Patient Stories: Car Accident

Physical therapy, massage, and chiropractic didn't help...

I was cleaning out my inbox the other day and found this testimonial gem from 2012. Apologies to Ms Thomas; she wrote me this wonderful review and I set it aside until I got my blog set up, then forgot to post! Still every bit as relevant today though:

I was experiencing a lot of pain in my back, hips, and neck.

I had a car accident five months ago. I was fortunate to have no signs of any broken bones, but I was experiencing a lot of pain in my back, hips, and neck. After getting physical therapy, massages and chiropractic treatment, I had no relief. It was just getting worse. I hurt everywhere. I couldn’t sleep at night, I struggled to get out of my car, up from a chair after sitting and definitely had a hard time walking any short distance. My chiropractor actually suggested I get a massage. It did feel better…for a day. In addition to my new found pains, I also was suffering from plantar fasciitis pain in my feet. I have had several steroid injections over the years to address this pain. I was at the point where just getting out of bed and keeping my head up all day was extremely difficult. Living with constant pain while you are just doing your normal routine can get to be exhausting and depressing. I was starting to believe and accept this was a normal state for me; that I was just getting older!

The payoff for me is when I sleep through the night comfortably...

 I was desperate for help so I decided to search for a massage therapist on the internet. To my now pleasant surprise, I found the Pain Free Maryland website. I have had several treatments now and feel like a different person. I can actually get through the day without thinking about how bad it feels to sit, walk, or sleep. Today, I actually feel lighter! As days pass, I just feel relieved and grateful! The payoff for me is when I sleep through the night comfortably and get up in the morning and place my feet on the floor, there is no pain. The rest of the day will follow suit! I am so pleased with my improvement, I am taking my teenage daughter to deal with her headaches and chronic neck pains as a result of a fall.

If you’ve tried various treatments that are not giving you relief, I highly recommend that you give myofascial trigger point therapy a try. 

This is not your grandmother’s massage! You won’t get the candles, floral scents and background music with ambiance (but there is a very friendly cat!). It is very focused, stress-relieving pressure on trigger points and stretching. If you’ve tried various treatments that are not giving you relief, I highly recommend that you give myofascial trigger point therapy a try. Don’t get caught up on the long phrase. You can always use it later to impress your friends at a party!

J. Thomas Silver Spring, Maryland

Muscles That Mimic

Easily-treatable Myofascial Pain Can Scare the Pants Off You

Ow! I think I have sciatica!

It is important to note that myofascial pain patterns commonly mimic those of other conditions and illnesses. High on the list of muscles that mimic other problems is the gluteus minimus, in the hip. Sitting for a long time in a chair or car seat with inadequate thigh support, or taking a fall can create trigger points in this muscle. These refer pain into the buttocks, and down through the thigh and calf, as in illustration A. When this particular pain occurs, lay people and healthcare professionals alike often reasonably presume this pattern to be a symptom of sciatica.

OMG!  I'm having chest pain!

Trigger points in the pectoralis major will cause pain in the chest and down into the arm, as in illustration B, mimicking a heart attack. Of course, a patient should immediately have this checked out by a physician, but when the appropriate tests for heart problems come back negative, the doctor may next refer the patient for myofascial trigger point therapy, having ruled out a more serious diagnosis.

Oh no, pelvic pain!  That has to be bad, right?!

There are numerous cases in which appendixes have been removed and found to be disease free. In these cases, the culprit might have been trigger points in the lower rectus abdominis, which, as you can see from the pain pattern in illustration C, cause pain in the lower abdominal area, mimicking appendicitis. These trigger points can be activated when a person is tired, worried or premenstrual. Trigger points in the other lower abdominals can cause diarrhea and symptoms mimicking diverticulitis or gynecological disease.

Ugh, these migraines are ruining my life!

With the ever increasing pace of today’s hectic lifestyle more and more people are suffering from migraine headaches on a monthly, weekly, or daily basis. Trigger points in the posterior cervical muscles (the back of the neck) are nearly always involved in severe headaches such as migraines, tension headaches, and post-traumatic headaches. When trigger points in the upper trapezius are activated, they mimic migraines (illustration D) and cause severe head and neck pain. These muscles can contract strongly, or cramp, compressing and entrapping the greater occipital nerve, causing not only muscle pain, but nerve pain, as well.

These are just a few examples of the tricks muscles can play on us if we are not aware of this common but sneaky type of pain. There are many more of these patterns, but even once correctly recognized, there are also key concepts to be aware of in order to treat this kind of pain effectively.

This is an excerpt of an article I wrote for Pathways, and contains material used with the permission of my excellent colleague, Vicki MacGown.

How Hard Does a Myofascial Trigger Point Therapist Press?

Eliminating Myofascial Pain Should Not Be Painful

How hard does a myofascial trigger point therapist press? This is how John F. Kennedy's White House physician and Trigger Point Manual author Janet G. Travell describes it:

"...clinician applies gentle, gradually increased pressure on the TrP until the fingers encounter a definite increase in the tissue resistance. At that point the patient may feel a degree of discomfort but should not experience pain. This pressure is maintained (but not increased) until the clinician senses relief of tension under the palpating finger. The palpating finger increases pressure enough to take up the tissue slack and to encounter a new barrier... the clinician again maintains only light pressure until more of the muscle tension releases."

