NMT150 wk 5

Physical Medicine Treatment for Lower Back Pain

• Identify physical medicine treatments for lower back pain, including Ischemic Compression (Trigger point therapy), Cross-Fibre Frictions, PNF - Contract-Relax Method, and Active Muscle Release (Hypertonic Muscle).

Myofascial Trigger Points

• A myofascial trigger point is a spot within a hypertonic band of skeletal muscle, usually around the muscle belly, that is hyper-irritable and can exhibit a predictable pain referral pattern.
• Trigger points can also occur in other structures such as ligaments, joint capsules, and fascia.
• They cause shortening of the muscle, making it more hypertonic and less functional.

Causes of Myofascial Trigger Points

• The physiological mechanisms behind trigger points are not fully understood, but some believe they form due to damaged muscle fibers from trauma, leading to a sustained contraction.
• This contraction can cause an increase in metabolism and a decrease in circulation, possibly as the body tries to contain the uncontrolled contraction or metabolic processes.

Types of Trigger Points

• Active Trigger Points
• Latent Trigger Points
• Primary Trigger Points
• Secondary Trigger Points
• Satellite Trigger Points

Ischemic Compression

• Ischemic Compression is a treatment that creates a temporary local ischemia, which is then released, creating a flushing effect that removes metabolites that cause nerve irritation.
• This breaks the pain cycle and reduces hypertonicity and spasms.
• The goal is to slowly break down the trigger point.

Ischemic Compression Methods

• Static Compression: applies gentle focused pressure to the identified trigger point, increasing pressure until the patient reaches a pain of 7/10, held for 30-120 seconds.
• Intermittent Method: applies gentle focused pressure, increasing pressure until the patient reaches a pain of 7/10, held for 10 seconds, released for 5-10 seconds, and repeated for a total of 3 sessions.

Cross-Fibre Frictions

• Cross-Fibre Frictions are a technique used to disrupt and break down adhesions in muscles, tendons, and ligaments.
• This method is used in the late sub-acute to chronic stages of injury, as it can be painful and should not be used in acute injury.
• The goal is to help the stages of healing and increase ROM by breaking down adhesions that are preventing normal motion of the joint or muscle.

PNF - Contract-Relax Method

• PNF is a stretching technique that is technically an active inhibition technique.
• The hypertonic muscle is reflexively inhibited, allowing it to relax and be lengthened.
• The Contract-Relax technique involves identifying the hypertonic muscle, stretching it in a comfortable and pain-free manner, and then having the patient contract the muscle with maximum strength while the practitioner holds the stretch.

Active Muscle Release

• Active Muscle Release is a soft tissue method that focuses on adhesions and hypertonic muscles.
• The goal is to release muscle tension and relieve pain or compression type pain.
• This technique is used in the chronic stage and is painful, but relieving at the same time.
• The technique is implemented for about 1-2 minutes and is based on patient tolerance to the pain.

OARS: A Framework for Active Listening

• OARS stands for Open-ended questions, Affirmation and acknowledgement, Reflection of content + emotion + meaning, and Summaries – smiles - silence
• OARS is a framework for active listening in conversations between a doctor and a patient

Open-Ended Questions

• Open-ended questions invite others to tell their story in their own words, without leading them in a specific direction
• Examples of open-ended questions:
  • "Can you tell me about stress in your life?"
  • "How do you experience that in your body?"
• Open-ended questions should be used often in conversation
• Closed questions, on the other hand, typically elicit a limited response such as “yes” or “no” and should not be heavily relied on in conversation

Affirmation and Acknowledgement

• Affirmation and acknowledgement convey empathy, understanding, and non-judgment
• Affirmation statements recognize a personal strength, or an ability, or a quality of resilience
• Examples of affirming responses:
  • "I appreciate that you are here today and are looking for some answers."
  • "You are clearly a very resourceful person."
• Acknowledgement can be part of an affirmative response and may also be used to bring attention to something that is happening in the present moment

Reflection of Content, Emotion, and Meaning

• Reflection of content, emotion, and meaning is a way of responding that demonstrates understanding and empathy
• Reflective listening can:
  • Demonstrate to the patient that you are listening and trying to understand their situation
  • Help to deepen or increase the intimacy between speaker and listener
  • Offer the patient an opportunity to “hear” their own words, feelings and behaviors
• Types of reflective listening:
  • Simple reflection: repeat the patient's words, noticing significant language
  • Paraphrasing with a reflection of meaning: listener makes a restatement in which the speaker's meaning is inferred
  • Reflecting present-moment experience: state an observation about the patient's behavior/body language and inquire about it with an OEQ
  • Reflecting feeling: listener emphasizes emotional aspects of communication through feeling statements

