This Session by Simon Strauss

1
This Session by Simon Strauss

• Myofascial Pain. Part A
• Myofascial Pain. Part B
• Pain Assessment Tools. Part C

2
Definitions and Language of Pain

• Allodynia- 1. A lower than normal pain
  threshold.
• 2. A clinical situation where
  pain results from a
• stimulus which should
  normally be painless.
• 3. Pain upon palpation at
  less than 4kg/cm2 or
• less at a site, which
  does not cause pain at the
  same anatomic site in normal individuals.
• Dysesthesia- Unpleasant sensations ranging from
  numbness
• to pins and needles.

3
Definitions and Language of Pain

• Hyperalgesia A greater than normal response to a
• stimulus expected to
  cause pain in a
• normal individual.
• Fibromyalgia Chronic widespread Allodynia.
• Nociception The neurochemical process by which
  pain
• signals are transmitted
  from the periphery
• to the CNS and perceived
  by the individual

4
Definitions and Language of Myofascial Pain

• Myofascial Trigger Points (MTrPs)
• 
  May be active or latent
• An active Myofascial trigger point
• is a focus of hyper-irritability
• in a muscle or its fascia
• that causes the patient pain.

5
Definitions and Language of Myofascial Pain

• An active Myofascial trigger point
• causes pain and tenderness at rest or with motion
  that
• stretches or loads the muscle.
• It prevents full lengthening of the muscle, as
  well as
• fatigue and decreased strength.
• Pressure on an active MTrP induces / reproduces
  some
• of the patients pain complaint and is recognised
  by the
• patient as being some or all of his or her pain.

6
Definitions and Language of Myofascial Pain

• A Latent Myofascial Trigger Point does not cause
  
• pain during normal activities.
• It is locally tender, but causes pain only when
  palpated.
• It also refers pain on pressure.
• It can be associated with a weakened shortened
  more easily
• fatigued muscle.
• A Palpable / Taut Band is a group of muscle
  fibres that
• is associated with MTrPs and is identifiable by
  its rope-like
• consistency.

7
Definitions and Language of Myofascial Pain

• Twitch response a transient contraction of part
  of the
• involved muscle in response to needling or
  snapping
• palpation
• Jump Sign A general pain response of the
  patient, who
• may wince, vocalise or jump in response to
  pressure on a
• MTrP.
• Involved muscle A muscle that contains one or
  more
• MTrPs

8
Myofascial Pain Syndromes
Can be thought of as Pain Syndromes that are
caused by and are maintained by one or more
active Trigger Points and their associated
reflexes
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Myofascial Pain Syndromes

• The
• Trigger Point
• is the
• Pain Generator

10
Myofascial Pain Syndromes Prevalence

• Unselected and Control Groups
• Danish study of 1504 people, aged 30 - 60, 37 of
  males
• and 65 of females had localised myofascial pain.
• 100 male and 100 female airforce personnel (Av.
  Age 19)
• 45 of males and 54 females had focal neck
  muscle
• tenderness ( latent trigger points).
• 269 female student nurses. 45 had TrPs in
  masseter,
• 35 had TrPs in trapezious.
• 28 had myofascial pain at the time of
  examination.

11
Myofascial Pain Syndromes Prevalence

• Unselected and Control Groups
• Lumbogluteal muscles Assessment of
• 100 asymptomatic control subjects.
• Revealed latent TrPs in
• 45 of Quadratus Lumborum,
• 41 of Gluteous Medius,
• 11 of Gluteous Minimus,
• 5 of Piriformis.

12
Myofascial Pain Syndromes Prevalence

• Anecdotal evidence suggests that
• Ballerinas, Swimmers, Runners and
• indeed any group of athletes that uses a
• group of muscles in a prolonged or
• repeatedly forceful manner are likely to have
• latent trigger points and therefore can be
• toppled into a Myofascial pain state.

13
Myofascial Pain Syndromes Prevalence

• Patient Groups
• Community pain medical center.
• 96 Patients studied by a neurologist
• 93 had at least part of their pain
• caused by myofascial TrPs
• and in
• 74 of the patients myofascial TrPs were
  considered to be the primary source of Pain.