Eliminating Muscle Pain Should Actually Be Relaxing

I like to say to my patients: “I'm going to press slowly and you're going to tell me 'when'. It should hurt a little bit, but not a lot. I want that trigger point talking to you, but not screaming at you. You should be able to talk and breathe and stay relaxed.” Just hearing this before I even begin to apply pressure goes a long way to relieving anxiety about anticipated pain, which in turn enhances the patient's total ability to relax. With the patient relaxed and confident of not being hurt, he or she can breathe into the process and aid it, at the same time learning how to do that on his or her own.

Trigger Point Myotherapists started developing their technique in the late 1970's. Different styles have evolved over the years with experience and better understanding from new research.

What About Compression on Fibromyalgia?

In the early years of my practice I used what some now consider a heavy hand - or elbow! - because that is how I was trained. The assumption was, the bigger the muscle, the heavier pressure required. The instructions were: press to the point of pain, and warn the patient what we are going to do, so they don't get a shock. It was understood that this type of treatment what necessarily if temporarily painful in order to be effective.

Then, within my first few months of practice, I got a new patient with severe fibromyalgia and I had to re-learn everything I knew about pressure and touch. I customized a combination of feather-light touch, heat, and gentle stretch that worked well for her and what do you think I discovered? Gentle compression, or if needed on a bad day, no compression at all can still be effective... at least for that patient.

On one hand, light treatment and stretch seemed to be working very well for some, but I still couldn't get stubborn trigger points out of others without some hardcore persuasion. For those people it had to be deep, sustained pressure only; any other technique was either more aggravating or ineffective.

Customizing Myofascial Trigger Point Therapy to Your Body

What I quickly realized is that all patients are different. Bodies all feel different, and people have different perceptions of pressure and different experiences of pain. They are irritated or soothed by different sensory input. Some people's muscles feel as hard as a Dunlop steel-belted radial while others' feel like they are made out mattress grade memory foam, and still others' twice-proofed sourdough. (Guess who hurts more!) Learning to touch and treat each new patient is like learning a unique new language. I get a knowledge and feel for what works best for a person, depending on the condition of their muscles and connective tissue, what feels good to them, and what technique releases their trigger points with minimal reaction and maximum results. I now know that different techniques, amounts of pressure, and even types of rehabilitative stretch are appropriate in different situations, with different patients. The real art is determining the correct match each time.

Travell and Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. 1999 Williams and Wilkins

What is Myofascial Pain?

The Basic Definition…

The word myofascial means muscle tissue (myo) and the connective tissue in and around it (fascia). When stressed or injured, muscles form trigger points - like bunched-up knots (see illustration) - that cause pain and tightness.

Establishing the Presence of Trigger Points 

A skilled practitioner who has been trained to recognize the symptoms of myofascial pain and palpate muscles for myofascial trigger points can assess whether myofascial trigger points are present. There are no commonly available lab tests or imaging studies that can confirm the diagnosis at this time. Myofascial trigger points can be seen on special MRI scans and special ultrasound but these are currently only used in research.

Common Types of Myofascial Pain 

A diagnosis of Myofascial Pain Syndrome or Chronic Myofascial Pain means that myofascial trigger points are the primary source of your symptoms. Sometimes trigger points are present secondarily to other sources of pain, such as arthritis or bulging discs. These trigger points may be fully or partially causing the painful symptoms attributed to these conditions. As such, they are often called "the great mimickers".

Diagnoses associated with myofascial trigger points include:

• Back pain
• Headaches
• Neck pain
• Frozen shoulder/Rotator cuff pain
• Jaw pain (TMJD)
• Tennis elbow
• Carpal tunnel syndrome
• Hand and arm pain
• Repetitive Strain Injuries
• Pelvic pain
• Hip pain
• Sciatica
• Leg and knee pain
• Plantar fasciitis (foot) pain
• Tendinitis
• Bursitis
• Arthritis
• Disc pain (bulge/rupture/herniation) and radiculopathy
• Fibromyalgia

Dear Doctor Michele

The Myofascial Pain "Doctor" Is In

OK.  To be clear and up front: I am not a doctor!  But I have always wanted to write an advice column, and more than once my happy patients have told me they want to call me "Doctor" anyway.  (I nip that in the bud, but compliment taken!)  So for advice-column purposes I can be "Doctor" in the go-to answer-woman sense of the word.

Google any product or project with the word "doctor" after it and someone out there is calling themselves the Car Doctor, the Soup Doctor, the Knitting Doctor.  Trouble is, I'm in allied healthcare, so if I call myself the Muscle Pain Doctor, it's not obvious that I'm being tongue-in-cheek, and I get myself into trouble.  Better to be the Cookie Doctor!  And while I do make a mean pan of shortbread, this blog is to help people understand as much as possible about how their pain can be reduced or eliminated.

While things are getting off the ground here, I'll supply some fake "Dear Dr. Michele" questions and answers, based on real questions that people ask me all the time.  I am not a doctor, but I am an LMT with over 600 hours of training in Myofascial Trigger Point Therapy and over 20 years in practice, so ask away!