Non-Pharmacological Approaches

**137**

**Chapter 9**

**Abstract**

or its accessories.

**1. Introduction**

spinal cord stimulation

Bench to Bedside

*Laura Tyler Perryman*

Wireless Neuromodulation: From

Spinal cord stimulation (SCS), as a neuromodulation therapy, has rapidly evolved over the past few decades to become the treatment of choice for many chronic pain syndromes. However, many equipment-related limitations such as the bulk of the equipment, an implantable pulse generator (IPG), the limited therapeutic stimulation frequency utilized, and the potential adverse events have restricted SCS applications. Recently, advanced nanotechnology and minimally invasive surgical techniques have shown promising options to expand the indications due to reduced surgical trauma/hospital time/costs. We describe the basis for nanotechnology neuromodulation and the preliminary experience with wireless SCS in the treatment of chronic pain conditions. The equipment utilizes a miniature stimulator with microelectronics, percutaneously placed at the appropriate stimulation target, with wireless control to provide the desired stimulation, and then moderated by the clinician and the patient. The wireless device reduces the bulk of the SCS equipment to a single electrode (with embedded sensors), using the new improved neuralelectric interface. This wireless neuromodulation (WNM) has been clinically used in several chronic pain conditions, including failed back surgery syndrome, facial pain, chronic regional pain syndrome, and postherpetic neuralgia, with encouraging outcome, without the complications of a traditional SCS resulting from the IPG

**Keywords:** neuromodulation, wireless, nanotechnology, chronic pain,

implanted pulse generator (IPG) to provide power.

Therapeutic modulation of excitable neural tissues in the body by electrical stimulation has become an important intervention to manage chronic disabling conditions like pain, involuntary movements, extrapyramidal syndromes, chronic peripheral vascular disease, and cardiac arrhythmias [1–9]. Devices are being implanted to deliver stimulatory signals to the target tissue, record vital signs or action potentials, perform electric cardiac pacing, and control drug release, as well as interface with auditory systems for assisted hearing or even image formation for visual prosthesis. All these systems utilize a subcutaneous battery-operated

Spinal cord stimulation (SCS) has been utilized for over five decades to provide therapeutically effective pain relief from chronic conditions like failed back surgery syndrome (FBSS), regional pain syndromes, and neuralgias, reducing the need for opioids. Several measurable outcomes like pain scores, disability scores, and quality

#### **Chapter 9**

## Wireless Neuromodulation: From Bench to Bedside

*Laura Tyler Perryman*

#### **Abstract**

Spinal cord stimulation (SCS), as a neuromodulation therapy, has rapidly evolved over the past few decades to become the treatment of choice for many chronic pain syndromes. However, many equipment-related limitations such as the bulk of the equipment, an implantable pulse generator (IPG), the limited therapeutic stimulation frequency utilized, and the potential adverse events have restricted SCS applications. Recently, advanced nanotechnology and minimally invasive surgical techniques have shown promising options to expand the indications due to reduced surgical trauma/hospital time/costs. We describe the basis for nanotechnology neuromodulation and the preliminary experience with wireless SCS in the treatment of chronic pain conditions. The equipment utilizes a miniature stimulator with microelectronics, percutaneously placed at the appropriate stimulation target, with wireless control to provide the desired stimulation, and then moderated by the clinician and the patient. The wireless device reduces the bulk of the SCS equipment to a single electrode (with embedded sensors), using the new improved neuralelectric interface. This wireless neuromodulation (WNM) has been clinically used in several chronic pain conditions, including failed back surgery syndrome, facial pain, chronic regional pain syndrome, and postherpetic neuralgia, with encouraging outcome, without the complications of a traditional SCS resulting from the IPG or its accessories.

**Keywords:** neuromodulation, wireless, nanotechnology, chronic pain, spinal cord stimulation

#### **1. Introduction**

Therapeutic modulation of excitable neural tissues in the body by electrical stimulation has become an important intervention to manage chronic disabling conditions like pain, involuntary movements, extrapyramidal syndromes, chronic peripheral vascular disease, and cardiac arrhythmias [1–9]. Devices are being implanted to deliver stimulatory signals to the target tissue, record vital signs or action potentials, perform electric cardiac pacing, and control drug release, as well as interface with auditory systems for assisted hearing or even image formation for visual prosthesis. All these systems utilize a subcutaneous battery-operated implanted pulse generator (IPG) to provide power.

Spinal cord stimulation (SCS) has been utilized for over five decades to provide therapeutically effective pain relief from chronic conditions like failed back surgery syndrome (FBSS), regional pain syndromes, and neuralgias, reducing the need for opioids. Several measurable outcomes like pain scores, disability scores, and quality

of life scales have shown consistent improvement with SCS in patients with back pain and leg pain [1–3].

Outcomes following SCS therapy have demonstrated superior results compared to conservative medical treatment for patients with FBSS in several studies [2, 4], and SCS was also shown to be more cost-effective over the long term due to a decrease in follow-up visits, diagnostic tests, and overall consumption of healthcare facilities [4, 5]. Historically, on the other hand, SCS has not been devoid of complications and limitations in its conventional form utilizing an IPG, since the device options have had a long history of severe adverse events primarily related to the IPG [6, 7]. A large percentage of patients, reportedly as high as 50%, have failed the trial period utilizing conventional SCS devices [6–8], while additional failures came from equipment complications caused by the migration/fracture of the electrodes as well as IPG failures and complications in recharging or reimplantation. Postsurgical complications like infection, hemorrhage, and painful operative wounds were frequently seen associated with IPG and its extension wires. Additionally, SCS in its conventional form is incapable of reaching some anatomical locations to provide targeted therapeutic localized pain relief [6, 8–12].

Several modifications have been introduced to the SCS equipment over the past few years, which have reduced adverse events while promoting the efficacy of the modality, thereby increasing the number of clinical indications [13]. Percutaneous techniques, smaller compact batteries, rechargeable batteries, increased life of the IPG, and improved anchoring methods are some of these modifications currently in use. Part of the refinement also comes from the advancements in the technology of nanomaterials and wireless power transfer techniques.

#### **2. Nanoelectrodes and wireless technology for neuromodulation**

An advancement in this field is the new miniature pulse generator (mini PG) with wireless access (WPG) utilizing a dipole antenna for electric field coupling. This is accomplished with "microwaves", which are very short wavelength pulsed electromagnetic waves at gigahertz (GHz) frequencies. This device (Stimwave Technologies, Florida, USA), instead of using lower frequencies of 100 – 500 kHz of the inductive range operational in most of the present-day implanted medical devices, is powered by a radiative electric field coupling through tissues at microwave frequencies that enable smaller-sized implants to be placed at a significant tissue depth through a percutaneous technique. It also affords minimal power loss, since the higher frequency allows a much better energy transfer to a smaller implant [14]. The principle behind the frequency changes in relation to the wavelength was elaborated earlier by Feynman: "If you build a corresponding circuit on a small scale, its natural frequency goes up, since the wave length goes down as the scale; but the skin depth only decreases with the square root of the scale ratio, and so resistive problems are of increasing difficulty. Possibly we can beat resistance through the use of superconductivity if the frequency is not too high, or by other tricks [15]."

**Figure 1.**

*MRI compatible electrode with nanostimulator and microcircuit to contact wireless pulse generator. This is the only implantable component required for WSCS.*

**139**

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

**stimulator (INS)**

**pulse generator**

ing the neural tissue (**Figure 1**).

signals based on the stimulus feedback.

procedures like laminectomy or laminotomy.

6 mm apart with a combined surface area of 0.8 to 60 mm2

series with one or more electrodes.

The micro-implant WPG is capable of delivering clinically appropriate stimula-

The INS has an enclosure housing the stimulating electrode array, designed to apply electrical pulses to the target tissue and antenna-1 and configured to receive electric energy input from an external antenna-2 through electrical radiative

coupling. The antenna-2, physically separated from the INS lead, is connected to the antenna-1 by electric circuits configured to generate electrical pulses for stimulat-

The INS is without any power source and stays in contact with the excitable neural tissue with passive components capable of receiving an external input signal at a frequency between 300 MHz and 8 GHz. A controller module, positioned in proximity to the patient body, to generate the input signals, sends them to the antenna-2; the latter transmits the input signal to the first dipole antenna placed within the INS through electrical radiative coupling, and antenna-1 extracts the stimulus feedback signal from signals received by the antenna-2 to adjust the parameters of the input

The electrical pulses from the activated stimulating electrode, however, result in zero net charge within the patient's body. The electrodes can be selectively marked as a stimulating return electrode or an inactive one. It can have one capacitor in

INS is designed to be placed in the patient through an introducer or a needle with

. The lead can also be a

electrodes (**Figure 2**) that include a semicylindrical array of electrodes/contacts made up of platinum, or platinum-iridium, or gallium-nitride, or titanium-nitride, or iridium-oxide or similar combinations. The contacts can be 2–16 in number having a length of 1 to 6 mm and 0.4 to 3 mm in width. They are spaced 1 to

paddle type, deliverable through a 14-gauge needle. The enclosure has an external

At present, several therapeutic intra-body electrical stimulation techniques are available to manage neuropathic pain. However, they utilize a bulky, heavy, subcutaneous IPG connected to the implantable wired leads and have many failures or adverse events like mechanical dislodgement, impingement of the lead extension cables, and infection, along with IPG-related discomfort, pain, and irritation. The lead configuration includes cylindrical percutaneous or paddle leads. Cylinders are usually 1.3 mm in diameter and contain several circular electrodes, which are used for trial testing, later followed by permanent placement by minimally invasive, percutaneous approach. Paddles contain electrodes with a wider surface area directionally targeted for control over neural excitation and require invasive surgical

tion with dimensions of 800–1350 μm diameter, a significantly miniature size compared to the conventional SCS-IPG. This is equal to the size of a standard lead body that also incorporates the nanoelectronics within the device itself. It also can be integrated with a variety of lead types carrying four or eight contacts, either in a percutaneous or a paddle-type electrode, and the receiver wire has circuits in the

stimulator device internally with wireless access (**Figure 1**).

**3. The implantable wireless lead or the implantable neural** 

**4. The nanoelectronic substrate of the miniature wireless** 

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

*From Conventional to Innovative Approaches for Pain Treatment*

targeted therapeutic localized pain relief [6, 8–12].

nanomaterials and wireless power transfer techniques.

pain and leg pain [1–3].

of life scales have shown consistent improvement with SCS in patients with back

Outcomes following SCS therapy have demonstrated superior results compared to conservative medical treatment for patients with FBSS in several studies [2, 4], and SCS was also shown to be more cost-effective over the long term due to a decrease in follow-up visits, diagnostic tests, and overall consumption of healthcare facilities [4, 5]. Historically, on the other hand, SCS has not been devoid of complications and limitations in its conventional form utilizing an IPG, since the device options have had a long history of severe adverse events primarily related to the IPG [6, 7]. A large percentage of patients, reportedly as high as 50%, have failed the trial period utilizing conventional SCS devices [6–8], while additional failures came from equipment complications caused by the migration/fracture of the electrodes as well as IPG failures and complications in recharging or reimplantation. Postsurgical complications like infection, hemorrhage, and painful operative wounds were frequently seen associated with IPG and its extension wires. Additionally, SCS in its conventional form is incapable of reaching some anatomical locations to provide

Several modifications have been introduced to the SCS equipment over the past few years, which have reduced adverse events while promoting the efficacy of the modality, thereby increasing the number of clinical indications [13]. Percutaneous techniques, smaller compact batteries, rechargeable batteries, increased life of the IPG, and improved anchoring methods are some of these modifications currently in use. Part of the refinement also comes from the advancements in the technology of

**2. Nanoelectrodes and wireless technology for neuromodulation**

An advancement in this field is the new miniature pulse generator (mini PG) with wireless access (WPG) utilizing a dipole antenna for electric field coupling. This is accomplished with "microwaves", which are very short wavelength pulsed electromagnetic waves at gigahertz (GHz) frequencies. This device (Stimwave Technologies, Florida, USA), instead of using lower frequencies of 100 – 500 kHz of the inductive range operational in most of the present-day implanted medical devices, is powered by a radiative electric field coupling through tissues at microwave frequencies that enable smaller-sized implants to be placed at a significant tissue depth through a percutaneous technique. It also affords minimal power loss, since the higher frequency allows a much better energy transfer to a smaller implant [14]. The principle behind the frequency changes in relation to the wavelength was elaborated earlier by Feynman: "If you build a corresponding circuit on a small scale, its natural frequency goes up, since the wave length goes down as the scale; but the skin depth only decreases with the square root of the scale ratio, and so resistive problems are of increasing difficulty. Possibly we can beat resistance through the use of superconductivity if the frequency is not too high, or by other

*MRI compatible electrode with nanostimulator and microcircuit to contact wireless pulse generator. This is the* 

**138**

**Figure 1.**

*only implantable component required for WSCS.*

tricks [15]."

The micro-implant WPG is capable of delivering clinically appropriate stimulation with dimensions of 800–1350 μm diameter, a significantly miniature size compared to the conventional SCS-IPG. This is equal to the size of a standard lead body that also incorporates the nanoelectronics within the device itself. It also can be integrated with a variety of lead types carrying four or eight contacts, either in a percutaneous or a paddle-type electrode, and the receiver wire has circuits in the stimulator device internally with wireless access (**Figure 1**).

#### **3. The implantable wireless lead or the implantable neural stimulator (INS)**

The INS has an enclosure housing the stimulating electrode array, designed to apply electrical pulses to the target tissue and antenna-1 and configured to receive electric energy input from an external antenna-2 through electrical radiative coupling. The antenna-2, physically separated from the INS lead, is connected to the antenna-1 by electric circuits configured to generate electrical pulses for stimulating the neural tissue (**Figure 1**).

#### **4. The nanoelectronic substrate of the miniature wireless pulse generator**

The INS is without any power source and stays in contact with the excitable neural tissue with passive components capable of receiving an external input signal at a frequency between 300 MHz and 8 GHz. A controller module, positioned in proximity to the patient body, to generate the input signals, sends them to the antenna-2; the latter transmits the input signal to the first dipole antenna placed within the INS through electrical radiative coupling, and antenna-1 extracts the stimulus feedback signal from signals received by the antenna-2 to adjust the parameters of the input signals based on the stimulus feedback.

The electrical pulses from the activated stimulating electrode, however, result in zero net charge within the patient's body. The electrodes can be selectively marked as a stimulating return electrode or an inactive one. It can have one capacitor in series with one or more electrodes.

At present, several therapeutic intra-body electrical stimulation techniques are available to manage neuropathic pain. However, they utilize a bulky, heavy, subcutaneous IPG connected to the implantable wired leads and have many failures or adverse events like mechanical dislodgement, impingement of the lead extension cables, and infection, along with IPG-related discomfort, pain, and irritation. The lead configuration includes cylindrical percutaneous or paddle leads. Cylinders are usually 1.3 mm in diameter and contain several circular electrodes, which are used for trial testing, later followed by permanent placement by minimally invasive, percutaneous approach. Paddles contain electrodes with a wider surface area directionally targeted for control over neural excitation and require invasive surgical procedures like laminectomy or laminotomy.

INS is designed to be placed in the patient through an introducer or a needle with electrodes (**Figure 2**) that include a semicylindrical array of electrodes/contacts made up of platinum, or platinum-iridium, or gallium-nitride, or titanium-nitride, or iridium-oxide or similar combinations. The contacts can be 2–16 in number having a length of 1 to 6 mm and 0.4 to 3 mm in width. They are spaced 1 to 6 mm apart with a combined surface area of 0.8 to 60 mm2 . The lead can also be a paddle type, deliverable through a 14-gauge needle. The enclosure has an external

**Figure 2.**

*Minimally invasive approach to place the wireless implantable neural stimulator in the spinal epidural space.*

biocompatible coating of polymethyl methacrylate (PMMA), polydimethylsiloxane (PDMS), perylene, polyurethane, polytetrafluoroethylene (PTFE), polycarbonate, or a silicone elastomer.

The antenna-1 within the INS enclosure has 2 to 8 contacts, configured to couple with each other as well as the circuit, and these contacts are located proximally relative to the electrode inside the enclosure. These contacts are 1 to 6 mm in length, 1 to 2.5 mm in width, and spaced 30 to 80 mm apart. One antenna is constructed as a conductive trace contained on the circuits and can be fabricated as a conductive wire connected to the circuits, which are flexible with a bend radius of 0.5 mm and located proximal in the enclosure with a waveform conditioning circuit.

#### **5. Remote control of power or polarity selection for a neural stimulator**

The dipole antenna receives input signals containing polarity assignment information and electrical energy, the former designating the polarities for the electrode contacts. The circuits are configured to control an electrode interface so that these electrode contacts have polarities designed by the polarity assignment information to create electrical pulses from the electrical energy contained in the input signal. These electrical pulses reach the contacts according to the polarities assigned.

#### **6. The remote radiofrequency power system with a low-profile transmitting antenna**

The antenna for this wireless system includes a metal signal layer with radiating surface, a feed port, a wave guide surrounding the antenna, and a configuration to guide electromagnetic (EM) energy transmitted from the radiating surface in a direction away from the antenna. It also has a controller module connected to the feed port to drive the antenna to transmit EM energy from the radiating surface, while the antenna, wave guide, and controller module are configured to match a reception characteristic of an implantable device, so that the latter can produce electrical pulses of sufficient amplitude to stimulate the target neural tissue utilizing the EM energy received from the antenna-2, located up to 10 cm away.

Adverse events related to the IPG, due to excessive absorption of EM energy, include burning of tissue, creation of undesirable blood clots, and skin irritation

**141**

neural tissue.

band.

**Figure 4.**

**Figure 3.**

**7. Wireless energy supply**

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

*Remote access by wireless antenna (experimental setting).*

because of adhesions between the implant and tissues. A wireless device, on the other hand, has the antenna located outside the body with a controller module con-

*Neurostimulator receiver. The contacts on the electrodes are managed by independently integrated, circuits that are application specific. The circuitry system within the device produces charge-balanced waveforms.*

The antenna has a dielectric lens filling the wave guide, protruding outward from an opening of the wave guide to narrow the transmitted EM energy and direct it away from the transmitting surface. It also has a return loss cutoff frequency associated with the wave guide; the dielectric lens lowers the return loss of cutoff frequency. The antenna operates within 500 MHz to 4 GHz frequency

The INS receives energy by a wireless method, which includes radiating EM energy from the surface on an antenna located up to 10 cm away, inside the patient, so that the implanted device creates appropriate electrical pulses to stimulate the target neural tissue, using the received EM energy, even during sleep. The radiating surface of the antenna can be placed 1 to 6 feet away from the INS and can be adjusted to increase the EM energy provided to the latter (**Figure 3**). The interface is facilitated by a link between the programmable module and the controller module so that the stimulation pulses created at the implantable device are transmitted as data-encoded parameters from the programming module to the controller module, thus effectively stimulating the

A dipole antenna receiver intercepts the high-frequency microwave EM energy coming from outside the body to produce an oscillating electric field. Frequencies in

necting the implantable device with the antenna (**Figures 3** and **4**).

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

**Figure 3.** *Remote access by wireless antenna (experimental setting).*

**Figure 4.**

*From Conventional to Innovative Approaches for Pain Treatment*

or a silicone elastomer.

**Figure 2.**

polarities assigned.

**transmitting antenna**

biocompatible coating of polymethyl methacrylate (PMMA), polydimethylsiloxane (PDMS), perylene, polyurethane, polytetrafluoroethylene (PTFE), polycarbonate,

*Minimally invasive approach to place the wireless implantable neural stimulator in the spinal epidural space.*

with each other as well as the circuit, and these contacts are located proximally relative to the electrode inside the enclosure. These contacts are 1 to 6 mm in length, 1 to 2.5 mm in width, and spaced 30 to 80 mm apart. One antenna is constructed as a conductive trace contained on the circuits and can be fabricated as a conductive wire connected to the circuits, which are flexible with a bend radius of 0.5 mm and

**5. Remote control of power or polarity selection for a neural stimulator**

The dipole antenna receives input signals containing polarity assignment information and electrical energy, the former designating the polarities for the electrode contacts. The circuits are configured to control an electrode interface so that these electrode contacts have polarities designed by the polarity assignment information to create electrical pulses from the electrical energy contained in the input signal. These electrical pulses reach the contacts according to the

located proximal in the enclosure with a waveform conditioning circuit.

**6. The remote radiofrequency power system with a low-profile** 

ing the EM energy received from the antenna-2, located up to 10 cm away.

Adverse events related to the IPG, due to excessive absorption of EM energy, include burning of tissue, creation of undesirable blood clots, and skin irritation

The antenna for this wireless system includes a metal signal layer with radiating surface, a feed port, a wave guide surrounding the antenna, and a configuration to guide electromagnetic (EM) energy transmitted from the radiating surface in a direction away from the antenna. It also has a controller module connected to the feed port to drive the antenna to transmit EM energy from the radiating surface, while the antenna, wave guide, and controller module are configured to match a reception characteristic of an implantable device, so that the latter can produce electrical pulses of sufficient amplitude to stimulate the target neural tissue utiliz-

The antenna-1 within the INS enclosure has 2 to 8 contacts, configured to couple

**140**

*Neurostimulator receiver. The contacts on the electrodes are managed by independently integrated, circuits that are application specific. The circuitry system within the device produces charge-balanced waveforms.*

because of adhesions between the implant and tissues. A wireless device, on the other hand, has the antenna located outside the body with a controller module connecting the implantable device with the antenna (**Figures 3** and **4**).

The antenna has a dielectric lens filling the wave guide, protruding outward from an opening of the wave guide to narrow the transmitted EM energy and direct it away from the transmitting surface. It also has a return loss cutoff frequency associated with the wave guide; the dielectric lens lowers the return loss of cutoff frequency. The antenna operates within 500 MHz to 4 GHz frequency band.

