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Myofascial Pain| Causes

Please see my recently published article on Myofascial Pain on singaporedoc.com.
This article is very informative for patients seeking solutions for pain and muscle discomfort.  The pain public is looking for new safe and efficacious ways to help relieve their pain.
The population with discomfort “normal functioners” like us, is not aware that the symptoms are resulting from muscle tightness triggered by aging nerve roots (a ubiquitous condition).  This aging process is aggravated by activities of daily living, sports, work, repetitive injuries, cumulative trauma and accidents.
This ”normal functioners” population must be reached and educated to prevent the cascade into chronic pain.  These individuals usually do not seek medical care and will try alternative methods until it is frank pain and when pain becomes chronic and refractory, there is no cure and the expense and burden to society becomes far too great (In the USA, the cost is 635 billion yearly).  eToims is a safe and efficacious method suitable to help such patients with chronic refractory pain to achieve quality of life, nonetheless more difficult when the pain has become chronic.

Lower Back Pain| Teenagers

Lower Back Pain| Teenagers

Lower back pain (LBP) starts very early and many teenagers do have lower back pain.  If not treated appropriately, the back pain can become chronic.  Like treating lower back pain in adults, treatments should always start first with conservative treatments that are safe and efficacious.  It is of utmost importance that treatments can be safely repeated on a regular basis for those suffering from acute and chronic lower back pain so that the teenager does not have to endure the pain and suffering and loss of quality of life since lower back pain tends to recur.

In our own experience, many of these teenagers have myofascial pain due to chronic partial lumbosacral nerve root irritation from spinal disc degeneration.  Teenagers (mean age 14.5 years) with chronic lower back pain have been noted to have lower endurance in trunk extensors, hip extensors and quadriceps (1).  We agree with these findings and have also noted on examination, that these patients also have neck and shoulder tightness that must be addressed during treatment.

In a study of 1180 (20.5%) teenagers studied reported one or more episodes of LBP, of whom 900 (76.3%) had consulted a health provider.  Nonspecific LBP is a frequent event in teenagers, particularly in females, sedentary children and those with a family history of LBP (2)

Lumbar disc hernia in children and teenagers has 4 main causes: familial history, trauma, congenital malformation of the spine and disc degeneration. The symptoms in young patients are dominated by local or radiating pain, but neurological discrepancies rarely occur (3).

In surveys among children and teenagers as many as half of all children in a community report a history of low back pain. Causal relation exists between the early evolution of a degenerative process of lower lumbar discs and recurrent low back pain in the near future. Individuals with disc degeneration soon after the phase of rapid physical growth not only have an increased risk of recurrent low back pain at this age, but also a long-term risk of recurrent pain up to early adulthood (4).

References:

1. Bernard JC. Bard R. Pujol A. Combey A. Boussard D. Begue C. Salghetti AM.: Muscle assessment in healthy teenagers, Comparison with teenagers with low back pain.

Annales de Readaptation et de Medecine Physique. 51(4):263-83, 2008 May.

2. Masiero S. Carraro E. Celia A. Sarto D. Ermani M.:Prevalence of nonspecific low back pain in schoolchildren aged between 13 and 15 years.  Acta Paediatrica. 97(2):212-6, 2008 Feb.

3.  Burnei, G. Gavriliu, S. Vlad, C. Georgescu, Ileana. Hurmuz, Lucia. Hodorogea, D.:

Discal hernia in children and teenagers: medical, surgical and recovery treatment.

Romanian Journal of Internal Medicine. 44(4):477-81, 2006.

4. Salminen JJ. Erkintalo MO. Pentti J. Oksanen A. Kormano MJ.: Recurrent low back pain and early disc degeneration in the young.  Spine. 24(13):1316-21, 1999 Jul 1.

Myofascial pain|Mediate cause

More Americans suffer from chronic pain than those affected by heart disease, cancer and

diabetes combined, yearly costing about $635 billion for treatment and lost productivity.

“Given the burden of pain in human lives, dollars and social consequences relieving pain

should be a national priority” [ (1) Institute of Medicine of the National Academies, 2011].

