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Myofascial pain is a common cause of regional chronic pain. Myofascial trigger points can refer pain to the head and face in the cervical region, thus contributing to cervicogenic headache. When identified properly, cervical myofascial pain is a treatable component of headache management. This article reviews current literature on the pathophysiology, diagnosis, and management of cervical myofascial pain.
The impressive pain relief experienced by sufferers of dystonia and spasticity from intramuscular injections of botulinum toxin suggested that patients with other chronic, musculoskeletal pain conditions also may benefit. However, there have been relatively few placebo-controlled studies of botulinum toxin in such non-neurologic conditions as myofascial pain syndrome, chronic neck and low back pain, and fibromyalgia; the results of these studies have not been impressive. One explanation for the lack of positive findings may be the lack of clinically evident muscle spasms (overactivity), despite the presence of muscle tenderness, tightness, or trigger points. Clinical observations of pain relief from injections of botulinum toxin for dystonia and spasticity and its apparent efficacy in treating migraine suggest an anti-nociceptive action independent of its neuromuscular junction-blocking action. Evidence from animal experiments supports this notion, and other data provide plausible physiologic mechanisms in the periphery and central nervous systems. These involve modulation of the activity of the neurotransmitters glutamate, substance P, calcitonin gene-related peptide, enkephalins, and others. However, even if botulinum toxin is firmly established as an analgesic, there is insufficient clinical evidence of its efficacy in treating non-neurologic, chronic, musculoskeletal pain conditions.
Myofascial pain syndrome (MPS) is caused by myofascial trigger points (MTrPs) located within taut bands of skeletal muscle fibers. Treating the underlying etiologic lesion responsible for MTrP activation is the most important strategy in MPS therapy. If the underlying pathology is not given the appropriate treatment, the MTrP cannot be completely and permanently inactivated. Treatment of active MTrPs may be necessary in situations in which active MTrPs persist even after the underlying etiologic lesion has been treated appropriately. When treating the active MTrPs or their underlying pathology, conservative treatment should be given before aggressive therapy. Effective MTrP therapies include manual therapies, physical therapy modalities, dry needling, or MTrP injection. It is also important to eliminate any perpetuating factors and provide adequate education and home programs to patients so that recurrent or chronic pain can be avoided.
Polygraphic recordings were collected for 11 normal subjects during sleep and wakefulness in order to investigate characteristics of the rapid eye movement (REM) associated potentials. EEGs were averaged using 5 different triggering points: (1) saccade onset under the normal ambient illumination, (2) saccade onset in the total darkness, (3) onset of REMs during REM sleep, (4) flash during REM sleep, and (5) flash during stage 2 sleep. In the central area, positive potentials appeared with waking saccades under the normal ambient illumination (P240L) and REMs (P185R). The latency of P185R associated with REMs was significantly shorter than that of P240L associated with waking saccades. These findings suggest that P185R is evoked by PGO waves occurring just before the REM. A small positive potential appeared in the occipital area with waking saccade under the normal ambient illumination (P260L) and REMs in the total darkness (P250R). Conspicuous absence of these waves for waking saccades in the total darkness suggests that P250R accompanied with REMs reflects activities involved with the cognitive processes occurring when a subject scans a dream image during REM sleep.
A fasciculation with an axonal origin may be followed by its own F-response. The time-lapse between these 2 potentials corresponds to the time for the antidromic wave to travel to the alpha-cell and to return to the trigger-point. This relatively stable interval may be compared with the difference between the latencies of the F- and M-responses of the same muscle evoked by distal nerve stimulation. This permits one to localise the origin of the fasciculation on the axon. This method showed that, of 201 fasciculations followed by their F-response, obtained in normal controls and in neurological patients, 97 and 89% respectively had their origin between the muscle and the stimulation site. In this series, the proportion of pathological fasciculations having an origin between the muscle and a point at half the M-latency, is similar to that found in a former study on unselected fasciculations using a collision method (Roth 1982). Comparison between these 2 studies therefore supports the concept that all or almost all fasciculations have an axonal origin.
Referred pain is common in the orofacial region and can cause considerable difficulties in diagnosis. Referred pain is defined as pain that is referred to a part of the body other than the site of origin, and as a result, severe pain may arise without an associated causative lesion. A muscular trigger point that resembled a tooth with endodontic involvement is discussed.