Summaries – Smiles - Silence

• Summaries are special applications of reflective listening
• Summaries can be used throughout a conversation but are particularly helpful at transition points, such as:
  • After the person has spoken about a particular topic, has recounted a personal experience, or when the encounter is nearing an end
• Summarizing helps to ensure that there is clear communication between the speaker and listener
• Structure of a summary:
  1. Begin with a statement indicating you are making a summary
  2. If the person expresses ambivalence, it is useful to name and include both sides in the summary statement
  3. It could be useful to include objective information in summary statements from other sources
  4. End with an invitation

TCM Spleen Functions

• Governs transformation and transportation: transforms ingested food and drink into Qi, and transports Qi and refined parts of food (food essences) to various organs and body parts. • Crucial to digestion and production of Qi and Blood: normal function ensures good digestion, appetite, and absorption, while impaired function leads to poor appetite, bad digestion, and abdominal issues. • Separates usable from unusable parts of fluids: clear part goes to the Lungs, and turbid part goes to the Intestines for further separation. • Implications for Dampness and edema: impaired function leads to accumulation of fluids, and Spleen must be treated when Dampness, Phlegm, or edema is present. • Affected by external Dampness: easily obstructs Spleen, causing dysfunction and symptoms like abdominal fullness, urinary problems, and vaginal discharges. • Likes dryness: excessive consumption of cold liquids or icy drinks can impair Spleen function. • Controls the ascending of Qi: separates usable from unusable parts of food, directing Food-Qi upwards to the Lungs and Heart. • Maintains proper organ placement: ascending of Spleen-Qi keeps internal organs in their proper place. • Controls Blood: keeps Blood in vessels and plays a crucial role in Blood production. • Implications for bleeding: Spleen Qi deficiency can lead to bleeding, especially downwards from the uterus, bladder, and bowels. • Controls the muscles and four limbs: extracts Food-Qi from food to nourish all tissues, and refined Qi is transported to the muscles, particularly those of the limbs. • Determines physical energy: Spleen is the central factor in determining physical energy, and tiredness is often related to Spleen Qi deficiency. • Opens into the mouth: functional relationship with the mouth, influencing the sense of taste, chewing, and appetite. • Manifests in the lips: a reliable indicator of Spleen state, with rosy and moist lips indicating normal Spleen-Qi. • Controls saliva: influences the secretion of saliva, which aids digestion and moistens the mouth. • Controls raising of Qi: produces a lifting effect on the organs, ensuring they are in their proper place.

TCM Spleen Additional Points

• Houses the Intellect (Yi): Spleen is the residence of the Intellect, responsible for applied thinking, studying, memorizing, focusing, and generating ideas. • Affected by pensiveness: brooding, nostalgic thinking, or excessive mental work can affect the Spleen, leading to poor digestion and stagnation of Qi in the Middle Burner.

TCM Stomach Functions

• Controls 'receiving': receives food and drink, holding them down, and is related to appetite and digestive function. • Controls the 'rotting and ripening of food': transforms ingested food and drink by fermentation, preparing the ground for the Spleen to separate and extract refined essence. • Controls the transportation of food essences: together with the Spleen, responsible for transporting food essences to the whole body and limbs. • Controls the descending of Qi: sends transformed food downwards to the Small Intestine, ensuring good digestion and trouble-free passage.

Low Back Pain with Radiculopathy

Lifestyle Guidance for Treatment/Prevention

• Keep moving to avoid worsening symptoms and prolonging recovery time
• Avoid high-impact/forceful movements and consider gentle activities such as walking, swimming, and cycling
• Regular exercise routine that stretches and strengthens back and abdominal muscles is essential
• Balancing exercises are crucial, as discs need loading (PCIS) to prevent increased risk, similar to astronauts

Weight Management and Cessation

• Support healthy weight management to alleviate low back pain
• Encourage smoking cessation, if applicable, to reduce pain exacerbation

Alternative Therapies

• Gentle yoga/pilates practice can help with stretching and relaxation
• Massage therapy and hydrotherapy (alternating hot and cold) can aid in pain relief

