Not very many people enjoy injections or procedures involving needles - except when they have found treatments such as trigger point injections, prolotherapy, perineural injections therapy so helpful that they eagerly anticipate their next visit to the clinic. Some, however, who could benefit from dental visits or medical procedures, postpone or avoid them due to a needle phobia. Needle Phobia is much more than a simple dislike of the discomfort associated with needles; a person with a needle phobia feels sudden severe anxiety, panic, perhaps nausea or may even faint at the the mere thought of a needle, or hearing someone describe an injection, or sees a picture or movie about medical procedures. Clinical hypnosis addressing the root cause of such fears can eliminate the phobia, usually in one or two sessions. You don't have to actually like having injections to be free of an unnecessary phobia.
Fibromyalgia is a common long-term condition, affecting 2-4% of the population, more commonly women than men, that causes pain all over the body along with many other symptoms. People with fibromyalgia often have:
Books and articles often say that the causes of fibromyalgia are unknown. It may be that it is the final destination arrived at from a variety of different starting points. For some people it occurs after an illness such as influenza; for others after an accident or other traumatic event. For many it develops gradually after an overwhelming incident or as the culmination of years of accumulated stressful events, often dating back to childhood. Numerous studies have found that between 50 and 63% of patients with fibromyalgia also meet the criteria for post-traumatic stress disorder, frequently reporting adverse childhood events or subsequent physical or emotional trauma. Adverse childhood events (such as the loss of a parent, abusive or chaotic households, early hospitalizations, accidents, neglect etc), and later traumas all can prime the nervous system's fight/flight/freeze response, giving rise to a sense of being unsafe in the world, and cause the body to respond with physical symptoms. Chronically elevated stress hormones change the way our glucose metabolism and digestive function work, cause increased muscular tone (tight muscles), and affect our immune system function.
There is a complex inter-relationship between our nervous systems, our hormones, immune systems, gastrointestinal system, and our muscular function, including how the energy powerhouses (mitochondria) in our cells function. In other words, although it is a very real physical condition, the pain is being produced in the nervous system in response to (usually prolonged and cumulative) internal (such as the demands or expectations we place on ourselves) and external sources of stress. It can also be triggered by sleep deprivation in some people.
For this reason, it is possible to turn the pain down or even off, by means of techniques that address past trauma, anxiety, stress, beliefs and expectations, as well as by optimizing nutrition, sleep and general well-being through regular exercise (while avoiding extreme of activity). Coming to an understanding of the condition reduces fear, which in turn can substantially reduce pain intensity.
Fibromyalgia can be best thought of as a central nervous system condition in which the brain and spinal cord are sensitized and therefore respond to sensations which are perceived as much more painful than the same sensation would be experienced by someone without fibromyalgia. It is sometimes referred to as a Central Pain Amplification Disorder. Similarly, people with irritable bowel syndrome will perceive the same degree of gaseous intestinal distension as being much more painful than someone without IBS would do. It is as though the pain ‘thermostat’ or dial has been turned up to a very high level.
Unlike rheumatoid arthritis or lupus, fibromyalgia is not an autoimmune or inflammatory condition. It can co-exist with arthritis but it is not primarily a joint condition. It does not lead to any ilife-threatening disease.
Fibromyalgia may run in families to some extent but whether this is genetic or due to a common environment (similar stresses) or a learned response to adverse circumstances is not clear. A small subset of people with symptoms suggestive of fibromyalgia have been found on skin biopsy to have an abnormality of small nerve fibres. Genetics alone cannot explain fibromyalgia. Symptoms tend to be worse with stress, over-work, excessive exercise, or sleep deprivation.
1. symptoms as mentioned above, present for more than 3 months with no other explanation
2. pressure at certain common soft tissue points on physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain.
There is no specific blood test or X-ray that can diagnose fibromyalgia. Commonly tests will be ordered to exclude other conditions, for example, sleep apnea, an underactive thyroid, or polymyalgia rheumatica, anemia, iron-deficiency, rheumatoid arthritis or lupus.
