Chronic Myofascial Pain

Mindy Wallace CRNA, APRN, MSN, FAAPM

Medical Director

Cottage Hospital Pain Clinic

Woodsville, NH

Objectives

1. Explain difference between Chronic Myofascial Pain and Fibromyalgia

2. Describe trigger point pathophysiology.

3. Describe one method of identifying trigger points

4. Describe common precipitating and perpetuating factors in myofascial pain

5. Describe two treatment options

What is Chronic

Myofascial Pain?

Myofascial Pain

• JFK appointed the first female U.S. Surgeon General, Dr. Janet Travell

• She treated his myofascial LBP

Chronic Myofascial Pain & Fibromyalgia

•Myofascial pain is a common painful muscle disorder•Caused by myofascial trigger

point•Differentiated from fibromyalgia

•Involves multiple tender spots or tender points

•Often concomitant

Importance

• Chronic Myofascial Pain very common• 30 – 50% of pain patients in general medical practice • 80 – 95% of patients in pain centers• 55% of patients at head and neck pain clinic

• Often misdiagnosed as fibromyalgia

• Tremendous cost and suffering due to repeated medical visits, investigations and failed medical therapies

• Patients often labeled as neurotic, psychosomatic or malingerers

Chronic Myofascial

Pain• Causes pain problems

• Complicates pain problems

• Mimics other pain problems

Anatomy & Physiology

Normal Muscle Structure and Function

Over 400 Muscles

There are more than 400

muscles in the body

and each may harbor a

number of typical sites for

Trigger Points

Clinical Characteristics of

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

Physical Effects of Trigger

Points

• Mechanical distress on

• Tendons

• Joints

• Nerves

• Spinal discs

• Other muscles

• Pain, spasm, stiffness

• Decrease in blood flow

• Increase in toxin accumulation

CNS & Trigger Points

Pathophysiology

Activation and Perpetuation of Trigger Points

Mechanical Perpetuating Factors

• Skeletal Asymmetry/ Disproportion• Short leg syndrome• Asymmetric Hemipelvis• Long Second Metatarsal• Short Upper Arms• Scoliosis

• Poor Posture• Eccentric Repetitive

Motions• Restrictive Clothing• Prolonged Immobility• Direct Trauma• Other Trigger Points

Systemic &

Environmental Perpetuating

Factors

• Nutritional Deficiencies

• Metabolic / Endocrine Inadequacies

• Psychological / Behavioral Stress

• Chronic Infections

• Allergies

• Neuropathies

• Impaired sleep

• Cold Stress

Vicious Cycle

Definitions• Trigger Point

• Active trigger point

• Latent trigger point

• Referred pain

• Taut band

• Jump sign

• Twitch response

Active Trigger Point

• Spot tenderness

• Muscle dysfunction

• Compression Pain

• Stimulated local twitch response (LTR)

• Referred phenomenon

• Pain

• Motor

• Autonomic

Latent Trigger Point

• Clinically quiescent TrP

• Painful only when palpated

• May have all other clinical characteristics of an active TRP

• Always has a taut band that increases muscle tension and restricts ROM Travell &

Simons

Referred Pain

• Active TrPs refer pain in pattern characteristic of that muscle

• Area of referred pain is often tender and may contain satellite TrPs

• Latent TrPs also refer pain on pressure but usually require more pressure

Taut Band

• A cord like band of fibers is present in the involved muscle

• This can be difficult to identify when there are overlying muscles or thick subcutaneous tissue

Jump Sign • Pressure on the tender spot causes the patient to physically react by exclaiming or moving

• Indicates the level of tenderness but is also dependent on the pressure exerted by the examiner

Twitch Response• Transient contraction of

muscle fibers of the taut band containing the trigger point

• Elicited by “snapping” palpation of the trigger point

• More commonly elicited by precise needling of the trigger point

• Usually seen with the first injection only

Other Musculoskeletal

Features

• Pain Recognition• Digital pressure on tender

spot reproduces patient’s pain

• “That’s It!”

• By definition identifies an active trigger point

• Restricted ROM

• Full stretching is often involuntarily restricted by pain.

