MYOFASCIAL MEDICINEWHERE WE ARE AND WHERE WE SHOULD GO

Treatment and Prevention

Chronic Pain Conference

Arlington, VA October 10, 2015

Michael R. Sorrell, MD

Associate Clinical Professor of Neurology

Tufts University School of Medicine

The University of Minnesota requires financial disclosures from the lecturer and the spouse of the lecturer

Michael R. Sorrell, MD

• Journal of Musculoskeletal Pain: Editor-in-Chief

• All illustrations are in the public domain

Spouse

• None. She discloses she is fed up with the lecturer not having other financial disclosures.

Proposed definition:

Myofascial Medicine• is a medical specialty • concerned with the diagnosis and treatment of pain and

other symptoms• caused by disturbance of myofascial trigger points, • [hyperirritable spots in skeletal muscle or in the fascia

associated with skeletal muscle]. • Myofascial pain occurs regionally in all parts of the body;

it can cause symptoms of or can be caused by disturbances of nerve, bone, viscera, cranial and intracranial structures.

Trigger Points• Trigger Points (TrPs) are hyperirritable and electrically

active spots in muscles and ligament.• Pressure on these TrPs will cause enough discomfort to

cause the patient to jump or wince (Jump Sign) and/or notice pain or numbness at a location at a distance from the area pressed (Referred Pain).

• TrPs are nodules usually located in Taut Bands of muscle. When a taut band is stimulated, i.e. plucked or strummed, it often contracts, causing a local twitch response, which is a spinal reflex. TrPs are less frequently located in tendons.

• Pressure on Active TrPs replicate the patient’s symptoms and pressure Latent TrPs do not.

• Myofascial Pain can mimic radiculopathy, migraine aura, boney, abdominal, cardiac pathology, and other symptoms.

Myofascial Pain: DemographicsSimons DG, Chapter 1 in Travell & Simons’ Myofascial Pain and Trigger Point Dysfunction, the Trigger Point Manual,,2nd ed, 1999; Williams & Wilkins, Baltimore

• 50% of young adults have Latent TrPs in the shoulder; 25% have referred pain

• Similar frequency in the masticatory muscles• 28% had pain in the temple, 33% in splenius capitis, 33%

in upper trapezius• In an Internal Medicine practice, 29% complained of pain;

30%of these were myofascial• In a Comprehensive Pain Clinic, a neurologist found 93%

of the patients had some part of their complaint from TrPs and 74% were primarily caused by active TrPs

The Examination of Myofascial Pain

• Find the taut band• Press where the patient says the pain originates• Enough pressure to blanche the fingernail (at least 4

Kg/cm)• Reproduce the patient’s pain• Identify secondary sites in the referral pattern and in the

same muscle• Press 5-15 seconds to provoke secondary phenomena,

e.g. ipsilateral blurred vision, lightheadedness

Examples of Referred Pain from Myofascial Trigger Points

Diagnosis of Myofascial Pain• Replicate the patient’s symptoms by pressing on the

trigger points• Use the physical exam to determine if the trigger point is

secondary to disease elsewhere ( a primary source) or is primary from no other cause.

• If the trigger point is primary, send the patient for physical therapy featuring stretching of the involved muscles along their lengths. If this worsens the symptoms, re-evaluate for a primary source.

Janet Travell, MD

David G. Simons, M.D

MYOFASCIAL MEDICINE: WHAT GOOD IS IT?

Case report

Back pain in the Emergency Room (1)

• 39 y.o. 7 month pregnant mother 2 picks up her 4 y.o. son from a chair and has the sudden onset of severe left low back pain radiating to the buttock and upper thigh.

• After lying flat on the floor for 1 hour, she goes to the local university affiliated hospital in suburban Boston, where she reports 9-10/10 level pain.

Back pain in the Emergency Room (2)

• After evaluation by the ER physician, Ultrasonography shows no problem with the pregnancy

• Plans are made for an MRI the next day to rule out an acute herniated nucleus pulposus and for overnight admission. An orthopedist is consulted.

• The patient calls in a neurologist from another city, who, 10 hours after onset of pain, finds that pressure on the left L4 paraspinal musculature reproduces her symptoms. The patient has an antalgic gait but no other abnormalities on examination.

