Somewhere at around the mile 8 marker of my 20 mile run a few weeks ago, I felt a familiar (and terrifying) sensation: My leg was beginning to cramp up and I wasn’t even halfway through my run. Having experienced this just one time before—and it ruined a marathon for me—I decided to use it as an opportunity to work on my problem-solving skills. I calmed down, increased my salt intake and used mental mantras to get myself through the run. And as soon as the run was over, I called my doctor of physical therapy (DPT) and scheduled an appointment for the next week.

I found my DPT late last fall after a painful marathon (involving that first cramping experience) that I followed up with another marathon in hopes to erase the pain of the previous one. I then ‘ran’ a race on an icy path and after that, I knew I needed to see a professional about my out-of-whack body. It was probably one of the best decisions I made. I learned that like many runners, my hips and glutes were weak, causing all sorts of problems.

Over the next few months, we worked through my problems and I got stronger and faster. My visits moved from twice a week to once a week, then to once a month and finally to maintenance visits every six weeks or so. When I was ‘cleared’ by my DPT, I decided to keep a standing appointment every two months just to keep myself honest regarding my drills and form. Having a professional to call when things don’t go as planned has been invaluable.

After my painful 20-miler, I went into my DPT’s office and told her what happened. She began massaging my tight calf and said, “Yep—glad you came in because this could’ve absolutely blown up into something awful.” As we moved from the massage to dry needling (not the most comfortable thing in the world, but tolerable), I just thought about how glad I was that I had someone I could call when things like a terrible calf cramp happened. A year ago, I would’ve just tried to continue to run through it and probably would’ve ended up doing something to make it worse.

Physical therapy is not free, so I know it’s a luxury for me to be able to go every two months or so, but it’s worth the cost to be able to stay running healthily. Even if you just go once to get evaluated, I would recommend not ignoring those little (or not so little) pains that just won’t go away. Let a professional help you fix it and become a stronger runner. I know I’m so grateful that I did.

Do you have a DPT you can call if you feel injured?

https://www.youtube.com/watch?v=BZYtAR4zUpg&feature=youtu.be&fbclid=IwAR3MXgXnOyKaRmcvvwmvqZQp69H27UhIIT4mQv3e03qoB6zL2yUHF01QxWE" target="_blank">http://https://www.youtube.com/watch?v=BZYtAR4zUpg&feature=youtu.be&fbclid=IwAR3MXgXnOyKaRmcvvwmvqZQp69H27UhIIT4mQv3e03qoB6zL2yUHF01QxWE

Please Watch this wonderful video explaining why we cant trust dermatomes as the only way for pain mapping. 

Your daily cup of coffee may be doing more for you than providing that early-morning pick-me-up. The health impact of coffee has long been a controversial topic, with advocates touting its antioxidant activity and brain-boosting ability, and detractors detailing downsides such as insomnia, indigestion and an increased heart rate and blood pressure. But the latest wave of scientific evidence brings a wealth of good news for coffee lovers. Here are 10 reasons drinking coffee may be healthier for you than you thought.

1. Coffee is a potent source of healthful antioxidants.

In fact, coffee shows more antioxidant activity than green tea and cocoa, two antioxidant superstars. Scientists have identified approximately 1,000 antioxidants in unprocessed coffee beans, and hundreds more develop during the roasting process. Numerous studies have cited coffee as a major — and in some cases, the primary — dietary source of antioxidants for its subjects.

How it works: Antioxidants fight inflammation, an underlying cause of many chronic conditions, including arthritis, atherosclerosis and many types of cancer. They also neutralize free radicals, which occur naturally as a part of everyday metabolic functions, but which can cause oxidative stress that leads to chronic disease. In other words, antioxidants help keep us healthy at the micro-level by protecting our cells from damage. Finally, chlorogenic acid, an important antioxidant found almost exclusively in coffee, is also thought to help prevent cardiovascular disease.

2. Caffeine provides a short-term memory boost.

When a group of volunteers received a dose of 100 milligrams (mg) of caffeine, about as much contained in a single cup of coffee, Austrian researchers found a surge in the volunteers’ brain activity, measured by functional magnetic resonance imagery (fMRI), as they performed a memory task. The researchers noted that the memory skills and reaction times of the caffeinated volunteers were also improved when compared to the control group who received a placebo and showed no increase in brain activity.

How it works: Caffeine appears to affect the particular areas of the brain responsible for memory and concentration, providing a boost to short-term memory, although it’s not clear how long the effect lasts or how it may vary from person to person.

