Use of cold in (self)-treatment of pain & trigger points

Spray and stretch methods - as described in several of my books, including those linked to these books.
Click on covers for more information



My previous posting looked (in part) at the protection against the common cold - with one example involving cold showers.
An earlier posting (February 2008) discussed the use of ice cold wet socks, to help with the symptoms of congestion associated with colds..... and so, what could be more natural in mid-winter than this post that offers a few thoughts on the use of ice and ice-sprays, in treatment and self-treatment of musculoskeletal pain, such as that caused by sprains and by myofascial trigger points.
In short, if there is an acute inflammatory musculoskeletal situation, it makes sense to try to make the process of recovery as painless as possible without actually blocking this natural healing process (represented by inflammation), and without causing any additional problems.

An old physical medicine acronym for management of such problems is RICE:

• Rest : this applies to the early stages after injury (e.g. sprain), but is not advised as healing progresses
• Ice: offers pain relief as well as reducing swelling which, if excessive, can slow the healing process
• Compression: this too reduces swelling, but must not be so tight as to cause throbbing
• Elevation: helps to reduce swelling

Many experts in sports medicine recommend RICE as a first step towards recovery, however if swelling and pain has not reduced after two days, or so - expert advice should be sought.
If progress towards reduced swelling and pain is obvious, then movement is called for, involving light exercise, light and careful stretching, and/or manual therapy such as massage or positional release. ....and none of these should cause pain.
If they do then whatever provokes it is probably premature or excessive.

The Mayo Clinic supports the use of ice - in inflammatory conditions - such as tendinitis:
"If tendinitis is recent, ice may be a better choice for reducing pain and inflammation. Ice causes narrowing (vasoconstriction) of blood vessels and is helpful in reducing swelling. Reducing swelling also helps reduce the level of some inflammatory substances that can be produced with tissue injury.
If tendinitis is long-standing, either heat or ice can help to improve pain.
In general, a new injury to a muscle or joint that causes swelling and pain is best treated with ice."

Sources of ice might include:

• Cold packs filled with gel can be purchased on-line, or from sports stores, as well as many pharmacies. The pack can be kept frozen and ready for use when needed. It should be applied, wrapped in a thin piece of material (toweling for example), rather than directly onto the skin.
  
• Frozen food, can be used as a readily available standby - frozen peas for example. This would be applied as in the example above - for 10 to 15 minutes per hour.
  
• A plastic drinking cup, filled with water and frozen, can be used for ice massage - with the icy surface applied directly onto the skin. A rotary pattern is recommended, involving constant slow movement to prevent 'ice-burn'. Five minutes of this, every half hour, should assist in pain control of acute musculoskeletal problems.
  

Myofascial trigger points
Manual approaches to treatment of myofascial trigger points and the pain and dysfunction they produce include :

• Identification of the trigger point by palpation
• Inhibition pressure (also known as ischemic compression and acupressure)
• Positional release methods (such as counterstrain)
• Post‐isometric relaxation or reciprocal inhibition of tissues housing trigger points followed by Muscle Energy stretching

Spray and stretch (use of vapocoolant spray during prolonged stretching of muscle housing trigger point)....SEE BELOW

• Deep tissue work (neuromuscular technique/massage)
• Procaine (or similar) injections
• Dry needling (acupuncture)
• Myofascial release of tissues housing trigger points
• Manipulation (e.g. articulation or adjustment) of associated joints as appropriate

Individually, each of these methods can partially or totally deactivate triggers. Combined, they results are often more lasting and efficient.

Cold spray and stretch methods for Myofascial trigger points
David Simons, the premier researcher into trigger points has reported that: ‘Spray and stretch is the single most effective non-invasive method to inactivate acute trigger points’
He has also said that the stretch component is the important part of this process, and that the spray is for ‘distraction’.

It is important that the coolant spray should be applied before, or during the stretch, and not after the muscle has already been lengthened.

