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Framing a debate: Myofascial Pain
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Framing a debate: Myofascial Pain - August 20, 2008 9:44:38 PM
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TexasOrtho
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There are obviously many ways of doing this. The most common format on an online forum, at least the one to which I am most accustomed, consists of an unmoderated and open discussion. This often results in spirited debates, but as we've seen has the tendancy to break down into less productive lines of discussion.
Here is what I propose: A series of debates regarding myofascial pain and treatment, with each debate focusing on specific aspects of theory and application. Whenever possible theoretical or clincal statements should be supported by some level of scientific evidence. Opinion and editorial should be encouraged, but some level of evidence should be the foundation of an argument.
I think a good start would be: Is the concept of myofascial pain a valid clinical entity? In other words what evidence (from basic science on up) is there to support or refute the concept of myofascial pain? I think if we focus on this issue first and foremost, it will make discussions of assessment, interventions, and outcomes stand on a more firm foundation. Any thoughts are of course welcome. This thread can be the beginning of the debate or just the start of how to frame a debate including a moderator and participants etc...
Any thoughts?
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 21, 2008 1:13:41 AM
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steve
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Rod,
I think your debate is a great idea but first I'd like a definition of myofascial pain that clearly delineates exactly what we are talking about. Ie. is myofascial pain referring to a syndrome of pain as defined by pain that persists and worsens as a theoretical result of muscles, fascia and trigger points or are you simply referring to the idea that pain can be the result of anything muscle or fascia? I also see this term used as a non specific junk diagnosis for patients with pain that does not have an identifiable cause and no apparent sinister pathology.
Steve
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RE: Framing a debate: Myofascial Pain - August 21, 2008 7:31:39 AM
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bobmfrptx
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Myofascial pain is, to me, a junk diagnosis as well. It is something MD's label people with when they can not find another label that works. Patients labeled in this fashion tend to become the diagnosis in my opinion based on clinical findings and do need the extra attention which I provide thru active listening and genuine compassion. The client has been thru countless doctors, PT's, medicine men etc, who have not listened, wrote them off as a head case or have just given up. Change the brain, change the pain. It starts with awareness and feeling first.
The benefit of the hands on techniques is exponential in these cases. Activating the homonculous, bringing awarenss to the neglected, "bad" body parts, actually feeling and connecting via fascia handles which are connected to the skin as well as everything else, starts the process. Being a good ole country boy and having "skinned" my share of deer gave me great visuals as to the effect of fascia pulling on structures way distant from the skin location under my hands. TREAT the WHOLE the PARTS will FOLLOW. Thanks Rod for the kind words. My philosophy and treatments are founded in several theories some accepted some not, but my committment to healthcare is paramount.
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RE: Framing a debate: Myofascial Pain - August 21, 2008 1:50:54 PM
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Sebastian Asselbergs
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Check the definitions of pain. Connecting the concept of pain with ANY particular tissue is - well, bogus. Pain is not tissue based. It is a construct of the brain - even called an "output". Even a broken leg has not been painful for the person running to save his child from a fire. The brain prioritised.
So, my take on pain and its causes is not in agreement with myofascial-, trigger point-, muscle- or any other tissue-pain.
It saddens me that we still talk about pain as if it comes from a structure other than the brain - I thought there was enough posted, researched, discussed etc etc to finally give that up?
_____________________________
Mundi vult decipi
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RE: Framing a debate: Myofascial Pain - August 21, 2008 3:21:17 PM
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Diane
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quote:
I think a good start would be: Is the concept of myofascial pain a valid clinical entity? No. See Sebastian's post for why.
quote:
In other words what evidence (from basic science on up) is there to support or refute the concept of myofascial pain?
None, as far as I know. Only habits of speaking and thinking that have misled for 400 years.
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RE: Framing a debate: Myofascial Pain - August 21, 2008 3:27:43 PM
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torques
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Hi all,
Here is my thoughts on the subject. MFPS (myofascial pain syndrome) is used as a blanket diagnosis together with fibromyalgia for patients who do not fit any pathological profile. The most commonly used definition is that of Simon and Travell as a muscle pain disorder with presence of taut band, local tenderness, pain referral , ROM restriction and autonomic phenomena. Simons and Travell have done several research studies and have established MFPS diagnostic criteria but its reliability and validity remains questionable.
