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Drugs

, Volume 64, Issue 1, pp 45–62 | Cite as

Myofascial Pain Disorders

Theory to Therapy
  • Anthony H. WheelerEmail author
Therapy In Practice

Abstract

Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and actuates movement against inertia. Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading. Muscular pain is often attributed to a myofascial pain disorder, a condition originally described by Drs Janet Travell and David Simons. Among patients seeking treatment from a variety of medical specialists, myofascial pain has been reported to vary from 30% to 93% depending on the subspecialty practice and setting. Forty-four million Americans are estimated to have myofascial pain; however, controversy exists between medical specialists regarding the diagnostic criteria for myofascial pain disorders and their existence as a pathological entity.

Muscles with activity or injury-related pain are usually abnormally shortened with increased tone and tension. In addition, myofascial pain disorders are characterised by the presence of tender, firm nodules called trigger points. Within each trigger point is a hyperirritable spot, the ‘taut-band’, which is composed of hypercontracted extrafusal muscle fibres. Palpation of this spot within the trigger point provokes radiating, aching-type pain into localised reference zones. Research suggests that myofascial pain and dysfunction with characteristic trigger points and taut-bands are a spinal reflex disorder caused by a reverberating circuit of sustained neural activity in a specific spinal cord segment.

The treatment of myofascial pain disorders requires that symptomatic trigger points and muscles are identified as primary or ancillary pain generators. Mechanical, thermal and chemical treatments, which neurophysiologically or physically denervate the neural loop of the trigger point, can result in reduced pain and temporary resolution of muscular overcontraction. Most experts believe that appropriate treatment should be directed at the trigger point to restore normal muscle length and proper biomechanical orientation of myofascial elements, followed by treatment that includes strengthening and stretching of the affected muscle. Chronic myofascial pain is usually a product of both physical and psychosocial influences that complicate convalescence.

Keywords

Neuropathic Pain Trigger Point Muscle Spasm Cervical Dystonia Myofascial Pain 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.