3. Coffee may help protect against cognitive decline.

In addition to providing a temporary boost in brain activity and memory, regular coffee consumption may help prevent cognitive decline associated with Alzheimer’s disease and other types of dementia. In one promising Finnish study, researchers found that drinking three to five cups of coffee daily at midlife was associated with a 65 percent decreased risk of Alzheimer’s and dementia in later life. Interestingly, the study authors also measured the effect of tea drinking on cognitive decline, but found no association.

How it works: There are several theories about how coffee may help prevent or protect against cognitive decline. One working theory: caffeine prevents the buildup of beta-amyloid plaque that may contribute to the onset and progression of Alzheimer’s. Researchers also theorize that because coffee drinking may be associated with a decreased risk of type 2 diabetes, a risk factor for dementia, it also lowers the risk for developing dementia.

4. Coffee is healthy for your heart.

A landmark Dutch study, which analyzed data from more than 37,000 people over a period of 13 years, found that moderate coffee drinkers (who consumed between two to four cups daily) had a 20 percent lower risk of heart disease as compared to heavy or light coffee drinkers, and nondrinkers.

How it works: There is some evidence that coffee may support heart health by protecting against arterial damage caused by inflammation.

5. Coffee may help curb certain cancers.

Men who drink coffee may be at a lower risk of developing aggressive prostate cancer. In addition, new research from the Harvard School of Public Health suggests that drinking four or more cups of coffee daily decreased the risk of endometrial cancer in women by 25 percent as compared to women who drank less than one cup a day. Researchers have also found ties between regular coffee drinking and lower rates of liver, colon, breast, and rectal cancers.

How it works: Polyphenols, antioxidant phytochemicals found in coffee, have demonstrated anticarcinogenic properties in several studies and are thought to help reduce the inflammation that could be responsible for some tumors.

6. Coffee may lessen your risk of developing type 2 diabetes.

A growing body of research suggests an association between coffee drinking and a reduced risk of diabetes. A 2009 study found that the risk of developing diabetes dropped by 7 percent for each daily cup of coffee. Previous epidemiological studies reported that heavy coffee drinkers (those who regularly drink four or more cups daily) had a 50 percent lower risk of developing diabetes than light drinkers or nondrinkers.

How it works: Scientists believe that coffee may be beneficial in keeping diabetes at bay in several ways: (1) by helping the body use insulin and protecting insulin-producing cells, enabling effective regulation of blood sugar; (2) preventing tissue damage; and (3) and battling inflammation, a known risk factor for type 2 diabetes. One component of coffee known as caffeic acid has been found to be particularly significant in reducing the toxic accumulation of abnormal protein deposits (amyloid fibrils) found in people with type 2 diabetes. Decaffeinated coffee is thought to be as beneficial, or more so, than regular.

Note: There is some evidence that coffee decreases the sensitivity of muscle cells to the effects of insulin, which might impair the metabolism of sugar and raise blood sugar levels. The significance of this finding, however, is still unclear.

7. Your liver loves coffee.

It’s true: In addition to lowering the risk of liver cancer, coffee consumption has been linked to a lower incidence of cirrhosis, especially alcoholic cirrhosis. A study in the Archives of Internal Medicine demonstrated an inverse correlation between increased coffee consumption and a decreased risk of cirrhosis — a 20-percent reduction for each cup consumed (up to four cups).

How it works: Scientists found an inverse relationship between coffee drinking and blood levels of liver enzymes. Elevated levels of liver enzymes typically reflect inflammation and damage to the liver. The more coffee subjects drank, the lower their levels of enzymes.

8. Coffee can enhance exercise performance.

We’ve been conditioned to believe that caffeine is dehydrating, one of the primary reasons why fitness experts recommend nixing coffee pre- and post-workout. However, recent research suggests that moderate caffeine consumption — up to about 500 mg, or about five cups per day — doesn’t dehydrate exercisers enough to interfere with their workout. In addition, coffee helps battle fatigue, enabling you to exercise longer.

How it works: Caffeine is a performance and endurance enhancer; not only does it fight fatigue, but it also strengthens muscle contraction, reduces the exerciser’s perception of pain, and increases fatty acids in the blood, which supports endurance.

9. Coffee curbs depression.

Multiple studies have linked coffee drinking to lower rates of depression in both men and women. In several studies, the data suggested an inverse relationship between coffee consumption and depression: in other words, heavy coffee drinkers seemed to have the lowest risk (up to 20 percent) of depression.

How it works: Researchers aren’t yet sure how coffee seems to stave off depression, but it is known that caffeine activates neurotransmitters that control mood, including dopamine and serotonin.