Method
The aim is to chill the surface tissues, while the underlying muscle (housing the trigger point) is being stretched.
• A container is needed of an environmentally friendly vapocoolant spray (such as ‘Gebauer Spray and Stretch’) that has a calibrated nozzle that delivers a fine jet stream.
• If this brand cannot be obtained then fluorimethane is acceptable, and is preferred over ethyl chloride, which is both a health hazard and colder than is needed for this treatment
• The cold jet stream should be strong enough to carry for at least 3 feet (± one meter).
• The person to be treated should be relaxed and warm.
• The spray container should be held 1–2 feet (25 to 50 cms) away from the skin surface, so that the coolant stream meets it at an acute angle.
• Each cold sweep should start just proximal to the trigger point (i.e. nearer the head) moving slowly through the reference zone to cover it, and to extend slightly beyond it.
• The direction of movement is usually in line with the muscle fibers toward their insertion
• Both the trigger and reference areas should be chilled because embryonic points may have developed in the referral zone.
• The optimum speed of movement of the sweep/roll over the skin seems to be about 4 inches (10 cm) per second.
• The sweeps are repeated in a rhythm of a few seconds on, and a few seconds off, until all the skin over the trigger and reference areas has been covered once or twice.
• If during the spraying a ‘cold pain’ develops, or if the application of the creates a referred pain, the interval between applications should be lengthened. Take great care not to frost or blanch the skin.
• During the application of cold, or immediately after, the taut fibers should be passively stretched. The fibers should not be stretched before the cold application.
• Steady, gentle, stretching is usually best, maintained for 20–30 seconds.
• After each series of cold applications, active motion is tested.
• An attempt should be made to restore the full range of motion, but always within the limits of pain, since sudden overstretching can increase existing muscle spasm
• The entire procedure may occupy 15–20 minutes and should not be rushed.
• Simple home exercises that involve passive or active stretching should be applied.

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thoughts on the common cold...and blog issues

This map shows locations of last 100 visitors to the blog (18 December 2008)

Back in February I wrote a short blog posting about the use of cold, wet socks in
self-treatment of some of the symptoms of a head cold - the stuffy congestion that makes life so miserable during that stage of the condition.
To my amazement that posting still attracts more readers than any other posting - even the ones I regard as being far more interesting and amusing!
Blog writing serves several purposes, and one of these is that it allows a simple stream-of-consciousness flow to emerge.
Unlike most of the writing with which I'm involved it doesn't need to be carefully crafted (although that would help, you might be saying!) or completely thought through.
Perhaps this is why it is potentially therapeutic (to the writer) in its own way?
If I feel an urge to express an idea or a feeling, off I trot to the blog page. And today I have an urge to revisit the common cold....but before doing so it might interest you to know just how much I know about you?

Tracking you.....
When you reach my blog you might not be interested in a current posting perhaps....in which case you are likely to become one of the brief visitors (10 to 15 seconds is how long about half of all visitors remain!)...or perhaps you find the topic of the day interesting and so hang around for 2 to 7 minutes (becoming a middle range visitor) ....or you might be completely hooked by my ramblings, and stay for 15 to 20 minutes (a few visitors actually do!), trawling through previous postings and downloading some.

How do I know this?
Well there is a whole industry that offers free (with advertising that makes it worth their while), or relatively inexpensive, systems, that track a wide range of data, such as :

• which country you come from
• what key words you used to find the blog
• what browser you are operating (Firefox version 3.0 just ahead of Internet Explorer 7.0, but with a significant number of you still operating version 6.0, because you have not bothered to update)
• what operating system you use (Windows XP just ahead of Mac OS10, and with a significantly lesser number using Windows vista)
• whether you are using an up-market macintosh - or a steam-driven PC - and what size screen you are viewing it on (1152x720 is the winner by a long way) - the majority of you use screens offering 32-bit 16 million colors..........
• plus what city you are in (see map above of the last 100 places visitors came from!)
• which site referred you if you arrived via a link
• ..... and much more.

I can track all this info ...... when I'm in the mood to discover just who is actually reading my jottings... but what it does not tell me is who you are...and that's frustrating!
The data available does however - via key words, when these are used - tell me what you are interested in (as does the record of which blog postings were visited).
And by a long way, the topic that has attracted repeat visitors, and new visitors (yes, that difference is also recorded), the most - some of whom have used specific phases and key words - are variations on :
'common cold' - and - 'wet sock treatment for cold'.
One visitor from China yesterday used the key words 'cartoons about common cold' as a phrase that
led him to my blog on wet socks... now there's a cultural mix for you to ponder on. And so, in respect for international cultural relations, (and in case he ever returns to the site) I've included two cartoons (above) on just that topic!

