Category: Pain Management

Rethinking Muscle Cramping and How to Treat It

Rethinking Muscle Cramping and How to Treat It with Valley Health Clinic in Albany, Oregon

Contrary to popular belief, muscle cramping after exercise has little to do with dehydration and electrolyte imbalance. While hydration and electrolyte restoration are important following a bout of intense exercise, there’s much more to cramping than formerly understood.

In this article, we will discuss the real reasons behind exercise-induced muscle cramping and address treatment methods for this condition.

Myth of Electrolytes

A study of 43 triathletes reported cramping (cramping group) and were compared with the 166 who did not report cramps (non-cramping group). There were no significant differences between groups in any pre-race–post-race serum electrolyte concentrations and body weight changes. The development of cramps was associated with faster predicted race times and faster actual race times, despite similarly matched preparation and performance histories in subjects from both groups. A regression analysis identified faster overall race time (and cycling time) and a history of cramping (in the last 10 races) as the only two independent risk factors for exercise associated muscle cramps (EAMC).

The study suggests that electrolyte levels are not a factor in cramping. Rather, competing at a faster pace and high intensity then what is normal can cause (EAMC). So why is this? The most up-to-date scientific theories attribute exercise-induced cramping to a body state called “alpha motor neuron excitability”. It may sound complicated, but alpha motor neuron excitability is relatively easy to understand and identify.

Read more: https://bjsm.bmj.com/content/45/8/650.short

Alpha Motor Neurons Explained

Alpha motor neurons (also referred to as alpha motoneurons) are an essential part of the body’s central and peripheral nervous systems. They’re present in the brainstem and spinal column, and they’re directly responsible for telling muscles when to contract.

Any time you contract (flex) a muscle to make a movement (for example, when you take a step, grasp a pencil or touch a finger to your nose), you’re putting your alpha motor neurons to use. During a bout of intense exercise, your alpha motor neurons work overtime.

Importantly, when it comes to understanding muscle cramps: the more active your alpha motor neurons are, the more prone your muscles are to contracting when you don’t necessarily want them to.

What is Alpha Motor Neuron Excitability?

Alpha motor neurons are an essential part of the body’s nervous system. However, they must strike a delicate balance with other neurons and body systems for your muscles to work correctly. One of these balancing agents is the Golgi tendon organ, which we’ll discuss in more depth further on.

When these systems become out of balance, your alpha motor neurons aren’t properly kept in check, and they enter a state of excitability. And since alpha motor neurons cause our muscles to contract, the result of this excitability is involuntary and prolonged muscle contraction: i.e. muscle cramps.

Causes of Alpha Motor Neuron Excitability

There are several factors that can cause alpha motor neuron excitability, including the following:

  • Fatigue
  • Dehydration and/or malnutrition
  • Inadequate conditioning
  • Muscle damage

Just one of these factors can lead to alpha motor neuron excitability and subsequent muscle cramping. However, the real problem begins when several of these factors coalesce, causing more severe excitability, and therefore, more intense pain.

Understanding the Golgi Tendon Organ

As briefly mentioned above, the Golgi tendon organ (GTO or tendon spindle) is one of the most important balancing agents to the body’s alpha motor neurons. Golgi tendon organs are proprioceptive sensory receptor organs, located in the tendons, adjacent to the myotendinous junction (MTJ).

So, how do the Golgi tendon organs located in the tendons keep alpha motor neurons in balance, and how can this aid in treating muscle cramps?

The Golgi tendon organ performs almost the opposite role of alpha motor neurons. Whereas alpha motor neurons tell your muscles to contract, the GTO’s role is to make sure your muscles don’t contract too forcefully.

When the body is fatigued, not only does alpha motor neuron activity increase, but Golgi tendon organ activity decreases, furthering the potential for unwanted muscle contractions.

This is important in understanding muscle cramps and how to treat them because by stimulating the Golgi tendon organ, we can essentially “switch off” unwanted muscle contraction.

