MyofascialPain Syndrome - Nopparat Pain Syndrome.pdf · Clinical criteria Major criteria 1. Regional pain 2. Pain or alteration of sensation in referred pain zone (as MPS pattern)

Myofascial Pain Syndrome

HistoryHistory

• Muscular Rheumatism• Fibrositis• Fibromyalgia• Myofascitis• Myofascial Pain• Myofascial Pain Syndrome

DefinitionDefinition

MPS; “Pain and/or autonomic phenomenon caused by active trigger point in skeletal muscles or fascia”

Myofascial trigger point(TrP)“A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band”

MyofascialMyofascial Trigger pointTrigger point

• Local tenderness in skeletal muscle or fascia

• Hyperirritable• Low pain pressure threshold• Produce pain, ANS, local twitch

EpidemiologyEpidemiology

• Female ; Male, 2.4:1• High prevalence in 31-35 yr• Postural muscles• Sedentary worker > Hard worker• Latent TrP > Active TrP

Symptoms and SignsSymptoms and Signs

• Pain• Autonomic phenomena• Myofascial TrP

PainPain

• Most common presenting symptoms• Regional Bizarre Referred pain pattern• Duration and severity

Autonomic phenomenaAutonomic phenomena

• Vasomotor disturbance• Sweating, lacrimation, coriza• Salivation• Pilomotor erection• Propioceptive disorder• tinnitus

Stress & Tension Sleep disorder Chr. Micro trauma-poor postural-repetitive motion

Macro trauma-sudden impact-injury

Muscle deficiency-general deconditionSystemic influences

-endocrine imbalance-nutritional def.

Post op influences-immobility-spasm

Neurogenic influence-secondary to n root compression

PathophysiologicPathophysiologic mechanism of mechanism of TrPTrP

• Energy crisis theory• Micro/macro injury to muscle; poor

posture, CTD, injury• “pathologic actin-myosin complex”• Increase sensitivities of muscle nociceptor

Physical ExaminationPhysical Examination• General PE• TrP examination

– Flat palpation– Snapping palpation– Pincer(grasping) palpation

TrPTrP palpationpalpation

• Local twitch response• Reproducible refer pain• Autonomic phenomenon• Weakness and restrict motion

Laboratory FindingLaboratory Finding

• No specific lab for diagnosis• Use for rule out other disease

Clinical criteriaClinical criteriaMajor criteria

1. Regional pain2. Pain or alteration of

sensation in referred pain zone (as MPS pattern)

3. Taut band palpation4. Decrease ROM

Minor criteria1. Pain complaint by

pressure on a nodule2. Local twitch response3. Injection or stretching

exercise can decrease pain

Fischer criteriaFischer criteria

• Tender point measured by algometer has lower PPT at least 2kg/cm2 than the different side

• Tender point compression can reproduce the symptoms

• Pain reduction by TrP injection or other treatment

Classification of MPSClassification of MPS

• Acute MPS(<2 mths)• Subacute MPS(2 – 6 mths)• Chronic MPS

Natural courseNatural course

• Spontaneous recovery• Persistence without progression• Additional TrP and chronicity

TreatmentTreatment

• Goal1.TrP inactivation2.Prevention of recurrence3.Correction of perpetuating factors

• Two step of treatment1.local treatment2.Correction of perpetuating factors

PrognosisPrognosis

• Correct diagnosis• Early and proper treatment• Acute MPS good prognosis

Local treatmentLocal treatment

• TrP injection• Massage• Heat• Acupuncture• Etc.

No single standard treatment

TrPTrP injectioninjection

• TechniqueCircular fan like techniquemultiple needle entry technique

AgentsAgents

• local anesthetic agents• steroids• saline• botulinum toxin

Effects of Effects of TrPTrP injectioninjection

• Mechanical effect• Chemical effect

Contraindication of Contraindication of TrPTrP injectioninjection

• Acute trauma• Bleeding tendency• Agents allergy• infection

Massage

Therapeutic heat

Electrotherapy

Perpetuating factorsPerpetuating factors

• Mechanical factorspoor posture, structural abnormal

• Systemic factorsvitamin deficiencyhypothyroidism

• Psychological factors

Single muscle MPSSingle muscle MPS

• Trapezius muscle• Infraspinatus muscle• Quadratus lumborum• Gastrocnemius muscle

TrapeziusTrapezius musclemuscle

• Most common myofascial TrP• Upper > lower > middle• D/Dx temporal headache, c spondylosis• Associate TrP; levator scapulae,

supraspinatus, rhomboid

InfraspinatusInfraspinatus musclemuscle

• S/S; shoulder pain, limit ROM• D/Dx; GH jt arthritis, frozen shoulder,CSR• Associate TrP; supraspinatus, teres minor,

deltoid

QuadratusQuadratus lumborumlumborum

• Most common LBP caused by muscle• D/Dx SI jt dysfunction, trochanteric

bursitis, HNP• Associate TrP; G. minimus(sciatica pain)

GastronemiusGastronemius musclemuscle

• Medial head > lateral head• D/Dx, S1 radiculopathy, compartment

syndrome• Associate TrP; soleus, hamstrings