More on the common cold
So, in this posting I'll expand on that apparently popular theme - the common cold - just a little.

Those of you who are involved in health care, especially in Europe, are probably all too familiar with the work of Professor Edzard Ernst, Department of Complementary Medicine, Peninsula Medical School, University of Exeter?
He has become a devisive figure, as he pursues an apparent quest to highlight all possible shortcomings in complementary health care (see his recent coauthored book Trick or Treatment - Alternative Medicine on Trial), with little apparent sensitivity towards the at least equal shortcomings in mainstream health care.
Well, back in 1990, Ernst, then a mere lecturer and researcher in Vienna, published a research paper in the British journal, Physiotherapy, on the effects on the incidence and severity of the common cold, when people took cold showers every morning (compared with taking warm showers).
I need to warn those of you who ducked out of the cold sock treatment - this blog posting is about to get seriously less comfortable to read!
Ernst (1990a, 1990b) showed that the regular (daily) use of a cold shower had a progressively beneficial effect on immune system efficiency (although in personal communication he denies that this was what the evidence suggests).

• Medical students were divided into two groups [I imagine the scene as ..."we need volunteers for this study...you, you and you!")
  
• For 6 months one group took a graduated cold shower (i.e. ending a hot shower with a brief cold shower application, increasing the length of the cold application to tolerance for up to 2 minutes).
• The other group took a warm or hot shower.
• After 6 months those taking the cold shower were found to be having half the number of colds compared with those having warm showers.
  
• The cold shower group’s colds lasted for approximately half as long as those having warm showers, and were accompanied by far less mucus production (measured by weighing the used paper handkerchiefs of cold sufferers - now there's teutonic efficiency for you!).
  
• Cold showers were avoided during, and for 1 week after, experiencing a cold.
  
• The various protective benefits did not become apparent until almost 3 months of regular cold showering

Just for balance ( a rarity in his way of doing thing some might say) Ernst et al (1990) also recommend saunas for cold prevention (remember to finish with a cold plunge though!)

Now a contrary perspective is offered by some...i.e. hot showers for cold prevention!
A particular website has a short video clip that suggests that hot showers prevent colds, because the steam will decongest nasal passages (true), kill bacterial/viruses (untrue), relax you (possibly true), help you be cleaner (undoubtedly true), sleep better (debatable).
I think this view is oversold and is singularly unresearched...just an opinion!

The manufacturers of a well know pharmaceutical product, widely used to 'kill' symptoms of the common cold (it's name - 7 letters - begins with a T and ends with an L) offers the following advice (my comments in capitals)
Tips for Preventing Colds
Frequently disinfect surfaces in your home and office-especially things like phones and doorknobs that many people touch.[GOOD ADVICE - TV REMOTE CONTROLS ALSO NEED REGULAR DISINFECTING]
Wash your hands often. [YES]
Keep your fingers away from your eyes and nose to prevent the spread of germs.[YES]
Avoid close contact with people who have a cold, especially during the first few days their symptoms appear. This is when they are more likely to spread their germs. [YES]
Tips for Treating Colds
A cold has to run its course (usually around a week), but you can make yourself more comfortable while your body fights it off by getting plenty of fluids.[YES]
Drink plenty of fluids, such as water and juice. And enjoy a warm bowl of chicken soup. It won't cure your cold, but warm liquids can help soothe a sore throat.[YES...AND APPARENTLY CHICKEN SOUP CAN REALLY HELP...SEE BELOW)
Stay comfortable. A humidifier may help ease your congestion and throat discomfort by keeping the air moist.[YES]
To avoid spreading the illness, try to stay away from others if you can- and wash your hands frequently.[YES]

As to chicken soup .... WebMD says: "Chicken soup does help clear nasal clog. Ginger seems to settle stomachs. Dark greens such as spinach are loaded with vitamins A and C. And salmon is a great source of omega-3 fatty acids, which have an anti-inflammatory effect. Quite simply, a well-nourished immune system is better able to ward off infections."

Apparently chicken soup was first recorded as being prescribed by 12th century physician Moses Maimonides, and its' therapeutic properties have been studied by a host of medical experts since then....for example Rennard et al (2000) show there are definite benefits!

