"SPRAY-AND-STRETCH"

TREATMENT FOR MYOFASCIAL PAIN

Most physicians encounter patients with myofascial pain. But all to often, we fail to recognize and treat it -- or we take easy ways out: aspirin, drugs, or heat. Many patients who don't respond to such treatment are labeled crocks or referred to psychiatrists.

You may be properly skeptical of this spray-and-stretch approach if you've been exposed to lectures, demonstrations, or articles dealing with ethyl-chloride spraying of painful areas. Certainly, I was skeptical years ago when I attempted to chill and anesthetize pain-trigger areas in patients. My results with ethyl chloride were poor, and I abandoned the attempts altogether.

Then I learned the special method used by Dr. Janet Travell, former physician to Presidents Kennedy and Johnson -- and I was astonished by the results. Now I use or prescribe this technique almost every day.

Instead of ethyl chloride, the substance used with this technique is a mixture of trichloromonofluoromethane (85 per cent) and dichlorodifluoromethane (15 per cent). It's available -- as Fluori-Methane under light pressure in glass and metal bottles with calibrated nozzles.

Pressing the handle produces a continuous jet stream that's directed at the skin from about 18 inches away. The mixture vaporizes almost immediately. On each muscle, use three to six sweeping strokes of one to two seconds each, in one direction. Stretch the muscles in a natural way with a free hand by moving the joints over which they or their tendons pass. For back muscles, rock the back, while sitting, or bend over a chair.

The liquid jet stream, used this way, has only a momentary chilling effect, but it doesn't freeze or anesthetize the flesh, as you might expect. Frosting must be avoided. The proper effect is best described as a light touch on the skin.

The hydrocarbon mixture is far safer to use than ethyl chloride. The hydrocarbon mixture is nonflammable, nonexplosive, and nontoxic in external use, and it ordinarily doesn't put patients to sleep if they inhale it. Shield your mouth and eyes.

Knowing exactly where to direct the liquid is essential. It's not enough to cover the area where you feel pain (which is often referred pain). Nor is it satisfactory to hit only the pain-trigger point. Sweep from the trigger point, or muscle origin, to its insertion and over the region in which the patient tells you he feels pain. For example, if pain is in the infraspinatus muscle, spray from the infraspinatus fossa of the scapula to the upper end of the humerus. At the same time, gently rotate the humerus medially -- with the patient's hand behind his back -- to stretch the infraspinatus muscle just short of producing pain, or to its resting length.

Ordinarily, you should jet the liquid into the primary-pain area. But if an occasional patient fails to get relief, try sweeping from the trigger point into the referred pain area. Satellite trigger points may have to be treated, too.

How does this combination of hydrocarbon stream and muscle stretching relieve pain? No one knows for sure, but there are rational explanations based on current knowledge about nerve impulses. For physicians who want a scientific hypothesis, here's one I consider logical: Myofascial pain is usually caused by muscle spasm, which probably reflects activity in an irritable trigger area. We can predict these trigger points, locate them, and reproduce the offending pain by palpation.

The jet stream apparently produces impulses that move faster from skin receptor organs along large afferent nerves than do painful impulses traveling from muscle spindles along smaller afferents. Both sets of impulses are relayed by the lateral spinothalamic tracts to an unknown center, perhaps at the level of the thalamus. Arriving first, the cooling impulses set up a refractory state that blocks reception of the slower pain impulses. This permits the muscle to relax and to be stretched to resting length. Then the muscle is in its normal physiological and pain-free state.

The spray-and-stretch technique has many applications. But there are contraindications, of course. For instance, if a patient has neuropathology causing muscle spasm and pain, you won't be able to help until you diagnose and treat the clinical problem. (In fact, the patient with nerve pain may get worse because stretching hurts the inflamed nerve.) Joint pain won't lessen if the joint is unstable, because the muscle can't rest without leaving the joint ligaments and/or capsule unsupported. If a bone has shortened in postfracture healing, its muscles cannot stretch to normal resting length, only to an adapted resting length.

And certain precautions are necessary. Be careful not to overchill or overstretch muscles, for that can set up painful spasms that will defeat therapy.

These qualifications notwithstanding, I recommend this therapy for selected cases of both chronic and acute pain. It can temporarily alleviate pain from cramps and burns.

 REFERENCES

Kraus, H.: Clinical Treatment of Back and Neck Pain. New York: McGraw-Hill, 1970.

Kraus, H.: Backache, Stress & Tension. New York: Simon & Schuster, 1965.

Travell, J.: Referred pain from skeletal muscle. NY State J Med 55:331, 1955.

Travell, J. and Rinzler, S.H.: The myofascial genesis of pain. Postgrad Med 2:425, 1952.

Webber, T..: Diagnosis and modification of headache and shoulder-arm-hand syndrome. J Am Osteopath Assoc 72:697, 1973.

Cutler, P., Rockwood, C.A., Jr., Grant, A.E., et al.: A practical guide to common aches and pains. Hospital Physician 8:36, 1972.

Casey, K.L.: The neurophysiologic basis of pain. Postgrad Med 53:58, 1973.

Berges, P.U.: Myofascial pain syndromes. Postgrad Med 53:161, 1973.

McMennel, J.: "Spray-and-stretch" treatment for myofascial pain. Hospital Physician 12:1-4, 1973.

Travell, J. and Simons, David: Myofascial pain and dysfunction. The Trigger Point Manual, Williams and Wilkins, 1983.

Travell, J. and Simons, David: Myofascial pain and dysfunction. The Trigger Point Manual, Volume II, Williams and Wilkins, 1992.

Barnes, John F.: Five Years of Myofascial Release. Physical Therapy Forum September 16: 12-14, 1987.

Barnes, John F.: Myofascial/Osseous Integration. Physical Therapy Forum Holiday Issue: 19-21, 1991.

Barnes, John F.: The Elasto-Collagenous Complex. Physical Therapy Forum Week of April 25 1988.

Barnes, John F.: Myofascial Release - An Introduction for the Patient. Physical Therapy Forum. Week of October 3, 1988.

Sherman, Carl: Managing Fibromyalgia With Exercise. The Physician and Sports Medicine 20:(10): 166&168-170, 1992.

Barnes, John et al: Myofascial Release: The Search for Excellence, 1990.MRF Seminars, 10 S.Leopard Rd., Suite 1, Paoli, PA, 19301.

Bennett RM, Campbell S, Burckhardt C, et al: A multidisciplinary approach to fibromyalgia management. J Musculoskel Med; 8(11);21-32, 1991

Boulware DW, Schmid LD, Baron M: The fibromyalgia syndrome: could you recognize and treat it? Postgrad Med;87(2):211-214, 1990

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