Three Types of Pain:
Medical diagnosis generally assumes that pain is a signal of tissue injury being being transmitted to the brain via a healthy nervous system. The International Association for the Study of Pain even promotes this limited view by defining pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage."
This definition is true when it comes to acute injury where tissue damage is clearly the culprit. However, it is very common for pain to persist for months or even years, long after the initial injury has healed. The majority of pain that presents in clinical practice is typically of this sort. These patients have often been previously subjected to numerous rounds of anti-inflammatory medications, corticosteroid ("cortisone") injections and if all else fails, antidepressants and sleeping pills. They bring a history of failed efforts to get relief because their pain reveals absent or minimal inflammation and no history of recent injury.
The traditional model fails to explain many common pain syndromes that are actually caused by problems affecting the spine, the spinal cord and spinal nerves. We typically think that pain is linked to tissue injury, but it is not necessarily so. In fact, most chronic pain does not persist due to tissue injury because the injury has already healed long ago. Injury does not always generate pain, nor does pain always signal injury. Persistent pain can occur in the presence of the following conditions:
1. Damaged tissue causing ongoing irritation (nociception) for example, an injury from a strain or accident, an unhealed fracture or persistent inflammation such as occurs in rheumatoid arthritis.
2. Psychological factors such as depression, somatization disorders, or adverse operant learning processes (for example, an individual can develop an emotional conditioned response pattern that causes them to experience pain).
3. Pinched nerve. Nerves passing through the spine and through the soft (connective) tissue. Nerve interference can induce a chronic pain syndrome call neuropathic pain. In neuropathic syndromes involving the muscles or other connective tissue we will often see muscle tightness and spasm, muscle, tendons and ligament weakness and which all contribute to pain and injury.
Careful examination of long term persistent pain syndromes often reveals them to be the effects of the third type of pain which is neuropathy (malfunction of a nerve) showing up in the musculoskeletal system. In other words, the real underlying problem is a malfunction in the nerves, not the muscles or connective tissues themselves, even though that is where the pain appears to emanate from. Patients that complain of painful muscle tightness and spasm are often surprised to learn that muscles don't contract without stimulation, typically from a motor neuron. Muscle tightness, spasm and pain, the common myofascial pain syndromes that appear without the presence of recent injury or underlying pathology in the muscle, are the result of nerve malfunction.
Signs of Neuropathy
Neuropathic pain shows visible features of nerve dysfunction in the painful area, as well as at the corresponding spinal level. There are subtle signs that you can even use yourself at home to confirm the category of pain. These signs outperform laboratory tests and are frequently more sensitive than radiological investigations which do little to show myofascial pain and neuropathy.
Sensory Alteration:
The painful area is tender to finger pressure. Tenderness is maximal over motor points where the nerve enters a muscle or tendon. These generally correspond to acupuncture and trigger points. Sometimes multiple tender points occur when more than one spinal segment is involved, which is known as fibromyalgia. Tenderness can also be located in the spinal muscles.
As the condition progresses and the nerve begins to degenerate the pain is replaced by numbness. At this point the patient may “feel better,” but the condition is actually getting worse.
Autonomic Features:
The painful part is usually colder due to vasoconstriction from irritation to autonomic nerves. There may be excess perspiration and/or goosebumps over the painful area. There may be excess fluid in the subcutaneous tissues.
Internal Organs:
Peripheral nerves all innervate internal organs. Neuropathy in these autonomic nerves often goes unsuspected. Patients frequently have no clue how many of their common health problems are the result of spinal nerve interference in the autonomic nerves. They are often being medicated for these conditions without realizing that the cause is very often a correctable spinal condition. For example high blood pressure, stomach and intestinal problems like irritable bowel syndrome, certain skin problems, certain respiratory conditions and a long list of other common health problems have a strong connection to spinal neuropathy. The list of common conditions that are known to actually be caused by spinal neuropathy is likely to continue to grow in the future as both patients and doctors demand answers that go deeper than merely altering symptoms with pharmaceuticals.
