Accurate Education – Myofascial Pain

Myofascial Pain

 

Myofascial pain is one of the most overlooked and ignored causes of chronic pain.  Myofascial pain is defined as pain derived from muscle and/or fascia, including scar tissue. Fascia is a tough, fibrous biological membrane that surrounds and connects every cell, tissue and structure in the body, the primary component of our “connective tissues.” It is continuous throughout the body and is responsible for maintaining the stability of the form and structure of our body. Wihout fascia, our tissues would lack cohesiveness and our bodies would simply be a skin sack of guts with a skeletal core.

 

Muscle and fascia both contain pain receptors that contribute to most if not all chronic, painful musculoskeletal conditions. They may be a primary, or independent, source of pain derived from an isolated injury or pathology of muscle or fascia or they may be secondary, related to another condition such as arthritis or spine injury. Myofascial pain is also believed to be a component of visceral pain conditions such as endometriosis, interstitial cystitis, irritable bowel syndrome, painful menstruation and prostatitis.

 

See Also:

Low Back Pain (LBP) – Overview

LBP – Arachnoiditis

LBP – Superior Cluneal Nerve Entrapment

LBP – Disc Pain

LBP – Facet Pain

LBP – Failed Back Surgery Syndrome

LBP – Myofascial Pain

LBP – Sacroiliac (SI) Joint Pain

LBP – Sciatica

LBP – Spinal Stenosis

 

Treatment Procedures:

Epidural Injections

Facet Joint Injections and Nerve Procedures

Heat & Cold Therapy

Inversion Therapy

Massage Therapy

Physical Therapy

Trigger Point Therapy

 

LBP – Surgery:

Considering Surgery?

Failed Back Surgery

Muscle pain

“Vitality shows in not only the ability to persist but the ability to start over.”

– Scott Fitzgerald

Myofascial Pain

Myofascial pain is usually experienced as a hypersensitive spot in a tight band of a skeletal muscle that is painful when compressed, stretched or overloaded when using the muscle. The pain is nociceptive, mostly described as deep and aching, cramping or dull. In the presence of a trigger point (TrP), a localized source of myofascial pain, the pain can be referred to areas distant from its source and usually has a distinct referred pain pattern.

 

Because myofascial pain frequently accompanies most chronic musculoskeletal conditions, it is important to evaluate these conditions for the co-existing presence of TrPs. Left untreated, TrPs can be responsible for severe pain that seriously compromises function and quality of life. Worse, the referral patterns of TrPs can mislead clinicians toward incorrect diagnoses and inappropriate procedures, even surgery. An extensive review of trigger points, their causes, manifestations and their treatment is found on another page on this website.

See: Trigger Point Therapy

 

Myofascial Pain Syndrome

The Myofascial Pain Syndrome (MPS) may be defined as meeting the following four criteria:

 

1. Regional pain location not restricted to a dermatomal pattern characteristic of nerve root pain

2. Presence of either:

Trigger points with referred pain OR
Muscular tender points (without referral) in the presence of taut bands, nodules, or ropiness in muscle

3. Normal neurological examination

4. At least one of the following:

Pain described as dull, achy, or deep

Decreased range of motion (ROM)

 

Principles of Understanding Myofascial Pain Syndrome (MPS) and Treatment

In addition to pain, the myofascial pain syndrome (MPS) compromises individuals in other ways: it provokes muscle dysfunction, e.g. muscle weakness, muscle irritability, muscle cramps and spasm along with impaired range of motion of the spine and joints. As a consequence of muscle dysfunction, postural imbalances then occur, further contributing to neck, back and/or joint pain. These imbalances coupled with muscle weakness increase the risk for falls and further injury. In effect, MPS not only contributes to existing pain and functional impairment but also perpetuates underlying pain conditions and perpetuates itself.

 

Clinical Examples of Conditions that Contribute to MPS

Whiplash (motor vehicle accidents, slip & fall, sports, injuries etc.)

The abrupt movement from impact triggers muscle  to contract to maintain postural stabilization
. The inertial forces produce a whipping motion that coupled with muscle contractions (often asymmetirc or eccentric when head is turned at the time) causes muscle and connective tissue damage and dysfunction.

 

Overuse Syndrome (typing, occupation, hobby, postural distortion, etc)

Constant contractions of muscles causes decrease blood circulation
 and metabolic waste increases along a with lack of oxygen and nutrients for muscle health. This results in tissue damage that includes disruption of the nerve receptors in the muscles and fascia and imbalances in neurtransmitters at the nerve-muscle junctions (acetylcholine and acetylcholine receptors), giving rise to muscle dysfunction including spasm and weakness. The long duration of postural distortion also leads to fascial distortion, further contributing to joint dysfunction.

 

Lack of use (bed rest, cast, splint, etc)

In the absence of adequate muscle movement, there is reduced production of fascial lubricant (glycosaminoglycans and mucopolysaccharides)
 generated by the fascia that facilitates and maintains normal muscle movement and range of motion. An additional consequence of lack of use is muscle atrophy
 as well as loss of motor “memory” that facilitates routine, repetitive motions resulting in muscle dysfunction.

 

Strain-Sprain (unaccustomed overload, eccentric or excessive stretching of the joint, etc)

The “strains” that occurs during whiplash, falls or near-falls, forceful overloads etc. result in tears of muscle and fascia structural proteins
. In “sprains” there is damage to the ligament caused by stretching beyond the elastic limit of that ligament which introduces an inflammatory response.  Local pain signals from these injuries produce functional muscle splinting, or impaired contractions.

