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Pain referral
Trigger points
Cranial nerve
Spinal nerve
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Virtually any condition, which results in
hypertonicity, rigidity or spasm, can aggravate trigger points.
Chronic or recurrent unresolved pain should always be evaluated for systemic
disease or biochemical imbalance. Nutritional and toxicological factors can be
preliminarily assessed from case history and interview.
However, the insidious nature of endocrine
disorders serving as perpetuating factors are more allusive through their rather
nondescript & diffuse symptoms and signs. Frequently, elaborate blood work
is required to determine neurotransmitting chemicals and their relationship on
hypersensitivity or the manufactured opioids of the body, which dampen pain
receptors.
A few basic laboratory tests frequently
used for differential diagnosis are referenced in this section. The physician
usually orders a SMAC24, or as it’s more recently referenced, an Executive
Panel, in addition to an Erythrocyte Sedimentation Rate (ESR). The
Executive Panel consists of Complete Blood Count, Complete Metabolic Production,
Lipid Panel and Thyroid Panel.
From this basic blood work more specialized
testing may be ordered. Chemistries to assess neurotransmission are specialized
and require specialty laboratories for testing. Nevertheless, we will discuss
neurotransmission as it is imperative to understand their functions as it
relates to pain and spasm.
(Definitions were taken from Dorland’s and
Merriam Webster Medical Dictionaries with elaboration by the authors.)
1. Acetylcholine (ACh)
...is a
neurotransmitter released at autonomic
synapses and neuromuscular junctions, active in the transmission of nerve
impulses and formed enzymatically in the tissue from choline. Myasthenia gravis
and possibly Alzheimer’s are diseases caused by the interruption of ACh.
Myasthenia gravis is considered an autoimmune disorder and is characterized by
muscle weakness especially of the eyes, neck, throat, arms and legs. In addition
to an eyelid droop, there can be fatigue with speaking, usually performed with a
soft voice, difficulty in swallowing with reflux, dyspnea, and difficulty in
climbing stairs and repetitive movement, and possible regurgitation through the
nose. Treatment is with corticosteroids to suppress the immune system or
surgical removal of the thymus.
Trigger points are not normally associated
with Alzheimer’s, a condition normally observed in the elderly and
typified by memory loss, agitation and paranoia, the persistent anxiety and fear
associated with this condition has psychological implications on the soft
tissue. Utilizing manual treatment for the secondary somatic effect of this
condition can be uncomfortable and potentially threatening to the individual.
Therefore technique should be employed gently, slowly and with constant
reassurance. Sudden movement, initiating painful stimuli or failure to
repeatedly explain what you will be doing may lead to a verbal explosion or a
combative situation.
...are any of various substances (as epinephrine, norepinephrine, and dopamine) that contain a benzene ring with two adjacent
hydroxyl groups and a side chain of ethylamine and that function as hormones or
neurotransmitters or both.
-
Dopamine - A monoamine that is a
decarboxylated form of dopa and occurs especially as a neurotransmitter in the
brain and as an intermediate in the biosynthesis of epinephrine. It is also
produced peripherally and acts on peripheral receptors, as in blood vessels. Its
association with the malfunction of the basal ganglia is a contributing factor
to Parkinson’s disease. A mask like face, muscle rigidity, sluggish movement and
foot fixation typifies Parkinsonism. This muscle rigidity obviously can produce
numerous triggers secondary to this condition. Parkinson’s disease is typified
by tremors, usually unilateral of the hand or arm, later becoming bilateral. As
it becomes more progressive there is hyperkyphosis or stooped posture, a flat
and emotionless facial expression, and a sluggish gait experiencing foot
fixation, which most individuals attempt to release by turning with the
occasional burst into small, rapid steps for a short distance to regain balance.
Individuals frequently experience depression and a decline in hygienic
maintenance. Occasionally, tremors are absent with muscle rigidity being the
only initial sign of onset. While reflexes are usually normal, unless affected
by tremor or rigidity, the initiating of passive extremity movement may be
difficult (lead pipe). The goal is to palliatively relieve rigidity, and perform
gentle ROM, and/or joint mobilization. High velocity techniques with these
individuals are quite difficult to perform and can be deleterious.