Also, I highly recommend use of zinc lozenges at the very start of the cold (scratchy throat...)
This opinion is not universally backed by research, but there is quite a lot that supports it (Al Nakib et al 1987, Eby 1994)
One commentator says:
"For zinc lozenges to work, you must (1) use a type with a high percentage of positive ions, and (2) let them dissolve in your mouth every hour or two all day, every day, until you feel better"
Another positive report offers this advice:
" Place the lozenge under your tongue, remember don’t chew it because it will end up in your stomach not stay where it’s needed. Also take zinc right before bedtime."

What about Echinacea?
Simple answer is - it works.... reducing chances of developing a cold by 58%, and the duration of colds by a day-and-a-half..see report on this link

....and vitamin C?
Maybe.....WebMD reports:
"In a July 2007 study, researchers wanted to discover whether taking 200 milligrams or more of vitamin C daily could reduce the frequency, duration, or severity of a cold. After reviewing 60 years of clinical research, they found that when taken after a cold starts, vitamin C supplements do not make a cold shorter or less severe. When taken daily, vitamin C very slightly shorted cold duration -- by 8% in adults and by 14% in children."

I will now enjoy tracking just how long you stay on the blog-site!
.

Al-Nakib W, Higgins P, Barrow I. 1987 Prophylaxis and treatment of rhinovirus colds with zinc gluconate lozenges. Journal of Antimicrobial Chemotherapy, 28:893-901
Eby G. 1994 Handbook for curing the common cold: the zinc lozenge story. Austin, Texas. George Eby Research
Ernst E 1990a Hydrotherapy. Physiotherapy76(4):207–210
Ernst E 1990b [Hardening against the common cold--is it possible?] (in German). Fortschr. Med. 108 (31): 586–8. PMID 2258128.
Ernst E, Pecho E, Wirz P, Saradeth T 1990 "Regular sauna bathing and the incidence of common colds". Ann. Med. 22 (4): 225–7. PMID 2248758
Robbins R et al 2000 Chicken soup inhibits neutrophil chemotaxis in vitro Chest 118(4)1150-1157.

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A backward look from Corfu ... to LA and the Bodhi Tree... and what flowed from that...

BELOW: The Bodhi Tree ABOVE: Craig Liebenson with a rehab. client COVERS: The one on the left hasn't changes in 25 years! The Muscle Energy cover is the latest incarnation (2007) of this book (3rd edition), a subject that I first discussed in detail in Soft Tissue Manipulation, in 1983.

It's a damp pre-Xmas Sunday in our countryside home in Corfu, and for no particular reason my mind has tracked back exactly 25 years to 1983, when we had just moved from Worthing, in Sussex, to live in this same house.
We had started building it some 5 years earlier, as a holiday home, on a hillside looking across the Corfu Straits, to Albania, a few short miles away.
The reasons for our decision to move to Greece, at that time were complex, but one immediate result was the opportunity it offered to take a sabbatical from the grind of clinical work, which was beginning to impact my health.
I had sold my well-established practice to my late uncle, Boris Chaitow ND DC, and therefore had an adequate cushion on which to coast along for some months...after which...well something would turn up.
In other words, at that time, I had no solid plan as to just how I would provide for the family's needs, but was confident that with writing and editing and clinical work, we would muddle along.
One of our immediate thoughts was to take Sasha (then four and a half) to Disneyland, before she started her primary schooling.
Our plans were well advanced, tickets had been bought, hotels reserved. And around that time a letter arrived, sent on by my (then) publishers.
It was from a young student at Los Angeles College of Chiropractic, who said that he had found a copy of my 1982 book, NeuroMuscular Technique (later updated and expanded to Soft Tissue Manipulation - and still in print).
The young man spotted the book (see cover above--it hasn't changed in 26 years) in a locked glass display case, reserved for more arcane tomes, in the Bodhi Tree book store in LA - and had bought it. A quick search on the Bodhi Tree website today shows that Soft Tissue Manipulation is still on sale there, at a special sale price of $44.95 (reduced from $49.95!)