The Answer is TRP Channels

If you’re familiar with the electrolyte depletion theory, you may be familiar with the theory that pickle juice relieves muscle cramps. It was originally thought that pickle juice does this by balancing electrolytes in the body. We now know this is not true. A study by Miller found that it takes pickle juice 30mins to leave the stomach and that the cramp revealing effects happens much faster. Instead, the researchers theorized that pickle juice worked to inhibit the firing of alpha motor neurons by triggering a reflex-response in the mouth, throat and stomach called transient receptor potential (TRP) channels.

https://www.ncbi.nlm.nih.gov/pubmed/19997012

https://www.ncbi.nlm.nih.gov/pubmed/21062184

TRP Channels and Muscle Cramps

TRP channels are pathways through which the body transports positively charged ions (i.e. magnesium, sodium, and calcium). These pathways, or channels, can be stimulated by small molecules like capsaicin and menthol, and by spices like red pepper, cinnamon, ginger, and mustard.

Numerous physical scenarios can also be explained by the alpha motor theory, where they cannot be explained by the traditional serum electrolyte depletion theory alone. For example, marathon-runners often suffer cramps when fully hydrated and electrolyte-balanced

TRP channels help the body rapidly and accurately interpret the surrounding environment and adapt. And when it comes to muscle cramping, strong simulation of the TRP channels can calm alpha motor neurons and diminish cramping (fasebj.org)

Read More: https://www.sciencedirect.com/topics/neuroscience/transient-receptor-potential-channel

Cramps and the Taste of Herbal Medicine

Since ancient times, Chinese herbalists have classified medicinal materials according to their tastes. The taste was understood to have a relationship to the effect of the herb when ingested. This relationship was seen as having great importance in guiding the combining of herbs within formulas. In most traditional Chinese herb books, taste was the first property of an herb to be mentioned, helping to orient the reader to the information that followed. There are five tastes—sweet, salty, sour, bitter, and acrid (sometimes called pungent or spicy)—consistent with the five element concept.

It is reasonable to raise the question whether or not the tastes really have a strong correlation with herbal effects. Now that we know about Transient receptor potential channels and their location in the mouth and esophagus, the answer to this is yes.

If we take pickle juice as an example of a way to control cramps and overexertion. It’s flavor is sour. Lemonade is another example of how sour can control the outward energy of excessive sweating and fatigue. There is norther better then a cool glass of lemonade on a hot day.

There are two major connotations of the sour taste in Chinese medical theory:

  • In five element systematic correspondence, the sour taste is associated with the liver. It has a moistening and softening effect, usually reducing contraction of the ligaments and tendons. Persons who are overly flexible may find that the sour tasting herbs worsen that condition. Peony, cornus, achyranthes, are among the main sour herbs used to affect the liver function and said to relax the tendons.
  • According to the taste/action dogma, the sour taste has an astringent and fluid recollecting function (that is, helping to reabsorb fluids as they begin to escape). Chinese medicine considers the sour and astringent qualities as restraining the leakage of any fluid, including perspiration, and blood. Tannins, a class of complex molecules with notable astringent effect, are present in some of the herbs. Schizandra, terminallia, cornus, and sanguisorba are commonly used as astringents.

Here is a Formula that can help with muscle spasm and cramps:

  • Bai Shao (Radix Paeoniae Alba) and Gan Cao (Radix Glycyrrhizae) are commonly combined to relieve muscle spasms and cramps. Clinically, they may be used for musculoskeletal spasms and leg cramps associated with external or sports injuries.
  • (Radix Paeoniae Alba) and Gan Cao (Radix Glycyrrhizae) have strong antispasmodic and anti-inflammatory effects as confirmed by modern research. Furthermore, Bai Shao (Radix Paeoniae Alba) and Gan Cao (Radix Glycyrrhizae) are effective in treating both skeletal and smooth muscles.

