Deep Trigger Point Stimulation (DTPS), also known as “Electric Twitch” - “Getting intramuscular stimulation” is a new treatment for myofascial pain. For the direct treatment of MTrPs, many methods are available. These include acupuncture methods, such as acupuncture, dry needles and local injections, which include water, saline, local anesthetics, steroids or Botox to inactivate, disrupt or suppress MTRP activity.
Meta-analysis did not show the effectiveness of treatment of Botox, acupuncture or dry needling of MTRP. In addition, due to security issues, none of these methods can be reused or often for the same MTrP, other MTrP in the same proximity or multiple MTrP, during the same session or with multiple treatments used by throughout the life of a patient with chronic pain. A common theme in the methods of physical therapy used in the treatment of MTRP is stretching, but little is known about the effectiveness of stretching or ways to increase its effectiveness. Techniques that include stretching, such as spraying and stretching, when used together with hot packs, active range of motion exercises, and interference current or TENS, have been found useful.
Similarly, a post-isometric relaxation technique that restores the full length of a muscle strain is recognized as beneficial in the treatment of MTrPs; and a home program consisting of ischemic pressure and sustained stretching in people with neck and back pain. In athletes, stretching reduces the incidence of new onset of pain, but does not significantly reduce the overall risk of injury, although this may reduce the risk of some injuries. On the contrary, stretching for three weeks has not proven to be effective in improving muscular extensibility in patients with chronic musculoskeletal pain, although this increases the tolerance to discomfort associated with stretch. A meta-analysis of randomized studies shows that stretching of muscles performed before, after, or before and after exercise does not lead to a clinically significant decrease in muscle pain with delayed onset in healthy adults. When muscles, such as the hamstrings, are stiff and undergo eccentric exercises, there is a loss of strength, pain, muscle tenderness, and increased creatine kinase activity. This is consistent with the theory of sarcomere muscle deformation, demonstrating experimental data on the association between flexibility and the tendency to muscle injury. These studies have shed light on the effects and limitations of mechanical stretching, limited to tensile muscles, which are usually superficial. The decision to make stretching consistently more effective may be to find new methods that include non-invasive electrostimulation procedures, such as a deep trigger point DTA, in order to effectively implement and mobilize deep muscle tissue in tensile areas, especially with damaged MTP. Morphological and electromyographic studies have demonstrated atrophy and delayed activation of the deep muscles of the spine in patients with chronic neck pain and chronic lower back pain. Reducing the maximum strength of deep muscle muscles, such as multifeedus, interpinals, ntertransversarii, rotators, iliocostalis, longissimus, psoas and quadratus lumborum, increase the resulting joint moments and decrease the stabilization function provided by these muscles to the lumbar spine. This makes it necessary to postulate that strengthening the deep muscles with electrical stimulations caused by the stimuli that muscles manifest can reduce the likelihood of injury and pain in the lumbar spine. DTPS supports the hypothesis that spondylosis radiculopathy with hypersensitivity to denervation is the main cause of myofascial pain.
Consequently, the denervation and / or conduction block leads to the formation of MTrP in many myotomes. DTPS electrically energizes MTrPs, causing jerking, which not only mobilizes deep muscles, but also through this mechanism allows intramuscular stretching therapy to relax shorter deep muscles during a spasm, which otherwise usually cannot stretch or train, especially in the presence of pain,
The ability of DTPS to stretch individual deep muscles of the extremities and the spine results in a decrease in traction effects on pain-sensitive structures, such as trapped intramuscular nerves and blood vessels, bone surfaces, and joint capsules. DTPS also performs as local, targeted intramuscular physiotherapy, which improves circulation in the affected areas. Experiments on rat skeletal muscle showed that dermal contractions from stimulation from 1 Hz increase muscle blood flow by 240%. Our prospective longitudinal study showed that DTPS is effective in reducing myofascial pain while improving range of motion. This appears to be related to its unique advantage, causing intramuscular stretching with the involved MTrPs, where the spasm and / or contraction of the muscle fiber is most concentrated. This includes those ITPH in the deepest layers of muscle, opposite the bones and joints. The ability of DTTs to perform internal stretching, which leads to relaxation of deep muscles, provides an increased ability of these deep muscles to withstand disease-related spasmosis / muscle contraction, which occurs at different times of the day, in patients with chronic pain every day. It is reported that massage reduces the symptoms of myalgia and, as has been shown, reduces systolic and diastolic blood pressure and pulse rate, which is explained by the ability of the massage to increase the parasympathetic tone and suppress the sympathetic tone. DTPS provides a modern massage that can mobilize deep tissues opposite to bones and joints that cannot be mobilized by hand massage. DTPS has the added ability to actively exercise, contract and relax muscles by stimulating MTrPs that cause cramps, especially with the participation of the deepest muscles. In our study, we showed that a steady decrease in systolic and diastolic blood pressure requires> 10 methods of treatment and the associated improvement in several dimensions of movement, even if there is a decrease in pain in 2 visual analogue scales (VAS). When there is no improvement in movement, pain during treatment can lead to an increase in sympathetic tone with a moderate increase in systolic and diastolic blood pressure. Therefore, despite the fact that a decrease in the frequency of pulsations is common for the treatment of DTPS, a moderate increase in systolic and diastolic blood pressure in those who have taken less than 10 treatment sessions cannot be a compensatory effect of a decrease in heart rate, but rather is due to the stimulation of nociceptors in tight muscles, although Stimulating MTrP seems completely painless. The fact that those who have more than 10 procedures showed a greater decrease in the pulse rate and, nevertheless, simultaneously showed a systolic and diastolic decrease in blood pressure, probably caused by inhibition of the sympathetic tone. The presented results confirm our previous work, in which DTPS reduces the pulse rate, possibly with the most consistent basic mechanism, including the stimulation of the parasympathetic nervous system. This may be due to the simultaneous stimulation of the vagus nerve during stimulation of the trapezium and other muscles of the neck. In addition, stimulation of the vagus nerve is known to reduce pain. In a slightly different perspective, pain is a known physiological stress.