-
Norepinephrine (Noradrenaline) - A
catecholamine that is the chemical means of transmission across synapses in
postganglionic neurons of the sympathetic nervous system and in some parts of
the central nervous system, is a vasopressor hormone of the adrenal medulla, and
is a precursor of epinephrine in its major biosynthetic pathway. Norepinephrine
elevates metabolic and heart rates. It also causes vasoconstriction, which
increases blood pressure. When excessive, it produces sustained “fight or
flight” syndrome or hypertension. Injections of norepinephrine are frequently
given when the blood pressure falls to dangerously low levels to avoid shock.
Additionally syncope (fainting) can occur with physiologic orthostatic
hypotension. This dysfunction is usually observed when an individual rapidly
moves from recumbency (lying down) to standing or as a result of self-infliction
of the Valsalva maneuver while eliminating. In addition to using a lying to
sitting and standing blood pressure check, the tilt test or as it is sometimes
referred to as the tilt table test can assess this condition. Pathological
orthostatic hypotension is less frequently observed but is due to adrenocortical
insufficiency. In addition to syncope you will observe conditions consistent
with depleted sodium (hyponatremia) and elevated potassium (hyperkalemia).
- Epinephrine (Adrenaline) - A
catecholamine hormone secreted by the adrenal medulla and a neurotransmitter
released by some neurons. It is stored in the chromaffin granules and is
released in response to hypoglycemia, stress, exercise and severe emotional
stimuli such as excitement. It is a potent stimulator of the sympathetic
nervous system and a powerful cardiac stimulant that accelerates the heart rate
and increases cardiac output. It also promotes glycogenolysis and exerts other
metabolic effects. It is also associated with “fight or flight” syndrome. By
constricting the blood vessels in the skin and intestines it enhances blood
supply to the muscles, thus causing a pooling of blood in the extremities and
pallor of face during situations which require an immediate excitatory response.
As a medication it may be used to elevate heart rate in the case of a myocardial
infarction or arrhythmia, dilate bronchi in response to an allergic reaction or
asthmatic attack or dilate bronchi and constrict blood vessels in response to
anaphylactic shock.
A group of neuropeptides that bind to opioid
receptors in the brain and have a potent analgesic activity. It is found in the
adenohypophysis, hypothalamus and other sites in the brain. One function appears
to be the modulation and/or inhibiting of painful stimuli. It is similar in
chemical composition to morphine therefore, received its name “endorphin” from
endogenous morphine.
4. Enkephalins
Either of two pentapeptides with opiate and
analgesic activity that occur naturally in the brain and have a marked affinity
for opiate receptors: leucine-enkephalin and methionine-enkephalin. Both
enkephalins and endorphins bind to opioid receptors; the two groups derive from
functionally and anatomically distinct groups of neurons. The enkephalins
function as neurotransmitters or neuromodulators at many locations in the brain
and spinal cord and play a part in pain perception and inhibition, movement,
mood, behavior and neuroendocrine regulation. They are also found in nerve
plexuses and exocrine glands of the gastrointestinal tract.
5. Gamma-aminobutyric Acid (GABA)
An amino acid that is a neurotransmitter that
induces inhibition of neuronal synapses. The medication Baclofen has an
agonistic effect with GABA thus serving as an antispasmodic agent. The reduced
activity of GABA has been associated with anxiety and epilepsy.
6. Substance P
A neuro poly-peptide that is composed of 11
amino acids and is found in the hypothalamus, substantia nigra, dorsal roots of
the spinal nerves, and in special endocrine cells in the gut where it increases
the contractions of gastrointestinal smooth muscle and causes vasodilatation, in
addition to serving as a neurotransmitter for touch, temperature and released
upon the afferent transmission of pain.
7. Glutamate
A salt, ester or anionic form of glutamic
acid. Four types of postsynaptic glutamate receptors have been identified:
Kainate, AMPA, NMDA and Metabotropic. Glutamate is a major excitatory
transmitter in the brain and spinal cord.
A decarboxylation product of histidine found
in all body tissues. Large amounts are found in the pituitary gland, the
hypothalamus and particularly in the mast cells and their related blood
basophils with the highest concentration being in the lungs. Damaged cells
release histamine in injured tissues increasing capillary permeability.