References

  1. 1.
    Simons DG, Travell JG, Simons LS. Travell and Simons’ myofascial pain and dysfunction: the trigger point manual. 2nd ed. Baltimore (MD): Williams & Wilkins, 1999Google Scholar
  2. 2.
    Fishbain DA, Goldberg M, Meagher BR, et al. Male and female chronic pain patient’s categories by DSM-III psychiatric diagnostic criteria. Pain 1986; 26: 181–97PubMedCrossRefGoogle Scholar
  3. 3.
    Gerwin RD. A study of 96 subjects examined both for fibromyalgia and myofascial pain [abstract]. J Musculoskeletal Pain 1995; 3 Suppl. 1: 121Google Scholar
  4. 4.
    Drewes AM, Jennum P. Epidemiology of myofascial pain, low back pain, morning stiffness and sleep-related complaints in the general population [abstract]. J Muscoskeletal Pain 1995; 3 Suppl. 1: G8Google Scholar
  5. 5.
    Bonica J. The management of pain. Vol. 1. 2nd ed. Philadelphia (PA): Lea & Febiger, 1990: 180–96Google Scholar
  6. 6.
    Magni G. The epidemiology of musculoskeletal pain. In: Voeroy H, Merskey H, editors. Progress in fibromyalgia and myofascial pain. Amsterdam: Elsevier Science, 1993: 3–20Google Scholar
  7. 7.
    Bohr T. Problems with myofascial pain syndrome and fibromyalgia syndrome. Neurology 1996; 79: 593–7CrossRefGoogle Scholar
  8. 8.
    Wheeler AH, Aaron GW. Muscle pain due to injury. Curr Pain Headache Rep 2001; 5: 441–6PubMedCrossRefGoogle Scholar
  9. 9.
    Noonan TJ, Garrett WE. Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg 1999; 7: 262–9PubMedGoogle Scholar
  10. 10.
    Wheeler AH, Murrey DB. Chronic lumbar spine and radicular pain: pathophysiology and treatment. Curr Pain Headache Rep 2002; 6: 97–105PubMedCrossRefGoogle Scholar
  11. 11.
    Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318: 291–300PubMedCrossRefGoogle Scholar
  12. 12.
    Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum 1990; 33: 160–72PubMedCrossRefGoogle Scholar
  13. 13.
    Pillemer SR, Bradley LA, Crofford LI, et al. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum 1997; 40: 1703–7CrossRefGoogle Scholar
  14. 14.
    Urban MO, Gebhart GF. Central mechanisms in pain. Med Clin North Am 1999; 83: 585–96PubMedCrossRefGoogle Scholar
  15. 15.
    Carlton SM, Zhou S, Coggeshal RE. Evidence for the interaction of glutamate and NK1 receptors in the periphery. Brain Res 1998; 83: 160–9CrossRefGoogle Scholar
  16. 16.
    Bennett RM. Emerging concepts in the neurobiology of chronic pain; evidence of abnormal sensory processing in fibromyalgia. Mayo Clin Proc 1999; 74: 385–98PubMedCrossRefGoogle Scholar
  17. 17.
    Fields HL. Pain. New York: McGraw-Hill, 1987Google Scholar
  18. 18.
    Liu H, Mantyh PW, Basbaum AI. NMDA-receptor regulation of substance P release from primary afferent nociceptors. Nature 1997; 386(6626): 721–4PubMedCrossRefGoogle Scholar
  19. 19.
    Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle EMG activity. Spine 1993; 18: 1803–7PubMedCrossRefGoogle Scholar
  20. 20.
    Hubbard DR. Chronic and recurrent muscle pain: pathophysiology and treatment, and review of pharmacologic studies. J Musculoskeletal Pain 1996; 4: 123–43CrossRefGoogle Scholar
  21. 21.
    Rivner MH. The neurophysiology of myofascial pain syndrome. Curr Pain Headache Rep 2000; 5: 432–40CrossRefGoogle Scholar
  22. 22.
    Brown WF, Varkey GP. The origin of spontaneous electrical activity at the end-plate zone. Ann Neurol 1981; 10: 557–60PubMedCrossRefGoogle Scholar
  23. 23.
    Russell IJ. Neurochemical pathogenesis of fibromyalgia syndrome. J Musculoskeletal Pain 1996; 4: 61–92CrossRefGoogle Scholar
  24. 24.
    Pappagallo M. Aggressive pharmacologic treatment of pain. Rheum Dis Clin North Am 1999; 25: 193–209PubMedCrossRefGoogle Scholar
  25. 25.
