Myofascial Pain Syndrome


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Myofascial pain syndrome: clinical manifestations, perpetuating and aggravating factors, treatment options.

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Myofascial Pain Syndrome

  1. 1. Myofascial Pain Syndrome <ul><li>Margarita Correa MD FAAPMR </li></ul><ul><li>Physical Medicine and Rehabilitation </li></ul><ul><li>Pain Medicine </li></ul><ul><li>Physical Medicine Institute </li></ul><ul><li>2020 Oakley Seaver Dr. Ste 1 </li></ul><ul><li>Clermont FL 34711 </li></ul>
  2. 2. Myofascial Pain Syndrome <ul><li>Myofascial pain is a condition that affects the fascia (connective tissue that covers the muscles) </li></ul><ul><li>Pain is regional , acute or chronic </li></ul><ul><li>Physical finding - trigger point (TP) with associated dysfunction </li></ul><ul><li>Myofascial trigger point = hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia </li></ul>
  3. 3. Trigger Points (TPs)
  4. 4. Myofascial Pain Syndrome <ul><li>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 </li></ul><ul><li>A latent trigger point (TP) is a dormant (inactive) area that has the potential to act like a trigger point </li></ul>
  5. 5. Myofascial Pain Syndrome <ul><li>Trigger point (TP) </li></ul><ul><li>Painful on compression </li></ul><ul><li>Can evoke characteristic </li></ul><ul><li>referred pain and auto- </li></ul><ul><li>nomic phenomena </li></ul><ul><li>When the muscle is slightly snapped there’s a twitch response > > “jump sign” </li></ul>
  6. 6. Myofascial Pain Syndrome <ul><li>TPs area activated </li></ul><ul><li>directly by: </li></ul><ul><li>acute overload </li></ul><ul><li>overwork fatigue </li></ul><ul><li>direct trauma </li></ul><ul><li>extreme cold </li></ul><ul><li>postural strains </li></ul><ul><li>disuse syndrome </li></ul><ul><li>TPs are activated indirectly by: </li></ul><ul><li>other TPs </li></ul><ul><li>visceral disease </li></ul><ul><li>arthritic joints </li></ul><ul><li>emotional distress </li></ul>
  7. 7. Myofascial Pain Syndrome
  8. 8. Myofascial Pain Syndrome
  9. 9. Myofascial Pain Syndrome
  10. 10. Myofascial Pain Syndrome <ul><li>Active myofascial TPs vary in irritability from hour to hour and from day to day </li></ul><ul><li>TPs irritability may be increased from a latent >> active level by many factors (stress, muscle in a shortened position, chilling of the muscle, etc) </li></ul><ul><li>TPs cause stiffness and weakness of the involved muscle </li></ul>
  11. 11. Myofascial Pain Syndrome <ul><li>Passive or active stretching of the affected muscle increases pain </li></ul><ul><li>The stretch range of motion ( ROM ) is restricted </li></ul><ul><li>Pain  when the affected muscle is weakened </li></ul><ul><li>Active TPs commonly radiate deep tenderness and dysesthesia (unpleasant sensation) to the zone of referred pain </li></ul>
  12. 12. Myofascial Pain Syndrome
  13. 13. Myofascial Pain Syndrome
  14. 14. Myofascial Pain Syndrome <ul><li>Laboratory Findings </li></ul><ul><li>Routine laboratory test : no abnormalities </li></ul><ul><li>EMG & muscle biopsy : no diagnostic abnormalities </li></ul><ul><li>Thermograms of skin overlying active TPs shows increase in skin temperature, 5-10 cm in diameter </li></ul><ul><li>Reduced skin resistance may be observed in a small region over TP </li></ul>
  15. 15. 'Perpetuating factors' <ul><li>Nutritional deficiencies : especially vitamins C, </li></ul><ul><li>D, B-complex and iron </li></ul><ul><li>Hormone imbalances : low thyroid hormone </li></ul><ul><li>levels, premenstrual or menopausal </li></ul><ul><li>Infections : bacterial, viral or yeast </li></ul><ul><li>Allergies : wheat and dairy in particular </li></ul><ul><li>Poor oxygenation of tissues : aggravated by </li></ul><ul><li>tension, stress, inactivity, poor sleep, smoking, </li></ul><ul><li>lung diseases COPD </li></ul>
