Physical Medicine and Rehabilitation for Myofascial Pain
- Author: Jennifer E Finley, MD, FAAPMR; Chief Editor: Consuelo T Lorenzo, MD more...
Background
Myofascial pain (MP) is a common, painful disorder that is responsible for many pain clinic visits. MP can affect any skeletal muscles in the body. Skeletal muscle accounts for approximately 50% of body weight, and approximately 400 muscles make up the body. MP is responsible for many cases of chronic musculoskeletal pain.
MP can cause local or referred pain, tightness, tenderness, popping and clicking, stiffness and limitation of movement, autonomic phenomena, local twitch response (LTR) in the affected muscle, and muscle weakness without atrophy. Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles, restricted range of motion (ROM), and a visible or palpable LTR to local stimulation, are classic signs of MP. Over 70% of TrPs correspond to acupuncture points used to treat pain.[1]
An active TrP is an area that refers pain to a remote area in a defined pattern when local stimulation is applied. Satellite TrPs appear in response to a primary, active TrP and usually disappear after the primary TrP has been inactivated. Latent TrPs cause stiffness and limitation of ROM but no pain. Frequently, they are found in asymptomatic individuals.
Although MP and fibromyalgia have some overlapping features, they are separate entities; fibromyalgia is a widespread pain problem, not a regional condition caused by specific TrPs.
Recent studies
Ge et al investigated whether the 18 tender points (TPs) used in the diagnosis of fibromyalgia are also MP TrPs. Manual palpation was used to evaluate TPs in 30 patients with fibromyalgia, after which intramuscular electromyographic registration was used to indicate whether TrPs existed at these sites. According to the authors, most of the TP sites were also TrPs, with local and referred pain from active TrPs partially reproducing the patients' spontaneous fibromyalgic pain pattern. Based on the data, Ge et al suggested that active TrPs may contribute to the generation of fibromyalgic pain.[2]
Pathophysiology
A taut band in a muscle may be necessary as a precursor to the development of a trigger point (TrP). Taut bands are common in asymptomatic individuals, but patients with them are more likely to develop a TrP. A latent TrP can develop into an active TrP for a number of reasons. Psychological stress, muscle tension, and physical factors, such as poor posture, can cause a latent TrP to become active.
The pathophysiology of myofascial pain is not well understood. Current research supports sensitization of low-threshold, mechanosensitive afferents associated with dysfunctional motor endplates in the area of the TrPs projecting to sensitized dorsal horn neurons in the spinal cord. Pain referred from TrPs, as well as LTRs, may be mediated through the spinal cord after stimulation of a sensitive locus.[3, 4]
In a study by Alonso-Blanco et al, a connection was found in women between the number of active myofascial TrPs and the intensity of the spontaneous pain and widespread mechanical hypersensitivity; nociceptive inputs from these myofascial TrPs may be linked to central sensitization.[5]
Epidemiology
Frequency
United States
Myofascial pain (MP) is extremely common, and almost everyone develops a trigger point (TrP) at some time. In the US, 14.4% of the general population suffers from chronic musculoskeletal pain. Approximately 21-93% of patients with regional pain complaints have MP. Studies have demonstrated that 25-54% of asymptomatic individuals have latent TrPs.
Mortality/Morbidity
Myofascial pain (MP) is not a fatal condition, but it can cause significant reduction in quality of life (QOL) and is a major cause of time lost from work. Costs associated with MP sap millions, perhaps billions, of dollars from the economy.
Race
No racial differences in the incidence of myofascial pain have been described in the literature.
Sex
Myofascial pain is distributed equally between men and women.
Age
Myofascial trigger points (TrPs) can be found in persons of all ages, even infants. The likelihood of developing active TrPs increases with age and activity level into the middle years. Sedentary individuals are more prone to develop active TrPs than are individuals who exercise vigorously on a daily basis.
Dorsher PT. Myofascial referred-pain data provide physiologic evidence of acupuncture meridians. J Pain. Jul 2009;10(7):723-31. [Medline].
Ge HY, Wang Y, Danneskiold-Samsoe B, et al. The Predetermined Sites of Examination for Tender Points in Fibromyalgia Syndrome Are Frequently Associated With Myofascial Trigger Points. J Pain. Nov 13 2009;[Medline].
McPartland JM. Travell trigger points--molecular and osteopathic perspectives. J Am Osteopath Assoc. Jun 2004;104(6):244-9. [Medline]. [Full Text].
Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. Jul 1998;79(7):863-72. [Medline].
Alonso-Blanco C, Fernández-de-Las-Peñas C, Morales-Cabezas M, Zarco-Moreno P, Ge HY, Florez-García M. Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. Clin J Pain. Jun 2011;27(5):405-13. [Medline].
Gerwin RD. A review of myofascial pain and fibromyalgia--factors that promote their persistence. Acupunct Med. Sep 2005;23(3):121-34. [Medline].
Graff-Radford SB. Myofascial pain: diagnosis and management. Curr Pain Headache Rep. Dec 2004;8(6):463-7. [Medline].
Simons DG, Travell JG, Simons LS. Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1999.
Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. Dec 2004;8(6):468-75. [Medline].
Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil. Jun 2008;89(6):1169-76. [Medline].
Hameroff SR, Crago BR, Blitt CD, et al. Comparison of bupivacaine, etidocaine, and saline for trigger-point therapy. Anesth Analg. Oct 1981;60(10):752-5. [Medline].
Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. Jul-Aug 1994;73(4):256-63. [Medline].
Venâncio Rde A, Alencar FG, Zamperini C. Different substances and dry-needling injections in patients with myofascial pain and headaches. Cranio. Apr 2008;26(2):96-103. [Medline].
Wreje U, Brorsson B. A multicenter randomized controlled trial of injections of sterile water and saline for chronic myofascial pain syndromes. Pain. Jun 1995;61(3):441-4. [Medline].
Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil. Oct 2011;92(10):1576-1580.e1. [Medline].
Aoki KR. Evidence for antinociceptive activity of botulinum toxin type A in pain management. Headache. Jul-Aug 2003;43 Suppl 1:S9-15. [Medline].
Lang AM. Botulinum toxin therapy for myofascial pain disorders. Curr Pain Headache Rep. Oct 2002;6(5):355-60. [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].
Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. Oct 1994;59(1):65-9. [Medline].
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. Apr 2009;31(4):705-20. [Medline].
Fleckenstein J, Zaps D, Ruger LJ, et al. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: results of a cross-sectional, nationwide survey. BMC Musculoskelet Disord. Feb 11 2010;11:32. [Medline]. [Full Text].
Gam AN, Warming S, Larsen LH, et al. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise--a randomised controlled trial. Pain. Jul 1998;77(1):73-9. [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].
Srbely JZ, Dickey JP, Lowerison M, et al. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: a randomized controlled study. Pain. May 26 2008;[Medline].
Ay S, Dogan SK, Evcik D, et al. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int. Mar 31 2010;[Medline].
Flor H, Birbaumer N. Comparison of the efficacy of electromyographic biofeedback, cognitive- behavioral therapy, and conservative medical interventions in the treatment of chronic musculoskeletal pain. J Consult Clin Psychol. Aug 1993;61(4):653-8. [Medline].
Birch S, Jamison RN. Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment. Clin J Pain. Sep 1998;14(3):248-55. [Medline].
Ma C, Wu S, Li G, et al. Comparison of miniscalpel-needle release, acupuncture needling, and stretching exercise to trigger point in myofascial pain syndrome. Clin J Pain. Mar-Apr 2010;26(3):251-7. [Medline].
Leite FM, Atallah AN, El Dib R, et al. Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database Syst Rev. Jul 8 2009;CD006830. [Medline].
Bendtsen L, Jensen R, Olesen J. Qualitatively altered nociception in chronic myofascial pain. Pain. May-Jun 1996;65(2-3):259-64. [Medline].
Danto JB. Review of integrated neuromusculoskeletal release and the novel application of a segmental anterior/posterior approach in the thoracic, lumbar, and sacral regions. J Am Osteopath Assoc. Dec 2003;103(12):583-96. [Medline]. [Full Text].
Facco E, Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir Suppl. 2005;92:147-50. [Medline].
Hsueh TC, Cheng PT, Kuan TS, et al. The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points. Am J Phys Med Rehabil. Nov-Dec 1997;76(6):471-6. [Medline].
Saggini R, Giamberardino MA, Gatteschi L, et al. Myofascial pain syndrome of the peroneus longus: biomechanical approach. Clin J Pain. Mar 1996;12(1):30-7. [Medline].
Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. Feb 2004;14(1):95-107. [Medline].
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