Summing Up Exercise-Induced Muscle Cramps

It’s easy to see how muscular fatigue—like that following a bout of intense exercise — can wear down the body’s natural systems and balances, leading to muscle cramps. When the body is fatigued, alpha motor activity increases and Golgi tendon organ activity decreases, leading to painful and involuntary muscle contraction. But by understanding the root cause of exercise-induced muscle cramps, and that TRP and taste has a strong we can better treat the issue in sports acupuncture and herbal medicine.

The Sports Acupuncture Pyramid

Each level of sports acupuncture has a unique purpose and set of treatment goals. Each level also has its own sublevels—or phases—which build upon each other in the same way.

What are the three levels of sports acupuncture? How do they build upon and work with one another?

Sports Acupuncture Has Three Levels

In sports acupuncture, our time falls into three main categories: injury, recovery and performance. These three categories work together and can be thought of as a pyramid with injury on the bottom, recovery in the middle, and performance at the top. Each level of sports acupuncture has a unique purpose and set of treatment goals. Each level also has its own sublevels — or phases — which build upon each other in the same way.

About: The Injury Phase

The Injury phase of the pyramid has three unique stages: pain, weakness and strength. Each process is equally important, but as acupuncturists, we tend to spend most of our time focusing on pain.

While pain may the driving factor behind many of our athletes seeking our help, relieving pain is only a small part of what we aim to do in sports acupuncture.

In the treatment of pain we often focus on musculoskeletal conditions and orthopedic acupuncture. This is only a small part of sports and performance acupuncture. Sports acupuncture is a greater field which includes orthopedic acupuncture, not vice-versa.

Orthopedic acupuncture is important in the pain stage. This is where trigger points, motor points, manual muscle evaluations and palpation examinations are amazing tools to have.

We can quickly get an athlete out of pain using orthopedic acupuncture methods, but what we do next–in the weakness stage–is just as important. The pain may be gone, but that doesn’t mean their muscles are working at 100%. At this point, we can say the muscles are “turned off”. We need to choose treatment methods that will turn them back on.

This “turned off” state connects to what’s known as “competitive plasticity” (use it or lose it). If you don’t use a particular skill or set of neuronal connections, your brain will re-purpose them to be used for something you are using more regularly.

If you hurt yourself (for example, if you sprain your ankle), the brain will try to stop using that muscle to allow it to heal. In doing so, the brain “turns off” the neuronal pathways that tell your ankle’s muscles to work.

A muscle might also be considered weak if there is damage to the proprioceptive system. (Proprioception is the sense of knowing where your body part is in space.) Your proprioception capabilities can be impaired when a joint tendon or ligament is injured. This is where the proprioceptors are located. An injury like an ankle sprain can damage the ligaments neurotendinous spindle that lie at the origins and insertion of skeletal muscle fibers and into the tendons of skeletal muscle. When you lose proprioception of your joint after an ankle sprain, you may experience an unstable sensation of the joint. Your joint may even give out. When treating weakness, you can use orthopedic techniques, but you’ll often find distal methods or press tacks to be more effective.

After you get rid of pain and restore muscle strength, you are able to move to the “Recovery” phase.

About: The Recovery Phase

During the Recovery phase, an athlete is not in pain but still dealing with stresses. This is where we need to focus on training stresses that affect the following:

  • Range of motion;
  • Sleep; and
  • Digestion.

Most of this is controlled by the parasympathetic nervous system (PNS).

When an athlete is training hard, they’re taxing their sympathetic nervous system (SNS); afterwards, they need to switch over to the parasympathetic nervous system (PNS) to rebuild and regenerate. The body’s sympathetic nervous system and parasympathetic nervous system balance each other out.

The SNS is catabolic and mobilizes the body’s resources to help the body “fight or flight” threatening situations. This system is upregulated during workouts. The PNS is anabolic and helps the body rest, digest, and recover after workouts.

Many athletes are especially vulnerable to being in a sympathetic-dominant state due to increased stress load. The chronic physical and mental stress that they experience may overtax their body’s ability to adapt and maintain homeostasis. Therefore, this type of athlete is more likely to experience challenges with recovery.