Back pain in the Emergency Room (3)

• The patient says, “Dad, nobody examined my back the way that you did. Nobody even touched it.”

• The neurologist demonstrated the physical findings to the ER attending and suggested injecting 1% Lidocaine into the tender area would probably resolve the pain, eliminating the need for hospitalization and the MRI.

• The ER room MD demurred, explaining she was not trained in such a technique, and would not perform it even if the neurologist talked her through it.

• The anesthesiologist on-call refused to consider performing a lidocaine block, since she was not Pain Fellowship trained.

• The neurologist called a neurologist friend on the hospital staff to ask if he would perform a nerve block. He demurred, explaining he did not perform injections at all.

Back pain in the Emergency Room (4)

• The patient was admitted to the obstetrics ward. She was given Tylenol III

• At 06:30 the next AM, the neurologist walked the patient down the corridor to the nurses’ station. She felt well enough to go home.

• The orthopedics consultation was cancelled. • The nursing staff applauded, since they had seen similar

patients with acute back pain. • The patient had follow-up care with a physical therapist

familiar with the treatment of myofascial pain. Symptoms resolved in 5 days.

MYOFASCIAL MEDICINE: WHAT GOOD IS IT?

Pilot Study

Myofascial Examination Leads to Diagnosis and Successful Treatment of Migraine Headache Sorrell MR, Journal of Musculoskeletal Pain, 2010. 18: 31-37.

• 49 patients with Migraine

• All given Myofascial Exam

• % whose migraine headache pain could be reproduced by the exam

• 23 of 23 (100%) of Migraine Without Aura

• 5 of 11(45%) of Migraine With Aura

• 15 of 15 (100%) of Chronic Migraine

Myofascial Headache study 2

• Effect of Physical Therapy with stretching involved muscles along their lengths (PTS)

• Global scale of self-improvement in %• % = or >50% improvement in a group (vs. no PT)• Group improvement %

Myofascial Headache 3

• Migraine without Aura: 11 of 13 treated had 50% or > improvement (85%) [group improvement 64%], 0 of 5 not treated with PTS = or >50%, p=0.01.

• Chronic Migraine: 5 of 6 treated had 50% or > improvement (86%) [group improvement 72%], 1 of 5 without PTS had 50% or > improvement {fentanyl patch} (20%) [group improvement 10%],p=0.0004.

What do we know about the Trigger Point?

• Heisenberg uncertainty principle: the more precisely the position of some particle is determined, the less precisely its momentum can be known

• Biologic variant of the Heisenberg uncertainty principle: disturbing tissue by using instruments to study one manifestation of a structure will probably alter another manifestation of the structure.

The Trigger Point is electrically different from other muscular tissue: Spontaneous Electric Activity

The Trigger Point is biochemically different from other muscular tissue

Altered Biochemistry of the Trigger PointShah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005; 99: 1977-84.

Higher in Active TrPs (no change in normal muscle and in Latent TrPs):

And Reduction in pH

• Bradykinin• CGRP• Substance P• TNF α• Interleukin 1β• Serotonin• Norepinephrine

The Trigger Point has different material properties than other tissue: sonoelastography shows it is stiffer

The Trigger Point has blood supply

The Trigger Point has its own theory of energy supply

But what is the anatomic structure of the Trigger Point?

Muscle fibers slide in and out of each other when they contract and release

Spontaneous electrical activity comes from end plate zones in the muscles Buchtal F, Rosenfalck M. Spontaneous electrical activity of human muscles. Clinical

Neurophysiology 1966; 20: 321-336.

Motor end plate pattern in muscle(nerve fiber in green, acetylcholine in red)

Or is the Trigger Point a Muscle Spindle?Partanen JV, Ojala TA, Arokoski JP. Myofascial syndrome and pain: a neurophysiological approach. Pathophysiology 2010; 17: 19-28.