I prefer to use the term soft tissue mechanical dysfunction(Cantu, Grodin) which can be objectively assessed based on the criteria of "somatic dysfunction": ART-asymmetry, ROM abnormality, tissue texture abnormality by observation and palpation. Clinical history could aid in ascertaining the cause of dysfunction. This can easily be differentiated with classic fibromyalgia (FM) and MFPS which typically don't have obvious injury or inflammation. I think treating syndromes other than SSMD with manual therapy is a loss cause since there is hardly any point of reference, hence I incorporate general exercise program as its intervention (low grade aerobic exercises, gen trunk flexibility program, postural exercises).
Tough EA, White AR, Richards S, Campbell J.Variability of criteria used to diagnose myofascial trigger point pain syndrome--evidence from a review of the literature.Clin J Pain. 2007; 23(3):278-86.
Cantu R, Grodin A. Myofascial Manipulation. Theory and Clinical application. Second Edition. Gaithersburg,MD: Aspen Publication 2001
_____________________________
Julius Quezon PT DPT MTC CPed
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RE: Framing a debate: Myofascial Pain - August 21, 2008 7:21:18 PM
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TexasOrtho
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quote:
ORIGINAL: Sebastian Asselbergs
Pain is not tissue based.
Bas I agree with your post with the exception of this key point. I know it wasn't intentional, but this portion of your statement is a misleading oversimplification of pain. To quote Butler and Moseley for the edification of those who haven't read their work "The amount of pain you experience does not necessarily relate to the amount of tissue damage". The wording here is important as there are some instances where tissue damage most certainly does correlate with the pain experience. Particularly when the tissue damage blends with other contextual cues the brain perceives as threatening. Saying "pain is not tissue based" is not only incomplete, but it builds a weak foundation for the following statement.
quote:
So, my take on pain and its causes is not in agreement with myofascial-, trigger point-, muscle- or any other tissue-pain.
Again, this may be the case in many, but not all clinical, situations. The task at hand is to determine whether dysfunctional fascia, or a trigger point, is capable of being a component of the nociceptive event. Based on histological investigations which show free nerve endings investing fascia, we have to state that this is indeed the case. Fascia is capable of producing a nociceptive event. Now, should this merit the designation of myofascial pain, or trigger point pain, or whatever is certainly up for debate.
Rhetorical question: If there is no connection between tissue damage and pain, what is the purpose of having sensation to begin with?
Lastly, I know I will be burned at the plinth for even implying this, but we might also want to acknowledge that the neuromatrix theory is still a theory and is subject to testing and falsifiability. We may have to brace ourselves for the possibility it too will be modified or even refuted to a certain degree. The pain neuromatrix is the best available theory right now, but I'm not sure I'm ready to say we've found the holy grail.
quote:
It saddens me that we still talk about pain as if it comes from a structure other than the brain - I thought there was enough posted, researched, discussed etc etc to finally give that up?
Don't be sad.
< Message edited by TexasOrtho -- August 21, 2008 8:04:45 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 21, 2008 7:33:32 PM
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ginger
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Bob, can you post a case study or two ?, Am keen to hear of your hands on interventions in particular. Tests, techniques, responses etc.
Cheers
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RE: Framing a debate: Myofascial Pain - August 23, 2008 9:34:26 PM
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Sebastian Asselbergs
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Rod, this is not productive. You now introduce quote:
a component of the nociceptive event. into the mix.
PAIN is a construct of the brain. Nociception can be triggered by tissue damage, yes. And it can CONTRIBUTE to pain experiences.
Simple really.
I have NEVER said that there is no connection between tissue damage and pain. There is NO pain in tissue - period.
_____________________________
Mundi vult decipi
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RE: Framing a debate: Myofascial Pain - August 24, 2008 8:18:29 AM
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TexasOrtho
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quote:
ORIGINAL: Sebastian Asselbergs
Rod, this is not productive. You now introduce quote:
a component of the nociceptive event. into the mix.
PAIN is a construct of the brain. Nociception can be triggered by tissue damage, yes. And it can CONTRIBUTE to pain experiences.
Simple really.
I have NEVER said that there is no connection between tissue damage and pain. There is NO pain in tissue - period.
If it were simple, why did you change what you said? Your reversal from 'pain is not tissue based' to 'there is no pain in tissue' is significant as they have entirely different meanings. Your first statement was incomplete, the second correct. Getting the facts right is productive Bas.