The above is especially true if restorative techniques are not utilized to minimize sympathetic dominance and strengthen the parasympathetic response.

During the Recovery phase, we are focusing on managing the PNS. We are watching and treating issues with sleep, digestion, and the immune system. We are also watching and treating issues in range of motion and muscle imbalances that are often the results of sport-specific movements.

About: The Performance Phase

The top level of the Sports Acupuncture Pyramid is the Performance phase. The Performance phase culminates on the day of an event or athletic performance, but it can also include up to two weeks leading up to the event.

Most athletes will begin to taper or decrease training intensity during this time period, so focusing on recovery becomes less important. Instead, now is the time to treat the spirit; shift your focus to the mental game.

Specifically, the three general areas of emphasis are as follows:

  • Stress vs. Relaxation;
  • Confidence & Optimism; and
  • Focus & Awareness

Stress: Does the athlete perform better under stress, or does stress decrease their performance? Where do they feel gameday stress the most: physically or mentally?

Russian sport psychologist Yuri Hanin suggested that different athletes had different levels of pressure at which optimum perform­ance occurs. He called these “zones of optimal functioning”. Some respond well to high tension and pressure; others do not. An athlete needs to learn what zone is best for him or herself.

Confidence: Check in about internal motivations, positive vs negative attitudes, and feelings of self-confidence.

Burnout is most common in athletes who feel like they’re playing for external motives, such as college scholarships or verbal commitments. Athletes who have a personal attachment to the sport or other internal motivations are much less likely to feel burned out.

Focus: The ability to maintain a state of full concen­tration is vital to top athletic performance, particularly during a key game or tense moment.

Visualization, for example, is a well-known technique in which the athlete imagines specific, important game-day situations as vividly as possible. When that specific situation occurs, the athlete feels better prepared, having already worked through the situation mentally.

The day of an athletic event is not the time to do any major treatments. Treatments are kept to less invasive procedures, such as ROM evaluation and soft tissue work with Gha Sha, or cupping to help warm up tight areas.

Press tacks or kinesio taping to clean up proprioceptive imbalances that are still present at that time can also be useful day-of.

Injury Stage

The Injury level is the base or foundation of the sports and performance acupuncture pyramid. This is where we tend to spend most of our time.

Overview:

A patient comes in with an injury. We treat the injury directly to relieve pain, overcome weakness and restore strength.

  • Pain. At the very bottom of the pyramid is the Pain phase of the Injury level. Before we can do anything else, we need to relieve the patient’s immediate pain. Treatment goal: Relieve pain.
  • Weakness. Treatment of an injury doesn’t end with pain relief. Once pain is resolved, the patient still has weakness in the injured area, where the muscles are essentially “turned off”. Treatment goal: Evaluate and overcome weakness.
  • Strength. Finally, once you’ve overcome weakness due to the injury, the patient can work to regain full strength. Treatment goal: Regain strength.

Treatment Methods

  • Trigger points
  • Motor points
  • Manual muscle evaluation
  • Proprioceptive Aids, Press Tacks, KenisoTape, Distal Needling

Recovery

The middle level of the pyramid is Recovery. This level comes after Injury and before Performance. It is where we spend most of our time second to the three phases of the Injury level.

Overview

Treatment doesn’t stop once an injury has healed. After an injury is resolved, the patient enters the Recovery level, which is where you can help them reintegrate into normal training and activity healthily and safely. Recovery focuses mainly on range of motion, sleep and digestion.

  • Range of Motion (ROM). As the patient heals, they begin to tax their sympathetic nervous system with training, which can cause imbalances. To continue to increase strength in the affected area and make sure it heals properly, we focus on range of motion.
  • Sleep. As the patient recovers, they need to switch their focus to the parasympathetic nervous system in order to heal from the taxes they’re putting on their sympathetic nervous system. This means focusing on improving sleep quality.
  • Digestion.Another crucial part of the parasympathetic nervous system is digestion. As the sympathetic nervous system gets put to work with increased training, more focus on improving digestion is needed to recover.

