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 Syndrome

• 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)

Myofascial Pain Syndrome

• 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

Myofascial Pain Syndrome

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”

Myofascial Pain Syndrome

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

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Myofascial Pain Syndrome

• 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

Myofascial Pain Syndrome

• 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

Myofascial Pain Syndrome

Myofascial Pain Syndrome

Myofascial Pain SyndromeLaboratory 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

Myofascial Pain SyndromeTreatments

• Stretch and Spray Technique

• Heat application / mobilization

• Injection and stretch

• Ultrasound (deep heat)

• Acupuncture

Myofascial Pain SyndromeTreatments

• Transcutaneous Electrical Stimulation

• Massage

• Low-level laser therapy (LLLT, also known as cold laser therapy)

• Medications

• Exercise / muscle rehabilitation

Myofascial Pain Syndrome

Stretch and Spray• Stretch is the actionaction• Spray is distraction

Vapocoolant spray :

Ethylchloride ( too cold, flammable, toxic) vs.

Fluori-Methane (non-flammable, non toxic, does not irritate skin)

Myofascial Pain Syndrome

Myofascial Pain SyndromeHeat 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

Myofascial Pain Syndrome

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

Myofascial Pain Syndrome

Ultrasound

(deep heat)• Can help inactivate

TPs• This modality can be

used in combination with electrical stimulation

Myofascial Pain SyndromeTranscutaneous 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

Myofascial Pain SyndromeMassage

• Myofascial release• Deep sedative• Foam rolls

Myofascial Pain Syndrome

Acupuncture • The procedure of

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

Myofascial Pain SyndromeMedications

• 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

Myofascial Pain Syndrome

• 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

Myofascial Pain Syndrome• 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

Myofascial Pain SyndromeExercises

• 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

Myofascial Pain Syndrome

Thanks!