#### **7. Wireless energy supply**

The INS receives energy by a wireless method, which includes radiating EM energy from the surface on an antenna located up to 10 cm away, inside the patient, so that the implanted device creates appropriate electrical pulses to stimulate the target neural tissue, using the received EM energy, even during sleep. The radiating surface of the antenna can be placed 1 to 6 feet away from the INS and can be adjusted to increase the EM energy provided to the latter (**Figure 3**). The interface is facilitated by a link between the programmable module and the controller module so that the stimulation pulses created at the implantable device are transmitted as data-encoded parameters from the programming module to the controller module, thus effectively stimulating the neural tissue.

A dipole antenna receiver intercepts the high-frequency microwave EM energy coming from outside the body to produce an oscillating electric field. Frequencies in the range of GHz were found to be more energy efficient [16]. Typically, the antenna within the device lumen can be anywhere from 2 to 8cm long and can be modified depending upon the indications and the depth at which the device is implanted, since the EM field energy is dissipated across the tissue layers of the skin, fat, muscle, blood vessels, and bone. The deeper the placement, the longer the antenna should be to receive adequate power. Each contact on the electrodes is provided with independent power, a part of an "application-specific" integrated circuit; the embedded circuitry within the device enables production of charge-balanced waveforms. This is managed by internalized addressing systems within the device (**Figure 4**). It is important to note that microwave fields are safe, since these high frequencies fail to activate cell membranes and thus nervous tissue damage is unlikely.

#### **8. Wireless pulse generator (WPG)**

The WPG employs standard cellular phone technology, with an average pulse output power of up to 1 W, depending upon the stimulation parameters and according to the requirements of the target tissue. A radiofrequency (RF) transmitter placed inside the WPG encodes stimulus waveforms into the signal according to the program settings. A microprocessor inside this transmitter controls the data communications and settings (**Figures 3** and **4**). Clinicians as well as patients communicate with the WPG via a controller that uses Bluetooth technology (**Figure 5**) and also can be accessed by a software application (app) on a mobile phone [14].

**Figure 5.** *External wireless pulse generator.*

#### **9. Discussion**

The traditional SCS (TSCS) system has electrodes in a catheter enclosure attached to a long extension cable(s) that connects the electrodes to an IPG that is placed inside the patient's body, inheriting the complications due to failure or malfunction of any of these components. Efforts have been ongoing to reduce the bulk of the implanted material and yet improve the efficiency of the system. Reduction in size has a challenge from the battery life expectancy with the conventional energy settings. Thus, TSCS equipment requires implantation of electrodes, extension cables, and the battery inside the body, requiring multiple incisions along with long segment tunnels under the skin, producing considerable tissue trauma with pain and hemorrhage.

**143**

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

**neuromodulation technology**

incisions/tissue trauma, and hospital visits.

tional SCS has a structure as follows:

body

The wireless SCS system with nanotechnology has been clinically used for SCS, dorsal root ganglia (DRG) stimulation, and peripheral nerve stimulation (PNS) throughout Europe and the USA for several years, and multiple trials have shown encouraging results. The capabilities of this system enabled its utility to be tested in a variety of chronic pain syndromes. Poon et al. [16, 17] demonstrated that in a biological media, the operating frequency for wireless-powered devices was in GHz range as opposed to the MHz, which could have potential advantages. At this frequency range, the size reduction of the receiver has been demonstrated in the subsequent studies by Tyler Perryman et al., while the tissue depth relationship to the energy transmission were further elaborated [17, 18]. Tyler Perryman et al. conducted studies in animals and verified the tissue depths at which the wireless stimulation could achieve effective current density [18]. The dipole antenna of the wireless system (at 915 MHz) could energize the stimulators implanted at a depth of 12 cm in porcine models, especially efficient with a 4.3 cm antenna. Successful stimulation has been observed to provide significant pain relief in patients with back and leg pain with FBSS [19, 20], post herpetic neuralgia [21], refractory craniofacial pain [22], occipital neuralgia [23], and CRPS [24]. Patients undergo implantation of the INS with integrated microcircuits enabling coupling with a pulse generator, while the wireless pulse generator circuit excludes surgical implantation of the IPG, thus eliminating complications related to multiple surgical incisions and interventions for failed IPG or its extension cables. Consequently, there is reduced operating time, minimal consumables, and increased comfort to the patient. In the long run, this should decrease

the costs of SCS and reduce overall healthcare budget in neuromodulation.

**10. Financial implications and economic benefits with the wireless** 

as the inventions arrive into the clinical practice. For easy understanding, tradi-

Conversely, wireless neuromodulation with nanotechnology utilizes only implantable stimulating electrodes and an implantable receiver placed in a microincision pocket. Because of the reduced bulk of the implants, wireless technology has much more to offer other than the costs alone. It reduces surgical trauma, operating time, con-sumables, anesthesia, complications secondary to multiple

Compared to the wireless neuromodulation, TSCS was reported to be more expensive (**Table 1**). There have been limited reports on the costs and long-term maintenance

2.External controller (for the patient as well as the clinician)

**11. Costs involved with nanotechnology wireless SCS**

The initial implantation of the wireless stimulator 18,000 Euros IPG costs: Zero (0) Annual maintenance of the neuromodulation cost 1500 Euros/3

Every innovation carries financial burden, and there are economic repercussions

1.Electrodes + connection cables + implantable pulse generator inside the patient

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

*From Conventional to Innovative Approaches for Pain Treatment*

branes and thus nervous tissue damage is unlikely.

**8. Wireless pulse generator (WPG)**

the range of GHz were found to be more energy efficient [16]. Typically, the antenna within the device lumen can be anywhere from 2 to 8cm long and can be modified depending upon the indications and the depth at which the device is implanted, since the EM field energy is dissipated across the tissue layers of the skin, fat, muscle, blood vessels, and bone. The deeper the placement, the longer the antenna should be to receive adequate power. Each contact on the electrodes is provided with independent power, a part of an "application-specific" integrated circuit; the embedded circuitry within the device enables production of charge-balanced waveforms. This is managed by internalized addressing systems within the device (**Figure 4**). It is important to note that microwave fields are safe, since these high frequencies fail to activate cell mem-

The WPG employs standard cellular phone technology, with an average pulse output power of up to 1 W, depending upon the stimulation parameters and according to the requirements of the target tissue. A radiofrequency (RF) transmitter placed inside the WPG encodes stimulus waveforms into the signal according to the program settings. A microprocessor inside this transmitter controls the data communications and settings (**Figures 3** and **4**). Clinicians as well as patients communicate with the WPG via a controller that uses Bluetooth technology (**Figure 5**) and also can be accessed by a software application (app) on a mobile phone [14].

The traditional SCS (TSCS) system has electrodes in a catheter enclosure attached to a long extension cable(s) that connects the electrodes to an IPG that is placed inside the patient's body, inheriting the complications due to failure or malfunction of any of these components. Efforts have been ongoing to reduce the bulk of the implanted material and yet improve the efficiency of the system. Reduction in size has a challenge from the battery life expectancy with the conventional energy settings. Thus, TSCS equipment requires implantation of electrodes, extension cables, and the battery inside the body, requiring multiple incisions along with long segment tunnels under the skin, producing considerable tissue trauma

**142**

**9. Discussion**

*External wireless pulse generator.*

**Figure 5.**

with pain and hemorrhage.

The wireless SCS system with nanotechnology has been clinically used for SCS, dorsal root ganglia (DRG) stimulation, and peripheral nerve stimulation (PNS) throughout Europe and the USA for several years, and multiple trials have shown encouraging results. The capabilities of this system enabled its utility to be tested in a variety of chronic pain syndromes. Poon et al. [16, 17] demonstrated that in a biological media, the operating frequency for wireless-powered devices was in GHz range as opposed to the MHz, which could have potential advantages. At this frequency range, the size reduction of the receiver has been demonstrated in the subsequent studies by Tyler Perryman et al., while the tissue depth relationship to the energy transmission were further elaborated [17, 18]. Tyler Perryman et al. conducted studies in animals and verified the tissue depths at which the wireless stimulation could achieve effective current density [18]. The dipole antenna of the wireless system (at 915 MHz) could energize the stimulators implanted at a depth of 12 cm in porcine models, especially efficient with a 4.3 cm antenna. Successful stimulation has been observed to provide significant pain relief in patients with back and leg pain with FBSS [19, 20], post herpetic neuralgia [21], refractory craniofacial pain [22], occipital neuralgia [23], and CRPS [24]. Patients undergo implantation of the INS with integrated microcircuits enabling coupling with a pulse generator, while the wireless pulse generator circuit excludes surgical implantation of the IPG, thus eliminating complications related to multiple surgical incisions and interventions for failed IPG or its extension cables. Consequently, there is reduced operating time, minimal consumables, and increased comfort to the patient. In the long run, this should decrease the costs of SCS and reduce overall healthcare budget in neuromodulation.

#### **10. Financial implications and economic benefits with the wireless neuromodulation technology**

Every innovation carries financial burden, and there are economic repercussions as the inventions arrive into the clinical practice. For easy understanding, traditional SCS has a structure as follows:


Conversely, wireless neuromodulation with nanotechnology utilizes only implantable stimulating electrodes and an implantable receiver placed in a microincision pocket. Because of the reduced bulk of the implants, wireless technology has much more to offer other than the costs alone. It reduces surgical trauma, operating time, con-sumables, anesthesia, complications secondary to multiple incisions/tissue trauma, and hospital visits.

#### **11. Costs involved with nanotechnology wireless SCS**


Compared to the wireless neuromodulation, TSCS was reported to be more expensive (**Table 1**). There have been limited reports on the costs and long-term maintenance

#### *From Conventional to Innovative Approaches for Pain Treatment*


#### **Table 1.**

*Literature on TSCS cost.*


*HF SCS therapy was similar to TSCS in its costs and complications. USD\*, US dollar; CAD\*, Canadian dollar; UKS\*, United Kingdom Sterling Pound.*

#### **Table 2.**

*Reported costs of traditional SCS (TSCS) and the wireless SCS (WSCS).*


#### **Table 3.**

*Costs for lead revision/repositioning in TSCS.*

of TSCS in the literature. Detailed report on follow-up costs, complications, and replacement charges for reimplantation has not been forthcoming. However, the natural course of TSCS with its multiple implant components leading to their inherent complications could be expected as reported in a few of the studies (**Tables 1–3**). Wireless neuromodulation is evolving, and only limited experience has been reported so far. However, large-scale multicenter studies have been initiated to improve our understanding about the efficacy and acceptable long-term results in the form of improved quality of life, reduced complications, reduction in healthcare costs, and better cosmetic results.

#### **12. Conclusions**

Nanoelectronics have contributed to the development of miniature implants for therapeutic purposes, and wireless technology coupled with mini WPG appears

**145**

**Author details**

Laura Tyler Perryman

provided the original work is properly cited.

Stimwave Technologies, Inc., Pompano Beach, Florida, USA

\*Address all correspondence to: laura@stimwave.com

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

with improved cosmetic and functional results.

2.US9254393B2. Wearable antenna assembly

5.US8849412B2. Microwave field stimulator

7.US9409030B2. Neural stimulator system

9.US9522270B2. Circuit for an implantable device

3.US9220897B2. Implantable lead

**Copyright information**

stimulator

exiting spinal nerves

from the patent applications.

to enhance the quality of neuromodulation in the field of functional neurosurgery and pain management therapies. Wireless neuromodulation, so far applied as SCS, DRG, and PNS, has provided efficient pain relief in cases of FBSS, neuralgic pain, CRPS, and facial pain syndromes. The results observed in small case series or case illustrations are comparable to traditional SCS methods and devoid of many of the complications of TSCS, primarily related to IPG/battery accessories. Further wireless neuromodulation experience may demonstrate improved quality of life associated with significant reduction in cost as well as reduction in complications,

Authors hold the following patents. Information in the chapter includes material

1.US9409029B2. Remote RF power system with low profile transmitting antenna

4.US9199089B2. Remote control of power or polarity selection for a neural

6.US8903502B2. Methods and devices for modulating excitable tissue of the

8.US15228715. Remote rf power system with low profile transmitting antenna

Author has copyrights on the publications referenced [18, 19, 22, 23].

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

to enhance the quality of neuromodulation in the field of functional neurosurgery and pain management therapies. Wireless neuromodulation, so far applied as SCS, DRG, and PNS, has provided efficient pain relief in cases of FBSS, neuralgic pain, CRPS, and facial pain syndromes. The results observed in small case series or case illustrations are comparable to traditional SCS methods and devoid of many of the complications of TSCS, primarily related to IPG/battery accessories. Further wireless neuromodulation experience may demonstrate improved quality of life associated with significant reduction in cost as well as reduction in complications, with improved cosmetic and functional results.

#### **Copyright information**

*From Conventional to Innovative Approaches for Pain Treatment*

**Author Journal Year No. of** 

of TSCS in the literature. Detailed report on follow-up costs, complications, and

1. Repositioning of electrode €360 \$2700 2. Replacement €1530 \$5450 3. Reimplantation following infection €6192 \$19,600

**Procedure TSCS USD\* TSCS CAD\* TSCS** 

*Reported costs of traditional SCS (TSCS) and the wireless SCS (WSCS).*

Implantation 32,882 21,595 15,081 €18,000 Complication cost 9649 5191 576 NA Revision cost 5450 5339 (lead) €2500 **IPG cost 13,150 10,591 7243 0 Maintenance 5071 (4 years) 3539 (4 years) NA 1500 (3 years)** *HF SCS therapy was similar to TSCS in its costs and complications. USD\*, US dollar; CAD\*, Canadian dollar;* 

1. Manca et al. [25] European J Pain 2008 52 CAD 19,486, Euro 12,653 2. Kumar et al. [10] J Neurosurg Spine 2006 160 CAD 23,205 3. Kumar and Bishop [26] J Neurosurg Spine 2009 197 CAD 21,595, USD 32,882 4. Hornberger et al. [27] Clin J Pain 2008 NA USD 26,005 (nonrechargeable)

5. Babu et al. [28] Neuromodulation 2013 4536 USD 30,200 (percutaneous)

6. Annemans et al. [29] J LTE Med Implants 2014 Model UK£ 15,056 (HF SCS)

**UKS\***

**patients**

**Stimwave WSCS**

**American experience [31]**

**Cost**

USD 35,109 (rechargeable)

4536 USD 29,963 (paddle electrodes)

replacement charges for reimplantation has not been forthcoming. However, the natural course of TSCS with its multiple implant components leading to their inherent complications could be expected as reported in a few of the studies (**Tables 1–3**). Wireless neuromodulation is evolving, and only limited experience has been reported so far. However, large-scale multicenter studies have been initiated to improve our understanding about the efficacy and acceptable long-term results in the form of improved quality of life, reduced complications, reduction in healthcare costs, and better cosmetic results.

**European experience [30]**

Nanoelectronics have contributed to the development of miniature implants for therapeutic purposes, and wireless technology coupled with mini WPG appears

**144**

**12. Conclusions**

*UKS\*, United Kingdom Sterling Pound.*

*Costs for lead revision/repositioning in TSCS.*

**Table 2.**

**Table 3.**

**Table 1.**

*Literature on TSCS cost.*

Authors hold the following patents. Information in the chapter includes material from the patent applications.


Author has copyrights on the publications referenced [18, 19, 22, 23].

#### **Author details**

Laura Tyler Perryman Stimwave Technologies, Inc., Pompano Beach, Florida, USA

\*Address all correspondence to: laura@stimwave.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Turner JA, Loeser JD, Bell KG. Spinal cord stimulation for chronic low back pain: A systematic literature synthesis. Neurosurgery. 1995;**37**:1088-1096

[2] Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: A 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008;**63**:762-770

[3] Kapural L, Yu C, Doust M, et al. Novel 10-kHz high-frequency therapy (HF10 therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain the SENZA-RCT randomized controlled trial. Anesthesiology. 2015;**123**:851-860

[4] Deer TR, Mekhail N, Provenzano D, et al. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: The neuromodulation appropriateness consensus committee. Neuromodulation. 2014;**17**:515-550

[5] Mekhail NA, Aeschbach A, Stanton-Hicks M. Cost benefit analysis of neurostimulation for chronic pain. The Clinical Journal of Pain. 2004;**20**:462-468

[6] Turner JA, Loeser JD, Deyo RA, Sanders SB. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain. 2004;**108**:137-147

[7] Mekhail NA, Mathews M, Nageeb F, Guirguis M, et al. Retrospective review of 707 cases of spinal cord stimulation: Indications and complications. Pain Practice. 2011;**11**:148-153

[8] Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: A 20-year literature review. Journal of Neurosurgery. 2004;**100**:254-267

[9] Krishna K, Jefferson RW, Gupta S. Complications of spinal cord stimulation, suggestions to improve outcome, and financial impact. Journal of Neurosurgery. 2006;**5**:191-203

[10] Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: Challenges in treatment planning and present status, a 22-year experience. Neurosurgery. 2006;**58**:481-496

[11] North RB, Kidd DH, Zahurak M, et al. Spinal cord stimulation for chronic, intractable pain: Experience over two decades. Neurosurgery 1993;**32**:384-394; discussion 394-395.

[12] Pineda A. Complications of dorsal column stimulation. Journal of Neurosurgery. 1978;**48**:64-68

[13] Slavin KV. Spinal stimulations for pain: Future applications. Neurotherapeutics. 2014;**11**:535-542

[14] Yearwood TL, Perryman LT. Peripheral neurostimulation with a microsize wireless stimulator. In: Slavin KV, editor. Stimulation of the Peripheral Nervous System. The Neuromodulation Frontier. Progress in Neurological Surgery. Basel, Switzerland: Karger Publishing; 2016. pp. 168-191

[15] Feynman RP. There's plenty of room at the bottom. CalTech, Pasedena CA: Presentation to the American Physical Society; 1959

[16] Poon AS, O'Driscoll S, Meng TH. Optimal operating frequency in wireless power transmission for implantable devices. In: Conf Proc IEEE Eng Med

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> neuralgia: Case illustrations. Journal of Neurology & Stroke. 2017;**6**:00213

[24] Herschkowitz D, Kubias J. Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: A case illustration introducing a novel technology. Scandinavian Journal of Pain. July

[25] Manca A, Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, et al. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). European Journal of Pain. 2008;**12**:1047-1058

[26] Kumar K, Bishop S. Financial impact of spinal cord stimulation on the health care budget: A comparative analysis of costs in Canada and the United States. Journal of Neurosurgery:

Spine. 2009;**10**:564-573

2008;**24**:244-252

2013;**16**:418-427

Implants. 2014;**24**:173-183

[27] Hornberger J, Kumar K,

Verhulst E, Clark MA, Hernandez J. Rechargeable spinal cord stimulation versus non-rechargeable system for patient with failed back surgery syndrome: A cost consequences analysis. The Clinical Journal of Pain.

[28] Babu R, Hazzard MA, Huang KT, Ugiliweneza B, Patil CG, Boakye M, et al. Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: A comparative analysis of complications, reoperation rates, and health-care costs. Neuromodulation.

[29] Annemans L, Van Buyten JP, Smith T, Al-Kaisy A. Cost effectiveness of a novel 10 kHz high-frequency spinal cord stimulation system in patients with failed back surgery syndrome (FBSS). Journal of Long-Term Effects of Medical

2018:555-560

Biol Soc; Lyon, France. 2007. pp.

[17] Poon A, O'Driscoll, Meng TH. Optimal frequency for wireless power transmission into dispersive tissue. IEEE Transactions on Antennas and Propagation. 2010;**58**:1739-1750

[18] Tyler Perryman L, Larson P, Glaser J. Tissue depth study for a fully implantable, remotely powered and programmable wireless neural stimulator. International Journal of Nano Studies and Technology.

[19] Weiner RL, Yeung A, Garcia CM, Perryman LT, Speck B. Treatment of FBSS low back pain with a novel percutaneous DRG wireless stimulator:

Pilot and feasibility study. Pain Medicine. 2016;**17**:1911-1916

[20] Billet B, Wynendaele R, Vanquathem N. Wireless

[21] Billet B, Wynendaele R, Vanquathem N. A novel minimally invasive wireless technology for neuromodulation via percutaneous intercostal nerve stimulation (PNS) for post-herpetic neuralgia: A case report with short term follow up. Pain Practice.

[22] Weiner RL, Garcia CM, Vanquathem N. A novel miniature wireless neurostimulator in the

management of chronic craniofacial pain: Preliminary results from a prospective pilot study. Scandinavian Journal of Pain.

