To address chronic musculoskeletal pain, consider the body as an interconnected entity.
By Frankie L. Burget, OTR, RMT, CNDT
Muscles, joints, and connective tissue are designed to work together as one smooth-flowing mechanism. When one of these components aren't working properly, discomfort will occur.
In many cases, those levels of discomfort persist and, over time, eventually turn into chronic musculoskeletal pain. That's the case for an estimated 35 million people in the United States who experience chronic musculoskeletal pain. But typical solutions may miss the mark, since many methods focus on immediately alleviating pain without removing underlying causes. When handling patients with chronic pain, you should know how to locate the source of pain and take the correct course to healing.
Musculoskeletal problems can affect any part of the body, such as the shoulders, elbows, knees, hips, or the back. These
complications can start with debilitating conditions, such as rheumatism, arthralgia, fibromyalgia, arthritis, and osteoarthritis.
In other cases, an injury or traumatic incident can cause chronic pain. A patient can heal, and pain disappears, but an unknown, underlying deficiency may still exist. Sometimes, the source of chronic pain comes from years of stress, misuse, and inappropriate movements.
To diagnose chronic musculoskeletal pain, you must take a complete medical history. This should include looking back several decades into a patient's life and not just examining recent events or injuries.
With some people, restrictions or misalignments can exist from birth, although pain may not surface until the person reaches his 30s or 40s. For example, the pain isn't caused by a current injury but is a repetitive stress injury that has slowly created damage because the body wasn't functioning properly from the beginning.
In some situations, you may realize that patients haven't progressed through proper neurodevelopmental sequences during
childhood. You can even trace the pain back to days as a toddler. For instance, did parents push a baby to walk before he'd even learned to crawl?
While a child's ability to walk ahead of schedule is admirable, it prevents him from progressing through appropriate movement sequences and can damage all sensory levels over the years. Encouraging a child to walk before he's physically and neurologically ready may set the stage for improper movement and chronic pain. Forcing the limbs and joints to bear weight before they're ready creates restrictions and misalignments that produce additional restrictions and adhesions. As a result, you may need to facilitate healing by retraining the body to move in natural, normal motions.
The next step is to conduct a complete physical evaluation of the person's posture and movement. These visual observations enable you to determine restrictions, imbalances, and weaknesses. Then, look at the pain site and body mechanics. Consider these examples of tracking pain back to its starting point.
Shoulder pain:
If a patient has chronic shoulder pain, such as a shoulder impingement, the root of the problem may be the scapula. Even though the painful site may be at the acromioclavicular joint, the joint associated with scapular movements, the problem may stem from poor scapular glide from fascial adhesions.
If the patient arrives hunched forward, you also must consider potential tightness in the anterior chest or pectorals. With tightness, the scapula may be locked down against the thorax, which prevents the scapula from gliding. He may have the strength to raise his arms above the head, but he's probably developed a repetitive stress injury from performing daily tasks and moving the arms incorrectly. As such, you must relieve restrictions to treat and remove the cause.
In this situation, pulleys can be used to increase strength and movement, but only after the patient has established a good range of motion and scapular glide. Applying strengthening exercises too soon can cause a person to compensate, which creates more physical damage.
Instead, give patients functional tasks and incorporate normal movements that fit into a daily lifestyle instead of the unnatural linear movements created by traditional pulley exercises. After evaluating the entire body, you'll know whether the patient can perform these exercises correctly.
Rib cage restrictions: Musculoskeletal limitations or fascial tightness can cause rib cage restrictions. If those restrictions are in the middle and lower ribs, it prevents the diaphragm from expanding and can cause shallow breathing.
This leads to muscle tightness and can set off a chain of events: The patient can't breathe properly during aerobic exercise, which prevents proper oxygenation uptake of nutrients decreases from the bloodstream and causes the patient to fatigue easily; blood flow to the brain decreases, which may cause headaches and dizziness; and the anterior cervicals and the diagastrics tighten, which may lead to swallowing difficulties and speech problems.
Foot pain.
