Specialty Care National Program Mini-Residency Pain Management February 10-12, 2015 Myofascial Techniques for Back and Neck Pain Presented by: Edward S. Lee MD National Program Faculty: Edward S. Lee MD Director, Interdisciplinary Pain Rehabilitation Program VA Pittsburgh Healthcare System Part 1
Disclosures Instructor, Medical Acupuncture for Physicians Course, Helms Medical Institute
Learning Objectives Know the differences between Myofascial Pain Syndrome (MPS) and Fibromyalgia (FM). Understand the anatomy and pathophysiology of myofascial pain. Appreciate the importance of diagnosing and managing MPS. Develop clinical skills in treating MPS. Utilize a multimodal, integrative, interdisciplinary approach to pain management.
Myofascial Pain Syndrome (MPS) Regional soft tissue pain commonly involving the neck, shoulders, trunk, arms, low back, hips and lower extremities Painful muscle dysfunction in one or several muscles in a region of the body with loss of range of motion Trigger points Central sensitization hypersensitivity, allodynia Referred pain Described as burning, stabbing, aching, nagging
Fibromyalgia (FM) Systemic somatic condition Widespread musculoskeletal tenderness and pain Tender points, may coincide with trigger points Central sensitization and augmentation Not excluded by Myofascial Pain Syndrome
FM Diagnostic Criteria, ACR 2010 Widespread Pain Index 7 and Symptom Severity scale score 5 OR Widespread Pain Index of 3-6 and Symptom Severity scale score 9
FM Widespread Pain Index Bilateral sites (total of 14) Jaw Shoulder Upper arm Lower arm Hips Upper leg Lower leg Unilateral sites (total of 5) Neck Upper back Chest/breast Abdomen Lower back
FM Symptom Severity Scale Fatigue, Cognitive Difficulties, and Sleep Disturbances Score each domain: 0 = No problem 1 = Slight or mild problems; generally mild or intermittent 2 = Moderate; considerable problems; often present and/or at a moderate level 3 = Severe: pervasive, continuous, life disturbing problems Somatic Symptoms 0 = 0 symptoms 1 = 1 to 10 2 = 11 to 24 3 = 25 or more
Muscle pain Irritable bowel syndrome Thinking or remembering problems Muscle weakness Headache Pain/cramps in the abdomen Numbness/tingling Dizziness Depression Constipation Pain in the upper abdomen Nausea Nervousness Somatic Symptoms Chest pain Blurred vision Fever Diarrhea Dry mouth Itching Wheezing Raynaud's phenomenon Hives/welts Ringing in ears Vomiting Heartburn Oral ulcers Loss of/change in taste Seizures Dry eyes Shortness of breath Loss of appetite Hair loss Frequent urination Painful urination Bladder spasms Rash Sun sensitivity Hearing difficulties Easy bruising Hair loss Frequent urination Painful urination Bladder spasm
Comorbid Conditions Found with Both FM and MPS Migraine headache Tension-type headache Temporomandibular joint disorder Hypermobility syndromes Painful bladder syndrome Irritable bowel syndrome Pelvic pain syndrome Vulvovaginitis Prostatitis Endometriosis Dysmenorrhea Hypothyroidism check TSH
Conditions More Commonly Associated with MPS Malabsorption Vitamin D deficiency Vitamin B12 deficiency Iron deficiency Parasitic infection Check stools x3 for O&P if significant GI symptoms Celiac disease Candida overgrowth
MPS: Epidemiology Prevalence up to 95% in patients with chronic pain disorders Overall prevalence: 37% of middle-aged men (30-60 years) 65% of middle-aged women 85% of elderly (>65 years) Costs up to $47 billion/year
MPS History Clinical studies of trigger points conducted by four separate investigators in the 1930 s and 40 s J. H. Kellgren at University College Hospital, London Hypertonic saline injection in healthy volunteers gave rise to zones of referred extremity pain. Michael Gutstein in Berlin Michael Kelly in Australia Janet G. Travell in New York Trigger point research and treatment of John F. Kennedy's back pain led to her becoming the first female Personal Physician to the President.
Osteopathic Medicine Founded by A.T. Still, Civil War surgeon, at a time when allopathic medicine had few safe and effective treatments. Holistic approach to health, on the premise that the body s capacity to heal can be optimized by assessing and manipulating the musculoskeletal system. Identified musculoskeletal pain and dysfunction as a manifestation of general health. Still and his successors developed numerous approaches for somatic dysfunction, including myofascial pain syndrome.
Myofascial Pain Syndrome: Etiology Often presents after an injury or with occupational repetitive activity/overuse. TrPs may develop when muscle use exceeds muscle capacity and normal recovery is disturbed. Local muscle metabolic stress may produce energy crisis. Dehydration may precipitate myofascial dysfunction Fascia plays central role. Shortened muscles lead to enthesopathy, tendonitis, postural changes, limited range of motion and limited flexibility, ie somatic dysfunction.
Myofascial Trigger Point Pathophysiology Fascial injury: tightness, restriction, compression, disruption, due to edema, hematoma, inflammation, tear etc. Adapted from Simons model of myofascial pain syndrome
Anatomy Revisited Musculoskeletal system is not simply a system of pulleys and levers. Bones are living, dynamic compressive elements that float in a sea of soft tissue. Muscles are incompressible, fluid-filled, contractile elements found in pockets of fascia, attached to bones via connective tissues.
Fascia Originates from embryonic mesodermal mesenchymal cells. Is a continuous network of living, dynamic connective tissue that surrounds, connects, and penetrates every organ and structure in the body. Is populated by fibroblasts, as well as adipocytes, reticulocytes and other immune cells. Is richly innervated. Imparts tensile strength. Is the target of manual therapies, including acupuncture.
Dr. Jean Claude Guimberteau: Strolling Under the Skin http://www.guimberteau-jc-md.com/en/videos.php
Tensegrity Buckminster Fuller Tension + Integrity Global balance between compression and tension
Artifact vs. Reality
Compartment Syndrome
Mechanotransduction in Fibroblasts Integrin family Link between ECM and cell interior Physical and informational Triggers gene expression Regulates protein synthesis Changes extracellular matrix composition Change in connective tissue around nerve terminals Cytoskeletal reorganization
Mechanotransduction Stretch fibroblast, focal adhesions serve as force sensors, Rho signals a remodel message to relax itself Cytoskeletal remodeling, influences connective tissue tension Prevent with Colchicine
Acupuncture affects fibroblasts several cm. away Reorganize their cytoskeleton, change shape Become larger and flatter Similar with sustained stretch(30 min.) Inhibited in animal models by injection of collagenase. Mechanotransduction
Fibroblast Response to Injury Production of collagen and ECM Matrix degrading enzymes when chronic Fibroblast myofibroblast Chronic; excess collagen, tissue tension, fibrosis
Wound Healing and Fibrosis
Connective Tissue Fibrosis Patients with chronic low back pain (LBP) have thicker connective tissues. Usually dense and areolar tissue alternate, allowing lamellar gliding. LBP has decreased gliding.
Sensory Innervation of Fascia Connective tissues have sensory innervation, including pain afferents that respond to stretch of inflamed connective tissue.
Trigger Points Palpable muscle nodules, characterized by shortened sarcomeres. Found within taut bands of muscle. Associated with tenderness that reproduces patient s pain. Typically causes referred pain in a predictable distribution. Twitch response elicited with palpation or needling the affected muscle; variable, low inter-rater reliability.
Taut Band and Trigger Point