Pain Doc - Ask Dr. P - The Pain Doc

How Sleep Quality Affects Healing and Pain

by Pain Doc | Feb 18, 2020 | Uncategorized

Can Poor Sleep Make Pain Worse?

We’ve all experienced a bad night’s sleep, and know the results: low energy in the morning, mental fog, grumpy attitude, slow reaction time, difficulty concentrating and basically feeling crappy all day.

On the contrary, we know what a good night’s sleep does for us, which is the exact opposite: feeling energized upon waking, good attitude for the day, and mental clarity and alertness.

The way your body and mind feel communicates health information, so obviously sleep is essential to your health since you feel and function better when you get good sleep, and feel and function worse when you are denied sleep.

While the precise, biological relationship between sleep and physiology is still a mystery, we do know that sleep impacts nearly every tissue and system in the body: brain, heart, lungs, kidneys and gut; metabolism, immune function, learning ability, memory, mood, and disease resistance. Research shows that chronically poor quality sleep increases the risk of many disorders, including high blood pressure, cardiovascular disease, diabetes, depression, and obesity.

But can sleep problems also interfere with your body’s ability to heal itself, and therefore affect pain levels of an injury?

It stands to reason that the answer is yes. Let’s say you fell and broke your leg bone. Your body’s innate healing response immediately kicks in: a cascade of biochemicals spring to action, thanks to functional proteins present in your blood and tissues. These proteins initiate inflammation to quarantine the injury; limit movement by generating pain; activate immune cells to kill microorganisms and remove debris; stem bleeding, regrow blood vessels and patch the injury with scar tissue. While the exact mechanism is not known, sleep can influence the quality of this healing process at many levels.

One study evaluated the healing rate of oral ulcers in rats. The test group of rats was denied sleep and the control group was allowed to sleep. It found that sleep deprivation worsened oral ulcers and significantly delayed their healing, compared to the control group. Sleep deprivation resulted in elevated levels of tumor necrosis factor alpha, a pro-inflammatory substance, and a decrease in superoxide dismutase, which cells use to neutralize oxidative stress (damage). Together, these changes worked to interfere with tissue healing.

While chronic pain can cause poor sleep due to over-stimulation to the brain, there is interest in examining whether the reciprocal is true—if poor sleep can cause an increase in pain. A review of independent studies analyzing the effects of sleep deprivation on pain processing found that for most of the studies, sleep deprivation produced hyperalgesic changes; i.e. made pain perception worse.

The lesson here is that if you have recent pain (acute injury or onset) or even chronic pain, it is important that you get quality sleep every day. The research is clear that sleep is essential to optimal injury healing and minimizing pain perception.

Of equal importance is maintaining a healthy diet consisting of protein, good fats (i.e. nuts, seeds, olive oil, fish oil, avocado, egg yolks), and generous amounts of vegetables while minimizing sugar and grain carbohydrates. Your diet provides the proteins needed for structural repair and micro nutrients (vitamins and minerals) needed for critical biological processes, many related to tissue healing.

To take it a step further, I recommend you try intermittent fasting, where you don’t eat for long stretches during a 24 hour period. Check out this article I wrote to see how intermittent fasting can reduce inflammation and pain. Despite the conventional wisdom of “three square meals a day” and “breakfast being the most important meal of the day,” your body is actually optimized to go without eating for long periods of time. Lowering your caloric intake via intermittent fasting lowers oxidative stress, keeps blood sugar in check and burns excess body fat. This can have an overall effect of lowering chronic pain.

Back to the importance of sleep: If you have difficulty sleeping, The National Institute of Neurological Disorders and Stroke (NIDDS) offers the following tips to improve your sleep:

Set a schedule – go to bed and wake up at the same time each day.
Exercise 20 to 30 minutes a day but no later than a few hours before going to bed.
Avoid caffeine and nicotine late in the day and alcoholic drinks before bed.
Relax before bed – try a warm bath, reading, or another relaxing routine.
Create a room for sleep – avoid bright lights and loud sounds, keep the room at a comfortable temperature, and don’t watch TV or have a computer in your bedroom.
Don’t lie in bed awake. If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired.
See a doctor if you have a problem sleeping or if you feel unusually tired during the day. Most sleep disorders can be treated effectively.

And let me share you a tip that helps me sleep when I’m having trouble sleeping: keep your eyes open as you lie in bed in the dark. It may sound counter-intuitive, but it works for me. After all, you can’t get drowsy if you are forcing your eyes closed when trying to sleep. Leaving your eyes open will eventually lead to the “drowsiness reflex,” which will transition you to sleep.

One more personal tip– use blackout blinds in your bedroom (not venetian blinds). These block 100% of light outside your room. Make sure to get the exact width to minimize light leaks around the perimeter. Even trace light that enters your eye can inhibit your pineal gland from producing melatonin, the substance that initiates sleep.

