A. Identification of the immediate cause of pain:

• Ask patient to point with one finger where the most intensive pain is.
• Find the point of maximum tenderness.
• Reproduction (recognition) of pain: Press over the maximum tender point and ask: is this the pain you are complaining about?
• Quantify the tenderness (degree of sensitization) by algometer.

B. Diagnosis of Sensitized Spinal Segment (SSS):

I. Dermatomal Hyperalgesia:


• Pain diagram
• Paper clip scratch test (use of sensory diagnostic tracks)
• Skin pinch and roll: Test sensitization of subcutaneous tissue.
• Electric skin conductance: Objective quantitative testing.
• Dorsal and ventral primary ramus hyperalgesia needs to be diagnosed
II. Sclerotomal Hyperalgesia:


• Palpation for tenderness of supraspinous/interspinous ligaments
• Palpation for tender spots (TsP) and MTrPs at attachment sites, and enthesopathies
C. Myotomal distribution of:


• Trigger points/tender spots by palpation and algometry
• Taut bands by palpation and tissue compliance meter which renders quantified, objective results
• Muscle spasm/reduced stretch range by palpation
D. Sympathetic hyperactivity:


• Microedema
• Increased electrical skin resistance
• Orange Peel skin

3. Treatment: Concentrate on the sensitized spinal segment corresponding to the immediate cause(s) of pain (MTrPs, TsP, and muscle spasms) and the associated supraspinous/interspinous ligament nociceptive irritative focus. The injection techniques to be described desensitize the dorsal horn, eliminate the SSS and eradicate the peripheral pain generators.

INJECTIONS: for immediate and long-term relieve of pain:

• PARASPINOUS BLOCK to desensitize the SSS.
• PREINJECTION BLOCK to anesthetize the painful sensitive area to be infiltrated.
• NEEDLING & INFILTRATION OF THE ENTIRE TAUT BAND (TB), to break up the entire underlying pathology of the TrPs/TSs.

Alternative methods to desensitize the segment

• spinal manipulation of the identified segment,
• needling of the identified segment,
• specific and selective range of motion movement to mobilize the identified segment.

post injection physical therapy:

A. Modalities – heat or cold; electric stimulation (sinusoid surging and tetanizing currents)

B. Exercises - Relaxation exercises followed by stretching:

• General (eye movement + expiration + pulling in of belly and holding for 2 seconds)
• Specific for the involved myotome, in which the pain generating TrPs/TSs and MSp are located; relaxation by activation of antagonist muscle(s) (RAA). Active relaxation: elimination of gravity. Stretch only when muscle is relaxed + stretching by gravity. Dry needling, post isometric relaxation, spretch and spray, deep transerse friction,

C. Specific postural correction: Loss of cervical and/or lumbar sacral lordosis, extension and flexion deficiencies.

4. Diagnosis and removal of perpetuating and etiological factors:

PHYSICAL EXAMINATION reveals:

• Mechanical overload of body parts, overuse, and cumulative trauma disorders,
• Deficiency of muscle function (loss of flexibility, weakness). (Kraus)
• Postural deficiencies such as loss of cervical or lumbar lordosis.(Robin McKenzie)
• The Pentad of discopathy radiculopathy paraspinal spasm and supraspinous ligament sprain: Spinal segmental sensitization., that consist of segmental hyperalgesia, and TrPs/TSs and MSp in the myotome.

LABORATORY RESULTS:

• Endocrine disorders, particularly, low thyroid or estrogen supply to the muscles (normal blood levels are sometimes insufficient)
• Metabolic or electrolyte disorders and
• Vitamin deficiencies.