[23] Perryman LT, Speck B, Weiner RL. A novel wireless minimally invasive neuromodulation device for the

treatment of chronic intractable occipital

Archives. 2017;**5**:1-8

2018;**3**:374-379

2017:350-354

neuromodulation by a minimally invasive technique for chronic

refractory pain. Report of preliminary observations. Medical Research

2016;**S2**(001):1-6

5674-5679

*Wireless Neuromodulation: From Bench to Bedside DOI: http://dx.doi.org/10.5772/intechopen.85501*

Biol Soc; Lyon, France. 2007. pp. 5674-5679

[17] Poon A, O'Driscoll, Meng TH. Optimal frequency for wireless power transmission into dispersive tissue. IEEE Transactions on Antennas and Propagation. 2010;**58**:1739-1750

[18] Tyler Perryman L, Larson P, Glaser J. Tissue depth study for a fully implantable, remotely powered and programmable wireless neural stimulator. International Journal of Nano Studies and Technology. 2016;**S2**(001):1-6

[19] Weiner RL, Yeung A, Garcia CM, Perryman LT, Speck B. Treatment of FBSS low back pain with a novel percutaneous DRG wireless stimulator: Pilot and feasibility study. Pain Medicine. 2016;**17**:1911-1916

[20] Billet B, Wynendaele R, Vanquathem N. Wireless neuromodulation by a minimally invasive technique for chronic refractory pain. Report of preliminary observations. Medical Research Archives. 2017;**5**:1-8

[21] Billet B, Wynendaele R, Vanquathem N. A novel minimally invasive wireless technology for neuromodulation via percutaneous intercostal nerve stimulation (PNS) for post-herpetic neuralgia: A case report with short term follow up. Pain Practice. 2018;**3**:374-379

[22] Weiner RL, Garcia CM, Vanquathem N. A novel miniature wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study. Scandinavian Journal of Pain. 2017:350-354

[23] Perryman LT, Speck B, Weiner RL. A novel wireless minimally invasive neuromodulation device for the treatment of chronic intractable occipital neuralgia: Case illustrations. Journal of Neurology & Stroke. 2017;**6**:00213

[24] Herschkowitz D, Kubias J. Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: A case illustration introducing a novel technology. Scandinavian Journal of Pain. July 2018:555-560

[25] Manca A, Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, et al. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). European Journal of Pain. 2008;**12**:1047-1058

[26] Kumar K, Bishop S. Financial impact of spinal cord stimulation on the health care budget: A comparative analysis of costs in Canada and the United States. Journal of Neurosurgery: Spine. 2009;**10**:564-573

[27] Hornberger J, Kumar K, Verhulst E, Clark MA, Hernandez J. Rechargeable spinal cord stimulation versus non-rechargeable system for patient with failed back surgery syndrome: A cost consequences analysis. The Clinical Journal of Pain. 2008;**24**:244-252

[28] Babu R, Hazzard MA, Huang KT, Ugiliweneza B, Patil CG, Boakye M, et al. Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: A comparative analysis of complications, reoperation rates, and health-care costs. Neuromodulation. 2013;**16**:418-427

[29] Annemans L, Van Buyten JP, Smith T, Al-Kaisy A. Cost effectiveness of a novel 10 kHz high-frequency spinal cord stimulation system in patients with failed back surgery syndrome (FBSS). Journal of Long-Term Effects of Medical Implants. 2014;**24**:173-183

**146**

*From Conventional to Innovative Approaches for Pain Treatment*

[8] Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: A 20-year literature review. Journal of Neurosurgery. 2004;**100**:254-267

[9] Krishna K, Jefferson RW, Gupta S.

[10] Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: Challenges in treatment planning and present status, a 22-year experience. Neurosurgery.

[11] North RB, Kidd DH, Zahurak M, et al. Spinal cord stimulation for chronic, intractable pain: Experience over two decades. Neurosurgery 1993;**32**:384-394; discussion 394-395.

[12] Pineda A. Complications of dorsal column stimulation. Journal of

[13] Slavin KV. Spinal stimulations for pain: Future applications. Neurotherapeutics. 2014;**11**:535-542

[14] Yearwood TL, Perryman LT. Peripheral neurostimulation with a microsize wireless stimulator. In: Slavin KV, editor. Stimulation of the Peripheral Nervous System. The Neuromodulation Frontier. Progress in Neurological Surgery. Basel, Switzerland: Karger Publishing; 2016. pp. 168-191

[15] Feynman RP. There's plenty of room at the bottom. CalTech, Pasedena CA: Presentation to the American Physical

[16] Poon AS, O'Driscoll S, Meng TH. Optimal operating frequency in wireless power transmission for implantable devices. In: Conf Proc IEEE Eng Med

Society; 1959

Neurosurgery. 1978;**48**:64-68

Complications of spinal cord stimulation, suggestions to improve outcome, and financial impact. Journal of Neurosurgery. 2006;**5**:191-203

2006;**58**:481-496

[1] Turner JA, Loeser JD, Bell KG. Spinal cord stimulation for chronic low back pain: A systematic literature synthesis. Neurosurgery. 1995;**37**:1088-1096

[2] Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: A 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery.

[3] Kapural L, Yu C, Doust M, et al. Novel 10-kHz high-frequency therapy (HF10 therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain the SENZA-RCT randomized controlled trial. Anesthesiology.

[4] Deer TR, Mekhail N, Provenzano D,

neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: The neuromodulation appropriateness consensus committee. Neuromodulation. 2014;**17**:515-550

et al. The appropriate use of

[5] Mekhail NA, Aeschbach A,

Stanton-Hicks M. Cost benefit analysis of neurostimulation for chronic pain. The Clinical Journal of Pain.

[6] Turner JA, Loeser JD, Deyo RA, Sanders SB. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain.

[7] Mekhail NA, Mathews M, Nageeb F, Guirguis M, et al. Retrospective review of 707 cases of spinal cord stimulation: Indications and complications. Pain

2008;**63**:762-770

**References**

2015;**123**:851-860

2004;**20**:462-468

2004;**108**:137-147

Practice. 2011;**11**:148-153

[30] Kemler MA, Furnee CA. Economic evaluation of spinal cord stimulation for chronic reflex sympathetic dystrophy. Neurology. 2002;**59**:1203-1209

[31] Bell GK, Kidd D, North RB. Costeffectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. Journal of Pain and Symptom Management. 1997;**13**:286-295

**149**

pain management

**1. Introduction**

status (**Figure 1**).

**Chapter 10**

**Abstract**

Resolution

*has the disease".*

*myoActivation*: A Structured

Process for Chronic Pain

*Gillian Lauder, Nicholas West and Greg Siren*

to all clinicians that manage people living with chronic pain.

**Keywords:** pain, chronic pain, paediatric pain, mobility dysfunction, fascia, myofascial trigger points, timeline of lifetime trauma, physical trauma, scars, palpation, catenated cycles, structured assessment, non-pharmaceutical,

Pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" [1]. Pain is a highly subjective sensation influenced by: degree of tissue damage, response to medications, diet, age, sex, genetics, cultural background, and psychosocial factors including attention, emotion, cognition, beliefs, expectations, and socioeconomic

Chronic pain is a significant burden in all societies. The myofascial origins of chronic pain are often unrecognized but play a major role in chronic pain generation. Myofascial release has been shown to be effective and can augment the limited number of therapeutic tools available to manage chronic pain. However, there is no standardized approach that allows for comparative analysis of this technique. *myoActivation*® is a unique therapeutic system, which targets active myofascial trigger points, fascia in tension, and scars in patients with chronic pain. Targets for intervention are determined through obtaining a history of lifetime trauma and a structured, reproducible posture, and movement assessment. Catenated cycles of movement tests, palpation, and needling are used to achieve the goal of pain resolution through restoration of soft tissue integrity. This chapter describes the distinctive features of *myoActivation* from the important key elements of the patient's clinical history, through to the aftercare instructions. Relevant evidence for each component will be presented. Case studies will be used to illustrate some important concepts and the effectiveness of *myoActivation*. This chapter is relevant

*"The good physician treats the disease; the great physician treats the patient who* 

*Sir William Osler, 1849–1919*

#### **Chapter 10**

*From Conventional to Innovative Approaches for Pain Treatment*

[30] Kemler MA, Furnee CA. Economic evaluation of spinal cord stimulation for chronic reflex sympathetic dystrophy.

[31] Bell GK, Kidd D, North RB. Costeffectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. Journal of Pain and Symptom Management. 1997;**13**:286-295

Neurology. 2002;**59**:1203-1209

**148**

## *myoActivation*: A Structured Process for Chronic Pain Resolution

*Gillian Lauder, Nicholas West and Greg Siren*

*"The good physician treats the disease; the great physician treats the patient who has the disease".*

*Sir William Osler, 1849–1919*

#### **Abstract**

Chronic pain is a significant burden in all societies. The myofascial origins of chronic pain are often unrecognized but play a major role in chronic pain generation. Myofascial release has been shown to be effective and can augment the limited number of therapeutic tools available to manage chronic pain. However, there is no standardized approach that allows for comparative analysis of this technique. *myoActivation*® is a unique therapeutic system, which targets active myofascial trigger points, fascia in tension, and scars in patients with chronic pain. Targets for intervention are determined through obtaining a history of lifetime trauma and a structured, reproducible posture, and movement assessment. Catenated cycles of movement tests, palpation, and needling are used to achieve the goal of pain resolution through restoration of soft tissue integrity. This chapter describes the distinctive features of *myoActivation* from the important key elements of the patient's clinical history, through to the aftercare instructions. Relevant evidence for each component will be presented. Case studies will be used to illustrate some important concepts and the effectiveness of *myoActivation*. This chapter is relevant to all clinicians that manage people living with chronic pain.

**Keywords:** pain, chronic pain, paediatric pain, mobility dysfunction, fascia, myofascial trigger points, timeline of lifetime trauma, physical trauma, scars, palpation, catenated cycles, structured assessment, non-pharmaceutical, pain management

#### **1. Introduction**

Pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" [1]. Pain is a highly subjective sensation influenced by: degree of tissue damage, response to medications, diet, age, sex, genetics, cultural background, and psychosocial factors including attention, emotion, cognition, beliefs, expectations, and socioeconomic status (**Figure 1**).

#### *From Conventional to Innovative Approaches for Pain Treatment*

#### **Figure 1.**

*The biopsychosocial contributors to chronic pain.*

Pain is a sensory output from the brain when the brain is on alert. In acute pain, this sensory output is important to protect the organism from further harm during the healing phase, and, is usually associated with a nociceptive stimulus.

Chronic pain is quite different; although it is typically considered to refer to pain lasting longer than 3 months, such a time limit seems to be reductive, and it more properly refers to "pain that extends beyond the expected period of healing" [2]. The overall prevalence of chronic pain conditions is estimated to be in the order of 35–51% of the adult population [3] and the incidence of widespread chronic pain estimated to be 10–15% [4]. Chronic pain occurs across the lifespan, including children [5] and the elderly [6]. The frequency of visits to physicians, emergency departments, and other healthcare providers is significantly increased in the presence of chronic pain [7]. Currently, the burden of chronic pain has a huge impact on quality of life in the lives of people with chronic pain [8, 9]. The economic burden of chronic pain in terms of healthcare costs is substantial, but pales in significance compared to the costs of lost productivity due to job redundancy and sick days [9].

#### **1.1 Background**

Chronic pain is a complex biopsychosocial phenomenon that requires a multidisciplinary approach to management. This usually includes return to physical function [10], graded return to work/school, medications to help with pain, mood and sleep, as well as non-pharmacological techniques to address the psychosocial components of pain [9, 11, 12]. The weakest link in this therapeutic process is the pharmacological approach, especially the overreliance on the use of *opioid* medications. The prescription of opioids for chronic non-cancer pain increased fourfold in USA from the early 1990s up to 2011 [13, 14]. Opioids contribute only modest relief of chronic pain. They have limited effects on improvement in function but cause significant opioid side effects [15]. Opioid substance abuse and opioid-related death are major issues associated with prescription of opioids for chronic pain. Review of opioid-related deaths demonstrates that the majority had a diagnosis of chronic pain in their last year of life [16]. Prescription of opioid medications has gradually decreased since 2011, but the opioid-related overdose death rate continues to rise exponentially [17]. This current opioid crisis constitutes a critical public health issue in USA and Canada [13]. Even though the prescription of opioid drugs does not appear to be causally

**151**

*myoActivation: A Structured Process for Chronic Pain Resolution*

with chronic musculoskeletal pain are prescribed opioids [19].

cant contributor to a chronic pain issue presenting many years later.

of the originating tissue to a normal anatomical state [41].

Chronic pain occurs from various combined sources, including nociceptive, inflammatory, neuropathic, myofascial, as well as peripheral and central sensitisation. *Musculoskeletal* (*MSK*) conditions are a predominant source of chronic pain worldwide [29]. The clinical and etiological characteristics of myofascial pain have been poorly investigated. The subsequent lack of evidence has led to undertraining of health care professionals, and poor recognition of the clinical importance of *myofascial pain syndromes* (a group of painful conditions that affect muscles and connective tissues) [30, 31]. Myofascial pain syndromes are characterized by pain, *myofascial trigger points* (*MTPs*) (palpable nodules in taut bands of muscle fibres), referred pain, coupled pain, and autonomic changes. Chemical changes within the muscle may also lead to peripheral sensitization. MTPs can generate continual nociceptive traffic to induce central sensitization, cortical re-organization, and alterations in descending inhibitory pain pathways [32–36]. MTPs are associated with muscles in sustained contraction causing limited movement across joints [37]. The MSK system is symmetrical; a muscle in sustained contraction on one side will cause compensatory MSK issues to occur on the other. Therefore, a patient with MSK imbalance may proceed to have many different myofascial areas affected from one previous injury or insult. It is important to note that *palpable pain points* (*PPPs*) exist, not only in skeletal muscle, but also in fascia and scars. One of the components of MSK pain is *coupled pain*, which is distinct from referred pain. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin of pain. Referred pain results from neuronal stimulation within a dermatome (a localized area of skin that has its sensation via a single nerve, from a single nerve root of the spinal cord). In coupled pain, the source of pain is distant, not dermatomal, from the localized area of pain. Examples include shoulder pain or knee pain originating from strained ipsilateral external oblique muscle, or lower quadrant abdominal pain originating from an ipsilateral quadratus lumborum muscle in sustained contraction [38–40]. This distant site has no direct muscular or neurological connection, yet the coupled pain is resolved by restoration

related to overdose deaths, it is clear that their prescription is one pathway to longterm use: 5.3% of opioid naïve adults prescribed opioids will still be on opioids 1 year later [18]. Increased numbers of opioids prescribed on the first prescription predicts a lower likelihood of opioid discontinuation [18]. It is notable that 20% of children

Up to 22.5% of chronic pain patients develop their chronic pain condition after surgery [20]. *Persistent postsurgical pain* (*PPSP*) represents a significant clinical problem, occurring after 10–50% of surgeries and resulting in severe chronic pain in 2–10% of these patients [21]. PPSP is considered to be primarily neuropathic (nerve damage during surgery) where the incidence depends on various perioperative factors, including genetic predisposition, preoperative anxiety, depression, preoperative pain, the extent of the surgical insult, surgical technique, length of surgery, and the quality of acute postoperative pain management [21, 22]. In 27% of patients receiving chronic opioid therapy, treatment for pain after surgery was the reason for opioid initiation [23]. There is 5.9–6.5% incidence of new persistent opioid use after surgery, not only after major surgery but also after minor surgical procedures [24]. Multiple traumas have a cumulative effect on chronic pain [25], independent of post-traumatic distress disorder symptoms [26]. Increased risk of physical ill-health is associated with exposure to a single traumatic event but accrues as more events are experienced [27]. It is not clear what characteristics of past traumatic experiences (type, duration, severity, earlier onset) influence the strength of the relationship between accumulative traumatic events and subsequent medical conditions [28]. Contemporary clinical history taking often neglects distant trauma as signifi-

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

#### *myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

*From Conventional to Innovative Approaches for Pain Treatment*

Pain is a sensory output from the brain when the brain is on alert. In acute pain, this sensory output is important to protect the organism from further harm during

Chronic pain is quite different; although it is typically considered to refer to pain lasting longer than 3 months, such a time limit seems to be reductive, and it more properly refers to "pain that extends beyond the expected period of healing" [2]. The overall prevalence of chronic pain conditions is estimated to be in the order of 35–51% of the adult population [3] and the incidence of widespread chronic pain estimated to be 10–15% [4]. Chronic pain occurs across the lifespan, including children [5] and the elderly [6]. The frequency of visits to physicians, emergency departments, and other healthcare providers is significantly increased in the presence of chronic pain [7]. Currently, the burden of chronic pain has a huge impact on quality of life in the lives of people with chronic pain [8, 9]. The economic burden of chronic pain in terms of healthcare costs is substantial, but pales in significance compared to the costs of lost productivity due to job redundancy and sick days [9].

Chronic pain is a complex biopsychosocial phenomenon that requires a multidisciplinary approach to management. This usually includes return to physical function [10], graded return to work/school, medications to help with pain, mood and sleep, as well as non-pharmacological techniques to address the psychosocial components of pain [9, 11, 12]. The weakest link in this therapeutic process is the pharmacological approach, especially the overreliance on the use of *opioid* medications. The prescription of opioids for chronic non-cancer pain increased fourfold in USA from the early 1990s up to 2011 [13, 14]. Opioids contribute only modest relief of chronic pain. They have limited effects on improvement in function but cause significant opioid side effects [15]. Opioid substance abuse and opioid-related death are major issues associated with prescription of opioids for chronic pain. Review of opioid-related deaths demonstrates that the majority had a diagnosis of chronic pain in their last year of life [16]. Prescription of opioid medications has gradually decreased since 2011, but the opioid-related overdose death rate continues to rise exponentially [17]. This current opioid crisis constitutes a critical public health issue in USA and Canada [13]. Even though the prescription of opioid drugs does not appear to be causally

the healing phase, and, is usually associated with a nociceptive stimulus.

**150**

**1.1 Background**

**Figure 1.**

*The biopsychosocial contributors to chronic pain.*

related to overdose deaths, it is clear that their prescription is one pathway to longterm use: 5.3% of opioid naïve adults prescribed opioids will still be on opioids 1 year later [18]. Increased numbers of opioids prescribed on the first prescription predicts a lower likelihood of opioid discontinuation [18]. It is notable that 20% of children with chronic musculoskeletal pain are prescribed opioids [19].

Up to 22.5% of chronic pain patients develop their chronic pain condition after surgery [20]. *Persistent postsurgical pain* (*PPSP*) represents a significant clinical problem, occurring after 10–50% of surgeries and resulting in severe chronic pain in 2–10% of these patients [21]. PPSP is considered to be primarily neuropathic (nerve damage during surgery) where the incidence depends on various perioperative factors, including genetic predisposition, preoperative anxiety, depression, preoperative pain, the extent of the surgical insult, surgical technique, length of surgery, and the quality of acute postoperative pain management [21, 22]. In 27% of patients receiving chronic opioid therapy, treatment for pain after surgery was the reason for opioid initiation [23]. There is 5.9–6.5% incidence of new persistent opioid use after surgery, not only after major surgery but also after minor surgical procedures [24].

Multiple traumas have a cumulative effect on chronic pain [25], independent of post-traumatic distress disorder symptoms [26]. Increased risk of physical ill-health is associated with exposure to a single traumatic event but accrues as more events are experienced [27]. It is not clear what characteristics of past traumatic experiences (type, duration, severity, earlier onset) influence the strength of the relationship between accumulative traumatic events and subsequent medical conditions [28]. Contemporary clinical history taking often neglects distant trauma as significant contributor to a chronic pain issue presenting many years later.

Chronic pain occurs from various combined sources, including nociceptive, inflammatory, neuropathic, myofascial, as well as peripheral and central sensitisation. *Musculoskeletal* (*MSK*) conditions are a predominant source of chronic pain worldwide [29]. The clinical and etiological characteristics of myofascial pain have been poorly investigated. The subsequent lack of evidence has led to undertraining of health care professionals, and poor recognition of the clinical importance of *myofascial pain syndromes* (a group of painful conditions that affect muscles and connective tissues) [30, 31].

Myofascial pain syndromes are characterized by pain, *myofascial trigger points* (*MTPs*) (palpable nodules in taut bands of muscle fibres), referred pain, coupled pain, and autonomic changes. Chemical changes within the muscle may also lead to peripheral sensitization. MTPs can generate continual nociceptive traffic to induce central sensitization, cortical re-organization, and alterations in descending inhibitory pain pathways [32–36]. MTPs are associated with muscles in sustained contraction causing limited movement across joints [37]. The MSK system is symmetrical; a muscle in sustained contraction on one side will cause compensatory MSK issues to occur on the other. Therefore, a patient with MSK imbalance may proceed to have many different myofascial areas affected from one previous injury or insult. It is important to note that *palpable pain points* (*PPPs*) exist, not only in skeletal muscle, but also in fascia and scars.

One of the components of MSK pain is *coupled pain*, which is distinct from referred pain. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin of pain. Referred pain results from neuronal stimulation within a dermatome (a localized area of skin that has its sensation via a single nerve, from a single nerve root of the spinal cord). In coupled pain, the source of pain is distant, not dermatomal, from the localized area of pain. Examples include shoulder pain or knee pain originating from strained ipsilateral external oblique muscle, or lower quadrant abdominal pain originating from an ipsilateral quadratus lumborum muscle in sustained contraction [38–40]. This distant site has no direct muscular or neurological connection, yet the coupled pain is resolved by restoration of the originating tissue to a normal anatomical state [41].

Myofascial release can be effective but lacks a standardized approach and therefore prevents good quality comparative analysis.

Given the societal burden of pain and overuse of opioid medications, it is clear that clinicians require a different and more effective model of assessment and treatment that minimizes opioid prescriptions and realizes myofascial components of pain [19, 42]. This chapter will outline the importance of surgical scars and myofascial dysfunction as other important determinants of a chronic pain presentation. *myoActivation* is one component of the multimodal approach to patient care that helps to accurately determine and treat the myofascial components of chronic pain without the need for prescription medications.

#### **1.2 Aim**

The aim of this chapter is to describe a system of standardized assessment and treatment for chronic pain called *myoActivation®*. We will comprehensively describe the distinctive features of this system, from the patient's clinical history to after-care management. We will present evidence for the scientific background and individual component techniques of *myoActivation*, where it exists, and outline future approaches for gathering evidence of the effectiveness and efficiency of the *myoActivation* treatment programme as a whole.

This chapter is practically orientated to enable clinicians to understand what *myoActivation* means. Three case studies will illustrate the effectiveness of *myoActivation*. Then, the next steps in the development and evaluation of *myoActivation* will be discussed. Barriers to integrative care (including alternative therapies) are awareness, availability, accessibility, and affordability [43]; these will be discussed in relation to *myoActivation* as well as the need to establish a firm basis of clinical evidence for this treatment system.

Finally, we must emphasize that *myoActivation* should be seen as one component of multidisciplinary care, i.e., part of a multimodal approach to care, which includes focus on eventual return to physical function and work/school, improving recovery from opioid dependency, weaning prescription drug use as well treating the psychosocial components of pain.

