Myofascial pain syndrome

1. MYOFASCIAL PAIN SYNDROME Steffi Andrat

2. What is Myofascial pain syndrome? • Often overlooked • Central feature – MYOFASCIAL TRIGGER POINTS so named because its stimulation is like pulling the trigger of a gun, producing effects at another place (target) called the reference zone Myofascial pain syndrome is defined as pain of muscular origin that originates in a painful site in muscle

3. History of Pain • Acute/Chronic • Dull, deep, aching • Mimics radicular/visceral pain • Often referred to head/ neck/ leg/ hip

4. Some predisposers • History of remote injury relevant • Postural stress, muscle imbalance, overuse • Iron deficiency • Hypothyroidism • Low Vit D • Low B12 • Parasitic infections

5. • Certain effects of sex hormones on pain mechanisms • Estradiol  modulates NMDA receptor in dorsal horn  increasing nociceptive response • Estradiol  modulates excitability of primary sensory afferent nerves Gender differences???

6. ETIOLOGY How a trigger is formed Mechanism for tenderness and referred pain

7. Substance P Bradykinin Serotonin Cytokines HISTAMINE Intracellular Ca Muscle fibre contraction Ach release SNS Ischemia Hypoxia

8. Central sensitization Central nervous system modulates afferent nociceptive activity • SENSITIZATION to peripheral noxious stimuli in DORSAL HORN NEURONS Substance P  enhances activation

9. Central sensitization Dorsal horn neuron  nociceptive impulses rostrally  activation of somatosensory cortex  interprets all input as coming from receptive field of that neuron (expanded due to sensitization)

10. On Examination • Identify MTrP • Can be active or latent

11. Taut Band Central TrP • Tight/hard muscle band • Palpated perpendicular to fibre direction • Once identified, palpate (pincer grasp) to find area of greatest hardness (it is most tender) = centre/heart of TrP • Compression at least for 5-10 seconds -Induces RP/LTR

12. Normal Fibres Contraction knots The purpose of locating the area of greatest hardness in the taut band, which is also the area of greatest tenderness, is that THIS IS THE AREA TO BE TREATED • Contains numerous electrically active loci and numerous contraction knots • Sarcomeres within contraction knot are markedly shorter and wider

13. Additional characteristics Mechanical stimulation of taut band  local contraction  Local Twitch Response • Should be differentiated from DTR (entire muscle contracts) • LTR = brief, 25-250 ms, high amplitude polyphasic electrical discharge • For LTR, intact spinal reflex arc is needed • Unique to TrP

14. Additional characteristics Referred pain Limited ROM • Due to pain on lengthening affected muscle • Examination gives clue about which muscle has TrP

15. Additional characteristics Weakness • Often but not always present • Reversed when TrP is inactivated Autonomic changes • Vascular dilatation and constriction  erythema/blanching/warmth/cool areas in distribution of nerve innervating involved muscle

16. DIAGNOSIS

17. • Located on taut muscle band • Exquisite Tenderness at a point on it • Reproduction of patients pain • Local twitch response • Referred pain • Produces weakness • Restricted ROM • Autonomic activity Essential for diagnosis Simmonds et al

18. Diagnostic inactivation When there is doubt clinically • Manually • Laser • Dry needling • TrP injection • An immediate unequivocal decrease in pain is good evidence

19. Objective identification • MR elastography – differentiates tissues of varying densities • Ultrasound – localizes hypoechoic elliptical focal areas • EMG – Signature signal - persistant low amplitude, high frequency discharge in the active TrP - spontaneous electrical activity

20. Lab investigations • Not very usefu for diagnosis • Can identify predisposers • Anemia • Hypothyroidism • Vit D • Vit B12 • Parasitic infections

21. Differential diagnosis of REGIONAL PAIN SYNDROMES

22. HEAD AND NECK • Headache • Dizziness • Neurological signs • ROM neck is painful • Upper trapezius • Levator scapulae • Posterior cervical msc • SCM • Facial muscles like masseter

23. SHOULDER • ACJ dysfunction • Rotator cuff signs • Impingement • Trapezius • Supraspinatus • Levator scapulae • Infraspinatus • Rhomboids • Subscapularis • Teres Major Minor • Pectorals • Lats dorsi • Deltoid

24. CHEST PAIN • History and signs of esophageal disease • Cardiac disease (angina) • Pectoralis Major • Abd obliques • Rectus femoris • Back muscles

25. LOW BACK • Spondyloarthropathis • Spondylolisthesis • PIVD • Spinal stenosis • Psoas • Quadratus lumborum • Paraspinals • Abd obliques • Rectii

26. PELVIS/HIP • Internal organ disease (painful bladder, IBS, endometriosis) • Radicular pain from LS spine • Abdominal msc • Psoas • Quadratus lumborum • Piriformis • Adductors • Hams (specially upper Semitendinosis)

27. KNEE • Intrinsic joint disease • Radiculopathy • Vastus medialis, lateralis • Hamstring, gastrocnemius

28. ANKLE/FOOT • Intrinsic joint disease • Radiculopathy • Anterior and posterior leg muscles • Gastroc-soleus • Tibialis anterior • Foot intrinsics

29. Treatment

30. • Education • Pharmacological management • Non pharmacological • Avoid unnecessary tests • Recognize and address underlying factors • Importance of sleep, cardiovascular fitness, body mechanics

31. • NSAIDs • Muscle relaxants • BZDs • Antidepressants • Tramadol • Lidocaine patch • Education • Pharmacological management • Non pharmacological

32. • Exercise • Postural and ergonomic modifications • Stress reduction • Acupuncture • Massage • Ultrasound • Needling • Botulinum toxin • Education • Pharmacological management • Non pharmacological

33. THANK YOU

Myofascial pain syndrome

Myofascial pain syndrome

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