA - NCMIC Stephen M. Perle, DC, MS 2017 4 Donald R. Murphy, DC Murphy DR. Clinical Reasoning in Spine Pain Volume II: Primary Management of Cervical Disorders Using the CRISP Protocols Case Studies in Primary Spine Care. Vol. 2. Cranston, R.I: CRISP Education and Research LLC; 2016. Murphy DR. Clinical Reasoning in Spine Pain Volume II: Primary Management of Cervical Disorders Using the CRISP Protocols Case Studies in Primary Spine Care. Vol. 2. Cranston, R.I: CRISP Education and Research LLC; 2016. MCA - NCMIC Stephen M. Perle, DC, MS 2017 5 The Three Essential Questions of Diagnosis 1. Are the symptoms with which the patient is presenting reflective of a visceral disorder, or a serious or potentially life-threatening disease? 2. From where is the pain arising? 3. What has gone wrong with this person as a whole that would cause the pain experience to develop and persist? MCA - NCMIC Stephen M. Perle, DC, MS 2017 6 Stephen M. Perle, DC, MS 2012 2
Disorder Detected by Cancer Benign tumor Infection Fracture Hx CA, no pos relief, fever, constit sx, wt loss Local severe pain, no pos relief, relief w/ NSAID, px percussion Hx fever, chills, febrile, pt tender, red, heat Hx trauma, hx osteoporosis, px percussion MCA - NCMIC Stephen M. Perle, DC, MS 2017 7 Disorder Detected by GI disease GU Disease Myelopathy Cauda Equina Snd GI complaints, pain w/ food, abd exam GU complaints, bleed, spot, discharge, GU exam Gait, bowel/ blad, UMN, spast, sens level Bowel/ blad, saddle anesth, anal sphincter tone MCA - NCMIC Stephen M. Perle, DC, MS 2017 8 Breast Lung Prostate Thyroid Kidney 1 CA That Has Predilection for Bone Bladder Endometrium Cervix Melanoma MCA - NCMIC Stephen M. Perle, DC, MS 2017 9 Stephen M. Perle, DC, MS 2012 3
Red Flags for Potentially Serious or Life Threatening Disease in HA Exam Finding Suggestive of Fever Infection Papilledema Tumor Visual Field Tumor Scalp tenderness Tumor UMN signs Tumor or infection Nuchal Rigid/ Kernig s Meningitis Enlarged temp. art. Temp. arteritis Fluid leak Skull fx MCA - NCMIC Stephen M. Perle, DC, MS 2017 10 Identify the Primary Pain Generator(s) Centralization signs (disc?) Segmental provocation signs (joint?) Neurodynamic signs (radiculopathy) Myofascial signs (trigger points?) 11 Myofascial Trigger Point (TrP) A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. Simons, Travell & Simons, 1999 p5 12 Stephen M. Perle, DC, MS 2012 4
Myofascial Trigger Point (TrP) A cluster of electrically active loci each of which is associated with a contraction knot and a dysfunctional motor endplate in skeletal muscle. Simons, Travell & Simons, 1999 p5 13 Myofascial Pain Syndrome The sensory, motor, and autonomic symptoms caused by myofascial trigger points. Simons, Travell & Simons, 1999 p5 14 Symptoms Referred phenomena Specific pain referral patterns Variable irritability Direct and indirect activation Outlasts precipitating event Peripheral nerve entrapment Phenomena other than pain Stiffness and weakness 15 Stephen M. Perle, DC, MS 2012 5
Symptoms Referred Phenomena Pain Dull, aching Often deep Rarely burning Area of pain is often not well localized Occasionally - sharp lancinating or lightning-like stabs of pain Low-grade discomfort to severe & incapacitating torture Increased motor unit activity (spasm) Tenderness 16 Tenderness Tenderness is pain upon palpation Tenderness is referred from a TrP whose reference zone is the location of tenderness DDx Tenderness is in skin not sub-q 17 Specific Pain Referral Patterns 18 Stephen M. Perle, DC, MS 2012 6
Best TrP Charts 19 http://www.triggerpoints.net http://www.realbodywork.com/mobile-apps/ 21 Stephen M. Perle, DC, MS 2012 7
22 Variable Irritability A hallmark of Myofascial TrP Syndrome Sx vary from Hour-to-hour Day-to-day Latent TrP is not spontaneously painful Active TrP is spontaneously painful 23 Continuum of Activity Latent Active Painfree Painful 24 Stephen M. Perle, DC, MS 2012 8
Activation Direct Acute overload Overwork fatigue Direct trauma Compression Chilling Indirect Visceral disease Arthritic joints Emotional distress Other TrPs (Primary TrP activates satellite TrP) 25 Key vs. Satellite Piriformis TrP Satellite QL TrP Key 26 Outlasts Precipitating Event Muscles learn to avoid pain Can result in chronic muscular pain, stiffness With rest TrP may become latent Patient may then forget precipitating event Occasional reactivation typical Hx of recurrent symptomatic episodes 27 Stephen M. Perle, DC, MS 2012 9
