PAIN-OUTLET Clinical Guide - Specialty Care …...Myofascial Pain Syndrome (MPS) • Regional soft tissue pain commonly involving the neck, shoulders, trunk, arms, low back, hips and

Myofascial Techniques for

Back and Neck Pain

Presented by:

Edward S. Lee MD

National Program Faculty:

Edward S. Lee MD

Director, Interdisciplinary Pain Rehabilitation Program

VA Pittsburgh Healthcare System

Part 1

Specialty Care National Program Mini-Residency – Pain Management

February 10-12, 2015

Disclosures

• Instructor, Medical Acupuncture for

Physicians Course, Helms Medical Institute

Learning Objectives

• Know the differences between Myofascial Pain

Syndrome (MPS) and Fibromyalgia (FM).

• Understand the anatomy and pathophysiology of

myofascial pain.

• Appreciate the importance of diagnosing and

managing MPS.

• Develop clinical skills in treating MPS.

• Utilize a multimodal, integrative, interdisciplinary

approach to pain management.

Myofascial Pain Syndrome (MPS)

• Regional soft tissue pain commonly involving the

neck, shoulders, trunk, arms, low back, hips and

lower extremities

• Painful muscle dysfunction in one or several

muscles in a region of the body with loss of range

of motion

• Trigger points

• Central sensitization – hypersensitivity, allodynia

• Referred pain

• Described as burning, stabbing, aching, nagging

Fibromyalgia (FM)

• Systemic somatic condition

• Widespread musculoskeletal tenderness and

pain

• Tender points, may coincide with trigger

points

• Central sensitization and augmentation

• Not excluded by Myofascial Pain Syndrome

FM Diagnostic Criteria, ACR 2010

Widespread Pain Index ≥7 and

Symptom Severity scale score ≥5

OR

Widespread Pain Index of 3-6 and

Symptom Severity scale score ≥9

FM Widespread Pain Index

Bilateral sites (total of 14)

• Jaw

• Shoulder

• Upper arm

• Lower arm

• Hips

• Upper leg

• Lower leg

Unilateral sites (total of 5)

• Neck

• Upper back

• Chest/breast

• Abdomen

• Lower back

FM Symptom Severity Scale

• Fatigue, Cognitive Difficulties, and Sleep Disturbances

– Score each domain:

• 0 = No problem

• 1 = Slight or mild problems; generally mild or intermittent

• 2 = Moderate; considerable problems; often present and/or

at a moderate level

• 3 = Severe: pervasive, continuous, life disturbing problems

• Somatic Symptoms

• 0 = 0 symptoms

• 1 = 1 to 10

• 2 = 11 to 24

• 3 = 25 or more

Somatic Symptoms

Muscle pain

Irritable bowel

syndrome

Thinking or

remembering

problems

Muscle weakness

Headache

Pain/cramps in the

abdomen

Numbness/tingling

Dizziness

Depression

Constipation

Pain in the upper

abdomen

Nausea

Nervousness

Chest pain

Blurred vision

Fever

Diarrhea

Dry mouth

Itching

Wheezing

Raynaud's

phenomenon

Hives/welts

Ringing in ears

Vomiting

Heartburn

Oral ulcers

Loss of/change in

taste

Seizures

Dry eyes

Shortness of breath

Loss of appetite

Hair loss

Frequent urination

Painful urination

Bladder spasms

Rash

Sun sensitivity

Hearing difficulties

Easy bruising

Hair loss

Frequent urination

Painful urination

Bladder spasm

Comorbid Conditions Found with Both FM and MPS

• Migraine headache

• Tension-type headache

• Temporomandibular joint disorder

• Hypermobility syndromes

• Painful bladder syndrome

• Irritable bowel syndrome

• Pelvic pain syndrome

• Vulvovaginitis

• Prostatitis

• Endometriosis

• Dysmenorrhea

• Hypothyroidism – check TSH

Conditions More Commonly Associated with MPS

• Malabsorption

– Vitamin D deficiency

– Vitamin B12 deficiency

– Iron deficiency

• Parasitic infection

– Check stools x3 for O&P if significant GI

symptoms

• Celiac disease

• Candida overgrowth

MPS: Epidemiology

• Prevalence – up to 95% in patients with

chronic pain disorders

• Overall prevalence:

– 37% of middle-aged men (30-60 years)

– 65% of middle-aged women

– 85% of elderly (>65 years)

• Costs up to $47 billion/year

MPS History

• Clinical studies of trigger points conducted by four separate investigators in the 1930’s and 40’s

– J. H. Kellgren at University College Hospital, London

• Hypertonic saline injection in healthy volunteers gave rise to zones of referred extremity pain.

