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Cervical Myofascial Pain Treatment & Management

  • Author: C Douglas Phillips, MD, FACR; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: Sep 10, 2014
 

Approach Considerations

Treatments for cervical myofascial pain include physical therapy, trigger point injection, stretch-and-spray therapy, and ischemic compression. Injection of botulinum toxin (BoNT) has also been used, although this procedure has received mixed reviews in the literature.

Various pain-relieving medications can also be employed in treatment, including the following:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Tricyclic antidepressants
  • Muscle Relaxants
  • Nonnarcotic analgesics
  • Anticonvulsants
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Physical Therapy

The primary goal of physical therapy is to restore balance between muscles working as a functional unit. The physical therapist may progress toward that goal initially by attempting to diminish pain. This goal can be accomplished using a modality-based approach performed in conjunction with myofascial release techniques and massage. Cervical stretch and stabilization are integral parts of the approach as well. Postural retraining is crucial in cervical myofascial pain. An ergonomic evaluation may be indicated if overuse in the work setting is contributing to the patient's symptoms.

In a study by Sherman et al, the authors concluded that massage may provide short-term relief for chronic neck pain. In this randomized, controlled trial, the investigators evaluated whether therapeutic massage is more beneficial than a self-care book for patients with chronic neck pain. Patients (n=64) were randomized to receive up to 10 massages over 10 weeks or a self-care book. Measurement of the Neck Disability Index at 10 weeks demonstrated more participants randomized to massage experienced clinically significant improvement (39%) than did the participants in the self-care book group (14%). However, a larger trial is warranted to confirm these results.[6]

In a study by Ma et al, patients who underwent biofeedback training to the bilateral upper trapezius showed greater reduction in work-related pain and better neck muscle activation than did patients who underwent exercise therapy or passive treatment modalities.[7]

A study by Bronfort et al concluded that both spinal manipulation treatment and a home exercise program were both superior to medication alone in the treatment of acute and subacute neck pain. No significant differences were seen in the outcome when comparing 12 weeks of manipulation to a home exercise program taught by a therapist in 2 separate sessions.[8]

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Trigger Point Injection

Several treatment options for cervical myofascial pain are discussed in the literature. Trigger point injection probably is one of the most accepted means of treating myofascial pain besides physical therapy and exercise. Injection is performed most commonly with local anesthetic, although dry needling has been shown to be equally effective.[9]

Palpate the trigger point in the taut band, and place the muscle in a slightly stretched position to prevent it from moving. Hold the trigger point between 2 fingers while injecting with the other hand, and then redirect the needle in the area to assure widespread infiltration of the anesthetic. (See the image below.)

Cross-sectional schematic drawing shows flat palpa Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show the use of alternate pressure between 2 fingers to confirm the location of the palpable module of the trigger point. C shows the trigger point being positioned halfway between the fingertips to keep it from sliding to one side during the injection.

Instruct the patient to be aggressive about compliance with stretching protocols, because they increase the injection's effectiveness. Production of a local twitch response helps to confirm the diagnosis. Hong and Simon's article describes a fast-in/fast-out method as more successful in eliciting the local twitch response.[4] This approach, therefore, generally is the most helpful technique for reducing myofascial pain.

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Stretch and Spray, Ischemic Compression, and Botulinum Toxin

Stretch and spray

Stretch and spray is another method of treating cervical myofascial pain (see the images below). This technique is performed using a vapocoolant spray applied to the affected muscle after it has been placed in passive stretch. Apply the vapocoolant spray to the region around the trigger point and the area of referred pain using parallel strokes in the same direction. Some authors recommend first spraying, then stretching, and only then repeating the spraying.

Sequence of steps to use when stretching and spray Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.
Schematic drawing showing how the jet stream of va Schematic drawing showing how the jet stream of vapocoolant is applied.

Ischemic compression

Ischemic compression involves application of sustained pressure on the trigger point. Have the patient place the muscle in a fully stretched position. Press firmly on the trigger point with a thumb. Gradually increase the pressure as the pain lessens.

Botulinum toxin

BoNT injection therapy has received mixed reviews in the literature. Injection directly into the trigger point produces inconsistent results. The best use of BoNT may be for correcting abnormal biomechanics that incite a myofascial response.[10, 11]

A study by Nicol et al of patients with cervical myofascial pain found improvements in pain when BoNT-A was injected directly into painful muscle groups. The study began with 114 patients with cervical and shoulder girdle myofascial pain who were injected with BoNT-A and assessed for their response to it. The investigators then conducted a 12-week, randomized, double-blind, placebo-controlled trial with 54 responders, who received either a second injection of BoNT-A, administered directly into a painful muscle group, or a placebo. Improvements in pain, as measured with visual numerical pain scores and Brief Pain Inventory general activity and sleep interference scores, were seen in the BoNT-A group, in comparison with the placebo group. Patients in the BoNT-A group also experienced a decrease in the weekly number of headaches.[12]

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Contributor Information and Disclosures
Author

C Douglas Phillips, MD, FACR Director of Head and Neck Imaging, Division of Neuroradiology, New York-Presbyterian Hospital; Professor of Radiology, Weill Cornell Medical College

C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Beth B Froese, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, Orthopaedic Associates of DuPage, Ltd

Beth B Froese, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, Illinois State Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Duyur Cakit B, Genc H, Altuntas V, et al. Disability and related factors in patients with chronic cervical myofascial pain. Clin Rheumatol. 2009 Feb 18. [Medline].

