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Pain And Pain Pathway : Pain is a somatic and emotional sensation that is unpleasant in nature and associated with actual or potential tissue damage. Physiologically, the function of pain is critical for survival and has a major evolutionary advantage. This is because behaviours that cause pain are often dangerous and harmful, therefore they are generally not reinforced and are unlikely to be repeated. The classification of pain is complicated and there are many different types of pain, each arising through unique mechanisms. Types of pain include: sharp pain, prickling pain, thermal pain, aching pain. In addition, the origin of pain can be somatic, visceral, thalamic, neuropathic, psychosomatic, referred, or illusionary. Pain can also be acute or chronic in nature. The General Pain Pathway Within the pain pathway there are 3 orders of neurones that carry action potentials signalling pain: First-order neurones – These are pseudounipolar neurones which have cells bodies within the dorsal root ganglion. They have one axon which splits into two branches, a peripheral branch (which extends towards the peripheries) and a central branch (which extends centrally into the spinal cord/brainstem). Second-order neurones – The cell bodies of these neurones are found in the Rexed laminae of the spinal cord, or in the nuclei of the cranial nerves within the brain stem. These neurones then decussate in the anterior white commissure of the spinal cord and ascend cranially in the spinothalamic tract to the ventral posterolateral (VPL) nucleus of the thalamus. Third-order neurones – The cell bodies of third-order neurones lie within the VPL of the thalamus. They project via the posterior limb of the internal capsule to terminate in the ipsilateral postcentral gyrus (primary somatosensory cortex). The postcentral gyrus is somatotopically organised. Therefore, pain signals initiated in the hand will terminate in the area of the cortex dedicated to sensations of the hand. Activation of First Order Neurons Nociceptors Some first-order neurones have specialist receptors called nociceptors which are activated through various noxious stimuli. Nociceptors exist at the free nerve endings of the primary afferent neurone. Since nociceptors are free nerve endings this means they are unencapsulated cutaneous receptors. This is opposed to encapsulated cutaneous receptors (e.g. Merkel’s discs) which detect other sensory modalities such as vibration and stretching of the skin. G.KAVIVARSHINI 1st YEAR "A" SNS COLLEGE OF PHYSIOTHERAPY #snsinstitutions #snsdesignthinkers #snscollegeofphysiotherapy

Are Trigger Points Useful for Shoulder/Arm Pain Relief? Put The Bible to The Test (12) Travell JG' et al's books on TrPs & Pain is the bible in mysofasical world, which claims MtrPs cause and are central to the myofascial pain. So there came “trigger point therapy”. But under scientific testing, such a therapy has advanced to nowhere in the past half century. Are MtrPs necessary? Jay Shah, a senior physiatrist in the NIH Clinical Center, among many critical thinkers, questioned the tenet (Shah J et al, 2015). TrPs for Shoulder/Arm Pain The bible claims more than dozens of TrPs located in shoulder area can cause shoulder and upper arm pain. If indeed “TrPs cause and are central to the myofascial pain”, then we can anticipate that the intervention not targeting any of the TrPs at shoulder area will not work, or work very poorly for arm pain. Under Scrutiny of Scientific Trials A 2018 systematic review (11 trials with 496 participants) published in Physiotherapy examined the effects of shoulder TrP-guided dry needling (TDN) for shoulder or upper arm pain and dysfunction. The review found: There was very low evidence that trigger point dry needling of the shoulder region is effective for reducing pain and improving function in the short term. The authors concluded: There is very low evidence to support the use of TDN in the shoulder region for treating patients with upper extremity pain or dysfunction. No Consensus Reached on Any Single Thing The review also identified “considerable heterogeneity” between trials with regards to how the TDN was performed by clinicians, how comparison group was designed, and how the outcomes were measured. 80 years having passed since the TrP theory established, we have no consensus reached among clinicians yet over any single factor which may affect the outcomes. Every clinician can claim their intervention design is the best. But none of any single intervention design has been proved by scientific tests to be better than others, or the outcome to be significantly superior to a placebo. Science Goes Nowhere on Blind Beliefs “Science is the belief in the ignorance of experts…” (Richard Feynman, Quantum Physicist). Science does not move forward if we blindly accept everything of what we see, hear or read (including this post). Instead, we need to keep thinking, testing and retesting. In this information-flooding era which sinks everyone, we all should be more skeptic than ever before. Do your test and retest on what this post is telling you. Shah JP et al, PM R. 2015 Jul;7(7):746-761. Hall ML et al, Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis, Physiotherapy, Vol 104, Is 2, 2018, P167-177. #shoulderpain #armpain #triggerpoints #myofascialpain #biblebooks #criticalthinking #blindbeliefs (Images from Tavell J et al, 1999)

