Myofascial Pain Syndrome Vasu Kanjana-huttakit M.D. Orthopedic Surgery & Rehabilitation Vibharam Hospital

Muscle pain

Muscle spasm involuntary contraction caused by trauma, excessive tension, organic disorder

Muscle tension Prolonged contraction of a muscle cause by Prolonged contraction of a muscle cause by Postural tension Postural tension Emotional tension Emotional tension Situational tension Situational tension

Muscle deficiency Inadequate muscular fitness to meet the requirements of activities of daily living Inadequate muscular fitness to meet the requirements of activities of daily living

Trigger point

Etiology

Epidemiology Female > male Female > male Prevalence y Prevalence y Axial, postural muscle groups Axial, postural muscle groups Most common cause of chronic pain Most common cause of chronic pain Latent trigger point > active Latent trigger point > active

Pathophysiology Micro,macro trauma Micro,macro trauma Disruption of sarcomere Disruption of sarcomere Release of free calcium Release of free calcium join ATP to stimulate actin-myosin join ATP to stimulate actin-myosin Increase metb,serotonin,pg,kinin,His Increase metb,serotonin,pg,kinin,His Stimulate nociceptor..pain,refer pain Stimulate nociceptor..pain,refer pain CNS stimulate muscle spasm CNS stimulate muscle spasm

Pathophysiology Decrease blood flow, ATP,calcium pump Decrease blood flow, ATP,calcium pump Local fibrosis Local fibrosis

Most frequent locations

Symptoms Local & refer pain Local & refer pain Pain w contraction Pain w contraction Stiffness Stiffness Weakness Weakness Paresthesia Paresthesia Propioceptive disturbance Propioceptive disturbance Autonomic dysfunction Autonomic dysfunction

Physical findings Local tenderness Local tenderness Refer pain Refer pain Single or multiple muscle involvement Single or multiple muscle involvement Palpable nodules Palpable nodules Firm or taut bands in muscle Firm or taut bands in muscle Twitch response Twitch response Jump sign Jump sign Weak, shortening, limit motion Weak, shortening, limit motion

Types of trigger point Active vs Latent Active vs Latent Primary, secondary, satellite Primary, secondary, satellite

Trigger point

History Systemic review Systemic review Trauma Trauma Previous medical & surgical treatment Previous medical & surgical treatment Chronic debilitating disorder Chronic debilitating disorder Endocrine disorder Endocrine disorder Dental Dental Allergy Allergy

History related to MPS Characteristic of pain Characteristic of pain Onset Onset Occupational activities Occupational activities Athletic activities Athletic activities Sleep problems Sleep problems Psychological Psychological Endocrine Endocrine

Physical examination General General Posture & Movement Posture & Movement Muscle evaluation Muscle evaluation ROM flexibility strength spasm tension trp ROM flexibility strength spasm tension trp Neurological exam Neurological exam

Trigger points vs Tender points Local tenderness, taut-band,twitch,jump sign Local tenderness, taut-band,twitch,jump sign Singular or multiple Singular or multiple Any muscle Any muscle Specific refer pain Specific refer pain Autonomic & propioception symptoms Autonomic & propioception symptoms Local tenderness Local tenderness Multiple Multiple Specific, symmetrical Specific, symmetrical No refer pain No refer pain

Trigger point palpation Flat palpation Flat palpation Snapping Snapping Pincer or grasping Pincer or grasping

Diagnosis Criteria (Yunus) Major 5 Major 5 1 regional pain 2 referred pain pattern of trigger point 3 taut band 4 hyperirritable spot in taut band 5 limit ROM

Diagnosis Criteria (Yunus) Minor Minor 1 reproducible referred pain 2 local twitch response 3 release by stretching exercise or trigger point injection Diagnosis with all major and one of minor

Natural course Spontaneous recovery Spontaneous recovery Persistence without progression Persistence without progression Additional trigger points and chronic Additional trigger points and chronic

Classification of MPS Acute <2 m Acute <2 m Subacute 2-6 m Subacute 2-6 m Chronic > 6 m Chronic > 6 m

