We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Myofascial Pain Syndrome

From WikiSM
Jump to: navigation, search

Other Names

  • Myofascial Neck Pain
  • MPS
  • Myofascial trigger points (MTrPs)

Background

  • This page refers to 'myofascial pain syndrome' (MPS), a myalgic condition
    • Definition: non-inflammatory disorder of musculoskeletal origin, associated with pain and muscle stiffness, characterized by the presence of trigger points

Epidemiology

  • Not well described in the literature
  • One study estimated 30% of patients with musculoskeletal complaints suffered from MPS[1]
  • Average age range is typically 27-50 years[2]

Pathophysiology

  • Pathophysiology is poorly understood
  • Energy crisis of muscle fibers is one postulated theory
    • Repetitive or pronged activity leads to overload myofibrils with subsequent hypoxia, ischemia
    • Dysfunctional intracellular calcium pumps
    • Inflammatory state
  • Other proposed theories include:
    • Neurogenic inflamation
    • Sensitization and limbic dysfunction
  • Trigger points (TP) can be more accurately defined as "hyperirritable palpable nodules in the skeletal muscle fibers"
    • Also described as tender points in a taut band of muscles
    • Defined as detectable superficial palpable tenderness in the muscle or located in areas of spasm
    • Typical size is 2-10 mm
    • Sensitivity of spot generally increases with increased tension/ pressure
  • Patients may have active or latent trigger points
    • Trigger points may oscillate between active and latent depending on internal or external stressors
  • Perpetuating and aggravating factors may lead from an acute to a more chronic syndrome
  • Other diseases can look like MPS making it a challenging diagnosis
    • No diagnostic gold standard, imaging, or laboratory modality for MPS

Etiology

  • Traumatic events
  • Muscular overloads such as overuse activities, abnormal posture
  • Structural factors such as spondylosis, scoliosis and osteoarthritis
  • Psychological stress
  • Systemic pathology including hypothyroidism, vitamin D deficiency and iron deficiency.
  • Physical deconditioning

Risk Factors


Differential Diagnosis

Differential Diagnosis Neck Pain

Differential Diagnosis Back Pain


Clinical Features

  • General: Physical Exam Neck, Physical Exam Back
  • History
    • Patients often suffer from localized muscle pain and referred pain in patterns
    • Infraspinatus pain can be referred to the Deltoid area
    • Onset of symptoms may be acute or more insidious
    • Some patients may have precipitating illness or trauma, others have no clear cause
  • Physical Exam
    • Digital pressure on a tender spot elicits pain similar to their usual pain distribution and/or aggravate current pain
    • May reproduce a loccal twitch response by repetitive stimulation of the trigger point
    • Pain may be referred to other areas
    • Range of motion can be restricted
  • Special Tests
    • Jump Sign: Palpation of tender nodule cause spontaneous exclamation or movement

Evaluation

  • Primarily a clinical diagnosis

Radiographs

  • Can be useful to exclude other etiology of the affected area(s)

Ultrasound

  • Trigger points may be more hypoechoic compared to surrounding muscle (need citation)
  • Useful to exclude other pathology

EMG/NCS

  • End plate noise

Classification

  • Acute MPS
  • Chronic MPS (persists longer than 6 months)

Management

Prognosis

  • By definition, non surgical
  • Primary goal should be to treat suspected underlying causal or contributing factors
  • Acute patients tend to have a favorable prognosis
  • In chronic cases, the average duration of symptoms is 63 months, with a range between 6 and 180[3]

Analgesics

  • NSAIDS
    • Oral formulations not studied in MPS however shown to help in MSK conditions
    • Hsieh et al: Topical diclofenac patch helped with symptoms of myofascial pain of the trapezius[4]
  • Tropisetron
    • Used for fibromyalgia, myofascial pain
    • One study showed it was superior to local anesthetics when used for local trigger point injections[5]
  • Opiates are not generally indicated
  • Lidocaine Patch
    • Limited studies showing some benefit[6]