#### **1.3** *myoActivation* **overview**

*myoActivation* is a unique structured system of assessment and treatment designed to reduce myofascial components of chronic pain. A key principle of *myoActivation* is to understand that the site of pain is often not the source of pain [38–41, 44]. For example, spasm of the quadratus lumborum muscle mimics appendicitis and low back pain may originate from the abdominal wall musculature [38, 39, 45]. Myofascial pain is characterised by the presence of myofascial trigger points. Myofascial trigger points develop in response to many different insults such as trauma, injury, surgery, repetitive microtrauma, poor posture, muscle overuse, or overload [46, 47]. Myofascial trigger points that cause pain can originate in scars, skeletal muscle, and/or fascia.

The *myoActivation* assessment is distinguished by recognition of the importance of lifetime trauma and the mechanisms of any injuries identified. Postural observations during systematized, ordered, movement tests identify the true origin of pain in soft tissues. The most painful or restricted movement on core tests distinguishes the most important tissues to treat first. Careful inspection and palpation of these tissues identifies the myofascial source of pain. Treatment entails refined trigger point injections, using micro-aliquots of physiological saline, to restore anatomic integrity to injured tissues. Fine gauge hypodermic needles are inserted into trigger points

**153**

*myoActivation: A Structured Process for Chronic Pain Resolution*

tion, scars, fascial lines of tension, and the interstitial space).

that compromise function of muscle, ligament, tendon, subcutaneous fascia, scar tissue, and the peripheral nerves of the skin. After each individual myofascial area is treated, movement tests are repeated to demonstrate immediate change and direct the clinician to the next most important target area. Several cycles occur during each *myoActivation* session. The purpose of these catenated cycles (see **Figure 6**) is to help unravel multiple sources that contribute to the full myofascial pain presentation.

Immediate treatment responses occur, which include reduction in pain, increased flexibility, and improved fluidity of movement. After-care instructions require the patient to change posture frequently but to refrain from exertional activity for 5 days following every *myoActivation* session. To understand how this technique might be useful in everyday care of patients with chronic pain, it is important to understand the essential components of myofascial pain (skeletal muscle in sustained contrac-

Myofascial pain syndrome is characterized by multisite pain, referred pain, coupled pain, and peripheral and central sensitisations. A component of myofascial pain is due to MTPs associated with muscles in sustained contraction causing limitation of movement across joints [37]. The mechanisms of myofascial pain have

A 2007 review identified 19 different descriptions of diagnostic criteria for myofascial trigger points and associated pain but found lack of consensus or standard

A trigger point is a hyperirritable spot in fascia or surrounding skeletal muscle.

Microdialysis techniques demonstrate unique biochemical changes in the region of trigger points, which include low pH, increased concentrations of bradykinin, calcitonin gene-related peptide, substance P, tumour necrosis factor (TNF), interleukins, serotonin, and norepinephrine. These are also associated with decreased local blood flow, reduced oxygen content, and increased reactive oxygen species. These nociceptive neuropeptides and inflammatory markers may be the source of peripheral nociception potentially initiating and maintaining central sensitization

The veracity of myofascial trigger points representing true pathologic entities have been questioned and debated [54]. However, leading experts in myofascial

A systematic MSK exam can distinguish patients with MTPs and chronic pain from subjects with no pain [56]. One of the main problems with medical community acceptance of MTPs has been the lack of objective imaging techniques to corroborate examination findings and to assess treatment outcomes [57]. Imaging techniques that have been reported to establish the presence of muscle MTPs include: *magnetic resonance elastography* (MRE) [58], and *sonoelastography* (SEG) (**Figure 2**) [59]. MRE couples MRI with cyclic shear waves to assess tissue stiffness in myofascial taut bands. Stiffness in taut bands was found to be 50% greater than adjacent normal muscle tissue. SEG is a non-invasive method that combines

Muscular trigger points are associated with palpable nodules in taut bands of muscle fibres. Compression of a trigger point may elicit local tenderness, referred pain, coupled pain, autonomic symptoms, or a local twitch response. The *local twitch response* (*LTR*) is recognized as a spinal reflex [50]. An LTR when the MTP is

needled or activated is considered a positive response to intervention [51].

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

**2. Scientific background**

definition [49].

**2.1 Skeletal muscle in sustained contraction**

been reviewed by Jafri [31] and Shah et al. [48].

in myofascial pain syndrome [48, 52, 53].

techniques consider this to be a biased view [55].

*myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

that compromise function of muscle, ligament, tendon, subcutaneous fascia, scar tissue, and the peripheral nerves of the skin. After each individual myofascial area is treated, movement tests are repeated to demonstrate immediate change and direct the clinician to the next most important target area. Several cycles occur during each *myoActivation* session. The purpose of these catenated cycles (see **Figure 6**) is to help unravel multiple sources that contribute to the full myofascial pain presentation.

Immediate treatment responses occur, which include reduction in pain, increased flexibility, and improved fluidity of movement. After-care instructions require the patient to change posture frequently but to refrain from exertional activity for 5 days following every *myoActivation* session. To understand how this technique might be useful in everyday care of patients with chronic pain, it is important to understand the essential components of myofascial pain (skeletal muscle in sustained contraction, scars, fascial lines of tension, and the interstitial space).

#### **2. Scientific background**

*From Conventional to Innovative Approaches for Pain Treatment*

therefore prevents good quality comparative analysis.

without the need for prescription medications.

*myoActivation* treatment programme as a whole.

evidence for this treatment system.

psychosocial components of pain.

**1.3** *myoActivation* **overview**

skeletal muscle, and/or fascia.

**1.2 Aim**

Myofascial release can be effective but lacks a standardized approach and

The aim of this chapter is to describe a system of standardized assessment and treatment for chronic pain called *myoActivation®*. We will comprehensively describe the distinctive features of this system, from the patient's clinical history to after-care management. We will present evidence for the scientific background and individual component techniques of *myoActivation*, where it exists, and outline future approaches for gathering evidence of the effectiveness and efficiency of the

This chapter is practically orientated to enable clinicians to understand what *myoActivation* means. Three case studies will illustrate the effectiveness of *myoActivation*. Then, the next steps in the development and evaluation of *myoActivation* will be discussed. Barriers to integrative care (including alternative therapies) are awareness, availability, accessibility, and affordability [43]; these will be discussed in relation to *myoActivation* as well as the need to establish a firm basis of clinical

Finally, we must emphasize that *myoActivation* should be seen as one component of multidisciplinary care, i.e., part of a multimodal approach to care, which includes focus on eventual return to physical function and work/school, improving recovery from opioid dependency, weaning prescription drug use as well treating the

*myoActivation* is a unique structured system of assessment and treatment designed to reduce myofascial components of chronic pain. A key principle of *myoActivation* is to understand that the site of pain is often not the source of pain [38–41, 44]. For example, spasm of the quadratus lumborum muscle mimics appendicitis and low back pain may originate from the abdominal wall musculature [38, 39, 45]. Myofascial pain is characterised by the presence of myofascial trigger points. Myofascial trigger points develop in response to many different insults such as trauma, injury, surgery, repetitive microtrauma, poor posture, muscle overuse, or overload [46, 47]. Myofascial trigger points that cause pain can originate in scars,

The *myoActivation* assessment is distinguished by recognition of the importance of lifetime trauma and the mechanisms of any injuries identified. Postural observations during systematized, ordered, movement tests identify the true origin of pain in soft tissues. The most painful or restricted movement on core tests distinguishes the most important tissues to treat first. Careful inspection and palpation of these tissues identifies the myofascial source of pain. Treatment entails refined trigger point injections, using micro-aliquots of physiological saline, to restore anatomic integrity to injured tissues. Fine gauge hypodermic needles are inserted into trigger points

Given the societal burden of pain and overuse of opioid medications, it is clear that clinicians require a different and more effective model of assessment and treatment that minimizes opioid prescriptions and realizes myofascial components of pain [19, 42]. This chapter will outline the importance of surgical scars and myofascial dysfunction as other important determinants of a chronic pain presentation. *myoActivation* is one component of the multimodal approach to patient care that helps to accurately determine and treat the myofascial components of chronic pain

**152**

#### **2.1 Skeletal muscle in sustained contraction**

Myofascial pain syndrome is characterized by multisite pain, referred pain, coupled pain, and peripheral and central sensitisations. A component of myofascial pain is due to MTPs associated with muscles in sustained contraction causing limitation of movement across joints [37]. The mechanisms of myofascial pain have been reviewed by Jafri [31] and Shah et al. [48].

A 2007 review identified 19 different descriptions of diagnostic criteria for myofascial trigger points and associated pain but found lack of consensus or standard definition [49].

A trigger point is a hyperirritable spot in fascia or surrounding skeletal muscle. Muscular trigger points are associated with palpable nodules in taut bands of muscle fibres. Compression of a trigger point may elicit local tenderness, referred pain, coupled pain, autonomic symptoms, or a local twitch response. The *local twitch response* (*LTR*) is recognized as a spinal reflex [50]. An LTR when the MTP is needled or activated is considered a positive response to intervention [51].

Microdialysis techniques demonstrate unique biochemical changes in the region of trigger points, which include low pH, increased concentrations of bradykinin, calcitonin gene-related peptide, substance P, tumour necrosis factor (TNF), interleukins, serotonin, and norepinephrine. These are also associated with decreased local blood flow, reduced oxygen content, and increased reactive oxygen species. These nociceptive neuropeptides and inflammatory markers may be the source of peripheral nociception potentially initiating and maintaining central sensitization in myofascial pain syndrome [48, 52, 53].

The veracity of myofascial trigger points representing true pathologic entities have been questioned and debated [54]. However, leading experts in myofascial techniques consider this to be a biased view [55].

A systematic MSK exam can distinguish patients with MTPs and chronic pain from subjects with no pain [56]. One of the main problems with medical community acceptance of MTPs has been the lack of objective imaging techniques to corroborate examination findings and to assess treatment outcomes [57]. Imaging techniques that have been reported to establish the presence of muscle MTPs include: *magnetic resonance elastography* (MRE) [58], and *sonoelastography* (SEG) (**Figure 2**) [59]. MRE couples MRI with cyclic shear waves to assess tissue stiffness in myofascial taut bands. Stiffness in taut bands was found to be 50% greater than adjacent normal muscle tissue. SEG is a non-invasive method that combines

**Figure 2.** *Sonography of muscle trigger points (reproduced from Sikdar et al. [59], with permission from Elsevier).*

ultrasound with simultaneously applied external vibration to distinguish ultrasound colour variance with tissue stiffness. Muscle trigger points identified as palpable painful nodules in muscle appear as focal, elliptical shaped, hypoechogenic areas. Localized regions of low entropy in symptomatic muscle make the tissue macroscopically more heterogeneous than a normal muscle that has relatively uniform echotexture. Texture analysis of SEG images can distinguish between painful muscle trigger points compared to normal muscle [60, 61].

#### *2.1.1 Muscle activation*

Muscle activation is the term used to describe when a muscle in sustained contraction is restored to a normal relaxed state, through manipulative therapies or needling techniques [62]. When a needling technique is used, there is no difference in outcomes between dry needling compared to a liquid injectate (such as lidocaine) [63–65]. Muscle activation is associated with reduction in pain, and improved flexibility, fluidity and range of movement. There is no consensus on the most effective needling techniques for different pain presentations [66]. Elicitation of an LTR has classically been required for effective muscle activation [51]. Recent work disputes that an LTR is necessary, but acknowledges more research is required [67]. Decreased spontaneous electrical activity and acetylcholine levels are seen at active myofascial trigger points after dry needling in rats [68].

Vascular, chemical, endocrine, neural, and central changes have been demonstrated following needling techniques [68–86]. Interestingly, dry needling also appears to be associated with activation of diffuse noxious inhibitory control reducing pain sensitivity in remote areas to the site of needling. This may be mediated through endogenous opioid mechanisms [69, 79–84].

**155**

*2.2.1 Scars*

*myoActivation: A Structured Process for Chronic Pain Resolution*

There are a number of papers in support of the treatment effects, beyond the placebo effect, of myofascial release [51, 62, 66, 87–99]. Recent reviews have concluded that better quality studies with standardized interventions and outcomes are required to show that myofascial release is an effective intervention in the different types of myofascial pain syndromes [100–102]. Despite this, it is clear that myofascial trigger points in skin, fascia, and muscles play an important role in myofascial

MTPs and their referral patterns have been eloquently outlined in two volumes by Travell and Simons, the first volume for the upper body and the second for the lower half of the body [46, 47]. Unfortunately, the publication of these volumes did not translate into everyday use in common clinical practice due to a number of factors: lack of basic scientific evidence around the aetiology of MTPs, no gold standard to identify clinical MTPs, failure to include reproducible assessment and examination of MTPs in medical curricula, complexity and diagnostic uncertainty from the interaction of more than one MTP on perceived pain, co-occurrence of myofascial pain with other disorders such as arthritis, and under-recognition of

The skin is one of the largest organs in the body and is naturally exposed to external stimuli. The skin provides a crucial interface between the body and its environment. Skin has different functions and connections, which include connections to the nervous system through the autonomic nervous system and the locomotor apparatus [103]. The autonomic nervous system constitutes the most important connection between the skin, the fascia, and the body [39]. There is continual nervous activity, in afferent and efferent mode, between the skin and central

There is an independent central emotional connection principally between the anterior cingulate cortex and the skin whereby a sympathetic electrical signal can be detected in the skin in response to viewing emotionally charged images [105]. The skin is also a primary site of small fibre nociceptive endings [106]. It is not difficult to speculate that any restriction or impact on the skin, like a scar, will have an impact

When the skin is breached by surgery or injury, a healing process occurs. There are four stages to healing: haemostasis, inflammation, proliferation, and remodelling [109]. The remodelling process can take many years and depends on the size and nature of the initial wound. During remodelling, type 3 collagen is replaced by a stronger type 1 collagen, but not in an ordered manner. Scar tissue is therefore strong but not as elastic or flexible as normal tissue [109]. There is an increase in nerves and neuropeptides in scar tissue especially hypertrophic scars [110]. In patients asked to move actively, electrical activity from a scarred area is higher than

on normal homeostasis and function and hold emotional memory [107, 108].

that from normal tissue in the same patient doing the same movement [111].

Mechanoreceptors and mechanosensitive nociceptors in scarred areas sense an alteration from normal and send non-physiological signals creating a pathological reflex arc [39]. Scars can limit normal movement and flexibility of skin, and underlying fascia and muscles. For example, an ankle scar will alter the gait dynamics through maldistribution of myofascial loads [39]. Patients with scars in the abdominal region often have low back pain related to impaired mobility of the soft tissues [111, 112]. Scars also have an impact on the distribution of forces

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

myofascial components in chronic pain [30].

nervous system to maintain normal homeostasis [39, 104].

**2.2 Skin and the impact of scars**

chronic pain presentations.

*myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

There are a number of papers in support of the treatment effects, beyond the placebo effect, of myofascial release [51, 62, 66, 87–99]. Recent reviews have concluded that better quality studies with standardized interventions and outcomes are required to show that myofascial release is an effective intervention in the different types of myofascial pain syndromes [100–102]. Despite this, it is clear that myofascial trigger points in skin, fascia, and muscles play an important role in myofascial chronic pain presentations.

MTPs and their referral patterns have been eloquently outlined in two volumes by Travell and Simons, the first volume for the upper body and the second for the lower half of the body [46, 47]. Unfortunately, the publication of these volumes did not translate into everyday use in common clinical practice due to a number of factors: lack of basic scientific evidence around the aetiology of MTPs, no gold standard to identify clinical MTPs, failure to include reproducible assessment and examination of MTPs in medical curricula, complexity and diagnostic uncertainty from the interaction of more than one MTP on perceived pain, co-occurrence of myofascial pain with other disorders such as arthritis, and under-recognition of myofascial components in chronic pain [30].

#### **2.2 Skin and the impact of scars**

The skin is one of the largest organs in the body and is naturally exposed to external stimuli. The skin provides a crucial interface between the body and its environment. Skin has different functions and connections, which include connections to the nervous system through the autonomic nervous system and the locomotor apparatus [103]. The autonomic nervous system constitutes the most important connection between the skin, the fascia, and the body [39]. There is continual nervous activity, in afferent and efferent mode, between the skin and central nervous system to maintain normal homeostasis [39, 104].

There is an independent central emotional connection principally between the anterior cingulate cortex and the skin whereby a sympathetic electrical signal can be detected in the skin in response to viewing emotionally charged images [105]. The skin is also a primary site of small fibre nociceptive endings [106]. It is not difficult to speculate that any restriction or impact on the skin, like a scar, will have an impact on normal homeostasis and function and hold emotional memory [107, 108].

#### *2.2.1 Scars*

*From Conventional to Innovative Approaches for Pain Treatment*

ultrasound with simultaneously applied external vibration to distinguish ultrasound colour variance with tissue stiffness. Muscle trigger points identified as palpable painful nodules in muscle appear as focal, elliptical shaped, hypoechogenic areas. Localized regions of low entropy in symptomatic muscle make the tissue macroscopically more heterogeneous than a normal muscle that has relatively uniform echotexture. Texture analysis of SEG images can distinguish between painful

*Sonography of muscle trigger points (reproduced from Sikdar et al. [59], with permission from Elsevier).*

Muscle activation is the term used to describe when a muscle in sustained contraction is restored to a normal relaxed state, through manipulative therapies or needling techniques [62]. When a needling technique is used, there is no difference in outcomes between dry needling compared to a liquid injectate (such as lidocaine) [63–65]. Muscle activation is associated with reduction in pain, and improved flexibility, fluidity and range of movement. There is no consensus on the most effective needling techniques for different pain presentations [66]. Elicitation of an LTR has classically been required for effective muscle activation [51]. Recent work disputes that an LTR is necessary, but acknowledges more research is required [67]. Decreased spontaneous electrical activity and acetylcholine levels are seen at active

Vascular, chemical, endocrine, neural, and central changes have been demonstrated following needling techniques [68–86]. Interestingly, dry needling also appears to be associated with activation of diffuse noxious inhibitory control reducing pain sensitivity in remote areas to the site of needling. This may be mediated

muscle trigger points compared to normal muscle [60, 61].

myofascial trigger points after dry needling in rats [68].

through endogenous opioid mechanisms [69, 79–84].

*2.1.1 Muscle activation*

**Figure 2.**

**154**

When the skin is breached by surgery or injury, a healing process occurs. There are four stages to healing: haemostasis, inflammation, proliferation, and remodelling [109]. The remodelling process can take many years and depends on the size and nature of the initial wound. During remodelling, type 3 collagen is replaced by a stronger type 1 collagen, but not in an ordered manner. Scar tissue is therefore strong but not as elastic or flexible as normal tissue [109]. There is an increase in nerves and neuropeptides in scar tissue especially hypertrophic scars [110]. In patients asked to move actively, electrical activity from a scarred area is higher than that from normal tissue in the same patient doing the same movement [111].

Mechanoreceptors and mechanosensitive nociceptors in scarred areas sense an alteration from normal and send non-physiological signals creating a pathological reflex arc [39]. Scars can limit normal movement and flexibility of skin, and underlying fascia and muscles. For example, an ankle scar will alter the gait dynamics through maldistribution of myofascial loads [39]. Patients with scars in the abdominal region often have low back pain related to impaired mobility of the soft tissues [111, 112]. Scars also have an impact on the distribution of forces

that pass through the body following motor vehicle accident (MVA) or injury [39]. It has also been suggested that the skin can keep a memory of trauma [107, 108]. It is clinically important to consider this when releasing scars associated with a particular emotional traumatic event. More research is required to ascertain the characteristics of scars that make a significant contribution to a chronic pain presentation.

#### *2.2.2 Scar release*

Scar release can be achieved with soft tissue mobilization techniques or subcision [107, 111, 113]. *Subcision*, or microneedling, also known as percutaneous collagen induction therapy, is a minimally invasive minor surgical procedure used for treating depressed cutaneous scars and wrinkles. Subcision is performed using a hypodermic needle inserted through a puncture in the skin surface [114] or dermaroller. First described in 1995 [115], subcision is a safe, and effective microneedling technique used as an aesthetic treatment for several different dermatological conditions including scars, rhytids, and striae [114, 116, 117]. Microneedling has been shown to induce new collagen formation via platelet and neutrophil release of growth factors (TGFβ, platelet derived growth factor, connective tissue growth factor, connective tissue activating protein), resulting in increased production of collagen, elastin, and glycosaminoglycans [118]. The penetration of a needle through skin has been shown to produce other physiological effects such as activation of the diffuse noxious inhibitory control systems [119], as well as oxytocin mediated peripheral stimulation that inhibits c-fibre discharge to suppress experimental behavioural nociception in rats [120].

Currently, the immediate relief of chronic pain following needling of surgical scars is limited to case reports [110], and to date, there is insufficient evidence to advise on the right time to treat scars after surgery [121]. It will be seen later that scar identification and release is an integral part of *myoActivation* therapy for chronic pain.

#### **2.3 Fascial lines of tension**

*Fascia* is described as "dense irregular connective tissue, this tissue surrounds and connects every muscle, even the tiniest myofibril, and every single organ of the body. It forms a true continuity throughout our whole body" [122, 123]. Fascia has traditionally been named according to the region in which it invests, for example, thoracolumbar fascia or the iliotibial band. This regional focus is considered to be a barrier to the understanding the whole-body interconnectivity of fascia [124]. Fascia has both loose and hard fibrous connective tissue components. Loose fascia functions to help slide and glide between structures and dense fascia exerts a tensile strength in tissues like tendons. Fascia is a complex structure. It contains cells (fibroblasts, fasciocytes, myofibroblasts, and telocytes), an extracellular matrix (fibres, hyaluronan, and water), nerve elements (proprioceptors, interoceptors, and nociceptors), and a system of microchannels (the primovascular system) [125]. The contractile elements may contribute to spasms, dysfunction, and pain [39]. The fasciocytes produce hyaluronan in response to shear stresses [125]. The fascial fibroblasts produce collagen in response to load and stretching. Telocytes are probably important in regeneration [126]. Fascia is rich in proprioceptors and is an essential integrative component in the locomotor apparatus in assessment and control of human posture and movement organization [70]. Fascia has been nicknamed our organ of form [39, 127, 128]. Techniques are currently being developed to improve imaging of fascia [129].

