CHAPTER 4
DIAGNOSIS AND TREATMENT
It is assumed that the reader of this book has some experience in working with myofascial pain. However, a few basic ideas, perhaps known in some disciplines but not in others, may serve as common ground in delineating a broad protocol for the diagnosis and treatment of myofascial disorders.
Spend some time looking at the patient. Observe how he or she walks, stands, sits, breathes, holds his hands, crosses his legs, reads intake forms, rubs his neck, carries a purse, backpack, or briefcase. These and myriad other behaviors provide clues regarding the nature of his condition. While some patients will have difficulty identifying the sites or patterns of their pain, the observant clinician can learn a great deal by paying close attention to this person who has come for help. It is rare that muscular constrictions and trigger points exist in an isolated, single muscle. Careful attention can reveal a great deal about the unique and often complex pattern presented by each patient. Watching how the patient rises from a chair, gets on or off a treatment table, removes a coat, or wears out his shoes can provide valuable information leading to the effective treatment of his complaint. As in many medical therapies the clinician must be part detective, developing an ability to pick up on these clues, since they can be as important as any diagnostic testing procedure.
We had the privilege of watching Dr. Janet Travell treat a number of patients. She began formulating her treatment the moment she saw the patient enter the room. She took note of the person’s shape, size, asymmetries, gait, posture, and the many ways he was holding himself, particularly when in pain. When the patient pointed out his problem, Dr. Travell was already aware of the muscular patterns involved—the history expanded the data she had already collected through observation. Before Dr. Travell touched the patient she knew a great deal about him; in fact, after fifty years of clinical experience she was so integrated in her awareness that she often saw the problem in seconds.
Dr. Travell trained herself as a better clinician with each patient she treated, which left us with another tenet for good practice: Do not assume that you know anything. Be it through palpation or questioning, in every treatment with every patient always seek more information about the problem (and the person) at hand.
Evolve palpation skills. Through touch the patient discovers much about the nature of the practitioner. That first touch tells the patient whether you are gentle or rough, respectful or invasive, careful or careless, and most importantly, if you know what you are doing. It is a good idea to first palpate the area where the patient is complaining of pain, since it demonstrates, in a matter of seconds, that you understand that he or she has pain and that the pain is there, where you are palpating. So often patients will exclaim, “That’s it,” and with those two words they have begun to accept and trust you as a practitioner. As the practitioner explores related areas the patient will often remember pains or injuries that were not mentioned in his medical history. It is as if the palpation examination opens new doors in the patient’s understanding of his own problem and encourages him to come to some insight regarding the direction of treatment.
Palpation is an art and a skill. It requires work, practice, and the constant awareness that you are touching a person, not just a muscle. As most myofascial problems involve sequences of numerous associated muscles, effective examination will generally involve extensive palpation around the area of most acute presentation. In acupuncture, a common assessment principle has the practitioner examine left and right, up and down, and front and back relative to the presenting region. This simply means that if a patient is complaining of pain in the left lumbar region, examination should include the right lumbar region, the upper back and shoulders, the buttocks and legs, and the abdomen. Such wide examination not only renders significant information but also respects the patient as a whole person.
Learning to touch another person includes awareness that the body will often tense to “guard” itself against invasive touch, particularly in painful areas. Such responses mitigate effective palpation, so the practitioner must learn how to touch, gradually applying pressure and earning the trust of his patients to allow for accurate palpation.
Regardless of the particular method of treatment employed, skillful palpation is the defining factor differentiating highly successful practitioners from those who obtain erratic results. Regardless of theory, method, or amount of treatment, skillful palpation is without question the singular most important component of treatment.
Listen closely. First, the patient has direct experience of the problem. His descriptions of what he feels and when and how he feels it are extremely important pieces of data. Second, many patients with chronic pain have suffered the experience of being told that the pain is “in their head” or “isn’t real.” They will often feel they have to convince you of the reality of their experience. Listening and confirming their reality is important in developing the trust necessary for treatment. Educating patients about the nature of myofascial pain syndromes, showing them wall charts of pain patterns, describing postures and movements that can trigger pain patterns as well as what kinds of organic dysfunctions might be associated with such syndromes is important. We have seen patients lose their tension and anxiety as soon as they saw their pattern on a wall chart; many have exclaimed, “I’m not crazy!” This kind of confirmation and education goes a long way in establishing a relationship that leads to effective treatment.
Additionally, it is important to remember and respect the subjective nature of the experience of pain. What might seem to be a mildly constricted area to your touch can in fact be a source of considerable pain to the patient. As you listen to your patient, hear him and embrace his reality.
