Specialty Care National Program - INTRODUCTION...References • Borg-Stein J, Iaccarion MA. Myofascial Pain Syndrome Treatments. Phys Med Rehabil Clin N Am 25 (2014) 357–374. •

Myofascial Techniques for

Back and Neck Pain

Presented by:

Edward S. Lee MD

National Program Faculty:

Edward S. Lee MD

Director, Interdisciplinary Pain Rehabilitation Program

VA Pittsburgh Healthcare System

PART 4

Specialty Care National Program Mini-Residency – Pain Management

February 10-12, 2015

Dry Needling

• Described by Travell as equally effective as

injection.

• Part of acupuncture traditions.

• Use acupuncture needles to minimize tissue

trauma.

Physiologic Effects of Dry Needling

Styles of Dry Needling

• Superficial – targeting

fascia surrounding muscle.

• Deep – Travell, Simons

• Intramuscular Stimulation –

Gunn

Drug Therapy

• Mild analgesics

– Nonsteroidal Anti-inflammatory Drugs

– Acetaminophen

• pain and sleep

– tricyclic antidepressants (nortriptyline low dose)

• Muscle relaxants

– Cyclobenzaprine

• Anticonvulsants - gabapentin

• depression and pain

– SSRI

– SNRI

• Topical lidocaine

• Avoid opioids – no studies to support use, and may cause hyperalgesia. However, tramadol, a weak opioid agonist, may be more effective due to effects on serotonin and NE uptake at dorsal horn.

Take Home • A biopsychosocial interdisciplinary team approach is most

effective.

• There are a wide variety of approaches to treatment of trigger

points and myofascial restriction.

• Physical rehabilitation is the mainstay of management for

both Fibromyalgia and Myofascial Pain Syndrome.

• Teach self-management and measure outcome using pain

rating and a function tool.

• Self-management insures active patient participation in

managing pain and achieving reasonable functional goals.

• Psychosocial rehabilitation, including cognitive behavioral

therapy for management of depression, stress, anger, fear,

avoidance, chemical dependency and non-restorative sleep,

is essential.

Acknowledgements

• Dr. Sandra Smeeding, for her pioneering work in developing an

integrative health care program at the Salt Lake City VA.

• Dr. David MacPherson, Dr. Timothy Burke, Dr. Michael Mangione,

Dr. Mark Wilson, Dr. Rajiv Jain, and Dr. Ali Sonel, for their support in

bringing integrative medicine to the Pittsburgh VA.

• Dr. Joseph Helms, for his vision for medical acupuncture in the US,

and his ongoing mentoring.

• Dr. Ilene Robeck, for her ongoing efforts to promote safe and

effective pain management at the Richmond VA and in VHA

nationally, and for the use of some of her materials.

• Dr. Mitchell Elkis, for his mentoring and for the use of some of his

materials.

• Dr. Cynthia Kirsch, Nick Vlasic DPT, Sue Delanko KT, and all of the

other IPRP team members, for their vision and hard work in

developing the Pittsburgh IPRP.

• Jean Yavorski RN, for her tremendous efforts in ushering us through

the CARF accreditation process.

References

• Borg-Stein J, Iaccarion MA. Myofascial Pain Syndrome Treatments.

Phys Med Rehabil Clin N Am 25 (2014) 357–374.

• Bron C, Dommerholt JD. Etiology of Myofascial Trigger Points. Curr

Pain Headache Rep (2012) 16:439–444

• Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M.

Physiologic effects of dry needling. Curr Pain headache Rep

(2013)17:348.

• Celik D, Mutlu EK. Clinical Implication of Latent Myofascial Trigger

Point. Curr Pain Headache Rep (2013) 17:353

• Desai MJ, Bean MC, Heckman TW, Jayaseelan D, Moats N, Nava A.

Treatment of myofascial pain. Pain Manage. (2013) 3(1), 67–79

• Gerwin RD. Diagnosing fibromyaltia and myofascial pain syndrome:

a guide. Journal of Family Practice (2013); 62(12)S19-25.

