7/23/18 Michael T Burnett Jr., LMT Page 1 of 5

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1 Case Study: Omohyoideus Myofascial Pain Syndrome Successfully Treated with Precision Manual Therapy Keywords Trigger Point: Hyperirritable spots in the fascia surrounding skeletal muscle. They are associated with palpable nodules in taut bands of muscle fibers. Myofascial Pain Syndrome: a syndrome characterized by chronic pain in multiple myofascial trigger points, or knots", and fascial constrictions. It can appear in any body part. Omohyoideus: A muscle that depresses the hyoid. It is located in the front of the neck and consists of two bellies separated by an intermediate tendon. Its superior belly serves as the most lateral member of the infrahyoid muscles, located lateral to both the sternothyoid and thyrohyoid muscles. Introduction Myofascial Pain Syndrome (MPS) is a condition that can affect any muscle of the body. 1 Common characteristics of MPS include referred pain, weakness, and limited range of motion. MPS can be attributed to Trigger Point (TrP) dysfunction that may not resolve without intervention. Precision Neuro-Muscular Therapy (PNMT) uses clinical reasoning based on observable evidence to assess and treat mechanical pain. Mechanical pain changes with movement or position and may be related to connective tissue dysfunction that manual therapies can alleviate. MPS has been studied for quite some time and was acknowledged with previous names such as Fibrositis, Myogelosis and Idiopathic Myalgia. Omohyoideus MPS is an uncommon condition with complex etiology. 2 This case study shows that if pain is mechanical in nature, connective tissue problems and manual therapies should not be ruled out of consideration. 7/23/18 Michael T Burnett Jr., LMT Page 1 of 5

2 Background In April of 2015, I was attending Professional Massage Training Center, and had just completed the PNMT seminar series with just 2 months to go before graduation. While working in the student clinic, I had my first client with pain problems looking for PNMT therapy. A 35 year old female presented with idiopathic chronic nerve pain in the right shoulder, neck, and head for the past year and a half. Mainly suffering with neck and arm pain, but also pain in the jaw, and nerve pain in the throat. The client works in the healthcare industry and her job requires a lot of typing and talking on the phone. She was involved in a traumatic Motor Vehicle Accident approximately 15 years prior with no other significant history. She had broke up with a long time boyfriend the night before the pain started. Past medical care included two Ear, Nose, and Throat specialists and even changed Primary Care Providers. Medications would only help a little and did nothing when her neck was aggravated. The side effects were debilitating. Neurologists referred her to the Mayo Clinic, without diagnosis, for exploratory surgery and to occlude the offending nerve root. Massage therapy was her last option before surgery. The pain was anterior and just lateral of the hyoid on the right side of her throat. It would radiate to the shoulder, rest of the neck, and head (ear & jaw). Here is why I decided that I may be able to help: her pain was aggravated by talking and eating. Talking and eating both involve movement, so this must be mechanical in nature. At this point, the problem was seriously affecting her life, in that she wanted to avoid talking and eating became unenjoyable. Treatment I conducted an extensive interview then tested only the Sniff Test with negative response. All of the issues were on the right side of the neck. I found the SCM muscle to be very tight in the cleido head only. Middle and Posterior Scalenes were extremely tight. Precise palpation of the muscle bellies revealed trigger points in the SCM, Upper Trapezius and Levator Scapulae. Release of TrP in SCM was accompanied by Local Twitch Response (LTR). Finished the treatment with acknowledgment that the Scalenes need more attention and directed her to stretch and move every 30 minutes at work. Client reported that throat had stopped hurting and didn't feel as tight, post treatment. I instructed her to exercise/stretch periodically Client reports that her neck was sore for 2-3 days after treatment, then felt great. Not as much pain in the throat and neck. Spurling test was negative. Facet testing revealed slight sensitivity in lower cervical area, ~C5-C6. Sniff test was negative, again. Pain-free, active cervical ROM measurements included Rotation L=63º/R=62º, Flexion=42º, Extension=49º, and Lateral Flexion L=36º/R=32º. No significant asymmetrical difference or restrictions noted. Treatment in supine position included release of TrP in the SCM, Scalenes, and Longus Colli. Pain was decreased on the Vocal Rating Scale (VRS) from=7/8 to 1/2, post treatment. Re-measurement of Cervical Lateral Flexion was recorded as L=42º/R=40º. During treatment, I was surprised to palpate a muscle running transversely superior to the clavicle. I had not felt this muscle on previous clients and could not readily identify the structure. Upon doing research, I found the Omohyoideus to be the palpated muscle Client reports that she only had one episode of pain in the past week that lasted a couple hours, This is a new world for me. Treatment released TrP in the Scalenus Medius and found a tender point in the Omohyoideus muscle between the SCM heads at their origin. The Upper Trapezius was also taut. The scalenes were noticeably more supple and the spasmodic inflammation appeared to be greatly diminished. Instructed client to keep icing the neck area for minutes 2x/day Her throat was sore the day after treatment, then flared up on the 2 nd day. Pain is decreased but constant since last session, VRS=7/8. Cervical ROM appeared normal without measuring. The SCM and scalenes, except Scalenus Medius, are supple. Levator Scapulae is swollen and tender. Only released one TrP in the Scalenus Medius and could not differentiate the Omohyoid muscle during this session. However, her throat pain was replicated by moving the Hyoid to the left. Pain was decreased from VRS=7/8 to 4, post treatment. I instructed the client to do mild ROM excercises. I decided to fully research the Hyoid and all attaching muscles. The Omohyoideus is an obscure muscle with unusual attachments and function. 7/23/18 Michael T Burnett Jr., LMT Page 2 of 5