• Muscle Weakness

• Muscle more easily fatigued

• unable to demonstrate normal muscle strength

Related Symptoms

• Autonomic dysfunction• Abnormal sweating• Persistent lacrimation• Post nasal drip• Pilomotor activation

(gooseflesh)• Vasoconstriction• Vasodilation

• Proprioceptive disturbance• Imbalance• Dizziness• Tinnitus

• Neurological Symptoms• Paresthesias• Numbness

Essential diagnostic

criteria

Taut, palpable band

Exquisitely tender nodule

in the fiber’s center

Patients' recognition of

current pain complaint

(active TrP) or of an

unfamiliar one (latent TrP)

when the TrP is provoked

Painful limit of stretch

range of motion (some

texts note as essential,

others as not essential)

Chronic Myofascial Pain Mimics

• Angina - TrP in Pectoralis major

• Sciatica – Gluteus Minimus

• Migraine – SCM, temporalis, posterior cervicals

• Low back pain – Lower rectus abdominis

• TMJ dysfunction – Masseter, pterygoids

• Rotator cuff – Supraspinatus

• C5-C6 Radiculopathy – Scalenes, supraspinatus, infraspinatus

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

Normal Muscles • Do not contain TrPs

• Do not have taut bands

• Do not exhibit twitch response

Let’s BeginHistory

Physical ExamTreatment

History

• Past Medical

• Occupational

• Full ROS• Weakness, fatigue

• Numbness, paresthesias

• Pain (PQRST)• Location of all pain

• Pain & Injury History

• Disability

• Sleep

• Psychological

• Diet

Patient Examination

• Mobility

• Posture

• Musculoskeletal Exam

• Neurological Exam

• Trigger Point Exam

Signs

• Regional tenderness

• Poorly localized

• 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

Palpation is Key!

• Flat Palpation: Use tip of middle finger and lightly glide over area that is painful.

• Feel with middle finger

• Feel for pea or marble sized nodule

• When trigger point is located it should feel like a small nodule under the skin.

• Snapping palpation: Roll the band quickly under fingertips. Can produce a localized twitch response.

Palpation is Key!

•Deep Palpation

•Pincer Palpation

Visual Inspection

• Musculoskeletal Symmetry:

• muscle tension, skin folds, stance

• Evenness shoulders, hips, trochanters, knees, pelvis

• Dominant hand

• Walker or cane use

• Leg length discrepancy

Treatment

Treatment for Chronic

Myofascial Pain

• Remove underlying cause

• Inactivate the trigger points

• Identify and correct perpetuating factors

• Help the patient to restore and maintain normal muscle function

Trigger Point Injections

One of the most effective treatment modalities to inactivate trigger points and provide

prompt relief of symptoms

Technique

• Patient Positioning

• Sitting

• Prone

• Supine

• Needle selection

• 25ga or 30ga

• Long and short

• Injection Solutions

• Buffered Lidocaine 0.5%-1%

• Procaine 0.5%-1%

• Botulinum toxin

• Other Additives

• Gloves, gauze, alcohol pads, bandage

Preparation

Technique

• Injection Technique

• Locate TrP

• Immobilize TrP

• Sanitize skin

• Warn patient

Injection

Injection Technique

Injection Technique

Post-Injection Care

• Soreness to be expected

• Should not be confused with failure of treatment

• Usually lasts 3 to 4 days

• Patient should remain active

• Avoid strenuous activity first 3 to 4 days after injection

• Use heat, not cold, treatments

Complications of Trigger-Point

Injections

• Vasovagal syncope

• Skin infection

• Pneumothorax

• Needle breakage; avoid by never inserting the needle to its hub

• Hematoma formation

Contraindications to Trigger-Point

Injection

• Local or systemic infection

• Allergy to agents

• Acute muscle trauma

• Extreme fear of needles

• Relative

• Anticoagulation or bleeding disorders

• Dystonia

• Severe anxiety

• Severe psych issues

Other Techniques to Treat CMP

Invasive Techniques

• Wet needling

• Dry needling

• Acupuncture

• Botulinum toxin

Non-invasive Techniques

• Correcting or removing the precipitating stimuli

• Ischemic compression

• Spray and stretch

• Myofascial release

• Biofeedback

• Pharmacotherapy

• Physical Therapy

• TENS, Ionto/Phono-pheresis, Heat, Microcurrent Stimulation

Spray and Stretch

• Passively stretching the target muscle while simultaneously applying spray topically