Therefore, based on this, if the increase in pain tends to increase in pulse, then the decrease in pain tends to decrease in pulse, which basically corresponds to the detection of the pulse over time, detected in the treatment of DTPS, regardless of whether the decrease in VAS decreases, exceeding level 2 has been noted. It is generally accepted in the VAS pain scale with the maximum level of pain reported before 10/10 that reducing the VAS to at least 2 levels to reduce the adequacy of the evaluation of the response to treatment requires caution in studies with observation periods longer than 12 weeks. Therefore, with caution, this evaluation method was used to analyze the results in this longitudinal study that recruited patients for 24 months.
However, since the treatment lasted for a long time, this assessment method, requiring a reduction in the scale of reduction ≥ 2, was not considered applicable, especially when assessing pain immediately after treatment, because there was a negative correlation with the number of procedures. Over time, we noted that the amount of treatment is important in terms of patient satisfaction with treatment. Since patients independently choose to pay for permanent treatment, the patient ultimately determined the number of procedures and, as a result, this led to the adoption of this parameter as an important factor for analyzing patient satisfaction with DTPS treatment over time. Patients who returned to several treatments over time, although an immediate reduction in pain was <2 degrees, indicated that reducing VAS by at least 2 levels was an arbitrary and subjective and possibly erroneous measure to measure pain relief and / or patient satisfaction with pain treatment. The potential importance of the number of treatments over time to demonstrate patient satisfaction becomes clearer, since there is no significant difference between reducing VAS over time between those who received more / less than 10 treatments.
Patients with chronic pain not only do not demonstrate continuous or gradual improvement in ROM and pain reduction with an increase in the number of treatments, they show less immediate improvement after treatment. Among the main reasons why patients continue to return for permanent treatment is that they experience an immediate reduction in pain ≥ 2 levels and an immediate improvement in the results of the ROM with each treatment compared to their immediate status before treatment. Because DTPS basically provides a painless, pleasant painkiller and active aerobic exercise that simultaneously provides some improvement in ROM, the role of endorphin release associated with this exercise from MTrP stimulation can also explain why patients return to re-treatment for a long duration. It is possible that the inability of patients with chronic pain to continue to gradually improve with an increase in the number of treatments, which is associated with difficulties in finding / stimulating all involved MTPs. This is probably due to a combination of significant tightness or stiffness of the overlying muscles in the presence of hypo-excitability dependent on activity and axonal hyperpolarization. Effect-related symptom fluctuations in CRMP are common. This may be due to a transient conduction block. Even natural activity leads to a substantial hyperpolarization of active axons and, at identical discharge rates; the degree of hyperpolarization is greater in motor axons than skin afferents. There is the potential to increase the susceptibility of MTRP in patients with chronic pain for further trauma caused by abrupt muscle contractions, as well as new injuries that include falls, lifting injuries, car crashes, exercise or even repeated contractions related to daily activities.
These injuries tend to keep patients with chronic pain in a constant state of constant pain. The inability of chronic pain patients to continue to demonstrate a progressive, cumulative increase in immediate improvement in range of motion and a progressive, cumulative immediate and / or dramatic reduction in pain with an increase in the number of treatments may also be associated with a decrease in the effectiveness of mutual inhibition. This leads to a delay and incomplete relaxation of muscles after exercise, irregular control of subtle movements and asymmetrical muscle activation. The increased ability to re-damage, the need for pain relief and / or the need to increase the range of motion explains why patients choose to stay in DTPS therapy for a long time. At the very least, patient needs seem to be temporarily met with re-treatment until the patient chooses the next course of treatment independently. If the patient’s condition is not severe, soft exercises under the supervision of DTPS may be helpful. Although potential bias was inadvertently entered into observations, because the treatment was not randomized, controlled or double-blind, our prospective longitudinal observations confirm that non-invasive DTPS have analgesic effects that appear safe and effective. Although observations were made only in patients who paid for the treatment themselves, this cohort included patients with severe pain who could not be mitigated by traditional methods, including physical therapy, multiple medications and spinal surgery. These patients self-paid for multiple treatments with DTPS over time due to experience with therapeutic efficacy and safety, appearing to get pain relief with a demonstrated increase in mobility associated with improved ROM, improved quality of life, which were improved. In this case, patients studying patients have benefited from continued treatment with DTPS over time.
conclusions
DTPS is safe and effective for repeated use on a regular basis in many muscles throughout the body over time with chronic long-term care for patients with CRMP. There were no complications or side effects associated with DTPS in patients that lasted for 24 months, similar to the results of our previous longitudinal study for more than 18 months. The immediate side effects after treatment, associated with some immediate improvement after treatment in ROM and a decrease in heart rate, appear to be related to patient satisfaction with the subsequent self-selection cycle to return to several treatments with DTPS over time. Self-selection for re-treatment, for which one pays for itself, is consistent with the experience of improving the quality of life. The treatment model is based on the traditional medical ethics of the doctor’s consent to the patient’s consent.
This relationship cannot be maintained over time without the patient’s perception of the increasing benefits of consent to treatment. This helps to explain the strong involvement of patients, as evidenced by the regular prescriptions for treatment of DTP. Further studies, especially randomized controlled studies, should be conducted to determine the effectiveness of DTPS compared to other treatments.
In CRMP management, muscle twitches provide a local key to pain relief.