Trophic Changes (due to reduced nerve stimulation):
Nerves control the growth and nourishment (trophic factors) of the parts they innervate. When nerve function is decreased there are nutritional losses to the tissue often seen in the skin, nails, muscle and bone in cases of neuropathy. These changes are often observed as localized hair loss, brittle nails, thin, weak, abnormal skin and skin conditions such as psoriasis. Internal changes include degeneration of discs, ligaments, tendons, cartilage as well as internal organs supplied by the affected nerve.
Muscle/Motor Abnormalities:
Changes in the muscles are usually the most symptom producing aspect of neuropathic pain. These changes can be extremely painful because of supersensitive nerve receptors in muscle. The shortened, irritated muscles can produce further mechanical pain by pulling on tendons and joints.
The most critical muscle shortening is in the spinal muscles that compress the disc and sometimes the nerve root. Neuropathy is the primary condition and the symptoms in the muscles, skin, organs and other peripheral structures are the results. Examination of the spine and target tissues may reveal muscle shortening, muscle contracture, shortened paraspinal muscles and facet joint syndrome (jamming of the posterior spinal joints).
Clinical Tests For Neuropathy
Typical neurological evaluation such as deep tendon reflex testing, nerve conduction studies and imaging studies like x-rays, CT and MRI scans often give little clue on the presence of the subtle type of neuropathy typically seen in clinical practice that creates so much misery for patients. Patient's often go from doctor to doctor, often being told the problem is “all in your head.”
Clinical evaluation should include basic neurological and orthopedic evaluations. However, for neuropathic syndromes we must also look for the signs listed above. In addition there are specific indicators that a doctor who understands this condition will look for. Detailed objective measures of skin temperature changes using paraspinal infrared thermography will help to isolate precise areas of neuropathic involvement of the autonomic nerves. Areas of paraspinal muscle imbalance (motor neuron) can be visualized using surface electromyography. Beyond their usefulness in evaluating subtle neuropathy, the advantage of these tests is that they are painless, non-invasive and non-irradiating and can be used to chart progress as well.
In addition physical evaluation by a skilled doctor should include examination of the areas of complaint, the motor points of involved muscles, the entire spine, and in particular the area of suspected nerve root involvement. The spine should be evaluated both segmentally and on an overall biomechanical level including the joints of the extremities (arms and legs) for potential involvement. Often areas of the spine with nerve root involvement are themselves the result of other areas of biomechanical compromise.
Neuropathy Leading To General Illness and Disease
Pain is just one possible result of the neuropathy. Chronic pain is most often neuropathic pain and when neuropathy is the culprit there can be involvement of any combination of sensory nerves (pain, tingling, numbness), motor nerves (spasm, weakness) or autonomic nerves (problems affecting the internal organs, glands and circulation).
It may be surprising to hear that nerve root problems can lead not just to pain, but to illness in the internal organs. In my own practice of nearly 20 years I have repeatedly seen the correction of lower back issues improving and even resolving many “unrelated” problems, including:
- Fertility problems
- Menstrual cramps
- Testicular pain
- Constipation
- Painful intercourse
- Migraine headaches
- Sleep disorders
- Vision problems
- High blood pressure
- Carpal tunnel syndrome
- Depression
- Asthma
- Stomach and digestive problems
- Shoulder pain
- Tennis elbow
The conditions I list here have resolved in numerous patients when the spine was corrected to the degree that pressure on the nerve roots and peripheral nerves was relieved. There are many more conditions than are shown here that have also improved when nerve pressure is relieved in the spine. The resolution of other health disorders with the correction of spinal problems continues to confirm the underlying anatomy and “wiring” of the nervous system to not only convey sensory information and muscle control, but also the signals that control the function of all the internal organs and even the cellular immune system. It would behoove anyone suffering from just about any health problem to resolve the underlying neuropathy.
Treatment:
Pharmacological Agents: Treat the symptom.