Another common problem is foot pain. Pain that's caused by plantar fasciitis and bunions may be felt in the feet, but you may need to look farther up the body for the cause. The effects of improper spinal alignment and poor posture can trickle down to the feet. And posture problems may be caused by fascial restrictions, adhesions or muscle imbalance.
Bunions can be the product of a spine and pelvis that are pitched forward or in a swayback position. When a patient puts weight on the forefoot, the metatarsal heads are forced to adapt to increased weight bearing. This motion throws the pelvis into an anterior rotation, which causes interior rotation of femoral heads and pressure at the first metatarsal head. With proper balance, body weight should be distributed over the entire foot. If ifs not, a person creates repetitive stress during a daily routine of walking.
Therapy can help stretch or strengthen certain muscle groups. However, pain-free movement requires more than strong muscles. The body must be balanced and the muscles free to move.
Treatment can include myofa~cial techniques and hands-on therapies to relieve restrictions and balance the body. With myofascial release, patients may report reduced pain after the first treatment. These techniques start breaking the chronic pain cycle by enabling you to reach deep tissue structures and alleviate pressure, which allows fluid to move through proper channels and promote healing. The body can then return to its correct, proper position. After you've started balancing the body and restoring posture, tailor exercises to a patient's particular weaknesses to enhance the healing process.
Consider the patient who came to us with bad neck pain. Traditional therapy to address neck exercises only made the problem worse.
We looked at her whole body and realized she had a horrible posture and was so weak in the trunk that she couldn't maintain postural alignment of her pelvis. Therefore, she was already out of alignment when she tried to do neck exercises.
After making her aware of the improper posture, we implemented abdominal exercises. First, we had to find "her center," the neutral point of her spine. Then, we taught her how to contract specific muscles to maintain correct posture. As she improved, we increased the abdominal activities until she could do "traditional" exercises.
In addition, consider adding aerobic exercise. Mild aerobic exercise can increase endorphin production and help reduce pain. But make sure a client possesses adequate posture to handle movements correctly because you don't want to cause more physical injury. For example, if a patient is slumped over, the diaphragm is compressed, and he can't take a full breath to allow adequate amounts of oxygen into the bloodstream. As a result, the patient can tire easily and experience muscle pain. The lack of oxygen-rich blood can't create endorphins or move valuable nutrients through muscles.
As adjuncts to therapy, clinicians may treat musculoskeletal pain with nonsteroidal anti-inflammatory drugs, steroids, opioids, and antidepressants.
But the short-term effects are limited, and the long-term effects are unknown.
New techniques for chronic pain use injections of local anesthetics to block pain conduction. Sometimes, these measures provide permanent relief, but often clinicians must repeat the process at regular intervals to keep producing the same effects. And many people experience symptom.reduction with complementary medicine such as herbs (white willow, dove), biofeedback, transcutaneous electrical nerve stimulation and relaxation techniques.
While these options may offer temporary relief, you must still address the underlying causes of chronic musculoskeletal pain.
People shouldn't have to live with chronic musculoskeletal pain every day. With your help, they may be able to leave those difficult days behind.
Resources:
Gallagher, R.M. (2000). Sources of late-life pain and risk factors for disability. Future Geriatrics, 55(9), 40-47.
Star1anyl, D., & Copeland, M.E. (20_01). Fibromya/gia and chronic myofascial pain: A survival manual. Oakland: New
Harbinger.
Bradley, L.A. et al. (1999). Abnormal regional cerebral blood flow in the caudate nucleus among fibromyalgia patients and nonpatients is associated with insidious symptom onset. Journal ofMusculoskatetal Pain, 7(1-2), 285-292.
Schultz, R.L., & Feitis, R. (1996). The endless web: Fascia/ anatomy and physical reality. Berkeley, North Atlantic Books.
Speece, C.A., & Crow, W.T. (2001). Ugarnentous arlicular strain: Osteopathic manipulative techniques for the body. Seattle, Eastland Press.
Gorman, C., & Park, A. (2002). The age of arthritis. Time, 160(24), 70-79.
Frankie L. Burget, OTR, RMT, CNDT, owns and founded Windsong Therapy in Bedford, Texas.
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