10. Coffee guards against gout.

Independent studies on the coffee consumption patterns of men and women suggest that drinking coffee regularly reduces the risk of developing gout. Researchers in the Nurses’ Health Study analyzed the health habits of nearly 90,000 female nurses over a period of 26 years and found a positive correlation between long-term coffee consumption and a decreased risk for gout. The benefit was associated with both regular and decaf consumption: women who drank more than four cups of regular coffee daily had a 57 percent decreased risk of gout; gout risk decreased 22 percent in women who drank between one and three cups daily; and one cup of decaf per day was associated with a 23 percent reduced risk of gout when compared to the women who didn’t drink coffee at all. Similar findings have been documented for men: another large-scale study, published in the journal Arthritis & Rheumatism, found that men who drank four to five cups of coffee per day decreased their risk of gout by 40 percent, and that those who consumed six cups or more lowered gout risk by 60 percent.

How it works: According to the Nurses’ Health Study, coffee’s antioxidant properties may decrease the risk of gout by decreasing insulin, which in turn lowers uric acid levels (high concentrations of uric acid can cause gout).

The Cons of Coffee Drinking

The potential health benefits of drinking coffee are exciting news, but that doesn’t mean more is better. For some people, coffee can cause irritability, nervousness or anxiety in high doses, and it can also impact sleep quality and cause insomnia. In people with hypertension, coffee consumption does transiently raise their blood pressure — although for no more than several hours — but no correlation has been found between coffee drinking and long-term increases in blood pressure or the incidence of cardiovascular disease in patients with pre-existing hypertension.

Caffeine affects every person differently, so if you experience any negative side effects, consider cutting your coffee consumption accordingly. It takes about six hours for the effects of caffeine to wear off, so limit coffee drinking to early in the day, or switch to decaf, which only contains about 2 to 12 mg of caffeine per eight ounces. Always taper your coffee consumption gradually. Avoid quitting coffee cold turkey; doing so can lead to caffeine withdrawal symptoms that may include severe headache, muscle aches and fatigue which can last for days.

How to Keep It Healthy

So how much coffee is healthy, and how much is too much? Two to three eight-ounce cups per day is considered moderate; heavy coffee drinkers consume four cups or more daily. Remember, the amount of caffeine per coffee beverage varies depending upon the preparation and style of beverage. Eight ounces of brewed coffee may contain as little as 80 to as much as 200 mg of caffeine per cup (an “average” cup probably contains about 100 mg).

Your best bet: Skip the sugar-laden coffeehouse beverages and order a basic black coffee. Alternatively, switch to plain whole milk or unsweetened soy or nut milk.

Have you ever wanted a quick way to see if you may be at risk or more likley to develop TMJ pain and or facial pain? 

There is a simple way to check you own facial lines. All you need is a mirror!

Take a lookat your self in a relaxed position in a mirror. Where do your eyes sit? Do they sit level with one another? Or is one slight lower or higher than the other? Where do the corners of your eyes sit? Upward or downward.

Now, Look at your ears. Sepcially ear lobes. If you have detached lobes this is a bit easier to do but will still work for those who has lobes attaches to their head. Does one of your ears appear slightly lower of higher than the other? Take note of this.

Lasty look at your mouth. Where are the corners lying? is one lower than the other? are the equal? Is one lip curled up or flattened out?

If you noticed that one side you have an eye, ear and corner of the mouth that all are lower or higher OR if your eye and ears are lower but the corner of the mouth on the same side is higher, it would be an indicator that, if you are having pain, it would be from that side, or you may be likely to experience pain on that side in the future. Try it out!  

What is Musculoskeletal Ultrasound?

Ultrasound imaging uses sound waves to produce pictures of muscles, tendons, ligaments and joints throughout the body. It is used to help diagnose sprains, strains, tears, and other soft tissue conditions. Ultrasound is safe, noninvasive, and does not use ionizing radiation.

 

What is Ultrasound Imaging of the Musculoskeletal System?

Ultrasound is safe and painless, and produces pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or sonography, involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin. High-frequency sound waves are transmitted from the probe through the gel into the body. The transducer collects the sounds that bounce back and a computer then uses those sound waves to create an image. Ultrasound examinations do not use ionizing radiation (as used in x-rays), thus there is no radiation exposure to the patient. Because ultrasound images are captured in real-time, they can show structures under the stresses they endure with normal movement. It is this unique property that allows us to see compromises of ligaments and tendons quite easily.

 

 

What are some common uses of the procedure?

Ultrasound images are typically used to help diagnose:

• Tendon tears, or tendinitis of the rotator cuff in the shoulder, Achilles tendon in the ankle and other tendons throughout the body.

• Muscle tears, masses or fluid collections.