– Michael Gutstein in Berlin

– Michael Kelly in Australia

– Janet G. Travell in New York

• Trigger point research and treatment of John F. Kennedy's back pain led to her becoming the first female Personal Physician to the President.

Osteopathic Medicine

• Founded by A.T. Still, Civil War surgeon, at a time when allopathic medicine had few safe and effective treatments.

• Holistic approach to health, on the premise that the body’s capacity to heal can be optimized by assessing and manipulating the musculoskeletal system.

• Identified musculoskeletal pain and dysfunction as a manifestation of general health.

• Still and his successors developed numerous approaches for somatic dysfunction, including myofascial pain syndrome.

Myofascial Pain Syndrome: Etiology

• Often presents after an injury or with occupational repetitive activity/overuse.

• TrPs may develop when muscle use exceeds muscle capacity and normal recovery is disturbed.

• Local muscle metabolic stress may produce “energy crisis”.

• Dehydration may precipitate myofascial dysfunction

• Fascia plays central role.

• Shortened muscles lead to enthesopathy, tendonitis, postural changes, limited range of motion and limited flexibility, ie somatic dysfunction.

Myofascial Trigger Point Pathophysiology

Fascial injury:

tightness,

restriction,

compression,

disruption,

due to edema,

hematoma,

inflammation,

tear

etc.

Adapted from Simons’ model of myofascial pain syndrome

Anatomy Revisited

• Musculoskeletal system is not simply a

system of pulleys and levers.

• Bones are living, dynamic compressive

elements that “float” in a sea of soft tissue.

• Muscles are incompressible, fluid-filled,

contractile elements found in pockets of

fascia, attached to bones via connective

tissues.

Fascia

• Originates from embryonic mesodermal mesenchymal cells.

• Is a continuous network of living, dynamic connective tissue that surrounds, connects, and penetrates every organ and structure in the body.

• Is populated by fibroblasts, as well as adipocytes, reticulocytes and other immune cells.

• Is richly innervated.

• Imparts tensile strength.

• Is the target of manual therapies, including acupuncture.

Dr. Jean Claude Guimberteau: “Strolling Under the Skin”

http://www.guimberteau-jc-md.com/en/videos.php

Tensegrity

• Buckminster Fuller

• Tension + Integrity

• Global balance

between

compression and

tension

Artifact vs. Reality

Compartment Syndrome

Mechanotransduction in Fibroblasts

• Integrin family

• Link between ECM and cell interior

• Physical and informational

• Triggers gene expression

• Regulates protein synthesis

• Changes extracellular matrix composition

• Change in connective tissue around nerve terminals

• Cytoskeletal reorganization

Mechano-transduction

• Stretch fibroblast, focal adhesions serve as force sensors, Rho signals a remodel message to relax itself

• Cytoskeletal remodeling, influences connective tissue tension

• Prevent with Colchicine

Mechanotransduction

• Acupuncture affects fibroblasts several cm. away

• Reorganize their cytoskeleton, change shape

• Become larger and flatter

• Similar with sustained stretch(30 min.)

• Inhibited in animal models by injection of collagenase.

Fibroblast Response to Injury

• Production of

collagen and ECM

• Matrix degrading

enzymes when

chronic

• Fibroblast

myofibroblast

• Chronic; excess

collagen, tissue

tension, fibrosis

Wound Healing and Fibrosis

Connective Tissue Fibrosis

• Patients with chronic low back pain (LBP) have thicker connective tissues.

• Usually dense and areolar tissue alternate, allowing lamellar gliding.

• LBP has decreased gliding.

Sensory Innervation of Fascia

• Connective tissues

have sensory

innervation,

including pain

afferents that

respond to stretch of

inflamed connective

tissue.

Trigger Points

• Palpable muscle nodules, characterized by

shortened sarcomeres.

• Found within taut bands of muscle.

• Associated with tenderness that reproduces

patient’s pain.

• Typically causes referred pain in a

predictable distribution.

• Twitch response – elicited with palpation or

needling the affected muscle; variable, low

inter-rater reliability.

Taut Band and Trigger Point