• Gerwin RD. A review of myofascial pain and fibromyalgia – factors

that promote their persistence. Acupuncture in Medicine (2005)

23(3):121-134.

References • Helms JM. An Overview of Medical Acupuncture. Alternative

Therapies. 1998;4(3):35-45.

• Kaptchuk TJ. Acupuncture: Theory, Efficacy, and Practice. Ann

Intern Med. 2002;136:374-383.

• De las Peñas CF, Campo MS, Carnero JF, Page CM. Manual

therapies in myofascial trigger point treatment: a systematic review.

Journal of Bodywork and Movement Therapies (2005) 9:27-34.

• Langevin HM et al., “Mechanical signaling through connective tissue:

A mechanism for the therapeutic effect of acupuncture,” FASEB J

2001 15:2275-82.

• Lauder TD. Musculoskeletal disorders that frequently mimic

radiculopathy. Phys Med Rehabil Clin N Am. 13 (2002) 469–485.

• Parker J; Heinking KP; Kappler RE. Efficacy of osteopathic

manipulative treatment for low back pain in euhydrated and

hypohydrated conditions: a randomized crossover trial. JAOA

112(5):276-84, 2012 May.

References

• Ramsook RR, Malanga GA. Myofascial Low Back Pain. Curr Pain

Headache Rep (2012) 16:423–432

• Seaman DRS. The diet-induced proinflammatory state: a cause of

chronic pain and other degenerative diseases. J MANIPULATIVE

PHYSIOL THER, 2002. 25 (3): 168-79.

• Smeeding S, Osguthorpe SG. The development of an integrative

healthcare model in the Salt Lake City Veterans Affairs Healthcare

System. Altern Ther Health Med. 2005.11(6); 46-51.

• Stecco A, Gesi M, Stecco C, Stern R. Fascial Components of the

Myofascial Pain Syndrome. Curr Pain Headache Rep (2013) 17:352.

• Teets RY, Dahmer S, Scott E. Integrative Medicine Approach to

Chronic Pain. Primary Care: Clinics in Office Practice. 2010. 37 (2):

407-421.

• Thomason, JM. Exercise in Muscle Pain Disorders. PM R (2012)

4:889-893.

References

• Vulfsons S, Ratmansky M, Kalichman. Trigger Point Needling:

Techniques and Outcome. Curr Pain Headache Rep (2012)

16:407–412

• Wang SM, Kain ZN, White P. Acupuncture Analgesia: I. The

Scientific Basis. Anesth Analg 2008;106:602–10.

References

• http://www.chronicpainperspectives.com/articles/feature-article/article/diagnosing-fibromyalgia-and-myofascial-pain-syndrome-a-guide/674266a2da3a75abf9b7c5002f54037c.html

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900090/

• http://www.jabfm.org/content/23/5/640.full

• https://www.handsonseminars.com/APTADryNeedlingResourcePaper.pdf

• http://cdn.intechopen.com/pdfs-wm/46881.pdf

• http://emedicine.medscape.com/article/313007-overview#showall

• http://emedicine.medscape.com/article/89095-overview#showall

References

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC290009

0/

• http://www.chronicpainperspectives.com/articles/feat

ure-article/article/diagnosing-fibromyalgia-and-

myofascial-pain-syndrome-a-

guide/674266a2da3a75abf9b7c5002f54037c.html

• http://www.istop.org/papers/imspaper.pdf

Are Active Self-Care Complementary and

Integrative Therapies Effective for

Management of Chronic Pain?

A Rapid Evidence Assessment of the

Literature and Recommendations for the Field

• Pain Medicine April 2014, Volume 15,

Supplement 1

• http://onlinelibrary.wiley.com/doi/10.1111/pme.20

14.15.issue-s1/issuetoc

Building the Evidence Base for Complementary and Integrative

Medicine Use among Veterans and Military Personnel

• Medical Care December 2014, Volume 52, Issue

12, Supplement 5

• http://journals.lww.com/lww-

medicalcare/toc/2014/12001

2011 Complementary and Alternative Medicine Survey

• http://shfwire.com/files/pdfs/2011CAM_FinalR

eport.pdf

Contact

[email protected]