Treat with precision and attention. The following approach to patient care is designed to help to focus in on the problem at hand and its resolution.
Poor breathing patterns connected to stress, muscular problems, or respiratory trauma can directly affect myofascial problems. The single biggest offender is paradoxical breathing, a phenomenon in which the movements opposite to those required for a full, relaxed breath occur. Instead of the abdominal muscles relaxing in order for the contracted diaphragm to fully enlarge the thoracic cavity, the abdominals contract and the chest lifts, inhibiting the tidal volume of the lungs. Watch a patient breathe and you may notice a raising of the chest and pulling in of the abdomen. Many people reflexively do this when they try to hold the breath. It is simply incorrect breathing and often nothing more than a bad habit.
Since it can be a perpetuating factor for a number of pain syndromes, as well as part and parcel of many stress-related disorders, this type of breathing should be corrected.1
The following exercise can help retrain breathing patterns.
Extend treatment beyond the office. Your job goes beyond releasing myofascial constrictions and trigger points. The treatment of myofascial pain is multifaceted and includes involving the patient in home care, such as applying moist heat; attending to postural, visual, work habit, or sleeping corrections; addressing stress management and nutritional considerations; correcting sports movements; or even suggesting new arrangements for furniture and computer stations. We often have asked patients to bring their bicycles or tennis racquets to the office if we suspected such activities were directly connected to the generation of their pain. The clinician as detective, one who sorts out and identifies the perpetuating factors associated with the patient’s condition, is only one of the roles we must assume. We must also be educators, prodding parents, or sometimes simply friends who care about the fact that a person is in pain. Familiarity with simple exercises, nutritional considerations, stress management techniques, breathing exercises, methods of changing eye-dominance, and furniture and exercise-equipment ergonomics is part of the diverse knowledge necessary for treating myofascial pain in a complete sense.
Soften the dichotomy between treatment and examination. From the outset the practitioner should view examination as treatment and treatment as examination. Failing to recognize the ongoing feedback involved in this process can result in the loss of important information. As you gather information by palpating the myofascial constriction, you are engaged in treatment. Just so, as you seek to release myofascial constrictions, you are engaged in evaluation. The act of treatment can show you the correctness of your palpation, the reactivity of the muscle, the extent of the problem, and possibly the approximate length of time this muscle has experienced distress. Further, each release can guide you to associated areas of constriction. Watching the skin surface and carefully feeling for the type and direction of the release provides evaluative information that directs the course of treatment. The patient will often describe loci of pain that are experienced at the time of palpation or treatment that correlate with the referred pain pattern, though he might also describe a distal location, demonstrating additional muscular constriction. Evaluation, treatment, and treatment planning are processes that occur simultaneously in working with myofascial pain syndromes. Therefore a certain mental framework—a diffuse state of attention coupled with a constant vigilance that records cues and transforms them into treatment modifications—is central to this approach. Such activity becomes part of a practiced process that is carried out in treatment.
While a diagnosis is made after the history is taken, the examination is finished, tests are reviewed, and palpation is completed, it should be considered preliminary. The treatment of myofascial pain problems is also diagnosis. Whether you are injecting trigger points, releasing tender points with acupuncture, applying ischemic pressure, or performing a spray-and-stretch technique, all procedures reveal further information about the patient’s condition. Attention to how the muscles respond, how the pain is experienced, the nature of the fasciculations, and how the patient responds to treatment are all pointing to the next steps of treatment. To make a firm diagnosis and carry out a rigid treatment plan is contradictory to the experience of interacting with myofascial problems. This is a world where as muscle fibers release others may constrict; where simple movements could drastically affect a recently released, but highly reactive, muscle. It is a world that is so interconnected it is impossible to understand one muscle in isolation from the whole body. The successful practitioner understands this deeply and engages in a practice that involves a kind of passive vigilance and fluidity of thought that allows for constant change. The idea that X, and X alone, is the problem and that Y will fix it is a classic error common in health care but disastrous in the world of treating myofascial pain.
John Upledger has referred to the fascia as “a single and continuous laminated sheet of connective tissue . . . [which] extends without interruption from the top of the head to the tips of the toes. It contains pockets which allow for the presence of the viscera, the visceral cavities, the muscles and skeletal structures.”2 The complex, interactive nature and homeodynamic activity of this system must be appreciated and respected.
As practitioners we have come to experience a fundamental state of awe that is with us each day as we treat our patients. The complexity and beauty of the myofascial system has led us to experience some amusement when a patient, learning of the nature of his or her condition, remarks, “You mean it’s just muscular?” Exactly. It’s just the Grand Canyon.