Medical Specialist #18

Recently, I had the privilege of evaluating and treating a young woman, “LM,” with chronic head pain. She was referred by her physical therapist for additional soft tissue treatment to assist an upper cervical rehabilitation program. He was the seventeenth medical specialist she had seen. I was number eighteen.

When LM was a sophomore in high school, she blacked out and stuck the right side of her head on a cement floor. She gradually began to experience fatigue, trouble concentrating, dizziness, nausea and difficulty sleeping. Although she continued to play sports her head, ear and jaw symptoms worsened to the point that she took a month’s leave of absence from her senior year in high school.

I was immediately struck by LM’s maturity and ability to describe pain. How many times, I wondered, had she told her story? She came prepared with a written chronological history documenting her treatment since the accident, including medications and imaging test results. Thankfully, all the major pathologies had been ruled out. But why couldn’t she sleep? Why couldn’t she concentrate now in college? Why was she non-responsive to migraine medications? Why did her head pain persist?

LM had already been seen by a pain management specialist, sports concussion specialist, TMJ specialist, chiropractor, neurologists, an endocrinologist, a Lyme specialist and an acupuncturist. I was shocked to discover that no one prior to her referring physical therapist had explored the possibility of myofascial pain syndrome (MPS). No one had mentioned active trigger points as possible causal or perpetuating factors of her pain.

As a myofascial trigger point therapist, I was certain that I could at least reproduce some of her familiar head symptoms via treatment to referring neck, face and cranial muscles she would improve. I would be the one to solve her enigmatic case! (Don’t we all, as manual therapists, secretly hope we can be the one to hit it out of the park?!)

LM was, however, so sensitive to touch that I could barely touch her without a jump response. Her system was so centrally sensitized that even the lightest therapeutic pressure received with a fight-or-flight response from her nervous system. I did the paper clip test for allodynia, and it was positive. Therefore, I tried every non-compressive trick up my sleeve including acute pain relief techniques via sensory distraction, myofascial release, jostling, ice/heat, etc. Nothing changed.

Since I couldn’t use my normal arsenal for trigger point deactivation, I also tried movement techniques such as Feldenkrais and Levitt’s phased-eye with phased- breathing stretch methods that we teach in our Nervous System Strategies courses. Unfortunately, they didn’t work either.

At the end of the session, LM asked if she needed to return because she didn’t feel much of a difference. I paused. Normally with this type of hyperalgesia, the answer is definitely yes. We normally would try a few sessions. But I looked her in the eyes and said, “not yet.”

I couldn’t believe it, but I was referring her to medical specialist number nineteen. I felt strongly that she needed a comprehensive biomechanical, biochemical and bio-psycho-social evaluation by a physiatrist for proper diagnose of myofascial pain syndrome. A skilled physiatrist could also provide trigger point injections and topical medications that could help interrupt nociceptive signals, preparing LM’s muscles to hopefully receive manual trigger point therapy more effectively.

I spoke at length to LM’s mother, explaining how one accident could have set off cumulative events in her nervous system to the point where she experiences widespread, chronic pain. I related trigger point formation theories, referred pain and neuroplasticity as they might contribute to her symptoms. And, even though my modality did not initially provide the relief they so desperately wanted, I do think my understanding of myofascial pain syndrome provided some hope.

As manual therapists, we must know when to refer out and we must be able to explain why in medical context. At 360 NeuroMuscular Therapy, we are receiving more and more referrals to assist treating these long-standing pain cases. We have success deactivating myofascial pain and preparing patients for proper neuromuscular re-education and strength exercises. We work collaboratively with physical therapists, and many other allied-health providers, providing adjunct soft-tissue treatment that is often the missing bridge between medical specialists. All of these cases take time, planning, communication and a team-based approach.

LM has just started her sophomore year in college. She’s now seen 23 specialists, but has not given up hope that her pain will fully recede. Her mom stays in touch with me, and recently wrote saying “LM leaves for school tomorrow. Her spirits are good and I have hope for her to feel better in the future. We are now on the cusp of where she can start to make progress.”

If you want to collaborate with physicians and physical therapists on patient care, is imperative to stay current with the pain sciences and research literature. I cannot stress this enough. Although my medical specialty barely ‘touched’ LM with hands-on manual treatment, I do believe I made an impact in her case. Perhaps I guided her in the right direction, or at the very least, to a greater understanding of potential muscular sourced contributions to her pain.