Cervical Myofascial Pain Treatment & Management

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 ^[12]

• Nonnarcotic analgesics

• Anticonvulsants

A study by Park et al indicated that extracorporeal shock-wave therapy (ESWT) can effectively treat myofascial pain syndrome of the upper trapezius, producing improvement in verbal numeric pain scale and Neck Disability Index scores, as well as in pressure threshold and neck range of motion (ROM). The investigators also reported that posttreatment improvements in the Neck Disability Index and in neck flexion were significantly greater in patients who received high-energy ESWT than in those who underwent low-energy therapy. ^[13]

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. ^[14]

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. ^[15]

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. ^[16]

A randomized, double-blind, placebo-controlled study by Ay et al indicated that kinesiology taping improves pain, the pressure pain threshold, and cervical ROM in patients with cervical myofascial pain syndrome but does not improve disability in the short-term. The study included 31 patients who underwent kinesiology taping and 30 patients who underwent sham taping. ^[17]

A study by Moustafa et al indicated that in patients with chronic cervical myofascial pain syndrome and defined abnormalities in cervical sagittal posture, the use of a Denneroll cervical orthotic device in combination with integrated neuromuscular inhibition technique (INIT) leads, possibly through improvement of sagittal cervical posture alignment, to better results with regard to pressure pain thresholds and cervical range of motion than does INIT alone. ^[18]

A prospective, randomized clinical study by Aydin et al indicated that exercise therapy can effectively treat dizziness associated with cervical myofascial pain syndrome, with a combination of exercise and dry needling producing better results than exercise alone. The severity of dizziness, weekly number of dizziness attacks, fall index, and Dizziness Handicap Inventory were among the measurements used in deriving the results. ^[19]

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. ^[6]

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 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.

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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. ^[10] This approach, therefore, generally is the most helpful technique for reducing myofascial pain.

A retrospective study by Affaitati et al indicated that in patients in whom target areas of myofascial cervical trigger points coincide with migraine pain sites, topical treatment of the trigger points with 3% nimesulide gel is as effective against migraine headache as injection of the trigger points with local anesthetic. ^[20]

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 spraying any muscle for myofascial trigger points.

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Schematic drawing showing how the jet stream of vapocoolant is applied.

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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. ^{[7, 8]}

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. ^[21]