**157**

*myoActivation: A Structured Process for Chronic Pain Resolution*

Fascia flexibility is reduced following injury and subsequent immobility; this worsens with time and persists even with restoration of movement [130]. Stretching, however, reduces thickness of inflammatory lesions, reduces migration of neutrophils, and increases concentration of pro-resolving mediators (resolvins) [130–134]. It is becoming increasingly clear that fascia has an extremely important role to play in molecular biology, functional anatomy, exercise, sport science, repair mechanisms, as well as therapeutic modalities [135]. As *myoActivation* is associated with improvements in flexibility and posture, it may well be that one of its effects is mediated through fascial mechanisms that enable movement and stretch in a more

*Proposed myofascial chains (reproduced from Wilke et al. [136], with permission from Elsevier).*

*Biotensegrity* is a structural design concept that defines the relationship between parts of an organism and the mechanical system that integrates them into a functional unit. Humans are described as tension-dependent organisms with myofascial chains (**Figure 3**) [136]. These myofascial chains enable three-dimensional movement while continually providing information on balance, stability, and mobility. These chains often have an opposing chain to help achieve this balance within the MSK system; for example, a posterior myofascial chain pairs with an anterior myofascial chain.

These chains may well help to explain how some pain presentations at distant sites, and how myofascial release at distant sites (or opposite sides of the body) resolve coupled pain presentations. For example, release of the external oblique muscle in sustained contraction will help shoulder pain, release of tension around the coccyx will help with neck pain, and/or release of the gastrocnemius/soleus

The interstitial space is a major fluid compartment present in many parts of the body. It contains dynamically compressible and distensible sinuses through which interstitial fluid flows around the body. It is distinct from, but drains into, the lymphatic system. In the average human, up to 15 L of extracellular fluid are normally housed in the extracellular interstitial space. *Interstitial fluid* (ISF) and flow is an important element of normal tissue function; it bathes and surrounds cells, delivers nutrients, and removes metabolic waste [137]. ISF also affects cell signalling, differentiation, remodelling, and migration (giving directional cues to cells) [138]. The ISF only flows under conditions of low hydraulic resistance. Blockage of these channels in pigs induces hyperalgesia [139]. Release of tight tissues, following *myoActivation*, may help to restore interstitial fluid flow and promote the delivery of

muscles in sustained contraction relieves occipital headaches.

nutrients and removal of metabolic waste of surrounding tissues.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

normal anatomical manner.

**Figure 3.**

**2.4 The interstitial space**

*myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

*From Conventional to Innovative Approaches for Pain Treatment*

presentation.

chronic pain.

**2.3 Fascial lines of tension**

to improve imaging of fascia [129].

*2.2.2 Scar release*

behavioural nociception in rats [120].

that pass through the body following motor vehicle accident (MVA) or injury [39]. It has also been suggested that the skin can keep a memory of trauma [107, 108]. It is clinically important to consider this when releasing scars associated with a particular emotional traumatic event. More research is required to ascertain the characteristics of scars that make a significant contribution to a chronic pain

Scar release can be achieved with soft tissue mobilization techniques or subcision [107, 111, 113]. *Subcision*, or microneedling, also known as percutaneous collagen induction therapy, is a minimally invasive minor surgical procedure used for treating depressed cutaneous scars and wrinkles. Subcision is performed using a hypodermic needle inserted through a puncture in the skin surface [114] or dermaroller. First described in 1995 [115], subcision is a safe, and effective microneedling technique used as an aesthetic treatment for several different dermatological conditions including scars, rhytids, and striae [114, 116, 117]. Microneedling has been shown to induce new collagen formation via platelet and neutrophil release of growth factors (TGFβ, platelet derived growth factor, connective tissue growth factor, connective tissue activating protein), resulting in increased production of collagen, elastin, and glycosaminoglycans [118]. The penetration of a needle through skin has been shown to produce other physiological effects such as activation of the diffuse noxious inhibitory control systems [119], as well as oxytocin mediated peripheral stimulation that inhibits c-fibre discharge to suppress experimental

Currently, the immediate relief of chronic pain following needling of surgical scars is limited to case reports [110], and to date, there is insufficient evidence to advise on the right time to treat scars after surgery [121]. It will be seen later that scar identification and release is an integral part of *myoActivation* therapy for

*Fascia* is described as "dense irregular connective tissue, this tissue surrounds and connects every muscle, even the tiniest myofibril, and every single organ of the body. It forms a true continuity throughout our whole body" [122, 123]. Fascia has traditionally been named according to the region in which it invests, for example, thoracolumbar fascia or the iliotibial band. This regional focus is considered to be a barrier to the understanding the whole-body interconnectivity of fascia [124]. Fascia has both loose and hard fibrous connective tissue components. Loose fascia functions to help slide and glide between structures and dense fascia exerts a tensile strength in tissues like tendons. Fascia is a complex structure. It contains cells (fibroblasts, fasciocytes, myofibroblasts, and telocytes), an extracellular matrix (fibres, hyaluronan, and water), nerve elements (proprioceptors, interoceptors, and nociceptors), and a system of microchannels (the primovascular system) [125]. The contractile elements may contribute to spasms, dysfunction, and pain [39]. The fasciocytes produce hyaluronan in response to shear stresses [125]. The fascial fibroblasts produce collagen in response to load and stretching. Telocytes are probably important in regeneration [126]. Fascia is rich in proprioceptors and is an essential integrative component in the locomotor apparatus in assessment and control of human posture and movement organization [70]. Fascia has been nicknamed our organ of form [39, 127, 128]. Techniques are currently being developed

**156**

**Figure 3.** *Proposed myofascial chains (reproduced from Wilke et al. [136], with permission from Elsevier).*

Fascia flexibility is reduced following injury and subsequent immobility; this worsens with time and persists even with restoration of movement [130]. Stretching, however, reduces thickness of inflammatory lesions, reduces migration of neutrophils, and increases concentration of pro-resolving mediators (resolvins) [130–134]. It is becoming increasingly clear that fascia has an extremely important role to play in molecular biology, functional anatomy, exercise, sport science, repair mechanisms, as well as therapeutic modalities [135]. As *myoActivation* is associated with improvements in flexibility and posture, it may well be that one of its effects is mediated through fascial mechanisms that enable movement and stretch in a more normal anatomical manner.

*Biotensegrity* is a structural design concept that defines the relationship between parts of an organism and the mechanical system that integrates them into a functional unit. Humans are described as tension-dependent organisms with myofascial chains (**Figure 3**) [136]. These myofascial chains enable three-dimensional movement while continually providing information on balance, stability, and mobility. These chains often have an opposing chain to help achieve this balance within the MSK system; for example, a posterior myofascial chain pairs with an anterior myofascial chain.

These chains may well help to explain how some pain presentations at distant sites, and how myofascial release at distant sites (or opposite sides of the body) resolve coupled pain presentations. For example, release of the external oblique muscle in sustained contraction will help shoulder pain, release of tension around the coccyx will help with neck pain, and/or release of the gastrocnemius/soleus muscles in sustained contraction relieves occipital headaches.

#### **2.4 The interstitial space**

The interstitial space is a major fluid compartment present in many parts of the body. It contains dynamically compressible and distensible sinuses through which interstitial fluid flows around the body. It is distinct from, but drains into, the lymphatic system. In the average human, up to 15 L of extracellular fluid are normally housed in the extracellular interstitial space. *Interstitial fluid* (ISF) and flow is an important element of normal tissue function; it bathes and surrounds cells, delivers nutrients, and removes metabolic waste [137]. ISF also affects cell signalling, differentiation, remodelling, and migration (giving directional cues to cells) [138]. The ISF only flows under conditions of low hydraulic resistance. Blockage of these channels in pigs induces hyperalgesia [139]. Release of tight tissues, following *myoActivation*, may help to restore interstitial fluid flow and promote the delivery of nutrients and removal of metabolic waste of surrounding tissues.

More research is required to determine exactly which component (muscle, biomechanics, the interstitium, fascia, skin, scars or a combination of these) is the major contributor to a chronic pain presentation. The rest of this chapter will outline the specific details of the basics of *myoActivation*, which provides the muchneeded standardized process to correctly identify and treat MTPs in priority order, to reduce chronic pain.

#### **3.** *myoActivation***: detailed methods**

#### **3.1 Clinical history**

As with all chronic pain presentations, it is important to define the clinical problem, the main site of perceived pain, with its transition over time, as well as the goals of treatment for the patient. The focus of a *myoActivation* history frames the clinical problem as the *Timeline of Lifetime Trauma* (TiLT) and the mechanisms of any injuries reported. TiLT requires careful questioning to determine if there have been any motor vehicle accidents, fractures, sprains, falls, tailbone injury, major surgery, minor surgery, burns, bites, or other scars (e.g., chicken pox or acne). The associated healing process of any scar is essential to determine their significance in the pain presentation. Infection during a healing process or injuries and scars sustained at a young age appear to have significant impact. Recreational and occupational activities with any associated injuries are important components that need to be asked. An important enquiry in the *myoActivation* history is to ask the patient what they consider to be their greatest physical trauma. All these details will be synthesized with the subsequent examination findings to help determine the true source of pain.

#### *3.1.1 Investigations*

Routine imaging investigations are typically not useful to guide *myoActivation* treatment. However, reports on imaging studies that are provided with a referral or by the patient should be reviewed and acknowledged in the encounter documentation.

#### *3.1.2 Examination*

Optimally, the patient has as much skin exposed as possible to allow easier evaluation of postural asymmetries, fascial lines of tension, skin creases, and forgotten scars. Initially, the patient is asked to identify the location of their perceived pain; this point helps direct the examination and is used as an index for subsequent treatment effect. Where the patient identifies the perceived origin of pain is rarely the tissue that is responsible for the true origin of pain. Then, core Biomechanical Assessment and Symmetry Evaluation (BASE) tests are administered (**Figure 4**). In execution of all tests, the clinician is always looking for postural asymmetries.

#### *3.1.3 Balance*

The first BASE test is balance. The talus has no muscular attachments and functions as a ball and socket joint around which the skeleton sways depending on the distribution of myofascial forces (**Figure 5**). The centre of the body mass is normally located anterior to the S2 vertebrae in humans. In an erect stance where there is no significant anatomical postural distortion, the centre of mass or gravity will be evenly distributed between the feet and over each plantar surface. Therefore, if one

**159**

**Figure 5.**

**Figure 4.**

*myoActivation: A Structured Process for Chronic Pain Resolution*

*The core biomechanical assessment and symmetry evaluation (BASE) tests.*

foot feels heavier than the other, then there is a shift of the centre of mass or gravity towards that side of the body. For example, if weight is perceived to be more on the right foot, then there is likely contracted musculature in the right leg "pulling" the pelvis to the right and shifting the centre of mass to the right. At this time, the patient is asked to report about the distribution of weight on their feet (i.e., right or

At the time of the balance test, the clinician observes postural and position between the right and left sides reviewing; feet (e.g., pronated, elevated little toe, clawed toes), knees (e.g., hyperextended or hyperflexed), level of the hips, shoulder height, any pelvic rotation or tilt, as well as any tilt of the torso or the head. No

This will be the first time the clinician touches the patient and a verbal consent

left predominance, towards heels or balls, outside of feet or inside).

abnormality detected (NAD) should also be documented.

prior to examination of any asymmetries is pertinent.

*Muscle groups that play a part in balancing the upright skeleton.*

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

**Figure 4.**

*From Conventional to Innovative Approaches for Pain Treatment*

to reduce chronic pain.

**3.1 Clinical history**

*3.1.1 Investigations*

documentation.

*3.1.2 Examination*

*3.1.3 Balance*

**3.** *myoActivation***: detailed methods**

More research is required to determine exactly which component (muscle, biomechanics, the interstitium, fascia, skin, scars or a combination of these) is the major contributor to a chronic pain presentation. The rest of this chapter will outline the specific details of the basics of *myoActivation*, which provides the muchneeded standardized process to correctly identify and treat MTPs in priority order,

As with all chronic pain presentations, it is important to define the clinical problem, the main site of perceived pain, with its transition over time, as well as the goals of treatment for the patient. The focus of a *myoActivation* history frames the clinical problem as the *Timeline of Lifetime Trauma* (TiLT) and the mechanisms of any injuries reported. TiLT requires careful questioning to determine if there have been any motor vehicle accidents, fractures, sprains, falls, tailbone injury, major surgery, minor surgery, burns, bites, or other scars (e.g., chicken pox or acne). The associated healing process of any scar is essential to determine their significance in the pain presentation. Infection during a healing process or injuries and scars sustained at a young age appear to have significant impact. Recreational and occupational activities with any associated injuries are important components that need to be asked. An important enquiry in the *myoActivation* history is to ask the patient what they consider to be their greatest physical trauma. All these details will be synthesized with the subsequent examination findings to help determine the true source of pain.

Routine imaging investigations are typically not useful to guide *myoActivation* treatment. However, reports on imaging studies that are provided with a referral or by the patient should be reviewed and acknowledged in the encounter

Optimally, the patient has as much skin exposed as possible to allow easier evaluation of postural asymmetries, fascial lines of tension, skin creases, and forgotten scars. Initially, the patient is asked to identify the location of their perceived pain; this point helps direct the examination and is used as an index for subsequent treatment effect. Where the patient identifies the perceived origin of pain is rarely the tissue that is responsible for the true origin of pain. Then, core Biomechanical Assessment and Symmetry Evaluation (BASE) tests are administered (**Figure 4**). In execution of all tests, the clinician is always looking for postural asymmetries.

The first BASE test is balance. The talus has no muscular attachments and functions as a ball and socket joint around which the skeleton sways depending on the distribution of myofascial forces (**Figure 5**). The centre of the body mass is normally located anterior to the S2 vertebrae in humans. In an erect stance where there is no significant anatomical postural distortion, the centre of mass or gravity will be evenly distributed between the feet and over each plantar surface. Therefore, if one

**158**

*The core biomechanical assessment and symmetry evaluation (BASE) tests.*

**Figure 5.** *Muscle groups that play a part in balancing the upright skeleton.*

foot feels heavier than the other, then there is a shift of the centre of mass or gravity towards that side of the body. For example, if weight is perceived to be more on the right foot, then there is likely contracted musculature in the right leg "pulling" the pelvis to the right and shifting the centre of mass to the right. At this time, the patient is asked to report about the distribution of weight on their feet (i.e., right or left predominance, towards heels or balls, outside of feet or inside).

At the time of the balance test, the clinician observes postural and position between the right and left sides reviewing; feet (e.g., pronated, elevated little toe, clawed toes), knees (e.g., hyperextended or hyperflexed), level of the hips, shoulder height, any pelvic rotation or tilt, as well as any tilt of the torso or the head. No abnormality detected (NAD) should also be documented.

This will be the first time the clinician touches the patient and a verbal consent prior to examination of any asymmetries is pertinent.

Then, the remaining five core BASE movement tests are performed. These tests are used to screen a patient's body for the true origin of pain. BASE tests compartmentalize the true origin of pain to a defined anatomical region. The objective in having the patient perform these BASE tests is to identify the most painful or restrictive BASE test. The most painful or restrictive BASE test identifies the tissues that are the most significant current contributor to perceived pain. There is a simple elegance to this construct in that each test defines a specific muscle group or body area. The most painful or restrictive test generally provides a clear indication of a starting point for treatment when a patient has multiple sites of pain or widespread pain. Even though the individual BASE tests are common human movements, the coordinated use of these movement tests to define anatomical areas that are the true origin of pain is unique. Administering these core BASE tests is quick, reproducible, and consistent. This is the distinctive feature of *myoActivation*, which will enable future reliable comparative research.


In performing these core BASE tests, the patient will subconsciously accomplish the required movements through accommodation of his/her previous injuries and joint restrictions. Deviations from normal symmetry often indicate tissue abnormalities. Common postural deviations seen in the performance of core BASE tests

**161**

**Table 1.**

*myoActivation: A Structured Process for Chronic Pain Resolution*

include: shifting of the pelvis, lifting of heels or toes, medial deviation of knees,

The most restricted or painful of the five movement core BASE tests is the guide

If EAR and EAD or SAD and SAR seem to be equivalent/comparable in causing pain or restriction, then the clinician needs to review lateral muscles and tissues. For example, comparable EAR and EAD requires testing of the quadratus lumborum muscles or the three lateral abdominal wall muscles (external oblique, internal oblique, and transversus abdominis = triceps abdominis). Comparable SAD and SAR requires testing of the tensor fascia lata, vastus lateralis, and the adductor

Once core BASE tests are complete, there are 55 regional BASE tests used in *myoActivation* to assess pain in the head, face, neck, shoulders, and limbs/extremi-

The technique of palpation develops with experience, but is not difficult to learn. A rolling motion is used, applied using both thumbs or index fingertips simultaneously, on symmetrical tissues to compare right and left sides. Differences between right and left may be apparent by the patient's physical reaction, patient's verbal report, and/or by sensory feedback to the examiner from

The goal in palpation of soft tissues is to identify increased density, which is painful to the patient and feels different to the clinician when comparing the same tissue on the other side. In most instances, when increased density of a soft tissue is identified, the patient will express or react to the noticeable increase in discomfort or pain associated with palpation of the abnormal tissue. When there are conflicting results between the results of BASE tests and findings from palpation, the palpation findings are more important as the indicator of the true source of pain. Where a patient has a high pain threshold, they may not feel discomfort with palpation. The clinician may need to rely on clinical experience to identify the palpable sensation of normal tissue density to identify points in the soft tissues that are outside of the

ties. It is beyond the scope of this chapter to outline all these regional tests.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

shoulder girdle rotation, or asymmetry.

muscles (see **Table 1** for specific muscles).

normal range for distortion with fingertip pressure.

SAD Squat arms down—upper leg pain

SAR Squat arms raised—upper leg pain

*Specific muscles associated with BASE tests.*

Squat arms down—lower leg pain

Squat arms raised—lower leg pain Squat arms raised—back pain

**Code BASE test Tissues commonly responsible**

EAD Extension arms down triceps abdominis/rectus abdominis FAD Flexion arms down gluteus maximus/gluteus medius

> quadriceps gastrocnemius/soleus

hamstrings medial tibial fascia quadratus femoris

adductor magnus/adductor longus

Comparable EAD/EAR triceps abdominis/quadratus lumborum Comparable SAD/SAR vastus lateralis/tensor fascia lata

EAR Extension arms raised paraspinal muscles

to a starting point for treatment.

*3.1.4 Palpation*

digital pressure.

BAL Balance

#### *myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

include: shifting of the pelvis, lifting of heels or toes, medial deviation of knees, shoulder girdle rotation, or asymmetry.

The most restricted or painful of the five movement core BASE tests is the guide to a starting point for treatment.

If EAR and EAD or SAD and SAR seem to be equivalent/comparable in causing pain or restriction, then the clinician needs to review lateral muscles and tissues. For example, comparable EAR and EAD requires testing of the quadratus lumborum muscles or the three lateral abdominal wall muscles (external oblique, internal oblique, and transversus abdominis = triceps abdominis). Comparable SAD and SAR requires testing of the tensor fascia lata, vastus lateralis, and the adductor muscles (see **Table 1** for specific muscles).

Once core BASE tests are complete, there are 55 regional BASE tests used in *myoActivation* to assess pain in the head, face, neck, shoulders, and limbs/extremities. It is beyond the scope of this chapter to outline all these regional tests.

#### *3.1.4 Palpation*

*From Conventional to Innovative Approaches for Pain Treatment*

medius and/or gluteus maximus muscles.

mius and/or soleus will be the source.

Then, the remaining five core BASE movement tests are performed. These tests are used to screen a patient's body for the true origin of pain. BASE tests compartmentalize the true origin of pain to a defined anatomical region. The objective in having the patient perform these BASE tests is to identify the most painful or restrictive BASE test. The most painful or restrictive BASE test identifies the tissues that are the most significant current contributor to perceived pain. There is a simple elegance to this construct in that each test defines a specific muscle group or body area. The most painful or restrictive test generally provides a clear indication of a starting point for treatment when a patient has multiple sites of pain or widespread pain. Even though the individual BASE tests are common human movements, the coordinated use of these movement tests to define anatomical areas that are the true origin of pain is unique. Administering these core BASE tests is quick, reproducible, and consistent. This is the distinctive feature of *myoActivation*, which will enable future reliable comparative

• *Extension arms raised* (*EAR*): the patient is instructed to bend backwards from the hips with his/her arms overhead. Wherever pain is perceived by the patient in this posture, the true source of pain originates in the paraspinal

• *Extension arms down* (*EAD*): the patient is instructed to arch backwards from the hips with his/her arms down. Wherever pain is perceived by the patient in this posture, the true source of pain originates in the abdominal muscles.

• *Flexion arms down* (*FAD*): the patient is instructed to flex forward with straight knees and bend forward to wherever he/she can reach comfortably. The patient is questioned in regards specifically to pain in the low back. If pain is perceived in the low back in this posture, the true origin of pain is in the medial gluteus

• *Squat arms down* (*SAD*): the patient is instructed to squat with their arms by their side to where he/she can crouch comfortably. If a patient has a very restricted squat, their technique in performing the squat can be improved by instructing them to drive their buttocks backwards. A deeper squat will invariably result due to increased pelvic rotation from this manoeuver. Wherever pain is perceived by the patient in this posture, the true origin of pain is in the quadriceps or calf muscles. If the pain is perceived to be in the upper leg, then the quadriceps will be the pain source. If in the lower leg, then the gastrocne-

• *Squat arms raised* (*SAR*): the patient is instructed to squat with his/her arms overhead to where he/she can crouch comfortably. Wherever pain is perceived by the patient in this posture, the true origin of pain is in the hamstrings or tissues overlying the shin. If the pain is perceived to be in the upper leg, then the hamstrings will be the pain source. If the pain report is the lower leg, then

In performing these core BASE tests, the patient will subconsciously accomplish the required movements through accommodation of his/her previous injuries and joint restrictions. Deviations from normal symmetry often indicate tissue abnormalities. Common postural deviations seen in the performance of core BASE tests

the medial tibial fascia or soft tissues will be the source.

