Ultrasound-Elastography for Imaging Trigger Points and Shock Wave Lithotripsy as Myofascial Treatment
On Saturday morning, October 10, at the Treating and Preventing Chronic Pain Conference, Dr. Wolfgang Bauermeister gave a presentation on a novel approach to identifying and treating TrPs (Trigger Points) and referred pain. That afternoon Dr. Bauermeister offered a two-hour workshop to teach health professionals and patients about myofascial pain identification and treatment.
Wolfgang Bauermeister MD PhD is a physiatrist specializing in Sports and Pain Medicine. He received a German medical degree and PhD from the University of Hamburg Medical School and a second medical degree in the USA.
In the U.S. he gained experience in pain clinics where he took care of athletes and chronic pain patients. After a residency at Tufts New England Medical Center – Tufts University Boston USA – in the specialty of Physical Medicine and Rehabilitation he received certification by the American Board of Physical Medicine and Rehabilitation.
Upon his return to Germany in 1988, Dr. Bauermeister became familiar with shock wave lithotripsy. Shockwave is an acoustic wave which carries high energy characterized by a sudden increase in pressure with a high positive and a low negative amplitude. High energy shockwaves destroy kidney stones whereas lower energies promote healing, regeneration and reparative processes of the soft tissue including pain relief. He found that some patients, who had suffered from low back pain and sciatica, were pain free after lithotripsy. They had severe bruising at the site of entrance of the shock waves, which coincided with typical trigger point areas responsible for low back pain and sciatica. Through his observations the idea was born that shock waves could remove myofascial TrPs.
Driven by the need to make TrPs visible, he subsequently started working with Ultrasound Elastography in 2000, which at the time was used for the diagnosis of prostate tumors. He found that by using this technology, myofascial TrPs could be visualized. After searching for several years, he obtained a suitable device which would enable him to acquire high definition elastography images of myofascial TrPs. Now the technology is generally available and is well suited not only to diagnose TrPs but to monitor the effects of any therapeutic approach.
With most musculoskeletal pain problems, including fibromyalgia, hard knots are found in the muscle accompanied by hardening of collagen fibers in the fascia. These muscle knots can be extremely small, but they can develop into large knots which are easy to palpate in superficial but not in deep muscles. They are called myofascial TrPs whereas the hardening of the fascia is termed fibrosis. TrPs and fibrosis can develop through injury caused by overuse in sports, at work or at home. Chronic pain syndromes develop when TrPs and fibrosis are not diagnosed and treated early.
Dr. Bauermeister explained that ultrasound Elastography (Us-E) is the only method which allows practitioners to see TrPs. In real-time imaging generated from this technology, practitioners can view TrPs in vivid colors. They appear (depending on the color scale) as reddish-yellow spots indicating hard tissue compared to the softer, more blue appearing surrounding tissue. The typical diameter of TrPs is usually 1.5-2.0mm but they can lump together and get significantly bigger. The accompanying pictures are of a patient who complained about right-sided sciatic type of pain. In the Us-E (Figure 1) the red-yellow spots indicate TrPs, which can be seen even at a depth of 8 cm. The Us-E mage (Figure 2) of the same patient shows only a few TrPs and clinically only minor pain on the left side.
Figure 1: Right quadratus lumborum area, maximum exploration depth is 10 cm. Figure 2: Left quadratus lumborum area, maximum exploration depth is 10 cm.
Shock wave stimulation of muscles helps to locate trigger points. When shock waves reach the nociceptors around the trigger points, the patient experiences local pain. When the trigger points are “active” the patient feels a referred pain in addition to the local pain.
In his presentation and workshop, Dr. Bauermeister revealed that trigger points are usually treated in a certain distance from the painful site, since trigger points refer pain into other parts of the body. The principles of this type of trigger point treatment are the same in all muscles.
For more information about this process please refer to the TAP Chronic Pain post conference videos where you can see Dr. Bauermeister using this technology and TrPs reatment to help a fibromyalgia patient. www.paintap.org/buy-live-stream