Sleep and Posture

• Educate patients on appropriate sleep positions (avoiding tummy sleeping) and use of pillows for support
• Consider the firmness of the mattress for optimal spinal alignment

Treatment Plan and Goals

• Identify treatment goals and propose a treatment plan with supported rationale for treatment
• Consider ND products, nutritional guidance, lifestyle modifications, and collaborative care in the treatment plan
• Top 3 suggestions for treatment plan: [insert specific suggestions]

Vitamin C

• Helps in the process of healing fractured and broken bones, wounds, and burns
• Increases calcium absorption in the body, promoting strong and healthy bones
• Food sources: kiwi, papaya, strawberry, citrus fruits, red peppers, parsley, broccoli, Brussels sprouts, asparagus, kale
• Percentage of vitamin C absorbed decreases with increasing intake, making intravenous administration necessary for high levels in the blood
• Those at most risk of deficiency: children under 1 year, the elderly, people with low fruit and vegetable intake, cigarette smokers, and those with gastro-esophageal reflux disease
• Upper tolerable intake level (UL) is 2g/d, with common adverse effects including gastrointestinal symptoms, diarrhea, and dental erosion
• Caution: increased risk of oxalate stone formation, and diseases of iron metabolism such as hemachromatosis, thalassemia, and sideroblastic anemia

Magnesium

• Deficiency is one of the main causes of chronic back pain
• Supports muscle and nerve function, with a deficiency directly related to impaired muscle and nerve function affecting the back
• Food sources: nuts and seeds, legumes, whole grains, most vegetables, seafood, dairy products, coffee, tea, cocoa, and chocolate
• Increased risk of deficiency: renal disorders, chronic alcohol abuse, and the elderly
• Deficiency symptoms: muscle tremor, spasms, cramps, tetany, chest tightness, shortness of breath, palpitations, cardiac arrhythmias, anxiety, depression, fatigue, insomnia, loss of appetite, nausea, and vomiting
• Contraindications: end-stage renal disease, myasthenia gravis, urinary tract infection with elevated urinary phosphates, kidney stones, and hyperparathyroidism

Proteolytic Enzymes

• Effective in reducing inflammation and symptoms related to inflammatory conditions
• Preliminary evidence suggests they may be helpful for various forms of chronic pain, including osteoarthritis
• Food sources: digestive enzymes (see sources)
• Recommended dosages: bromelain 1,200-2,000 GDU, fungal protease 100,000-200,000 HUT, nattokinase 2,000-4,000 FIP, papain 3,000,000-6,000,000 PU, and serrapeptase 80,000-160,000 SPU

Vitamin D

• Bone and lower back pain may be symptoms of inadequate vitamin D levels
• Maintains bone health by improving calcium absorption
• Skin production depends on length of exposure to the sun, amount of bare skin exposed, season, time of day, level of latitude, degree of pigmentation, and age
• One study linked lower levels of vitamin D to more severe pain in adults with lower back pain
• Recommended dosage: 1000 IU/day

Summary

• Recommended supplements for low back pain: vitamin C 1000 mg/day, magnesium 400 mg/day, proteolytic enzymes, and vitamin D 1000 IU/day

Radiculopathy

• Radiculopathy is a condition where the pain radiates from the low back down the buttock and leg, accompanied by numbness or tingling, weakness in the leg/foot, and symptoms are typically unilateral (affecting one side of the body).
• Symptoms worsen with prolonged sitting or walking, and sometimes with coughing or sneezing.

Remedies for Back Pain with Radiculopathy

• Colocynth (bitter cucumber)
• Kali-phos (potassium phosphate)
• Mag-phos (magnesium phosphate)

Colocynth

• Contains cucurbitacin glycosides, also present in Bryonia Alba.
• Affinity: Smooth muscles of digestive tract, peripheral nervous system, and cranial nerves.
• Sensations: Violent cramping pain, drawing, twitching pains in the region of the left hip or sharp pains in the region of the right hip.
• Modalities: Aggravations from annoying vexation, amelioration from strong pressure, flexing the thigh towards the pelvis, heat, and pain better in the warmth of the bed.
• Concomitants: Extreme irritability, anger, and agitation during pain, urinous odor of perspiration.