While there is no one specific cure for fibromyalgia, approaching it from a number of different angles – certain medications, carefully structured aerobic exercise within one’s capabilities, and mind-body approaches such as relaxation, stress-reduction, Cognitive Behavioural Therapy, mindfulness, Tai Chi, and clinical hypnosis or guided imagery, can be helpful. Ensuring adequate sleep is essential. Some people have co-existent anxiety, depression, PTSD, panic disorder, all of which can also be treated. Proper nutrition is also important. Anecdotally, some patients report a correlation between pain intensity and diet, such as refined carbohydrates, gluten, nightshades, or meat. This may be an individual response.
A number of medications are often tried to reduce symptoms. Most of these are “off-label”.
Low doses of an antidepressant called amitriptyline (Elavil) or related medications (such as nortriptyline or trazodone) can often be very helpful for pain, sleep, and to reduce migraines.
A muscle relaxant such as cyclobenzaprine (Flexeril) can be helpful. This is structurally similar to tricyclic antidepressants (TCAs) such as amitriptyline.
A newer SNRI medication, duloxetine (Cymbalta) can sometimes help.
Additional medications include pregabalin (Lyrica) and gabapentin (Neurontin) can be used.
Another off-label medication is low dose naltrexone.
Opioid narcotic medications are best avoided as they have significant side-effects, are largely ineffective, addictive and can lead to a conditions known as opiate-induced hyperalgesia, a parodoxical increase in pain the more opiates one cosumes. Of the opiates Tramadol may be better than the others but shares all the same risks as other opiates and interacts with other medications.
Acetaminophen and anti-inflammatories (such as ibuprofen) are generally not effective for fibromyalgia but may help other co-existing pain. Sleeping tablets such as Zopiclone and benzodiazepines are not recommended.
One small study published in December 2018 suggested that some patients with fibromyalgia may respond to treatment with a diabetes drug called metformin if their average sugar level (HBA1C) was in the high normal or elevated range.
Gaining an understanding of fibromyalgia, engaging in self-care, ensuring good sleep, reducing stress, modifying behaviour, counselling, dietary modifications and supplements, and a judicious exercise regimen can all be helpful.
In my own practice a combination of tender point injections, counselling, relaxation techniques, clinical hypnosis, medication and nutritional advice, and patient-education (which may include recommended reading and journalling) can lead to a significant reduction in symptoms, periods of remission, or even resolution.
Sometimes it is helpful to combine different treatments to achieve a better result, either at the same visit or subsequently.
It stands to reason that when one has an injury more than one structure may be affected- muscles, fascia, ligaments, tendons etc. What is not as well known is that cutaneous nerves become sensitized and may perpetuate pain through the release of specific chemicals (such as CGRP). Different structures require different approaches.
We may have already treated myofascial pain with the pain neutralization technique (PNT) or trigger point injections but the patient may have some residual symptoms. We often combine perineural injections with prolotherapy or may combine prolotherapy with PRP. Sometimes we use acupuncture or acupressure to calm symptoms of anxiety or light-headedness if a person is apprehensive. PNT can substantially reduce the number of trigger point injections needed.
One example: A lady was referred for acupuncture for treatment of longstanding shoulder and upper back pain which was interfering with her work. She was very keen to have this fixed but was so apprehensive about the needles that she broke out in a sweat (quite unnecessarily) before she could be examined. Instead of tackling the painful area directly she was initially asked to lie down on the exam table and four thin sterile acupuncture needles were gently inserted into peripheral points in her hands and feet which are known to have pain-modifying effects and which moderate the "fight and flight" response. After resting quietly for 20 minutes she was feeling much better (people often find acupuncture and acupressure quite relaxing or soporific). Then all but one of the tender points in her shoulder, arm and upper back were released with PNT using finger pressure only (no needles needed!). Only one resistant point on the side of her upper arm was still tender (what the Chinese would call an ah shi point); this was treated with an acupuncture needle briefly. When seen in follow-up she remained pain-free and able to work without discomfort.
Another example: A lady was seen for chronic pain in her neck, shoulders, back, thigh and hip which had persisted following a motor vehicle collision. Her X-rays were normal; all her pain was "soft-tissue" but her function was limited. At the initial visit she was found to have very limited range of movement of her one shoulder with multiple tender points around the neck, shoulder and upper back. She also had limited movement of her lower back and one hip because of pain. PNT released her shoulder and neck pain the first visit and she regained full range of movement within a few minutes. On a few subsequent visits some recurrent tender points were released. PNT also released painful areas in her abdominal muscles which can cause referred pain to the back. Her back muscles and thigh needed trigger point injections and some of her hip pain responded to perineural injections. Obviously, these methods will not correct major structural abnormalities but because pain reduces function by inhibiting muscle movement, when the pain is relieved function is often restored.