At least 15-30% American adults currently experience regional musculoskeletal pain, eg. low

back pain (LBP), while 70-85% adults experience LBP sometimes in life. Most low back pain

episodes settle after 2 weeks but many have a recurrent course. Further acute episodes affect

20-44% of patients within one year in the working population with 85% experiencing lifetime

recurrences (Bone and Joint Decade Report, 2005). Due to myofascial pain’s high prevalence,

finding safe and efficacious methods for treatment is essential.

Presently compounding the chronic pain problem is the lack of effective treatments for its management (2) .

Chronic pain should be treated long-term similar to other chronic diseases such as diabetes, heart disease, hypertension, etc.  Treatments should be directed at the mediate cause of the problem from which neuromuscular pain arises.

Myofascial pain syndrome involves pain from myofascial trigger points (MTrPs or nervemuscle

junctions) in skeletal muscle, which appear characteristic. Nerves communicate with

muscles at such neuromuscular junctions. MTrPs appear localized taut bands with tender

points, which when compressed produce stereotypical referred pain patterns. Snapping

palpation of the myofascial band produces a local twitch response. A muscle twitch consists of

contraction, then relaxation.

One MTrP formation theory suggests that muscle trauma or strain causes damage to the

trigger point area, resulting in local, partial contraction of a muscle fiber at the MTrP, leading

to ischemia and pain. Another suggests spinal nerve roots age prematurely due to trauma,

induced by activities of daily living, sports, auto accidents, work and repetitive motion, injuring

or irritating involved nerve roots. This leads to muscle shortening or spasm that produces

intramuscular entrapment of nerves and blood vessels, with tension pulling pain sensitive

regions, such as bone and joint coverings.

Compression of intramuscular nerves and blood vessels or traction on bone and joint

coverings, causes pain.  It is more difficult to treat nerve related pain that produces tingling,

numbness, burning, throbbing, shooting or sharp pain.

Commonly, treating underlying etiologies responsible for MTrP activation involve procedures

that inactivate, disrupt or suppress MTrP activity. Such procedures include injections into

muscle trigger points or spinal nerve roots or oral medications. However, none of these

methods release muscle spasms formed in deepest muscle layers, closest to involved bones

and joints.

eToims® (Electrical Twitch Obtaining Intramuscular Stimulation Technique) excites deep MTrPs

by electrically locating the most irritable and active MTrPs, exciting them to generate muscle

twitches. Identification of such MTrPs, generating pathognomic twitches, relieves pain.

eToims promotes healing of irritable MTrPs through twitch elicitation, stretching problematic

tight and shortened muscle fibers (in spasm), releasing compression of intramuscular blood

vessels, including those involving their nerve fibers, and reducing traction on pain sensitive

structures. Consequently, twitch induced exercise also promotes local blood flow, improving

tissue oxygenation, promoting healing and removing local accumulation of pain producing

neurochemicals. The twitch, when an involved muscle is electrically stimulated to contract,

and then relax, ending pathologic muscle spasm, is diagnostic, therapeutic and prognostic.

Release of spasm relieves pain. Twitches are key to relief of myofascial pain or discomfort.

While exercises are often prescribed for nerve related muscle pain, if too many painful

muscles contract simultaneously, increase in pain can occur.  In presence of spasm induced

preexistent nerve and muscle ischemia, exercise increases ischemia, as well as increases local

accumulation of tissue wastes, both increasing pain. This helps explain activity related

fluctuation of symptoms commonly found with myofascial pain/discomfort. However,

focused, painless, pain relieving exercise can be done, one muscle at a time, with eToims.

In acute pain without underlying chronic neuromuscular problems, if eToims is begun

immediately, esp. within 24 hours, progression to chronic pain may be averted, leading to

possible cure in 1-3 treatments. It appears best to begin eToims when muscle symptoms

begin or are minimal, rather than wait until chronic pain/discomfort occurs, associated with

tight muscle spasm, causing ischemia. Individuals with deep-seated chronic myofascial pain/

discomfort may require chronic eToims treatments to relieve pain, similar to treatments for other chronic diseases.