Poor prognosis (chronic) Unrecognized Unrecognized Overlook Overlook Improper treatment Improper treatment Inadequate treatment Inadequate treatment

Principle of MPS managemment Trigger point management Trigger point management Correct Perpetuating factors Correct Perpetuating factors

Trigger point management Injection Injection Stretch and Spray Stretch and Spray Massage Massage Heat therapy Heat therapy Acupuncture Acupuncture Electrotherapy Electrotherapy Exercise Exercise Drug Drug

Perpetuating factors Mechanical Mechanical Systemic Systemic Psychological Psychological

Trigger point injection Local anesthetic agent Local anesthetic agent Steroids Steroids NSAIDS NSAIDS Saline Saline Distilled water Distilled water Botulinum toxin Botulinum toxin

Mechanism of injection Mechanical Mechanical -feedback disruption -release of intracellular K -wash out effect -focal necrosis Chemical Chemical -local vasodilatation -local anesthetic -focal necrosis

Stage of recovery Local anesthetic period ½ -1 hr Local anesthetic period ½ -1 hr Post injection soreness 2-3 days Post injection soreness 2-3 days Migrating pain Migrating pain Healing phase Healing phase

Complications Internal organ injury Internal organ injury Pneumothorax Pneumothorax Pneumoperitoneum Pneumoperitoneum Muscle injury Muscle injury Nerve injury Nerve injury Infection Infection Toxic, allergic Toxic, allergic

Contraindications Acute trauma Acute trauma Bleeding tendency Bleeding tendency Allergy Allergy Infection Infection Pregnancy Pregnancy

Stretch and spray Inhibit pain gate Inhibit pain gate Disruption of trigger point Disruption of trigger point Restoration of normal length Restoration of normal length

Massage Circulation Circulation Gate control Gate control Waste product removal Waste product removal

Stroking

Stripping

Kneading

Friction

Acupressure

Precaution Hyperirritable trigger point Hyperirritable trigger point DVT DVT Infection Infection CA CA Skin disease Skin disease Personel Personel

Heat therapy Deep Deep-ultrasound -short wave Superficial Superficial -hot pack -hydrocollator

Thermal effect Gate control theory Gate control theory Endorphins Endorphins Increase pain threshold Increase pain threshold Increase circulation Increase circulation Sedation Sedation Relaxing effect Relaxing effect

Contraindications Impair sensation Impair sensation Impair circulation Impair circulation Bleeding disorder Bleeding disorder CA CA Acute inflammation Acute inflammation

Acupuncture Acupuncture point Acupuncture point yin yang balance meridian Trigger point Trigger pointendorphins common location

Electrotherapy Muscle stimulation Muscle stimulation -AC..DC faradic -continuous mode -surged-interrupted Nerve stimulation Nerve stimulation -Hi (fq) TENS gate control -lo TENS acupuncture like -Burst

Muscle stimulation

Nerve stimulation

Exercise Stretching Stretching Strengthening Strengthening Endurance Endurance Relaxation Relaxation

Common drugs Simple analgesic Simple analgesic Muscle relaxant Muscle relaxant NSAIDs NSAIDs Steroid for post injection soreness Steroid for post injection soreness Water soluble vitamins Water soluble vitamins Hormones Hormones Psychotropes,,antidepressant,anxiolytic Psychotropes,,antidepressant,anxiolytic Balms and gels Balms and gels

Mechanical factor Internal Internal Poor posture Anatomical abnormalities Constriction of the muscle External(ergonomic) External(ergonomic) -modern office (sedentary) -field work (heavy duty)

Systemic factor Nutritional insufficiency Nutritional insufficiency Vitamin water soluble ;folic acid, B vit C Metabolic & Endocrine Metabolic & EndocrineAnemiaHypothyroidmenopausegout

Systemic Infection Infection Allergy Allergy Impair sleep Impair sleep Nerve impingement Nerve impingement

Psychological Stress Stress Fear Fear Anxiety Anxiety Depression Depression Cognitive – behavior modification Cognitive – behavior modification Social factor Social factor

Wake up!!!

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