Treating facet joint generated pain

5 Treating facet joint generated pain

Facet joints are the posterior articulating joints in the spine. They carry most of the compressive load when the spine is in extension and guide motion during flexion, extension and rotation. High and low threshold mechanoreceptors and mechanically sensitive pain receptor nerves fire as the joint capsule is stretched and the cartilaginous joint surface compressed during joint movement. Proprioceptive nerve endings in the joint capsule fire during normal range of motion of the joint. Abundant free and encapsulated nerve endings and small nerve fibers capable of secreting substance P and calcitonin gene-related peptide (CGRP) enervate the capsule and joint surfaces. During trauma the joint approaches end range extension stretching the joint capsule and compressing the cartilage to the point of injury. Injury and inflammation of the facet joint and surrounding muscles excite and sensitize the nerves at the joint (Cavanaugh 1996). Excessive capsule stretch, seen in whiplash and hyperextension injuries, activates nociceptors in the joint capsule, leads to prolonged neural after-discharges and can cause damage to the capsule and to the axons in the capsule and is a probable cause of persistent neck and back pain. Facet joints have been implicated as a major source of low back and neck pain (Cavanaugh 2006).

Facet joints become painful as the joint tissues degenerate and become inflamed (Beaman 1993). The cartilage surface becomes irregular, frayed and calcified. The periosteum and subchondral bone becomes inflamed and calcified. Nerve fibers infiltrate the inflamed and degenerated tissues and secrete substance P in the eroded areas sending pain signals to the brain via the nerves and spinal cord. The nerves at the facet joint capsule transmit proprioceptive information in normal joints and pain information in inflamed or injured joints. Chen found more c-fiber receptors on the dorsolateral aspect of the facet joint where muscles and tendons were attached (Chen 2006). Inflammation leads to decreased firing thresholds and elevated baseline discharge rates of nerve endings in facet capsules (Cavanaugh 2006). Chronic inflammation leads to fibrosis between the nerves and soft tissues such as the capsule, the muscles and the fascia (Lewis 2004). These adhesions can make even normal motion painful as the nerves are stretched by the movement of the soft tissues to which they are adhered.

The reduced firing threshold, increased baseline neural discharge and perineural fibrosis in the injured and degenerated facet joint tissues feeds constant neural input into the spinal cord which feeds back to the muscles around the joint contributing to the formation of taut bands and myofascial trigger points in the paraspinal and postural muscles (Gerwin 2004). The myofascial trigger points compound the pain (Travell 1983, 1992) and the taut bands complicate joint function when the shortened sensitized muscle fibers contribute to joint compression and sensitized neural input and help perpetuate joint inflammation. This interaction between the nerve, joint and muscle forms a feed-back–feed-forward neuro-mechanical cycle that is very difficult to break once it becomes established and is the reason that chronic low back and neck pain is so pervasive and difficult to treat. To interrupt it effectively, all three aspects of dysfunction should be addressed at once. FSM makes this possible in most cases.

Identifying which pathologies in which tissues are creating the pain becomes important when treating with FSM because the frequency choices are specific to the tissue and pathology. FSM has been shown to decrease COX and LOX mediated inflammation, inflammatory cytokines and CGRP (McMakin 2005, 2007, Phillips 2000). FSM has been shown to decrease scar tissue and to reduce the pain associated with myofascial trigger points (McMakin 1998, 2004, Huckfeldt et al 2003). FSM has frequencies for calcium deposits and calcium influx into soft tissues, for nerve pain and for myofascial trigger points in the involved muscles.

By using adjunctive modalities such as appropriate exercise and stretching, posture re-education, oral or topical anti-inflammatory medications and oral anti-inflammatory nutrients such as fish oils (EPA/DHA) even the most chronic facet joint pain can improve. Complete resolution of acute or chronic facet pain may require more invasive interventions such as steroid and lidocaine injections into the joint under fluoroscopy to “get on top of” the inflammation so the more conservative modalities can be effective. Studies show that facet injections as a sole treatment modality aren’t effective for long term facet joint pain relief but clinical experience has shown that when combined with other therapies such as FSM, appropriate exercise, nutritional supplementation and postural reeducation they can be a very successful adjunct.

Figure 5.1 • A healthy facet joint has intact cortical bone, periosteum and cancellous bone. The joint capsule and ligaments are not thickened; the cartilage is hydrated and smooth and the synovial fluid is uniformly lubricating.

Figure 5.2 • Inflammation and chronic inflammation of the facet joint causes thickening of the joint capsule and ligaments and calcium deposits at the periosteum, the ligaments and the joint capsule. The cartilage is thinned and uneven and the synovial fluid is thick.

