Myofascial pain syndrome

Myofascial Pain Syndrome
Margarita Correa MD FAAPMR
Physical Medicine and Rehabilitation
Pain Medicine
Physical Medicine Institute
2020 Oakley Seaver Dr. Ste 1
Clermont FL 34711

Myofascial pain is a condition that affects the fascia (connective tissue that covers the muscles)
Pain is regional , acute or chronic
Physical finding - trigger point (TP) with associated dysfunction
Myofascial trigger point = hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia

Trigger Points (TPs)

An active trigger point (TP) is an area of extreme tenderness that usually lies within the skeletal muscle and which is associated with a local or regional pain
A latent trigger point (TP) is a dormant (inactive) area that has the potential to act like a trigger point

Trigger point (TP)
Painful on compression
Can evoke characteristic
referred pain and auto-
nomic phenomena
When the muscle is slightly snapped there’s a twitch response > > “jump sign”

TPs area activated
directly by:
acute overload
overwork fatigue
direct trauma
extreme cold
postural strains
disuse syndrome
TPs are activated indirectly by:
other TPs
visceral disease
arthritic joints
emotional distress

Active myofascial TPs vary in irritability from hour to hour and from day to day
TPs irritability may be increased from a latent >> active level by many factors (stress, muscle in a shortened position, chilling of the muscle, etc)
TPs cause stiffness and weakness of the involved muscle

Passive or active stretching of the affected muscle increases pain
The stretch range of motion ( ROM ) is restricted
Pain  when the affected muscle is weakened
Active TPs commonly radiate deep tenderness and dysesthesia (unpleasant sensation) to the zone of referred pain

Laboratory Findings
Routine laboratory test : no abnormalities
EMG & muscle biopsy : no diagnostic abnormalities
Thermograms of skin overlying active TPs shows increase in skin temperature, 5-10 cm in diameter
Reduced skin resistance may be observed in a small region over TP

'Perpetuating factors'
Nutritional deficiencies : especially vitamins C,
D, B-complex and iron
Hormone imbalances : low thyroid hormone
levels, premenstrual or menopausal
Infections : bacterial, viral or yeast
Allergies : wheat and dairy in particular
Poor oxygenation of tissues : aggravated by
tension, stress, inactivity, poor sleep, smoking,
lung diseases COPD

Treatments
Stretch and Spray Technique
Heat application / mobilization
Injection and stretch
Ultrasound (deep heat)
Acupuncture

Treatments
Transcutaneous Electrical Stimulation
Massage
Low-level laser therapy (LLLT, also known as cold laser therapy)
Medications
Exercise / muscle rehabilitation

Stretch and Spray
Stretch is the action
Spray is distraction
Vapocoolant spray :
Ethylchloride ( too cold, flammable, toxic) vs.
Fluori-Methane (non-flammable, non toxic, does not irritate skin)

Heat application
Moist heat is more effective than dry heat
Post-treatment muscle soreness is markedly reduced by applying a hot pack for a few minutes after stretch and spray
Electric heating pad - Thermal Pack Moist Heat

Injection and Stretch
Dry needling
With the patient recumbent, using sterile technique to inject TPs with 0.5% procaine in isotonic saline, until area becomes non tender
Passively stretch

Ultrasound
(deep heat)
Can help inactivate TPs
This modality can be used in combination with electrical stimulation

Transcutaneous Electrical Stimulation
High frequency, high intensity, avoid electrical stimulation of sufficient intensity to cause muscular contraction
Frequently stimulation is applied to the acupuncture points or to reference zones where pain is felt, rather than to TPs where pain originates

Massage
Myofascial release
Deep sedative
Foam rolls

Acupuncture
The procedure of inserting and manipulating needles into various points on the body to relieve pain or for therapeutic purposes

Medications
Corticosteroids - (local injections) can be destructive to muscle fibers
Analgesics and Muscle Relaxants – some benefit ?; acetaminophen, cyclobenzaprine
NSAID’s – indicated for excessive muscle soreness after treatment and in the presence of connective tissue inflammation

Antidepressant - short term for reactive
depression or long term for chronic pain management
Tricyclic antidepressants - Amitriptyline (Elavil), Nortriptyline (Pamelor)
Selective serotonin reuptake inhibitors ( SSRIs ) – Zoloft, Paxil, Lexapro, Prozac
Selective serotonin and norepinephrine reuptake inhibitor ( SNRIs ) – Savella, Cymbalta

Low-level laser therapy (LLLT, also known as cold laser therapy, laser biostimulation)
It is unclear how LLLT works
Short term use for pain
Cold lasers are also sometimes used for acupuncture

Exercises
As the TPs are inactivated and rest pain fades , a carefully graded exercise program is needed to increase endurance
Stretching and postural exercises
Strengthening – i.e. Therabands
Conditioning - low impact aerobic - warm pool, swimming

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Myofascial pain syndrome

by Margarita Correa MD - Physical Medicine Institute

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