(1) Institute of Medicine 2011: Relieving Pain in America A Blueprint for Transforming Prevention, Care, Education, and Research

(2) Dennis C Turk, Hilary D Wilson, Alex Cahana: Treatment of chronic non-cancer pain. Lancet 2011; 377: 2226–35

Chronic Pain| Railtrack Therapy|eToims

November  13, 2011

Prevention and capacity to be able to perform self treatment is the key to managing chronic diseases, especially chronic neuromuscular pain.  Also chronic pain needs regular and ongoing treatment.  All these features have been met in these videos, except of course the safety issues need to be addressed to:

Talk of self treatments and ongoing regular treatments for chronic pain.

http://www.youtube.com/watch?v=e-RLg6v6Mek

http://www.youtube.com/watch?v=Zca97nkMkHE

You can see the muscles twitching, a gross form of self treatments with  eToims.    I calculated the frequency which was right on target, low frequency stimulation in the range used in eToims indeed.

Twitching muscles works as shown here by proof of mass approval initiated and vouched by the very poor on their cohort study!  Since there is improvement in micro-circulation it worked for them not only for their arthritic symptoms but for other related illnesses such as stroke, hypertension and diabetes since these diseases are accompanied by the effects of aging nerve roots, tight muscles and poor circulation.  Railtrack therapy is just too dangerous for the average person or the person who can afford proper scientific treatment!

The article in the Lancet 2011 (1) shows you that there is little progress in the management of pain to date and the article (2) by the Institute of Medicine (2011) shows the huge expenditure of chronic pain in the USA (635 billion annually!)  and that pain management should be a priority because it is a public health issue.  There has been a huge surge in use of narcotics as pain killers in the USA as reported on the BBC recently.  http://www.bbc.co.uk/go/em/fr/-/news/world-us-canada-15548478.

The advantage of eToims is that it can treat not only chronic pain but able to treat acute and sub-acute pain and is useful for diagnosis, therapy and prognosis.  Additionally eToims is ideal for individuals without pain but has discomfort and wants the competitive edge to play, work and travel that meets their life-style.

Since eToims has physical rejuvenation effects through improving micro-circulation it can be used for its anti-aging effects in Aesthetic Medicine and Cosmetology also.  eToims is an ideal and complementary partner to looking good and feeling young.

eToims appeal to the mass market is huge because it is the only technology that can stimulate the deep trigger points and at the same time be safe and efficacious for repetitive long term use, even daily use and even multiple times daily.

There is no other technology to date that can provide this value for ROI.  eToims does not suppress pain like other methods, it treats pain at the mediate source and removes pain.

References:

  1. Turk DC. Wilson HD. Cahana A. Treatment of chronic non-cancer pain. Lancet. 377(9784):2226-35, 2011 Jun 25.
  2. Institute of Medcine of the National Academies: Relieving Pain in America. For more www.iom.edu/relievingpain

Sports | Strains| Sprains

Friday, June 10, 2011

These injuries occur when the muscles are weak and/or tight and made to contract in an abnormal position. Either the ligament is stretched excessively or partially torn (sprained) or the muscle or tendon is stretched or partially torn (strained).

In both situations, there will be pain, swelling, tenderness but if the pain and swelling is significant with excessive tenderness and bruising, fracture needs to be ruled out and x-rays of the involved joint will be necessary. Always have a physician check condition for the line of treatment needed.

General treatments involve resting, icing, compression and elevation of the involved limb. Support of the joint may be needed with a light brace or cast. However, movements and partial weight-bearing should begin by the second day. Remember that healing may be take 6 weeks.

Rehabilitation will involve stretching and strengthening exercises of muscles around the joint as well as total body conditioning. The best way to exercise these muscles is to be able to twitch exercise them individually which performs neuromuscular reeducation for proper contraction patterns of these muscles as well as to provide circulation to the injured muscle(s) . Prevention of recurrent injuries is the goal.

Acupuncture|Pain|Medicine Today

This is my response to the most recent acupuncture article in the Wall Street Journal on April 23rd 2011. This is another important dimension for the understanding of pain mechanisms since pain and/or discomfort is a public health issue. Here is the link to the original article:

http://online.wsj.com/article_email/SB10001424052748703561604576150110202228764-lMyQjAxMTAxMDIwMzEyNDMyWj.html

Dear Sir:

There are many hypotheses behind acupuncture’s mechanism of action and all involve needling specific points on imaginary meridians. As you described in the article, patient input is required to find involved specific acupuncture points. Yet, for acupuncture points to be objectively found, why is subjective patient input necessary? Shouldn’t these body points be readily apparent to others? Shouldn’t finding such involved acupuncture points be among the most important factors in obtaining clinical results? Is invasive insertion of a needle necessary? Considering three dimensions, upon insertion, what if the needle is deflected from stimulating the specific acupuncture point due to tissue resistance or the specific point lies below the depth to which the needle can penetrate? On finding the correct point, should the needle be inserted only once, should it be oscillated, should several needles be inserted in that same point, and should needles be withdrawn if at the wrong point? What objective criteria determines how many needles need to be inserted in a treatment session, how deep should the needles be inserted, how long should needles remain at each point and how long should the treatment session last? Independent of patient report, are there quantifiable factors that determine whether treatment was a failure or success?

