clinicians to always look for these proximal and distal contributors to the pain experience, even in acute injuries, as an acute event may elicit the activation of previously dormant trigger points, making the clinical picture more difficult to understand. There could be inconsistencies in the symptoms relative to the structural extent of the acute injury that can only be explained by the activation of those pre-existing TPs. Functional “deactivation” of TPs using needling techniques such as neurofunctional electro-acupuncture or dry needling is the current gold standard for dealing with these important contributors to pain syndromes. However, other therapeutic approaches using miscellaneous manual techniques have also proven valuable in the management of these syndromes. #3: REFERRED PAIN FROM VISCERA Visceral trigger points (VTPs) are the equivalent to the myofascial TPs discussed above, and curiously, they were known long before Travell and Simons published their books. For instance, in the last half of the 19th century, Dr. Henry Head, later the editor of the journal Brain , published a number of articles, with beautiful drawings, presenting the many clinical observations he had gathered from patients with visceral disease that manifested pain on the trunk and girdles. The beautiful image(s) provided on page 20 is from Dr. Head’s article “ On Disturbances of Sensation with Especial Reference to the Pain of Visceral Disease. Parts I and II” published on the journal Brain in 1893! Some insight into pain from visceral origin: • A number of nerve fibres are involved in this phenomenon, such as C and A-delta fibres: intensity coding receptors, high threshold receptors, and silent nociceptors. • Multiple causative factors could be involved in the activation of the above-mentioned fibers: distension, necrosis, inflammation, and ischemia. • Clinically, pain of visceral origin is usually poorly localized, and most of the time is accompanied by reflex autonomic manifestations such as nausea, vomiting, diffuse sweating, anxiety, and unpleasantness. Visceral pain frequently refers to somatic structures that are innervated by fibres in the same spinal segments as the innervation of the diseased visceral organ; these can produce referred muscle hyperalgesia and increased contractions in that territory. Another common examples of this phenomenon include shoulder pain from gall bladder or liver disease, or problems in the ureter felt on the lumbar musculature. CONTINUED ON PAGE 20 symposium at HOMECOMING May 31 -June 1, 2019 CMCC and the Hilton Toronto/Markham Suites The first event of its kind! Join world class experts on the Prevention and Management of Low Back Pain – The Expanding Role of the Chiropractor, inspired by the Lancet papers and the Global Spine Care Initiative Enjoy an exciting social events program which includes: President’s Welcome Home Barbecue; Governors’ Club Lunch; Grand Reception, Dinner and Awards All classes are welcome. Register today at www.cmcc.ca/symposiumathomecoming www.canadianchiropractor.ca CC_CMCC_homecoming_May19_CSA.indd 1 May 2019 Canadian Chiropractor 17 2019-03-25 3:13 PM
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