The Holistic Sleep Summit

If you have trouble falling asleep, or feel that you are not getting enough quality sleep and wish to do something about it, you might want to consider attending the Holistic Sleep Summit this coming March 5-8. It’s a live webinar featuring 27+ leading experts in the science of sleep. You do not have to drive anywhere, just have a computer and internet connection, and make sure your speakers are on.

Discover Simple Ways To Sleep Quickly And Soundly
Learn How To Be More Alert And Feel Well-Rested
Sleep Soundly All Night Long, The Easy Way
How to Sleep On Demand

This online event is free. It is structured like a professional course, with each expert speaking on a topic related to sleep. There are no sales pitches, just pure content. If you have pain, or don’t feel your best, quality sleep will help you feel and function better–mentally, emotionally and physically.

If you do attend, as I will as I am a big advocate of telehealth, please do me a favor and comment below to let me know what you thought of it. The mission of this site is to bring together the best minds in self-management of common ailments, and the Holistic Sleep Summit is just another form of telehealth that has the potential to improve the lives of many people via online health education and guidance. If you are plagued by insomnia, restless sleep, sleep apnea or simply have bad habits or addictions that interfere with your sleep, I hope you check it out because you just might find the solution to your problem.

Quick Exercises to Prevent Neck and Back Pain if You Sit Often

by Pain Doc | Feb 10, 2020 | Uncategorized

Did you know that by natural design, the human body is optimized for STANDING and WALKING, not sitting and lying down?

The evidence is longer and stronger legs for standing and walking compared to the arms. Your femur, tibia and fibula (leg bones) are longer and thicker than their counterparts; respectively the humerus, ulna and radius bones of the arm. Millions of years of evolution made our species homo sapiens develop this bi-pedal frame in order to survive and thrive. No other animal as far as we know has a frame like ours.

But there’s a problem: the bipedal design of man evolved during a time when there were no desks, computers and automobiles whose operation is better suited for sitting. Back then, there was only rough terrain to walk for miles in order to seek shelter and food. There was fast prey to subdue by foot in order to not starve.

Fast forward to today: just about all occupations these days involve using a laptop. White collar jobs, and increasingly blue collar jobs require sitting at a desk. Sitting is required for operating airplanes, trucks, and cars. To add to the problem, food is plentiful; overall less nutritious and higher in calories — no need to walk that much (expend calories) to get it while it packs on the pounds. Humans are much heavier than they were millions of years ago, on average, and it’s not due to muscle. This makes standing less tolerable, and makes sitting feel better on our feet.

ape to human

So the combination of frequent sitting and weight gain, which places more pressure on your joints, is a harmful combination that leads to pain and injury, affecting tens of millions of people. Osteoarthritis is the gradual degeneration of the joints, particularly the weight-bearing joints (hips, knees, feet, lumbar spine) and it is hastened with obesity and sedentary living.

Here are the detrimental things that happen in your body when you sit for prolonged periods throughout the day:

The pressure to your lumbar discs increases. Sitting removes back support from your legs, pelvis and abdominal muscles, which contract less when you sit.
Your postural muscles turn off somewhat, and as a result you burn less calories. Some studies connect this to a rise in bad cholesterol levels in the blood.
When you bend your neck to look at a monitor screen while sitting, it creates forward head posture. This strains the neck and upper shoulder muscles, and compresses the neck vertebrae; hastening osteoarthritis in the cervical spine. It can even cause tension headaches.

Sitting is an inescapable part of life. The key is to compensate for it by standing and walking when you can. Neutralize its effects. There are many ways to do this while living a modern lifestyle: walk to work, walk during lunch breaks, take the stairs instead of escalator, and do 15-minute workouts right in your office or work area, to name a few.

Drs. Brent and Tiffany Caplan, integrative medicine practitioners based in Ventura, California recommend the following simple stretches to do to counteract sitting:

Let’s talk about creep. No, I am not talking about a person unwelcomely staring at you all night from across the bar. I am talking about a constant load of stress applied to soft tissues (muscles, ligaments, fascia, discs) over an extended period of time resulting in a progressive deformation of those soft tissues. This can lead to muscles or ligaments changing their functional resting length and adaptively shorten or lengthen. These imbalances will lead to degeneration of your spine and will also set you up for future injuries. Creep to your intervertebral discs, the cushion between each spinal segment, may cause them to deform eventually leading to a herniated disc.

A common position that we are constantly in, as working professionals or students, is sitting. The sitting position, especially if in a poor slouched posture, puts an overload of strain in your neck, mid back, and lower back. It may also affect how well you are breathing. Poor respiration will lead to a decrease in oxygen supply to your body and brain!

