Musculoskeletal Treatment | Solving Problem Pain

Musculoskeletal medicine treatment

Musculoskeletal medicine is a generalist medical discipline that takes a whole-of-patient approach to body pain and dysfunction. Although it covers all aspects of pain, musculoskeletal medicine has a unique medical interest in the role of muscles and connective tissues (fascia) in the mediation of persistent pain. It strives to optimize the complex interactions between the “software” of the nerves and muscles; the “hardware” of the skeleton, joints and their supportive ligaments; and the “central processing” of the spinal cord and brain.

Musculoskeletal doctors have usually specialized in general practice before undertaking extensive postgraduate training in musculoskeletal medicine. 

They have an advanced knowledge of the science relevant to body pain. Musculoskeletal doctors typically use a combination of manual therapy and needle/injection techniques to improve neuromuscular functioning and thereby reduce pain. This complements their advanced medical skills in musculoskeletal history taking, examination, targeted investigation, diagnosis, spinal injections, pain education, counselling, judicious drug prescription and appropriate referral.

Principles of good musculoskeletal treatment

• Treat the whole patient and the whole body.
  The human body is a complex system in which everything is interconnected.

• Wherever possible, treat the cause(s), not just the symptom.
  “Where you think the problem is, it ain’t”.

• Have a broad range of tools available to treat with.
  What works in one body may not work in the next.

• In general, it is preferable to optimise the neuromuscular “software” of the body before undertaking “hardware” interventions.

• Provide knowledge and encourage habits that reduce the likelihood of problems persisting or recurring.

Gentle Manual Therapies

In one-way or another, most physical therapies aim to influence the body’s neuromuscular “software”. That is, they aim to change the tension in the muscles and / or the firing of the nerves. The underlying principle is to improve the neuromuscular balance of the body so that function is increased and the likelihood of pain is decreased. 

There are dozens and dozens of overlapping physical techniques used by various body therapists around the world. Unfortunately, a lot of physical therapy performed on patients is of limited effect because it focuses on treating the symptom rather than the cause. The best therapies seek lasting improvement by either reducing load from overloaded structures and /or decreasing the irritation of nerves. Some of the physical treatments that I use include:

• Finch Therapy – a whole-of-body therapy that uses very specific, gentle muscle activations to retrain / reset chains of muscles that are out of balance. One of its strengths is that patients can repeat the specific activations for homework over one week to rehabilitate dysfunctional muscles and ensure more lasting improvement. I find this excellent for correcting the pelvic misalignments that are commonly associated with low back pain.
   
• Positional Release Technique (aka Strain-Counterstrain; Jones Technique) – seeks to reset muscle balance. It essentially works by shortening “overstretched” muscles, and thereby lengthening their opposing “shortened” antagonists. The process is “facilitated” by brief patient breath-holding and gentle pressure across the affected joints. The targeted muscles often gently twitch as they reset via the activation of a spinal reflex.
   
• Muscle Energy Technique (aka Post Isometric Relaxation) – another physical technique that aims to improve joint range by resetting neuromuscular balance. Generally a joint is moved up to the point of maximal restriction before the patient lightly contracts the muscles against the therapist’s resistance. The contraction can either be towards the restriction (direct) or away from it (indirect). The aim is to create a subsequent window of enhanced muscle relaxation in which the restricted muscle can be gently stretched further.
   
• Balanced Ligamentous Tension – this is an extremely gentle osteopathic technique that aims to improve the balance of the soft tissues in the body. Typically, the skin and underlying fascia are gently moved in the direction of maximal ease and held there until some change occurs. It is then slowly allowed to return in the opposite direction, where the restriction will have reduced.
   
• Joint Impulses – a targeted force is applied across a joint to help release it. This is occasionally used in the chest and ribs. I never perform this technique on the neck, as I believe that there are gentler techniques that can be used.
   
• Targeted Stretching – selected gentle home stretches are often prescribed to patients to help maintain improved function. It is critical that these stretches target the shortened muscles that are actually driving the problem. Note that these are usually not the muscles that actually hurt, as the sore ones are frequently already overstretched! The paradox is that stretching muscles that are already overstretched may feel good in the moment, but it generally increases the likelihood that they’ll keep hurting in the longer term.

Soft Tissue Injection Therapies

• Muscular Trigger Point Injections – this injection technique is probably the most powerful way to rapidly change soft tissues. It was developed by Drs Travell and Simons in the 1950’s; who later wrote the industry bible “The Trigger Point Manual”. The technique uses injections of local anaesthetic to release trigger points (knots of spasm) within muscle by eliciting a spinal reflex. Gentle stretching is then used to consolidate the change.
   
• Peri-neural Injection Treatment – this injection technique uses very shallow injections of glucose (sugar) solution to help down-regulate pain circuits. It targets the shallow skin nerves with tiny injections that are only 1-2mm deep. These shallow injections are thought to reduce the release of pain-mediating chemicals (like substance-P and CGRP) from nerve ends.
   
