eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders
Cervical Myofascial Pain: Treatment & Medication
Updated: Apr 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
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.
Medical Issues/Complications
The primary concern for patients with cervical myofascial pain is chronicity. Recurrence of myofascial pain is a common scenario. Prompt treatment prevents other muscles in the functional unit from compensating, thereby producing a more widespread and chronic problem. Migraine headaches and muscle contraction headaches are known to occur frequently in the patient with myofascial pain.4 Temporomandibular joint (TMJ) syndrome also may be myofascial in origin.2
Other Treatment
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.5
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. (See image below and Image 4.) Then redirect the needle in the area to assure widespread infiltration of the anesthetic. Instruct the patient to be aggressive about compliance with stretching protocols, because they increase the injection's effectiveness. Production of an LTR 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.3 This approach, therefore, generally is the most helpful technique for reducing myofascial pain.
Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show 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.
Stretch and spray is another method of treating cervical myofascial pain. (See images below and Images 5, 6.) 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 spraying any muscle for myofascial trigger points.
Schematic drawing showing how the jet stream of vapocoolant is applied.
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 injection therapy has gotten mixed reviews in the literature. Injection directly into the trigger point produces inconsistent results. The best use of botulinum toxin may be for correcting abnormal biomechanics that incite a myofascial response.6,7
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Nonsteroidal anti-inflammatory drugs
The goal of medication for patients with cervical myofascial syndrome is to reduce pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs DOC for initial treatment of myofascial pain. Keep narcotic analgesics at a minimum if at all possible. If the clinical picture is one of more chronic pain accompanied by sleep dysfunction, consider use of a tricyclic antidepressant (TCA).
Ibuprofen (Motrin, Advil)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Used to provide relief of cervical myofascial pain.
Adult
400-600 mg PO tid with food; 800 mg if pain is severe and patient has no history of gastric ulceration
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Tricyclic antidepressants
TCAs are commonly used for chronic pain. They help to treat insomnia and reduce painful dysesthesia. They treat nociceptive and neuropathic pain syndromes.
Amitriptyline (Elavil)
Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May increase or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity.
Adult
30-100 mg PO qhs
Pediatric
Children: 0.1 mg/kg PO qhs; increase, as tolerated, over 2-3 wk to 0.5-2 mg/d qhs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; use of MAOIs within 14 d of initiating therapy; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in the elderly
Muscle relaxants
Muscle relaxants are commonly used to treat muscle pain, but they must be used cautiously because of sedation and because of the addictive potential of some of the medications in this category of drugs (benzodiazepines).
Cyclobenzaprine (Flexeril)
Acts centrally and reduces motor activity of tonic somatic origins, influencing both alpha and gamma motor neurons. Structurally related to TCAs.
Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.
Often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Adult
10 mg PO tid with a range of 20-40 mg/d in divided doses; not to exceed 60 mg/d
Pediatric
Not established
Coadministration with MAOIs and TCAs may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine
Documented hypersensitivity; MAOIs within last 14 d
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in angle closure glaucoma, and urinary hesitance
Tizanidine (Zanaflex)
Centrally acting muscle relaxant metabolized in liver and excreted in urine and feces.
Adult
4-8 mg PO q8h prn; not to exceed 36 mg/d
Pediatric
Not established
May interact with alcohol (increase somnolence, stupor) and oral contraceptives (which decrease its clearance), and can cause increased hypotensive effects when administered concurrently with diuretics
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal impairment
Non-narcotic analgesics
Tramadol is a weak opioid and an inhibitor of serotonin and norepinephrine reuptake in the dorsal horn. Studies have shown efficacy when treating fibromyalgia, although no formal studies have been performed for myofascial pain. Tramadol is known to help with chronic low back pain and osteoarthritis pain, both of which are commonly associated with myofascial pain.
Tramadol (Ultram)
Analgesic probably acting over monoaminergic and opioid mechanisms. Monoaminergic effect shared with TCAs. Tolerance and dependence appear to be uncommon.
