Doctors with even minimal experience in myofascial therapy know it usually works quickly and spectacularly in relieving patients' pain. But then they encounter some patients who don't respond the usual way -- even though the doctor has found taut bands with pain-referring trigger points. In fact, the usual myofascial techniques and modalities may worsen these patients' pain and make the best myofascial therapist doubt his clinical skills.
Many doctors don't seem to realize that when the therapy is applied properly but doesn't work, this does not necessarily mean that the patient isn't a "myofascial case." If the patient has myofascial constrictions and trigger points, he is (at least in part) a myofascial case. The trouble in most instances is that underlying factors are undermining the patient's recovery.1 The factors can be biomechanical, like a short leg; biochemical, like energy-impairing drugs; or psychological, like job burnout. Most often, multiple factors are impinging on the patient. Freeing patients from these factors -- often an arduous task -- is the ultimate challenge to the myofascial therapist.
Some clinicians are totally mystified by these unresponsive patients, while other clinicians use good sense to both target and eradicate the sources of tenacious myofascial pain.2 I recently heard two famed clinicians -- one bumfuzzeled over the mystery of unresponsive patients, the other not -- publicly discuss this matter. Their comments are worth reviewing.
Dr. Robert Bennett, a well-known rheumatologist, was asked if he often finds hypothyroidism associated with myofascial pain syndromes (which he calls fibromyalgia). He answered (verbatim): "People who are hypothyroid do have a muscle pain syndrome that in some respects does resemble fibromyalgia. Over the last few years we've picked up three patients who do have a hypothyroidism and when we've treated them effectively, they still have fibromyalgia -- so I'm confused as to what the relationship is, but it's certainly worthwhile looking for."
Dr. Janet Travell, master myofascial therapist, replied: "The problem is that there are multiple causes in the myofascial pain syndrome. I'm thinking of one patient who had some mechanical factors, gout, hyperuricemia, crystal deposition in areas of muscle strain where the pH tends to be lower, and the uric acid would be soluble in the pH of the blood but crystalize out in the pH of the muscle or areas of injury. Now this was one factor, and a number of physical factors and a short leg and body asymmetry and other things were corrected. We then found he was borderline low thyroid, and a very small dose of Synthroid (T4) of 0.05 mg. per day has produced a complete remission in every symptom of muscle soreness, pain, fatigue and tenderness, and he's now 100% well; but half a dozen things had to be done to arrive at this point."3
Dr. Travell sees the condition of the treatment-resistant patient for what it is -- snow-balling layers of globally-spread pain and physiological dysfunction, intensified and perpetuated by a multiplicity of underlying factors. She's not mystified by them; she attacks them one-by-one to defuse their influence. Looking for a single cause of die-hard myofascial pain can doom a doctor to clinical failure. Underlying factors can be as complex and intertwined as those of the federal budget deficit or urban decay, but the patient's prognosis -- under the guidance of a properly oriented clinician -- is far brighter than those of such sociopolitical problems.
The myofascial patient who doesn't respond to myofascial techniques brings you face-to-face with a fascinating and challenging phase of myofascial therapy: Identifying and eliminating (or controlling) factors that perpetuate myofascial syndromes. Pin-point and neutralize these factors and you'll free even your most desperate patients from pain.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
