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

2. Muscle pain

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

4. 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

5. 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

6. Trigger point

7. Etiology

8. Epidemiology Female > male Female > male Prevalence 31-50 y Prevalence 31-50 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

9. 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

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

11. Most frequent locations

12. 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

13. 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

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

15. Trigger point

17. 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

18. 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

19. 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

20. 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

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

25. 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

26. 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

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

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

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

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

31. 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

32. Perpetuating factors Mechanical Mechanical Systemic Systemic Psychological Psychological

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

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

35. 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

36. 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

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

38. 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

41. Massage Circulation Circulation Gate control Gate control Waste product removal Waste product removal

42. Stroking

43. Stripping

44. Kneading

45. Friction

46. Acupressure

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

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

49. 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

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

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

52. 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

53. Muscle stimulation

54. Nerve stimulation

55. Exercise Stretching Stretching Strengthening Strengthening Endurance Endurance Relaxation Relaxation

56. 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

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

60. Systemic factor Nutritional insufficiency Nutritional insufficiency Vitamin water soluble ;folic acid, B1 6 12 vit C Metabolic & Endocrine Metabolic & EndocrineAnemiaHypothyroidmenopausegout

61. Systemic Infection Infection Allergy Allergy Impair sleep Impair sleep Nerve impingement Nerve impingement

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

64. Wake up!!!

65. Suggest reading Myofascial pain syndrome by Myofascial pain syndrome by Pradit Prateepavanich Myofascial pain and Fibromyalgia Myofascial pain and Fibromyalgia Edward S. Rachlin