#Sciatic Nerve Pain: What You Need to Know By Mark Gurarie Published on March 27, 2024 Medically reviewed by Amy Kwan, PT person experiencing sciatic nerve pain Overview: Sciatic nerve pain, also known as sciatica or lumbar radiculopathy, impacts the lower back and can extend to the thighs and legs. This condition arises from compression at the root of the sciatic nerve, resulting in chronic pain and potential nerve damage. Symptoms: - Sharp, electrical pain in the lower back, buttocks, or hip - Persistent cramps or shooting pain in the legs - Additional symptoms like tingling, numbness, leg weakness, or loss of bladder control may occur. Causes: 1. Herniated Lumbar Disc: Disc protrusion or bulging presses on the sciatic nerve. 2. Spinal Stenosis: Narrowing of spinal spaces causes nerve compression. 3. Piriformis Syndrome: Inflammation or injury to the piriformis muscle. 4. Spondylolisthesis: Vertebrae misalignment pinches the nerve. 5. Pott Disease: Tuberculosis infection affecting the spine. 6. Weight Changes: Obesity or pregnancy can increase pressure on the nerve. Diagnosis: - Medical history review - Physical examination - Imaging scans (X-ray, CT, MRI) - Nerve conduction studies Treatment: 1. At Home: NSAIDs, heat/ice therapy, gentle stretching, exercise, posture improvement. 2. Physical Therapy: Tailored exercises to manage symptoms. 3. Medications: Opioids, muscle relaxants, anticonvulsants, corticosteroid injections. 4. Surgery: Laminotomy or discectomy for severe cases. 5. Alternative Therapies: Acupuncture, with provider approval. When to Seek Help: - Persistent or worsening symptoms affecting daily life. - Emergency medical attention if experiencing severe symptoms or signs of cauda equina syndrome. Understanding the causes, symptoms, and treatment options for sciatic nerve pain is crucial for managing this condition effectively and improving quality of life. A Quick Review Sciatic nerve pain, or sciatica, affects the lower back, hips, thighs, and legs. This pain occurs when the sciatic nerve becomes compressed usually due to underlying conditions like a herniated disc, spinal stenosis, or injury and infection in the spine.1 Everything from at-home treatments to physical therapy and surgeries treat sciatica. If you have chronic pain and discomfort, getting medical support can help treat symptoms and improve your quality of life. #drameerhamza #healthawareness #health

POSSIBLE CAUSES OF RADIATING PAIN DOWN THE LEG ————————————————————————————————— “What is simple, is simply seen. And what is simple is rarely understood.” - unknown ————————————————————————————————— As usual, trigger points are rarely considered as a possible cause of radiating pain down the leg. Check it out. https://lnkd.in/gR_yAbqg. Not one mention. I personally have no problem determining nerve pain from myofascial pain. BECAUSE I PALPATE FOR TRIGGER POINTS. It’s simple. If I find no trigger points, or the patient doesn’t feel dramatically better after eliminating the trigger points. I know it’s nerve pain. It’s very simple. I don’t need to bother with imaging, or sophisticated orthopedic testing in order to determine either way. It takes just a few minutes. So someone misdiagnosed with nerve pain goes through rehab therapy designed for nerve pain. It ain’t gonna work. In this patients case. IT WAS ONLY TWO TRIGGER POINTS. So he suffered needlessly for months because no one bothered to palpate for trigger points. ONLY 2 TRIGGER POINTS !!!! No way this patient needed to be referred to a Pain Management Clinic. But that’s what happened. ————————————————————————————————— Those clinicians who have become skilled at diagnosing and managing myofascial trigge points frequently see patients who were referred to them by other practitioners as a last resort. These patients commonly arrive with a long list of diagnostic procedures, none of which satisfactorily explained the cause of, or relieved, the patient's pain. Myofascial Pain and Dysfunction, by David Simons, Janet Travell and Lois Simons, P36 ————————————————————————————————- Reason for Appointment 1. Right hip pain, with radiation down the leg History of Present Illness Manual Therapy: Physical pain or discomfort (0-10): 4/10. Emotional pain or discomfort (o-10): n/a. Assessments 1. Myofascial pain - M79.1 Procedures Manual Therapy: Painful palpatory areas: n/a. Modalities applied: trigger point release. Trigger points found and deactivated: RIGHT, sacrum(Si), quadratus lumborum. Post therapy response: All the trigger points deactivated quickly and easily. Pain is completely gone. Patient might need a follow up treatment in a few days, otherwise it's over. Post physical pain or discomfort: 0/10. Post emotional pain or discomfort: n/a. Length of session: 15 minutes. Performed by: Gordon Wallis, LMT. Procedure Codes 97140 MANUAL THERAPY Electronically signed by GORDON WALLIS, Lmt