So now that we know about creep and sitting how do we prevent it? The answer is simple. You should not sit for more than 20 minutes without taking a micro-break. These include Brügger’s relief position and the standing overhead arm reach. No pain should be felt during these movements. These movements are beneficial if you have any back or neck pain or want to support your spine and prevent any degeneration or future injury.

Bruggers exercise

Brügger’s relief position:

Do while standing or sitting on the edge of your seat.
Relax arms at side and turn palms outward, spread fingers, bring shoulders down and back, tuck your chin (attempting to make a double chin, not looking down but straight ahead).
Now exhale repeatedly as if trying to make a candle flame flicker but not go out. Be aware to make sure you are stomach breathing and not chest breathing. (To test this put one hand on your chest and one hand on your stomach. You should feel your stomach rising up and down as your inhale and exhale but your chest should remain still).

Do this for 10 seconds every 20 minutes.

standing overhead arm stretch

Standing overhead arm reach:

Stand up and gently raise both arms above your head with palms facing forward and elbows slightly bent.

Take a deep breath in through your nose and hold the breath while reaching up as high as you comfortably can (a stretch should be felt in your lower back).
Hold for a couple seconds then release the breath through your mouth and go back to the starting position.

Do 10 repetitions every 20 minutes.

Now you’re done and your micro-break only lasted 30 seconds, totaling a mere 1.5 minutes per hour, to maintain your health and prevent spinal injuries.

Dr. Brent Caplan & Dr. Tiffany Caplan
Central Coast Center for Integrative Health
1730 S Victoria Avenue, Ste 230
Ventura CA 93003

What Is Scar Tissue, and How Do I Get Rid of It?

by Pain Doc | Feb 5, 2020 | Uncategorized

The human body has magnificent intelligence to monitor, maintain, and repair itself 24/7. These complex, biological functions are the result of millions of years of evolution and of course play a major role in the survival and thriving of our species.

But even nature has its faults. When it comes to injury repair, the body’s repair mechanisms can inadvertently create a new set of problems.

When you sustain tissue damage, whether from sudden trauma such as spraining your ankle or gradual trauma such as a cumulative/repetitive tendinous strain or joint wear and tear, your body initiates a cascade of events to heal the injured tissue.

First, clotting factors appear and thicken the blood to stop any bleeding (hemostasis). This is a complex chain reaction that involves many types of substances, each with a specific role. Some clotting factors make blood vessel walls more permeable, allowing fluids to exit around the area and accumulate into the extracellular (outside the cells) spaces. This is why edema, or swelling occurs following an injury. The purpose of swelling to quarantine the injury site by creating a wall of pressure around it. The swelling also contains noxious substances (“the inflammatory soup”) such as substance p and arachidonic acid that produce pain and therefore discourage movement, protecting against further damage.

While this is happening, cells called fibroblasts start laying down a net of protein fibers called fibrin around the damaged tissue, which could be skin, muscle, bone or organ.

hemostasis

This fibrous net catches red blood cells, which stack up and form a fibrous blood clot, plugging damaged blood vessels and filling in the space formed by the injury. The fibrous clot gradually contracts, hardens and pulls damaged tissues together. The blood clot material eventually thins out, falls off, and may even be picked off by the person. Underneath, the reparative collagen fibers remain, forming what we call scar tissue.

stages of wound healing

You can observe this process if the injury is superficial such as a gash in the skin, but this process also happens in ligament, tendon, muscle and bone tissue injuries where there is no damage to the skin above. If it was a paper cut, you may not see a scar, but if it was a gash/laceration, when it finally heals you will see a scar.

scar on hand

Upon close inspection, the scar is lighter in color, feels harder, and is raised. Now imagine this scar tissue in the ligaments and tendons of a healed sprained ankle, knee or shoulder where there is movement and proximity to other structures such as bone, muscle, bursae, and nerves.

scar tissue illustration in underlying soft tissue injury, not visible from outside

Unlike the scar tissue of a skin gash, which does not take much physical stress to it, ligaments and tendons by nature are subject to frequent movement and stress (bearing a load). They are components of all joints in your body, and the function of joints is movement and generating force. So, excess scar tissue in deeper muscle, ligaments and tendons present potential problems, described next.

Going back to the repair process, as the fibroblasts continue to lay down strands of collagen, they do so in a random, criss-crossed pattern forming the scar tissue. It’s tough and dense, which is good for repairing, but can also pose a problem in a couple of ways.

