National Fibromyalgia Association FAME Conference Orange, CA - - PowerPoint PPT Presentation

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National Fibromyalgia Association FAME Conference Orange, CA - - PowerPoint PPT Presentation

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National Fibromyalgia Association FAME Conference Orange, CA March 17, 2006 Treating Myofascial Pain Hal Blatman, MD Medical Director Blatman Pain Clinic Holistic Comprehensive Pain Care www.blatmanpainclinic.com PAIN THEORY In

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National Fibromyalgia Association FAME Conference Orange, CA March 17, 2006

Treating Myofascial Pain

Hal Blatman, MD Medical Director Blatman Pain Clinic Holistic Comprehensive Pain Care

www.blatmanpainclinic.com

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PAIN THEORY

  • In school, we are taught theories

regarding pain

– Mechanisms of causation – Treatment protocols and procedures – Medications

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FIRST THEORY WE’RE TAUGHT IS INFLAMMATION

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Pain Theory

  • Inflammation words

– Tendonitis – Bursitis – Arthritis

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Uncle George Has had shoulder pain for TEN years!

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All of His Friends Have Turned Into Doctors

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Eventually, George Hurts Badly Enough To See Doctor Jones

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Doctor Jones

  • X-ray of the shoulder
  • MRI scan of the shoulder

– Spurs – Bones too close together

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Therefore George Has ARTHRITIS

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George Goes Home with a Bottle of Arthritis Pills

  • He is a happy camper

– Not because he gets any better – But because he knows what he’s got

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Doctor Jones Took a Leap of Faith

  • He was taught when he went to school:

– If he could demonstrate an abnormality on

x-ray…

– Close to where George had pain…

  • He could tell George that the pain comes

from what is seen on the X-ray.

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That Requires a “Leap of Faith” We Have No Right to Make

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Second Theory: PINCHED NERVE, HERNIATED DISC

  • If pain goes from the neck down the

arm…

  • Or from the lower back down the

leg…

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PINCHED NERVE, HERNIATED DISC

  • We know how to find that disc
  • And we know how to fix it!
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Third Theory: Pain can Come From Nerves

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Neuropathic Pain Theory

  • Peripheral nerve disorders
  • Peripheral neuropathies
  • Causalgia, Reflex Sympathetic

Dystrophy

  • Pain after amputation

– Phantom Limb and Stump Pain

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Fourth Theory: DEPRESSION

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Middle Age Depressed Woman Theory of Pain

  • If you’re 40 years old and a

woman

– And you’ve hurt for a couple of years

  • You must be depressed

– And your depression causes your

pain

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In Actuality This Pain

Causes the Depression

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If you get Bummed Out on a bad pain day, your body can do it to your head, even if your life is perfect, and your childhood was normal.

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Fifth Theory: SUPRA-TENTORIAL PAIN THEORY

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If all our Tests ARE NORMAL And you still think you hurt….

You must be making it up! You must be making it up!

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Are These Theories Correct?

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People With FMS/CFS Go to The Doctor, And What They’ve Got Doesn’t Fit Anything We’re Taught

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Many Fibromyalgia Patients are among the most Medically Educated People I see in my Office

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Much of The Pain of Fibromyalgia

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MYOFASCIAL PAIN MYOFASCIAL PAIN

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A Different Theory Myofascial Pain

  • Much of This Pain is Caused by:

– Myofascial Trigger Points In Muscle and

Fascia

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MYOFASCIAL PAIN

  • Referred from T.P.’s in specific and

consistent patterns, characteristic of each muscle

  • Patient usually presents with symptoms

related to the most recently activated T.P.’s

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Myofascial pain can cause:

  • Numbness and tingling
  • Burning pain
  • Radiating pain

– neck, face, teeth, head – neck, shoulder, arm, hand – low back, buttocks, thigh, leg, foot

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AUTONOMIC PHENOMENA

  • Localized vasoconstriction
  • Sweating
  • Salivation
  • Proprioceptive disturbance

– imbalance – dizziness, vertigo – tinnitus

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THERE IS LIFE AFTER A NEGATIVE EMG

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THERE IS LIFE AFTER A NEGATIVE MRI

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ALL THAT RADIATES IS NOT RADICULAR