Four hundred consecutive classic closed lock cases were examined. Of these, 301 were treated. Mandibular range of motion was restored by condylar distraction during jaw opening, anterior, and lateral movements. Mandibular appliances were used to prevent complete closure during healing. Of the 45 males and 355 females examined, almost all reported jaw restrictions, but 38% reported little or no pain. Secondary disorders of temporomandibular joint inflammation, muscle spasm, trigger points, and cervical dysfunction were seen on patients with temporomandibular joint pain. Of the 301 conservatively treated patients, 209 were successfully treated, 55 were moderately successful, and 37 failed. Occlusal factors did not appear as primary etiologic factors. Because all locks were preceded by clicking, treatment is recommended for clicking temporomandibular joint's that lock, however briefly, to prevent future locking. Conservative closed lock treatment is successful in many cases.
In many cases of whiplash injury symptoms persist and do not respond to treatment. There is uncontrolled evidence to suggest that intracutaneous injections of sterile water might help. Since that route may be unacceptable to patients the subcutaneous route is used in the randomised trial reported here. 40 patients with whiplash syndrome, mean age 46 years (24-73) were given subcutaneous injections of 0.3-0.5 ml sterile water or saline over tender and trigger points in the neck and shoulder. A maximum of three treatments were given during the first two months of the study and the patients were followed up for 8 months. The accidents had occurred 4-6 years previously. X-ray examinations revealed no traumatic spinal lesions. Neck mobility and pain levels were evaluated by a physiotherapist immediately before and after the first treatment and after 1, 3, and 8 months. After 3 months, the mean total mobility of the cervical spine had increased by 39 degrees in the sterile water group and 6 degrees in the saline group (p < 0.05). Minimum and maximum levels of pain in the weeks just before treatment were evaluated by a visual analogue scale from 0 to 10. After 3 months the minimum pain level had fallen from 2.2 to 1.4 in the sterile water group but was not reduced in the saline group (p < 0.02); the maximum had fallen from 8.1 to 3.8 in the sterile water group and from 8.3 to 7.5 in the saline group (p < 0.001). After 3 months, 19 of 20 patients in the sterile water group assessed their condition as generally improved but only 6 in the saline group felt that they had got better. After 8 months there were still significant differences for minimum pain score and for mobility but not for maximum pain or for self-assessment of improvement.
In patients with either Paget's disease or hypercalcaemia associated with malignancy (HCM) we have assessed the parathyroid response to pamidronate therapy, both by immunoassay of serum intact parathyroid hormone PTH (1-84) and by measurement of indirect parameters of PTH bioactivity, tubular maximum reabsorption of phosphate (TmPO4/GFR) and nephrogenous cyclic AMP (NcAMP). In 12 patients with Paget's disease, therapy with pamidronate produced a small but significant decrease in adjusted serum calcium within the reference interval which was accompanied by a progressive increase in PTH (1-84) secretion and a corresponding fall in TmPO4/GFR and increase in NcAMP. In 12 patients with HCM pretreatment, PTH (1-84) concentrations were suppressed, whilst mean TmPO4/GFR was reduced and NcAMP was increased, compatible in most patients, with parathyroid hormone-related peptide (PTHrP) driven hypercalcaemia. Therapy with pamidronate produced the expected fall in serum calcium but caused an increase in PTH (1-84) secretion in the presence of absolute hypercalcaemia. The initial subnormal TmPO4/GFR decreased further to a nadir on day 5, and there was a corresponding further increase in NcAMP. By day 7, however, when PTH (1-84) concentrations were maximal, there was a significant paradoxical rise in TmPO4/GFR and a corresponding decrease in NcAMP. These data are consistent with a variable trigger point for PTH (1-84) secretion, one consequence of which is a reduction in the risk of hypocalcaemia following pamidronate. The results have major clinical implications for the interpretation of PTH (1-84) measurements in patients who are being treated or about to be treated for bone disease or for hypercalcaemia of malignancy (HCM).(ABSTRACT TRUNCATED AT 250 WORDS)
The purpose of this study was to examine the effects of brief, intense transcutaneous electrical stimulations at trigger points or acupuncture points on severe clinical pain. The McGill Pain Questionnaire was used to measure the change in pain quality and intensity produced by stimulation. The data indicate that the procedure provides a powerful method for the control of some forms of severe pathological pain. The average pain decrease during stimulation sessions was 75% for pain due to peripheral nerve injury, 66% for phantom limb pain, 62% for shoulder-arm pain, and 60% for low-back pain. The duration of relief frequently outlasted the period of stimulation by several hours, occasionally for days or weeks. Different patterns of the amount and duration of pain relief were observed. Daily stimulation carried out at home by the patient sometimes provided gradually increasing relief over periods of weeks or months. Control experiments, which included two forms of placebo stimulation, showed that brief, intense electrical stimulation is significantly more effective than placebo contributions. Possible neural mechanisms that underlie these patterns of pain relief by brief, intense stimulation are discussed.