First, the criss-cross pattern of scar tissue makes it less elastic (stretchable). So after it heals, and the area is later subject to substantial stress, the scar tissue will give, and you’ll have a re-injury. This explains why boxers easily get flesh cuts after getting hit in the right spot—it’s an area of scar tissue from a previous cut that “broke” upon absorbing stress forces. Fibrosis is a term that describes pathological scar tissue; i.e. abnormal scar tissue deposition that causes disease/dysfunction such as pain and restricted movement.

scar tissue matrix

Second, the very dense nature of scar tissue can cause pain receptors to bunch up around it, as they cannot penetrate it. This makes the injury site sensitive after healing completes, and contributes to the pain becoming chronic (recurring). Small, focalized areas of pain are called trigger points, as they can trigger pain in other areas when pressed.

Third, scar tissue build up constricts blood vessels, which compromises waste removal from the area and inhibit oxygen delivery to the area. In some cases, this results in chronic, low-grade inflammation, which contributes to pain sensation.

Fourth, the body may try to stabilize scar tissue by calcifying it. Calcium ions in the blood deposit on the scar tissue, hardening it and making it have rougher edges, which can cause restricted and painful movement. This is common in chronic shoulder injuries.

calcific tendonitis

The bottom line is that scar tissue is essential to healing, but due to the aforementioned reasons it may also lead to pain chronicity, whether it is an acute onset sprain/strain injury; a cumulative strain such as tennis elbow; or pain from tissue degeneration such as hip osteoarthritis.

So how does one fix chronic pain caused by excess scar tissue build up?

The Ideal Approach to Ensure Proper Soft Tissue Healing, Minimize Scar Tissue and Prevent Chronicity

The best defense is a good offense: immediately after an injury, follow the standard methods of treatment: apply cold directly to the area; add some compression, elevate the area if possible to help prevent excessive swelling/edema, and rest the injured area for at least two days. If the pain is unbearable, you can take over-the-counter anti-inflammatory medications (non-steroidal anti-inflammatories like Tylenol and Ibuprofen) but I recommend trying to just stick with ice if you can, and tough it out.

r.i.c.e. graphic

As the acuteness subsides, you can introduce passive movement of the injured area. This stresses the ligaments and tendons just enough which causes the fibroblasts to lay down the scar tissue collagen fibers in a more organized fashion, which will result in better healing/ quality of healed structures.

shoulder rehab

Then, perhaps on the third day do active movements of the injured area, then a week later, active-resistance movements (weights, resistance bands, swimming pool) to stress the structures in a controlled fashion, encouraging quality remodeling of scar tissue. You may need assistance from a rehab specialist to gauge how much resistance to use, and when.

And finally and ideally, your injury will be 100% healed, without loss of strength or range-of-motion.

What to Try if You Did Not Rehabilitate Your Injury Properly and Have Chronic Pain and/or Stiffness

But what if you didn’t do all of this, and now your pain is chronic, a year after the injury or onset of pain? Scar tissue could be the main culprit: limiting mobility, getting re-injured, attracting pain-sensing nerve endings (forming trigger points), and constricting arterial, venous and lymph flow to and from the injury site causing chronic, low-grade inflammation.

infrared heat lamp for knee

Will heat do the job? Heat such as that delivered by a hotpack vasodilates blood vessels close to the skin. If you use an infrared heat lamp, you could treat deeper areas such as the hip. This may help your chronic injury feel better, as more circulation means more oxygen, nutrients, proteins and other substances that benefit cells. But heat doesn’t do much to that hard, rigid scar tissue. Heat offers temporary relief.

TENS treatment for pain

Will electrical stim (TENS) help? Devices like TENS that deliver an electrical current to the skin transcutaneously (through the skin) can be helpful in temporarily reducing pain perception, but they do nothing to address scar tissue.

pulsed emf

Will pulsed EMF help? Pulsed EMF uses magnetic fields to generate pulses of electromagnetic energy. PEMF has been used since the 1950s to help heal broken bones. Scientists know that biological tissue reacts to electromagnetic fields. They affect cell membrane permeability and gene expression, which can have beneficial effects such as reducing inflammation and synthesizing functional proteins. PEMF may make chronic pain feel better, but it does not have any therapeutic effect on scar tissue itself.

therapeutic ultrasound

Will therapeutic ultrasound help scar tissue? Ultrasound (not the kind used for imaging) is the delivery of high frequency sound waves through the body to generate heat. Ultrasound is popular for treating deep joint structures, particularly the shoulder (glenohumeral joint), hip and knee joints. Unlike topically-applied heat, ultrasound heats from the inside of the body. Sound, physically, is reverberating pressure waves traveling through a medium. When the ultrasound waves pass through the skin and strike something of higher density; i.e. tendons, ligaments or bone, it generates heat, just as rubbing your skin really hard will generate heat. The pressure waves of the ultrasound may be strong enough to loosen some of the scar tissue fibers as well, making it a good choice for treating chronic joint pain.

active release therapy

Will massage therapy help? It can, depending on the nature of the scar tissue. It’s most effective in reducing fibrosis if started during the sub-acute phase, and continuing past the remodeling phase of tissue healing. Massage is known for its soothing/relaxing effect, but it is also appropriate for soft tissue injuries, particularly myofascial release/ trigger point release, deep tissue massage, instrument-assisted soft tissue therapy, and Active Release technique. These methods are more accurately described as “soft tissue mobilization” techniques and involve placing pressure into areas of scar tissue to break them up, stretch them as they are being laid down by fibroblasts, or to separate scar tissue adhesions—points where scar tissue binds to other structures.