**160**

research.

muscles.

The technique of palpation develops with experience, but is not difficult to learn. A rolling motion is used, applied using both thumbs or index fingertips simultaneously, on symmetrical tissues to compare right and left sides. Differences between right and left may be apparent by the patient's physical reaction, patient's verbal report, and/or by sensory feedback to the examiner from digital pressure.

The goal in palpation of soft tissues is to identify increased density, which is painful to the patient and feels different to the clinician when comparing the same tissue on the other side. In most instances, when increased density of a soft tissue is identified, the patient will express or react to the noticeable increase in discomfort or pain associated with palpation of the abnormal tissue. When there are conflicting results between the results of BASE tests and findings from palpation, the palpation findings are more important as the indicator of the true source of pain. Where a patient has a high pain threshold, they may not feel discomfort with palpation. The clinician may need to rely on clinical experience to identify the palpable sensation of normal tissue density to identify points in the soft tissues that are outside of the normal range for distortion with fingertip pressure.


#### **Table 1.**

*Specific muscles associated with BASE tests.*

#### *3.1.5 Synthesis*

At this time, it is helpful to stop and consider the: history of the presenting complaint, TiLT, most painful or restrictive BASE tests, identified postural anomalies, and notable findings on palpation. This deliberation serves to connect all these factors to discern the relevant myofascial components of the pain presentation. Reviewing the cascade of chronological events that have altered the normal anatomical form will help to untangle the multiple sources associated with the presenting chronic pain complaint. With experience, pattern recognition will be part of this process for common conditions like low back pain.

#### *3.1.6 Consent*

Written consent should be obtained after informing the patient of associated risks.

#### *3.1.7 Contraindications to needling treatment*

Contraindications to a needling-based treatment include current anticoagulant use, immunocompromised state, needle aversion (trypanophobia), or presyncope.

#### *3.1.8 Treatment anticipation*

Patients may be anxious due to needle aversion and anticipation of pain from an unfamiliar procedure. Offering to provide a trial of a single needle insertion usually allows the patient to realize that the actual discomfort is less than the anticipated pain of the needling technique. Use of non-pharmacological and pharmacological techniques to minimise pain of injection and anxiety are essential [140–143].

#### *3.1.9 Choosing a starting point*

Once patients are comfortable with the process, start in the area directed by the most painful or restricted core BASE test. In anxious patients, consider an easily tolerated point first. This may be a treatment area that they cannot visualize or a less sensitive body area such as the gluteus medius. In patients who seem skeptical or uncertain, begin treatment closer to their perceived source of pain. Alternatively, start at a site that is guaranteed to make a significant difference in pain and/or flexibility, such as releasing any scar that is in a tissue area directed by the most restrictive or painful core BASE test, i.e., considered to have some association with the presenting problem.

#### *3.1.10 Scars*

Scars have significant biomechanical consequences in movement and in the transmission of forces following a subsequent injury. Abdominal incisions are major contributors to pain, pain at distant site, and disturbances in function of internal organs [144, 145]. Inspection of scars for guttering or tethering with movements helps to determine their significance. Scars with a very high potential of significance are associated with Caesarean-section procedures, surgical drains, bone grafts, burns, fasciotomies, chicken pox, and penetrating wounds. Scars with moderate potential of significance include any incisional or excisional surgical scar, especially in the feet. Other important scars include immunization scars, or scars from glass cuts, animal bites, and cystic acne.

Scars can be released by a series of needle insertions through scar tissue. Release of normal skin adjacent to the scar and palpably dense myofascial tissues

**163**

*myoActivation: A Structured Process for Chronic Pain Resolution*

surrounding the scar will also contribute to reduction of scar-related tension. Wide scars can be released in a zigzag pattern of needle insertions through the scar tissue. Release of myofascial tension following scar release is proportional to the degree of the "biting" sensation felt while undermining the scar. With experience, it will become apparent that some scars hold emotions related to the traumatic event when the scar occurred [108]. Release of traumatic scars can induce some remarkable, involuntary patient emotional responses. Patients need to be pre-warned about this possible experience. The patient may maintain composure during the clinical encounter, but subsequently report that the emotional release occurred minutes or

Palpation of the targeted tissue, based on the core BASE tests, will provide the clinician with the relevant tissue to release. It is important to release this tissue at the most painful palpable pain point. Skin antisepsis prior to needling will be dictated by the clinician's institutional policy. Needle selection depends on the site to be treated but usually requires a 30-gauge 25 mm or a 25-gauge 50 mm hollow-bore needle connected to a syringe of

Common responses to trigger point activation (release) reported by patients include pain reduction, pain resolution, movement of the pain from the original site, pain with needle insertion, "biting" (especially with significant scars), burning (presumed blood flow into a released muscle), muscle twitch, muscle relaxation, release of tension, or shooting pain down a limb (not related to needling of an adjacent nerve). All these sensations are positive therapeutic symptoms and merit acknowledgement. In the uncommon instance where needling results in a muscle spasm, additional needle insertions are indicated to activate more trigger points.

Breathing techniques and other appropriate non-pharmacological techniques should also be utilized to distract from the needling process [140–142]. At all times, the clinician must observe the patient for any signs of potential light-headedness/presyncope.

Catenated cycles (**Figure 6**) are repeated sequences of BASE testing, palpation, and needling in each session to unravel the multiple sites of anatomical distortion contributing to chronic pain. This is an important process as chronic pain, particularly when it has been persistent for years or decades, results from multiple sites or contributors to the pain pattern. Catenated cycles assist in identifying the various contributing tissues to the larger pain pattern. Each cycle usually identifies the next new and different most painful or restrictive BASE test resulting in a new area of treatment. Poor results from *myoActivation* will result from only performing an initial series of BASE tests to find a starting point for treatment and then needling

Catenated cycles demonstrate to the clinician some or all of the following visible

For the patient, catenated cycles will demonstrate some or all of the following subjective changes in post-treatment movement: reduction in overall perceived pain at rest and/or in movement, reduction or a diffusion in the area of pain, shift in pain location, perception of pain only at end range rather than throughout the range, or a

changes in patient movement: increase in joint range, greater range of motion, increase in speed of movement, increase in ease, smoothness, or fluidity of move-

*3.1.12 Tips and tricks to help with tolerating needling techniques*

many tissues without undertaking the catenated cycles.

ment. This provides immediate feedback on treatment.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

hours after the treatment.

0.9% normal saline.

*3.1.13 Catenated cycles*

*3.1.11 Needling MTPs technique*

#### *myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

surrounding the scar will also contribute to reduction of scar-related tension. Wide scars can be released in a zigzag pattern of needle insertions through the scar tissue. Release of myofascial tension following scar release is proportional to the degree of the "biting" sensation felt while undermining the scar. With experience, it will become apparent that some scars hold emotions related to the traumatic event when the scar occurred [108]. Release of traumatic scars can induce some remarkable, involuntary patient emotional responses. Patients need to be pre-warned about this possible experience. The patient may maintain composure during the clinical encounter, but subsequently report that the emotional release occurred minutes or hours after the treatment.

#### *3.1.11 Needling MTPs technique*

*From Conventional to Innovative Approaches for Pain Treatment*

process for common conditions like low back pain.

*3.1.7 Contraindications to needling treatment*

*3.1.8 Treatment anticipation*

*3.1.9 Choosing a starting point*

the presenting problem.

from glass cuts, animal bites, and cystic acne.

*3.1.10 Scars*

At this time, it is helpful to stop and consider the: history of the presenting complaint, TiLT, most painful or restrictive BASE tests, identified postural anomalies, and notable findings on palpation. This deliberation serves to connect all these factors to discern the relevant myofascial components of the pain presentation. Reviewing the cascade of chronological events that have altered the normal anatomical form will help to untangle the multiple sources associated with the presenting chronic pain complaint. With experience, pattern recognition will be part of this

Written consent should be obtained after informing the patient of associated risks.

Contraindications to a needling-based treatment include current anticoagulant use, immunocompromised state, needle aversion (trypanophobia), or presyncope.

Patients may be anxious due to needle aversion and anticipation of pain from an unfamiliar procedure. Offering to provide a trial of a single needle insertion usually allows the patient to realize that the actual discomfort is less than the anticipated pain of the needling technique. Use of non-pharmacological and pharmacological techniques to minimise pain of injection and anxiety are essential [140–143].

Once patients are comfortable with the process, start in the area directed by the most painful or restricted core BASE test. In anxious patients, consider an easily tolerated point first. This may be a treatment area that they cannot visualize or a less sensitive body area such as the gluteus medius. In patients who seem skeptical or uncertain, begin treatment closer to their perceived source of pain. Alternatively, start at a site that is guaranteed to make a significant difference in pain and/or flexibility, such as releasing any scar that is in a tissue area directed by the most restrictive or painful core BASE test, i.e., considered to have some association with

Scars have significant biomechanical consequences in movement and in the transmission of forces following a subsequent injury. Abdominal incisions are major contributors to pain, pain at distant site, and disturbances in function of internal organs [144, 145]. Inspection of scars for guttering or tethering with movements helps to determine their significance. Scars with a very high potential of significance are associated with Caesarean-section procedures, surgical drains, bone grafts, burns, fasciotomies, chicken pox, and penetrating wounds. Scars with moderate potential of significance include any incisional or excisional surgical scar, especially in the feet. Other important scars include immunization scars, or scars

Scars can be released by a series of needle insertions through scar tissue. Release of normal skin adjacent to the scar and palpably dense myofascial tissues

*3.1.5 Synthesis*

*3.1.6 Consent*

**162**

Palpation of the targeted tissue, based on the core BASE tests, will provide the clinician with the relevant tissue to release. It is important to release this tissue at the most painful palpable pain point. Skin antisepsis prior to needling will be dictated by the clinician's institutional policy. Needle selection depends on the site to be treated but usually requires a 30-gauge 25 mm or a 25-gauge 50 mm hollow-bore needle connected to a syringe of 0.9% normal saline.

Common responses to trigger point activation (release) reported by patients include pain reduction, pain resolution, movement of the pain from the original site, pain with needle insertion, "biting" (especially with significant scars), burning (presumed blood flow into a released muscle), muscle twitch, muscle relaxation, release of tension, or shooting pain down a limb (not related to needling of an adjacent nerve). All these sensations are positive therapeutic symptoms and merit acknowledgement. In the uncommon instance where needling results in a muscle spasm, additional needle insertions are indicated to activate more trigger points.

#### *3.1.12 Tips and tricks to help with tolerating needling techniques*

Breathing techniques and other appropriate non-pharmacological techniques should also be utilized to distract from the needling process [140–142]. At all times, the clinician must observe the patient for any signs of potential light-headedness/presyncope.

#### *3.1.13 Catenated cycles*

Catenated cycles (**Figure 6**) are repeated sequences of BASE testing, palpation, and needling in each session to unravel the multiple sites of anatomical distortion contributing to chronic pain. This is an important process as chronic pain, particularly when it has been persistent for years or decades, results from multiple sites or contributors to the pain pattern. Catenated cycles assist in identifying the various contributing tissues to the larger pain pattern. Each cycle usually identifies the next new and different most painful or restrictive BASE test resulting in a new area of treatment. Poor results from *myoActivation* will result from only performing an initial series of BASE tests to find a starting point for treatment and then needling many tissues without undertaking the catenated cycles.

Catenated cycles demonstrate to the clinician some or all of the following visible changes in patient movement: increase in joint range, greater range of motion, increase in speed of movement, increase in ease, smoothness, or fluidity of movement. This provides immediate feedback on treatment.

For the patient, catenated cycles will demonstrate some or all of the following subjective changes in post-treatment movement: reduction in overall perceived pain at rest and/or in movement, reduction or a diffusion in the area of pain, shift in pain location, perception of pain only at end range rather than throughout the range, or a

**Figure 6.** *Catenated cycles, unravelling pain.*

different pain focus altogether at a different location that only becomes perceptible when the initial painful site has been treated. Another advantage of the catenated cycles is that the patient has to get up and move after each treatment, which distracts from any pain resulting from the treatment process.

#### *3.1.14 When to stop*

It is optimal to end sessions at a successful end-point. These might include resolution of pain, reduction in pain, improved flexibility, increased fluidity of movement, positive postural changes, or change in the weight distribution of the feet to being more grounded (even plantar weight distribution). Otherwise, the decision during treatment to stop further needle insertions is a clinical judgement that is dictated primarily by the patient's ability to tolerate the procedure. Fatigue and feeling overwhelmed are not uncommon responses especially during the first treatment session. Despite receiving written consent, it is always advisable to request ongoing verbal consent at the appropriate times to ensure the patient is agreeable with ongoing care. An important principle is not to do too much at each session.

#### *3.1.15 Risks*

In general, there are very few significant risks associated with *myoActivation*. Most common are bruising and short-term muscle pain. The most significant, but extremely rare complication is potential for a pneumothorax. All clinicians needling in the neck and thoracic region must be aware of the preventative strategies, and the symptoms and signs of pneumothorax. Written information should be supplied to patients detailing: what symptoms to notice, and the contact numbers for help and an algorithm of appropriate actions if these symptoms occur once the patient has left a clinical area.

Potential side effects of *myoActivation* include: sweating, light-headedness/ presyncope, pain from needle insertion, hematoma, muscle spasm, nausea, vomiting, syncope, post-treatment muscle pain [146], pneumothorax, infection, and failure to respond.

**165**

urinary dysfunction.

*myoActivation: A Structured Process for Chronic Pain Resolution*

and the psychosocial factors related to chronic pain.

Instructions following treatment are directed to promote recovery of treated tissues and prevent symptom regression. Patients are advised to move regularly, with frequent changes in posture (every 10–15 minutes) while awake in the first 24–48 hours after each treatment. They are also advised to avoid myofascial loading, repetitive exertion, and prolonged postures for 5 days. After this time, they can start graduated activity. The post-treatment response will be an individualized experience for each patient. Multiple factors will govern the outcome resulting from treatment including: degree of sedentary activity in daily life, physical demands in the workplace, patient age, genetically determined responsiveness of soft tissues,

It is optimal to schedule 2–3 sessions, 1 or 2 weeks apart, to minimize the need to do too much at each session, minimize pain following therapy and to help determine responsiveness. After three sessions, the clinician can determine if there is sufficient positive response to continue. There is a wide range in numbers of sessions

Chronic pain is a complex biopsychosocial problem. *myoActivation* is just one component of a multidisciplinary care. Most patients benefit from concurrent treatment in collaboration with other health professionals knowledgeable in treatment

Three cases are presented. Patients 1 and 2 were seen by a family physician with a focused practice in chronic pain exclusively employing *myoActivation.* Patient 3 received care from a paediatric pain physician. Assessment and treatment for all

A 31-year-old labourer was referred by his family physician for management of back and right lower extremity pain. He was not using regular prescription analgesia medications, but used occasional ibuprofen and marijuana. He had been dealing

Eight months prior to this assessment, he "pinched a nerve on the left side of this body" while lifting a granite countertop. He was off work for 1 month, participated in a return to work program, and was judged fit for work. He did not feel ready to return to physical labour and took 3 months off. At the end of this period (2 months before this visit), he experienced a pinching sensation in the right buttock while sitting. The symptoms progressed to "sciatic pain" in his upper back radiating to the right knee. These symptoms dissipated but he presented with episodic excruciating pain in the right upper buttock radiating down the right leg. The pain was precipitated by standing, going up stairs, or starting to walk. He had no symptoms of motor weakness, saddle numbness or

cases primarily involved application of the *myoActivation* methodology.

**4.1 A 31-year-old male with right sciatic and low back pain**

with intermittent lower back pain since he was 15.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

*3.1.16 myoActivation after-care*

*3.1.17 Number of sessions*

required in positive responders.

of patients living with chronic pain.

*3.1.18 Concurrent therapy*

**4. Case studies**

#### *3.1.16 myoActivation after-care*

*From Conventional to Innovative Approaches for Pain Treatment*

different pain focus altogether at a different location that only becomes perceptible when the initial painful site has been treated. Another advantage of the catenated cycles is that the patient has to get up and move after each treatment, which dis-

It is optimal to end sessions at a successful end-point. These might include resolution of pain, reduction in pain, improved flexibility, increased fluidity of movement, positive postural changes, or change in the weight distribution of the feet to being more grounded (even plantar weight distribution). Otherwise, the decision during treatment to stop further needle insertions is a clinical judgement that is dictated primarily by the patient's ability to tolerate the procedure. Fatigue and feeling overwhelmed are not uncommon responses especially during the first treatment session. Despite receiving written consent, it is always advisable to request ongoing verbal consent at the appropriate times to ensure the patient is agreeable with ongo-

In general, there are very few significant risks associated with *myoActivation*. Most common are bruising and short-term muscle pain. The most significant, but extremely rare complication is potential for a pneumothorax. All clinicians needling in the neck and thoracic region must be aware of the preventative strategies, and the symptoms and signs of pneumothorax. Written information should be supplied to patients detailing: what symptoms to notice, and the contact numbers for help and an algorithm of appropriate actions if these symptoms occur once the patient has

Potential side effects of *myoActivation* include: sweating, light-headedness/ presyncope, pain from needle insertion, hematoma, muscle spasm, nausea, vomiting, syncope, post-treatment muscle pain [146], pneumothorax, infection, and

tracts from any pain resulting from the treatment process.

ing care. An important principle is not to do too much at each session.

*3.1.14 When to stop*

*Catenated cycles, unravelling pain.*

**Figure 6.**

*3.1.15 Risks*

left a clinical area.

failure to respond.

**164**

Instructions following treatment are directed to promote recovery of treated tissues and prevent symptom regression. Patients are advised to move regularly, with frequent changes in posture (every 10–15 minutes) while awake in the first 24–48 hours after each treatment. They are also advised to avoid myofascial loading, repetitive exertion, and prolonged postures for 5 days. After this time, they can start graduated activity. The post-treatment response will be an individualized experience for each patient. Multiple factors will govern the outcome resulting from treatment including: degree of sedentary activity in daily life, physical demands in the workplace, patient age, genetically determined responsiveness of soft tissues, and the psychosocial factors related to chronic pain.

#### *3.1.17 Number of sessions*

It is optimal to schedule 2–3 sessions, 1 or 2 weeks apart, to minimize the need to do too much at each session, minimize pain following therapy and to help determine responsiveness. After three sessions, the clinician can determine if there is sufficient positive response to continue. There is a wide range in numbers of sessions required in positive responders.

#### *3.1.18 Concurrent therapy*

Chronic pain is a complex biopsychosocial problem. *myoActivation* is just one component of a multidisciplinary care. Most patients benefit from concurrent treatment in collaboration with other health professionals knowledgeable in treatment of patients living with chronic pain.

#### **4. Case studies**

Three cases are presented. Patients 1 and 2 were seen by a family physician with a focused practice in chronic pain exclusively employing *myoActivation.* Patient 3 received care from a paediatric pain physician. Assessment and treatment for all cases primarily involved application of the *myoActivation* methodology.

#### **4.1 A 31-year-old male with right sciatic and low back pain**

A 31-year-old labourer was referred by his family physician for management of back and right lower extremity pain. He was not using regular prescription analgesia medications, but used occasional ibuprofen and marijuana. He had been dealing with intermittent lower back pain since he was 15.

Eight months prior to this assessment, he "pinched a nerve on the left side of this body" while lifting a granite countertop. He was off work for 1 month, participated in a return to work program, and was judged fit for work. He did not feel ready to return to physical labour and took 3 months off. At the end of this period (2 months before this visit), he experienced a pinching sensation in the right buttock while sitting. The symptoms progressed to "sciatic pain" in his upper back radiating to the right knee. These symptoms dissipated but he presented with episodic excruciating pain in the right upper buttock radiating down the right leg. The pain was precipitated by standing, going up stairs, or starting to walk. He had no symptoms of motor weakness, saddle numbness or urinary dysfunction.

TiLT revealed a laceration to the right upper lip from a shovel at age 6 requiring stitches, multiple sutured lacerations on hands from work as a chef and a chicken pox scar on right upper lip. He sustained a right ankle injury from a snowboarding injury aged 15. He had snowboarded for 21 years prior to his work-related back injury but felt that he would never be able to snowboard again.

Past medical history included a 12-year history of depression with frequent suicidal ideation. Current antidepressant medications include bupropion and escitalopram.


Worst BASE test in terms of limited ROM and pain was flexion arms down.


On the principle of not doing too much especially on the first visit, it was deemed appropriate to stop at this time. Over the course of the next 28 days, the patient was seen three times to manage ever diminishing right-sided back and leg pains. Rightsided jaw and neck pains became more prominent in the patient's symptomatology with resolution of his back pain. *myoActivation* principles and process were followed using core and regional BASE tests to resolve these issues as well.

On visit 5, 51 days after initial assessment, the patient stated he was doing really well. Nothing was really troubling him although he was a bit stiff after snowboarding 2 days previously. He remarked his hamstrings were tight, but he was working on stretching them every day and doing some yoga. He did, however, snowboard for a half-day and then a full day. He told himself he would go easy, but was able to snowboard without limitation. He reported that to have the confidence in his body and be able to snowboard was important for him as it was very meditative and his escape. His also reported that his mood had significantly improved. No treatment was necessary on this visit and the patient was discharged.