Therefore, histamine is responsible for swelling as well as inflammation. In
skeletal muscle the release of histamine around trigger points is attributed for
their characteristic: increased metabolism, but decreased circulation. Soft
tissue manipulation and trigger point injection flushes histamines and
metabolites, referenced as noxious stimuli, into the circulatory and lymphatic
systems and may result in rebound tenderness. Decreased circulation elicits
ischemia and induration of skeletal muscle.
Histamine has several functions, including
vassal dilation, which results in a drop of blood pressure; contraction of
most smooth muscle tissue, including bronchial smooth muscle of the lung;
induces gastric secretion; and acceleration of the heart rate.
It is also implicated as a mediator of the
triple response and immediate hypersensitivity. The triple response is a release
of histamine typified by erythema, wheals & flare. Based on current research
there are two types of histamine: H1 and H2. The H1 receptor mediates the
contraction of smooth muscle and the effects on capillaries; the H2 receptor
mediates the acceleration of heart rate and the promotion of gastric acid
secretion. Both H1 and H2 receptors mediate the contraction of vascular smooth
muscle. Histamine has also been postulated to be a neurotransmitter in the
central nervous system.
9. Serotonin
In humans it is synthesized in the intestinal
chromaffin cells or in central or peripheral neurons and is found in high
concentrations in many body tissues, including the intestinal mucosa, pineal
body, and central nervous system. Produced enzymatically from tryptophan by
hydroxylation and decarboxylation, serotonin has many physiologic properties. It
inhibits gastric secretion, stimulates smooth muscle, serves as a central
neurotransmitter and is a precursor of melatonin. Melatonin is a popular over
the counter sleep aid. However, caution should be used in the recommendation of
long-term usage for males. There is preliminary evidence that chronic usage may
result in feminine characteristics. While those studies are far from conclusive,
the studies pertaining to ecstasy (extasy) an illegal recreational substance
which floods the brain with serotonin providing a euphoric state, is conclusive.
Permanent irrevocable CNS damage will occur in addition to cardiovascular damage
and myologic dysfunction.
The CBC or complete blood count
consists of the Leukocytes and Erythrocytes. The Leukocytes are the white blood
cells or WBC’s. Leukocytes consist of granulocytes, monocytes and lymphocytes.
The Erythrocytes are the red blood cells or RBC’s.
White Blood Count (WBC): The function
of Leukocytes is to fight infection. Other reasons for Leukocyte elevation or
Leukocytosis may be due to stress reactions, inflammation, blood disorders,
leukemia, myocardial infarction, anesthesia, burns, hemorrhage, gout, eclampsia,
and menstruation.
Leukopenia or a decrease of Leukocytes
may occur in a pathologic disorder of the blood (blood dyscrasias).
Viral or bacterial infections perpetuate
triggers and give rise to elevated white counts as determined by a CBC.
Erythrocytes Sedimentation Rate (ESR) determines inflammation. Elevation
over 50mm/h suggests polymyositis, dermatomyositis or Mixed
Connective Tissue Disease. Polymyalgia Rheumatica frequently exhibits
a value of over 100 mm/h, and is frequently concomitant with Giant Cell
Arteritis or Temporal Arteritis, which usually occurs in the
population over 50 years of age. Elevated SED rates are also observed in
malignancy.
With all of these conditions characteristic
muscle pain, headaches, and/or proximal weakness is evident. Trigger point
formation should be considered secondary to these insidious conditions. As in
Vasculitis there is a hypersensitivity to touch and rebound tenderness.
Similar to fibromyalgia a positive 12 of 18 tender point exam can be
exhibited. Prompt medical care is needed for suspected malignancies and Temporal
Arteritis, which may lead to irreversible blindness.
Elevated ESR’s are usually proportional to the
activity of the disease as noted in Systemic Lupus Erythematosus (SLE).
Usually observed in young women and children it in can occur in both genders and
at all ages. Its initial physical symptomatology is similar to rheumatoid
arthritis (RA), which also demonstrates an elevated SED rate. An elevated
rheumatoid factor (RF) is not always observed with RA. However, when observed,
it is considered an additional indicator of the disease. When the RF titer is
extremely elevated it infers a very progressive form of RA, which could elicit
nodules, Vasculitis, and pulmonary involvement.