    Davidoff RA. Trigger points and myofascial pain: toward understanding how they affect headaches. Cephalalgia 1998; 18: 436–48PubMedCrossRefGoogle Scholar
  26. 26.
    Cyriax J. Textbook of orthopaedic medicine: diagnosis of soft tissue lesions. 8th ed. Baltimore (MD): Williams & Wilkins, 1984Google Scholar
  27. 27.
    Cantu RI, Grodin AJ. Myofascial manipulation: theory and clinical application. Gaithersburg (MD): Aspen, 1992Google Scholar
  28. 28.
    Magee DJ. Orthopedic physical assessment. 2nd ed. Philadelphia (PA): WB Saunders, 1992Google Scholar
  29. 29.
    Galer BS, Dworkin RH. A clinical guide to neuropathic pain. Minneapolis (MN): McGraw-Hill, 2000Google Scholar
  30. 30.
    Downer AH. Physical therapy procedures. Springfield (IL): Charles C Thomas, 1970Google Scholar
  31. 31.
    Lee JM, Warren MP, Mason SM. Effects of ice on nerve conduction velocity. Physiotherapy 1978; 64: 2–6PubMedGoogle Scholar
  32. 32.
    Waylonis GW. The physiological effects of ice massage. Arch Phys Med Rehabil 1967; 48: 37–42PubMedGoogle Scholar
  33. 33.
    Wheeler AH, Hanley EN. Nonoperative treatment of low back pain: rest to restoration. Spine 1995; 20: 375–8PubMedCrossRefGoogle Scholar
  34. 34.
    Argoff CE, Wheeler AH. Spinal and radicular pain disorders. Neurol Clin 1998; 4: 833–49CrossRefGoogle Scholar
  35. 35.
    Deyo RA. Nonoperative treatment of low back disorders: differentiated useful from useless therapy. In: Frymoyer JW, Ducker TB, Hadler NM, et al., editors. The adult spine principles and practice. Philadelphia (PA): Lippincott-Raven, 1997: 1777–93Google Scholar
  36. 36.
    Hawkey C, Kahan A, Steinbruck K, et al. Gastrointestinal tolerability of meloxicam compared to diclofenac in osteoarthritis patients. Br J Rheumatol 1998; 37: 937–45PubMedCrossRefGoogle Scholar
  37. 37.
    Silverstein F, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis. The class study: a randomized controlled trial. JAMA 2000; 284(10): 1247–55Google Scholar
  38. 38.
    Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. N Engl J Med 2000; 343(21): 1520–8PubMedCrossRefGoogle Scholar
  39. 39.
    Enffaard TP, Kiltgaard NA, Gram LF, et al. Specific effect of venlafaxine on single and repetitive experimental painful stimuli in humans. Clin Pharmacol Ther 2001; 69(4): 245–51CrossRefGoogle Scholar
  40. 40.
    Sumpton JE, Moulin DE. Treatment of neuropathic pain with venlafaxine. Ann Pharmacother 2001; 35(5): 557–9PubMedCrossRefGoogle Scholar
  41. 41.
    Harkens S, Linford J, Cohen J, et al. Administration of clonazepam in the treatment of TMD and associated myofascial pain: a double-blind pilot study. J Craniomandib Disord 1991; 5(3): 179–86Google Scholar
  42. 42.
    Fromm GH, Terence CF, Chatta AS. Baclofen in the treatment of trigeminal neuralgia. Ann Neurol 1984; 15: 240–7PubMedCrossRefGoogle Scholar
  43. 43.
    Waldman SD. Recent advances in analgesic therapy: tizanidine. Pain Digest 1999; 9: 40–3Google Scholar
  44. 44.
    Wagstaff AJ, Bryson HM. Tizanidine: a review of pharmacology, clinical efficacy and tolerability in the management of spasticity associated with cerebral and spinal disorders. Drugs 1997; 53: 436–51Google Scholar
  45. 45.
    Muramatsu I, Kigoshi G. Tizanidine may discriminate between imidazoline-receptors and adrenoreceptor. Jpn J Pharmacol 1992; 59: 457–9PubMedCrossRefGoogle Scholar
  46. 46.
    Milanov I, Georgiev D. Mechanisms of tizanidine in spasticity. Acta Neurol Scand 1994; 89: 274–9PubMedCrossRefGoogle Scholar
  47. 47.
    Wiesendanger M, Corboz M, Palmeri A, et al. Noradrenergic mechanisms involved in muscle relaxation: significance for the treatment of spasticity. Schweiz Acta Neurol Psychiatr 1991; 142(2): 132–4Google Scholar