**167**

*myoActivation: A Structured Process for Chronic Pain Resolution*

**4.2 A 42-year-old female with fibromyalgia and chronic fatigue syndrome**

A 42-year-old hospital kitchen worker was referred by her family physician for fibromyalgia and chronic fatigue syndrome. She had been receiving out-patient care (assessment, investigations (MRIs, X-rays, bone scan) and therapy) through a hospital-based complex chronic diseases programme. She had completed an online programme for pain self-management strategies at a local university, which she

The patient described the onset of pain symptoms 15 years previously following a tooth extraction with subsequent infection. She had a pain and fatigue crisis 3 years previously from which she was unable to get out of bed for 4 months. She reported that currently she has had widespread symptoms including; gastrointestinal upset, brain fog, left temporomandibular joint dysfunction, nerve issues, right-sided migraines, central posterior neck pain, and bilateral scapular pain, left greater than right. A diagnosis of fibromyalgia and chronic fatigue syndrome was made 2 months prior to this visit. She is on long-term

TiLT revealed that at age 10, she had been launched over the handle bars of her bicycle breaking an upper front tooth. Again, at age 10, she fell onto her tailbone requiring her to sit on a donut for a prolonged time after injury. At age 11, she rode a bike that was too big for her and injured her right knee from repetitive movement. She had bilateral knee scars from childhood injuries, right forearm burns from cooking, and a scar from a cut in the mid back from an exploding

Past medical history revealed that she had had previous surgeries including dental and a lower segment C-section (LSCS). The patient reported post traumatic stress disorder related to severe pain during her LSCS due to inadequate analgesia from her epidural. Other relevant past medical issues included Hashimoto's thyroiditis, postural orthostatic tachycardia syndrome, irritable bowel syndrome, and

Current medications Synthroid, naltrexone, acetaminophen with codeine

Knees level, hips level

Right shoulder elevated

Head NAD

No pelvic rotation or tilt, no torso shift

The TiLT identified a significant tailbone injury in childhood. Clinical experience has demonstrated that tethering of soft tissues overlying the coccyx results in a significant biomechanical distortion. Therefore, in this case

Plantar weight distribution More weight on left foot, medial sides, heels

the first test indicated is sacrococcygeal palpation.

Pain focus Left scapula Postural assessment Feet NAD

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

found tremendously helpful.

*4.2.1 Visit 1*

disability.

soda bottle, aged 12.

*4.2.1.1 Catenated cycle 1*

**Standing posture findings**

fibromyalgia.

#### **4.2 A 42-year-old female with fibromyalgia and chronic fatigue syndrome**

#### *4.2.1 Visit 1*

*From Conventional to Innovative Approaches for Pain Treatment*

escitalopram.

**BASE testing**

**Treatment**

**Standing posture findings**

injury but felt that he would never be able to snowboard again.

Pain focus No pain at rest while standing Postural assessment Feet, no abnormality detected (NAD)

Extension arms down Normal ROM with no pain

Squat arms down Normal ROM with no pain Squat arms raised Normal ROM with no pain

Trigger point injections Right gluteus maximus at origin Post-treatment assessment Normal ROM in flexion arms down Patient quotes "I am not feeling any pain. It feels nice."

TiLT revealed a laceration to the right upper lip from a shovel at age 6 requiring stitches, multiple sutured lacerations on hands from work as a chef and a chicken pox scar on right upper lip. He sustained a right ankle injury from a snowboarding injury aged 15. He had snowboarded for 21 years prior to his work-related back

Past medical history included a 12-year history of depression with frequent suicidal ideation. Current antidepressant medications include bupropion and

Knees level, hips level

Left shoulder elevated

Head NAD

Plantar weight distribution Equal weight on feet, lateral edges**,** central

Extension arms raised Normal range of motion (ROM), pain low back

Flexion arms down Limited ROM, pain low back, right more than left

No pelvic rotation or tilt, no torso shift

Worst BASE test in terms of limited ROM and pain was flexion arms down.

On the principle of not doing too much especially on the first visit, it was deemed appropriate to stop at this time. Over the course of the next 28 days, the patient was seen three times to manage ever diminishing right-sided back and leg pains. Rightsided jaw and neck pains became more prominent in the patient's symptomatology with resolution of his back pain. *myoActivation* principles and process were followed

On visit 5, 51 days after initial assessment, the patient stated he was doing really well. Nothing was really troubling him although he was a bit stiff after snowboarding 2 days previously. He remarked his hamstrings were tight, but he was working on stretching them every day and doing some yoga. He did, however, snowboard for a half-day and then a full day. He told himself he would go easy, but was able to snowboard without limitation. He reported that to have the confidence in his body and be able to snowboard was important for him as it was very meditative and his escape. His also reported that his mood had significantly improved. No treatment

using core and regional BASE tests to resolve these issues as well.

was necessary on this visit and the patient was discharged.

**166**

A 42-year-old hospital kitchen worker was referred by her family physician for fibromyalgia and chronic fatigue syndrome. She had been receiving out-patient care (assessment, investigations (MRIs, X-rays, bone scan) and therapy) through a hospital-based complex chronic diseases programme. She had completed an online programme for pain self-management strategies at a local university, which she found tremendously helpful.

The patient described the onset of pain symptoms 15 years previously following a tooth extraction with subsequent infection. She had a pain and fatigue crisis 3 years previously from which she was unable to get out of bed for 4 months. She reported that currently she has had widespread symptoms including; gastrointestinal upset, brain fog, left temporomandibular joint dysfunction, nerve issues, right-sided migraines, central posterior neck pain, and bilateral scapular pain, left greater than right. A diagnosis of fibromyalgia and chronic fatigue syndrome was made 2 months prior to this visit. She is on long-term disability.

TiLT revealed that at age 10, she had been launched over the handle bars of her bicycle breaking an upper front tooth. Again, at age 10, she fell onto her tailbone requiring her to sit on a donut for a prolonged time after injury. At age 11, she rode a bike that was too big for her and injured her right knee from repetitive movement. She had bilateral knee scars from childhood injuries, right forearm burns from cooking, and a scar from a cut in the mid back from an exploding soda bottle, aged 12.

Past medical history revealed that she had had previous surgeries including dental and a lower segment C-section (LSCS). The patient reported post traumatic stress disorder related to severe pain during her LSCS due to inadequate analgesia from her epidural. Other relevant past medical issues included Hashimoto's thyroiditis, postural orthostatic tachycardia syndrome, irritable bowel syndrome, and fibromyalgia.


#### *4.2.1.1 Catenated cycle 1*

The TiLT identified a significant tailbone injury in childhood. Clinical experience has demonstrated that tethering of soft tissues overlying the coccyx results in a significant biomechanical distortion. Therefore, in this case the first test indicated is sacrococcygeal palpation.


#### *4.2.1.2 Catenated cycle 2*


#### *4.2.1.3 Catenated Cycle 3 and Cycle 4*


The straight-arm pinch BASE test specifically assesses restriction in scapular mobility from sustained contraction of the ipsilateral serratus anterior muscle.


#### *4.2.1.4 Post-treatment assessment*

Decreased lower back pain and left posterior shoulder pain. Increased ease and range in flexion arms down, extension arm raised, extension arms down, and straight-arm pinch.

**169**

problem.

*myoActivation: A Structured Process for Chronic Pain Resolution*

Pain focus Head pressure Postural assessment Feet NAD

The patient reported she had had a rough week, with soreness and pain for about 5 days, especially from the injection over the coccyx. She felt her pain pattern was different. She felt lighter but was still feeling brain fog. The left shoulder blade felt

Knees' level, hips' level

Shoulders' level Head NAD

Plantar weight distribution Equal weight on feet, medial sides, heels

Extension arms raised Mild ROM limitation with pain lower back Extension arms down Moderate ROM limitation with pain lower back

No pelvic rotation or tilt, no torso shift

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

"That's crazy!" "I feel so light!"

*4.2.2 Visit 2 (7 days after visit 1)*

*4.2.1.5 Patient quotes*

stiff but not painful.

**Standing posture findings**

*4.2.2.1 Catenated cycle 1*

**BASE testing**

*4.2.2.2 Post-treatment assessment*

*4.2.3 Visit 3 (14 days after visit 1)*

**Standing posture findings**

Decreased brain fog. Increased ease in ambulation.

Pain focus standing No pain at rest while standing

Plantar weight distribution Equal weight on feet, central, balls of feet

Postural assessment Feet NAD

**Treatment C-section scar**

Flexion arms down Normal ROM with no pain Squat arms down Normal ROM with no pain Squat arms raised Normal ROM with no pain

She has not had any pain in her neck or shoulder. Right knee was biggest

Knees' level, hips' level

Shoulders' level Head NAD

No pelvic rotation or tilt, no torso shift

*myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

*4.2.1.5 Patient quotes*

*From Conventional to Innovative Approaches for Pain Treatment*

**Treatment Fascia over coccyx**

**Palpation findings Exquisitely tender in midline over coccyx**

Extension arms raised Severe ROM limitation with left shoulder pain Extension arms down Moderate ROM limitation, left shoulder pain Flexion arms down Moderate ROM limitation with pain lower back Squat arms down Moderate ROM limitation with pain calves Squat arms raised Severe ROM limitation with pain thighs

**Palpation findings Palpable pain points C5-T11, left more than right**

**Treatment Bilateral paraspinals from C6 to T12**

*4.2.1.2 Catenated cycle 2*

**BASE testing**

**BASE testing**

*4.2.1.3 Catenated Cycle 3 and Cycle 4*

Extension arms raised Severe ROM limitation with left shoulder pain Extension arms down Moderate ROM limitation, left shoulder pain Flexion arms down Moderate ROM limitation with pain lower back Squat arms down Moderate ROM limitation with pain calves Squat arms raised Severe ROM limitation with pain thighs

**Palpation findings Palpable pain points C5-T11, left more than right**

**Treatment Bilateral paraspinals from C6 to T12** Extension arms raised Mild ROM limitation with left shoulder pain Extension arms down Moderate ROM limitation with left shoulder pain Flexion arms down Moderate ROM limitation with pain lower back Squat arms down Moderate ROM limitation with pain calves Squat arms raised Moderate ROM limitation with pain thighs

Straight arm pinch Limited range in left shoulder

**Treatment Left serratus anterior**

**BASE testing**

*4.2.1.4 Post-treatment assessment*

straight-arm pinch.

The straight-arm pinch BASE test specifically assesses restriction in scapular mobility from sustained contraction of the ipsilateral serratus anterior muscle.

**Palpation findings Palpable densities overlying left ribs 4–6 between anterior and posterior axillary lines**

Decreased lower back pain and left posterior shoulder pain. Increased ease and range in flexion arms down, extension arm raised, extension arms down, and

**168**

"That's crazy!" "I feel so light!"

*4.2.2 Visit 2 (7 days after visit 1)*

The patient reported she had had a rough week, with soreness and pain for about 5 days, especially from the injection over the coccyx. She felt her pain pattern was different. She felt lighter but was still feeling brain fog. The left shoulder blade felt stiff but not painful.


#### *4.2.2.1 Catenated cycle 1*


#### *4.2.2.2 Post-treatment assessment*

Decreased brain fog. Increased ease in ambulation.

#### *4.2.3 Visit 3 (14 days after visit 1)*

She has not had any pain in her neck or shoulder. Right knee was biggest problem.


#### *4.2.3.1 Catenated cycle 1*


#### *4.2.3.2 Catenated cycle 2*


*[The lateral arch BASE test specifically assesses restriction in pelvic mobility from sustained contraction of the ipsilateral iliopsoas muscle].*


#### *4.2.3.3 Post-treatment assessment*

Decreased lower back and flank pain. Increased ease in ambulation, extension arms raised, extension arms down, and lateral arches.

#### *4.2.4 Visit 4 (50 days after visit 1)*

She had a lot more mobility since the last visit with no significant pain other than the right knee. She had not had a migraine in several weeks.


#### *4.2.4.1 Catenated cycle 1*


**171**

history.

**Standing posture findings**

*myoActivation: A Structured Process for Chronic Pain Resolution*

Decreased right knee pain. Increased range in extension arms raised, extension

The patient reported significant improvement in all her symptoms. Previous blinding aura migraines occurring 2–3/week were now reduced to mild aura migraines 1–2/month. She had full resolution of her neck pain at the base of her skull (pain previously scored at 7–10/10), her coccygeal pain (previously 2–4/10), and hip pain (previously 6–8/10). She reported significant reductions in her left scapular pain (previously 6–8/10, now 2–6/10) and right knee pain (previously 4–7/10, now 2–4/10). She was also experiencing improved cognitive function,

A 4-year-old girl was referred to a paediatric complex pain clinic by her neurosurgeon with a 2-year history of low back pain. Her mother reported that her daughter's pain started approximately 1 month following lumbosacral dermal sinus tract surgery. There had been no obvious pain prior to surgery. Her pain was focused in the midline from level of T12 to sacrum. The pain was variable but worse towards end of day, early evening, and night-time. The pain was associated with her being "cranky and irritable". Relief was gained with heat, necessitating many hours per day in a warm bath. The pain was aggravated by swimming, sitting and cold weather, but there were no issues with walking. The pain was not relieved by acetaminophen or ibuprofen. There were no scoliosis, no motor deficits, and no

In the past medical history, there had been no motor vehicle accidents, no fractures or other trauma, no falls on the coccyx/tailbone, and no other surgeries. The only scar was that related to her dermal sinus surgery. In response to the question "What has been her greatest physical trauma?" the answer was her dermal sinus surgery with a minor delayed healing of a part of the wound. The child was born at term by normal spontaneous vaginal delivery following a normal pregnancy. There were no other health issues, no allergies, and no current

The lumbosacral dermal sinus tract excision surgery was uncomplicated, followed by an uneventful recovery and discharge from hospital 3 days postoperatively. Recent investigations included blood work, X-rays, and an MRI of the spine: all reported to be normal. Neurological, neurosurgical, and orthopaedic consulta-

The child was 22 kg and very active and clingy to her mother. She was reluctant to be examined, but interestingly was keen to participate in the core BASE tests as long as she was copying her mum. Pain site was as reported in the

tions revealed no abnormality to explain her ongoing pain.

Pain focus Low back

Postural assessment Hips level, shoulders level Plantar weight distribution Patient unable to differentiate

arms down, and lateral arch BASE tests as well as ease in ambulation.

improved focus and reduced sensitivity to light and sound.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

*4.2.4.2 Post-treatment assessment*

*4.2.5 Follow-up (294 days after visit 1)*

**4.3 Paediatric case study: low back pain**

urinary or bladder issues.

medications.

#### *4.2.4.2 Post-treatment assessment*

*From Conventional to Innovative Approaches for Pain Treatment*

*sustained contraction of the ipsilateral iliopsoas muscle].*

**Treatment Right iliopsoas**

**Treatment Right external oblique**

arms raised, extension arms down, and lateral arches.

the right knee. She had not had a migraine in several weeks.

Flexion arms down Normal ROM with no pain Squat arms down Normal ROM with no pain Squat arms raised Normal ROM with no pain

**Treatment Right external oblique**

Plantar weight distribution Equal weight on feet, medial sides, heels

Extension arms raised Moderate ROM limitation, pain in quadriceps Extension arms down Moderate ROM limitation, pain in right knee

**Palpation findings Palpable tenderness and density in right external oblique inferomedial to ASIS**

Pain focus standing Right knee

*[The lateral arch BASE test specifically assesses restriction in pelvic mobility from* 

**Palpation findings Exquisite tenderness to light palpation of the right iliopsoas** 

**tendon in the femoral triangle**

Right lateral arch Mild ROM limitation with right low back pain Left lateral arch Mild ROM limitation with hip tension

Extension arms raised Moderate ROM limitation with fatigue in right lower back Extension arms down Severe ROM limitation with fatigue in right lower back and neck

**Palpation findings Palpable tender density in right external oblique muscle** 

**medial to anterior superior iliac spine (ASIS)**

Flexion arms down Limited ROM with pain in low back Squat arms down Normal ROM with no pain Squat arms raised Normal ROM with no pain

Decreased lower back and flank pain. Increased ease in ambulation, extension

She had a lot more mobility since the last visit with no significant pain other than

*4.2.3.1 Catenated cycle 1*

**BASE testing**

*4.2.3.2 Catenated cycle 2*

**BASE testing**

*4.2.3.3 Post-treatment assessment*

*4.2.4 Visit 4 (50 days after visit 1)*

*4.2.4.1 Catenated cycle 1*

**BASE testing**

**Standing posture findings**

**170**

Decreased right knee pain. Increased range in extension arms raised, extension arms down, and lateral arch BASE tests as well as ease in ambulation.

#### *4.2.5 Follow-up (294 days after visit 1)*

The patient reported significant improvement in all her symptoms. Previous blinding aura migraines occurring 2–3/week were now reduced to mild aura migraines 1–2/month. She had full resolution of her neck pain at the base of her skull (pain previously scored at 7–10/10), her coccygeal pain (previously 2–4/10), and hip pain (previously 6–8/10). She reported significant reductions in her left scapular pain (previously 6–8/10, now 2–6/10) and right knee pain (previously 4–7/10, now 2–4/10). She was also experiencing improved cognitive function, improved focus and reduced sensitivity to light and sound.

#### **4.3 Paediatric case study: low back pain**

A 4-year-old girl was referred to a paediatric complex pain clinic by her neurosurgeon with a 2-year history of low back pain. Her mother reported that her daughter's pain started approximately 1 month following lumbosacral dermal sinus tract surgery. There had been no obvious pain prior to surgery. Her pain was focused in the midline from level of T12 to sacrum. The pain was variable but worse towards end of day, early evening, and night-time. The pain was associated with her being "cranky and irritable". Relief was gained with heat, necessitating many hours per day in a warm bath. The pain was aggravated by swimming, sitting and cold weather, but there were no issues with walking. The pain was not relieved by acetaminophen or ibuprofen. There were no scoliosis, no motor deficits, and no urinary or bladder issues.

In the past medical history, there had been no motor vehicle accidents, no fractures or other trauma, no falls on the coccyx/tailbone, and no other surgeries. The only scar was that related to her dermal sinus surgery. In response to the question "What has been her greatest physical trauma?" the answer was her dermal sinus surgery with a minor delayed healing of a part of the wound. The child was born at term by normal spontaneous vaginal delivery following a normal pregnancy. There were no other health issues, no allergies, and no current medications.

The lumbosacral dermal sinus tract excision surgery was uncomplicated, followed by an uneventful recovery and discharge from hospital 3 days postoperatively. Recent investigations included blood work, X-rays, and an MRI of the spine: all reported to be normal. Neurological, neurosurgical, and orthopaedic consultations revealed no abnormality to explain her ongoing pain.

The child was 22 kg and very active and clingy to her mother. She was reluctant to be examined, but interestingly was keen to participate in the core BASE tests as long as she was copying her mum. Pain site was as reported in the history.



The worst BASE test in terms of limited ROM and pain was EAR and FAD.

It was not possible to determine the weight distribution on the feet. The core BASE tests that appeared to be most restricted were EAR and FAD; the most painful of these was EAR. The child was able to perform the other core BASE tests with no apparent difficulty. The surgical scar over her sacral area was well healed, but the mid portion of it had a 2-cm wider part that had presumably been the site of the reported delayed healing. There was no tenderness over the coccyx.

The examination revealed no obvious abnormality other than the scar in the midline and a right paraspinal muscle in sustained contraction.

The child was started on magnesium bisglycinate, vitamin K2, and vitamin D3. Three weeks later, scar release and right paraspinal release were performed under general anaesthesia. At follow-up, 4 months after initial assessment, the child was pain free and active in dance.

#### **5. Discussion**

#### **5.1 How does myoActivation work?**

*myoActivation* is a process that enables the clinician to connect or link the patient's TiLT with the myofascial findings on examination. The targeted myofascial activations appear to restore the biomechanical, neuroendocrine, and autonomic balance to reduce chronic pain. Research is required to determine which components of the myofascial system are really important in making the observed changes seen following *myoActivation*.

#### **5.2 What makes myoActivation different?**

A distinctive and foundational principle of *myoActivation* is that the perceived site of pain is often not the source of pain. *myoActivation* constitutes a paradigm shift in how to take a pain history and examine a patient with chronic pain.

The history focuses on a TiLT, including surgery, motor vehicle accidents, fractures, scars, and injuries. It highlights the importance of scars as contributors to chronic pain, especially scars inflicted at a young age or associated with poor healing. It relies on excellent clinical acumen to observe postural abnormalities and skeletal asymmetries, and to locate palpable painful points that help guide therapy as illustrated in the cases presented.

Standard structured BASE tests are used to distinguish significant fascial or muscle trigger point contributors to chronic pain. This structured assessment and treatment is reproducible and therefore a unique framework to perform comparative research. A synthesis of pertinent findings connects the dots that link the patient's TiLT with the myofascial findings, looking at the patient as a whole biomechanical structure and not as segmented symptomatic parts.

