You seem to have neglected to emphasise the importance of myofascial
pain in common chronic back pains. Most back pains are caused by muscle
dysfunction, and most physical therapies (osteopathy, chiropractic,
acupuncture) can help the chronic sufferer if the acute phase is not self-
limiting. Chronic muscular back pain, if unrelieved, will cause bone,
joint, and disc disorders eventually.
I think we all, as medical practitioners, would be wise to look back
at the important work done decades ago by the following authors:
- 1938 BMJ 1: 321-325; Sir Thomas Lewis, director of clinical
research at U.C.H., “Suggestions Relating To The Study Of Somatic Pain”.
“As an experimental method of producing muscle pain, the injection of a
minute quantity of salt solution is the most satisfactory … In these
observations I have noted that muscle pain is referred to a distance. Thus
pain arising from the lower part of the triceps is often referred down the
inner side of the forearm to the little finger, from the trapezius it is
usually referred to the occiput. I have been fortunate in interesting Dr.
Kellgren in this matter. In a long series of very careful researches
carried out in my laboratory he has formulated some very striking
principles underlying the reference of pain from muscle - principles which
appear to have an important practical bearing”.
- 1938 Clinical Science 3: 175-190; Dr. J. Kellegren at UCH London
(Later Prof. of Rheumatology at Manchester), injected hypertonic saline
into muscle to produce the “Observation of pain arising from muscle”.
i) pain of myalgia arises from small discrete and exquisitely tender
areas within muscle. The pain is reproduced by pressure, relieved by
Novocain (procaine).
ii) these exquisitely tender areas found on palpation are some distance
from the pain described by the patient, i.e. muscular pain is referred,
and follows a segmental distribution.
- 1944 Journal Of Nervous And Mental Diseases 99: 660-667; V. Inman
(anatomist) & Dr. J. Saunders (orthopaedic surgeon) at University Of
California Medical School, “Referred Pain From Skeletal Structures”.
i) stimulation of the periosteum or the insertions of ligaments and
tendons causes extensive and distant radiation of pain.
ii) so constant is the distribution of radiated pain, that it can be
mapped and charted.
iii) the distribution of radiated pain does not relate to the known
anatomical distribution of the peripheral nerves.
- 1952 Postgraduate Medicine II: 425-434; Dr. Janet Travell & S.
Rinzler in USA followed up Kellegren’s work to show its clinical
significance with the classic text “The Myofascial Genesis Of Pain”.
i) mapped out the patterns of referred pain in about 1000 patients.
ii) found that tender areas in muscle trigger off a referred distant
pain noticed by patient.
iii) coined terms trigger point, and myofascial pain, and zones of pain
referral.
iv) neural hyperactivity at trigger points can be abolished applying:
- sustained pressure
- ethyl chloride spray to skin
- injecting procaine
- mechanical stimulation of a dry needle.
These researchers showed that the current specialist model of chronic
back (and other musculoskeletal) pain is too narrow and simplistic. They
help to identify where our current theories fall short, and why much
orthopaedic management of these conditions is doomed to failure.
It is a shame that their work has been forgotten, and I hope to
rekindle interest in their discoveries, for the sake of our patients.
Rapid Response:
Don't forget muscle pain mimics disc/nerve compression
You seem to have neglected to emphasise the importance of myofascial
pain in common chronic back pains. Most back pains are caused by muscle
dysfunction, and most physical therapies (osteopathy, chiropractic,
acupuncture) can help the chronic sufferer if the acute phase is not self-
limiting. Chronic muscular back pain, if unrelieved, will cause bone,
joint, and disc disorders eventually.
I think we all, as medical practitioners, would be wise to look back
at the important work done decades ago by the following authors:
- 1938 BMJ 1: 321-325; Sir Thomas Lewis, director of clinical
research at U.C.H., “Suggestions Relating To The Study Of Somatic Pain”.
“As an experimental method of producing muscle pain, the injection of a
minute quantity of salt solution is the most satisfactory … In these
observations I have noted that muscle pain is referred to a distance. Thus
pain arising from the lower part of the triceps is often referred down the
inner side of the forearm to the little finger, from the trapezius it is
usually referred to the occiput. I have been fortunate in interesting Dr.
Kellgren in this matter. In a long series of very careful researches
carried out in my laboratory he has formulated some very striking
principles underlying the reference of pain from muscle - principles which
appear to have an important practical bearing”.
- 1938 Clinical Science 3: 175-190; Dr. J. Kellegren at UCH London
(Later Prof. of Rheumatology at Manchester), injected hypertonic saline
into muscle to produce the “Observation of pain arising from muscle”.
i) pain of myalgia arises from small discrete and exquisitely tender
areas within muscle. The pain is reproduced by pressure, relieved by
Novocain (procaine).
ii) these exquisitely tender areas found on palpation are some distance
from the pain described by the patient, i.e. muscular pain is referred,
and follows a segmental distribution.
- 1944 Journal Of Nervous And Mental Diseases 99: 660-667; V. Inman
(anatomist) & Dr. J. Saunders (orthopaedic surgeon) at University Of
California Medical School, “Referred Pain From Skeletal Structures”.
i) stimulation of the periosteum or the insertions of ligaments and
tendons causes extensive and distant radiation of pain.
ii) so constant is the distribution of radiated pain, that it can be
mapped and charted.
iii) the distribution of radiated pain does not relate to the known
anatomical distribution of the peripheral nerves.
- 1952 Postgraduate Medicine II: 425-434; Dr. Janet Travell & S.
Rinzler in USA followed up Kellegren’s work to show its clinical
significance with the classic text “The Myofascial Genesis Of Pain”.
i) mapped out the patterns of referred pain in about 1000 patients.
ii) found that tender areas in muscle trigger off a referred distant
pain noticed by patient.
iii) coined terms trigger point, and myofascial pain, and zones of pain
referral.
iv) neural hyperactivity at trigger points can be abolished applying:
- sustained pressure
- ethyl chloride spray to skin
- injecting procaine
- mechanical stimulation of a dry needle.
These researchers showed that the current specialist model of chronic
back (and other musculoskeletal) pain is too narrow and simplistic. They
help to identify where our current theories fall short, and why much
orthopaedic management of these conditions is doomed to failure.
It is a shame that their work has been forgotten, and I hope to
rekindle interest in their discoveries, for the sake of our patients.
Competing interests:
None declared
Competing interests: No competing interests