2. Introduction:-
Myofascial pain is a "pain associated with inflammation or irritation
of muscle or fascia surrounding the muscle".
Myofascial pain is a common issue with estimates that 85% of the
general population will experience it at some point in their lifetime.
Myofascial pain syndrome (MPS) is a common clinical problem,
arising from the muscle and produces sensory, motor and autonomic
symptoms which are caused by myofascial trigger points which are
focal areas of tenderness caused by hypercontracted muscle tissue.
3. They are usually a taut band of skeletal muscle which is painful on
compression or deep palpation and can give rise to characteristic referred
pain ,motor dysfunction and autonomic phenomena.
MPS is a soft tissue pain syndrome where the pain is present primarily in a
single area or quadrant of the body, as compared to other soft tissue pain
syndromes, such as chronic fatigue syndrome, hypermobility syndrome, or
fibromyalgia, where the pain is generalized.
It can be acute or chronic; it can also be post-traumatic, lasting beyond the
“normal” time of healing, usually over 6 months.
4.
5. Classification and Clinical Presentation:-
Myofascial trigger points are classified into-
1.active and
2.latent
An active trigger point is one with spontaneous pain or pain in
response to movement that can trigger local or referred pain.
A latent trigger point is a sensitive spot with pain or discomfort only
elicited in response to compression.
6. Common clinical characteristics of myofascial TrPs :-
o Pain on compression, may elicit local pain and/or referred pain that is
similar to a patient's usual clinical complaint or may aggravate.
o Palpable taut band with cross fiber flat or pincer palpation
o Hypersensitive spot within taut band
o Local twitch response when adequately stimulated
o May produce motor and autonomic phenomena ,including vasoconstriction,
pilomotor response and hypersecretion.
o May prevent full lengthening of the muscle (restrict ROM)
o May cause weakness of muscle
7.
8. Active TrPs: –
o Refers or produces a patient’s recognized pain
o Spontaneous local or referred pain
o Reproduce any symptom, not just pain , experienced by the patient
o Patient recognizes the symptoms as familiar
o The symptoms may be absent at the moment of the examination , but
will appear during manual palpation.
9. Latent TrPS:-
o Local and referred unrecognized pain
o Painful only when palpated or needled
o Do not reproduce symptoms experienced by the patient
o Patient does not recognize symptoms caused by cross – fiber flat or
pincer palpation
o Latent TrPs contribute the process of nociception , but without
reaching the threshold to activate ascending pathway from the dorsal
horn to brain.
10. Satellite TrPs:-
When pain becomes persistent by an active TrPs patient may develop A
other trigger point in localized referral zone of primary TrPs, which
usually in an overloaded synergist muscle known as satellite TrPs.
Referral zone:-
o Corresponds to the pain pattern described by the patient
o Often as diffuse pain,
o Usually distant to the active trigger point location
o Each trigger point has its own referral zone
11. o When spontaneous electrical activity (SEA) recorded in myofascial Trp
sites with needle EMG, site of this electrical activity is called "active
locus".
o SEA consists of continuous, noise-like action potentials that can range from
5 to 50 µV, with intermittent large amplitude spikes up to 600 µV.
o This abnormal endplate potential is caused by an excessive release of
acetylcholine at the motor endplate.
o The magnitude of SEA is related to the pain intensity in patients with
myofascial trigger points.
12. Etiology
Several possible mechanisms of myofascial trigger points, including;-
o Low-level muscle contractions,
o Muscle contractures,
o Direct trauma,
o Muscle overload,
o Postural stress,
o Unaccustomed eccentric contractions,
o Eccentric contractions in unconditioned muscle, and
o Maximal or submaximal concentric contractions
13. Pathophysiology:-
o Development of taut band, is a motor abnormality
o Several mechanisms have been hypothesized to explain this motor
abnormality,
o The most accepted one is "Integrated Hypothesis" first developed by
Simmons and later expanded by Gerwin.
14. Simmons' integrated hypothesis:-
Is a six-link chain starts with abnormal
acetylcholine release. This triggers an increase in
muscle fiber tension (formation of taut band). The
taut band is thought to constrict blood flow that leads
to local hypoxia. The reduced oxygen disrupts
mitochondrial energy metabolism reducing ATP and
leads to tissue distress and the release of sensitizing
substances. These sensitizing substances lead to pain
by activation of nociceptors and also lead to
autonomic modulation that then potentiates the first
step: abnormal acetylcholine release.