If acupuncture effects are mainly attributed to release of endorphins, why is it that endorphins released during exercise, not only fail to relieve, but aggravate pain of those who suffer from neuromuscular conditions, such as myofascial pain and fibromyalgia?

The mediate source of pain and/or discomfort in the majority of individuals, including those suffering from concussion who improved with acupuncture, appears reversible ischemia (deficient blood supply) at trigger points. This is due to relaxation of vice-like clamping effects that shortened and tight involved muscles produce on intramuscular blood vessels and nerves, specifically concentrated at trigger points. These shortened and tight muscles result from spinal nerve root irritation related to aging compounded by trauma. The mixture of reversible as well as permanent nerve damage also leads to a tugging effect of involved muscles on pain sensitive coverings on bones and joints to which they attach. This traction magnifies the pain and/or discomfort associated with the aforementioned ischemic effects. The degree of suffering appears dependent on the duration, type and extent of nerve damage.

Acupuncture points have been identified to be trigger points (neuromuscular junctions) and these points can be objectively recorded with electromyography (please see enclosed peer reviewed published manuscripts). Among the best stimuli to excite nerves is electricity, not mechanical stimulation as with the needle. When neuromuscular junctions are excited, the involved muscle that is innervated responds with twitch contractions. This twitch induced active exercise can produce an internal stretch where muscle spasm and/or muscle shortening is concentrated, namely the trigger point. This way, many shortened and tight individual muscles can be painlessly stretched and exercised individually to improve the microcirculation. By such action, the underlying local muscle ischemic changes are reversed. Consequently, involved muscle twitch elicitation is often accompanied by “pleasant and pleasing” sensations, leading to relief of pain or discomfort. Acupuncture on the correct points may also achieve this, albeit with less consistency than electrical stimulation, through obtaining twitches or micro-twitches, similarly relieving pain or discomfort. However, it is the electrical excitation of local trigger points with the elicitation of focal twitches, strong enough for observation to note that the action of the treated muscle was reproduced, preferably in an antigravity manner, and that this objective finding is associated with predictable production of pain relief. The time needed to seek and treat the trigger points should be objectively quantifiable, as revealed by the susceptibility and excitability of the trigger points to electrical stimulation. Therefore, freed from meridians and patient subjectivity, objective criteria for treatment parameters and efficacy now exist.

If nerve damage is present in multiple areas in many muscles, an improvement in how acupuncture is performed is desirable and necessary. This allows the treatments to be provided multiple times daily on a long term basis without side effects and without pain during treatment, leading to better treatment acceptance by patients, including those who are needle phobic. Advanced technology for needle-less acupuncture that can stimulate deep trigger points is now available, befitting 21st-century medicine.

Back Pain| Discomfort| New Technology

I just read this article dated 4/5/11 in the LA Times “Back pain is a complicated issue” http://www.latimes.com/health/la-he-back-pain-20110404,0,4021531.st

In most articles one reads on back pain, the major thrust is on discussion of pain related to herniated disks, facet joints and nerve roots.  Thus, the tests (XRays, MRIs) and treatments performed revolve around using spinal surgery, injections into nerve roots or muscles, radiofrequency cauterization, medications etc. to use of alternative methods such as acupuncture, massage, yoga, biofeedback, meditation, etc.  Then, there will be mention that most lower back pain will disappear and that 10% will suffer from chronic pain.   If one considers that 80% of us in a nation of 300 million Americans suffer from low back pain at some point in time, and if 10% goes into chronic pain (regardless of the treatments and some more added on to suffer chronic pain because of the treatments themselves), just please do the math.  One will realize that the population suffering from chronic pain is in the many millions.  This is a huge number indeed.
 