Hyperuricemia is demonstrated through
an elevated Uric Acid Level. This urate crystal formation is responsible for
the joint deposition and peripheral joint pain associated with gout.
Osteoarthritis (OA) is typified by a modeling of bone with spicule as
exhibited on radiograph. This “modeling” or erosion of lumbar cervical vertebra,
hips, shoulders and weight bearing long bones usually has its asymptomatic onset
when an individual is in their thirties. However, it is not uncommon for
arthralgia to develop in an individual in there twenties. Rest usually
reduces the pain associated with OA, while the pain associated with RA may be
reduced by moderate exercise. When either RA or OA is advanced, pain is
persistent with only palliative relief being possible.
Another form of metabolic bone disease is
Osteopenia, the precursor for Osteoporosis. Osteopenia is
usually represented by 30% reduction or loss of bone mass. Osteoporosis,
the more severe form, results in a greater reduction of bone density and usually
is attributed to estrogen depletion in women or hypogonadism in men, as observed
in Klinefelter’s Syndrome. While this condition is usually radiolucent,
bone density studies provide far greater value as it pertains to susceptibility
to fracture. This condition is usually associated with aging. However, in
addition to the above-mentioned conditions, excessive alcohol consumption,
endocrine disease, medications or conditions which would elicit a Vitamin D
deficiency, malabsorption syndromes, as well as possible malignancy are primary
disease states which could yield secondary Osteoporosis. Osteopenia
is frequently asymptomatic; however, Osteoporosis frequently demonstrates
diminished height, stooped shoulders, hyperkyphosis, muscle weakness and back
pain, in addition to any symptoms associated with the primary disease, when
Osteoporosis is secondary. In its more advanced form patient management is
more difficult due to the high susceptibility to fracture. Gentle transferring
of an individual from gurney to bed could cause fracture. Therefore soft tissue
techniques must be performed extremely light with any form of mobilization or
joint manipulation being contraindicated. Persons who seem to have the highest
prevalence for Osteoporosis are:
Petite Caucasian females over fifty
Obese Caucasian females over fifty
Petite Black females over fifty
Petite Caucasian males over fifty
Obese Black females over fifty
Petite Black males over fifty
Obese Caucasian males over fifty
Obese Black males over fifty
While these rankings have been developed from
bone density studies and hold poor qualitative value due to the exclusions of
other ethnic groups and limited population, they do provide the manual
practitioner with the ability to rapidly discern susceptibility of fracture
prior to initiating technique. Before initiating rigorous treatment protocol
with individuals whom are in the top 50% of this survey, whom have had a
condition or surgical procedure, which depletes estrogen for a period of more
than ten years, regardless of the age, or a family history of Osteoporosis,
a bone density study should be performed.
As previously mentioned, with Vitamin D
deficiency Osteomalacia and Osteoporosis can coexist.
Osteomalacia, the adult form of Ricketts, is typified through the
softening of bone, thinning of vertebra, narrowing of pelvis and bowing of
weight bearing long bones.
The pituitary gland & hypothalamus controls
the function of the thyroid gland. Common thyroid dysfunctions include:
Hypothyroidism, hyperparathyroidism, goiters, Graves’
disease, & Hashimoto’s thyroiditis.
Uncommon dysfunctions can be caused by
congenital defects, genetic disorders, infection, tumors, other autoimmune
disorders, hormonal disorders, nutritional disorders, radiation, and myxedema.
Hypothyroidism occurs in approximately
1% of the population and while it usually afflicts women over the age of 60, it
can occur in both genders and at all ages. When it occurs in children it can
affect sexual, mental and growth development, if untreated. Additional symptoms
are dependent upon deficiency of thyroid hormones. If the deficiency is slight
it may be asymptomatic. If more progressive, the individual may possess a coarse
voice, fatigue, lethargy, eczema, muscle weakness with periodic cramps resulting
in trigger point referral, as well as bradycardia, and when severe, this
results in myxedema.
Myxedema is severe hypothyroidism
characterized by firm inelastic edema (represented by thickened dry skin),
dryness and loss of hair, fatigue, with an increase of fluid accumulation in
body cavities, muscle weakness, and retarded tendon reflex.
Hashimoto’s Thyroiditis is an
autoimmune disorder whereby the body develops antibodies towards its own thyroid
gland, which results in hypothyroidism and the same symptomatic manifestations
associated with that disease.