  48. 48.
    Ono H, Mishima A, Ono S, et al. Inhibitory effects of clonidine and tizanidine on release of substance P. Neuropharmacology 1991; 30: 585–9PubMedCrossRefGoogle Scholar
  49. 49.
    Lataste X, Emre M, Davis C, et al. Comparative profile of tizanidine in the management of spasticity. Neurology 1994; 44: 53–9Google Scholar
  50. 50.
    Berry H, Hutchinson DR. A multicenter placebo-controlled study in general practice to evaluate the safety and efficacy of tizanidine in acute low back pain. J Int Med Res 1988; 16: 75–82PubMedGoogle Scholar
  51. 51.
    Felder M. Tizanidine in the treatment of neck and low back pain. AIDS Int 1990; 1: 9Google Scholar
  52. 52.
    Berry H, Hutchinson DR. Tizanidine and ibuprofen in acute low back pain: results of a multicenter double-blind study in general practice. J Int Med Res 1988; 16: 83–91PubMedGoogle Scholar
  53. 53.
    Fryda-Kaurimsky Z, Muller-Fassbender H. Tizanidine in the treatment of acute paravertebral spasms: a controlled trial comparing tizanidine with diazepam. J Int Med Res 1981; 9: 501–5PubMedGoogle Scholar
  54. 54.
    Tse FLS, Jaffe JM, Bhuta S. Pharmacokinetics of tizanidine in health volunteers. Fundam Clin Pharmacol 1987; 1: 479–88PubMedCrossRefGoogle Scholar
  55. 55.
    Rosenberg JM, Harrell C, Rishi H, et al. The effect of gabapentin on neuropathic pain. Clin J Pain 1997; 13: 251–5PubMedCrossRefGoogle Scholar
  56. 56.
    Bardin M, Chantelauze C, Lavarenne J, et al. Study of the sensitivity of the diabetes-induced pain model in rats to a range of analgesics. Pain 1994; 57: 153–60PubMedCrossRefGoogle Scholar
  57. 57.
    McCain GA. Fibromyalgia and myofascial pain syndromes. In: Wall PD, Melzack R, editors. Textbook of pain. 3rd ed. New York: Churchill Livingstone, 1994: 475–93Google Scholar
  58. 58.
    Jay GW. Chronic daily headache: pathophysiology and treatment. Pain Digest 1994; 16: 851–68Google Scholar
  59. 59.
    Deyo RA. Drug therapy for back pain: which drugs help which patients? Spine 1996; 21: 2840–50PubMedCrossRefGoogle Scholar
  60. 60.
    Lipman AG. Analgesic drugs for neuropathic and sympathetically maintained pain. Clin Geriatr Med 1996; 12: 501–15PubMedGoogle Scholar
  61. 61.
    McQuay HJ, Moore RA, Eccleston C, et al. Systemic review of outpatient services for chronic pain control. Health Technol Assess 1997; 1(6): i–iv, 1–135PubMedGoogle Scholar
  62. 62.
    Garcia J, Altman RD. Chronic pain states: pathophysiology and medical therapy. Semin Arthritis Rheum 1997; 27: 1–16PubMedCrossRefGoogle Scholar
  63. 63.
    Pancrazio JJ, Kamatchi GL, Roscoe AK, et al. Inhibition of neuronal Na+ channels by antidepressant drugs. J Pharmacol Exp Ther 1998; 284: 208–14PubMedGoogle Scholar
  64. 64.
    Reveille JD. Soft-tissue rheumatism: diagnosis and treatment. Am J Med 1997; 102 Suppl. 1A: 23S–9SPubMedCrossRefGoogle Scholar
  65. 65.
    Wasner G, Backonja M-M, Baron R. Traumatic neuralgias: complex regional pain syndromes (reflex sympathetic dystrophy and causalgia): clinical characteristics, pathophysiologic mechanisms and therapy. Neurol Clin 1998; 16: 851–68PubMedCrossRefGoogle Scholar
  66. 66.
    Bonezzi C, Demartini L. Treatment options in postherpetic neuralgia. Acta Neurol Scand Suppl 1999; 173: 25–35PubMedCrossRefGoogle Scholar
  67. 67.
    Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain 1999; 83: 389–400PubMedCrossRefGoogle Scholar
  68. 68.
    Watson CP. The treatment of neuropathic pain: antidepressants and opioids. Clin J Pain 2000; 16 (2 Suppl.): S49–55PubMedCrossRefGoogle Scholar
  69. 69.
    Redillas C, Solomon S. Prophylactic pharmacological treatment of chronic daily headache. Headache 2000; 40: 83–102PubMedCrossRefGoogle Scholar
