Overview: Myofascial Pain Syndrome

• Myofascial pain syndrome (MPS) and similar terms (Box 62-1) refer to pain and associated sequelae developing from and aggravated by myofascial trigger points (TePs).

• The actual prevalence of MPS varies, based on terminology and diagnostic criteria. Myofascial pain is considered to to be the leading cause of musculoskeletal pain, however, and it affects up to 85% of the population at some point during their lives. The prevalence of MPS aho appears to be related to age and gender.

• Persons 30 to 60 years of age appear to a have a 37% (male) and 65% (female) prevalence, whereas those older than 65 years of age have a rate higher than 80%.

• Although MPS is highly prevalent, because of its varied presentation and complex comorbidities, no widely accepted treatment guidelines currently exist, and physicians often characterize available individual treatment options as insufficient.

Synonyms for MPS

• Myofascial pain and dysfunction

• Trigger points syndrome ocalized fibromyalgia\

• Fibromyositis Muscular rheumatism

• Soft tissue syndrome

• Somatic dysfunction

• Tension myalgia

Important points to consider

• Consider checking serum levels of vitamin B, 25-hydroxyvitamin D, coenzyme Q10, and electrolytes, as well as red blood cell magnesium levels in patients with myofascial pain syndrome.

Prevention Prescription

• Encourage posture awareness with frequent repositioning and adaptive stretching to reduce

  strain.

• Consider an ergonomic evaluation if patients remain in one position for prolonged periods at work

• Incorporate stress management techniques to identify and reduce stress baildup. Ask patients to pay attention to where they carry stress in the body and use this to learn from the body's symptoms.

• Incorporate a regular exercise and movement program. At a minimum, patients should exercise three times/week for 30 minutes each session while stimulating movement, range of motion, and tone in

  all muscle groups.

• Encourage adequate quantity and quality of sleep. Encourage the consumption of a healthy diet rich in fruits and vegetables with adequate fluid content to ensure perfusion to muscles.

• Encourage maintenance of an ideal weight.

Integrative therapeutics review

Myofascial pain syndrome (MPS) is a disorder that affects up to 85% of the general population at some point and is primarily characterized by local and referred pain, as well as comorbidities affecting mood, sleep, energy, and functional status. Although numerous treatment options are available, no widely accepted treatment guidelines exist. Clinically, MPS is a condition that is often difficult to treat, and physicians often characterize available treatments as insufficient. Based on its complex nature, MPS is a condition that requires a biopsychosocial evaluation and incorporation of individualized, preferably active, treatments option geared at underlying propagating factors with a focus on long-term neurobehavioral and functional rehabilitation.

Exclusion and Treatment of Conditions That Mimic or Contribute to Myofascial Pain Syndrome

• Symptom-focused laboratory testing should be considered, including 25-OH vitamin D, coenzyme Q10, carnitine, vitamin B, folate, methylmalonic acid, and, as appropriate, baseline thyroid-stimulating hormone, creatine phosphokinase, alkaline phosphatase, and complete blood count and electrolytes with intracellular magnesium to rule out modifiable causes of MPS and associated symptoms.

Removal of Exacerbating Factors

• Take measures to correct sleep dysfunction, including sleep hygiene and other interventions.

• Increase awareness of stress and environmental triggers (poor posture, repetitive stress) by using periodic daily cues.

Lifestyle Measures

• Incorporate stress management techniques Biofeedback, preferred for baseline myofascial and autonomic measures and retraining efforts

• Guided imagery

• Meditation

• Exercise to decrease deconditioning and improve myofascial biomechanics. Mindful exercise (e.g.. yoga, tai chi) is especially helpful in improving MPS.

Biomechanical Interventions

• Posture evaluation and correction: Consider ongoing optimization with yoga, Feldenkrais, and physical therapy.

• Manual and manipulative techniques, including massage, myofascial release, and spray and stretch:

  These should be considered in areas of distinct trigger points. Osteopathic manipulation is desired when functional skeletal asymmetry is provoking MPS. Refer to Simmons and Travell for detailed instructions. Several techniques can be taught to and successfully incorporated by the patient (e.g., compression massage with stretch).

• Biostimulation: Low-level laser therapy, electrostimulation, hydrotherapy, and thermotherapy are recommended on a regular basis to assess reduction in symptoms, especially pain, with transition to home therapy.

Bioenergetic Interventions

• Acupuncture is used to release trigger points and decrease autonomic arousal.

• Other energetic treatments (e.g.. healing touch, Reiki) should be used to assess for and treat energy imbalance.

Nutrition

• Have patients increase their intake of fruits and vegetables, with a focus on appropriate levels of vitamins and minerals essential for musculoskeletal function.

• Consider a trial of an antiinflammatory diet or elimination diet (see Chapter 86, The Antiinflammatory [Omega-3] Diet, and Chapter 84, Food Intolerance and Elimination Diet).

Supplements

• Consider an 8-to 12-week trial of supplements for correction of myofascial pain and comorbid conditions (including identified deficiencies):

• Magnesium: starting with a chelated form if available for increased gastrointestinal tolerance; magnesium glycinate, 100 to 200 mg twice daily, advance as tolerated (other formulation doses vary, typically, starting at a low dose and advanced based on gastrointestinal tolerance)

• Malic acid: 600 mg, one to two capsules daily Carnitine: 2000 mg/day

• D-Ribose: 5 g twice daily

• Coenzyme Q10: 100 to 300 mg/day (dose increased based on response and serum levels)

• B vitamins typically used: 50 to 100 mg of thiamine (vitamin B,) and pyridoxine (vitamin B), 0.5 to 2 mg of folic acid and vitamin B

• Vitamin D, 800 to 1000 units/day (higher levels in deficiency states)

Pharmaceuticals

• Topical pharmaceuticals

• Compounded creams with ingredients based on patient presentation are applied to affected areas three times/day. Patients should be warned that some topical agents cause localized burning or rare allergic reactions. Systemic absorption negligible if these agents are used as directed.

• Ketoprofen 10% to 20%

• Lidocaine 5%

• Capsaicin 0.025% to 0.075%

• Cyclobenzaprine 5%

• Oral pharmaceutical

• If the response to other interventions is unsatisfactory, consider a trial of amitriptyline (up to 75 mg/day) for long-term treatment, as well as a trial of short-term antiinflammatory agents for acute exacerbations.

• Needle-based injection therapy

• If the patient's symptoms persist or worsen despite the preceding measures, consider needle-based intervention in a stepwise approach.

• Acupuncture or dry needling

• Saline injection

• Anesthetic injection (e.g., a combination of 2% lidocaine and 0.05% bupivacaine in a 1:3 ratio up to 8 ml. total)

• Botox injection

Key Web Sources

• http://www. mayoclinic.com/health/myofascial-painsyndrome/DS01042/METHOD-print

• www.reliefinsite.com

• http://www.theacpa.org

• http://www.theacpa.org/painlog/painlog.aspx

• http://www.mayoclinic.com/health/relaxation-technique/SR00007

• http://www.uhs.wisc.edu/services/wellness/stress.shtml

• http://ergonomics.ucla.edu/exercises.html

• http://www.ymca.net/

• http://www.arthritis.org