14
Myofascial Pain Syndromes Prevalence

• Patient Groups
• Comprehensive pain
  center
• 283 consecutive admissions to a comprehensive
  pain center
• The diagnosis made independently by a
  Neurosurgeon and a
• Physiatrist based on physical examination as
  described by
• Travell and Simons assigned a primary organic
  diagnosis of myofascial pain in 85 of the cases.

15
Myofascial Pain Syndromes Prevalence

• Percentage of Patients with another diagnosis who
  also
• had Myofascial TrPs contributing to their pain
  problems

16
Myofascial Trigger Points Clinical Features

• History of spontaneous pain associated
• with acute overload or chronic overuse of
• the muscle.
• The mildest symptoms are caused by latent TrPs
  which
• cause no pain but cause some degree of functional
  
• disability.
• More severe involvement results in pain related
  to the
• position or movement of the muscle.
• The most severe level involves pain at rest.

17
Myofascial Trigger Points Clinical Features

• Palpable Band.
• A cord like band of fibres is present in the
  involved
• muscle.
• This can be difficult to identify when there are
  overlying
• muscles or thick subcutaneous tissue.

INJURY
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Myofascial Trigger Points Clinical Features

• Spot Tenderness
• A very tender small spot which is found in a
  Taut
• Band.
• The sensitivity of this spot (TrPs) can be
  increased by
• increasing the tension on the muscle fibres of
  the taut
• band.

19
Myofascial Trigger Points Clinical Features

• Jump Sign
• Pressure on the tender spot causes the patient to
  
• physically react to the precipitated pain by
  exclaiming or
• moving.
• Ah-Shi - Oh yes!
• This reaction indicates the level of tenderness
  but is
• also dependent on the pressure exerted by the
  examiner.

20
Myofascial Trigger Points Clinical Features

• Pain Recognition
• Digital pressure on or needling of the tender
  spot
• induces / reproduces some of the patients pain
• complaint and is recognised by the patient as
  being
• some or all of his or her pain.
• Ah-Shi - Oh yes!
• This finding by definition identifies an active
  trigger point.
• This replication of the patients pain may
  require
• sustained pressure (5 - 60 seconds) on the TrP.

21
Myofascial Trigger Points Clinical Features

• Twitch Response
• Is a transient contraction of the muscle fibres
  of the
• taut band containing the trigger point.
• The twitch response can be elicited by snapping
• palpation of the trigger point.
• Or more commonly by precise needling of the
  trigger
• point.

22
Myofascial Trigger Points Clinical Features

• Elicited referred pain and or tenderness
• An active MTrP refers pain in a pattern
  characteristic of
• that muscle -Usually to a site distant to the
  TrP.
• 85 of TrPs project distally.
• The area of the referred pain is often tender
  and may
• contain satellite trigger points.
• Latent TrPs also refer pain on pressure but
  usually require
• more pressure to do so.

23
Myofascial Trigger Points Clinical Features

• Restricted Range of Movement.
• Full stretching of the affected muscle is often
  involuntarily
• restricted by pain.
• Inactivation of the associated MTrP releases the
  taut band
• that is (? reflexly) restricting the muscle.

24
Myofascial Trigger Points Clinical Features

• Muscle Weakness
• The patient is unable to demonstrate normal
  muscle
• strength on static testing of the affected side
  as compared to
• the contra-lateral non-affected side.
• The involved muscle is also more easily fatigued.

25
Myofascial Trigger PointsPostulated Explanations
of Clinical Features
26
Myofascial Trigger PointsPathogenic Factors

• Acute overload
• Overwork - Fatigue (Including postural stress)
• Chilling
• Gross Trauma
• Other Trigger Points
• Emotional distress
• Joint or nerve damage
• Visceral disturbance

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Chart outlining the natural course of Myofascial
pain caused by Trigger Points
Taut Band
Pathogenic Factors
Latent TrPs
STRESS
Perpetuating Factors
Active TrPs
Persistence without progression
Additional TrPs Chronicity
Spontaneous Recovery