There is no pain in tissue but dysfunctional tissue can be a component of the acute pain experience. This includes bone, skin, ligament, and even fascia. Once we agree that fascia is capable of nociception (it is) we can move on to where we think MFR begins to break down. Once we can isolate where MFR does or does not break down, we can provide a rational basis for why it should be marginalized within our profession.
< Message edited by TexasOrtho -- August 24, 2008 8:23:36 AM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 24, 2008 8:42:17 AM
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Jon Newman
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According to the IASP, nociception is the neural processes of encoding and processing noxious stimuli. Given that definition, fascia is not capable of nociception. However, fascia does contain nociceptive neurons which are central or peripheral neurons that are capable of encoding noxious stimuli.
I think the distinction is important and using the shortcut (fascia proper is capable of nociception) leads to errors in interpreting observed events especially at the point when generalizations of those observations are being made.
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RE: Framing a debate: Myofascial Pain - August 24, 2008 9:33:37 AM
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Diane
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Rod said, quote:
Once we agree that fascia is capable of nociception (it is) we can move on
I cannot agree with this. Only nociceptors (which are neural tissue) are capable of nociception.
Oh, I see Jon has said the same thing.
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RE: Framing a debate: Myofascial Pain - August 24, 2008 9:44:47 AM
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TexasOrtho
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Well if Jon said it...
Jon, I don't think the fact nociception is a neural event is under question here. That being said I do need to modify my comment that "fascia is capable of nociception" as this was also innacurate.
The question reformulated: Is fascia capable of triggering a nociceptive event? By extension is it capable of being part of the patient's pain experience? I believe yes on both counts.
I think once we have these foundational terms operationally defined like this we can proceed to the next step. I would also like to hear what Bob and others think on this issue as well.
< Message edited by TexasOrtho -- August 24, 2008 10:06:31 AM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 24, 2008 11:24:00 AM
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PTupdate.com
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I know where you are at Rod. We all agree that the nervous system is what receives, transmits and perceives pain. We also know the various physical factors that can cause this impulse, from the fat guy that just stepped on my big toe, to the chemical mediators that are saturating one of my DRG's, to the subchondral bone exposed by OA that undergoes pressure when standing and walking.
So, can fascia,especially after an injury, thicken and perhaps either entrap nerve endings or compress them? How about trigger points and "knots" from a referral event......is there hypoxia that irritates the nerve endings? Does the compression of that local myospasm compress and irritate the nerve ending? Can a punch to my thigh cause a hematoma that heals with scar and entrapment of the fascia, therefore creating a perpetuating neural event? I dont' see why not.
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Framing a debate: Myofascial Pain - August 24, 2008 12:41:29 PM
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Diane
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Does everyone agree that we should include skin as the most sensitive layer? i.e. the layer with the most variety, kind, and number of active (as opposed to "silent") nociceptors?
Does everyone agree that the next tissue with the next greatest number of active nociceptors/nociceptive function is the neural protective layer itself?
< Message edited by Diane -- August 24, 2008 12:46:51 PM >
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RE: Framing a debate: Myofascial Pain - August 24, 2008 12:58:49 PM
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Sebastian Asselbergs
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Ok Rod:
quote:
If it were simple, why did you change what you said? Your reversal from 'pain is not tissue based' to 'there is no pain in tissue' is significant as they have entirely different meanings. Your first statement was incomplete, the second correct. Getting the facts right is productive Bas.
Never changed what I said: I still maintain that pain is NOT tissue based. Meaning (watch out - explanation coming) of "based" : having a basis in, derived from. Tissue has, AT MOST, a contributing role in development of pain.
Can a fascial problem contribute to pain? Of course it can. How can we ever find out? What test do we have to check fascia? How do we relate the fascia to the pain?
Well, that is not so easy to establish. Unless Bob has a good explanation and set of tests (see Ginger's post), I guess we will have to "believe" that the changes that occur with myofascial treatment, actually come from the changes in that tissue.
Duffy, I do not think that entrapment of the fascia by itself can be assumed to cause pain - there must be some neural irritation/stress there as well. Just since we are trying to keep clear (I have so many scars, and none of them hurt...).
_____________________________
Mundi vult decipi
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RE: Framing a debate: Myofascial Pain - August 24, 2008 2:19:05 PM
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TexasOrtho
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quote:
still maintain that pain is NOT tissue based. Meaning (watch out - explanation coming) of "based" : having a basis in, derived from. Tissue has, AT MOST, a contributing role in development of pain.