Tissue specimens look like Muscle Spindles

Normal Anatomy of a Muscle Spindle Muscle Spindle in Myofascial Pain David Hubbard, M.D., Hubbard Foundation website, 2011

MYOFASCIAL MEDICINE

Where we are

Trigger point injections for headache disorders: expert consensus methodology and narrative review. Robbins M, Kuruvilla D, Blumenfeld A, Charleston L 4th, Sorrell M, Robertson CE, Grosberg BM, Bender SD,

Napchan U, Ashkenazi A. Headache, 2014. 54: 1441-59.

• 2014 Headache Member’s Choice Award

• Brick Cox, illustrator

Trigger Point Treatment Options

• 3,060,000 results on Goggle in 0.41 seconds (September 14, 2015)

• Myotherapy• Mechanical vibration • Ultrasound• Electrostimulation • Dry needling• Spray and stretch • Low level laser therapy

• Trigger Point injections• Massage• Tapotement• Muscle energy

techniques• Proprioceptive

neuromuscular facilitation

Physician and Physical Therapy Treatment of Myofascial Pain • Trigger Point Injections : 838,000 results on Google but

very few physicians know how to do them• Dry Needling: can be done by mid level providers, but

government standards should be required• Absence of consensus: in preparation of a study on the

effect of a specific stretching technique for the treatment of headache, a group in Springfield, MA surveyed over 200 Physical Therapy Clinics. In the 130 replies, there was no common practice for the treatment of headache and fewer than 10 regularly used a stretching technique which the patient could use at home.(Laura Martorello DPE, MSPT, American International College, Department of Physical Therapy, personal communication, 2012)

MYOFASCIAL MEDICINE

Where should we go?

How can society benefit from Myofascial Medicine?• Faster and more accurate diagnoses • Improved understanding of disease processes• Reduce needless testing• Reduce needless treatment• Recognize certain illnesses are mostly myofascial, e.g.

headache• Reassures patients• Reduce costs

Myofascial Medicine: what do we lack?

• Identify the anatomic nature of the trigger point• Identify the mechanism of referred pain (spinal cord,

sympathetic ganglia, other structures)• Determine if the central physiologic (and perhaps

anatomic) manifestations of MFP are different from other types of pain.

• Identify the exact biochemistry , metabolism, and genome of the trigger point

• Devise a pharmacology for the trigger point (revisit botulinum toxin injections?)

Myofascial Medicine: what do we lack? 2

• Physician training program starting in medical school• Academic support for clinical research• Validated methods of diagnosis• Validated methods of treatment or a consensus

methodology• Succession planning• Forum for communication of developments of practice and

research

Suggestions for the field of Myofascial Medicine

• Construct clinical experiments that control for placebo effects

• Lobby for funding of basic science research in myofascial pain.

• Fund professorships and then departments in myofascial pain

• Start medical training in myofascial pain in first year anatomy class

• Incorporate training in myofascial pain in Neurology, Emergency Room, Internal Medicine, General Practice, and Anesthesiology Pain fellowship training

Suggestions for the field of Myofascial Medicine 2

• Board certification in Myofascial Medicine (joint boards between Neurology, ER, GP, IM Pain fellowship constituencies requiring board certification in the primary specialty with special competency in Myofascial Medicine).

• Standard or consensus protocols for treatment of Myofascial Pain and specific training within the fields of Physical Therapy, Chiropractic, and other disciplines

• A forum for the discussion of the science and practice of Myofascial Medicine which will expect academic rigor and which will put new information in context for the professional and lay reader.

Journal of Musculoskeletal Pain

Mission

• Official journal of the International Myopain Society

• Forum for research and discussion of muscle pain, particularly myofascial pain and fibromyalgia

• Will encourage research and commentary on muscle pain

• Coming soon by post and by electronic devise.

Associate and Section Editors

• Scott Mist, PhD, Portland OR• Robert Gerwin MD,

Bethesda, MD• Matthew Robbins MD, New

York, NY• Siddhartha Sikdar, PhD,

Fairfax, VA• Daniel Wallace MD, Los

Angeles, CA• Kim Jones, PhD, Portland,

OR

Journal of Musculoskeletal PainTHE OFFICIAL JOURNAL OF T HE INTERNATIONAL MYOPAIN SOCIETY

• Research Articles Reviews• Editorials Essays• Literature Summaries Letters

Thanks for Your Attention