Adult
100-400 mg PO qd shown to be effective in diabetic neuropathic pain
Pediatric
Not established
Decreases carbamazepine effects significantly; cimetidine increases toxicity, risk of serotonin syndrome with coadministration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 d; use of SSRIs, TCAs, opioids, acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breast-feeding; seizure; development of tolerance or dependency with extended use
Anticonvulsants
Anticonvulsants used as neuropathic analgesics may be helpful, because myofascial pain may at its core be a spinal-mediated disorder affected by neuropathic dysfunction. Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.
Gabapentin (Neurontin)
Membrane stabilizer, a structural analogue of inhibitory neurotransmitter GABA, which paradoxically is thought to not exert effect on GABA receptors. Appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels.
Used to manage pain and provide sedation in neuropathic pain.
Titration to effect occurs over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).
Adult
Day 1: 100 mg PO tid or 300 mg hs
Day 2: 400 mg PO tid for 3 d and titrate prn; not to exceed 1200 mg PO tid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may increase norethindrone levels significantly
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe renal disease
More on Cervical Myofascial Pain |
| Overview: Cervical Myofascial Pain |
| Differential Diagnoses & Workup: Cervical Myofascial Pain |
 Treatment & Medication: Cervical Myofascial Pain |
| Follow-up: Cervical Myofascial Pain |
| Multimedia: Cervical Myofascial Pain |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Travell JG, Simons DG. Myofascial Pain and Dysfunction. vol 2. Baltimore, Md: Lippincott Williams & Wilkins; 1992.
Duyur Cakit B, Genc H, Altuntas V, et al. Disability and related factors in patients with chronic cervical myofascial pain. Clin Rheumatol. Feb 18 2009;[Medline].
Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. Jul 1998;79(7):863-72. [Medline].
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. Oct 10 2008;[Medline].
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. Apr 2008;71(4):200-6. [Medline].
Jabbari B. Botulinum neurotoxins in the treatment of refractory pain. Nat Clin Pract Neurol. Dec 2008;4(12):676-85. [Medline].
Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting--a review of the literature. Pain Pract. Jul-Aug 2008;8(4):269-76. [Medline].
Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. Mar 2002;83(3 Suppl 1):S40-7, S48-9. [Medline].
De Andres J, Cerda-Olmedo G, Valia JC, et al. Use of botulinum toxin in the treatment of chronic myofascial pain. Clin J Pain. Jul-Aug 2003;19(4):269-75. [Medline].
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.
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. Oct 2002;83(10):1406-14. [Medline].
Jacob AT. Myofascial pain. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 5. 1991:573-583.
Rosen NB. Myofascial pain: the great mimicker and potentiator of other diseases in the performing artist. Md Med J. Mar 1993;42(3):261-6. [Medline].
Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004;64(1):45-62. [Medline].
Further Reading
Related eMedicine topics:
Back Pain, Mechanical
Cervical Spine Sprain/Strain Injuries
Cervical Sprain and Strain
Cervical Strain
Mechanical Low Back Pain
Myofascial Pain
Myofascial Pain in Athletes
Therapeutic Injections for Pain Management
Guidelines:
ACR Appropriateness Criteria Chronic Neck Pain
Assessment and Management of Chronic Pain
Clinical studies:
The Natural History of Upper Trapezius Myofascial Trigger Points: Comparison of Local and Remote Tissue Milieu in Normal Muscle, Latent and Active Myofascial Trigger Points Over Time
Keywords
cervical myofascial pain, neck pain, fascia, myofascial, cervical spine, trigger point, myalgia, myofascial pain, neck and shoulder pain, trigger point therapy, trigger points, trigger point injections, TMJ, TMJ pain, temporomandibular joint, trigger point injection, myofasciitis, interstitial myofibrositis, fibrositis, nonarticular rheumatism affecting the cervical spine, tension myalgia