There is yet even a larger number of people, and that is the majority of us without pain but living in discomfort.  The original pain had disappeared, but the discomfort remains and because we have no pain, we are not considered or diagnosed to be a statistic for pain and/or disability.  However, tightness, stiffness, soreness, aching and/or tenderness of muscles is disabling to many and becomes more serious depending on one’s occupation. Consider what those signs and symptoms leading to easy fatigue mean to a surgeon, ballerina, trapeze artist, airline pilot or professional athlete where movements need to be precise and well-timed? 
 
Please consider the person who is tight and stiff from shortened muscles due to chronic spasms from presence of long-standing irritable trigger points (neuromuscular junctions).  This is related to painless involvement of the spinal nerve roots known as spondylotic radiculopathy (aging of the nerve roots).   These individuals are candidates for progressing into chronic pain when an injury occurs.  This injury may be sudden as that resulting from an auto accident, a fall or a lifting injury or more insidious as from activities of daily living, repetitive motion activities or overuse injuries. Whenever pain occurs from further trauma to the nerve roots, there is more signaling from the nerve roots to cause further shortening of muscle fibers at the trigger points.  Formation of many more new and active trigger points with active muscle spasms compound the original tightness related long-standing trigger points.
 
So what is the mediate source of pain and/or discomfort in the majority of individuals?  Consider ischemia (deficient blood supply) at trigger points from the vice-like clamping effect that muscle spasms have on the intramuscular blood vessels and nerves.   Also, the tugging effect of these muscles in spasm on the pain sensitive bone and joints constitute to magnify the pain.
 
If pain is so deep and present in so many trigger points of many muscles, how best to approach them?  Clearly, the usual armamentarium for treating pain will not be sufficient to address this problem of neuromuscular pain and/or discomfort.  Pain related to  neuromuscular problems is difficult enough to address when it is focal involving only a joint or one limb segment as in myofascial pain but truly very difficult when the problem is diffuse as in fibromyalgia. 
 
Physicians always advise patients to exercise.  But the hallmark in neuromuscular pain due to ischemia as in myofascial pain or fibromyalgia is pain on movements with or without resistance. These patients cannot exercise since too many muscles and too many joints are moved simultaneously.   However, active exercise can still be performed by stimulating the trigger points in individual muscles.  This stimulation induced active exercise can produce an internal stretch where muscle spasm is concentrated, namely the trigger point.  This way, many shortened and tight muscles can be exercised one at a time painlessly, often accompanied by pleasant and pleasing sensations that lead to pain relief.
 
It thus behooves those in the technology sector to find ways that can address pain at the deep trigger points.  This type of technology should be able to manage pain and/or discomfort non-invasively, and should be able to be used long-term regularly and consistently even on a daily basis with few contraindications and rare side effects.   Finding this technology is akin to finding the holy grail for managing the ubiquitous disease known as neuromuscular aging.  And this technology exists now.
 

Overuse| Aging

 

Who does not have overuse injuries?  In this computer age, we all perform a lot of keyboarding and moving the mouse.  If you are reading this blog, you are an Internet user and therefore computer savvy. 

 

Have you noticed yet aches or discomfort in your hands, wrists primarily?  Have you been told that you have tendonitis, bursitis or carpal tunnel syndrome?  Have you been told to wear a wrist splint?  Have you bought a wrist splint for yourself already from the local drug store? Massaging your muscles often?

 

This is just one of the overuse or repetitive stress injuries.  One can get repetitive stress injuries just from activities of daily living.  Add the effects of aging onto it.  Add the effects of work, sports injuries, auto accidents, falls, twists, lifting, twisting, pushing, and we are living with some pain and/or discomfort in some part of the body.

 

Most of the symptoms in the muscles and joints are coming from irritation of aged spinal nerve roots.  You may not have to have pain right now in the back or neck.  You will however have discomfort, stiffness and/or tightness in the neck and/or lower back. One might accept this as due to the effects of aging if one is older, but when one is a young teenage athlete, or computer user, or a musician or dancer, and when one is only a child of eight or nine years age and has pain due to overuse, is that aging as we know it? 

 

What is important is not the chronological age but the physiological age.  Correct?