  2. Travell JG, Simons DG. Myofascial Pain and Dysfunction. Baltimore, Md: Lippincott Williams & Wilkins; 1992. vol 2:

  3. Harden RN, Cottrill J, Gagnon CM, et al. Botulinum toxin A in the treatment of chronic tension-type headache With cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study. Headache. 2008 Oct 10. [Medline].

  4. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998 Jul. 79(7):863-72. [Medline].

  5. Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011 Oct. 30(10):1331-40. [Medline].

  6. Sherman KJ, Cherkin DC, Hawkes RJ, Miglioretti DL, Deyo RA. Randomized trial of therapeutic massage for chronic neck pain. Clin J Pain. 2009 Mar-Apr. 25(3):233-8. [Medline].

  7. Ma C, Szeto GP, Yan T, Wu S, Lin C, Li L. Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: a randomized controlled trial. Arch Phys Med Rehabil. 2011 Jun. 92(6):849-58. [Medline].

  8. Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med. 2012 Jan 3. 156(1 Pt 1):1-10. [Medline].

  9. Lee SH, Chen CC, Lee CS, et al. Effects of needle electrical intramuscular stimulation on shoulder and cervical myofascial pain syndrome and microcirculation. J Chin Med Assoc. 2008 Apr. 71(4):200-6. [Medline].

  10. Jabbari B. Botulinum neurotoxins in the treatment of refractory pain. Nat Clin Pract Neurol. 2008 Dec. 4(12):676-85. [Medline].

  11. Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting--a review of the literature. Pain Pract. 2008 Jul-Aug. 8(4):269-76. [Medline].

  12. Nicol AL, Wu II, Ferrante FM. Botulinum toxin type a injections for cervical and shoulder girdle myofascial pain using an enriched protocol design. Anesth Analg. 2014 Jun. 118(6):1326-35. [Medline]. [Full Text].

  13. Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. 2002 Mar. 83(3 Suppl 1):S40-7, S48-9. [Medline].

  14. De Andres J, Cerda-Olmedo G, Valia JC, et al. Use of botulinum toxin in the treatment of chronic myofascial pain. Clin J Pain. 2003 Jul-Aug. 19(4):269-75. [Medline].

  15. Gnatz SM. Referred pain syndromes of the head and neck. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:585-596.

  16. Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002 Oct. 83(10):1406-14. [Medline].

  17. Jacob AT. Myofascial pain. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:573-583.

  18. Rosen NB. Myofascial pain: the great mimicker and potentiator of other diseases in the performing artist. Md Med J. 1993 Mar. 42(3):261-6. [Medline].

  19. Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004. 64(1):45-62. [Medline].

 
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Schematic of a trigger point complex of a muscle in longitudinal section. A: The central trigger point (CTrP) in the endplate zone contains numerous electrically active loci and numerous contraction knots. A taut band of muscle fibers extends from the trigger point to the attachment at each end of the involved fibers. The sustained tension that the taut band exerts on the attachment tissues can induce a localized enthesopathy that is identified as an attachment trigger point (ATrP). B: Enlarged view of part of the CTrP shows the distribution of 5 contraction knots. The vertical lines in each muscle fiber identify the relative spacing of its striations. The space between 2 striations corresponds to the length of 1 sarcomere. The sarcomeres within one of these enlarged segments (ie, contraction knot) of a muscle fiber are markedly shorter and wider than the sarcomeres in the neighboring normal muscle fibers, which are free of contraction knots.
Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. The skin is pushed to one side to begin palpation. B. The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it. C. The skin is pushed to the other side at completion of the movement. This same movement performed vigorously is called snapping palpation. Right: A. Muscle fibers are surrounded by the thumb and fingers in a pincer grip. B. The hardness of the taut band is felt clearly as it is rolled between the digits. C. The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response.
Longitudinal schematic drawing of taut bands, myofascial trigger points, and a 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, which usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.
Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show the use of alternate pressure between 2 fingers to confirm the location of the palpable module of the trigger point. C shows the trigger point being positioned halfway between the fingertips to keep it from sliding to one side during the injection.
Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.
Schematic drawing showing how the jet stream of vapocoolant is applied.
 
 
 
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