• Ligament sprains or tears.

• Inflammation or fluid (effusions) within the bursae and joints.

• Early changes of rheumatoid arthritis.

• Nerve entrapments such as carpal tunnel syndrome.

• Benign and malignant soft tissue tumors.

• Ganglion cysts.

• Hernias.

• Foreign bodies in the soft tissues (such as splinters or glass).

• Dislocations of the hip in infants.

• Fluid in a painful hip joint in children.

• Neck muscle abnormalities in infants with torticollis (neck twisting).

• Soft tissue masses (lumps/bumps) in children.

 

Mindful Observation

This exercise can be simple but powerful by helping you start to appreciate seemingly simple elements of your environment.

 

The exercise is designed to connect us with the beauty of the natural environment, something that is easily missed when we are rushing around in the car or hopping on and off trains on the way to work.

 

1 Choose a natural object from within your immediate environment and focus on watching it for a minute or two. This could be a flower or an insect, or even the clouds or the moon.

2 Don’t do anything except notice the thing you are looking at. Simply relax into watching for as long as your concentration allows.

3 Look at this object as if you are seeing it for the first time.

4 Visually explore every aspect of its formation, and allow yourself to be consumed by its presence. Notice the color, shapes, textures, movements, and sounds.

5 Allow yourself to connect with its energy and its purpose within the natural world.

Throughout the month of March give your mindful observation a try. When waiting for a friend or family member practice this observation. Don’t forget about your breathing and continue to practice the mindful breathing you practiced last month.

 

 

Great Tumblers a patient made us. We are so fortunate to work with such a great group of people!

Temporomandibular joint dysfunction

 

 

Introduction

The temporomandibular joints (TMJ) connect your lower jaw to your skull. There are two matching joints, one on each side of your head, just in front of your ears. They let your jaw move up and down and from side to side.

The abbreviation "TMJ" refers to the joint but is often used to refer to any problems with the joints. Such problems include:

Popping sounds in your jaw

Not being able to completely open your mouth

Jaw pain

Headaches

Earaches

Toothaches

Other types of facial pain

Most people with TMJ problems have pain that comes and goes, but some have chronic (long-term) pain.

 

Signs and Symptoms

TMJ problems often cause the following symptoms:

Pain, particularly in the chewing muscles or jaw joint or an ache around your ear

Limited movement or locking of the jaw

Pain in the face, neck, or shoulders, or near the ear

Clicking, popping, or grating sounds when opening your mouth

Trouble chewing

Headache

A sudden change in the way your upper and lower teeth fit together

Also, sometimes earaches, dizziness, and hearing problems

 

What Causes It?

Sometimes TMJ dysfunction can be caused by an injury, such as a heavy blow, to the jaw or temporomandibular joint. But in other cases there may not be a clear cause. Other possible causes include:

A bad bite, called malocclusion

Orthodontic treatment, such as braces and the use of headgear

Wearing away of the disk or cartilage in the joint

Stress or anxiety. People with TMJ problems often clench or grind their teeth at night, which can tire the jaw muscles and lead to pain.

 

Who is Most At Risk?

The risk for TMJ problems may be higher with these factors:

Gender: more women than men seek treatment

Age: people ages 30 to 50 have the most problems

Children and adolescents with arthritis

Grinding teeth, clenching jaw

Malocclusion (bad bite)

High stress levels

 

What to Expect at Your Provider's Office

 

Your health care provider will check muscles in the area of the TMJ, and will:

Look for asymmetry or inflammation in your face

Listen for joint clicking or scraping sounds

Test the range of motion in your jaw

Look at your teeth for evidence of jaw clenching or teeth grinding

If you are having any neurological symptoms, such as numbness, your provider will give you a neurological exam. Your provider may also order imaging tests, such as an x-ray, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) scan to look for degenerative disease or disk problems.

 

Treatment Options

 

Prevention

Reducing stress and keeping yourself from grinding your teeth or clenching your jaw may help prevent TMJ problems or lessen the symptoms.

 

Treatment Plan

In many cases, you can treat TMJ dysfunction at home. Your doctor may:

Ask you to change your eating habits: cut food into small pieces, avoid too much chewing, and stop chewing gum.

Give you exercises that stretch the muscles around your jaw.

Your doctor may also recommend:

If your bite is out of alignment, your dentist may suggest you wear a biteplate over your teeth to help bring your upper and lower jaw into alignment.

If you grind your teeth in your sleep, you may be asked to wear a night guard over your teeth.

If stress is causing you to clench your jaw, your doctor may suggest stress reduction techniques or cognitive behavioral therapy to help you manage anxiety and tension.

