Dr. Kalika’s comprehensive approach to treatment of myofascial pain syndrome is completely a non-invasive, but exceptionally effective approach to pain management and treatment.
Myofascial pain syndrome (MPS) is a musculoskeletal disorder that produces local and referred pain. MPS is characterized by a palpable a taut band which upon palpation produces movement dysfunction, unpleasant sensation and pain.
MPS can be a primary or a secondary disorder that is caused by another condition. It can be acute or chronic, regional or generalized. The functional unit of MPS is called a trigger point (TP). Treatment of chronic MPS requires a multifactorial approach addressing posture, ergonomics, structural deviations, misalignments and metabolic factors.
Historically MPS have been treated with variety of manual techniques. Myofascial trigger point therapy has been done with simple compression of palpable knots in the muscles or approximation of the muscular tissue with compression. It has been my clinical experience as well as experience of my European colleagues that trigger points (TP) in different locations of a muscle respond better to different type of treatment.
With advancement of shockwave technology MPS treatment has much higher success rate with the use of combination of different types of shockwaves, manual techniques and remedial exercise. Moreover, the long-term effects of shockwaves are superior to then those of classic muscle treatments due to the regenerative process they induce (angiogenesis and mechanotrunsduction).
Shockwaves are sonic waves that induce physiological reactions diminishing impact of local muscle pain upon penetration of a muscle tissue.
Based on our experience and experience of our European colleagues shockwave therapy offers better diagnostic accuracy and higher therapeutic effectiveness then classic trigger point treatments.
At NYDNRehab we have tremendous experience treating muscle pain and myofascial pain syndromes with a variety of manual methods combined with advanced technological methods and acupuncture.
We have consistently seen that each of these modalities compliments our manual therapies in different ways when we treat myofascial pain (pain induced from local trigger points). For the past eight years we have been using two different shockwave machines (EPAT-pulse activated and focused electromagnetic shockwave) we have been able to map which trigger points respond better to shockwave versus acupuncture and yet there are still others conditions that respond better to manual methods. Concurrently the combined approach to treatment of myofascial pain literature from European leaders in manual medicine confirmed our experiences. Orthopedic physicians and physiotherapists in Europe have rapidly adopted this approach today.
FSW stimulate a reduction of small pain fibers (nociception), whereas EPAT waves (radial pressure waves) produce pain modulation and decrease irritation effect through GABAergic interneurons in the dorsal horn of the spinal cord.
Moreover, the oscillations and pressure of EPAT waves increase blood circulation and facilitate lymphatic drainage. The trigger points occurring at the tenoperiosteal junction (bone-tendon interphase) as well as taut bands and scar tissue may be successfully eliminated by cross movement swiping of the EPAT waves to the direction of the tendon.
The effectiveness of EPAT waves on the myofascial chains as described by Karel Lewit MD (the pioneer of manual and needling treatment of myofascial pain) and later by Thomas Myers in his Myofascial trains research, can be shown through the use of EPAT smoothing in the direction of muscle fiber or in the direction of connections between muscles. Once the particular patterns of these myofascial chains are recognized and their connections are understood, EPAT smoothing application can address these muscular crosslinks. The application of EPAT has also shown to have effect in improving local circulation (reactive hyperemia) and reduce the quantity of vasoneuro-active substances within the generalized treatment area.
FSW provides the most reliable diagnosis of inducible myofascial pain (trigger point phenomena). They are also used diagnostically because their depth of wave penetration can be altered. FSW can reach up to four inches deep in the muscle tissue. When suspected area of muscle pain is scanned with a focused head it picks up active myofascial trigger points by pain feedback of sound wave hitting the painful trigger point area. Depending on the type of transmitter different depth in the muscle can be reached. Some of the trigger points localized by focused scanning are so deep that they are not reachable with manual techniques or radial shock wave. Then we proceed by mapping these deep-seated active trigger points and depending on location and anatomy we choose between focused shockwave and acupuncture needling treatment. Once active trigger points are mapped out with focus shockwaves and the passive trigger points and satellites are palpated we begin treatment with EPAT going over larger muscles in the area for smoothing effect. Then needling and/or focused shockwaves are performed for deep-seated trigger points or tendon insertion trigger points. If on needle penetration of a tendon in proximity with the bone (bone tendon interface) insertion hardening is noted tendonopathy (degeneration of the tendon) or enthesiopathy (degenerative condition of tendon insertion to the bone) is suspected and based on the depth we clinically choose between focused and radial shockwaves. In our experience we maintain that using manual fascial release has much better results in combination with EPAT/ESWT and acupuncture that targeting the muscle tissue directly. Our patients have much better rate of success with this combined approach then using either one of them separately. We have perfected this elaborate combination into a very effective treatment method.
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