Diagnosing facet joint pain

When the patient complains of neck, thoracic or lumbar spine pain, or “backache” the facet joints should be considered and examined for involvement. In general, the pain from the inflamed joint will be at the spine and radiating in a scleratomal pattern into the area just adjacent to the joint. Facet joint referred pain rarely goes below the knee in the lumbar spine and is most commonly seen in the upper back and shoulder in cervical spine facets.

The pain level may be rated from mild, 3–4/10 on a 0 to 10 visual analog scale (VAS) to severe, 7–8/10 VAS depending on the severity of recent injury, previous facet joint damage, degeneration, inflammation and scarring.

The pain will be worse with extension and sitting which compress the posterior joints and better with flexion which gaps the joints and relieves the pressure. The patient will state that they cannot lay prone at all and if laying supine must have the knees and hips flexed at 90 degrees. The pain will be worse with rotary motions that compress the joint on one side and move soft tissues that are adhered to nerves and the joint capsule. Movements that use trigger point laden muscles will create both local and referred pain from the myofascial trigger points. Inflammation in the facet joints can trigger neural pain and create dermatomal nerve pain although this is less common. The same injuries that traumatize and damage the facet joints can also damage the discs and the patient may have pain with flexion or rotation caused by disc inflammation (see Chapter 4).

The saying “The patient is entitled to more than one diagnosis” is especially true of patients with facet generated pain. The patient may have overlapping facet joint, neuropathic, discogenic and myofascial trigger point pain.

History of causation consistent with facet Injury

Any trauma that creates sudden spinal extension or compression can injure a facet joint. The most common traumatic mechanisms are automobile accidents and falls.

Figure 5.3 • During trauma ballistic extension forces stretch the facet joint capsule beyond its normal limits, compress and bruise the cartilage and subcortical bone, may cause micro-fractures in the cortical bone and traction injuries to the dorsal root medial branch. The damage causes inflammation; post-traumatic fibrosis impairs circulation and often leads to chronic inflammation and progressive joint degeneration. The capsule and ligaments are further stretched during the rebound flexion in a whiplash injury.

Prolonged static posture in extension while sitting or chronic poor muscle balance can lead to chronic segmental joint extension; compressing the facet joint and leading to local joint damage – most commonly seen in the lumbar or cervical spine.

The psoas muscle is the ultimate culprit in most chronic low back facet generated pain. The psoas and iliacus form the iliopsoas and attach to the anterior vertebral bodies and discs of the lumbar spine and the lesser trochanter of the femur. The psoas is a trunk flexor. When the psoas is tight it should pull the trunk into flexion but the posterior lumbar and thoracic paraspinal muscles tighten to keep the torso upright. These opposing mechanical forces compress both the facet joints and the discs but the facet joints seem to take the brunt of the insult.

A similar muscular imbalance exists in the cervical spine with the scalenes as neck flexors and the posterior neck muscles opposing to keep the neck upright. The lower cervical discs and the upper cervical facet joints are compromised in this case. Chronic forward head posture while seated reading or typing at a computer is responsible for muscle pain and fatigue and facet joint compression and degeneration.

Physical examination

Most practitioners reading this text have been trained to perform a physical examination to evaluate spine and facet joint pain. This brief description is meant to be a reminder rather than a comprehensive or definitive instruction. The reader who desires more complete instruction is referred to Hoppenfeld (1976) or Souza (2009) or a similar resource.

This examination procedure may seem incredibly simply but it has been completely foolproof in the authors, experience when combined with a probable history and mechanism of injury. To examine the lumbar and thoracic spine facet joints, lay the patient prone and briefly and gently apply pressure to the suspect facet joints with the thumb placed perpendicular to the spine and parallel to the direction of the facet joint. If the patient says “ouch” then that facet joint is a pain generator. As the joint is compressed and patient reports pain, the paraspinal muscles will usually splint. If the examination is too forceful it will increase the patient’s pain and in the worst case may contribute to further facet joint damage.

To examine the cervical spine facet joints have the patient lay supine or seated and gently and briefly use the finger pads to compress the joints. If the patient is supine gently lift up into the joints with the finger pads following the joint line and feel for the muscle splinting and guarding that accompanies the patient’s report of pain. The joint capsule and surrounding muscles will feel like a tight firm ball just lateral to the midline. If the patient is seated support the head with one hand and gently and briefly use the pads of the fingers to compress the joints. If the patient says “ouch” then that joint is a pain generator. The postural muscles will be activated while the patient is seated and may camouflage the local muscle splinting that occurs when the joint is compressed.

If it is necessary for forensic or medical legal purposes to confirm that the joint identified by the physical examination is indeed a pain generator, the practitioner may order a facet block to be done to the joint in question. Facet blocks should be done, with some pain medication or light sedation, under fluoroscopy by physicians trained and certified by ISIS (International Spinal Injection Society) or some similar body. The block may be done with local anesthetic for diagnosis only but it is more common to do a block that is both diagnostic and therapeutic which combines an anti inflammatory steroid with a local anesthetic. If the block reduces or eliminates the joint pain it confirms that the joint was a pain generator.

