Pain Management and Treatment of Arthritis, Bursitis and Tendonitis, Injuries, Migraine Stress and Tension Headaches, Chronic Back and
Neck Pain, Myofascial Pain and Trigger points; Fibromyalgia.

ALGORHYTM FOR MANAGEMENT OF NEUROMUSCULOSKELETAL PAIN.

GOALS:
SHORT TERM GOALS: to alleviate pain before patient leaves the office. This is achieved by treating the immediate causes of pain, which most frequently consist of Tender Spots (TSs), Trigger Points (TrPs), Muscle Spasm (MSp) or Inflammation.

LONG TERM GOALS: to remove perpetuating and etiological factors responsible for the immediate cause(s) of pain, in order to prevent recurrence of the condition.

PHASE I.
Identify the immediate cause of pain: Trigger Points, Tender Spots (TrPs/TSs), Muscle Spasm (MSp), Inflammation.

Quantify the tenderness (degree of sensitization) by Algometer.


Pain vs. Physical findings:
General Principle: Pain is consistently associated with abnormal physical findings, which are quantitative, objective, and highly specific. They include the following:

PHASE II.
Diagnose the Spinal Segmental Sensitization (SSS) and specify the segment corresponding to the trigger point/tender spot.

Spinal Segmental Sensitization (SSS) is the state of the spinal cord, which occurs as a reaction to a peripheral irritative focus that is formed by sensitized nerve fibers. SSS represents a state of hyperactivity, facilitation, which spreads from the sensory component of the spinal segment, to the anterior horn cells, that control the myotome, and also to the sympathetic centers located in the involved spinal level.

Diagnosis of SSS: Can be performed, clinically, by hyperalgesia and pressure pain sensitivity that extends over the sensory, motor, and skeletal areas supplied by the involved spinal segment.

1. SENSORY: Diagnose the hyperalgesic DERMATOMES by:
a. Scratching along the sensory diagnostic tracks, which replaces pin-prick
b. Electric skin conductance, which objectively documents nerve fiber dysfunction
c. Pinch & roll (P&R): tests sensitization of subcutaneous tissue
Can be quantified by Pressure Algometer

SENSORY DIAGNOSTIC TRACKS for efficient and precise evaluation of dermatomal dysfunction as developed by A. A. Fischer, superimposed over the correct dermatome chart are shown on Figure 1. If on sensory tests findings over the proximal and distal limb (i.e. below and above elbow or knee) do not correspond, than it indicates a peripheral nerve dysfunction.

ADVANTAGES OF THE IMPROVED EXAMINATION TECHNIQUES:
1. More sensitive than conventional methods.
2. Diagnosis of dysfunctional territory is made with millimeter precision.
3. Quantitative and objective results.
4. Much faster than conventional methods.

2. MOTOR : Diagnose the affected MYOTOME:
a. Point tenderness (TrP/TSs) by palpation and algometry.
b. Taut bands by palpation and Tissue Compliance Meter.
c. Muscle spasm (tender hypertonicity affecting the entire muscle) diagnosed by palpation. and Tissue Compliance Meter.

3. SCLEROTOME: Sensitization ( tenderness and edema) within the affected segment:
a. Enthesopathy, tenderness and edema at attachments of taut bands to bones, bicipital tendonitis C5
b. Bursitis, tendonitis, epicondylitis (lateral C6; medial C8)
c. Pericapsulitis, shoulder

4. SYMPATHETIC hyperactivity:
a. Microedema
b. Increased electric skin resistance
c. “Orange peal skin”

5. VISCERAL DYSFUNCTION WITHIN THE SSS.
Visceral pain, diarrhea, nausea, vomiting, heart burn, spasm frequency, burping, etc.

PHASE III.
TREATMENT: Concentrate on the sensitized spinal segment corresponding to the immediate cause of pain (TrPs/TSs, MSp, neurogenic inflammation), the associated supraspinous ligament sprain and PENTAD .

1. INJECTIONS: for immediate and long-term relieve of pain:
a. PARASPINOUS BLOCK to desensitize the SSS.
b. PRE-INJECTION BLOCK to anesthetize the painful sensitive area to be infiltrated. Figure 4.
c. NEEDLING & INFILTRATION OF THE TAUT BAND (TB), to break up the entire underlying pathology of the TRPs/TSs..
d. SPECIFIC INJECTION TECHNIQUES:

ADVANTAGES OF INJECTIONS: Only injection can achieve:
a. Immediate and complete relief of pain.
b. Long-term relieve of pain by eradication the fibrotic tissue causing symptoms (N&I).
c. Desensitization of the sensitized spinal segment(s) by PSB.

2. PHYSICAL THERAPY : POST INJECTION and INDEPENDENT 3x/week.
Goals are: 1. Heal the injection sites (electric stimulation).
2. Concentrate treatment on desensitization of the sensitized segment.
3. Restore function, ROM, Muscle power.
4. Prevent recurrence.
a) Modalities -- heat or cold; electric stimulation (sinusoid surging and tetanizing currents), Ultrasound for TRP treatment.
b) Exercises: Relaxation exercises and stretching:
A. General (eye movement + expiration + pulling in of belly and holding for 2 seconds)
B. Specific for the involved myotome,
c) Specific postural correction: Loss of cervical and/or lumbar sacral lordosis, extension and flexion deficiencies.

PHASE IV.
DIAGNOSIS & REMOVAL OF PERPETUATING AND ETIOLOGICAL FACTORS:
PHYSICAL EXAMINATION reveals:
1. Mechanical overload of body parts, overuse, and cumulative trauma disorders.
2. Deficiency of muscle function (loss of flexibility, weakness). (Kraus)
3. Postural deficiencies such as loss of cervical or lumbar lordosis. (Robin McKenzie)
4. The Pentad of discopathy radiculopathy paraspinal spasm and supraspinous ligament sprain.
5. Spinal Segmental Sensitization, that consists of segmental hyperalgesia, and TrPs/TSs and MSp in the myotome, sclerotome.

LABORATORY RESULTS:
1. Endocrine disorders, particularly, low thyroid or estrogen supply to the muscles (normal blood levels are sometimes insufficient, measure baseline temperature+ muscle vs. bone pressure sensitivity).
2. Metabolic or electrolyte disorders.
3. Vitamin deficiencies.