Myofascial Syndromes

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Chapter 36 Myofascial Syndromes

INTRODUCTION

Description: Myofascial syndrome is characterized by muscular and fascial pain associated with localized tenderness and pain referred to sites that are often remote. Myofascial pain syndromes and fibromyalgia frequently demonstrate trigger-point involvement. These syndromes may present as chronic lower abdominal or pelvic pain that is easily confused with gynecologic causes.
Prevalence: Three percent of the population.
Predominant Age: Sedentary middle-aged women.
Genetics: No genetic pattern. More common in women (80% to 90%). Several studies indicate that women who have a family member with fibromyalgia are more likely to have fibromyalgia themselves.

ETIOLOGY AND PATHOGENESIS

Causes: Abnormal spasm of a small portion of a muscle resulting in an extremely taut, tender band of muscle (trigger point). Compression of this site elicits local tenderness and often reproduces the referred pain. Most trigger points are located at or near areas of moving or sliding muscle surfaces, although they are not limited to these locations. Genetics and physical and emotional stressors are possible contributory factors to the development of the illness.
Risk Factors: Stress, sleep deprivation, trauma, depression, and weather changes.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Chronic pain referred to remote sites.
• “Trigger points” (hypersensitive areas overlying muscles that induce spasm and pain) that induce or reproduce the patient’s symptoms. (Trigger points may be found throughout the body but are most common in the abdominal wall, back, and pelvic floor when pelvic pain is the symptom.) Most patients have 11 or more trigger points.
• Pain is worse in the morning, with stress or weather change, after nonrestorative sleep. Pain is better with activity, stress reduction, and rest.
• Two criteria established by the American College of Rheumatology: a history of widespread pain lasting more than 3 months and the presence of tender points.

DIAGNOSTIC APPROACH

Differential Diagnosis

• Somatization
• Sympathetic dystrophy
• Muscle strain or sprain
• Polymyalgia rheumatica
• Temporal arteritis
• Irritable bowel syndrome (IBS)
• Low back strain or sprain

Associated Conditions: Chronic pain syndromes, irritable bowel syndrome, depression, reduced physical endurance, and social withdrawal.

Workup and Evaluation

Laboratory: No evaluation indicated. Screening with an erythrocyte sedimentation rate (normal) may be helpful. Others based on diagnosis being considered.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: History and physical examination generally sufficient.

Pathologic Findings

A trigger point is often felt as an extremely taut band of muscle. (Normal muscle should not be tender to firm compression and does not contain taut bands.)

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, analgesics, heat (low-level continuous topical heat [ThermaCare], hot packs, ultrasound therapy), and general conditioning exercises.
Specific Measures: Transcutaneous electrical nerve stimulation (TENS), trigger-point injections. A 22-gauge needle is selected for trigger-point injection because of the amount of movement within tissue often required to probe for and block a taut muscle bundle. Thinner needles may bend or break under these circumstances. The length of the needle should be sufficient to allow the entire trigger point to be reached without indenting the skin or having the hub at the skin surface. Superficial trigger points may also be treated with a “spray-and-stretch” technique. (The area overlying the trigger point is sprayed with a coolant or freezing spray [e.g., ethyl chloride] for several seconds, and the muscle is forcibly stretched by passive extension.) Hypnosis may also be used.
Diet: No specific dietary changes indicated.
Activity: No restriction except that caused by pain.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP099 (Pelvic Pain).

Drug(s) of Choice

Nonsteroidal anti-inflammatory drugs (NSAIDs).
Sleep aids—flurazepam (Dalmane) 15 mg PO every night, triazolam (Halcion) 0.125 mg PO every night, amitriptyline (Elavil) 20 to 25 mg PO every night.
Muscle relaxants—cyclobenzaprine (Flexeril) 10 mg PO three times a day.
Local anesthetic for injection (generally 1% lidocaine without epinephrine, limit injection to approximately 10 mL/site).
Emerging: Adjuvant therapy with gabapentin and 5-HT3 receptor-blocking agents has been advocated in some studies.

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Contraindications: See individual agents. Trigger-point injections should not be attempted when infection is present near the planned site.
Precautions: Watch for side effects or dependence.

Alternative Drugs

Trazodone (Desyrel) 50 mg PO every night.

FOLLOW-UP

Patient Monitoring: Normal health maintenance, monitor for medication side effects.
Prevention/Avoidance: Adequate restorative sleep, stress reduction, physical fitness, and activity.
Possible Complications: Depression, reduced physical endurance, social withdrawal, chronic pain, work compromise or absence. The most common complications of trigger-point injection are local ecchymoses and anesthetic agent toxicity. The latter is best avoided by strictly limiting the total dose given. Infection is rare if the skin is first disinfected and areas of frank infection are avoided.
Expected Outcome: Improvement with medical therapy generally is seen in 2 to 4 weeks. With the identification of a specific trigger point and the use of trigger point injection, results should be good. (Response to trigger point injection routinely persists longer than the duration of action of the anesthetic agent used. This frequently extends to permanent relief after only one or two injections.)

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Pregnancy may limit some therapies. Pregnancy is generally not a contraindication to trigger-point injections.
ICD-9-CM Codes: Based on type and location.

REFERENCES

Level I

Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine. 1989;14:962.

Gobel H, Heinze A, Reichel G, et alDysport Myofascial Pain Study Group. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicentre study. Pain. 2006;125:82. Epub 2006 Jun 5

Graboski CL, Gray DS, Burnham RS. Botulinum toxin A versus bupivacaine trigger point injections for the treatment of myofascial pain syndrome: a randomised double blind crossover study. Pain. 2005;118:170. Epub 2005 Oct 3

Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25:604. Epub 2004 Sep 15

Level III

American College of Obstetricians and Gynecologists. Chronic pelvic pain. ACOG Practice Bulletin 51. Washington, DC: ACOG, 2004.

Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and related disorders. Phys Med Rehabil Clin N Am. 2006;17:491. viii.

Campbell SM. Regional myofascial pain syndromes. Rheum Dis Clin North Am. 1989;15:31.

Ling FW, Slocumb JC. Use of trigger point injections in chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:809.

McClaflin RR. Myofascial pain syndrome. Primary care strategies for early intervention. Postgrad Med. 1994;96:56.

Rothschild B. Diagnosing and treating fibrositis and fibromyalgia. Geriatr Consultant. 1990;9:26.

Slocumb JC. Neurologic factors in chronic pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am J Obstet Gynecol. 1984;149:536.

Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33:160.

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