Muscle Relaxants

  • Tizanidine
    • Malanga et al: effective in treating spasticity, pain in up to 89% of patients and 79% of physicians[7]
  • Benzodiazepines
    • One study showed statistically significant decrease in pain[8]
  • Cyclobenzaprine has not been studied in MPS

Anticonvulsants

Antidepressants

Other Pharmacotherapy

  • Botox (Botulinum Toxin)
    • One study study demonstrated botox injections a statistically significant difference in pain intensity, duration, and reduction of trigger points[9]
    • Other studies have showed no benefit[10]

Nonpharmacologic Therapies

  • Dry Needling
    • Hong et al showed benefit with or without lidocaine[11]
  • Trigger Point Injections
    • systematic review article concluded the ‘‘nature of the injected substance makes no difference to the outcome and that wet needling is not therapeutically superior to dry needling’[12]
  • Corticosteroid Injections are not currently recommended
  • Manual Therapy
    • Considered one of the more effective treatments for MPS
    • Definition is broad and includes deep pressure massage, spretch therapy, superficial heat, myofascial release among others
    • No high quality studies evaluating manual therapy
  • Therapeutic Ultrasound
    • Most studies have found mixed results, although they are generally of poor quality
    • Gam et al found no benefit for therapeutic ultrasound in any MSK disorder[13]
  • Transcutaneous Electric Nerve Stimulation (TENS)
    • Multiple studies appear to show some benefit among non-invasive modalities
    • One study compared it to trigger points and showed no statistically significant difference[14]
  • Magnetic Stimulation
  • Physical Therapy
    • Patients should be educated on stretching exercises

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications

  • Chronic pain

See Also


References


  1. Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West. J. Med. 1989 Aug;151(2):157-60
  2. Vázquez-Delgado E, Cascos-Romero J, Gay-Escoda C. Myofascial pain syndrome associated with trigger points: a literature review. (I): Epidemiology, clinical treatment and etiopathogeny. Med Oral Patol Oral Cir Bucal. 2009 Oct 01;14(10):e494-8.
  3. Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep. 2001 Oct;5(5):412-20.
  4. Hsieh L, Hong C, Chern S. Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius. J Pain Symptom Manag. 2010;39:116–25
  5. Muller W, Stratz T. Local treatment of tendinopathies and myofascial pain syndromes with the 5-HT3 receptor antagonist tropisetron. Scand J Rheumatol Suppl. 2004;119:44–8.
  6. Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic pain thresholds. Clin Ther. 2009;31:705–20.
  7. Malanga G, Gwynn M, Smith R, Miller D. Tizanidine is effective in the treatment of myofascial pain syndrome. Pain Physician. 2002;5:422–32.
  8. Fishbain D, Cutler R, Rosomoff H, Rosomoff R. Clonazepam open clinical treatment trial for myofascial syndrome associated chronic pain. Pain Med. 2000;1:332–9
  9. Benecke R, Heinze A, Reichel G, Hefter H, Gobel H, Dysport Myofascial Pain Study Group. Botulinum type A toxin complex for the relief of upper back myofascial pain syndrome: how do fixed-location injections compare with trigger point-focused injections? Pain Med. 2011;12:1607–14.
  10. Lew H, Lee E, Castaneda A, Klima A, Date E. Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study. Arch Phys Med Rehabil. 2008;89:75–80.
  11. Hong, Chang-Zem. "Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response." American journal of physical medicine & rehabilitation 73.4 (1994): 256-263.
  12. Cummings T, White A. Needling therapies in the management of myofascial trigger point pain: a systemic review. Arch Phys Med Rehabil. 2001;82:986–92.
  13. Gam A, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis. Pain. 1995;63:85–91
  14. Gu¨l K, Onal SA. Comparison of non-invasive and invasive techniques in the treatment of patients with myofascial pain syndrome. Agri. 2009;21:104–21.
Created by:
John Kiel on 25 April 2020 22:17:14
Authors:
Last edited:
17 November 2020 16:36:45
Categories:
Muscle Pathology | Neck | Back | Chronic