Most of the people reading this will agree that myofascial pain is a major cause of morbidity in our society.
It is noted that anywhere from 20 to 95% of patients who go to their general medicine practitioners and pain management centers with musculoskeletal pain will be diagnosed with myofascial pain.1 The people most affected by this condition are between the 27 and 50 years old. The reason for and best treatment of myofascial pain remains to be resolved. It costs the U.S. hundreds of billions of dollars per year to treat myofascial pain.1 One of the complications driving the magnitude of the myofascial pain problem is that many causes of this pain are poorly understood. Travell and Simmons made a number of interesting observations on this subject and gave us some useful insight on the subject in their book.2 They introduced the concept of the “trigger point,” described as “A highly irritable localized spot of exquisite tenderness in a nodule in a palpable taut band of (skeletal) muscle.” These hyperirritable localized spots can vary in size and have been described as “tiny lumps,” “little peas” and “large lumps,” and they can be felt beneath the surface, embedded within the muscle fibers. There has been an impressive body of evidence for the existence of trigger points. Some of the objective scientific measurements regarding trigger points include changes in the electrical activity inside the muscle when studied by needle EMG, lower pain thresholds, increased irritability, moderate hypoxia, lower pH and highest levels of substance P, bradykinin, norepinephrine and interleukin-1. The reason why people get trigger points is not generally understood. There are many proposed etiologies, but it is known that trigger points can occur in the absence of tissue damage.2 There is one thing we know for sure: the muscle tissue involved in trigger points is not functioning properly. Restoration of tissue to its proper functionality has always been a strong suit of DCs.
What is mechanotransduction?
Whether you know it or not, you’ve been using a process called mechanotransduction since performing your first adjustment. What is mechanotransduction? Mechanotransduction is the biological response to a mechanical stimulation.3 With each chiropractic adjustment, you induce mechanotransduction by applying mechanical pressure to your patient, and your patient’s body changes as a result. Scientists have been able to observe mechanotransduction on the cellular and molecular level.
Human cells are programmed to adapt to the physical world around them. Thus, changes in local mechanical pressure on the cellular level can change the way human cells behave.3 Mechanotransduction will be the way DCs will lead the world in restoration of dysfunctional tissue, and not just helping patients with pain, but with conditions you never imagined you could address. While you have been using mechanotransduction your entire career, there are some new tools available that will catapult you and your practice into the exciting new field of mechanobiology (using mechanotransduction). One such tool is extracorporeal shockwave therapy (ESWT).
Mechanical waves of extremely high amplitude and short duration are known as shockwaves. Revolutionary new devices can produce shockwaves that can be transmitted into the tissue of your patients. These shockwaves can produce a dose-dependent response in living tissue. Shockwaves produce an impressive array of measured biological responses at the cellular level. Some of these cellular responses include an increase in cell membrane permeability, increases in mitosis (cellular division and replication), angiogenesis (growth of new blood vessels), reduced expression of pro-inflammatory cell signaling molecules, increased expression of anti-inflammatory cell signaling molecules, enhanced collagen synthesis, accelerated migration of osteoblasts, dampening of the pro-inflammatory profile of M1 macrophages while promoting the acquisition of anti-inflammatory profile macrophages (M2),4 remodeling of fiber scar and the reduction of excessive extracellular matrix.3 In other words, shockwave=induced mechanotransduction can stimulate the restoration needed in human cells to address the dysfunction seen in trigger points. In fact, pharmaceutical companies are trying to induce the changes using drugs that are already observed using shockwave-induced mechanotransduction.1
With respect to the nervous system, shockwave-induced mechanotransduction can affect the nervous system and neurophysiological processes at different levels. An analgesic effect from shockwaves has been demonstrated experimentally. Shockwave exposure can modify the presence of small unmyelinated nerve fibers and some neurotransmitters; for example, substance P and calcitonin gene related peptide.3
The shockwave therapy difference
I have been using shockwave therapy in my office for the past four years. One particular advantage that shockwave therapy has above other modalities available to DCs is shockwave therapy is both therapeutic and diagnostic. DCs who perform shockwave use a technique known as clinical focusing. During clinical focusing, it’s possible to isolate a pathological area of myofascial pain based on the patient’s response to the mechanical stimulation. Once the location is isolated the therapy can be placed over the area until the patient’s response is diminished. Often, patients will leave your office noticing an immediate improvement. This is an extremely powerful and satisfying experience for both the patient and the physician.
Final thoughts
So, how can using shockwave in your office assist you in the treatment of myofascial pain syndrome? Unfortunately, the exact etiology of myofascial pain syndrome is unclear. We do know that the tissue involved is not functioning properly. It has also been demonstrated that the etiologies of myofascial pain can often be different for different patients. Shockwave therapy is unique in its ability to be very precise in targeting a pathological tissue. However, its therapeutic value spans several different aspects of cellular biology. Shockwave therapy can affect the nervous system, the cell signaling molecules, the blood supply, the genetic expression of cellular proteins and even the thickness of fibrous scar. Perhaps most importantly, shockwave does all of this by stimulation rather than destruction, thereby preserving the sanctity and dignity of your patients down to the cellular level. Shockwave stimulates cells and tissue to self-repair without interfering with patients’ innate intelligence. What could be more chiropractic than that?
PETER J. BROCKMAN, DC, is a native of Los Angeles, California. He received his undergraduate (BS) training in microbiology at the University of South Florida. He then received his doctor of chiropractic degree from Cleveland Chiropractic College Los Angeles. He is board-certified in acupuncture. He has been in private practice since 1999 and is currently the clinic director/owner of South Lake Wellness and Injury Center, PL. Brockman is an instructor for KDT Decompression Systems/Technique, as he enjoys giving back to the chiropractic profession.
References
- Galasso I, et al. A comprehensive review of the treatment and management of myofascial pain syndrome. Curr Pain Headache Rep. 2020;24(8):43. https://pubmed.ncbi.nlm.nih.gov/32594264/. Accessed September 10, 2024.
- Travell JG, et al. Myofascial Pain and Dysfunction: The Trigger Point Manual. 1992. Published by Wolters Kluwer.
- Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-724. https://pubmed.ncbi.nlm.nih.gov/22607834/. PubMed. Accessed September 10, 2024.
- Sukubo NG, et al. Effect of shock waves on macrophages: A possible role in tissue regeneration and remodeling. Int J Surg. 2015;24(Pt B):124-130. https://pubmed.ncbi.nlm.nih.gov/26291028/. Accessed September 10, 2024.
- Cheng JH, Wang CJ. Biological mechanism of shockwave in bone. Int J Surg. 2015 Dec;24(Pt B):143-146. https://pubmed.ncbi.nlm.nih.gov/26118613/. PubMed. Accessed September 10, 2024.
- Zhu X, et al. Subchondral bone remodeling: A therapeutic target for osteoarthritis. Front Cell Dev Biol. 2021;8:607764. https://pubmed.ncbi.nlm.nih.gov/33553146/. PubMed. Accessed September 10, 2024.