Goiter is an enlargement of the thyroid
gland, which may occur from iodine deficiency leading to thyroxine insufficiency
or as a result of toxicity (thyrotoxicosis), which usually is observed
from the medication for hyperparathyroidism or birth control pills.
Thyrotoxicosis is also observed in Graves’ disease. However, goiter
may be seen in all ages or as a result of pregnancy. Frequently, goiter is
idiopathic (cause unknown) with no evidence of thyroid dysfunction.
Graves Disease or Hyperthyroidism
is an autoimmune disorder resulting in the overproduction of thyroid hormones.
It is typified by a toxic goiter, thyrotoxicosis, bulging eyeballs (exophthalmos),
and drooping eyelids, usually accompanied with appetite irregularities and
weight loss. Other systemic symptoms include tachycardia, palpitations, muscle
weakness, and tremors with possible atrophy, heat intolerance, hyperactivity,
insomnia, blank stare, and excessive perspiration or fever. Graves’ disease is
the most common form of hyperthyroidism; however, thyroid nodules or tumors can
also elicit elevated thyroid hormones.
Hyperparathyroidism is a result of the
parathyroid and thyroid glands producing excessive hormones, which elevates the
level of calcium in the blood (hypercalcemia). The cause is usually
attributed to either enlargement of the parathyroid gland (cause unknown) or a
benign tumor on the glands. These hormones pull calcium from the bone resulting
in osteoporosis or osteomalacia as well as muscle aches and pain.
When the body attempts to eliminate this excess calcium from the blood, renal
calculi frequently form resulting in dysfunction and possible renal failure.
Serum calcium, phosphorus and hormone levels in addition to bone density studies
and radiograph are needed to determine cause and extent of this disease. You
will seldom see the above-mentioned symptoms to the exclusion of a host of other
orthopedic, gastrointestinal, endocrine, and neuropsychological complaints.
As previously mentioned with the thyroid
glands, the adrenal glands are also controlled by the hypothalamus and pituitary
glands. The adrenal glands, also known as suprarenal glands are located directly
above the kidneys. Thus, they derive their name adrenal. These triangular shaped
glands consist of two major components. The cortex, which surrounds the medulla,
is responsible for the production of hydrocortisone, corticosterone, and
androgenic hormones, with the medulla responsible for the production of
epinephrine and norepinephrine.
When the cortex is examined under microscopy
three zones can be observed. The most superficial or outermost zone is
responsible for the manufacture of the aldosterone hormone, which inhibits
sodium excretion and regulates blood pressure and volume. The two deeper zones
are responsible for the manufacture of hydrocortisone, corticosterone, and
androgen hormones. Hydrocortisone controls the digestion of protein, fats and
carbohydrates, and collectively with corticosterone assists in the suppression
of inflammation and enhancing the immune system. The androgen hormones are also
referred to as testoids due to the fact they are the masculinizing hormone and
have influence on body shape and hair.
The medulla produces epinephrine and
norepinephrine, and as previously discussed are neurotransmitters which have
numerous functions, the most significant being regulation of heart rate, blood
volume and pressure and responsible for the “fight or flight syndrome”.
Dysfunctions of the adrenal glands may be due
to pituitary dysfunction, which could cause over production of hydrocortisone
(Cushing’s syndrome) or under production (adrenal failure). Tumors in the
adrenal glands, which are rare, could result in excess hormone production
causing Aldosteronism, masculinizing hormones in females, high blood pressure,
or neuroblastoma.
Autoimmune disorders or infection may cause
adrenal failure or deficiency of hormone production resulting in Addison’s
disease.
Cushing’s syndrome is caused by the
overproduction of hydrocortisone. Its symptoms include rounded “moon” face with
a red appearance. There is obesity of the trunk with “buffalo hump”; the distal
extremities and fingers are usually quite slender. Muscle atrophy and weakness
are present. The skin is thin and easily bruised with poor wound healing. Purple
stretch marks may appear on the abdomen, breasts and thighs. Menstrual
irregularities, osteoporosis, glucose intolerance, hypertension, renal calculi,
reduced resistance to infection, and psychiatric disturbances are common.