  16. 16. Myofascial Pain Syndrome <ul><li>Treatments </li></ul><ul><li>Stretch and Spray Technique </li></ul><ul><li>Heat application / mobilization </li></ul><ul><li>Injection and stretch </li></ul><ul><li>Ultrasound (deep heat) </li></ul><ul><li>Acupuncture </li></ul>
  17. 17. Myofascial Pain Syndrome <ul><li>Treatments </li></ul><ul><li>Transcutaneous Electrical Stimulation </li></ul><ul><li>Massage </li></ul><ul><li>Low-level laser therapy (LLLT, also known as cold laser therapy) </li></ul><ul><li>Medications </li></ul><ul><li>Exercise / muscle rehabilitation </li></ul>
  18. 18. Myofascial Pain Syndrome <ul><li>Stretch and Spray </li></ul><ul><li>Stretch is the action </li></ul><ul><li>Spray is distraction </li></ul><ul><li>Vapocoolant spray : </li></ul><ul><li>Ethylchloride ( too cold, flammable, toxic) vs. </li></ul><ul><li>Fluori-Methane (non-flammable, non toxic, does not irritate skin) </li></ul>
  19. 19. Myofascial Pain Syndrome
  20. 20. Myofascial Pain Syndrome <ul><li>Heat application </li></ul><ul><li>Moist heat is more effective than dry heat </li></ul><ul><li>Post-treatment muscle soreness is markedly reduced by applying a hot pack for a few minutes after stretch and spray </li></ul><ul><li>Electric heating pad - Thermal Pack Moist Heat </li></ul>
  21. 21. Myofascial Pain Syndrome <ul><li>Injection and Stretch </li></ul><ul><li>Dry needling </li></ul><ul><li>With the patient recumbent, using sterile technique to inject TPs with 0.5% procaine in isotonic saline, until area becomes non tender </li></ul><ul><li>Passively stretch </li></ul>
  22. 22. Myofascial Pain Syndrome <ul><li>Ultrasound </li></ul><ul><li>(deep heat) </li></ul><ul><li>Can help inactivate TPs </li></ul><ul><li>This modality can be used in combination with electrical stimulation </li></ul>
  23. 23. Myofascial Pain Syndrome <ul><li>Transcutaneous Electrical Stimulation </li></ul><ul><li>High frequency, high intensity, avoid electrical stimulation of sufficient intensity to cause muscular contraction </li></ul><ul><li>Frequently stimulation is applied to the acupuncture points or to reference zones where pain is felt, rather than to TPs where pain originates </li></ul>
  24. 24. Myofascial Pain Syndrome <ul><li>Massage </li></ul><ul><li>Myofascial release </li></ul><ul><li>Deep sedative </li></ul><ul><li>Foam rolls </li></ul>
  25. 25. Myofascial Pain Syndrome <ul><li>Acupuncture </li></ul><ul><li>The procedure of inserting and manipulating needles into various points on the body to relieve pain or for therapeutic purposes </li></ul>
  26. 26. Myofascial Pain Syndrome <ul><li>Medications </li></ul><ul><li>Corticosteroids - (local injections) can be destructive to muscle fibers </li></ul><ul><li>Analgesics and Muscle Relaxants – some benefit ?; acetaminophen, cyclobenzaprine </li></ul><ul><li>NSAID’s – indicated for excessive muscle soreness after treatment and in the presence of connective tissue inflammation </li></ul>
  27. 27. Myofascial Pain Syndrome <ul><li>Antidepressant - short term for reactive </li></ul><ul><li>depression or long term for chronic pain management </li></ul><ul><li>Tricyclic antidepressants - Amitriptyline (Elavil), Nortriptyline (Pamelor) </li></ul><ul><li>Selective serotonin reuptake inhibitors ( SSRIs ) – Zoloft, Paxil, Lexapro, Prozac </li></ul><ul><li>Selective serotonin and norepinephrine reuptake inhibitor ( SNRIs ) – Savella, Cymbalta </li></ul>
  28. 28. Myofascial Pain Syndrome <ul><li>Low-level laser therapy (LLLT, also known as cold laser therapy, laser biostimulation) </li></ul><ul><li>It is unclear how LLLT works </li></ul><ul><li>Short term use for pain </li></ul><ul><li>Cold lasers are also sometimes used for acupuncture </li></ul>
  29. 29. Myofascial Pain Syndrome <ul><li>Exercises </li></ul><ul><li>As the TPs are inactivated and rest pain fades , a carefully graded exercise program is needed to increase endurance </li></ul><ul><li>Stretching and postural exercises </li></ul><ul><li>Strengthening – i.e. Therabands </li></ul><ul><li>Conditioning - low impact aerobic - warm pool, swimming </li></ul>
  30. 30. Myofascial Pain Syndrome Thanks!