eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes
Myofascial Pain: Treatment & Medication
Updated: Aug 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Physical therapy for patients with myofascial pain focuses on correction of muscle shortening by targeted stretching, strengthening of affected muscles, and correction of aggravating postural and biomechanical factors. Modalities can be useful in decreasing pain, allowing the patient to participate in an active exercise program.
Corrections of leg-length discrepancies with a heel lift or the use of dynamic insoles also may be helpful. Various other techniques and procedures, including the following, have been demonstrated to be effective in some patients:
- Indomethacin phonophoresis
- Massage and exercise18
- Stretching
- Electrical muscle stimulation (EMS) using interferential current (IFC), functional electrical stimulation/electrical nerve stimulation (FES/ENS), or high-frequency transcutaneous electrical nerve stimulation (TENS)19
- Ultrasonography18,20
- EMG biofeedback21
Occupational Therapy
Occupational therapy can be helpful in assessing and setting up ergonomically correct workstations for patients with myofascial pain. Properly set up work sites can help to decrease aggravating postural factors.
Medical Issues/Complications
Trigger points (TrPs) can result from noxious stimuli, such as a herniated disc. Inquire about such precipitating factors in the patient's environment.
The treatment of TrPs can provide temporary relief of visceral pain referred from other organs and can mask the pain of serious conditions (eg, appendicitis, myocardial infarction).
Complications of TrP injections are rare and depend on the area being injected. They include local pain, bleeding, bruising, intramuscular hematoma formation, infection, and, more rarely, neural or vascular injury, or penetration of an underlying organ (which could lead to pneumothorax).
Consultations
Consultation with a specialist in physical medicine and rehabilitation may be indicated and should be arranged as needed.
Other Treatment
- Acupuncture may be helpful.22
- Osteopathic manipulation techniques may include integrated neuromusculoskeletal release, myofascial release, strain-counterstrain, muscle energy, and high-velocity/low-amplitude manipulation.
Medication
Muscle relaxant medications23 and nonsteroidal anti-inflammatory drugs (NSAIDs) can at times be a useful adjunct to active, exercise-based treatment for myofascial pain, but they are helpful only rarely on their own. Medications such as low-dose amitriptyline may help to improve the patient's sleep cycle. Botulinum toxin type A injected into trigger points can reduce muscular contractions through the inhibition of acetylcholine release at the neuromuscular junction and appears to have an antinociceptive effect.13,14,15,16 Current research suggests that peripheral sensitization is blocked, which indirectly reduces central sensitization.
Nonsteroidal anti-inflammatory drugs
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as the inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Ibuprin, Advil)
DOC for patients with mild to moderate pain. Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; may increase PT when taking anticoagulants (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
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Anaprox, Naprelan)
For relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by reducing the activity of cyclooxygenase, which results in decreased prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; may increase PT when taking anticoagulants (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
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
Pregnancy category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ketoprofen (Orudis, Actron, Oruvail)
For relief of mild to moderate pain and inflammation.
Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient for a response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse 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; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
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
Pregnancy category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Tricyclic antidepressants
Tricyclic antidepressants are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. These agents have central effects on pain transmission. They block the active re-uptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain.
Adult
30-100 mg PO qhs
Pediatric
Not established
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; has history of seizures, cardiac arrhythmias, glaucoma, and 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 elderly patients
More on Myofascial Pain |
| Overview: Myofascial Pain |
| Differential Diagnoses & Workup: Myofascial Pain |
 Treatment & Medication: Myofascial Pain |
| Follow-up: Myofascial Pain |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Further Reading
Related eMedicine topics:
Cervical Myofascial Pain
Fibromyalgia [Pediatrics: General Medicine]
Fibromyalgia [Physical Medicine and Rehabilitation]
Fibromyalgia [Rheumatology]
Massage, Traction, and Manipulation
Myofascial Pain in Athletes
Transcutaneous Electrical Nerve Stimulation
Keywords
myofascial pain, myofascial, trigger point, myofascial pain, myofascial pain syndrome, trigger point pain, chronic myofascial pain, trigger point therapy, myofascial trigger point, myofascial trigger, trigger point injections, trigger pain, pain and myofascial, musclehãrten, myogeloses, osteochondrosis, myofascitis