 

Drug Therapies

Your doctor may recommend the following medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs): to relieve pain. These drugs include ibuprofen (Advil, Motrin) and naproxen (Aleve).

Minor tranquilizers or muscle relaxants at bedtime to reduce spasms and pain.

Injections of a local anesthetic.

Corticosteroid injections, for severe cases.

Botox (botulinum toxin A) injections: can reduce muscle spasms

 

Surgical and Other Procedures

In some cases, removing fluid from the joint may help reduce pain, especially for people whose jaws lock. When other measures have failed, surgery may be needed to repair or take out the disk between the temporal bone and the jaw.

 

Complementary and Alternative Therapies

A comprehensive treatment plan for TMJ dysfunction may include a range of complementary and alternative therapies (CAM). Work with a health care provider who has experience treating TMJ and be sure to tell all of your doctors about any medications, herbs, and supplements you are taking. Treatments, including physical medicine, may help.

 

Nutrition and Supplements

The following nutritional tips may help prevent or reduce symptoms of TMJ dysfunction:

Eat soft foods high in flavonoids, such as cooked fruits and vegetables. Flavonoids are plant-based antioxidants that may help decrease joint pain.

Avoid saturated fats, fried foods, and caffeine. These foods may increase inflammation.

DO NOT chew gum.

 

Some supplements that may help:

Glucosamine: may reduce pain and help rebuild cartilage in the joint, which helps improve range of motion. Some studies show that glucosamine helps reduce pain in people with arthritis, which involves painful joints. One study found that glucosamine worked as well as ibuprofen (Advil, Motrin) for relieving pain and other TMJ symptoms. Glucosamine is often combined with chondroitin sulfate. Glucosamine may increase the risk of bleeding, especially if you also take blood thinners like warfarin (Coumadin), clopidogrel (Plavix), or aspirin. Some doctors think glucosamine might interfere with medications used to treat cancer. Ask your doctor before taking glucosamine and chondroitin.

Vitamin C: is also used by the body to make cartilage. It may improve range of motion in your joints, including your jaw, although there are no scientific studies investigating vitamin C for TMJ problems. Vitamin C supplements may interact with other medications, including chemotherapy drugs, estrogen, warfarin (Coumadin), and others.

Calcium and magnesium: may help the jaw muscle relax, although there are no scientific studies using them for TMJ problems. Magnesium and calcium interact with several medications, herbs, and supplements. They can also affect your heart and blood pressure, so be sure to tell your doctor before you take them.

 

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects, and can interact with other herbs, supplements, or medications. For this reasons, take herbs with care, under the supervision of a health care provider.

Cramp bark (Viburnum opulus) and lobelia (Lobelia inflata) may help reduce muscle spasms, although there are no scientific studies to support using them for TMJ problems. Rub 5 drops tincture of each herb into joint. Use on the skin only and do not apply to broken skin. DO NOT take these herbs by mouth (orally).

 

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of TMJ dysfunction based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Causticum: for burning pains

Hypericum perforatum: for sharp, shooting pains

Ignatia: for tension in the jaw

Kalmia: for face pain, especially with other joint pains or arthritis

Magnesia phosphorica: for muscle cramps

Rhus toxicodendron: for pains that feel better in the morning and in dry weather, and worse after movement or in wet weather

Ruta graveolens: for pains from overuse or injury

Physical Medicine

Contrast hydrotherapy, which is alternating hot- and cold-water applications, may:

Lower inflammation

Provide pain relief

Speed healing

Use hot packs and ice wrapped in a clean, soft cloth and apply to area. Alternate 3 minutes hot with 1 minute cold. Repeat 3 times for 1 set. Do 2 to 5 sets per day.

 

Acupuncture

Very good evidence suggests dry needling can treat TMJ dysfunction. Several well-designed studies found that needling therapies can relieve pain long term for TMJ problems.

 

Manipulation

There is some Evidence that Cervical manipulation as well as manipulation to the TMJ as well can help with TMJ dysfunction and restore range of motion

 

Craniosacral Therapy

This therapy is a very gentle form of body work. Practitioners use their hands to get rid of restrictions in the craniosacral system, the fluid and membranes surrounding the spine and brain. Although there are not many studies, some people say they feel better after craniosacral therapy. Find a practitioner who has training and experience with TMJ problems. You can interview several practitioners before deciding which one is right for you.