Trigger points are tender taut bands in muscle or fascia which, when pressed, often elicit a "jump" or "ouch" response from the patient, and may produce a predictable referred pain pattern to other areas nearby. Some people call them "palpable pain points". They may be active (i.e. produce pain even when not pressed) or latent, (producing tenderness when pressed but not otherwise). They may be primary - the original site of the injury, or secondary , due to the muscle having to over-work because of lax ligaments, for instance. There is a tendency for new tender points to form in the same muscle or neighbouring muscles.
Trigger point pain may mimic other conditions because of referred pain. Some examples: Trigger points in the sternocleidomastoid muscle (the long strap-like muscle that stretches from behind your ear down to the collar bone and turns your head to the other side) can cause pain in the upper teeth leading to unnecessary dental work being done. Trigger points in the pectoralis major can mimic a heart attack or produce breast pain.
Trigger points can form as a result of injury (such as a muscle strain or fall), or form over-use, posture or poor ergonomics, or when the muscle has to compensate for other structures which are not functioning adequately.
Trigger points (known as ah shi points) were treated with acupuncture long before western physicians began treating them in the 1940s. Drs. Travell and Simons produced a two volume encyclopedic description of different muscles and their pain patterns and how to treat them with a combination of injections, stretches and cool sprays. Most trigger point charts, pictures and books are based to a greater or lesser degree on those two volumes.
Trigger Point Treatment Options:
1. ischemic compression - this involves identifying a tender point, pressing on it with a thumb, finger, ball or other object (such as a theracane) firmly enough to cause discomfort but not severe pain. One then stretches the muscle along its long axis, takes in a deep breath and presses a little firmer. An excellent explanation of this technique can be found on Dr Kuttner's website. This is not the method we use but it is effective and can be a useful form of self-therapy. Dr Kuttner's site is very informative and he has inexpensive resources available there.
2. Various myofascial release techniques have been used by physiotherapists and massage therapists and are often effective but may aggravate the pain if administered too vigorously, or if the pain is due to inflamed sensory nerves rather than primarily a muscular problem.
3. Our preferred non-needle technique is a group of simple, painless, and safe procedures collectively known as the "Pain Neutralization Technique", which, when effective, works nearly instantly.
4. Acupuncture or "dry-needling" has been used for centuries to treat trigger points. Modern versions - using a very fine, single-use, pre-packaged, sterile, disposable, solid (not hypodermic) acupuncture needle - include Dr. Chan Gunn's Intramuscular Stimulation (IMS) and Dr Cynthia Gokavi's adaptation, the Gokavi Transverse Technique. IMS or dry-needling are often offered by physiotherapists and pain clinics and do not involve any medications.
5.Trigger points can also be injected with a hypodermic needle and syringe. With injections one has both the direct needle effect and the ingredient effect. The needle itself does much of the work in releasing the tight band. Drs. Travell and Simon pioneered the use of local anesthetic injections into trigger points using Procaine. Today Lidocaine is usually the local anesthetic of choice; some physicians mix this with longer-acting local anesthetic such as Bupivicaine (Marcaine) and may add some steroid (cortisone-like medication). There is no evidence that steroids are helpful for this and may be harmful. Longer-acting anaesthetics are said to reduce the post-injection soreness from the needle which some people feel later, but carry greater risk if used in excess doses, or if they get into the bloodstream too quickly. Some alternative practitioners add herbs, vitamins and homeopathic remedies to their injections but we do not advocate this. Some physicians use normal saline without anaesthetic for trigger point injections. This avoids the rare risks associated with the medications but may leave a little more soreness the next day. Dr Greg Siren (at the Myo Clinic and Changepain) uses this method very effectively and has generously taught this to other physicians in BC.
A study was published in Korea in 1997 comparing three groups of patients with trigger point injections, one group with normal saline, one group with local anesthetic, and another group with 5% dextrose (D5W). Each method was effective but, of these, the local anesthetic group did better than saline, and D5W performed the best of the three. This is possibly because of the known benefit of dextrose in relieving neurogenic pain. This is only one study and if repeated elsewhere might produce a different outcome.
David is a fan of books and no doubt will be sharing some good reads here.