The Paper Clip and Back Pain

Dry Needling, Back Pain & the Abdominal Muscles

Are you treating someone with stubborn back pain symptoms and not getting anywhere with your treatment approach? If you are, you should consider examining the abdominal muscles for Trigger Points. Abdominal muscle myofascial trigger points can refer into the lower back, groin, buttocks, ischial tuberosities, pelvis, and genital region. In addition, the presence of abdominal MTrPs is likely in patients with visceral pain and cutaneous hyperalgesia.
The presence of abdominal myofascial trigger points is also associated with many conditions affecting the pelvic viscera including interstitial cystitis, incontinence, chronic prostatitis, endometriosis, prostadynia, pudendal neuralgia, vulvar pain disorders, coccygeal pain, vaginismus, bowel disorders, and pelvic floor muscle tension disorders.

Some might think that Pelvic Pain only happens to women. If you did think that, you’d be mistaken. Chronic prostatitis (CP)/Chronic pelvic pain syndrome (CPPS) has a worldwide prevalence between 2-16% and is the most common urologic disease in men below 50 years old.
But what has this got to do with you as a Dry Needling/Manual Therapist? Well, as not only a Dry Needling therapist but a Manual Therapist, you have an incredible opportunity to help patients of both sexes overcome highly prevalent musculoskeletal pain presentations like back pain but pelvic pain disorders as well.

In a recent study of 40 women with chronic pelvic pain aged between 18-60 years old and 40 matched healthy controls, significant difference were found in TrP presence in patients with chronic pelvic pain (P < 0.001) compared with those included in the control group. There was also widespread pressure pain hyperalgesia found, with pressure pain tolerances (PPTs) significantly reduced in the points assessed.
The methodology in this study included assessing trigger points in the gluteus maximus, gluteus medius, gluteus minimus, quadratus lumborum, and adductor magnus muscles.

The referred pain from trigger points in these muscles reproduced lumbopelvic symptoms. The interesting thing about this type of presentation is that the medical profession is already on board. The European Association of Urology and the Society of Obstetricians and Gynaecologists of Canada recommend that Trigger Points be considered in the diagnosis of pelvic pain.
The American Urological Association lists release of TrP’s as a secondary line of Treatment for interstitial cystitis/bladder pain syndrome (IC/BPS), behind self-care and patient education.

The Canadian Urological Association considers that looking for tenderness, spasm/tight bands, and/or trigger points, is important for both diagnosis and treatment recommendations as part of the mandatory physical examination of patients with interstitial cystitis/bladder pain syndrome.
The key muscles that you should checkout in patients presenting with abdominal or pelvic pain are external oblique, internal oblique, and rectus abdominus.
Trigger points in the Multifidi/Rotatores, Erector Spine, Gluteus Maximus, Medius & Minimus, Piriformis, Quadratus Lumborum, Iliopsoas may refer into the abdominal region and may indicate the presence of dysfunction in the lumbar/thoracic spine.

Trigger Points that refer into the abdominal Region

 

As a manual therapist you’re highly skilled at locating MTrP’s in the muscle tissue. However, you might not be as familiar with a really simple technique of finding MTrP’s in the abdominal muscles.

As we know, MTrP’s are associated with hyperalgesia and allodynia. Hyperalgesia is an increased sensitivity to pain or enhanced intensity of pain sensations. Allodynia is where you perceive pain from a stimulus that should not normally give you pain.

A validated way of finding areas of allodynia is to scratch the abdominal skin using the end of a paper clip or a culture stick.

By passing the end of a paper clip over the abdominal skin, from lateral to medial in an oblique direction, areas of allodynia should appear as redness and the patient may complain of pain. Usually, the patient will not be aware of these areas of increased sensitivity.

It’s a simple technique and it works! Try it and see.

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1. Krieger JN et al. 1999 NIH consensus definition and classification of prostatitis. JAMA. 1999;282:236–7.
2. Fuentes-Marquez P et al. Trigger Points, Pressure Pain Hyperalgesia, and Mechanosensitivity of Neural Tissue in Women with Chronic Pelvic Pain.
3. Jarell etyal., 2005;Fall et al. 2010
4. Qaseem et al.’ 2014
5. Cox et al., 2016
6. Itza et al., 2010
7. Jarrell J. Documentation of Cutaneous Allodynia among women with chronic pelvic pain. Journal of Visual Experiments. 2009;28 Article ID e1232.
8. Yarnitski DGM. Neurophysiological examinations in neuropathic pain. Quantitative sensory testing Handbook of Clinical Neurology. 2006;27(4):397–409.

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