Needling is performed with hollow bore needles, with a cutting tip, which is utilized to target and release scars, fascia in tension and PPPs in muscles; therefore, it is not the

**173**

*myoActivation: A Structured Process for Chronic Pain Resolution*

same as classical intramuscular stimulation (IMS), traditional Chinese acupuncture, western medicine acupuncture, prolotherapy, or dry needling targeted at the site of pain. Immediate changes occur such as decreased pain, improved flexibility and improved fluidity of movement, which are easily demonstrated with the repetition of BASE tests. Even if a needling technique is not used, for example in children or in individuals with needle aversion, the *myoActivation* TiLT, assessment, and examination can be used to determine if there is a myofascial component to chronic pain and direct

*myoActivation* uses catenated cycles of intervention and reassessment of baseline tests to unravel the important muscle groups and fascial tensions contributing to the particular pain problem, then repeats baseline tests to highlight the next biomechanically significant tissue in tension. It typically requires 2–5 *myoActivation* sessions to get to the treatment goal of improved flexibility and reduced pain or

*myoActivation* can be used to reduce pain in different pain populations for a variety of different pain conditions. It can cause an emotional release, fatigue, sense of lightness, or well-being at the time of *myoActivation*. It restores hope to patients as it provides an answer to the cause of years of pain. It provides a tool in the toolbox for clinicians, which is low cost, effective, and does not require specialized equipment or imaging. It can be easily incorporated into primary care practice and, therefore, not subject to tertiary care waitlists. However, to be effective, it does need to be

*myoActivation* as an effective tool means the clinician does not have to rely on pharmaceutical analgesic agents for myofascial pain. Pain resolution and its effects on improved function, and ultimately mood, enables weaning of established

With its low cost and no requirement for resource-intensive clinical investigations, *myoActivation* has the potential to support the movement for "winding back the harms of too much medicine" [147]. However, for that to happen, we need to develop programmes of research and training and to address the barriers of awareness,

Demonstrating a firm evidence base for the perceived benefits of *myoActivation* will ultimately require prospective research studies, including multi-centre clinical trials [148]. Many questions remain about mechanism of action, specific approaches in different populations, benefits of integration with other therapeutic techniques, timing of *myoActivation,* and integration with other management techniques. In the meantime, we must rely on patient voices, case studies, audit through patient registries (where *myoActivation* has been delivered by accredited personnel), population–based, case-controlled studies [149] and N-of-1 studies, especially considering the diversity of chronic pain presentations

Clinicians will need to be trained in the art of determining palpable pain points and to learn *myoActivation* before they can fully incorporate this process into their everyday practice. A core group of *myoActivation* faculty, led by Dr. Siren, is developing a programme for training and dissemination of *myoActivation.* Assessment and treatment strategies often begin as local initiatives and are developed into widely accepted standards for care; for example, Managing Emergencies in Paediatric Anaesthesia started in one centre in the UK [151], but is now an internationally recognized course teaching a standard approach worldwide [152, 153]. Other examples include Advanced Cardiac Life Support and Advanced Paediatric Life Support [154].

patients to non-needling therapies such as physiotherapy and massage.

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

applied by an appropriately trained clinician.

**5.3 What is the future of myoActivation?**

availability, and accessibility [43].

in the population [150].

analgesia medications, including opioid medications.

resolution of pain.

#### *myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

*From Conventional to Innovative Approaches for Pain Treatment*

The worst BASE test in terms of limited ROM and pain was EAR and FAD. It was not possible to determine the weight distribution on the feet. The core BASE tests that appeared to be most restricted were EAR and FAD; the most painful of these was EAR. The child was able to perform the other core BASE tests with no apparent difficulty. The surgical scar over her sacral area was well healed, but the mid portion of it had a 2-cm wider part that had presumably been the site of the

Flexion arms down Limited ROM with pain low back, right greater than left

The examination revealed no obvious abnormality other than the scar in the

*myoActivation* is a process that enables the clinician to connect or link the patient's TiLT with the myofascial findings on examination. The targeted myofascial activations appear to restore the biomechanical, neuroendocrine, and autonomic balance to reduce chronic pain. Research is required to determine which components of the myofascial system are really important in making the observed changes

A distinctive and foundational principle of *myoActivation* is that the perceived site of pain is often not the source of pain. *myoActivation* constitutes a paradigm shift

The history focuses on a TiLT, including surgery, motor vehicle accidents, fractures, scars, and injuries. It highlights the importance of scars as contributors to chronic pain, especially scars inflicted at a young age or associated with poor healing. It relies on excellent clinical acumen to observe postural abnormalities and skeletal asymmetries, and to locate palpable painful points that help guide therapy

Standard structured BASE tests are used to distinguish significant fascial or muscle trigger point contributors to chronic pain. This structured assessment and treatment is reproducible and therefore a unique framework to perform comparative research. A synthesis of pertinent findings connects the dots that link the patient's TiLT with the myofascial findings, looking at the patient as a whole

Needling is performed with hollow bore needles, with a cutting tip, which is utilized to target and release scars, fascia in tension and PPPs in muscles; therefore, it is not the

in how to take a pain history and examine a patient with chronic pain.

biomechanical structure and not as segmented symptomatic parts.

The child was started on magnesium bisglycinate, vitamin K2, and vitamin D3. Three weeks later, scar release and right paraspinal release were performed under general anaesthesia. At follow-up, 4 months after initial assessment, the child was

reported delayed healing. There was no tenderness over the coccyx.

Extension arms raised Mildly ROM with pain low back Extension arms down Normal ROM with no pain

Squat arms down Normal ROM with no pain Squat arms raised Normal ROM with no pain

midline and a right paraspinal muscle in sustained contraction.

pain free and active in dance.

seen following *myoActivation*.

as illustrated in the cases presented.

**5.2 What makes myoActivation different?**

**5.1 How does myoActivation work?**

**5. Discussion**

**BASE testing**

**172**

same as classical intramuscular stimulation (IMS), traditional Chinese acupuncture, western medicine acupuncture, prolotherapy, or dry needling targeted at the site of pain. Immediate changes occur such as decreased pain, improved flexibility and improved fluidity of movement, which are easily demonstrated with the repetition of BASE tests.

Even if a needling technique is not used, for example in children or in individuals with needle aversion, the *myoActivation* TiLT, assessment, and examination can be used to determine if there is a myofascial component to chronic pain and direct patients to non-needling therapies such as physiotherapy and massage.

*myoActivation* uses catenated cycles of intervention and reassessment of baseline tests to unravel the important muscle groups and fascial tensions contributing to the particular pain problem, then repeats baseline tests to highlight the next biomechanically significant tissue in tension. It typically requires 2–5 *myoActivation* sessions to get to the treatment goal of improved flexibility and reduced pain or resolution of pain.

*myoActivation* can be used to reduce pain in different pain populations for a variety of different pain conditions. It can cause an emotional release, fatigue, sense of lightness, or well-being at the time of *myoActivation*. It restores hope to patients as it provides an answer to the cause of years of pain. It provides a tool in the toolbox for clinicians, which is low cost, effective, and does not require specialized equipment or imaging. It can be easily incorporated into primary care practice and, therefore, not subject to tertiary care waitlists. However, to be effective, it does need to be applied by an appropriately trained clinician.

*myoActivation* as an effective tool means the clinician does not have to rely on pharmaceutical analgesic agents for myofascial pain. Pain resolution and its effects on improved function, and ultimately mood, enables weaning of established analgesia medications, including opioid medications.

#### **5.3 What is the future of myoActivation?**

With its low cost and no requirement for resource-intensive clinical investigations, *myoActivation* has the potential to support the movement for "winding back the harms of too much medicine" [147]. However, for that to happen, we need to develop programmes of research and training and to address the barriers of awareness, availability, and accessibility [43].

Demonstrating a firm evidence base for the perceived benefits of *myoActivation* will ultimately require prospective research studies, including multi-centre clinical trials [148]. Many questions remain about mechanism of action, specific approaches in different populations, benefits of integration with other therapeutic techniques, timing of *myoActivation,* and integration with other management techniques. In the meantime, we must rely on patient voices, case studies, audit through patient registries (where *myoActivation* has been delivered by accredited personnel), population–based, case-controlled studies [149] and N-of-1 studies, especially considering the diversity of chronic pain presentations in the population [150].

Clinicians will need to be trained in the art of determining palpable pain points and to learn *myoActivation* before they can fully incorporate this process into their everyday practice. A core group of *myoActivation* faculty, led by Dr. Siren, is developing a programme for training and dissemination of *myoActivation.* Assessment and treatment strategies often begin as local initiatives and are developed into widely accepted standards for care; for example, Managing Emergencies in Paediatric Anaesthesia started in one centre in the UK [151], but is now an internationally recognized course teaching a standard approach worldwide [152, 153]. Other examples include Advanced Cardiac Life Support and Advanced Paediatric Life Support [154].

#### **6. Conclusion**

In the face of the burden of chronic pain, including its economic impact, it is imperative to establish new and effective tools to minimize the impacts of this condition. Early intervention is key to success in managing chronic pain. This requires that a tool be available, accessible, and affordable to community clinicians. The current opioid crisis and limited therapeutic effectiveness of many pharmaceutical agents in chronic pain necessitate a different approach.

This chapter has described the core assessment and therapeutic process of a novel technique to manage myofascial components of chronic pain. *myoActivation* is structured and reproducible, with a high benefit to risk ratio. It can be applied to many different chronic pain presentations and different age groups.

Clinicians will need to be trained to successfully incorporate core and regional components of *myoActivation* into their practice. We hope that this chapter will be an incentive for clinicians to learn more about this system of care. It is clear from experience that this is an effective approach and brings a much-needed tool into the toolbox for chronic pain, which, so far, has evaded an efficacious therapeutic modality.

*"In departing from any settled opinion or belief, the variation, the change, the break with custom may come gradually; and the way is usually prepared; but the final break is made, as a rule, by some one individual, […] who sees with his own eyes, and with an instinct or genius for truth, escapes from the routine in which his fellows live."*

 *Sir William Osler, 1849–1919*.

**175**

**Author details**

Gillian Lauder1

provided the original work is properly cited.

3 The myo Clinic, Victoria, BC, Canada

, Nicholas West2

1 BC Children's Hospital, Vancouver, BC, Canada

2 University of British Columbia, Vancouver, BC, Canada

\*Address all correspondence to: greg.siren@myoclinic.ca

*myoActivation: A Structured Process for Chronic Pain Resolution*

*DOI: http://dx.doi.org/10.5772/intechopen.84377*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

and Greg Siren3

\*

#### **Acknowledgements**

The authors would like to thank Mark Ansermino, Patrick Yu, and Barbara Eddy for their insightful comments on a draft of this chapter and Shona Massey for the artwork in **Figure 5**.

#### **Disclosures**

Dr. G. Siren is the inventor of *myoActivation*. He trademarked *myoActivation* principally to ensure that a structured assessment and process is followed and maintained.

Dr. G. Lauder and Mr. N. West have no disclosures.

*myoActivation: A Structured Process for Chronic Pain Resolution DOI: http://dx.doi.org/10.5772/intechopen.84377*

*From Conventional to Innovative Approaches for Pain Treatment*

agents in chronic pain necessitate a different approach.

many different chronic pain presentations and different age groups.

In the face of the burden of chronic pain, including its economic impact, it is imperative to establish new and effective tools to minimize the impacts of this condition. Early intervention is key to success in managing chronic pain. This requires that a tool be available, accessible, and affordable to community clinicians. The current opioid crisis and limited therapeutic effectiveness of many pharmaceutical

This chapter has described the core assessment and therapeutic process of a novel technique to manage myofascial components of chronic pain. *myoActivation* is structured and reproducible, with a high benefit to risk ratio. It can be applied to

Clinicians will need to be trained to successfully incorporate core and regional components of *myoActivation* into their practice. We hope that this chapter will be an incentive for clinicians to learn more about this system of care. It is clear from experience that this is an effective approach and brings a much-needed tool into the toolbox for chronic pain, which, so far, has evaded an efficacious therapeutic

*"In departing from any settled opinion or belief, the variation, the change, the break with custom may come gradually; and the way is usually prepared; but the final break is made, as a rule, by some one individual, […] who sees with his own eyes, and with an instinct or genius for truth, escapes from the routine in which his* 

 *Sir William Osler, 1849–1919*.

The authors would like to thank Mark Ansermino, Patrick Yu, and Barbara Eddy for their insightful comments on a draft of this chapter and Shona Massey for the

Dr. G. Siren is the inventor of *myoActivation*. He trademarked *myoActivation* principally to ensure that a structured assessment and process is followed and

Dr. G. Lauder and Mr. N. West have no disclosures.

**6. Conclusion**

modality.

*fellows live."*

**Acknowledgements**

artwork in **Figure 5**.

**Disclosures**

maintained.

**174**

#### **Author details**

Gillian Lauder1 , Nicholas West2 and Greg Siren3 \*

1 BC Children's Hospital, Vancouver, BC, Canada

2 University of British Columbia, Vancouver, BC, Canada

3 The myo Clinic, Victoria, BC, Canada

\*Address all correspondence to: greg.siren@myoclinic.ca

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[21] Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet (London, England). 2006;**367**(9522):1618-1625

[22] Macrae WA. Chronic post-surgical pain: 10 years on. British Journal of Anaesthesia. 2008;**101**(1):77-86

[23] Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn MA. The initiation of chronic opioids: A survey of chronic pain patients. The Journal of Pain. 2017;**18**(4):360-365

[24] Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery. 2017;**152**(6):e170504

[25] Sledjeski EM, Speisman B, Dierker LC. Does number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey-Replication (NCS-R). Journal of Behavioral Medicine. 2008;**31**(4):341-349

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[27] Scott KM, Koenen KC, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Benjet C, et al. Associations between lifetime traumatic events and subsequent chronic physical conditions: A cross-national, cross-sectional study. PLoS One. 2013;**8**(11):e80573

[28] Schilling EA, Aseltine RH, Gore S. The impact of cumulative childhood adversity on young adult mental health: Measures, models, and interpretations. Social Science & Medicine. 2008;**66**(5):1140-1151

[29] Croft P, Blyth F, van der Windt D. Chronic Pain Epidemiology: From Aetiology to Public Health. Oxford: Oxford University Press; 2010

[30] Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. Journal of Electromyography and Kinesiology. 2004;**14**(1):95-107

[31] Jafri MS. Mechanisms of myofascial pain. International Scholarly Research Notices. 2014;**2014**:16. Article ID 523924. DOI: 10.1155/2014/523924

[32] Gerwin RD. Diagnosis of myofascial pain syndrome. Physical Medicine and Rehabilitation Clinics of North America. 2014;**25**(2):341-355

[33] Botelho LM, Morales-Quezada L, Rozisky JR, Brietzke AP, Torres ILS, Deitos A, et al. A framework for understanding the relationship between descending pain modulation, motor corticospinal, and neuroplasticity regulation systems in chronic myofascial pain. Frontiers in Human Neuroscience. 2016;**10**:308

**176**

*From Conventional to Innovative Approaches for Pain Treatment*

[9] Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care.

EXPLORE. 2018;**14**(3):177-211

Schiltenwolf M, Cashin A, Davies M, Hübscher M. Exercise for chronic musculoskeletal pain: A biopsychosocial

approach. Musculoskeletal Care.

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*From Conventional to Innovative Approaches for Pain Treatment*

Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low Back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2017;**166**(7):514-530

[43] Burke A, Nahin RL, Stussman BJ. Limited health knowledge as a reason for non-use of four common complementary health practices. PLoS

[44] Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Current Pain and Headache Reports.

[45] Bordoni B, Zanier E. Cranial nerves XIII and XIV: Nerves in the shadows. Journal of Multidisciplinary Healthcare.

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[49] Tough EA, White AR, Richards S, Campbell J. Variability of criteria used to diagnose myofascial trigger point pain syndrome—Evidence from a review of the literature. The Clinical

Journal of Pain;**23**(3):278-286

Pain. 1995;**3**(1):15-33

[50] Hong C-Z, Torigoe Y, Yu J. The localized twitch responses in responsive taut bands of rabbit skeletal muscle fibers are related to the reflexes at spinal cord level. Journal of Musculoskeletal

Williams and Wilkins; 1999

Williams and Wilkins; 1992

One. 2015;**10**(6):e0129336

2004;**8**(6):468-475

2013;**6**:87-91

[34] Botelho L, Angoleri L, Zortea M, Deitos A, Brietzke A, Torres ILS, et al. Insights about the neuroplasticity state on the effect of intramuscular electrical stimulation in pain and disability associated with chronic myofascial pain syndrome (MPS): A double-blind, randomized, sham-controlled trial. Frontiers in Human Neuroscience.

[35] Thibaut A, Zeng D, Caumo W, Liu J, Fregni F. Corticospinal excitability as a biomarker of myofascial pain syndrome.

[36] Thapa T, Graven-Nielsen T, Chipchase LS, Schabrun SM. Disruption of cortical synaptic homeostasis in individuals with chronic low back pain. Clinical Neurophysiology. 2018;**129**(5):1090-1096

[37] Akamatsu FE, Yendo TM, Rhode C, Itezerote AM, Hojaij F, Andrade M, et al. Anatomical basis of the myofascial trigger points of the gluteus maximus muscle. BioMed Research International.

[38] Roldan CJ, Hu N. Myofascial pain syndromes in the emergency department: What are we missing? The Journal of Emergency Medicine.

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[41] Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: A musculoskeletal examination model whose time has come. The Journal of Orthopaedic and Sports Physical Therapy. 2007;**37**(11):658-660

[42] Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines

2017;**2017**:4821968

2015;**49**(6):1004-1010

Healthcare. 2013;**7**:11-24

Healthcare. 2014;**7**:401-411

Pain Reports. 2017;**2**(3):e594

2018;**12**:388

**178**

[52] Mense S. The pathogenesis of muscle pain. Current Pain and Headache Reports. 2003;**7**(6):419-425

[53] Mense S, Gerwin RD. Muscle Pain: Understanding the Mechanisms. Berlin, Heidelberg: Springer-Verlag; 2010

[54] Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford, England). 2015;**54**(3):392-399

[55] Dommerholt J, Gerwin RD. A critical evaluation of Quintner et al: Missing the point. Journal of Bodywork and Movement Therapies. 2015;**19**(2):193-204

[56] Gerber LH, Sikdar S, Armstrong K, Diao G, Heimur J, Kopecky J, et al. A systematic comparison between subjects with no pain and pain associated with active myofascial trigger points. PM & R: The Journal of Injury, Function, and Rehabilitation. 2013;**5**(11):931-938

[57] Vulfsons S, Ratmansky M, Kalichman L. Trigger point needling: Techniques and outcome. Current Pain and Headache Reports. 2012;**16**(5):407-412

[58] Chen Q, Bensamoun S, Basford JR, Thompson JM, An K-N. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Archives of Physical Medicine and Rehabilitation. 2007;**88**(12):1658-1661

[59] Sikdar S, Shah JP, Gebreab T, Yen R-H, Gilliams E, Danoff J, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of Physical Medicine and Rehabilitation. 2009;**90**(11):1829-1838

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[63] Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: A randomized controlled trial. Clinical Rheumatology. 2010;**29**(1):19-23

[64] Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: A systematic review. Archives of Physical Medicine and Rehabilitation. 2001;**82**(7):986-992

[65] Rodríguez-Mansilla J, González-Sánchez B, De Toro García Á, Valera-Donoso E, Garrido-Ardila EM, Jiménez-Palomares M, et al. Effectiveness of dry needling on reducing pain intensity in patients with myofascial pain syndrome: A metaanalysis. Journal of Traditional Chinese Medicine = Chung i tsa Chih Ying wen pan. 2016;**36**(1):1-13

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Journal of Manual & Manipulative Therapy. 2015;**23**(5):276-293

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[69] Tsai C-T, Hsieh L-F, Kuan T-S, Kao M-J, Chou L-W, Hong C-Z. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. American Journal of Physical Medicine & Rehabilitation. 2010;**89**(2):133-140

[70] Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotransduction-based mechanism. Journal of Cellular Physiology. 2006;**207**(3):767-774

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[81] Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. Journal of Rehabilitation Medicine. 2010;**42**(5):463-468

*From Conventional to Innovative Approaches for Pain Treatment*

sites near to and remote from active myofascial trigger points. Archives of Physical Medicine and Rehabilitation.

[74] Larsson R, Oberg PA, Larsson SE. Changes of trapezius muscle blood flow and electromyography in chronic neck pain due to trapezius myalgia.

[75] Lee S-H, Chen C-C, Lee C-S, Lin T-C, Chan R-C. Effects of needle electrical intramuscular stimulation on shoulder and cervical myofascial pain syndrome and microcirculation. Journal of the Chinese Medical Association.

[76] Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical and

[77] Napadow V, Webb JM, Pearson N, Hammerschlag R. Neurobiological correlates of acupuncture: November 17-18, 2005. Journal of Alternative and Complementary Medicine.

[78] Cagnie B, Barbe T, De Ridder E, Van Oosterwijck J, Cools A, Danneels L. The influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation. Journal of Manipulative and Physiological Therapeutics. 2012;**35**(9):685-691

[79] Graven-Nielsen T, Arendt-Nielsen L. Peripheral and central sensitization in musculoskeletal pain disorders: An experimental approach. Current Rheumatology Reports.

[80] Reinert A, Treede R, Bromm B. The pain inhibiting pain effect: An electrophysiological study in humans. Brain Research.

2002;**4**(4):313-321

2000;**862**(1-2):103-110

endocrinological changes after electroacupuncture treatment in patients with osteoarthritis of the knee. Pain.

2008;**89**(1):16-23

Pain. 1999;**79**(1):45-50

2008;**71**(4):200-206

2009;**147**(1-3):60-66

2006;**12**(9):931-935

Journal of Manual & Manipulative Therapy. 2015;**23**(5):276-293

2017;**21**(4):940-947

[68] Liu Q-G, Liu L, Huang Q-M, Nguyen T-T, Ma Y-T, Zhao J-M. Decreased spontaneous electrical activity and acetylcholine at myofascial

trigger spots after dry needling treatment: A pilot study. Evidencebased Complementary and Alternative

Medicine. 2017;**2017**:3938191

[69] Tsai C-T, Hsieh L-F, Kuan T-S, Kao M-J, Chou L-W, Hong C-Z. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. American Journal of Physical Medicine & Rehabilitation. 2010;**89**(2):133-140

[70] Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotransduction-based mechanism. Journal of Cellular Physiology. 2006;**207**(3):767-774

[71] Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypotheses. 2007;**68**(1):74-80

[72] Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology.

[73] Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, et al. Biochemicals associated with pain and inflammation are elevated in

2005;**99**(5):1977-1984

[67] Perreault T, Dunning J, Butts R. The local twitch response during trigger point dry needling: Is it necessary for successful outcomes? Journal of Bodywork and Movement Therapies.

**180**

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Section 5

Opioid Research