There is another modality that is not well-known to most people that has a high success rate in treating chronic tendinopathies due to scar tissue fibrosis: extracorporeal shockwave therapy (ESWT), or shockwave for short. Shockwave uses pulsed, high energy acoustic (sound) waves delivered right through the skin to physically break apart/ thin out underlying scar tissue. You may have heard of how doctors can dissolve kidney stones using a machine that sends waves through the skin all the way to the kidney stone, without surgery, called lithotripsy. This is precisely extracorporeal (meaning “outside the body”) shockwave therapy.

Shockwave treatment is often described as “ultrasound on steroids” since it uses sound pressure waves, but at a lower frequency and higher energy. Think of thunder, clapping hands, and a jet breaking the sound barrier.

shockwave treatment for plantar fasciitis

When a shockwave enters living tissue and encounters changes in tissue density or impedance (such as from fat to muscle) it will either be reflected, refracted, transmitted or dissipated just like any other wave. According to the site Shockwave Therapy Education, energy is released at these interfaces of different impedance values, creating compression and shear loads on the surface of the material with the greater impedance (mostly scar tissue, tendons, and ligaments), like very tiny explosions.

The energy released by shockwaves causes microtrauma (tissue destruction), which triggers the reparative process: new blood vessels form (neovascularization) and fibroblasts secrete collagen fibers in a more organized fashion, replacing the old, disorganized scar tissue. Blood flow improves, and the old, chronic injury undergoes new healing and heals more completely the second time around. The restructuring of collagen fibers results in less nociceptors than when fibrosis was present, and the result, after a brief soreness following the microtrauma, is less pain.

effects of eswt on scar tissue

Conditions Extracorporeal Shockwave Therapy is used to treat include:

Plantar fascitis
Epicondylitis
Trochanteric bursitis
Dupruyten’s contracture
Carpal tunnel syndrome
Achilles, patellar and other tendinopathies
Post surgical scar tissue fibrosis

Below are video fluoroscopy images of ESWT breaking apart a calcaneous (heel) bone spur:

image of eswt breaking off heel spur

TYPES OF SHOCKWAVE MACHINES

There are two, main types of shockwave machines, ballistic and piezoelectric. In a ballistic machine, a small pellet is accelerated back and forth inside a metal tube by strong electromagnets or by compressed air. When the pellet strikes inside the end of the metal tube (strikeplate), it produces a radial shockwave. This type of shockwave is considered low-energy, as the shockwave dissipates and expands radially as it enters and travels through tissue.

illustration of radial shockwave

A piezoelectric machine uses an array of tiny crystals at the end of a concave treatment head. An electric current is passed through the crystals, which causes them to quickly expand and contract, generating pulsed acoustic pressure waves. A silicone cone attachment is affixed to the treatment head to conduct, focus and direct the shockwaves produced by the tiny crystals.

piezoelectric extracorporeal shockwave treatment head

The shape of the cone attachment and the output voltage determine the depth to which the soundwave travel. Piezoelectric machines are considered high-energy, as the acoustic wave is focused into a small area and does not dissipate much. These machines therefore are used with more caution.

BOTTOM LINE:

Scar tissue is like biological “glue” the body uses to repair injuries to itself, but it can cause problems long after the injury heals. Scar tissue fibrosis is a mass of hardened protein strands laid down haphazardly by fibroblasts at the injury site. It is often a factor in chronic musculoskeletal pain. It develops in injuries, such as shoulder and knee strains, and is worse if the injury is not properly treated/ rehabilitated. Scar tissue perpetuates chronic pain by inhibiting proper movement of soft tissue structures– tendons, ligaments, fascia and muscles, which can cause abrasion to adjacent tissues; inhibit vascular flow to the area; and cause sensory nerve endings to bunch together. Extracorporeal Shockwave Therapy (ESWT) is a treatment that uses high-energy pressure waves to break down scar tissue fibrosis so that new, organized fibers can replace it; abrasion and congestion are reduced, and movement and strength are improved. It is a highly-effective modality for tendinopathies and similar musculoskeletal diseases, with some studies finding an 80% success rate.