You used an example earlier that someone with a broken leg wouldn't feel pain saving another individual. You forgot to describe what life would have been like a few hours later in the ER/ED. Don't you suppose that the tissue injury would have eventually contributed to some form of discomfort? Please say yes.
Instead of defending yourself, why not just admit your comment was incomplete? Pain is not neccessarily tissue based is more complete and accurate than pain is not tissue based. Incidentally, BOTH statements are inaccurate as nerve is tissue based on the last histology course I've taken. Maybe we should just start over...hi I'm Rod and I'd like to talk about fascia.
quote:
ORIGINAL: Diane
Does everyone agree that we should include skin as the most sensitive layer? i.e. the layer with the most variety, kind, and number of active (as opposed to "silent") nociceptors?
Does everyone agree that the next tissue with the next greatest number of active nociceptors/nociceptive function is the neural protective layer itself?
Hard for me to disagree with this statement, however how much the brain accurately portrays the information coming from the skin is another question entirely...and a good topic for another thread.
Focusing on the question at hand regarding of fascia contributing to the pain experience. I think even the most rigorous opponents of MFR would have to conceed that this is not where MFR breaks down. Fascia is capable of triggering (pardon the word) nociception and thus contrubuting to the patient's pain experience.
So to ask this question: How do we know fascia is dysfunctional and is contributing to the pain experience?
< Message edited by TexasOrtho -- August 24, 2008 2:47:36 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 24, 2008 3:27:01 PM
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Jon Newman
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Bas, I was hoping you would chime in on what you meant by "based" (essentially "necessary") because I agree that
quote:
there are some instances where tissue damage most certainly does correlate with the pain experience.--Rod
is not a refutation of the contention that "pain is not tissue based" even though we both agree with Rod's assertion. However, I will attempt to dissuade you from your position at the end of this post. But first I'd like to try to back up and sketch nociception in a way I hope everyone can agree upon. I won't hold my breath however.
The cells making up a tissue (fasica or otherwise) may produce noxious chemicals or may spill noxious chemicals when lysed resulting in a reaction in a chemosensitive nociceptor. The cells making up a tissue (fascia or otherwise) can transmit forces and some can produce forces. These forces may have a resultant vector resulting in a reaction in a mechanosensitive nociceptor. A chemical environment may be produced (e.g. via injection) that results in a reaction in a chemosensitive nociceptor.
For reference (credit again to the IASP) a nociceptor is a sensory receptor that is capable of transducing and encoding noxious stimuli.
We have now made it to the level of tranducing and encdoing noxious (or potentially noxious) stimuli but not further. That is, we're not at pain yet and may or may not get there. If we do get there from this point then the IASP defines this as "nociceptive pain" versus "pain" in general.
Now, my attempt to dissuade Bas from his position...Pain, on my understanding, requires the presence of nervous tissue and as such is tissue based. No nervous tissue, no pain. Now if someone comes along and demonstrates that some sort of silicon AI can experience pain then I'm the one that will be wrong. I'm not sure how we'll ever know.
< Message edited by Jon Newman -- August 24, 2008 5:50:57 PM >
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RE: Framing a debate: Myofascial Pain - August 24, 2008 4:55:36 PM
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TexasOrtho
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So I'm taking a course this semester called "Neuroscience in Orthopedics" and just opened up my shiny new copy of Fundamental Neurosicence for Basic and Clinical Applications (Haines 3rd ed). The vernacular used by that of the IASP to describe pain doesn't appear to be consistent with what is being taught in medical education. For example, the authors describe nociceptors (A-delta and C polymodal) as "pain receptors". They go on to descrive "pain receptors in muscles, joints, and viscera". Given this incongruence, what are we made to consider as the best way to discuss issues like this without getting our wires crossed?
Do pain fellows and other pain specialists make these same distinctions with their patients or students? If so, I guess it must just take time for these things to filter out to the rank-and-file. However, if pain is still being taught as a sensory modality, we may have persistent difficulty getting others to see things the way the IASP does. Jon, I'm not familiar with IASP initiatives, are they out there talking about this?
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Framing a debate: Myofascial Pain - August 24, 2008 5:47:47 PM
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Jon Newman
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See here and here
< Message edited by Jon Newman -- August 24, 2008 5:55:38 PM >
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