15. Gerwin expanded this hypothesis by adding more specific details:-
Sympathetic nervous system activity augments acetylcholine release and that local
hypoperfusion caused by the muscle contraction (taut band) resulted in muscle ischemia
or hypoxia leading to an acidification of the pH.
The prolonged ischemia leads to muscle injury resulting in the release of potassium,
bradykinins, cytokines, and substance P which might stimulate nociceptors in the
muscle.
The end result is the tenderness and pain observed in myofascial trigger points.
Depolarization of nociceptive neurons causes the release of calcitonin gene-related
peptide (CGRP).
CGRP inhibits acetylcholine esterase, increases the sensitivity of acetylcholine
receptors and release of acetylcholine resulting in SEA.
16. In recent studies Shah et al. confirmed the presence of following
substances using microdyalisis techniques at trigger point sites:-
Elevations of substance P, protons (H+), CGRP, bradykinin, serotonin,
norepinephrine, TNF, interleukins, and cytokines were found in active
trigger points compared to normal muscle or even latent trigger points.
The pH of the active trigger point region was decreased as low as pH 4
(normal pH value is 7,4) causing muscle pain and tenderness as well as
a decrease in acetylcholine esterase activity resulting in sustained
muscle contractions.
17. Perpetuating Factors
In some cases, there may be perpetuating factors that have a feed-
forward effect on myofascial pain.
These factors may chronify the pain and tenderness.
Perpetuating factors may also have an important role in wide
spreading the referred pain by central sensitizing mechanisms.
18. (a)Mechanical perpetuating factors :-
1. Scoliosis
2. Leg length discrepancies
3. Joint hypermobility
4. Muscle overuse
(b)Systemic or metabolic perpetuating factors :-
1. Hypothyroidism
2. Iron insufficiency
3. Vitamin D insufficiency
4. Vitamin C insufficiency
5. Vitamin B12 insufficiency
19. (c)Psychosocial perpetuating factors:-
1. Stress
2. Anxiety
(d)Other possible perpetuating factors:-
1. Infectious diseases
2. Parasitic diseases (e.g. Lyme disease)
3. Polymyalgia rheumatica
4. Use of statin-class drugs
20. In some cases, managing and correcting an identified
perpetuating factor may lead to a complete resolution of pain and
may be the sole therapeutic approach needed to relief the patient’s
symptoms.
21. Diagnosis:-
Palpation is the gold standard in identifying the presence of taut
bands in muscle. This involves the training and accurate skills of
practitioners to identify these taut bands.
Palpation of taut bands needs a precise knowledge of muscle
anatomy, direction of specific muscle fibers and muscle function.
The palpation on muscle must meet several essential criteria and
confirmatory observations to identify the presence of trigger
points.
22. Essential criteria:-
•Taut band palpable (where muscle is accessible)
•Exquisite spot of tenderness in a taut band
•Patient recognition of current pain complaint by pressure
of examiner
•Painful limit to full stretch ROM
23. Confirmatory observations:-
•Visual or tactile local twitch response
•Referred pain sensation on compression of the taut band
•SEA confirmed by electromyography
•Microdyalysis at trigger point site
Recent diagnostic techniques:-
1.Magnetic resonance elastography
2.Sonoelastography combined with Doppler imaging
24. Magnetic resonance elastography:-
The technique involves the introduction of cyclic waves into the
muscle, and then using phase contrast imaging to identify tissue
distortions.
The speed of the waves is determined from the images. Shear
waves travel more rapidly in stiffer tissues.
The taut band can then be distinguished from the surrounding
normal muscle.
25. Sonoelastography combined with Doppler imaging:-
Technique used to confirm the extension of myofascial trigger
point sites.
It uses a clinical ultrasound imaging system with a 12-5 MHz
linear array, associated to an external vibration source (hand
held vibrating massager) working at cycles of approximately
92Hz. Doppler imaging is used to identify surrounding blood
flows.
26. Differential Diagnosis:-
One source of confusion associated with myofascial pain is
fibromyalgia.
Both entities are likely to cause severe muscle pain and
tenderness but they do not share the same etiology or
pathogenesis and their clinical presentation not same.