• Steroid (cortisone) Injections – cortisone is a strong anti-inflammatory substance that mimics the body’s own cortisol hormone. An injection provides targeted anti-inflammatory action for up to 4 weeks, with minimal impact on the rest of the body. It can be helpful to break the cycle of pain and assist the neuromuscular soft tissues to reset. The number of injections in any one spot is generally limited to 3 in any 12 months to avoid weakening the tissues. Cortisone injections generally only cause temporary improvements for joints, although this can literally be good for a holiday.
   
• Referral for Guided Injections – these can be helpful for spinal-mediated pain when the clinical and imaging (MRI) findings both suggest a particular cause. Specialized radiologists are requested to perform specific injections to diagnose and treat spinal-mediated pain.
   
• Superficial Dry Needling – shallow needling with acupuncture needles is used to create change in the deeper tissues. This often follows lines of increased fascial tension that correlate closely with the myofascial chains of the body, the meridians of acupuncture and the lines of stretch in many yoga asanas. 

Regenerative Injections

• Prolotherapy – this is the original “Regenerative Injection Therapy” and has been used since the 1930’s. It uses irritating injections of a strong sugar solution to stimulate enhanced healing of ligaments and cartilage around joints. It can be transiently painful to have performed and generally requires a series of fortnightly injections to build its effect. However, the joint hardware improvements achieved with prolotherapy tend to last into the medium and long term.
   
• PRP-Injections (platelet-rich plasma) – these are a newer type of “Regenerative Injection Therapy”. They involve drawing some blood off the patient and spinning it down in a special tube to isolate the “platelet-rich plasma”. This PRP solution is then re-injected into the patient’s joint, ligament or tendon to enhance healing.

Whole-of-Patient Issues

• Medical Review – specialized GP training allows investigation and diagnosis of serious medical conditions that may be presenting with pain. The exclusion of sinister diagnoses, such as cancer, can often make pain much easier to tolerate. Alternately, the identification of inflammatory autoimmune conditions can facilitate their effective treatment. The identification of psychosocial factors (yellow flags) that increase the likelihood of persisting pain can also be critical to successful treatment.
   
• Identification of Skeletal Asymmetries – differences in leg lengths can have a major impact on the performance of the musculoskeletal system and increase the likelihood of overload pain across the body. Accurate measurement using a CT scan can be used to assess this. Simple interventions such as heel lifts can significantly reduce the impact of such influences.
   
• Habit / Posture Change – the body is very clever, adapting to however it is routinely used. Unfortunately, if the body is used poorly, this will tend to decrease its capabilities and increase the risk of pain. For example, there is an epidemic of people slumping forward at their desks and shortening up the pectoral muscles at the front of their chests. This results in painful overload of the muscles on the back of the neck and chest, causing headaches, neck and upper back pain. Awareness of how we are using our bodies, in combination with an understanding of good posture, can dramatically reduce the likelihood of body pain continuing.
   
• Pain education / Counselling – persistent pain leads to predictable changes that tend to worsen the pain experience. Over time, affected nerves become sensitized and the brain becomes more focused on the pain. Understanding this physiologic process can help patients more effectively deal with pain. Challenging of unhelpful thoughts (catastrophising) can also help turn down pain and improve quality of life. Retraining neural circuits using the principles of neuroplasticity can also be very helpful.
   
• Mindfulness / Meditation – whilst stress never directly causes pain, it is often the wind that fans its flames! Stress increases muscle tone, increases brain activity and increases the release of inflammatory chemical messengers that sensitize nerves. Nearly all body pain is worse at phases of higher stress, although severe pain can set up a vicious circle by being a source of stress in itself. Mindfulness and meditation are ancient strategies designed to quiet the mind and reduce stress activation. At the end of the day, stress is not what happens to us but rather how we respond to it.
   
• Drug Therapy – medications can be a helpful addition to physical treatment. Their role can be to directly reduce pain (analgesia), reduce stress / anxiety / depression, improve sleep, reduce inflammation or calm irritated nerves (neuropathic pain).
   
• Nutritional Strategies – certain nutritional strategies may help reduce pain. These can include supplementing with omega-3 fats (fish oil), glucosamine-chondroitin, curcumin (from turmeric) and green-lipped mussel extract. Weight loss can help osteoarthritic joints, not just by reducing mechanical load, but also by decreasing the inflammatory chemicals that are released from fat stores. Improving gut health can reduce irritable bowel symptoms and reduce inflammation levels in the body. A low inflammatory diet may also reduce pain by decreasing the level of inflammatory chemicals circulating in our system.
   
• Referral for Surgical Management – occasionally, joint hardware problems are the overwhelming driver of a patient’s pain. In this situation, the patient may be best served by accurate diagnosis of the problem and referral to an orthopedic or neurosurgeon. Although most of us would prefer not to have an operation if we can help it, avoiding a necessary one can increase the size of the problem. 
   

Dr. Chris Homan
MBBS FRACGP FACRRM DRANZCOG PGDipMSM(Otago)