Myofascial Pain Patterns for Head and Neck Disorders. Sajid A. Surve, D.O. UMDNJ School of Osteopathic Medicine NeuroMusculoskeletal Institute

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1 for Head and Neck Disorders Sajid A., D.O. UMDNJ School of Osteopathic Medicine NeuroMusculoskeletal Institute

2 2 Learning Objectives By the end of this presentation, participants will be able to: Correctly distinguish between referred pain patterns of different origins Appropriately refer patients to interventional pain management or perform injections on affected structures in myofascial pain Recognize the indications for Osteopathic Manipulative Treatment in myofascial pain

3 3 Disclosures I have no relevant financial disclosures with regard to this presentation.

4 4 Outline Introduction Myotomic patterns Dermatomic patterns Sclerotomic patterns Conclusion

5 5 Introduction 45-year old male presents with 6 year history of headache following motor vehicle accident Restrained driver of sedan travelling mph, rearended by another sedan travelling mph

6 6 Introduction Rates pain VAS 4/10 during flare-ups which occur 3-4 times per month. Otherwise pain-free Describes as throbbing, achy pain with no other associated symptoms

7 7 Introduction Saw PCP, has been taking prescription naproxen intermittently, which helps Within 6 months of accident had x-rays and MRI of c- spine which were both negative

8 8 Introduction Remainder of history is unremarkable On physical exam, patient has tenderness to palpation of cervical spine and restricted range of motion x x x

9 9 Introduction What do we think about this case? What is the treatment plan for this patient? OMT? Trigger point injection? Spray and stretch? Botox? Something else? x x x

10 10 Myotomic Pain Patterns

11 11 Myotomic Pain Patterns Originally described by Travell, Simons, and Simons in years later, still debate about exact diagnostic criteria General consensus describes trigger points as derangement of muscle or fascial tissue hallmarked by referral of pain in a predictable pattern upon direct palpation Myburgh et al. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance.arch Phys Med Rehabil Jun ;89(6):

12 Myotomic Pain Patterns New imaging techniques are giving us greater insight into underlying pathology Diagnosis is still made from history and physical exam findings Number of treatment options

12 12 Myotomic Pain Patterns New imaging techniques are giving us greater insight into underlying pathology Diagnosis is still made from history and physical exam findings Number of treatment options have been considered, although few have solid evidence Chen Q, Bensamoun S, Basford JR, Thompson JM, An K-N. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil 2007;88:

13 13 Myotomic Pain Patterns Evidence-based beneficial treatments: OMT Trigger Point Injection / Dry Needling / Acupuncture TENS Iontophoresis with indomethacin Spray and Stretch Annaswamy TM et al. Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions.pm R Oct ;3(10):

14 14 Myotomic Pain Patterns Botox is not considered an effective modality for myofascial pain Soares A, Andriolo RB, Atallah ÁN, da Silva EMK, da Silva EMK. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD DOI: / CD pub2

15 15 Trapezius Images courtesy of

16 16 Sternocleidomastoid Images courtesy of

17 17 Splenius Capitis/Cervicis Images courtesy of

18 18 Suboccipitalis Images courtesy of

19 19 Frontalis (A) / Occipitalis (B) Images courtesy of

20 20 Temporalis Images courtesy of

21 21 Lateral Pterygoid Images courtesy of

22 22 Medial Pterygoid Images courtesy of

23 23 Dermatomic Pain Patterns

24 24 Dermatomic Pain Patterns Neuropathic radicular pain related to entrapment of either nerve roots or peripheral nerves May be caused by canal stenosis, disc disease, or external pressure (peripheral nerves only) OMT indicated primarily as adjunct, HVLA contraindicated at level of entrapment Chila et al. Foundations of Osteopathic Medicine, 3 rd edition. LWW pp. 524

25 25 Dermatomic Pain Patterns NSAIDs and TCAs indicated in cervical radiculopathy Opiates generally indicated through WHO guidelines Oral corticosteroids not well studied for radicular pain Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353:

26 26 Dermatomic Pain Patterns Low level evidence for cervical immobilization, traction, physical therapy in radiculopathy Acupuncture is recommended for both acute and chronic radiculopathy Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353: Council of Acupuncture and Oriental Medicine Associations. Acupuncture and electroacupuncture: evidence-based treatment guidelines. National Guideline Clearinghouse. Available at

27 27 Dermatomic Pain Patterns Moderate to high level evidence for cervical epidural steroid injection and selective nerve root blocks Moderate to high level evidence for peripheral nerve blockade in peripheral nerve entrapment Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.pain Physician Jul-Aug ;12(4):

28 28 Segmental Nerve Patterns

29 29 Peripheral Nerve Patterns

30 30 Sclerotomic Pain Patterns

31 31 Sclerotomic Pain Patterns Cervical facets are innervated by medial branch

32 32 Sclerotomic Pain Patterns In cervical facet disease (i.e. spondylosis) bony hypertrophy and sclerosis can produce referred pain which is independent from all other referral patterns OMT of limited use for improving referred pain, although indicated for compensatory changes

33 33 Sclerotomic Pain Patterns Moderate to high level evidence for diagnostic cervical facet injections Moderate to high level evidence for radiofrequency ablation to medial branch Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.pain Physician Jul-Aug ;12(4):

34 34 Sclerotomic Pain Patterns

35 35 Conclusion

36 36 Conclusion Different structures have different referral patterns Being cognizant of pain patterns will help to guide interventions OMT has indications for many causes of cervical myofascial pain

Regional Pain Syndromes: Neck and Low Back

Regional Pain Syndromes: Neck and Low Back Srinivas Nalamachu, MD Disclosures Consultant/Independent Contractor/Honoraria: Ferring 1 Learning Objectives Identify the most common painful conditions in the