MYOFASCIAL

PAIN
SYNDROME
Cabanting|Casco|Reyes

MUSCLE
- Muscles tendon and Fascia are richly
supplies with nociceptive nerve
endings
- They may be damaged acutely
- They may be damaged associated with
other injuries

MUSCLE SPASM
- Occurs to protect underlying damaged tissue
such as joints
- If pain and inflammation from joint injury
persist, MUSCLE SPASM will also persist
- Increase in muscle tension will lead to
chemical and mechanical stimulation of
nociceptive nerve endings

ANAPHYSIO OF MUSCLE PAIN

- A part of somatic deep
pain
Pain derived from muscles, tendons,
joints and bones

- Less localized, sharp/dull

and aching
- Follows myotomes,
dermatomes and
sclerotomes

ANAPHYSIO OF MM PAIN:
- MP is not a prominent feature of the
serious progressive diseases affecting mm.
- Mm are relatively insensitive to pain when
elicited by needle or knife cut, but
overlying fascia is very sensitive to pain.
- Events that may lead to mm pain?

SPINAL AND
SUPRASPINAL
MXNSM OF PAIN
PATHWAY

MXNSM OF NOCICEPTOR ACTIVATION:

Group III (A delta) and Group IV (C fibers)
Located where? Termination?
Bradykinin most potent stimulator of mm nociceptor;
sensitizes nociceptor activating them and lowers
threshold of some mech. Stimuli of some HTM
receptors
Prostaglandin? Aspirin?
Epinephrine damaged tissue are most sensitive when
epinephrine is activated -> Sympathetic NS = PAIN

SPINAL MXNSM OF PAIN

SUPRASPINAL MXNSM OF MM PAIN

Acute Pain
- Inc. cerebral blood flow=inc. activity of thalamus
- SI and SII encodes the sensory discriminative
dimension of pain
- -Anterior Cingulate Cortex encodes the aversive
emotional dimension of pain
Serotonin: one of major neurotransmitter of the
inhibitory system

DERMATOME

MYOTOMES
UPPER EXTREMITY
C1-C2 : NECK FLEXION
C3: LATERAL FLEXION

LOWER EXTREMITY
L2: HIP FLEXION

C4: SHOULDER SHRUG

L3: KNEE EXTENSION

C5: SHOULDER ABDUCTION

L4: ANKLE DORSIFLEXION

C6: ELBOW FLEXION AND WRIST

EXTENSION

L5: BIG TOE EXTENSION

C7: ELBOW EXTENSION AND WRIST

FLEXION
C8: FINGER FLEXION AND THUMB
EXTENSION
T1: FINGER BADUCTION

S1: ANKLE PLANTARFLEXION

CONCEPT OF MYOFASCIAL PAIN

- Janet Travell
- Insidious onset of localized mm spasm
which led to pain & through a reflex
vicious circle, to more spasm & pain
- Most common cause?

HISTORICAL OVERVIEW:
Early German Literature:
MYELOGELOSIS
- Change in the colloidal state of mm
cytoplasm
Massage??

HISTORICAL OVERVIEW:
EARLY BRITISH LITERATURE:
William Balfour (1815)
Concept of Fibrositis
edema and exudate*

HISTORICAL OVERVIEW:
EARLY BRITISH LITERATURE: Concept of
Fibrositis
- Valleix (1841)
- Sir William Gower (1904
SOFT TISSUE RHEUMATISM = FIBROSITIS

EPIDEMIOLOGY
30% occur among pt. in a general clinic
setting
85% occur among pt. tx in a pain center
F>M

DIFFERENT TYPES OF MM PAIN

SYNDROME:
OVERUSE SYNDROMES
Overuse injury/repetitive strain injury
Repetitive use of mm not from a single
bout exercise*
MICROTRAUMA?

DIFFERENT TYPES OF MM PAIN

SYNDROME:
POST EXERCISE MM SORENESS
Pain that is felt following unaccustomed
exercise using untrained mm & peaks
24-48hrs after exercise.

SSX:
3 CARDINAL SIGNS OF MPS:
- Trigger Points
- Taut Bands
- Localized Twitch Response

TRIGGER POINT

TRIGGER POINT

TAUT BAND

DX CRITERIA:
5 major criteria of MPS
Regional Pain Complaint
Pain complaint
Taut band palpable in an accessible
muscle.
Spot tenderness at one point along the
length of the taut band.
Some degree of restricted range of
motion, when measurable.

DX CRITERIA:
Criteria for Classification of
Fibromyalgia
Widespread pain of 3 months duration
Pain in 11 of 18 tender points on digital
palpation.
Digital palpation must be performed
with an approximate force of 4kg

DX TEST:
No laboratory test or diagnostic imaging
technique has been established as a
diagnostic for MPS.
3 Tools that are helpful as to explain
the occurrence of trigger points:
Needle Electromyography
Ultrasound
Surface EMG

DX TEST:
NEEDLE EMG
Presence of spontatneous low-voltage
motor endplate noise activity
High-voltage spikes may occur.

DX TEST:

ULTRASOU
ND

DX TEST:
SURFACE EMG
Trigger points can cause disruption or
distortion of muscle function.
- muscles is indicated by abnormally
high amplitude of EMG activity when
the muscle is voluntarily contracted
and loaded.

DIFFERENTIAL DX:

MEDICAL MGT:
Drug Therapy
Muscle Relaxants
NSAID injections after Needling
technique
Sleep medications
Trouble-Making Drugs

MEDICAL MGT:
Trouble Making Drugs:
Caffeine
Tobacco
Sleep Relaxant:
Ramelteon (Rozerem)
Diphenhydramine(found in brand names like
Nytol, Sominex, Sleepinal, Compoz)
Doxylamine(found in brand names like Unisom,
Night time Sleep Aid)
Eszopiclone (Lunesta)
Zalepon (Sonata)
Zolpidem (Ambien)
Muscle Relaxant:
carisoprodol,cyclobenzaprine,metaxalone,
andmethocarbamol

MEDICAL MGT:

NEEDLING TECHNIQUE
Botulinum Toxin
Injections

PT MGT AND TX:

- biofeedback, ultrasound, lasers, and
massage
- Spray & stretch: flouromethane
- TENS
- US
- HMP c high voltage galvanic
stimulation
Sedative massage or gentle soft tissue
mobilization

PT MGT AND TX:

General Stretching Programs
MFR (standard)- myofascial release
PRT- positional release therapy
MET- manual exercise techniques

SECONDARY COMPLICATIONS:
-

Atrophy
Contractures
Tightness
LOM