For more a more in-depth explanation of how extracorporeal shockwave therapy works, watch my interview with Dr. Ulyss Bidkaram, a chiropractor who uses ESWT in his practice:

REFERENCES:

Shockwave Education

http://www.shockwavetherapy.education/index.php/theory/biological-effects

Angela Notarnicola and Biagio Moretti. The biological effects of extracorporeal shock wave therapy (eswt) on tendon tissue. Muscles Ligaments Tendons J. 2012 Jan-Mar; 2(1): 33–37.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666498/

Semra Aktürk,1,* Arzu Kaya, et al. Comparision of the effectiveness of ESWT and ultrasound treatments in myofascial pain syndrome: randomized, sham-controlled study, J Phys Ther Sci. 2018 Mar; 30(3): 448–453.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857456/

Image credits:

https://www.biodermis.com/what-are-the-stages-of-wound-healing-s/221.htm

http://www.shockwavetherapy.education/index.php/theory/biological-effects

https://www.verywellhealth.com/what-is-rice-190446

https://www.pediagenosis.com/2019/10/exercises-for-range-of-motion-and.html

https://www.verywellhealth.com/what-is-rice-190446

How to Fix Sudden Onset TMJ (Jaw) Pain

by Pain Doc | Dec 21, 2019 | Uncategorized

I think we’ve all had an incident of one-sided jaw pain at some point, where it’s difficult to open and close the jaw without experiencing sharp pain. I’m not referring to chronic TMJ pain related to malocclusion (called TMD—temporomandibular joint dysfunction); I’m referring to those isolated incidents that happen to everyone on occasion. This condition can be caused by chewing hard/tough food requiring stronger than usual jaw muscle contraction; chewing a large piece of food on one side of your jaw; teeth grinding, and of course trauma to the jaw such as from boxing and other contact sports. The TMJ can also be misaligned from rear-end collision car accidents (acceleration-deceleration), as the force of impact is enough to violently hyper extend and flex the TMJ. Some cases of sudden onset TMJ pain self-resolve, but in other cases it can last for weeks, which can obviously be a nuisance as chewing food becomes uncomfortable.

tmj diagram The jaw, or temporomandibular joint is classified as a synovial, condylar joint. Joints are named after the two bones that comprise it, so the TMJ is formed by the articulation of the mandibular fossa (depression/pit) of the left and right temporal bones of the skull and the left and right condylar heads of the mandible (lower jaw), hence temporomandibular joint. It could have been named the “mandibulotemporal joint,” or MTJ, but someone long ago decided temporomandibular sounded better.

TMJ movement is very complex, involving flexion, extension, rotation, translation and oblique movements. These movements are accomplished by varying- magnitude, combined contractions of the temporalis, masseter, medial pterygoid and lateral ptergoid muscles controlled by the central nervous system, including nuclei in the brainstem. So, the simple act of chewing is neurologically complex; perhaps the most complex out of all the joints in the body.

Synovial means that the joint is encapsulated by ligaments and has an inner tissue lining called synovium that produces synovial fluid, a clear viscous fluid that reduces friction in the joint, very much like how motor oil reduces friction between a car engine’s cylinders and pistons. Not all joints are synovial, such as the acromioclavicular (AC) joint of the shoulder which is a fibrous joint; only the joints that are tasked to move frequently and have a comparatively larger range of motion i.e. knees, hips, shoulders, fingers, etc. The TMJ also has an articular disc, a thin slip of tissue that sits between the mandibular heads and temporal bone that provides cushioning/ shock absorption. Since the TMJ is a heavily used joint, nature added this extra protection. Just imagine the number of times the TMJ extends and flexes (opens and closes) in a typical day, from talking and eating!

So what is going on when you have one-sided jaw pain when you previously didn’t? The answer is that the jaw is slightly misaligned and the resultant, abnormal movement is pulling excessively on the soft tissues of the affected side and/or the condyle is pressing against the mandibular fossa excessively, firing surrounding nerve endings. Muscle spasm reflex of any of the aforementioned jaw movement muscles may also be contributing to the pain by maintaining the misalignment in place. TMJ misalignment is typically subtle and not usually visible, but sometimes you can see it if you open your mouth in front of a mirror. If you notice your mouth opening forms a tilted oval shape as opposed to an even oval shape, it means your mandible is deviating to one side due to TMJ misalignment. Usually, the mandible deviates to the same side of the misalignment/jaw pain, but not always.

To restore alignment and balance to your TMJ, try this:

picture of mandible

Relax your jaw. This may sound easy, but for some people, especially those who subconsciously tend to clench their jaw, it is not. Just concentrate on your jaw and facial muscles, commanding them to let go. Your mandible should drop slightly so that your teeth are not touching at all.