Treating chronic facet joint pain

• The patient must be hydrated to benefit from microcurrent treatment.

• Hydrated means 1 to 2 quarts of water consumed in the 2 to 4 hours preceding treatment

• Athletes and patients with more muscle mass seem to need more water than the average patient.

• The elderly tend to be chronically dehydrated and may need to hydrate for several days prior to treatment in addition to the water consumed on the day of treatment

• DO NOT accept the statement, “I drink lots of water”

• ASK “How much water, and in what form, did you drink today before you came in?”

• Coffee, caffeinated tea, carbonated cola beverages do not count as water.

• Water may be flavored with juice or decaffeinated tea.

3 Channel B: facet joint tissue frequencies

• Bone: ___/ 59 and ___/ 39

Both frequencies are used when treating bone. It is presumed that one frequency is for cortical bone and one is for cancellous bone but it is not known what portion is addressed by which frequency.

• Periosteum: ___/ 783

The periosteum lines the outside of the bone, interweaves with tendinous and ligamentous attachments and is very well innervated and pain sensitive.

• Cartilage: ___/ 157

Cartilage lines the facet joint and becomes damaged, degenerated, calcified and inflamed when traumatized by acute or chronic compression of the joint surface.

• Joint Capsule: ___/ 480

The joint capsule attaches to the periosteum, surrounds the joint and becomes fibrosed, calcified, scarred and inflamed when over stretched by trauma.

• Tendons: ___ / 191

The tendons attach the muscles and fascia to the postero-lateral joint capsule and periosteum.

• Ligament: ___/100

The spinal ligaments connect adjacent joints by attaching bone to bone at the periosteum.

• Nerve: ___/ 396

The recurrent nerves innervating the joint capsule transmit proprioceptive information in the normal facet joint and pain information in the degenerated joint. They infiltrate the joint in response to chronic inflammation becoming fibrosed and scarred to the capsule and fascia as degeneration progresses. Dermatomal nerve roots may become painful as inflammatory peptides diffuse out from the inflamed facet joint tissues.

• Fascia: ___/142

The fascia is the thin connective tissue covering surrounding the muscles and all soft tissues. The fascia becomes inflamed, calcified and fibrosed during the degenerative process.

• Artery and Elastic Tissue in the Muscle Belly: __/ 62

62 is the frequency used for the artery and the elastic tissue in the arterial walls. The muscle belly responds to this frequency either because it is full of small arteries or because the elastic tissue in the muscle belly is somehow related to the artery wall.

A/B pairs for scar tissue

These frequencies were discovered in a list of frequencies published by Albert Abram’s in Electromedical Digest in 1931. 58 / 00 was the frequency combination to remove “abnormal cellular stroma”, whatever that might have been. 58 / 01 was used for scar in bony tissue. 58 / 02 was used for scar in soft tissue and 58 / 32 was used for scar tissue adhesions.

In treating chronic complaints the 58/’s are used in order as listed above for approximately 1 to 2 minutes each at the beginning of the treatment to soften the tissues. If there is no bone involved in the complaint it is customary to leave out 58 / 01. For those practitioners who can feel the softening produced by the frequency, it is often helpful to run the frequency until the softening is reduced and the tissue becomes relatively more firm. There may be some patients in whom one or more of these frequencies will produce softening for up to 3 to 4 minutes.

The 58/’s will increase range of motion but do not change pain.

Caution: 58 / 00, 01, 02, 32

• Do not use these frequencies on injuries newer than 5 to 6 weeks old.

• Newly injured tissue must form scar tissue in order to repair itself.

• Removing the scar tissue seems to undo the healing by weeks in a new injury.

• The 58/’s can be used very briefly (15 seconds) to modify scar tissue as it is forming after the first four weeks.

• Never use this combination before the injury is 4 weeks old

This precaution is the result of trial and uncomfortable error. A patient was being treated for facet and soft tissue injuries caused by an auto accident that had occurred 3 weeks previously. She was pain free after four treatments in 21 days and was treated on a Tuesday. She returned on Thursday complaining that whatever had been done on Tuesday had “undone” 2 weeks of healing and she felt as much pain as she had 2 weeks previously. Review of the Tuesday treatment revealed that the 58/’s had been used in addition to the protocols that had been reducing the pain for the preceding 3 weeks. She was so pain free that it seemed as if the injury was much older and the date of injury was not checked before treatment. The presumption was made that the 58/’s had removed repair tissue necessary to keep the joint and soft tissues pain free and stable. Two more errors in the first year of treating with FSM in similar situations helped to determine that the 58/’s should not be used within five to six weeks of a new injury. They can be used briefly four weeks after the date of injury – for 5 to 10 seconds each – to thin out scar tissue as it is forming, especially in athletes who seem to heal faster.