Treatment Methods

  • Traditional Chinese Medicine Diagnosis. Focus on Sleep, Digestion and Mood to evaluate Autonomic Nervous System

Performance

The top of the pyramid — Performance — is where we tend to spend the least of our time, but where we should try not to neglect important aspects of patient care.

Overview

Finally, the patient isn’t in pain, they’ve worked hard to train healthily and to avoid further injury, and now it’s the day of. Now, our job is to address and treat the spirit: fears, motivation and focus.

  • Stress. When treating the spirit, it’s important to identify and address any fears or Levels of mental, emotional physical stress that might hinder—or improve—performance.
  • Motivation. Identify and create a focus around what makes the patient want to succeed and perform well.
  • Focus. Identify and address any distractions that can detract focus and energy away from peak performance the day of.

Treatment Methods

  • Acupuncture with Performance Visualization

Acupuncture and Pain Types

Acupuncture and Pain Types - Valley Health Clinic, Albany Oregon

Identify your pain at triggerpoints.net.

Acute Pain

Acute Pain is the easiest to understand because there was a pain and it was recent. The patient can point to it and can remember what happened to cause it. The body is sending pain and location signals to the brain. Recent acute pain is often the east to treat and the body responds quickly because a chronic pattern or pain expectation has not set in. If the pain is sever, light local needling or distal needling is best. Strong local needling will add stress to a system that is already over stressed and aggravated. Light local needling with stimulation encourages a local healing response but not aggravation. It will act like a kind of homeopathic treatment. Distal points can block the pain and help the muscles rest.

Chronic Pain

Chronic Pain has affected the whole system and a correct local treatment will improve the condition but the pain will return because the body can not adjust to the pain free movement. You must treat local and adjacent points. With chronic pain the body can loose the location signal and the pain may feel vague or wandering. Local needling will stimulate the location nerves and help the body heal.

Nerve Pain

Nerve Pain is often described as burning or prickling or electrical shock. Some people with nerve pain will have hypersensitivity to temperature or touch. Very often it will radiate past two joints. Muscle pain radiation rarely passes two joints. Radiation will be along a path and patients will trace an area with there finger when describing it.

Psychogenic Pain

Psychogenic Pain aggravated with stress responds better to distal treatment. Pain will often feel better after treatment but always come back once the patient returns to work. It will be very frustrating to treat and can look like a repetitive injury that is aggravated from work. Often time psychogenic pain will be aggravated eerily in the work day will repetitive pain will be aggravated later.

Muscle Pain

Muscles Pain is classic. Dull, tight, and achy. It will be local and effected with pressure on the area either by aggravating or relieving pain. For tendon, meniscus, and ligaments, this pain is sharp and often sudden. Patients will describe a giving out of the joint or sudden weakness. For example patient has dull achy shoulder pain, this is muscle pain. When the patient does the arch of pain test at around 90 degrees they say ouch and drop their shoulder. The sudden sharp pain causing weakness would be the tendon being pinched. Another classic example is a tore meniscus or ligament in the knee. The patient will have dull achy pain and suddenly will step wrong and get a sharp pain. They will say it feels like their knee is giving out.

Itis

Inflammation will have swelling heat and redness. Arthritis is worse in the morning and better with heat and movement as the swelling is moved out of the joint. Muscle pain is also worse in the morning and better with heat and movement but it will not come back as quickly with rest. Muscle pain will be aggravated at the end of the day with when patient over does the activity.

Bursitis will be painful with pressure on bursae, It will typically only be painful with exercises or excessive movement but fine with normal movement. For example, it will only hurt when the patient runs.

Tendonitis is worse in the morning. The most common pain that is worse in the morning is “itis”. The joints fill with inflammation at night and when you first start to move can be painful. The best example of this is Plantar Fasciitis. It will feel like stepping on glass when they first get up in the morning but will feel better once they move around.