Next, with your jaw still relaxed, using the palm of your hand on the side opposite to the painful side of your jaw, tap the opposite side of the jaw (the side of the jaw bone, not directly on the joint itself) firmly three times. Pause for ten seconds, then do it again. Wait for a couple more seconds, and see if you notice reduced pain. If pain is less, it means the TMJ settled back into alignment and the pain should start to go away and should be gone in about an hour or two. If not, tap obliquely at an upward angle towards the affected joint, then re-evaluate. If you notice the pain lessens, then that’s it—just wait a little longer, and the pain will disappear and your jaw will be back to normal.

If there is no change, try this: with your jaw still relaxed place your hand to the sides of your face with the tips of your index fingers directly on top of the protuberances of the condylar heads of the mandible and your thumbs cradling the back of the jaw bone (ramus). Alternately press gently inwards with your index fingers for a total of six times (three on each side). Then, using your thumbs gently pull the jaw forward three times. You can also gently push your jaw side to side alternating sides, three times per side. I need to emphasize that you must keep your jaw totally relaxed while you do this; otherwise it may not work.

Watch this video where I demonstrate these simple moves:

If you find that you get one-sided TMJ pain quite often, you may have malocclusion of your bite. Make sure to see your dentist/ orthodontist.

Sometimes TMJ can trigger headaches. If you have both, fixing the TMJ misalignment is likely to fix your headaches.

How to Slow Down Joint Degeneration from Aging

by Pain Doc | Dec 11, 2019 | Uncategorized

Do you notice that it takes more effort than before to do simple things like run, squat, or get out of your car? You can still do them, but not as fast and springy as when you were younger. If you’re over age 40, it’s likely you can identify with this.

The inevitable reality of being mortal is that our body starts to deteriorate after maturity, which is around age 21. For those who “age well” the deterioration rate progresses slowly and is hardly perceptible until the later years; for those who do not age well, the changes can occur relatively fast and are obvious.

The main musculoskeletal changes associated with aging are:

Muscle atrophy, especially in the upper leg and glutes
Decreased muscular strength and endurance
Decreased cardiovascular endurance
Decreased ligament and tendon elasticity
Decreased joint cartilage thickness and suppleness
Increased body fat percentage

The focus of this article and following ones will be on slowing down the gradual breakdown of the musculoskeletal system via exercises, stretches, diet, new habits and routines and other lifestyle modifications. Yes, slowing down the aging process and extending your “full functional” years is very possible if you have a good plan, and diligently stick to it. In other words, start developing good wellness/ life extension habits if you haven’t done so already.

In this article, the topic is joints. I previously wrote about the importance of keeping your joints strong by doing specific joint exercises during your workouts. This discussion is on doing daily joint stretches to counter the degenerative forces that come with aging.

One of things most people first notice as a sign of getting older is decreased ability to absorb and rebound from external forces and mechanical stress. You start to notice that it takes a bit longer to jump up from a seated position and get up after falling. You find it more difficult to bend, squat and maintain other awkward body positions. If you trip and fall to the ground, it takes more effort to get back up. And, when running you notice that you can feel the shock in your knees more, and therefore do not run as long, or give it up entirely. The reasons for this are decreased muscle strength, decreased ligament and tendon elasticity, and most of all, thinning cartilage in the weight-bearing joints. It takes more energy and effort to do these things because your body “hardware” has lost some of its youthful, structural integrity. Your mindset /motivation to move may be unchanged but your body isn’t responding as quickly and strongly.

As you get older, the cartilage lining your synovial joints (the joints encapsulated by ligaments) loses fluid content. To compound matters, when you are past the age of 40, human growth hormone (HGH) secretion by your pituitary gland practically ceases. HGH is the “fountain of youth” hormone that is largely responsible for the features associated with youth: energy, high metabolism, supple skin, thicker muscles and thicker, bouncier cartilage. It’s why younger people can bounce right back up after falling down, making it look effortless.

If you are over the age of 50 and your occupation or recreational interests involved placing pressure on your feet, knees, hips, spine, shoulders, elbows or hands chances are you are experiencing aches and stiffness. Your age, plus your history are not doing your weight bearing joints any favors. So what can you do?

If you are over the age of 40 and feel the slightest stiffness in your joints, I highly advise you start a daily routine to keep your cartilage healthy. Your goal is to effectively counter the natural progression of osteoarthritis—the disease that involves advanced thinning of cartilage, bone-on-bone contact, and resultant chronic inflammation and joint dysfunction (stiffness, pain, reduced range of motion). It plagues millions of people over the age of 50. Practically all former football players have osteoarthritis.

By investing just a couple of minutes a day every day, you can literally save yourself years of pain down the road, and perhaps preclude the need to take harmful anti-inflammatory medications and even the need to get knee and/or hip replacement surgery. Instead of pain, you will be able to squeeze out a decade or more of pain-free movement. That is a huge, quality of life issue because most of the enjoyable things in life require some degree of physical fitness—walking, bending, lifting etc. and joint pain can severely restrict your ability to engage in these activities.