Pain | Acute Trigger Points| Tendinitis

July 3, 2010


Many methods do exist for treating acute trigger points (neuromuscular junctions) which is the root source of ischemic neuromuscular or myofascial pain.  Tendinitis starts when the muscle is chronically tight and shortened and pulls on its own tendon.  The tendon then pulls on underlying bone and joints.  Over a course of time, the tendon becomes thick and swollen.  Treating the tendon alone is not sufficient.  Treatments have to be directed to the trigger points in the muscles associated with these tendons.

eToims is state-of-art non-invasive electrical stimulation that can be applied to trigger points in the deepest muscle layers apposed to bone and joints where the most pain arises due to the significant traction on underlying pain sensitive receptors in bone and joints together with the vice-like compression of intramuscular nerves and blood vessels.

eToims provides real time diagnosis and prognosis in addition to simultaneous therapeutic pain/discomfort relief.

  1. Diagnosis: Smaller twitch forces and slower twitches are found in tight muscles, chronically involved muscles or weak muscles.  Larger twitch forces with rapid rates that can fatigue the trigger point are found with acute nerve irritation before the muscle has become tight. Such acute trigger points are also present in chronic pain but are more difficult to find and significant clinical skill is needed to be able to locate and stimulate these points.
  2. The therapeutic effect and hence diagnosis and prognosis for pain/discomfort relief is directly dependent on twitch force, ease in eliciting large force twitches and ability of trigger points to fatigue.

eToims treatments need to be directed to:

1. Both sides of the body.
2.  To the muscles on both sides of the joint because the eccentric muscles at the back are weak from chronic injury making the muscles on the other side of the joint in the front to become very tight.

Since most patients and athletes and even asymptomatic individuals have very tight and/or stiff muscles, the clinician may not be able to bring the trigger point to fatigue.  However, if that trigger point can fatigue, you will notice that suddenly the twitches will become more forceful and more rapid termed the pre-fatigue phenomenon. The trigger point will then suddenly fatigue abruptly so that the clinician will not be able to elicit such twitches at the same point.

It is very important to find as many active trigger points/unit time as possible to provide the patient with optimal pain/discomfort relieving results.

The best time to treat any individual especially athletes is when they have little to no pain since the muscle tissue is softer and the electrical stimulation is able to reach the deep trigger points easily without pain. eToims treatments have to be titrated well to be painless and will give pleasure on stimulation at the trigger points.

eToims results will be invaluable for any individual to perform at their peak. Since eToims is noninvasive and is a localized exercise to individual muscles, it can be used daily and even multiple times in the same day. The importance of eToims is in the ability to prevent injuries by increasing the margin of safety for neuromuscular tissues and to reduce the healing time when injuries do occur.

Please click on this link to see how eToims is actually performed.

http://www.youtube.com/watch?v=5vpFK1zAKvI


Massage| Pain| Complications

Who does not enjoy a relaxing massage? Massage is used in many cultures across the world in many types of painful and non-painful body conditions associated muscle tightness. It has been used in individuals with neck and low back pain, chronic fatigue, anxiety, and depression.

The National Center for Complementary and Alternative Medicine (NCCAM) considers massage therapy to be a manipulative and body-based method of complementary and alternative medicine.

Massage provides relief of muscle tension through tissue mobilization that stimulates nerves and through increasing blood flow. Generally, massage is considered safe but must be applied by trained and certified practitioners.

There are many types of massage and it can be applied superficially or deep. Superficial massage consists of gentle stroking, or light circular movements. Neuromuscular massage is used for reaching deeper tissues and is not benign. Deep tissue massages can result in the individual experiencing more pain after the therapy. Exciting deep neuromuscular tissues with manual stimulation is not sufficient to depolarize the nerve and may result in more muscular tension and hence more pain. There may also be more tissue tightness due to muscle spasms induced by the massage itself especially in patients with preexistent muscle pain and tightness. The optimal way to stimulate deep neuromuscular tissues resulting in deep tissue relaxation is to apply electrical excitation at neuromuscular junctions by individuals well-trained in the eToims technique.

The complications of manual massage include increased pain and spasm, dizziness and lightheaded and fainting from stimulating the carotid sinus. Massage has also been reported as a cause of rhabdomyolysis-induced acute renal failure. It has also been reported to cause inflammatory myositis and prolonged myopathy (Tanriover MD. Guven GS. Topeli A: An unusual complication: prolonged myopathy due to an alternative medical therapy with heat and massage. Southern Medical Journal. 102(9):966-8, 2009).