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Myofascial Trigger Points

  • Generate TWO Pain

Patterns

– Localized and Referred

  • Quality of Pain

– Pain – Numbness – Tingling – Burning

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Treasure Map

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HEAD AND NECK PAIN HEAD AND NECK PAIN

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Look at These Pain Patterns Think about Headache…

Migraine Tension TMJ

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Sternocleidomastoid

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Temporalis

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Masseter

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Lateral pterygoid

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Trapezius

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Trapezius

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Suboccipital

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Semispinalis

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Palpation Exercise

  • Be GENTLE!!
  • This can cause a headache
  • This can also relieve a headache
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PALPATION

  • Grasp muscle between thumb and fingers
  • Cross palpate -- roll the muscle between

the thumb and fingers

  • Taut band twitches as the active trigger

point passes between the thumb and fingers

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Pinch Grasp and Palpate

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Palpating Sternocleidomastoid Muscle Trigger Points

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Palpating Sternocleidomastoid Muscle Trigger Points

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UPPER EXTREMITY PAIN UPPER EXTREMITY PAIN

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Scalene

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Infraspinatus

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Subscapularis

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Biceps

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Latissimus

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Pectoralis

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Triceps

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Tennis Elbow

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Hand

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Pinch Grasp and Palpate

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Palpating Tennis Elbow Trigger Points

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TRUNK and BODY PAIN TRUNK and BODY PAIN

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Paraspinal Thoracic

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LOW BACK PAIN LOW BACK PAIN

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Quadratus lumborum

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Rectus abdominus

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Piriformis Gluteus Minimus

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Gluteus maximus

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Piriformis

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PELVIC PAIN PELVIC PAIN

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Pelvic pain

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LOWER EXTREMITY PAIN LOWER EXTREMITY PAIN

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Quadraceps

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Hip Adductor

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Hip adductor

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Hamstring

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Tibialis posterior

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Tibialis anterior Gastrocnemius

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Pinch Grasp and Palpate

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Palpating Gastrocnemius Trigger Points

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Ipsilateral Soleus

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T TREATMENT

REATMENT

  • Inactivate the trigger points
  • Stretch the involved musculature
  • Opioid pain medication
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Inactivating Trigger Points

  • Needle/injection
  • Acupressure
  • Fascial stretching/Rolfing
  • Compounding pharmacy
  • Decrease sympathetic tone
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Case Report

  • Medical Information is not shown here.
  • Pain diagrams follow this slide showing

improvement over a few months for this patient.

  • All she did between the first and second

visits was change her diet, stretch, and use a small rubber ball.

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Diet Body work Thyroid

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Side Effect of Cortisone Injection

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Case Report

  • Medical Information is not shown here.
  • Pain diagrams follow this slide showing

improvement over a few months for this patient.

  • All she did between the first and second

visits was change her diet, stretch, and use a small rubber ball.

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People With MPS/FMS/CFS Go to The Doctor, And What They’ve Got Doesn’t Fit Anything We’re Traditionally Taught

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Much of The Pain of Fibromyalgia is Myofascial Pain

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Fibromyalgia Summary

  • A lot of the pain that has been called

fibromyalgia is actually from myofascial trigger points.

  • There is no such thing as a fibromyalgia

trigger point.

  • People can’t get “fibromyalgia of the

shoulder.”

  • Central sensitization of FMS can

be perpetuated by MTrPs, so that those lumps and bumps and ropy bands need to be treated ASAP.

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American Holistic Medical Association

  • Wouldn’t it be great if more doctors took the time to

listen and think about us as a whole person

  • Organization committed to catalyzing the change in
  • ur healthcare to a holistic system
  • You can help

– Join as a friend -- $30 – Join as an associate member

  • Web site referral information

http://www.holisticmedicine.org

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American Academy of Pain Management

  • Where can I find a pain doctor?
  • Interdisciplinary organization of

healthcare providers who treat pain patients

  • Web site provides referral information
  • http://www.aapainmanage.org
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Reference

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New Book

The Art of Body Maintenance:

Winners’ Guide to Pain Relief

By Hal Blatman and Brad Ekvall

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THANK THANK YOU YOU

blatmanpainclinic.com winoverpain.com