 

Massage

Some types of massage and chiropractic manipulation may help:

Reduce muscle spasms

Provide pain relief

Prevent symptoms from coming back

 

 

Biofeedback

Biofeedback teaches you how to reduce muscle tension through relaxation and visualization techniques. At first, sensors are placed on your jaw, and a machine shows the amount of tension in your muscles. Using relaxation and visualization techniques, you learn to reduce the amount of tension around your jaw while the machine provides instant feedback so you can see how you are doing. Once you have mastered the technique, you can do the relaxation and visualization techniques anywhere, without the machine.

Improving posture

Two types of movement therapy can sometimes help treat TMJ problems: the Alexander technique and the Feldenkrais method.

The Alexander technique teaches you how to properly align your head, neck, and spine, and move your body. It can help relieve tension in your head and jaw muscles, which may reduce the symptoms of TMJ dysfunction.

The Feldenkrais method teaches you to recognize bad posture habits and movements that cause your body to tense. It is a gentle therapy aimed at making you more aware of how your body moves, and helping you develop an inner awareness of your body. Feldenkrais is popular with dancers and musicians, who often do repetitive motions that can lead to overuse injuries.

 

Prognosis and Possible Complications

About 75% of people with TMJ problems who follow a treatment plan with more than one treatment find relief. In rare cases, long-term teeth clenching or grinding, injury, infection, or connective tissue disease may cause degenerative joint disease or arthritis. If you have severe grinding, a nighttime bite guard worn inside your mouth may help.

 

Following Up

You may need to see your health care provider regularly to make sure your treatment plan is working for you.

 

Here is a microspcopic view of a filament needle at various stages of "use". Many people "re-use" their needles to save money. Needles are Cheap (relatively speaking)...people aren't. Get a NEW NEEDLE. 

The global burden of chronic pain has reached epidemic proportions; furthermore, it is estimated that 136 million Americans are currently suffering with chronic pain.1 Despite this large number, the diagnosis and management of conditions such as Fibromyalgia Syndrome (FMS) remains poorly understood, widely criticized, and routinely mistreated by physical therapists and medical physicians alike. The use of dry needling is described in the literature as a novel and potentially effective intervention for treating FMS. Despite the evidence supporting neuronal plasticity and centrally-mediated changes in chronic pain, the traditional conservative interventions for FMS have exhausted light exercise, gentle mobilization, and/or electro-thermal modalities, with little more than poor patient outcomes. Perhaps it is time to change the way we treat chronic pain and utilize the best possible evidence to guide us in delivering the highest quality of care for conditions such as FMS.

A large body of evidence supports that exercise has little to no benefit in patients with FMS, and further, that chronic muscle pain appears to worsen with exercise.2,3 McVeigh et al found 85% of patients with FMS reported increased fatigue and pain following exercise.4 Therefore, perhaps the repetitive movement or “more exercise for everyone” model does not fit all categories or patient conditions.

The concept of neuroplasticity, or the structural and functional cortical changes related to chronic pain states, has been described by multiple sources.7,8 Neurophysiologic changes have been identified at multiple levels of the central nervous system including the spinal cord, brainstem, and cortex.9,10,11,12 Coghill et al found specific brain areas of increased activation in chronic pain states including the anterior cingulate cortex, primary somatosensory cortex and prefrontal cortex.9 Yu et al reported specific disruptions in functional connectivity at enkephalin producing pain control centers of the periaqueductal gray in chronic pain conditions.13 Moreover, the mechanism of hypersensitivity has been found to largely occur at the dorsal horn involving wide-dynamic-range neurons (WDR).14 WDR neurons are regulated by diffuse noxious inhibitory controls (DNIC) via the subnucleus reticularis dorsalis in the caudal medulla.14

Patients with FMS are thought to have defective DNIC systems; that is, the WDR neurons, which are responsible for innocuous and noxious stimuli, develop increased receptive fields, thus increasing the region of perceived pain.14 Disrupted brain circuitry has been described by Loggia et al who articulates that decreased activation of the periaqueductal gray area in the midbrain accounts for decreased descending pain modulation in patients with FMS.15 Two studies reported augmented pain processing in patients with FMS via disruptions of cortical areas responsible for the anticipation, attention, and emotional manifestation of pain.16, 17

The role of myofascial trigger points in FMS has been largely utilized in identifying the diagnosis. The biochemical properties of myofascial trigger points, including localized acidity and the increase in inflammatory mediators, may contribute to peripheral changes in patients with FMS.18 That is, sustained peripheral nociceptive input may sensitize dorsal horn neurons and supraspinal structures leading to hyperalgesia, allodynia, and referred pain.19