In the present study 366 patients suffering acute or chronic musculoskeletal pain of different origin were given vibratory stimulation for the pain. Many of the patients had previously had treatments of various kinds without satisfactory relief. The effect of vibratory stimulation was assessed during and after stimulation using a graphic rating scale. Sixty-nine per cent of the patients reported a reduction of pain during vibratory stimulation. The best pain reducing site was found to be either the area of pain, the affected muscle or tendon, the antagonistic muscle or a trigger point outside the painful area. In most patients the best pain reducing effect was obtained when the vibratory stimulation was applied with moderate pressure. To obtain a maximal duration of pain relief the stimulation had to be applied for about 25-45 min.
Patients who receive worker's compensation or are awaiting litigation after an accident have long been regarded as neurotics or malingerers who are exaggerating their pain for financial gain. However, there is a growing body of evidence that patients who receive worker's compensation are no different from patients who do not. In particular, a recent study found no differences between compensation and non-compensation patients based on pain scores obtained with the McGill Pain Questionnaire (MPQ). Since the MPQ is usually scored by using rank values rather than more complex scale values, the negative finding might be attributable to the loss of information by using rank values. Consequently, a simple technique was developed to convert rank values to weighted-rank values which are equivalent to scale values. A study of 145 patients suffering low-back and musculoskeletal pain revealed that compensation and non-compensation patients had virtually identical pain scores and pain descriptor patterns. They were also similar on the MMPI pain triad (depression, hysteria, hypochondriasis) and on several other personal that were examined. The only differences were significantly lower affective or evaluative MPQ scores and fewer visits to health professionals by compensation patients compared to non-compensation patients. These results suggest that the financial security provided by compensation decreases anxiety, which is reflected in the lower affective or evaluative ratings but not the sensory or total MPQ scores. Compensation patients, contrary to traditional opinion, appear not to differ from people who do not receive compensation. Accidents which produce injury and pain should be considered as potentially psychologically traumatic as well as conducive to the development of subtle physiological changes such as trigger points. Patients on compensation or awaiting litigation deserve the same concern and compassion as all other patients who suffer chronic pain.
A vascular-supraspinal-myogenic (VSM) model for pain in migraine based on our previous clinical and pathophysiological observations is proposed. According to the model, perceived pain (headache) intensity is determined by the sum of nociception from cephalic arteries and pericranial myofascial tissues converging upon the same neurons and integrated with supraspinal effects (usually facilitating). Vascular input predominates over myofascial input in migraine, whereas significance of supraspinal facilitation is difficult to estimate. The importance of these 3 effects may vary between patients and in the same individual with time. The model is in accordance with recent experimental studies showing convergence of somatovisceral afferents upon n. caudalis neurons. Also, long term potentiation due to nociceptive activation and sensitization of neurons to input from wider areas and non-nociceptive stimuli are relevant to our model. In tension-type headache, nociception is primarily myofascial, but vascular input cannot be disregarded. Supraspinal facilitation probably plays a large, sometimes dominant role (the MSV model). The model explains much of the complexity of the clinical picture of these disorders as well as their tendency to overlap and to change into one another. Also, a number of pathophysiological observations such as why muscles are tender during migraine, why trigger-point injection may cure migraine attacks and why chronic tension-type headache is often associated with episodes of pulsating pain, can be explained. The model gives a rational explanation of empirically developed, internationally accepted, multimodal treatment strategies for migraine and tension-type headache. It may thus serve a useful purpose in explaining the disorder to patients. Finally, the model points to several avenues of future research in animals and man.