Medical treatment has had limited success with pharmaceutical treatment because it does nothing to correct the underlying mechanisms of the condition. Controlled clinical trials for peripheral neuropathic pain have concluded that pharmacological management of neuropathic pain has limited success in most cases. Corticosteroids can often give dramatic and sometimes long-term relief, but they have the detrimental effect of weakening the connective tissue being injected and may set the stage for further re-injury of the very tissues seeking help. The data is contradictory for oral non-steroidal anti-inflammatory medication (NSAID's) such as ibuprofen and acetaminophen, and intravenous morphine. There are numerous other drugs that have limited or negligible effectiveness when it comes to neuropathic pain including codeine, magnesium chloride, propanol, lorazepam, intravenous phentolamine, topical dimethyl sulfoxide, epidural clonidine, intravenous regional blocks with bretylium and ketanserin. and regional and systemic adrenergic blockages.
Pharmaceutical treatment is more helpful in relieving acute inflammatory symptoms such as those immediately following injury. Pain from psychosomatic origins is likely to respond best to psychological therapy aimed at behavioral modification such as cognitive therapy. However, there is no long-term data to support the effectiveness of any drug in treating neuropathic conditions. If a person is choking the obstruction must be removed. There is no drug that can do that. When a nerve is "choked" medication cannot correct it.
Physical Therapy & Massage: Treat the effects.
Physical therapy is widely used with some effectiveness as a first-line treatment for peripheral neuropathic pain that arises due to nerve entrapment in the peripheral tissues. That being said, most nerve entrapment doesn't actually occur in the peripheral tissue. Since neuropathic pain is a nerve supersensitivity issue, physical therapy treatment involves desensitization by electric stimulation, massage to activate tactile and pressure receptors, exercise, and heat and cold to act on thermal receptors. Symptomatic changes are possible by altering the sensitivity of the affected tissues, but this does nothing to correct the underlying nerve root disorder which is most often the result of spinal misalignment and/or degeneration.
Massage can address issues in the outermost muscle layers, but the small strong inner muscles that directly impact the disc and nerves of the spine, cannot be reached with massage. However, specific soft tissue work is important in addressing the secondary changes in the target muscles and tendons such as fibrotic adhesion.
Chiropractic: Correct the Cause
Removing the cause of neuropathy is the key to successful treatment. Spinal misalignment and degeneration (spondylosis) is, by far, the most common cause of neuropathic pain and radiculopathy (radiating symptoms). Rather than merely chemically altering the inflammatory response with drugs, treatment needs to be aimed at relieving the cause of impingement or entrapment of the nerve root at the level of the spine. In some instances a peripheral entrapment can also occur as a nerve passes through a muscle or tendon. Local treatment involving the specific release or tender, shortened muscle fibers in the distribution of the affected nerve (myotome), including the muscles along the spine (paraspinal muscles). Most importantly, the spinal vertebrae surrounding the affected nerve root level must then be assessed to determine the precise imbalance or misalignment that is causing the pressure. The skilled chiropractor must then reposition the vertebrae to the best degree possible. Long term misalignment typically requires a series of adjustments to reduce nerve pressure below the threshold that is producing the neuropathy. The outcome of treatment depends on the appropriateness of the techniques and the skill of the practitioner.
Going Beyond Pain
It is only through hands-on examination of patients, explicitly searching for neuropathic signs, that one is able to understand and treat neuropathic myofascial pain. Drug treatment does nothing to address the real cause. Physical treatment focusing on the actual source of the problem at the site of nerve pressure is the logical and effective approach. It is a convincing experience to diagnose the source of a neuropathic problem, correct the spine and associated soft tissues and see the signs disappear, often within minutes.
Relief from pain is certainly a strong motivator and often sets us on the path to seek a remedy. However, once we understand the underlying mechanisms that created the problem and the potential overall affect of neuropathic syndromes on our health, even in the absence of pain, we should seek regular chiropractic care in a more proactive way.
Neuropathy from the spine is so common, not just in pain syndromes, but in health problems of all sorts, that even in the absence of pain, chiropractic should be part of regular health care for every person, including children and adolescents, with the purpose of helping maintain health and well being in every area.