In my view, in order for a preventive measure to be feasible, it must meet the following criteria:

It must be practical, with minimal preparation required
It must be realistic – no super-human feats required
It must address the problem and have close to immediate results

Here is the basic routine that I personally do every day to guard against cartilage deterioration. I will update this post with a video that illustrates these exercises, but for now, here is the description so that you can get started right away:

Arm propellers – slowly and with focused intent, make large circles with your arms, with the left arm moving counter-clockwise and the right arm clockwise, crossing in front. Keep the angle of your upper arm about 30 degrees relative to the coronal plane of your shoulder to avoid jamming your shoulder joints. Do about 20 rotations, and then reverse directions of both arms.

This exercise moves the glenohumeral (GH) joint, where your upper arm (humerus) articulates with your scapula. Many people don’t realize that in a typical day, they rarely raise their arms above shoulder level. This prevents areas of the GH joint to get proper lubrication, causing the cartilage to “dry out.” This exercise exposes all parts of the cartilaginous-lined humeral head to synovial fluid, the “motor oil” of joints and even stimulates production of it. The rigorous movement also stimulates lubricin production, a compound that further reduces friction inside the joint.

Elbow propellers – similar to the arm propellers, rotate your lower arm (forearms) in opposite circles by keeping your upper arm relatively stationary so that most of the movement is at the elbow joint. There is some movement in the GH joint, but also some in the radio-ulnar and humero-ulnar joint. Do 20; reverse directions.

Wrist stretches – interlace fingers as if to pray, then alternately pronate and supinate the hands while making a circular motion, stretching the wrist joints in all directions.

Finger flexion and extension – make loose fists with both hands, and then unfold the fists segmentally (extend the fingers) first at the metacarpal-phalangeal joints (knuckles), then proximal interphalangeal joints, and then the distal interphalangeal joints until your hands are flat, fingers fully extended. Then, reverse the process (flex the fingers segmentally) back into a fist. Repeat about ten times.

Collarbone stretches – this mobilizes the sternoclavicular (SC) joint, where the proximal clavicle articulates with the sternum (breast bone). The joints are identified by the two, large bony protuberances at the base of the neck. For this exercise, make a shortened swimming stroke with your arm: bring it backwards, raise it up for the stroke and with elbow bent about 90 degrees, make a big scooping motion downwards, reaching all the way back (palm of hand should be facing upwards), and then supinate your forearm and repeat the motion. You will probably hear some grinding noises in your SC joint as it moves. Do about 10 repetitions; switch sides.

Torso circles – This nicely moves the joints of the lumbar spine in a stirring motion—the facet joints and the intervertebral discs, forcing their hydration. Place feet about two feet apart and place your hands on the sides of your pelvis. Hinge at the hip joints (bend torso forward and down, being careful to contract your back muscles for support) and then move your torso in a large, counter-clockwise circle reaching the maximum lumbar active range of motion in all directions of the circle. Do ten circles; reverse directions.

Lumbar extensions – I recommend doing these especially if your job involves prolonged hours of sitting, such as a desk worker, airline pilot, or truck driver. Sitting flexes your lumbar spine, which encourages posterior disc migration, a risk for herniated discs. Simply place the palms of your hands behind you, just below your waistline. Then, lean backwards and bend over your hands (try to keep them stationary in space), arching your back and hold for two seconds. You should feel tightness in your low back. If not, bend back some more. Return to neutral. Do 10 repetitions.

Hula hoops – this targets your hip joints by moving your pelvic bowl around the femur heads. With feet shoulder length apart and hands on your sides, make big circles with your pelvis like a hula hoop motion. You should feel your hip joints moving even though your legs are stationary. By doing this, you bathe all areas of the femur heads and stimulate synovial fluid production.

Knee circles – the knees move mainly as a hinge joint (flexion and extension) but there is some ability to rotate and translate (move in a circular motion and side to side motion). With feet together touching, bend your knees bout 30 degrees and place your hands around them. Move your knees together in a clockwise direction 20 times; reverse direction.

Ankle circles – point your toes to the ground, and flex them against the ground by placing light, downward pressure. Then, move your ankle in a clockwise direction keeping your toes in place. This moves the many articulation points of the ankle, as well as the joints of the forefoot: metatarsal-phalangeal joints and interphalangeal joints.

BOTTOM LINE: As you age, your joint cartilage loses its fluid content and starts to get stiffer. If the joint doesn’t get much movement, it compounds the problem. You can arrest this process by diligently doing these exercises to ensure all your joints are tasked to move, which signals the body to produce more joint fluids.