3 During research, I found Dr. Michael Rask's report of four patients with Omohyoideus Myofascial Pain Syndrome and provided it to the client. 2 Her throat was irritated from excessive talking for two days after the last session, then decreased to VRS=3 for a day. The following day (4 days post tx) was pain free. The next day hurt, then relief again through today. I found the SCM to be supple. The middle and posterior Scalenes were taut again and the Levator Scapulae was swollen with edema in the area. It seemed that toxins from a dysfunctional muscle will permeate local tissues and affect muscles that are not even on the same nerve root. They only need to be in close proximity to the dysfunctional muscle to be affected by toxin buildup. I also noticed that the client was clenching her jaw intermittently during treatment. I released TrP in the Middle Scalene and the Omohyoid at the superior insertion on the hyoid. Instructed the client to stop neck ROM exercises, work on jaw clenching, and ice the area 2-3x/day until the next visit Client reports a lot of neck pain today down to the shoulder and that it was a stressful week at work. Treated prone for first 30 minutes after applying hydrocollator heat pack on upper back and hot towel on neck. The Levator Scapulae was still tense and the Middle and Posterior Scalenes were tight and inflamed. Worked the origin of Omohyoideus at the lateral edge of the superior angle of the scapula with release of some TrPs. MOST IMPORTANTLY, I found the Omohyoid between the SCM cleido head and Scalenus Anticus at the origins. I was able to release a TrP in that muscle that referred her throat pain! Instructed her to keep icing the area for minutes 3x/day, stop moving the hyoid manually, and stay mindful of jaw clenching Client says that her throat started hurting after leaving the last session and was sore for 2-3 days as usual. Feeling OK today, but was tensing up as we talked. She had not been icing much because she wasn't in as much pain as normal. Treated prone with hydrocollator on shoulder initially. The Scalenus Posterior found to still be in spasmodic inflammation and no other muscles were significantly taut. In supine position, I found the Omohyoid with TrP in between the SCM heads. No other TrPs found. Finished the treatment with Cryoball application to anterior neck. Instructed client to ice 2-3x/day and stay mindful of jaw clenching I had graduated and was preparing to enter private practice. The client returned to the school for a relaxation massage with another student massage therapist with no pain complaints. Follow-Up The client came to my new office for treatment and follow-up with a half hour treatment. Slight pain in throat (VRS=2) only 2-3 times in the past week. Her scalenes were taut bilaterally and some inflammation was still present on right side. Did not find any hypersensitive areas or TrPs. I used a hot towel before treatment, treated, then applied alcohol, and conducted ROM exercise on the right shoulder. Her neck pain came from a muscle attached to the scapula. I requested her to schedule weekly ½ hour treatments for a month Half hour session. Client reports ZERO pain in throat for the past week. The middle scalenes were inflamed bilaterally and taut. After applying a muscle liniment (dit-da-jow) and doing precision palpation of the scalenes, I applied a topical analgesic lotion called Real Time Pain Relief. Ended the treatment with passive neck/shoulder ROM Half hour session. She had a flare-up the week before for two days with pain down the right arm. I found the middle and posterior scalenes to be very taut. Performed mild palpation of the scalenes and again found TrP in the Omohyoideus between Scalenus Anticus and the SCM that referred to the throat. This is the location that I believe was the root of the problem. I instructed client to apply moist heat, then cryo treatment 3x/day. Need to do a 1 hour appointment next week One hour session. There was no pain for the past week, but the Left side of her neck is irritated. The scalenus group was taut and inflamed bilaterally. Cervical distraction relieved neck pain. Looking back, I should have worked more to alleviate facet inflammation since it was initially indicated with the facet test on Instructed client to continue heat/cold applications 1x/day and cryo only 2x/day. 7/23/18 Michael T Burnett Jr., LMT Page 3 of 5