Six patients with chronic myofascial pain syndrome involving cervical paraspinal and shoulder girdle muscles received trigger point injections of botulinum toxin type A (Botox) or saline in a randomized, double-blind, placebo-controlled study. Four patients experienced reduction in pain of at least 30% following Botox, but not saline, injections, as measured by visual analog scales, verbal descriptors for pain intensity and unpleasantness, palpable muscle firmness, and pressure pain thresholds. Results were statistically significant. Botox, which inhibits muscle contraction by blocking the release of acetylcholine from peripheral nerves, appears to be an effective treatment for focal myofascial pain disorders.
A new theory is proposed to explain various pain phenomena hitherto unexplainable. It is hypothesized that neurons in the thalamic region are responsible for the generation of most pain, particularly in chronic pain states. It is also hypothesized that the thalamic neurons are organized according to a master scheme representing a homunculus in the fetal position. Various painful conditions and the treatments of them including the trigger points phenomena, neurosurgical techniques, acupuncture and acupuncture anesthesia can be explained on this basis.
Two cases are cited of patients who sometimes exhibited a condition of temporary unconsciousness which proceeded to spontaneous recovery without harmful sequelae. This type of cerebral arrest is frequently called general anesthesia:however, these patients had not received any drugs. What they did have was an irritant in the respiratory passages as shown by coughing. Three cases of general anesthesia are described wherein the duration of the phenomenon appeared to be partly due to the presence of an extra-integumentary foreign body, confined to the respiratory passages. In this trio there was evidence that the drugs did not affect the patients in any unusual way, whatever their effects on whichever side of the alveolar walls. Many anesthetic agents act like unabsorbable foreign bodies, in that they enter and leave the body unchanged, despite the fact that they do pierce the integument. Of course, almost everything, except inspirable and expirable air, but including anesthetic agents, is a foreign body in the respiratory tract. On the basis of these considerations, I suggest that one way, in which general anesthetic agents work, is an extra-integumentary foreign bodies, causing Reflex Coma by irritating or stimulating the trigger points in the walls of the respiratory tract, thereby arresting the cerebrum.
Xiphodynia is an uncommon musculoskeletal disorder that mimics a number of common abdominal and thoracic diseases. We report three cases of xiphodynia. The diagnosis is suggested when a given patient's chest or abdominal discomfort is completely or almost completely reproduced with light pressure on the xiphoid process. Local injection with an anesthetic-steroid combination is frequently curative. No more than 5 to 7 mL of solution should be injected, and results are variable when several trigger points are found on the anterior chest wall. Tack hammer deformity of the xiphoid, another cause of xiphoid pain, has been successfully treated with surgical excision.
OBJECTIVE: To compare the efficacy of sertraline versus physical therapy (ultrasonography and physical therapy) in fibromyalgia. DESIGN: A 6-month comparative, prospective, randomised study of 70 female patients, aged 42 to 52, with fibromyalgia according to the criteria of the American College of Rheumatology. One group (N=36) underwent 6-month treatment with sertraline, 50 mg/24 h. The other group (N=34) received 15 sessions of 1 W/cm2 ultrasonography on the cervical trigger points plus physical therapy. Variables analyzed on a visual 10-point scale were pain and morning stiffness and sleep disorders by use of the sleep questionnaire of the Medical Outcome Study (MOS). Measurements were taken at the beginning of the study and at 3-month and 6-month follow-up. RESULTS: Pain significantly diminished in the sertraline group during the entire study (visual numeric scale: 7.2+/-1.1 initially, 5.3+/-?? at 3 months and 3+/-0.7 at 6 months, P<0.05). Morning stiffness and sleep disorder scores were positive only for the sertraline group during the entire 6 months (P<0.05). Results from the MOS questionnaire showed improvement only for the sertraline group. Of the Sertraline group, 83% evaluated the treatment as good or very good, as compared with only 6% of the ultrasonography group. No patient withdrew from the study. CONCLUSION: Patients treated with sertraline had a better outcome in terms of pain, morning stiffness and sleep disorders, than the group treated with ultrasonography and physical therapy.