Download - Specialty Care National Program
Myofascial Techniques for
Back and Neck Pain
Presented by:
Edward S. Lee MD
National Program Faculty:
Edward S. Lee MD
Director, Interdisciplinary Pain Rehabilitation Program
VA Pittsburgh Healthcare System
Part 2
Specialty Care National Program Mini-Residency – Pain Management
February 10-12, 2015
IMAGING STUDIES Magenetic Resonance Elastography Thermography
Ultrasound
Referred Pain
• Dorsal horn sensitization spreads to adjacent
myotomes, via antidromal mechanisms
involving substance P, causing referred pain.
• Predictable patterns.
• Can mimic radicular pain, nerve
entrapment, intrinsic joint disease or even
visceral referred pain.
• Follow “anatomy trains”, or acupuncture
meridians, rather than dermatomes.
Piriformis Syndrome
• Due to local pressure on sciatic nerve.
• History of direct trauma or prolonged sitting.
• Internal rotation exacerbates symptoms.
• External rotation relieves pressure on nerve.
• Patients may undergo laminectomy but have persistent symptoms.
Other Conditions Associated with Trigger Points
• Iliotibial band syndrome
• Temporomandibular disorder
• Lateral epicondylitis
• Achilles tendonitis
• Rotator cuff tendonitis
• Radiculopathy
Etc.
Infraspinatus
• Strain from reaching
backwards.
• Mimics C4
radiculopathy,
glenohumeral
arthritis, rotator cuff
tear, subacromial
bursitis.
Active vs. Latent Trigger Points
• Active – spontaneous pain, may cause pain
with movement, or limit range of motion.
• Latent – pain elicited with palpation. Latent
trigger points can influence muscle activation
patterns, which can result in poorer muscle
coordination and balance.
Location of Trigger Points
• Central – within a taut band.
• Attachment – at tendinomuscular junction.
Other Classifications
• key trigger point – has pain referral pattern along a pathway that activates a latent satellite trigger point on the pathway, or creates it.
• Successfully treating the key trigger point will often resolve the satellite, either converting it from being active to latent or completely treating it.
• primary trigger point – biomechanically activates a secondary trigger point in another structure.
• Treating the primary trigger point does not treat the secondary trigger point.
Superficial Paraspinal Muscles
• TrP may be a satellite of a key TrP in
the latissimus dorsi.
• Due to sudden overload or traumatic
event, or repeated contraction over a
period of time;
• Quick awkward movement combining
bending and twisting of the back,
especially when muscles are fatigued;
• Almost any factor that contributes to a
significant gait deviation can activate
TP’s in iliocostalis;
• Also associated with prolonged
immobility – sitting, bedrest, etc.
• Mimic inguinal hernia, cholecystitis,
splenic, or even appendiceal pain.
Quadratus Lumborum • Acute trauma – lifting,
twisting strain.
• Deep, aching low back
pain at rest, severe
pain in unsupported
standing or sitting.
• Deep trigger points
refer to SI joint.
• Superficial trigger
points refer to hip, iliac
crest, groin.
• Mimics radiculopathy,
hip OA, trochanteric
bursitis, hernia, etc.
Scalenes
• Associated with
“whiplash” injury.
• Referral pattern in the
distribution of the fifth
cervical nerve root
dermatome and myotome,
with spillover into the
adjacent root distributions.
• May be associated with
Thoracic Outlet Syndrome
– compressing brachial
plexus, axillary vessels, or
lymphatics.
Palpation of Trigger Point
Left: Skin pushed to one side to begin
palpation (A). The fingertip slides
across muscle fibers to feel the cord-
line texture of the taut band rolling
beneath it (B). The skin is pushed to
other side at completion of movement.
This same movement performed
vigorously is snapping palpation
(C).Right: Muscle fibers surrounded by
the thumb and fingers in a pincer grip
(A). The hardness of the taut band is
felt clearly as it is rolled between the
digits (B). The palpable edge of the
taut band is sharply defined as it
escapes from between the fingertips,
often with a local twitch response (C).
Local Twitch Response
A: Palpation of a taut band
(straight lines) among normally
slack, relaxed muscle fibers
(wavy lines). B: Rolling the band
quickly under the fingertip
(snapping palpation) at the
trigger point often produces a
local twitch response that
usually is seen most clearly as
skin movement between the
trigger point and the attachment
of the muscle fibers.
MPS Diagnosis
• Consider myofascial pain when there is regional
pain without any findings on imaging studies.
• Sometimes, persistent myofascial pain may be a
muscle response to an underlying structural
spine or visceral problem.