Aldosteronism or Conn’s Syndrome
is caused by the overproduction of aldosterone. Symptoms are over excretion of
potassium, excessive thirst, and high blood pressure, due to elevated sodium
levels, muscle fatigue, weakness, and kidney dysfunction.
Pheochromocytoma is a nonmalignant
tumor on the adrenal medulla causing over secretion of epinephrine and
norepinephrine resulting in high blood pressure, which is the main symptom.
Pressure on the tumor can cause symptoms such as headache, nausea, vomiting,
rapid heart rate, hypertension, palpitations, or impending morbidity.
Neuroblastoma, usually found in
children under the age of ten, is a tumor in the adrenal gland or sympathetic
nervous system. They begin in the abdomen, thorax, neck, pelvis, or very rarely
as a primary CNS tumor. Due to the secretion of excessive epinephrine and
norepinephrine hypertension, diarrhea, skin flushing, and fight or flight
response may be present. Symptoms vary due to the sight of tumor; however,
symptoms may include paleness, general aches and pains, weight loss, and
irritability. Respiratory problems may occur with thorax involvement. As the
tumor metastasizes along the sympathetic nerve path, the symptoms become more
extreme with bone pain, liver enlargement, anemia, petechiae, and focal
neurologic deficits due to metastases of the spinal canal.
Ganglioneuroma is a benign form of
neuroblastoma occurring in adults. While it does not metastasize it has
pertinence to the manual medicine practitioner as it can easily be mistaken as
biomechanical peripheral nerve compression. Symptomatology will vary dependent
upon the ganglia, which are affected. Thoracic and retroperitoneal involvement
is difficult to assess even though they are frequently palpable when large.
Occasionally a test for fremitus will reveal thoracic involvement.
Addison’s disease was once considered
fatal with its primary cause being tuberculosis. This rare disease results in
the underproduction of hydrocortisone and aldosterone, and can now be treated
with hormone replacement. Its usual causation is autoimmune disorder. If this is
the cause it is chronic and insidious. Addisonian crises are acute and are
caused by infection, injury, or stress. The most specific indication is an
unusual darkening of the skin, predominantly in the creases of the palms,
elbows, and plantar surface of the feet. However with the popularity of tanning
beds these indications can be deceptive. Therefore for the suspicious
practitioner, examine for darkening of the bucco mucosa of the mouth, especially
when this discoloration is accompanied with extreme muscle weakness,
hypotension, dehydration, confusion, or coma. Utilizing the pinch test for
dehydration should be invoked in the physical exam sequence to avert dyer
consequence.
Diabetes Insipidus, although not
affecting the adrenal glands themselves, is worthy of mention in this section.
It usually results from the failure of the pituitary gland to secrete
antidiuretic hormones, which causes excessive amounts of water being passed by
the kidneys thereby depleting the constant dilution of the blood. Constant
thirst and excessive urination are the only symptoms. The output of urine must
be matched by intake of water or the signs and symptoms of dehydration will
appear leading to confusion, stupor and coma. Congenital diabetes insipidus
usually called nephrogenic diabetes insipidus is due to lack of the kidneys
responding to normal levels of ADH and may result in pyelonephritis (kidney
disease).
The pancreas is located behind the stomach at
the back of the abdomen with the head, or right-hand end lying in the loop of
the duodenum while the tapered end, or tail ends near the spleen. This
elongated, tapered gland consists of exocrine tissue that holds nests of
endocrine cells called the islets of Langerhans. Digestive enzymes and
bicarbonate are secreted by the exocrine cells and are carried into the main
pancreatic duct, which connects to the common bile duct to form the ampulla of
Vater chamber. This chamber opens into the duodenum where the enzymes are then
activated by other enzymes, which break down fats, proteins, carbohydrates, and
nucleic acids. The islets of Langerhans endocrine cells secrete insulin and
glucagon hormones into the blood vessels by which they are surrounded. These
hormones regulate the level of glucose in the blood.
Cancer, diabetes, cystic fibrosis, trauma,
poisons, drugs, and autoimmune disorders cause the major dysfunctions of the
pancreas. There is suspicion that chronic pancreatitis could be hereditary.
The most common pancreatic dysfunction is
caused by Diabetes.