In simple terms, Gordon Wallis highlights the importance of considering trigger points as a possible cause of radiating leg pain. He emphasizes that through palpation for trigger points, he can easily differentiate between nerve pain and myofascial pain. By identifying and treating just two trigger points, he successfully relieved the patient's pain, proving that specialised diagnostic procedures were unnecessary. This approach, based on the book "Myofascial Pain and Dysfunction," can lead to effective pain management and prevent unnecessary referrals to Pain Management Clinics.

Trigger Points Causing Mysofascial Pain: Truth or A Circular Reasoning Fallacy? Trigger point-mysofascial pain theory was developed by Travell et al (from 1940s). In 2015, Quinter et al argued that the construct of myofascial pain caused by TrPs is nothing but conjecture from circular reasoning: TrP causes pain; pain induces TrP (Quinter JL et al, 2015). The Reasoning Behind The Theory The theory goes that muscle tissue contracts excessively, generates a lot of metabolic waste products, which poisons the tissue and perpetuates a vicious cycle (Paul Ingraham, 2023). According to Travell et al, “The critical trigger point abnormality now appears to be a neuromuscular dysfunction at the motor end plate of an extrafusal muscle fiber. …” A Theory Led to Little Clinical Benefits 80 years passed since TrP as a cause for myofascial pain was first time described (in 1942), it has not led to any remarkable clinical benefit yet. The efficacy of trigger point therapy performed by practitioners today is no more effective than that performed by practitioners 80 years ago. A Theory Looks Quite Convincing Travell et al's theory goes that myofascial pain arises from trigger points; the latter are the sites of myofiscial tissue damage, and resided within the taut bands located in the culprit myofascial tissues. Put it in a more straightforward way, myofascial TrPs causes myofascial pain; myofascial pain induces myofascial abnormality -- the myofascial TrPs. By a little bit deeper thinking, you will find that this theory is established on circular reasoning, though unintentionally. Circular Reasoning: A Logical Fallacy Circular reasoning is a logical fallacy in which the reasoner begins with what they are trying to end with. It is a pragmatic defect in an argument whereby the premises are just as much in need of proof as the conclusion (wikopedia). The elusive TrP (premise) provided no independent ground for the myofascial pain (conclusion) when the reasoner at the same time believes myofascial damage gives rise to TrP. Circular reasoning often comes out in the form: "A is true because B is true; B is true because A is true." In the case of TrP-myofascial pain theory, it comes as: TrP is true (a tiny cramp) because muscle pain is true; and muscle pain is true because TrP is true. Circular Reasoning Not Easy to Detect Circularity in reasoning can be difficult to detect if it involves a longer chain of propositions. Travell et al's theory falls very much under this scenario Truth or A Fallacy? Trigger point causes mysofascial pain, myofascial abnormality leads to TrP. Truth or a circular reasoning fallacy? Before any remarkable advance can happen in myofasial pain science, clinicians and researchers in this field need to first find a correct answer to this question. References … #trigerpoints #myofisicalpain #trp #mtrps #criticalthinking #circularreasoning #logialfallacy #evidence-based #myofascialmedicine (Image by PinMasters)