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Fibromyalgia, Myofascial pain syndrome
Introduction
Injuries to muscles, bones, joints, ligaments, tendons, tendinous sheaths, bursae
Hard to see on radiographs, MRI
Massage therapists are well equipped to assess these
Introduction, cont.
Bones
Bone Structure
Calcium, phosphorus on collagen matrix: concentric circles with holes for blood vessels
Long bones are spiraled
Shaft is hollow
Resilience, efficiency, lightweight construction
Osteoblasts, osteoclasts under hormonal control
Wolff’s law
Introduction, cont.
Bone Function
Framework, protection, leverage, blood cell production, mineral storage
Muscles
Muscle function
Pull bony attachments together
Wastes: aerobic or anaerobic combustion
Effect of massage?
Muscle structure
Myofibers wrapped in layers of deep fascia:
Endomysium, fascicles, perimysium, epimysium, superficial fascia
Introduction, cont.
Joints
Synarthroses, amphiarthroses, diarthroses (the rest of this chapter)
Joint structure
Bones
Articular cartilage
Synovial membrane and fluid
Synovial capsule (Fig. 3.2)
Introduction, cont.
Joint function
Allow movement between bones, providing the fulcrum that bones can use
Other connective tissues
Tendons, tendinous sheaths, ligaments, bursae
Introduction, cont.
Connective tissue problems in general
Weak connective tissue: overuse, stress, cortisol, poor sleep: everything is interrelated
Fibromyalgia
Definition
Syndrome involving chronic pain in muscles, tendons, ligaments, and other soft tissues, along with other symptoms
Demographics
85–90% of diagnoses are in women
Fibromyalgia, cont.
Frequently seen with chronic fatigue syndrome, irritable bowel syndrome, migraine headaches, sleep disorders, and several other chronic conditions
Fibromyalgia, cont.
Etiology
Etiology is not well understood. Consistent factors include… Sleep disorder: little or no stage IV sleep Fatigue: may be related to sleep; could also be mitochondrial inefficiency
Fibromyalgia, cont.
Pain: may be related to neurotransmitters, esp. high substance
P and nerve growth factor levels
Other issues: oxidative stress, free radicals, inefficient hypothalamic-pituitary-adrenal (HPA) axis, aspartame use, others
Tender points: (Fig. 3.3) Develop in all four quadrants of the body
Fibromyalgia, cont.
Signs and Symptoms
Widespread pain in shifting locations; can range from a deep ache to burning and tingling
Tender points: nine predictable pairs of these are distributed among all quadrants of the body
Fibromyalgia, cont.
Stiffness after rest
Poor stamina
Sensitivity amplification and low pain tolerance
Fibromyalgia, cont.
Diagnosis
Rule out similar diseases (challenging!)
Diagnostic criteria:
Chronic pain for a minimum of 3 months
Fibromyalgia, cont.
11/18 tender points are active (elicit diffuse pain with digital pressure of about 4 kg)
Tender points must be distributed all over body
Persistent fatigue
Sleep not refreshing; awaken with morning stiffness
Fibromyalgia, cont.
Complications
Depression, difficulty with relationships and jobs, poor quality of life
Treatment
Education
Patient controls nutrition, sleep, exercise, stress
Fibromyalgia, cont.
Medications
Guaifenesin
Tricyclic antidepressants
Drugs for restless leg syndrome (?)
Fibromyalgia, cont.
Massage
Can be safe and appropriate within tolerance of client
Avoid ice
Avoid overtreatment
Don’t treat tender points like trigger points
Myofascial Pain Syndrome
Definition
The development of trigger points
Demographics
Affects men and women about equally
May be more prevalent with age
Precise incidence is not known
Myofascial Pain Syndrome, cont.
Etiology
Trigger points
Microscopic injury leading to pain spasm cycle
Myofascial Pain Syndrome, cont.
Energy crisis: sustained involuntary contraction of isolated group of sarcomeres
At neuromuscular junction (NMJ), central trigger point
At tenoperiosteal junction, attachment trigger point
May also involve folded, dehydrated collagen
Myofascial Pain Syndrome, cont.
Contraction causes a knot or taut band
Myofibers need more fuel
Ischemia prevents blood from flowing into area
This is adenosine triphosphate (ATP) energy crisis
Myofascial Pain Syndrome, cont.
Pain-sensitizing chemicals are released; muscle tightens; more acetylcholine is released at NMJ; neutralizing enzymes can’t get near; this causes small, involuntary, painful contraction
Myofascial Pain Syndrome, cont.
Neurons become demyelinated, may contribute to referred pain pattern (Fig. 3.4)
Satellite points form
Points may be active or latent
Figure 3.4
Myofascial Pain Syndrome, cont.
Signs and Symptoms
Taut bands or nodules (Fig. 3.5)
Predictable trigger point map
Referred pain pattern
Regional pain
Figure 3.5
Myofascial Pain Syndrome, cont.
Diagnosis
No consistent criteria; most people have some trigger points
Myofascial Pain Syndrome, cont.
Treatment
Eradicate trigger points:
Vapo-coolant spray
Injections of anesthetic
Dry needling
Botox to interfere with acetylcholine release
Acupuncture
Myofascial Pain Syndrome, cont.