• Palpate for taut bands and trigger points.
• MPS may be associated with weakness and
autonomic signs (warmth, erythema,
piloerection).
• Screen for endocrine abnormalities and
nutritional deficiencies.
MPS Diagnosis
• Screen for serious medical pathology
(Red Flags), and for psychological and social
factors that may delay recovery
(Yellow Flags).
• Use a numeric pain rating and functional
scale to determine severity of pain disability.
• Identify and manage perpetuating factors
(posture, repetitive actions, occupational
factors).
Myofascial Assessment
Symptoms
• Local and referred pain
• Pain with isometric
contraction
• Stiffness and limited ROM
• Muscle Weakness
• Myofascial holding pattern
• Paresthesia and
numbness possible
• Autonomic dysfunction
Physical Findings
• Local Tenderness
• Single or multiple
muscles
• Trigger points active
• Firm or Taut Bands
• LTR
• Muscle weakness
• Muscle Shortening
Collaborative Care Model
Biopsychosocial interdisciplinary team
approach with cognitive-behavioral components
encouraging
exercise and active participation
of the patient in the plan of care
MPS Treatment
• Treatment consists more in restoring muscle
balance and function through physical
techniques rather than with medication
management.
• Behavioral interventions are vital to success.
Treatments
• Behavioral management
• Physical Therapy
• Exercise
• Nutrition, including proper hydration.
• Posture correction
• Complementary/Traditional/Integrative Medicine
• Manual Therapies
• Needle Interventions
• Pharmacotherapy
Behavioral Management
• Depression – 50% comorbidity
• Stress management
• Relaxation techniques
• Mindfulness-Based Stress Reduction
• Cognitive behavioral therapy
• Chemical dependency treatment, including
nicotine.
• Anger management
• Biofeedback
Nutrition and Inflammation
• Typical American diet is pro-inflammatory –
high in simple carbohydrates and
hydrogenated fats.
• Ideally omega-6 to omega-3 should be < 4:1;
typical dietary omega-6:omega-3 is 10:1 or
greater.
Omega-3 Fatty Acids
Supplementing
EPA and DHA, 3
g daily, can
reduce
inflammatory
cytokines and
eicosanoids,
leading to
decreased
cardiovascular
disease,
improved mood,
and decreased
joint pain in RA.
Antioxidants
• Free-radical damage can trigger inflammatory
response, and is implicated in chronic pain,
cardiovascular disease, cancer, degenerative
neurologic disorders, etc.
• Pathways to scavenge free radicals are
nutrient-dependent.
• Plants provide numerous antioxidant
phytochemicals including flavenoids,
carotenoids, lycopene, tocopherols (vitamin
E), vitamin C, etc.
Nutritional Deficiencies
• Vitamin D
– if 25-OH vitamin D<18 ng/mL,
check PTH, serum and urine calcium,
calculate fractional excretion.
• Vitamin B12
– Screen for anemia.
– Check for elevated methylmalonic acid for
borderline low cobalamin (200-300 pg/mL).
– Consider Intrinsic Factor antibody testing.
• Iron - screen for anemia.
• Water!
Simple Dietary Guideline
• Michael Polan
• In Defense of Food
• “Eat food. Not too much. Mostly vegetables.”
Consider Mediterranean Diet
• Meets recommendations for anti-inflammatory
diet.
• Less restrictive than many other dietary
regimens.
• High in fruits, vegetables, fish, and
monounsaturated fats such as olive oil.
• Low intake of dairy products and red meat.
• May be effective for reducing pain in
rheumatoid arthritis.
Physical Rehabilitation
• Fitness program
– Gentle graded strength training
- Cardiovascular (aerobic activity)
- Flexibility
- Balance
• Body mechanics and posture
• Modalities
- Ice/Heat, Massage, TENS, Ultrasound, Laser,
Aquatic Therapy, etc.
Aerobic Exercise
• Start with 5 to 10 minute sessions, 50% of
maximum heart rate, 3 days/week.
• Goal of 30 minutes sessions, 75-85%
maximum heart rate, 5 days/week.
• Rule of thumb:
maximum heart rate = 220-age.
Posture
Anterior Pelvic Tilt
• Problem: Lack of support through the transverse abdominus, instability of lower two lumbar vertebra, leading to contracture of psoas & iliacus. Hip joints may be unstable due to stretched joint capsules as well.
• Exercise: Kneel on left knee, with right foot on the floor in front, knee bent. Press forward to stretch left hip. Tighten gluteus on left side. Reach upward with left arm and stretch to the right side. Hold for a count of 30 seconds. Switch sides, three repetitions on each side.