 

Treatment Based on Mechanisms of Myofascial Pain

Pain felt at the source of pain is termed “local pain” or “primary pain,” whereas pain felt in a region away from the source of pain is termed “referred pain.” Referred pain can be perceived in any region of the body, but the size of the referred pain area is variable.

Local Myofascial Pain

Muscle pain is associated with the activation of muscle pain receptors (nociceptors) by a variety of local substances, including neuropeptides and inflammatory mediators that have been triggered by injury. Studies have confirmed the presence of multiple biochemical substances in the immediate proximity of TrP. It is believed that peripheral sensitization occurs, described as a reduction in the pain threshold and an increase in responsiveness of the peripheral nociceptors, leading to heightened perception of pain in the area of TrPs. Local myofascial pain is typically described as deep, dull and achy, characteristic of nociceptive pain. Nociceptive pain tends to be very responsive to NSAIDs and low potency opioids.

Referred Myofascial Pain

The mechanisms of referred mysofascial pain/TrPs is a combination of peripheral sensitization and central sensitization. The intensity of referred pain and the size of the referred pain area are positively correlated with central nervous system excitability and it is believed that muscle referred pain is a central sensitization process mediated by a peripheral sensitization phenomenon, with additional sympathetic activity facilitation and dysfunctional descending pain inhibition.

 

According to current theory, referred pain occurs in the spinal cord at the dorsal horn level and is the result of activation, by means of peripheral and central sensitization mechanisms, of inactive nerve connections between nerve fibers. The referred pain triggered by a TrP is a central phenomenon initiated, activated, and maintained by peripheral sensitization. Peripheral nociceptive input can sensitize previously silent dorsal horn neurons.

 

Central sensitization processes are also involved in the development of spreading pain, because larger referred pain areas in patients with chronic pain are a consequence of higher central neural plasticity. Maintenance of referred pain is dependent on ongoing nociceptive input from the site of primary muscle pain. It remains uncertain which sensitization mechanism, peripheral or central, is more dominant in the development of referred pain. These mechaisms, however, are consistent with a neuropathic basis for the referred pain of TrPs. Characteristic findings of neuropathic pain, hyperalgesia and allodynia, are associated with the hypersensitivity of TrPs and is another argument for a neuropathic pain component to myofascial pain syndrome. Neuromodulators including the gabapentinoids and other agents effective for nerve pain have been found to offer benefit is many patients with MPS.

 

Moving Beyond

Treating MPS is not just about treating trigger points; it is about addressing the perpetuating factors that maintain the MPS, including the changes in the fascia and the joint dysfunction. Perpetuating factors can be physical:  leg length inequalities, joint or extremity deformities etc; or behavioral: repetitive work activities or poor ergonomics in the home or workplace. 

 

Successful management of MPS includes identifying and correcting all perpetuating factors – postural, structural, ergonomic, endocrine, metabolic, nutritional, infectious and psychological aspects. Management includes movement rehabilitation based in physical therapy, exercise training, yoga or other stretching techniques and massage. It often requires a multidisciplinary approach to address stress-related contributions to MPS. Anxiety and stress result in increased muscle tone and chronic muscle contractions that further the MPS. Learning effective techniques for coping with stress can be coupled with techniques specifically directed at reducing muscle tension. Meditative techniques, mindful exercises and self-hypnosis training are proven methods of reducing the impact of stress and anxiety on muscle dysfunction.

See Using the Mind

 

References

Myofascial Pain and TrP – Overviews

  1. Myofascial Pain and Dysfunction: The Trigger Point Manual (2 vol. set, 2nd Ed.). Travell, Janet; Simons David; Simons Lois (1999). USA: Lippincott Williams & Williams.
  2. Treatment of myofascial pain syndrome with lidocaine injection and physical therapy, alone or in combination – 2016
  3. Identification and quantification of myofascial taut bands with magnetic resonance elastography. – PubMed – NCBI
  4. New views of myofascial trigger points: etiology and diagnosis. – PubMed – NCBI
  5. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. – PubMed – NCBI
  6. Botulinum toxin for myofascial pain syndromes in adults. – PubMed – NCBI
  7. Needling therapy for myofascial pain – recommended technique with multiple rapid needle insertion – 2014
  8. Evaluation of the Sympathetic Skin Response to the Dry Needling Treatment in Female Myofascial Pain Syndrome Patients – 2016
  9. New Frontiers in the Pathophysiology of Myofascial Pain Enter the Matrix

 

Myofascial PainMechanisms of Pain

  1. The Discriminative Validity of “Nociceptive,” ” Peripheral Neuropathic,” and “Central Sensitization” as Mechanisms-based Classifications of Musculoskeletal Pain – 2011
  2. Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians – 2010
  3. Myofascial Trigger Points – Peripheral or Central Phenomenon? -2014

 

Myofascial Pain and TrP – Shoulder Pain

  1. Treatment-of-myofascial-trigger-points-in-patients-with-chronic-shoulder-pain-a-randomized-controlled-trial-2011
  2. High-prevalence-of-shoulder-girdle-muscles-with-myofascial-trigger-points-in-patients-with-shoulder-pain-2011
  3. chronic-shoulder-pain-of-myofascial-origin-a-randomized-clinical-trial-using-ischemic-compression-therapy-pubmed-ncbi

 

Emphasis on Education

 

Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.

 

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Should you wish more information regarding any of the subjects listed – or not listed –  here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.

 

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