Peripheral and centrally-mediated changes associated with dry needling have been described in the literature; furthermore, dry needling to specific distal points in the upper or lower extremities has been found to activate sensorimotor cortical networks and deactivate limbic-paralimbic areas.20, 21 Deactivation of limbic areas following dry needling is thought to affect the sensory, cognitive, and affective dimensions of pain.20 Studies utilizing fMRI have demonstrated that dry needling at specific distal points activates the descending pain centers including the PAG.22 Moreover, dry needling with electric stimulation has been shown to activate enkephalinergic inhibitory interneurons, thereby modulating central pain.19 In addition, dry needling has also been found to reduce pain by peripheral mechanisms. One recent study found peripheral opioid receptors contribute to the anti-nociceptive effects of electrical dry needling via activation of cannabinoid CB2R receptors.23 Moreover, the stimulation of ATP release and the subsequent activation of adenosine A1 receptors via electrical dry needling is thought to sharply reduce inflammatory and neurogenic pain.24

The use of dry needling to target solely trigger points within muscles has been challenged.25 Several authors have articulated that the effectiveness of dry needling lies in the mechanical disruption of the integrity of dysfunctional endplate at the neuromuscular junction.19 That is, dry needling to the endplate region is thought to cause increased discharges, decrease acetylcholine stores, and thus reduce spontaneous electrical activity.19 However and importantly, not all patients with fibromyalgia have trigger points, and not all patients with trigger points develop FMS.26 Some investigators have distinguished the “tender points” associated with fibromyalgia from trigger points—i.e. tender points may lack taught bands.27 Given that skeletal muscle in patients with FMS has been shown to have altered oxygen utilization,28 perhaps dry needling can be useful to help improve muscle vascularity and oxygenation, and hence reduce sustained peripheral nociception.29,30

Nevertheless, the efficacy for the use of dry needling in patients with FMS is limited; that is, to date, there are few high methodologic quality studies on the topic. Two recent systematic reviews provide conflicting evidence for the use of acupuncture (i.e. the insertion of needles without injectate without the intent of moving qi along traditional Chinese meridians) in FMS—i.e. both concluding further high quality research is needed before definitive conclusions can be made in regards to efficacy.31,32 In a randomized controlled trial, Deluze et al found electroacupuncture provided significant improvements in pain perception and sleep quality (limbic system) in patients with FMS.33 Additionally, a recent systematic review and meta-analysis found that dry needling may be effective in the immediate and short-term in patients with upper quarter myofascial pain syndrome.34

REFERENCES

1 Tsang A , Von Korff M, Lee S, Alonso J, Karam J. Common Chronic Pain Conditions in Developed and Developing Countries: Gender and Age Differences and Comorbidity With Depression-Anxiety Disorders. Pain. 2009;10(5): 553.

2 Fricton J. Myofascial pain. Baillière’s Clinical Rheumatology. 1994;8(4): 857-880.

3 Mengshoel AM, Vollestad NK, Forre O: Pain and fatigue induced by exercise in fibromyalgia patients and sedentary healthy subjects. Clin Exp Rheumatol. 1995;13: 477-482.

4 Vierck, C, Staud R, Price D. The Effect of Maximal Exercise on Temporal Summation of Second Pain (Windup) in Patients With Fibromyalgia Syndrome. Pain. 2001;2(6): 334-344.

5 Hebb, D. O. Organization of behavior. New York: Wiley. Journal of Clinical Psychology. 1950;6(3): 307-307.

6 Melzack R, Wall P. Pain Mechanisms: A New Theory. Science. 1965; 150(3699): 971-978.

7 Melzack, Ronald, Terence J. Coderre, Joel Katz, and Anthony L. Vaccarino. Central Neuroplasticity and Pathological Pain. Annals of the New York Academy of Sciences. 2001; 157-74.

8 Wand, Benedict Martin, Luke Parkitny, Neil Edward O’Connell, Hannu Luomajoki, James Henry Mcauley, Michael Thacker, and G. Lorimer Moseley. Cortical Changes in Chronic Low Back Pain: Current State of the Art and Implications for Clinical Practice. Manual Therapy. 2011; 15-20.

9 Coghill R, McHaffie J, Yen Y. Neural correlates of interindividual differences in the subjective experience of pain. Proceedings of the National Academy of Sciences. 2003;100(14): 8538-8542.

10 Sandkühler J. Understanding LTP in pain pathways. Molecular Pain. 2007;3(1): 9.

11 Tinazzi M, Fiaschi A, Rosso T, et al. Neuroplastic changes related to pain occur at multiple levels of the human somatosensory system: A somatosensory-evoked potential study in patients with Cervical Radicular pain. The Journal of Neuroscience. 2000; 20(24): 9277–9283.