Diabetes Mellitus is caused by the lack
of insulin produced by the pancreas. Insulin is a protein hormone that is
essential for the metabolism of carbohydrates, lipids, and proteins. It
regulates blood sugar levels by facilitating the uptake of glucose into tissues
and promoting its conversion into glycogen, fatty acids, and triglycerides. It
also reduces the release of glucose from the liver. Lack of insulin causes
glucose to remain in the body in excessive amounts, which causes constant
thirst, hunger, excessive urination, fatigue, and weight loss. Diabetes
mellitus causes degeneration of small blood vessels and lipid metabolism
disorder. In early stages the symptoms of diabetes mellitus are similar to
diabetes insipidus; however, that is the only correlation. Bronze
diabetes or hemochromatosis is rare and can be the precursor for diabetes
mellitus.
Type I diabetes mellitus (juvenile
onset) results from no production of insulin by the pancreas and is the more
severe type of diabetes. Type I DM usually occurs in people under the age of 35
and most commonly between the ages of 10 and 16. While inherited genes can be a
factor in causing Type I diabetes mellitus, it is more commonly caused by
a viral infection resulting in an immune response, which destroys the cells in
the pancreas that secrete insulin. A complication of type I DM is ketosis (ketoacidosis)
caused by fat being used by the body for energy instead of glucose. When the
fatty acids are released into the blood, excessive amounts of ketones, such as
acetone are produced. Sweet smelling breath, nausea, vomiting, loss of appetite
and abdominal pain are the symptoms of ketosis and when left untreated can
result in death. Without insulin injections on a regular basis, coma, and death
will occur.
Type II diabetes mellitus (mature
or adult onset) is caused by the gradual onset of the pancreas not producing enough insulin
and is usually only found with a physical examination. While usually occurring
in people over the age of 40, they may be asymptomatic and never diagnosed with
type II diabetes mellitus. Patients with type II DM may develop
nonketotic coma. However, when progressive, complications may occur of the
large and small vessels as well as muscle
wasting (atrophy). Large vessel involvement includes coronary artery disease
(CAD) and peripheral vascular disease (PVD). Small vessel involvement
includes renal disease (nephropathy), peripheral and autonomic disease or
neuropathy and retinal disease (retinopathy). The onset of
neuropathy is usually noticed by the loss of sensation in the hands and feet
and persons state that they feel as if they are walking on cotton. This loss of
sensation effects proprioception and when severe, makes the individual oblivious
to foot trauma which can either damage skin or joints (Charcot’s joints). While
usually painless, Charcot’s joints can palpate similar to a bag of rocks, with
the joints being freely mobile. Also in the more progressive form of this
disease, cranial neuropathy can ensue. If the gene is inherited and the person
is overweight, it usually is contracted. Other causes of type II diabetes
mellitus are pregnancy, infections, pancreatitis, thyrotoxicosis,
certain prescription medications such as corticosteroids and diuretics.
It is possible for diabetics to lead a normal
lifestyle through the regulation of diet and possibly the use of oral medication
and proper foot care; however, when complications occur they can be severe.
Severe complications can include minor skin breaks of the feet resulting in
amputation, coronary artery disease resulting in heart attack, kidney disease
resulting in renal shutdown, and retinopathy resulting in total blindness. The
clinician usually receives the first indication through symptoms derived from
history or interview. As this disease is insidious the individual frequently
attributes their physical change to the aging process. Symptoms most frequently
stated are weight loss, fatigue, weakness, polyuria, nocturia, emotional
outbursts with little or no provocation, erectile dysfunction or impotency in
men, recurrent vaginal itching or candida in females, cramping of calves with
muscle ischemia and triggers, cold hands or feet, numbness, tingling or burning
of toes, feet or hands which have a glove and stocking distribution, dizziness
resulting in a staggered gait, and/or blurred vision. As vascular insufficiency
is the cause for poor wound healing, decreased ability to fight off infection,
visual phenomena, claudification, and hypoesthesia; the individual may
seek the initial care of a manual medicine practitioner. As peripheral
vascular disease and vascular thrombosis are secondary to this
condition, the practitioner should avoid utilizing any manual technique, which
could dislodge a clot or compromise a blood vessel. However, after a vascular
work up has been performed, soft tissue manipulation can be quite beneficial in
promoting vassal circulation thus offsetting the negative effects of this
disease or to serve as a mechanical pump to push medications such as Topamax or
Neurontin to assist in the sensory deprivation. Due to this sensory
deprivation, hot packs, heating pads, and exceedingly warm whirlpools are
contraindicated as well as any manipulation around wounds or bruises.