The letter explained that he was interested in the ideas it expressed, and wondered if, at any stage, I had plans to be in the US, where he said he'd like to follow-up on the subject matter, and possibly arrange for me to address his classmates at LACC (which has since morphed into the Southern California University of Health Science).
Well, as we were heading for LA just a few weeks later, I wrote back and arranged for him to visit us at the Disneyland hotel.
We went to LA, loved it, thoroughly enjoyed the nonsense of the Disney fantasy, and met up with Craig, who drove us to LACC to meet tutors and classmates, and then on to Santa Monica beach and pier.
We had a great time in LA...met other people who have remained friends ever since - about whom, more another time .....and agreed to return to the college to teach periodically - an arrangement that went on for some years.
Since then Craig Liebenson has gone on to become a world leader in the chiropractic field, with his rehabilitation methods taught at most chiropractic colleges, and his phenomenal book Rehabilitation of the Spine, that incorporates a few of the ideas and methods that he first stumbled across at the Bodhi Tree.

Craig is now one of my most valued Associate Editors on the journal I edit (JBMT), for which he writes a regular series on rehabilitation methods.
Craig has also contributed a chapter to my book on Muscle Energy Techniques.

What do these rambling backward glances all signify?
I really don't know, but it's clear that the links and threads that connect now with then, and the synchronicity of it all, defined my life in many ways.
If we had not had the time and funds, at that particular time, to take the extended excursion to the USA, at just the same time that this particular young man had found himself at a mystical bookshop, which carried that book and ideas he wanted to pursue, which led him to write to me just before our trip .... his life and mine, and therefore those closest to me, might very well have taken different directions.
Of such coincidences - if that's what they are - are life's elements comprised.....much as they were when I mistook Morocco for Greece (or vice versa) some years before....see my earlier posting on this for what that led to!

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Biomechanics, malalignment and adaptation

These illustrations show variations on the theme of 'crossed syndromes' where
muscle groups alternately short/tighten, or are inhibited/lengthen, with
negative effects on functionality

The central figure above shows a lower crossed syndrome with weak abdominals and gluteals, as well as short tight hip flexors and erector spinae

On the left, this individual has:
Short tight : pectorals, upper trapezius, neck extensors
Inhibited/lengthened/weak : deep neck flexors, lower shoulder stabilisers

The figures below illustrate variations on
lower crossed syndromes....neither of these are
likely to have normal respiratory or pelvic
function

For the past 3 months I have been immersed in putting together a team of writers, in order to compile a book on the physical medicine approaches to management of chronic pelvic pain - CPP (for Elsevier).
These efforts are now virtually complete, with 20 superb researchers, practitioners, therapists now assembled
They will be collaborating on this project over the next year or so - after which my co-editor and I will have several months to stitch the 20 chapters (some of which we will write ourselves) together, with bridging sections to hopefully create a coherent story.

As I reflect on the multiple influences that can result in CPP, a theme keeps repeating itself - that these particular (and indeed almost all) health problems, can be seen to be the result of processes of failed adaptation - of 'decompensation' - the result of repetitive adaptive loads, involving biochemical, biomechanical or psychosocial (or combination of these) stressors, interacting with the unique cocktail of acquired and inherited characteristics of the person involved.

That model leads logically to the conclusion that 'treatment' should firstly not add to the adaptive melt-down, and should not just mask the symptoms, but should ideally be directed at reducing the stressor load, and enhancing the normal self-regulating functions of the individual.
Where biomechanics (posture and the way we use, abuse and overuse the structures of the body) are concerned, my mind turns to some great observers of the human condition.
For example:
The first comprehensive discussion, that I was aware of, as to how biomechanical alignment – posture - influences visceral function, was by the orthopedic surgeon Joel E. Goldthwait (and colleagues), in the book Essentials of Body Mechanics in Health & Disease (1945).
The concepts described by Goldthwait are still extremely relevant today....see the illustrative figures above (taken from an insightful paper written by Australian physiotheapist Josphine Key, and her associates, and published in The Journal of Bodywork & Movement Therapies in 2007)