• Sudden drop in skin temperature thought to produce temporary anesthesia blocking spinal stretch reflex and the sensation of pain at a higher center

• Decreased pain sensation allows the muscle to be passively stretched toward normal length

Spray & Stretch

Spray & StretchGluteus Minimus

Dry Needling, Acupuncture

&IM Stimulation

• Dry Needling

• Simple insertion and removal of an acupuncture type needle

• Acupuncture

• Needling at accupoints along meridians and extra meridians

• Intramuscular Stimulation

• Manipulation of the inserted needle until a local twitch response is attained

Correct Other Factors that

Contribute to Trigger Points

• Poor Sleeping Patterns

• Systemic Factors

• Biomechanical Factors

• Poor Posture

• Nutrition

• Regular Stretching Program

• Aerobic Exercise

• Strength Training

• Stress Management Techniques

Self Help

Neck Posture Exercise

Head and Neck Pain

Posterior Cervicals

Deep Posterior Cervicals

Lateral Neck Muscles

Trapezius TrPs

Trapezius TrP Injection

Trapezius Spray & Stretch

Sternocleidomastoid TrP

SCM TrP Injection

Levator Scapulae TrP

Upper Back, Shoulder

Upper Back Muscles

Levator Scapulae TrP

Trapezius TrPs

Supraspinatus TrP

Infraspinatus TrP

Rhomboid TrP

Middle & Low Back Pain

Latissimus Dorsi TrP

Quadratus Lumborum TrP

Gluteus Maximus TrP

Gluteus Medius TrP

Gluteus Minimus TrP

Piriformis TrP

What is Fibromyalgia?

A Neurosensory DisorderCharacterized by Abnormal Central

Nociceptive Processing

Potential Causesof

Fibromyalgia

• Heredity

• Female Sex

• Age

• Sleep

• Trauma & Tissue Injury

• Physical Conditioning

• Stress

• Neuroendocrine & Autonomic Dysregulation

• Central sensitization

• Viruses or other infections

Biologic

Variables

Potential Causes of

FMS

• Personality Traits

• Low Self-Efficacy

• Ineffective Pain Beliefs

• Sense of Helplessness

• Perceived lack of control

• Hypervigilance

• Catastrophizing

• Depression & Anxiety

• Pain Behaviors

Cognitive-

Behavioral

Variables

Potential Causes of

FMS • Developmental Issues

• Interpersonal Issues

• Work Environment

• Cultural Norms

Environmental

and

Sociocultural

Variables

Primary Feature • Chronic widespread pain for at least three months

• Tender points in 11 of 18 specific anatomic locations

• Tender everywhere!

Other Features

• Central Sensitization*

• Sleep Disturbance*

• Fatigue*

• Cognitive Difficulties (“Fibrofog”)

• Psychological Issues: Anxiety, PTSD, Depression

• Shortness of Breath

• Allergic Symptoms

• Also: IBS, Reynaud's, HA, Dysmenorrhea, Restless Legs Syndrome

Fibromyalgia vs.

Chronic Myofascial Pain

Myofascial Pain• 1 female: 1 male

• Local or regional pain

• Focal tenderness

• Muscle tense, taut

• Reduced ROM

• Examine for TrPs

• Immediate response to TPI

• 20% also have FM

Fibromyalgia• 4-9 females : 1 male

• Widespread pain

• Widespread tenderness

• Muscle feels soft, doughy

• Hypermobile

• Examine for tender points

• Delayed or poor response to TPI

• 72% have TrPs

Pearls

• People always underestimate the severe pain a muscle can cause

• Warn patients that their TrP may twitch the first time it is injected but usually will not jump a second time

• Warn patients to expect soreness for a few days

• PT/massage right after ok

• Stretching while LA in effect is essential

• Extremely anxious patients may do worse, be cautious

Conclusion • Myofascial Pain and Dysfunction: The Trigger Point Manual by Travell & Simons is essential

• Flip Chart excellent for patient education & quick reference