Peripheral Nerve Entrapment Neurapraxia from nerve compression between TrP taut bands between TrP taut band & bone 28 Peripheral Nerve Entrapment Neurapraxia from nerve compression between TrP taut bands between TrP taut band & bone Patient's have two types of Sx Nerve compression effects numbness & tingling hypoesthesia & sometimes hyperesthesia 29 Peripheral Nerve Entrapment Neurapraxia from nerve compression between TrP taut bands between TrP taut band & bone Patient's have two types of Sx Nerve compression effects numbness & tingling hypoesthesia & sometimes hyperesthesia Aching pain from TrP 30 Stephen M. Perle, DC, MS 2012 10
Phenomena Other Than Pain Autonomic Excessive lacrimation Nasal secretion Pilomotor activity Changes in sweat pattern Reflex vasoconstriction Postural dizziness Spatial disorientation Disturbed weight perception Visual & auditory disturbances Visceral disorders 31 Phenomena Other Than Pain Stiffness Worse in morning Recurs after overactivity or immobility E.g., after long conversation on airplane Weakness Patient learns movements to avoid Limits force of contractions below pain threshold Note: These are present in active AND latent trigger points 32 Etiology Sudden onset Acute overload stress Trauma Extreme exertion Eccentric component of an exercise is more culpable Gradual onset Overuse fatigue Excessive repetitive action Repetitive action with poor biomechanics 33 Stephen M. Perle, DC, MS 2012 11
Diagnostic Criteria 1 Essential Criteria Taut Band palpable (if muscle accessible) 34 Palpation of Taut Band Taut band feels like bass guitar string Always transverse to muscle fibers Flat palpation Slide over muscle Pincer grip palpation Grab wad of muscle 35 Diagnostic Criteria 1 Essential Criteria Taut Band palpable (if muscle accessible) Exquisite spot tenderness of nodule in taut band Painful limit to full stretch ROM Patient's recognition of current pain complaint by pressure on tender nodule (active trigger point) 36 Stephen M. Perle, DC, MS 2012 12
Palpatory Stimulation of Pain Referral Latent Active No ref Pain ref Sx > No chx Painfree Painful 37 Diagnostic Criteria 2 Confirmatory observations Identification of local twitch response Local twitch response induced by needle penetration of tender nodule Pain or altered sensation (in distribution expected from a TrP in that muscle) on compression of tender nodule EMG spontaneous electrical activity characteristic of active loci in tender nodule of a taut band 38 Treatments Electrical stimulation (intermittent better) Ultrasound (intermittent better) Hot packs and/or massage Injection Stretch and spray Static pressure Manual pressure release: Trigger point pressure release Ischemic compression Receptor Tonus Technique (Nimmo) Post-Isometric Relaxation (PIR) Lewit stretch technique 39 Stephen M. Perle, DC, MS 2012 13
Manual Pressure Release Application of tolerably painful, persistent manual pressure Effective in latent TrP of Upper Trap Fryer G, Hodgson L. J Bodywork Movement Ther 2005; 9(4): 248-55. 40 Manual Pressure Release Effective in active TrP of Upper Trap Longer treatment more effective: 30, 60 90 s Harder pressure more effective: threshold vs average thresholdtolerance Combination of Tx best hot pack plus active ROM and stretch with spray hot pack plus active ROM and stretch with spray as well as TENS hot pack plus active ROM and interferential current as well as myofascial release technique (passive stretching) hot pack plus active ROM and ischemic compression hot pack plus active ROM and ischemic compression as well as TENS combined with stretch and spray, myofascial release, or interferential current therapies Hou et al. Arch Phys Med Rehabil 2002; 83(10): 1406-14. 41 Post-Isometric Relaxation (PIR) Bring muscle to max comfortable ROM Minimal force contraction 10-15s Inhale and hold, continue contraction 5s Exhale and relax Dr. takes up slack, do not stretch Repeat at max comfortable ROM Passive movement through total ROM 42 Stephen M. Perle, DC, MS 2012 14
Post-Isometric Relaxation (PIR) 43 http://clinicalce.org/?page_id=181 44 http://www.mckenzieinstitute.org 45 Stephen M. Perle, DC, MS 2012 15
Neurodynamics Neuromobilization 46 www.chiroup.com 47 Neurodynamics http://www.noigroup.com/en/product/ndpp Shacklock M. Clinical neurodynamics: a new system of musculoskeletal treatment. Butterworth-Heinemann; 2005. 48 Stephen M. Perle, DC, MS 2012 16