This reaction is predictable and reproducible. Take this precaution seriously. The wise practitioner will only make this mistake once; it is better not to make it at all.

Treatment protocol chronic facet pain

Channel A condition / Channel B tissue

58 / 00, 01, 02, 32

• A/B pair for Removing scar tissue and adhesions

• Treatment time: When used to treat chronic complaints the 58/’s are used in order as listed above for approximately 1 to 2 minutes each at the beginning of the treatment to soften the tissues and remove scar tissue. Facet joints have bone as a tissue so 58 / 01 is usually included in the protocol. For those practitioners who can feel the softening produced by the frequency, it is often helpful to run the frequency until the softening is reduced and the tissue becomes relatively more firm. There may be some patients in whom one or more of these frequencies will produce softening for up to 3 to 4 minutes.

40 / 396, 59, 39, 783, 157, 480, 191, 100

• Inflammation / Nerve, bone, periosteum, cartilage, capsule, tendon, ligament.

• Treatment time: Use these combinations for 2 to 4 minutes each. Research has shown 40Hz to have a time dependent response in a mouse model of inflammation. 50% of the reduction in inflammation was present at 2 minutes. The full response was present at 4 minutes. Treat the nerve first as it seems to relax the muscles and allow better palpation of the facet tissues. The periosteum is the most pain sensitive part of the bone and the nerve and the joint capsule are the most sensitive to inflammation and should respond best to this frequency. This protocol should reduce the joint pain but will not change range of motion.

284 / 396, 59, 39, 783, 157, 480, 191, 100

• Chronic inflammation / Nerve, bone, periosteum, cartilage, capsule, tendon, ligament.

• Treatment time: Use these combinations for 1 to 2 minutes each or if you are sensitive to the feel of tissue softening and time allows use the frequency as long as the softening happens.

91, 13 / 142, 396, 480, 783, 157, 191

• Calcium ions, scar tissue / fascia, nerve, joint capsule, periosteum, cartilage, and tendons.

• 91 / 783, 480, 157, 396 seems to reduce joint pain most effectively and softens the joint capsule dramatically.

• 13 / 142, 396, 480 usually increase range of motion most effectively. Scarring between the capsule and the nerve appear to create sharp pain with palpation and respond well to treatment. See manual technique below.

• Treat all the tissues if time allows.

• Treatment time: Use these combinations for 1 to 2 minutes each or if you are sensitive to the feel of tissue softening and time allows, use the frequency as long as the softening happens.

81, 49 / 142

• 81Hz is used for increasing secretions. / 142Hz is used for the fascia. The fascia secretes the ground substance necessary for repair of the fascia, ligaments and tendons.

49 / 59, 39, 783, 157, 480

• 49 / treat one or two tissues that responded best to 40 / for 1 minute each. Treat all tissues with 49 / if time allows.

If response is slow: narcotics

Experience has shown that patients who are on high levels of narcotics or who have had multiple injections with anesthetics respond slowly to treatment. This effect is reversed by the frequencies to “remove” narcotics and anesthetics. It is not thought that these frequencies actually remove the narcotic or anesthetic since they do not increase pain. It is much more likely that they somehow influence the membrane in such a way as to make it more receptive to treatment.

Use 43, 46, 19 / 396 first if the patient is on narcotics. The current application and lead placement are the same as for the joint treatment.

Stenosis precaution

If there is dense scar tissue or bony stenosis of the nerve root or spinal cord or if a disc fragment is compressing the nerve root or cord at the involved level the patient’s pain may increase when polarized positive current is applied. If the patient is positioned comfortably, it is the only time the pain will increase during polarized positive treatment for nerve inflammation. It may increase in the dermatome or at the spine or both. Assess patient position to determine whether it is contributing to the pain increase.

Stop treating immediately if pain goes up during treatment. Move the patient to a seated position if possible. Move the contacts slightly up the spine superior to the nerve root being treated, reduce current levels and change the current from polarized positive to alternating. If this is going to reduce the reaction it will do so in 5 to 10 minutes. If the pain continues to increase, stop treating with current. The pain should go back down in a few hours although it may take up to 24 hours to reduce to base line.

This reaction is diagnostic. If physical examination findings of reduced sensation and deep tendon reflexes at the involved level or hyperactive deep tendon reflexes below the involved level are present this reaction suggests the need to x-ray or perform an MRI to confirm the presence of compression.

Treat the muscles

When treating the facet joint remember to treat the muscles and trigger points. The taut muscles act as confounding pain generators and at the same time compress the facet joint increasing the degenerative forces on both the facet joint and the disc (see Chapter 7).

Treat the psoas and lumbar paraspinals muscles in the low back.

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Tags: Frequency Specific Microcurrent in Pain Management

Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off

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