4 Half hour session. Facets are still irritated and had a throat flare-up today. The middle and posterior scalenes on the right side had TrPs that were released with PNMT precision palpation. Applied a lymphatic Kinesio taping to both sides of the neck. Goal now is to reduce the spasmodic inflammation as toxins are still being released and metabolized Half hour session. No throat pain for the past week. Found that only the middle scalenes were taut/inflamed bilaterally. PNMT palpation found no TrPs. Applied muscle liniment (dit-da-jow) bilaterally and lymphatic K-tape to right side only. Client has appointment to start Physical Therapy this week. I instructed the client to return after 2 weeks of PT. Outcome The client never had the nerve occlusion surgery and is living pain free. Here is the referral she gave: I was in bizarre throat pain for over a year, talking became unbearable. I have had many tests done and had seen several specialists without answers. The only solution was to treat my symptoms with medication. The medication they gave me came with severe side effects. I was dizzy and/or tired all the time. I was about to give up, thinking it must all be in my head. In my last effort, doing my own research, I learnt of PNMT massage therapy. I scheduled an appointment (at PMTC) and met Mike Burnett. I told him of my bizarre pain, expecting him to look at me like I'm crazy, but he didn't! He embraced what I was saying, agreed with me and gave me his own input. I was blown away thinking, oh this guy is just trying to be nice. Session after session I could tell Mike was in it for the long haul, he was supportive and he used all his resources to help me get out of pain. The result of persistent and precision manual therapy was avoiding surgery and precluding the use of medication to treat the pain. There were no adverse events during her treatment with manual therapy. Discussion There are many insights that I have gained from treating this client. Among them are: I would like to have recorded a VRS pain reference at the beginning and for every session. Now, I try to be consistent with measurements that are presumed critical to the clients' care. I also noticed that the cervical extension measurement was less than nominal and should have been monitored and remeasured. I now instruct clients to return when the pain returns, attempting to extend the time between treatments until the pain does not return. When treating inflamed muscles, heat should be used minimally if at all, and followed by cryotherapy. Additionally, I now like to treat muscles cold since the thixotropic action seems to dissipate problems temporarily only to return when the tissues cool down. Once a restriction or problem is identified, consistent treatment/measurement is needed to observe improvements and changes. I have since created a comprehensive assessment form to document this evidence. I now offer 15 minute sessions for specific treatment of identified muscle dysfunctions, usually anterior neck problems. When anterior neck work is needed, a little goes a long way, especially when spasmodic inflammation is involved and toxic chemicals are released. 3 Typically, I ask clients to give me 3 sessions to assess/determine how to help them with chronic problems. I needed 6 sessions in this case. All treatment of muscle dysfunctions should include the client's active ROM to re-establish the pain free mind-body connection. 7/23/18 Michael T Burnett Jr., LMT Page 4 of 5

5 Conclusion It is very important to believe clients when they report pain, no matter how strange it may seem. This case showed me that if pain is mechanical in nature, manual therapies should be considered for treatment. Modern medical resources do not seem to understand and/or respect the implications of Myofascial Pain Syndrome. 4 Better research and education of the Interstitium is required. This case also suggests that precision manual therapies can intervene and resolve chronic mechanical pain problems without the use of invasive medical procedures. Reference List 1. Travell J.G. and Simons D.G. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: The Williams and Wilkins Company; Rask M.R. The Omohyoideus Myofascial Pain Syndrome: Report of Four Patients. J Craniomandibular Pract. 1984; 2(3): Accessed June 1, McPartland J. M. Travell Trigger Points - Molecular and Osteopathic Perspectives. J Am Osteopath Assoc. 2004; 104(6): Accessed June 1, DerSarkissian C., ed. Myofascial Pain Syndrome (Muscle Pain). WebMD Medical Reference. Published April 30, Accessed June 1, /23/18 Michael T Burnett Jr., LMT Page 5 of 5