tion to make stretching consistently more effective lies in finding new methods including DTPS. Effective summation of twitch-induced stretch forces focused to MTrPs are best with repetitive 1-3 Hz stimulation.

Not commonly recognized is thixotropy of muscle which is a ubiquitous and functionally important phenomenon since it results from tendency of actin and myosin filaments to stick together when inactive for a period of time. Passive properties of thixotropy can be reduced with previous movements as evident with preventive warm-up activities of athletes before strenuous sports. Overcoming thixotropy may be the basis by which DTPS is able to clinically improve function in muscle tightness without pain, fibromyalgia, stroke or Parkinsonism. Reduced muscle thixotropy/stiffness persists as long as motion persisted but will return to its previous state. Stiffness reduction afforded by twitch exercise allows more mobility and the increased mobility and increased blood flow perpetuates to improve muscle function and QOL.

Improving Denervation Supersensitivity Related CRMP

Partial denervation and/or conduction block in the presence of DS leads to ongoing MTrPs formation in many myotomes at various times daily with ADL. Morphologic and electromyographic studies have demonstrated atrophy and delayed activation of deep muscles of the spine in patients with chronic NP and chronic LBP. Decrease in maximum force of deep back muscles improve resultant joint moments and reduce the stabilization function provided by these muscles to the lumbar spine. Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic LBP. There is conflicting evidence for effectiveness of exercise in reducing the number of recurrences or the recurrence rate.

DTPS is aerobic exercise therapy to individual muscles. If there is no pain relief with the first DTPS session, the primary diagnosis of CP is not CRMP and other causes need consideration, e.g. neuropathic, inflammatory, psychiatric or nociceptive. Further DTPS sessions are advised even in such patients to treat co-morbid CRMP and/or muscle tightness to facilitate management of the primary pain.

For best functional results optimal treatment in CRMP includes these 5 muscle areas: trapezius, latissimus dorsi, gluteus maximus, adductor magnus, and paraspinal muscles from neck to sacral areas. This is needed even if patient presents only with NP/upper limb pain or LBP/lower limb pain as in this patient. Additionally, other muscles connected to the thoracolumbar fascia and along the kinetic chain must be treated proximo-distally starting with the largest muscles that cross multiple joints to small muscles of hands and feet as needed. Treatments begin with weakened muscles exposed to injurious eccentric contractions before directing treatments to strong muscles used primarily for concentric contractions. In the presence of weak symptomatic-side muscles, asymptomatic-side muscles are stronger by default and from overuse developing MTrPs that need treatment. This balances chronic strong pull of muscles toward asymptomatic side that more weakens symptomatic side. Treatments begin on the symptomatic-side starting with upper trapezius MTrPs with DS which can be easily located. Through its myofascial connections, other muscles on the symptomatic side become easier to treat. Provided MTrPs with DS are stimulated, Grades 3-5 twitch elicitation is facilitated by aged neuromuscular junctions exhibiting enhanced pre-synaptic nerve terminal branching, post-synaptic distribution of neurotransmitter receptor sites, increased Ach quantal content and more rapid decline of endplate potential strength during continuous pre-synaptic neuron stimulation.

Additionally, central sensitization amplifies DS. Noxious stimuli and/or misinterpretation of non-noxious stimuli (secondary hyperalgesia and allodynia) can induce chronic pain. Injury induced functional and adaptive changes include ineffective synapses unmasking, receptive field shifts and reorganization or altered effectiveness of surviving neural networks at the brain cortex level as well at peripheral nerves and receptors.

DTPS Role in CRMP

With DTPS we have originated an algorithm with consistent pain/discomfort relief and reproducible results without concurrent use of multiple medications or other therapies. Presence of DS in CRMP requires that treatments be safe and effective for regular life-long use on the entire body. We studied our case with statistical process control (SPC). Studying one case in detail sequentially over time can produce statistical results superior to that of a RCT. In these circumstances SPC has greater statistical power to exclude chance as an explanation.

DTPS is suitable for use in developing countries since it is cost effective.

LEARNING POINTS/TAKE HOME MESSAGES

1. CRMP is a neuromusculoskeletal disease caused by spondylotic radiculopathies following acute or chronic cumulative trauma with DS induced peripheral and central, mechanical and electrical hyper-excitability.

2. The mediate cause of CRMP is neuromuscular ischemia at deep MTrPs in tightened/shortened/stiffened muscles from spondylotic radiculopathy related partial denervation that maintains/aggravates CRMP.

3. Systematic reviews show lack of effective treatments for CRMP. As CRMP is a global public health problem with huge economic toll on society, governments of developed and developing nations should invest in safe, efficacious, cost effective novel systems such as DTPS for its prevention and management.

4. DTPS is a safe and efficacious innovation for repetitive, life-long whole body treatments for CRMP management as a real-time preventive, diagnostic, therapeutic and prognostic armamentarium. It empowers patients in their own health-care since it can also be self-performed.

5. Commonly available sphygmomanometer is useful as an inexpensive, practical, objective, real-time pain monitor for clinical follow-up of DTPS treatments.

PATIENT’S PERSPECTIVE

I, Crawford Hill, had a spinal surgery two years ago in July 2013. The hypothesis was that my inability to walk uphill effectively was severely compromised by a herniated disc at L4-L5. I had had several injuries and trauma which probably contributed to the problem, whether it was a herniated disc or some other cause of compromising function- especially walking uphill. One of these was an expedition trip to Ecuador during which I was on a boat which slammed up and down for four hours. I had to tighten my buttock intensely and hold on for the entire boat-ride. The next day I was on a horse which trotted causing me more bouncing effects on my spine for four hours. This was an extreme challenge as I had to tighten my buttock again to endure the bouncing up-and down. These two back to back incidents followed about five months after I fell from a rock climb gym wall. After that fall, I laid on the padded mat for several minutes thinking I had severely hurt myself. However I was able to get up and I seemed to be okay. I thought that these injuries did not apparently compromise my function. However on hindsight it probably did – especially in conjunction with the traumatic incidents in Ecuador which I mentioned. Going further back in time about 10 years ago I attempted to water ski and ended up in a very compromised position and felt some tremendous strain on my hamstrings. I let go of the rope and thought that I had damaged my hamstrings severely. However again I was able to function and forgot about the injury.

Going further back in time I did “pull my groin” as they say, in high school football. There was no good treatment available. Lots of heat and inappropriate exercise probably contributed to the injury. However once again I moved on because I was generally very fit and probably have a high tolerance for pain and compromised function. I have tried just about every treatment possible including many versions of physical therapy, gravity-assisted traction, yoga, Feldenkrais exercises, spinal manipulations, acupuncture with four different practitioners, chiropractic release, medications, epidural injections, many anti-inflammatory medications including opioids and even spinal surgery. In addition I have a stretching and myofascial release program which does give me relief. Pain is on my mind 23 hours/day and I sought relief with eToims. After treatment with DTPS within six months, I can feel my affected musculature namely the gluteal and hamstrings muscles returning to function. The deep twitching has released most of the spasms and the muscles feel more functional and I’m ready to start light exercise. In June of 2015, I went on my first expedition since 2011. I went to Crete and I was able to walk on level and inclines for 3-6 miles daily for two weeks. This has been a dramatic development after years of frustration with all the other modalities I tried.

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