Main differences between myofascial pain and fibromyalgia:-
27. Myofascial Pain Fibromyalgia
1).Local Pain 1).Widespread Pain
2).Regional Condition 2).Bilateral as well as axial Pain
3).Presence of Taut Band 3).Absence of taut bands
4).Referred Pain 4).Presence multiple tender
points (at least 11)
28. A differential diagnosis should be made with other conditions such
as: -
o Muscle Spasm
o Neuropathic Or Radicular Pain
o Delayed Onset Muscle Pain
o Articular Dysfunction And
o Infectious Myositis.
29. Management:-
There are two different approaches in the treatment of myofascial
trigger points:-
1. Non-Invasive and
2. Invasive techniques
30. Non-Invasive techniques :-Therapeutic Ultrasound, Low-level laser
therapy, Transcutaneous Electrical Nerve Stimulation (TENS), drug therapy
(e.g. NSAIDs, muscle relaxants, benzodiazepines, antidepressants, lidocaine
patch etc.) and several physical and manual therapy techniques such as:-
•Stretching techniques (e.g. spray and stretch)
•Post-isometric relaxation
•Active Release Techniques
•Trigger point pressure release
•Muscle energy techniques
•Massage
31. Invasive techniques :- The inactivation of an active loci in a
central trigger point with a needle.
Different modalities exist:-
•Dry needling
•Anesthetic injections
•Botulin toxin A injection
32. FIBROMYALGIA
CLINICAL FEATURES
Diffuse aching stiffness and fatigue with multiple tender points in
specific areas
Headaches
Neck and upper trapezius discomfort
Upper extremity paraesthesia
Fatigue
lack of sleep
33. May experience morning stiffness but it varies throughout the
day
May be associated with IBS, RA, Lyme, hyperthyroidism
Triggers may exacerbate symptoms:-
1. Physical activity
2. Inactivity
3. Sleep disturbance
4. Emotional stress
34. ARA CLASSIFICATION:
1. Widespread pain ( ≥ 3 months)
pain in the left and right side of the body above and below the
waist.
Axial involvement—Cervical, anterior chest, thoracic, and low
back
2. Patient must exhibit ≥ 11 of 18 tender points
Bilateral involvement
Occipital, lower cervical, trapezius, supraspinatus, second rib,
36. 1.Trigger points can be activated by a range of factors. Which of these
is not a factor?
1.Overstreching/ overuse
2.Working in or living in a cold environment
3.trauma/ sudden change in emotional state
4.Heat
37. 2.Which of the following is the most appropriate method for
diagnosing myofascial pain syndrome in the temporomandibular joint?
1.Measurment of ESR
2.Physical examination
3.Polysomnography
4.X-ray
38. 3.A hyperirritable spot with in a taut skeletal muscle band that was
activated by acute or chronic overload of the muscle in which it occur ,
and was not activated as a result of trigger point activity in another muscle
of the body is known as?
1.Secondary trigger point
2.Tertiary trigger point
3.Primary trigger point
4.Beginning trigger point
39. 4.Which of these is not a treatment of trigger points?
1.Stretch and spray
2.Variable ischemic pressure
3.Direct ischemic pressure
4.Twitch response
40. 5.Trigger points originate at:
1.Beginning of muscle fiber
2.Midpont of muscle fiber
3.End of muscle fiber
4.One quarter along a muscle’s fiber
41. 6. A…………………trigger point may be activated by a trigger
point in another area of the body:
1.Satellite
2.Key
3.Attachment
4.Central
42. 7. In differentiating fibromyalgia from myofascial pain syndrome,
which of the following is more characteristic of myofascial pain
syndrome?
1.Patient have pain in bones and joints
2.There are no histologic abnormalities
3.All fibromuscular tissue is sensitive to touch
4.Pain and tenderness, often related to trauma, are localized
43. 8.synergistic muscle act on movable joints .synergists are sometimes
referred to as “neutralizers” because they help cancel out, or neutralize,
extra motion from the agonists to make sure that the force generated
works within the desired plane of motion. Which pair is synergist?
1.quadricepss,hamstring
2.Brachoradialis ,biceps
3.biceps, triceps
4.Tibialis anterior, calf muscle
44. 9.Treatment of myofascial pain syndrome may include any except
which of the following:
1.Oral appliance
2.Surgery
3.Benzodiazepine
4.Acetaminophen
45. 10.In addition to a history of widespread pain for at least 3 months, a
diagnosis of fibromyalgia is confirmed based on which of the following
criteria?
1.Pain and stiffness when getting up from a sitting position
2.Tenderness at specified tender points
3.Loss of interest in usual hobbies
4.Abrupt onset of pain and tenderness