Kali-phos (Kali Carbonicum)

• Affinity: Digestive and respiratory mucous membranes, circulatory system, central nervous system, and articular system.
• Sensations: Shooting, stabbing, burning, hypersensitivity to noise, and sensation of anxiety in the epigastric pit (solar plexus).
• Modalities: Aggravations between 2 to 4 AM, slightest draft or cold weather, improvement from heat, when sitting, leaning forward, and during movement.
• Concomitants: Viscous secretion, difficult to expel, craving for sweets, sweating, anxiety felt in the solar plexus, and swelling around/above/below the eyes.

Magnesium Phosphate (Mag-phos)

• Affinity: Central nervous system and muscles.
• Sensations: Intense, shooting, flashing pains appearing and disappearing quickly.
• Modalities: Aggravations from cold, improvement from bending over double, from local pressure, and from heat.
• Concomitants: Agitation, need to move constantly because of the pain.

Review Question

• A 64-year-old female with severe shooting pain in her back, weakness, and knee instability, accompanied by anxiety and a butterfly sensation in the stomach, resonates with the symptoms of Kali-phos.

Outcome Measures for Lumbar Radiculopathy

• Increase pain-free range of motion
• Increase time-to-onset of pain during activities
• Restore proper sensation to affected areas

Botanical Actions to Consider for Lumbar Radiculopathy

• Anti-inflammatory
• Hepatic
• Diuretic
• Analgesic
• Adaptogen

Featured Herbs by Botanical Action

Anti-inflammatory

• Turmeric (Curcuma longa)
• Devil's claw (Harpagophytum procumbens)
• Frankincense (Boswellia serrata)
• Cat's claw (Uncaria tomentosa)
• St. John's wort (Hypericum perforatum)

Analgesic

• Corydalis (Corydalis yanhusuo)
• Kava kava (Piper methysticum)
• Cayenne (Capsicum annua)
• Cannabis (Cannabis indica)
• Jamaican dogwood (Piscidia piscipula)

Adaptogen

• Ganoderma spp.
• Bone broths to promote macro and micro nutritional requirements

TCM Integration - Lumbar Radiculopathy

• Sciatic pain caused by an obstruction of the nerve or nerve roots is diagnosed as a Bi (pain obstruction) syndrome
• Sciatic pain is often viewed as an obstruction of the Gall Bladder meridian
• Pain is treated by removing the obstruction to re-establish the smooth flow of Qi and Blood

Selected Monographs

Bupleureum chinensis (Chai hu)

• Primary Actions: Hepatic, alterative, anti-inflammatory, hepatoprotective
• Constituents: Triterpene saponins, sterols, volatile oils, polysaccharides
• Indications: Hepatic congestion, arthritis, chronic inflammation, acute infections with fever
• Cautions/Contraindications: Avoided in cold conditions or constitutions
• Pairs Well With: Berberis vulgaris, Uncaria tomentosa, and Harpagophytum procumbens for inflammation, especially of joints

Boswellia serrata (Frankincense)

• Primary Actions: Antimicrobial, anti-inflammatory, astringent
• Constituents: Resins, boswellic acid, volatile oils
• Indications: Inflammatory joint conditions, IBD, topical antimicrobial
• Cautions/Contraindications: Considered safe, though not generally taken internally in large amounts
• Pairs Well With: Salvia officinalis as an antimicrobial for oropharyngeal and upper GI infections

Capsicum frutescens (Cayenne)

• Primary Actions: Stimulant, circulatory tonic, rubefacient, sialagogue, libido tonic
• Constituents: Capsaicinoids (capsaicin), steroidal saponins
• Indications: Circulatory deficiencies, arthritic conditions, pain relief, depression
• Cautions/Contraindications: Non-toxic, but large doses will cause sweating and possible syncope
• Pairs Well With: Zanthoxylum americanum as warming circulatory tonic

Corydalis yanhusuo (Corydalis, Yan hu suo)

• Primary Actions: Analgesic, hepatic, warming carminative
• Constituents: alkaloids, volatile oils
• Indications: Any pain, often used specifically for menstrual pain relief
• Cautions/Contraindications: Do not use in pregnancy, will cause drowsiness in higher doses
• Pairs Well With: Curcuma longa for menstrual cramp pain, or any pain due to stagnation/obstruction

Curcuma longa (Turmeric)

• Primary Actions: Anti-inflammatory, mild antimicrobial, carminative, circulatory tonic
• Constituents: Phenolic antioxidants, curcumin, volatile oils, starches
• Indications: General inflammatory conditions, OA and RA, possibly cancer lesions (topical), stomach ulcers and dyspepsia
• Cautions/Contraindications: Broadly considered safe, though acts as a mild inhibitor of phase I and inducer of phase II liver conjugation
• Pairs Well With: Dioscorea villosa for inflammation related to circulation