Hypoglycemia is the abnormally low
amount of glucose in the blood. While symptoms vary with the cause it usually is
typified by weakness, tremor, coma, and even death. The most frequently observed
causes originate from fasting, or elevated levels of insulin in the body.
Skipping meals, especially breakfast, can produce hypoglycemia, which is usually
mild but can be easily remedied by sugar intake. Insulin dependent diabetics
must eat after taking a prescribed dosage otherwise, their glucose can drop to
dangerously low levels. In addition to insulin injections resulting in elevated
insulin levels and depleted blood sugar; pancreatic stimulants must also be
considered when symptoms of hypoglycemia are experienced. There are numerous
medications on the market that either suppress glucose production or enhance the
level of insulin. Reactive hypoglycemia usually occurs as a result of the
overproduction of insulin due to the rapid consumption and processing of a
meal. This usually occurs 2-4 hours following a meal and is known as a “dumping
syndrome”. It also is referenced as a post gastrectomy syndrome due to its
reaction of rapid passing of food through the elementary tract with persons whom
have had a hemi-gastrectomy.
Fasting hypoglycemia as previously
mentioned, frequently occurs with persons whom have self-imposed starvation,
such as Anorexia Nervosa. The symptoms of weakness and vertigo normally persist
for over four hours after eating. However, pancreatic tumor, adrenal
insufficiency, alcohol consumption, or renal failure, as well as hepatic disease
and pregnancy, especially in the first trimester, may also cause these
symptoms. Drug induced hypoglycemia is frequently observed with insulin
dependent type I diabetics. Occasionally, type II or non-insulin dependent
diabetics experience hypoglycemia in the early onset of this disease.
Symptoms of hypoglycemia include headache, veracious appetite, visual
disturbances, proprioceptive dysfunction, anxiety, agitation and if untreated,
delirium, coma, and death.
Pancreatitis is the inflammation of the
pancreas usually caused by gallstones or alcoholism. However, viral infections,
trauma to the abdomen or injury to the biliary tract are uncommon causes. In an
acute pancreatic attack symptoms include severe upper abdominal and possible
back pain, nausea, vomiting, and pain from movement. Acute pancreatitis,
which can lead to chronic pancreatitis, causes disturbances of the
functions of the pancreas, which usually returns to normal within a few days.
However, if the gland is damaged severely it may lead to hypotension, heart and
renal failure, respiratory failure, abdominal fluid accumulation (ascites),
cysts or abscesses. Chronic pancreatitis is usually caused by alcoholism
or hemochromatosis (Bronze Diabetes). Although symptoms are usually the
same as for acute pancreatitis, the episodes last much longer and become
more frequent as the condition progresses. Pain is not always a symptom;
sometimes malabsorption syndrome or diabetes mellitus are the first
clinical indications of chronic pancreatitis. However, it is not uncommon
for trigger points to develop in the rectus abdominis or mid thoracic region
secondary to this condition. Additionally, a mid thoracic peripheral nerve
compression (pseudo GI syndrome) can elicit the same physical manifestations to
include abdominal distention. Bile duct obstruction and aortic aneurysm must
also be considered prior to initiating manual care. Chronic pancreatitis does
result in permanent damage to the pancreas as well as releasing pancreatic
enzymes into the blood. Complications of chronic pancreatitis are the
development of ascites and cysts, Cholecystitis, diabetes mellitus,
splenic thrombosis, or the antecedent manifestation of pancreatic
carcinoma.
Pancreatic Cancer can be the result of
chronic pancreatitis, heavy smoking, alcoholism and high amounts of fat
in the diet; however the actual causes are unknown. Symptoms include boring
abdomen pain that radiates to the back, indigestion, loss of appetite and
weight, nausea, vomiting, diarrhea, jaundice and fatigue. However, by the time
symptoms appear, the disease has usually spread to the liver, stomach, or
lungs. © Copyright
Myofascial trigger point perpetuating factor: metabolic and endocrine inadequacies