Massage
Indicates massage
Sustained ischemic pressure is traditional
Short, pulsing pressure may be more effective
Chapter 3
Musculoskeletal System Conditions
Shin Splints
Spasms, cramps
Strains
Osteoporosis
Shin Splints
Definition
Umbrella term for variety of lower leg problems
Shin Splints, cont.
Etiology
Anatomy review
If feet don’t absorb, shock is translated into the lower leg Chronic overuse or misalignment Exercise without cooling down period Lower leg trauma All lead to edema inside compartments
Figure 3.7
Lower leg muscles attach whole length of the bones
Figure 3.8
Muscles are contained in four tight compartments
Shin Splints, cont.
Signs and Symptoms
Mild or severe pain
Worse with muscle activity
Shin Splints, cont.
Lower leg injuries
Tibialis anterior, tibialis posterior injury
Medial tibial stress syndrome
Periostitis
Stress fractures
Chronic compartment syndrome
Acute compartment syndrome
Shin Splints, cont.
Treatment
Reduce activity
Improve equipment (shoes, running surfaces, etc.) and training practices
Hydrotherapy
Steroid injection
For acute compartment syndrome: surgery to split fascial sheaths
Shin Splints, cont.
Massage
May indicate massage if no acute inflammation is present
Can stretch lower leg muscles better than other interventions: good preventative
Stress fractures, compartment syndrome need medical attention
Spasms, Cramps
Definition
Involuntary contraction of voluntary muscle
Cramps are strong, painful, acute (charleyhorse)
Spasms may be chronic
Spasms, Cramps, cont.
Etiology
Four main contributing factors:
Nutrition
Ischemia (Fig. 3.9)
Exercise-associated muscle cramping
Splinting
Massage
Indicated, with caution
Watch for contraindicating conditions
Respect splinting mechanism
Figure 3.9
Strains
Definition
Injury to muscle-tendon unit, with emphasis on muscle damage
Strains, cont.
Etiology
Can be specific trauma
Chronic cumulative overuse
Myofibers are torn, fibroblasts lay down scar tissue
Graded by severity:
First degree: mildly painful, no functional limit
Second degree: moderate injury
Third degree: rupture, possibly avulsion fracture
Strains, cont.
Signs and Symptoms
Mild to intense local pain
Pain exacerbated by resisted movement or passive stretching
Usually no palpable heat or swelling
Scar tissue may accumulate, leading to
Impaired contractility
Adhesions (Fig. 3.10)
Figure 3.10
Strains, cont.
Treatment
Get an accurate diagnosis
Control inflammation: RICE, PRICES
Rehabilitate damaged tissues
Prevent further injury
Massage
Can be extremely useful to shorten recovery time, improve quality of healing tissue
Osteoporosis
Definition
Porous bones: calcium is removed faster than replaced
Osteoporosis, cont.
Demographics
34 million have precursor, osteopenia (may be silent)
Women more at risk
Lower density to start with
Childbearing
Hormone fluctuations at menopause
Osteoporosis, cont.
Etiology:
Bone density increases until about age 30
Then bone density remains stable or decreases
Osteoporosis, cont.
Calcium consumption may have influence on bone density, but so do other factors:
Other vitamins, minerals
Exercise habits
Blood pH
Other diseases
Medications
Mood
Osteoporosis, cont.
Calcium absorption
Requires acidic environment in stomach
Requires vitamins D, K
(Too much vitamin A can impede calcium uptake)
Osteoporosis, cont.
Calcium loss
Sweat, urine
Meat-based proteins cause more calcium to be excreted with urine
Caffeine (coffee, soda)
Medications
Hyperthyroidism
Osteoporosis, cont. Heavy alcohol use Smoking Inflammatory bowel disease Hormonal imbalances Eating disorders
Calcium loss
Osteoporosis, cont.
Maintaining bone density
Osteoblasts and osteoclasts, under hormonal control
Most activity in trabecular bone (epiphyses and vertebral bodies)
Loss of key struts increases risk of collapse
Osteoporosis, cont.
Calcium is used outside of bones too
Blood clotting
Nerve transmission
Buffer for pH balance in blood
Osteoporosis, cont.
Osteoporosis develops when calcium absorption/loss/maintenance balance is lost
(Figs. 3.13, 3.14)
Vertebrae and femur especially vulnerable
Figure 3.13
Figure 3.14
Osteoporosis, cont.
Signs and Symptoms
Silent while early
Later: thinned, collapsed vertebrae, loss of height, widow’s hump, back pain
Osteoporosis, cont.
Complications
Spontaneous fractures
Hip fracture refers to head of femur
Slow healing: < 1/3 return to previous activity levels
Osteoporosis, cont.
Diagnosis
DEXA: dual X-ray absorptiometry
Maybe ultrasound, CT
Presence of fractures
Osteoporosis, cont.
Treatment
Hormone replacement therapy can slow progression
These carry other possible risks
Bisphosphates
SERMS (selective estrogen receptor modulators)
Exercise
Diet, calcium supplements
Osteoporosis, cont.
Prevention
Four main steps:
Get dietary calcium from absorbable sources
Exercise
Get vitamin D
Avoid substances and behaviors that pull calcium off bones
Osteoporosis, cont.
Massage
Depends on resiliency of client
Adjust for fragility, etc.
Can offer important pain relief