Glycyrrhiza glabra (Licorice)

• Primary Actions: Adaptogen, particularly to the adrenals; anti-inflammatory, demulcent, antiviral, hypertensive
• Constituents: Triterpene saponins (glycyrrhizin), glycyrrhetinic acid, chalcones
• Indications: Ongoing stress, hypotension, asthma, eczema, chronic or acute bronchitis, emphysema, URTI, post-viral cough, stomach ulcers (mostly DGL)
• Cautions/Contraindications: CI in hypertension, Preg A, Lact C
• Pairs Well With: Rosmarinus officinalis for coughs, especially viral coughs, Bupleurum sinensis in anti-inflammatory combos where clearance by the liver is suboptimal, and Hypericum perforatum and Melissa officinalis (as infused oil) for the topical treatment of herpes infections

GABA Derivatives

• Pregabalin and Gabapentin are typically reserved for soft tissue and hyperalgesic pain
• Act centrally, with a complicated mechanism of action that has yet to be fully explained
• Originally designed as GABA analogues and are classified as anticonvulsants, but do not interact with GABA receptors
• Bind α2δ1 receptors of voltage-gated calcium channels, modifying calcium entry and reducing neurotransmitter release
• Most important area is the dorsal horn of the spinal column, where these receptors are upregulated in response to pain

Adverse Effects of GABA Derivatives

• Most common: sedation, ataxia, tremor, dizziness, dry mouth, weight gain
• May also cause GI upset, peripheral edema, and vision changes
• Cannot be abruptly discontinued – dose should be tapered over a minimum of 1 week to avoid withdrawal effects

Dosing of GABA Derivatives

• Gabapentin: initial dose is 300-400 mg/day PO divided TID, can increase at weekly intervals to a maximum of 3600 mg/day divided TID
• Pregabalin: initial dose is 50-150 mg daily PO divided BID, may increase weekly by 50-150 mg/day to a maximum of 600 mg/day divided BID
• Does not have any significant interactions and is typically preferred as it is taken twice a day vs three times a day with gabapentin

Muscle Relaxants

• A broad term that includes drugs from different classes, loosely differentiated into antispasmodics and antispastics
• All muscle relaxants are not recommended for those over the age of 65

Antispasmodics

• Decrease muscle spasm associated with pain
• Further classified as benzodiazepines or non-benzodiazepines
• Methocarbamol is a non-benzodiazepine antispasmodic that actually has no effect on the contraction of muscle fibers, motor end plates, or nerve fibers
• Mechanism of action is thought to be dependent on its CNS depressant activity, blocking spinal polysynaptic reflexes, decreasing nerve transmission, and prolonging the refractory period of muscle cells

Adverse Effects of Methocarbamol

• Can cause drowsiness, dry mouth, dizziness, fatigue, nausea, and constipation
• Combination with other CNS depressants or opioids can increase the risk of CNS depression

Dosing of Methocarbamol

• 1 g QID PO

Antispastics

• Reduce muscle rigidity/spasticity that interferes with therapy or function (as in cerebral palsy, for example)
• Mechanism of action is dependent on the actual drug as there are a number of drugs from various classes that fall into this category
• Baclofen is a GABA receptor agonist specific for the beta subunit, which is primarily expressed on pre- and post-synaptic neurons
• Binding causes an influx of potassium into the neuron, causing hyperpolarization and decreased calcium influx at presynaptic nerve terminals
• Results in the reduced rate of action potentials and reduced activation of post-synaptic motor neurons that innervate muscle spindles

Adverse Effects of Baclofen

• Can cause sedation, muscle weakness, nausea, dizziness
• In rare cases can cause hepatotoxicity
• Potential additive CNS depression with other drugs like opioids and benzodiazepines
• Dose should be adjusted gradually to minimize adverse effects and tapered to avoid withdrawal symptoms

Dosing of Baclofen

• Initial dose: 5 mg TID PO
• Increase gradually to a maximum of 20 mg TID

Low Back Pain

• Use of muscle relaxants for low back pain is controversial, mostly due to significant adverse effects
• Most guidelines caution against their use
• Despite that, they are widely used, possibly given increased hesitancy to recommend opioids