According to Goldthwait, they demonstrate the normal progression as tissues adapt to postural imbalance, with the influences of aging and gravity adding to the picture:
“The main factors which determine the maintenance of the abdominal viscera in position are the diaphragm and the abdominal muscles, both of which are relaxed and cease to support in faulty posture. The disturbances of circulation resulting from a low diaphragm and ptosis may give rise to chronic passive congestion in one or all of the organs of the abdomen and pelvis, since the local as well as general venous drainage may be impeded by the failure of the diaphragmatic pump to do its full work in the drooped body. Furthermore, the drag of these congested organs on their nerve supply, as well as the pressure on the sympathetic ganglia and plexuses, probably causes many irregularities in their function, varying from partial paralysis to overstimulation. All these organs receive fibers from both the vagus and sympathetic systems, either one of which may be disturbed. It is probable that one or all of these factors are active at various times in both the stocky and the slender anatomic types, and are responsible for many functional digestive disturbances. These disturbances, if continued long enough, may lead to diseases later in life. Faulty body mechanics in early life, then, becomes a vital factor in the production of the vicious cycle of chronic diseases and presents a chief point of attack in its prevention . . . In this upright position, as one becomes older, the tendency is for the abdomen to relax and sag more and more, allowing a ptosic condition of the abdominal and pelvic organs unless the supporting lower abdominal muscles are taught to contract properly. As the abdomen relaxes, there is a great tendency towards a drooped chest, with narrow rib angle, forward shoulders, prominent shoulder blades, a forward position of the head, and probably pronated feet. When the human machine is out of balance, physiological function cannot be perfect; muscles and ligaments are in an abnormal state of tension and strain. A well-poised body means a machine working perfectly, with the least amount of muscular effort, and therefore better health and strength for daily life.”

Some 70 years later Schamberger’s malalignment model (2002) has offered important messages for consideration, as he follows Goldthwait and takes the discussion of postural imbalance beyond the biomechanical towards body-wide adaptational influences. He describes some of the inevitable changes that are associated with common asymmetries, as follows.
“Malalignment of the pelvis, spine and extremities remains one of the frontiers of medicine . . . the associated biomechanical changes – especially the shift in weight-bearing and asymmetries of muscle tension, strength, joint ranges of motion – affect soft tissues, joints and organ systems throughout the body and therefore have implications for general practice and most medical sub-speciality areas.”

Schamberger offers examples of visceral problems emerging from malalignment of the pelvis, resulting in pelvic floor dysfunction:
“Typical visceral problems that have been attributed to pelvic floor dysfunction include:

• Incontinence of bowel and bladder attributed to a lax floor
• Constipation and incomplete voiding with excessive tension
• Dysmenorrhoea, dyspareunia, impotence and sexual dysfunction
• Recurrent cystitis and urinary tract infection."

In more recent years Vladimir Janda developed his extremely useful overview of the adaptations that evolve when posture and use patterns are less than optimal, in his 'crossed syndrome' model (see figures at the start of the posting).
Over time, adaptational changes, as listed by Goldthwait, Schamberger and Janda, may progress from the production of dysfunction (e.g. low back pain) to the development of actual pathological changes.

For example Gofton & Trueman (1971) found a strong association between leg length and unilateral osteoarthritis on the side of the anatomically long leg.
They noted that all subjects with this type of OA ‘had led healthy active lives prior to the onset of hip pain’, and few subjects were aware of any difference in leg length.
They also point out that this form of OA has its onset around the age of 53, but acknowledge that many people with precisely this anatomic asymmetry failed to develop an arthritic hip, suggesting that factors other than the leg length disparity are also important.
This underscores the importance of the context in which this mechanical adaptation was being processed by the tissues under stress – with some joints becoming arthritic and others not. What were the other variables? Nutritional? Genetic? Gender? Weight? Occupation? Other . . . ?

Holistic perspectives require evaluation of the obvious anatomic and biomechanical, as well as identifiable contextual (e.g. environmental, psychological, nutritional, etc.) etiological features.

References:
Gofton J, Trueman G 1971 Studies in osteoarthritis of the hip: Part II. Osteoarthritis of the hip and leg-length disparity. CMA Journal 104:791–799
Goldthwait J et al 1945 Essentials of body mechanics in health and disease. Lippincott, Philadelphia
Janda V 1986 Muscle weakness and inhibition (pseudoparesis) in back pain syndromes. In : Grieve G (ed) Modern Manual Therapy of the Vertebral Column. Churchill Livingstone, Edinburgh
Schamberger W 2002 The malalignment syndrome. Churchill Livingstone, Edinburgh, p 238–239

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