12 Benoist J, Gautron M, Guilbaud G. Experimental model of trigeminal pain in the rat by constriction of one infraorbital nerve: changes in neuronal activities in the somatosensory cortices corresponding to the infraorbital nerve. Experimental Brain Research. 1999;126(3): 383-398.

13 Yu R, Gollub R, Spaeth R, Napadow V, Wasan A, Kong J. Disrupted functional connectivity of the periaqueductal gray in chronic low back pain. NeuroImage: Clinical. 2014;6: 100-108.

14 Van Wijk G, Veldhuijzen D. Perspective on Diffuse Noxious Inhibitory Controls as a Model of Endogenous Pain Modulation in Clinical Pain Syndromes. The Journal of Pain. 2010;11(5): 408-419.

15 Loggia M, Berna C, Kim J et al. Disrupted Brain Circuitry for Pain-Related Reward/Punishment in Fibromyalgia. Arthritis & Rheumatology. 2014;66(1): 203-212.

16 Gracely R, Petzke F, Wolf J, Clauw D. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis & Rheumatism. 2002;46(5): 1333-1343.

17 Burgmer M, Pogatzkizahn E, Gaubitz M, et al. Altered brain activity during pain processing in fibromyalgia. NeuroImage. 2009;44(2): 502-508.

18 Shah JP, Danoff JV, Desai MJ et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. Jan 2008;89(1): 16-23.

19 Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Current pain and headache reports. Aug 2013;17(8): 348.

20 Chae Y, Chang DS, Lee SH, et al. Inserting needles into the body: a meta-analysis of brain activity associated with acupuncture needle stimulation. J Pain. Mar 2013;14(3): 215-222.

21 Biella G, Sotgiu ML, Pellegata G, Paulesu E, Castiglioni I, Fazio F. Acupuncture produces central activations in pain regions. Neuroimage. Jul 2001;14: 60-66.

22 Hui K, Liu J, Marina O et al. The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. NeuroImage. 2005;27(3): 479-496.

23 Su T, Zhang L, Peng M et al. Cannabinoid CB2 Receptors Contribute to Upregulation of β-endorphin in Inflamed Skin Tissues by Electroacupuncture. Molecular Pain. 2011;7(1): 98.

24 Goldman N, Chen M, Fujita T et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci. 2010 July; 13(7): 883–888.

25 Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 2014; 19(4): 252-265.

26 Castro-Sanchez A, Aguilar-Ferrandiz M, Mataran-Penarrocha G, Sanchez-Joya M, Arroyo-Morales M, Fernandez-de-las-Penas C. Short-term effects of a manual therapy protocol on pain, physical function, quality of sleep, depressive symptoms, and pressure sensitivity in women and men with fibromyalgia syndrome. Clin J Pain. 2014;30: 589-597.

27 Chae Y, Chang DS, Lee SH, et al. Inserting needles into the body: a meta-analysis of brain activity associated with acupuncture needle stimulation. J Pain. Mar 2013;14(3): 215-222.

28 Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain.1977;3: 3-23.

29 Cagnie B, Barbe T, De Ridder E, et al. The influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation. J Manipulative Physiol Ther. 2012;35(9): 685–91.

30 Sandberg M, Larsson B, Lindberg LG, et al. Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia. Eur J Pain. 2005;9(5): 497–510.

31 Mayhew E, Ernst E. Acupuncture for fibromyalgia—a systematic review of randomized clinical trials. Rheumatology. 2007;46 (5): 801-804.

32 Bai J, Guo Y, Wang H, et al. Efficacy of acupuncture on fibromyalgia syndrome: a Meta-analysis. J Tradit Chin Med. August 2014; 34(4): 381-391.

33 Deluze C, Bosia L, Zirbs A, Chantraine A, Vischer TL. Electroacupuncture in fibromyalgia: results of a con- trolled trial. BMJ. 1992;305: 1249-1252.

34 Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2013;43: 620-634.

I have just read a wonderful book, provided to me by one of my patients. It details many causes of dysautonomia. It has a patient side and a physician side which discusses the topics of each chapter in clear language from both a lay perspective and professional perspective. Wonderful resrouce to anyone who is struggling with chornic pain, "wonky" symptoms (my word...;) ) or anything that just seems to confound many practioners. Almost eveyr person who has had some type of chronic pain has some form of sensitization. I have experienced this myself with abdominal pain. There is hope though and we can begin to reverse aspects of this disorder. 

Take a look at the link below for more info. Of course we at Bluegrass Doctors of PT will always be resources to our patients on this topic. 

https://www.amazon.com/Dysautonomia-Project-Understanding-Autonomic-Physicians/dp/1938842243