Chronic Myofascial Pain

Chronic Myofascial Pain : 

Chronic Myofascial Pain Dr. E. McIntosh January 2008

Case 1 : 

Case 1 30 year old female Severe pain to neck, rt. shoulder, upper back x 1 year after whiplash injury to neck due to MVA Constant, dull ache, severe Cramps, weakness to hands Aggravated by activity, severe activity limitation Poor response to various pain medications and physiotherapy

Case 1 - Exam : 

Case 1 - Exam Young female, painful distress. Depressed+ Severe muscle spasm to neck, shoulders and upper back Markedly reduced active and passive ROM to neck, rt. Shoulder Severe tenderness with multiple foci of exquisite tenderness (trigger points) No neurological deficits

Chronic Myofascial Pain : 

Chronic Myofascial Pain Formerly Myofascial Pain Syndrome Pain +/- motor +/- autonomic symptoms due to myofascial trigger points Local or regional distribution

Myofascial Trigger Points : 

Myofascial Trigger Points A hyper-irritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band Always tender Weakens the muscle Prevents full lengthening of muscle (Restricts ROM ) Refers specific pattern of pain +/- motor +/- autonomic phenomena when stimulated Active or Latent

Scope of the Problem : 

Scope of the Problem Myofascial TrPs very common 30 – 50% of pain patients in general medical practice 80 – 95% of paitents in pain centers 55% of patients at head and neck pain clinic Often misdiagnosed Tremendous cost and suffering due to repeated medical visits, investigations and failed medical therapies Patients often labeled as neurotic, psychosomatic or malingerers

Cause : 

Cause Acute or chronic muscle overload Poor Posture Poor biomechanics Repetitive stress Cold stress Trauma Radiculopathy

Pathophysiology : 

Pathophysiology

Trigger Point Complex : 

Trigger Point Complex

Symptoms : 

Symptoms Pain – poorly localized, regional, aching Can be severe, even disabling Weakness, fatigue Numbness, paresthesias, dysesthesias Poor sleep Varying levels of disability Depression

Symptoms : 

Symptoms Autonomic dysfunction Abnormal sweating Persistent lacrimation Post nasal drip Pilomotor activation (gooseflesh) Proprioceptive disturbance Imballance Dizziness Tinnitus

Signs : 

Signs Regional tenderness Taut band – ropelike induration in the muscle Tender nodule – along the taut band, Highly localized, exquisitely tender Jump sign Local twitch response Pain Limited ROM, muscle weakness

Pain Referral Patterns : 

Pain Referral Patterns

Pain Referral Patterns : 

Pain Referral Patterns

Pain Referral Patterns – Trapezius : 

Pain Referral Patterns – Trapezius

Pain Referral Patterns - SCM : 

Pain Referral Patterns - SCM

Pain Referral Patterns – Levater Scapulae : 

Pain Referral Patterns – Levater Scapulae

Common Misdiagnoses : 

Common Misdiagnoses Angina - TrP in Pectoralis major Appendicitis – Lower Rectus Abdominis Migraine – SCM, temporalis, posterior cervicals Low back pain – Lower rectus abdominis TMJ dysfunction – Masseter, pterygoids Rotator cuff – Supraspinatus C5-C6 Radiculopathy – Scalenes, supraspinatus, infraspinatus,

Treatment Approach : 

Treatment Approach Remove underlying cause Inactivate the trigger points Identify and correct perpetuating factors Help the patient to restore and maintain normal muscle function

Treatment : 

Treatment Spray and stretch Trigger point injection Trigger point pressure release Stretch/ROM exercises Deep stroking massage Heat therapy Activity modification Elimination of perpetuating factors Drugs

TPI in upper Trapezius : 

TPI in upper Trapezius

TPI Mid and Lower Trapezius : 

TPI Mid and Lower Trapezius

TPI – SCM : 

TPI – SCM

Shower Self-Stretch Exercise : 

Shower Self-Stretch Exercise

Prognosis : 

Prognosis Depends on: Duration of symptoms Effectiveness of treatment Patient motivation Removal of perpetuating factors Good to excellent for most patients who are motivated and compliant

Case 1, Conclusion : 

Case 1, Conclusion Treatment Weekly TPIs over 5wks Stretch and ROM exercises Daily heat therapy Oral Lyrica, Scutamil C Outcome Pain-free, off medications Normal activities