Re: Recovery question

[Guest guest]

Jim,

Good luck with your recovery. I have some thoughts...but let me see

if I have it right...

You had onset of acute pain in the upper trapezius area ~2 weeks ago,

following overtraining and physical therapy, superimposed on possible

chronic changes from old injury. Pain is shoulder girdle/upper trap,

and arm. Current treatment consists of heat, pain meds, muscle

relaxants, and gentle exercises. Prior history of rotator cuff tear

and clavicular fracture.

Okay?

My own questions:

Is the pain reproduced or increased with neck range of motion?

What is the exact distribution of pain in your arm? Is is constant or

intermittent?

Do you have any numbness and tingling?

Can you sleep on that side? And are able to sleep?

From my point of view:

> 1) The doctor said the spasm was painful due to lactic acid buildup

in the trap. This statement was made two weeks after the acute onset

and there had been no improvement during this time. It seems strange

to me that lactic acid would accumulate and stay in a muscle for that

period of time. Is the doctor correct in his statement?>

Nope. Pain of this nature is likely due to the inflammation and

stimulation of pain fibers in the area. Another scenario is that

it's all referred pain from another source, i.e. your neck. But the

issue is still inflammation. Tissue trauma causes release of enzymes

and neurotransmitters and neurofacilitators which mediate

inflammation. The arm pain, as you said, could either be referred or

local.

>Is there something I don't understand about lactic acid? I

thought it accrued during intense exercise and dissipated over a

reasonable period of time following the exercise.<

You got it (though there's stuff we don't know about a lot of things,

perhaps including lactic acid). Lactic acid accumulates during heavy

exercise and is not implicated in the inflammatory process as far as

I know. The exercise physiologists with us can explain better than I

can the role that lactic acid plays in production of short term

energy.

>Do ice packs applied four or five times a day prevent the

dissipation of lactic acid?<

I don't know of any studies that discuss the effect of cold on lactic

acid following exercise. Lactic acid production and " removal " is an

oxidation-reduction reaction. Lactic acid is produced during

exercise. During recovery the lactic acid gives up hydrogens and is

oxidized back to pyruvic acid. Don't know what affect cold has on

this...Anyone else?

>Does a TENS unit create an accumulation of lactic acid?<

REALLY unlikely. The intensity of the TNS unit stimulation would

have to be incredibly great so as to cause maximal muscle

contraction, repeatedly. I don't know many folks who could stand

that. Nor do I think the TNS unit, per se, could cause THAT great a

contraction. Maybe...I'm not gonna test it though.

>Does heat dissipate lactic acid as the doctor suggests?<

Heat will cause tissue temperature elevation, which causes

vasodilation. There's less resistance to blood flow if the vessel is

opened more. So I suppose you may move the blood lactate around more

readily. But I don't think the lactic acid is the problem here.

<Does the spasm itself continually generate lactic acid?>

If a spasm is unrelenting and the muscle runs out of oxygen I guess

that could happen, but muscle spasms are usually transient/

intermittent, and in response to movement. I think the pain you feel

has other generators.

> 2) What role does cortisol play in all of this and does perhaps the

doctor actually mean a cortisol buildup or crash (as opposed to

lactic acid) causing the pain at the site of the injury?<

Cortisol is increased in heavy exercise. According to my exercise

phys book (McArdle, Katch, and Katch, c1996), cortisol levels can

stay up as long as 2 hours following exercise. Looking at what

cortisol does I don't see any reference to it's role in pain

mediation.

>Is it correct not to use ice on a muscle spasm? What about when

it's no longer in spasm and starting to heal -- is it okay to use ice

at that time?<

I use ice on muscles that tend to go into spasm, cuz cold application

tends to slow down nerve conduction velocity and will quiet the

neurological drive behind the spasm. Also if there's still obvious

inflammation and the patient tolerates, I'll have him/her ice. With

trigger points (versus generalized inflammation following injury),

I'll have them apply heat followed by gentle stretching, or vice

versa.

>The doctor's course of treatment outlined above is beginning to offer

modest relief. What is right about his course of treatment and what

is not, e.g. what do members of the list feel is the best way to

facilitate the rapid healing in this type of overuse injury?<

If what you're doing is working keep it up, but I don't think it's

working for the reasons your doctor thinks it is. Sometimes I think

doctors, etc., give us answers they think we'll understand, even if

they're not exactly correct. Or maybe he believes all that stuff,

but I don't have the same references he does.

What I'd do as a PT is evaluate your neck...make sure it's not the

source, or at least contributing to your symptoms. If the neck is

fine, then I'd check the shoulder itself.(Were your prior shoulder

injuries on this same side?). I'd then look at the surrounding

musculature for inflammation and trigger points, and treat

accordingly. For an acutely inflamed injured tissue I'd like to see

my patients on a short course of anti-inflammatories (NSAIDS, etc.)if

they tolerate. Then I'd treat to decrease the inflammation while also

having the patient do gentle ROM /stretching to prevent adaptive

shortening. I haven't had much luck with muscle relaxants. Pain

meds for sure if they're helping, especially if they're useful in

getting a normal night's sleep, which is critically important, and I

think really overlooked even when we're not recovering from injury,

but I digress...

For trigger point treatment I typically do heat (packs, or ultrasound

for it's heating capacity) and gentle stretching, and soft tissue

mobilization. I also use Spray and Stretch a la Travell/Simons.

>Are there any supplements that help in reducing lactic acid and

cortisol following a workout? Are there supplements that make it

worse?<

Great question for which I have absolutely no clue.

>Any exercise suggestions for rehabbing a muscle spasm in the

trapazius?<

In addition to the above, gentle side bending (ear to opposite

shoulder) while keeping the affected shoulder girdle down will help

stretch the upper trap. Keep your chin slightly tucked. If this

causes increased pain down the arm, check it out with someone first.

Remember the neck can certainly cause shoulder girdle and arm pain.

Watch your posture...a forward head position puts increased stress on

this muscle. I'd recommend holding off on strengthening until you

have no pain.

Good luck. If you don't continue to improve, I'd see someone...a

good PT... but of course I'm biased! And, just a caveat, " this

should in no way take the place of the advice of your physician or

health care provider " . Be careful; advice to friends, or over the

internet, shoud be given and taken with great caution.

Happy healing.

Betty Smoot (PT)

[Guest guest]

Den,

I had a three tier lower lumbar fusion w/fixation rods and cages in

1999. It's almost ten years out and I am still in some pain. Granted

it's not as much as before surgery, but some. Not sure if I will ever be

totally pain free. It took me about 2 years to begin to feel normal if

that is even a word..LOL

Tonja

apparitionalden wrote:

>

> Hi all. I posted a number of times already but wanted to pose this

> question for any who had a cervical spine fusion done. I had an

> anterior 4 level discectomy with fusion done on Dec 28th 2007. Three

> discs were replaced using cadaver bone and a plate screwed into levels

> C3 through C7. I wore a rigid collar for 10 weeks and have been

> transitioning out of it along with wearing my bone growth stumulation

> unit.

>

> All that said, I am finding the healing VERY slow. The incision is

> healed nicely and per xrays, the bone is starting to fuse-but I still

> have a good bit of pain and stiffness in the neck with " nerve like "

> pain shooting down into the shoulder blades....almost like before my

> surgery. My Neurosurgeon says this is normal, but I am still off work

> recovering after 12 weeks. I do have Crohns Disease which is an auto-

> immune disorder which will slow my healing, but wanted to know how

> quickly others of you have healed after C-spine surgery? Thanks in

> advance.

>

> Den

>

>