  70. 70.
    Pettengill CA, Reisner-Keller L. The use of tricyclic antidepressants for the control of chronic orofacial pain. J Craniomandibular Pract 1997; 15: 53–6Google Scholar
  71. 71.
    Jacobson LO, Bley K, Hunter JC, et al. Anti-thermal hyperalgesic properties of antidepressants in a rat model of neuropathic pain [abstract]. American Pain Society Annual Meeting; 1995 Sep 9–12; Los Angeles (CA)Google Scholar
  72. 72.
    Taylor K, Rowbotham MC. Venlafaxine for chronic pain [abstract]. American Pain Society Annual Meeting; 1995 Sep 9–12; Los Angeles (CA)Google Scholar
  73. 73.
    Wheeler AH. Therapeutic injections for pain management. In: Mendozabal J, Talavera F, Halsey JH, et al., editors. Neurology section of EMedicine [textbook online; updated 2000 Mar 2]. Available from URL: http://emedicine.com/neuro/topic514.htm [Accessed 2003 Sep 20]
  74. 74.
    Bonica JJ, Buckley FO. Regional anesthesia with local anesthetics. In: Bonica JJ, Loeser JD, Chapman RC, et al., editors. The management of pain. 2nd ed. Philadelphia (PA): Lea & Febiger, 1990: 1883–1966Google Scholar
  75. 75.
    Brown DL. Atlas of regional anesthesia. Philadelphia (PA): WB Samuels, 1992Google Scholar
  76. 76.
    Garvey TA, Marks MR, Wiesel SW. A prospective, randomized double-blind evaluation of trigger-point injection therapy for low-back pain. Spine 1989; 14: 962–4PubMedCrossRefGoogle Scholar
  77. 77.
    Dreyer SJ. Commonly used medications in pain procedures. In: Lennard JA, editor. Pain procedures in clinical practice. Philadelphia (PA): Hanley & Belfus, 2000: 1–9Google Scholar
  78. 78.
    Criscuolo CM. Interventional approaches to the management of myofascial pain syndrome. Curr Pain Headache Rep 2001; 5: 407–11PubMedCrossRefGoogle Scholar
  79. 79.
    Lacy CF, Armstrong LL, Goldman MP, et al. Drug information handbook. Hudson (OH): Lexi-Comp, 1999Google Scholar
  80. 80.
    Noerdlinger MA, Fadale PD. The role of injectable corticosteroids in orthopedics. Orthopedics 2001; 24(4): 400–5PubMedGoogle Scholar
  81. 81.
    Wiggins ME, Fadale PD, Barrach H, et al. Healing characteristics of a type I collagenous structure treated with corticosteroids. Am J Sports Med 1994; 22: 279–88PubMedCrossRefGoogle Scholar
  82. 82.
    Cohen IK, Diegelmann RF, Johnson ML. Effect of corticosteroids on collagen synthesis. Surgery 1977; 82: 15–20PubMedGoogle Scholar
  83. 83.
    Jankovic J, Brin JF. Therapeutic uses of botulinum toxin. N Engl J Med 1991; 342: 1186–94Google Scholar
  84. 84.
    Wheeler AH. The therapeutic uses of botulinum toxin. Am Fam Physician 1997; 55: 541–5PubMedGoogle Scholar
  85. 85.
    Guyer BA. Mechanism of botulinum toxin the in relief of chronic pain. Curr Rev Pain 1993; 3: 427–31Google Scholar
  86. 86.
    Wheeler AH, Goolkasian P. Open label assessment of botulinum toxin A for pain treatment in a private outpatient setting. J Musculoskeletal Pain 2001; 9: 67–82CrossRefGoogle Scholar
  87. 87.
    Blasi J, Chapman ER, Link E, et al. Botulinum neurotoxin A selectively cleaves the synaptic protein SNAP-25. Nature 1993; 365: 160–3PubMedCrossRefGoogle Scholar
  88. 88.
    Schiavo G, Benfenati F, Poulain B, et al. Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin. Nature 1992; 359: 832–5PubMedCrossRefGoogle Scholar
  89. 89.
    O’Brien CF. Clinical applications of botulinum toxin: implications for pain management. Pain Digest 1998; 8: 342–5Google Scholar
  90. 90.
    Zwart JA, Bovim G, Sand T, et al. Tension headache: botulinum toxin paralysis of temporal muscles. Headache 1994; 34: 458–62PubMedCrossRefGoogle Scholar
  91. 91.
    Relja M. Treatment of tension-type headache by local injection of botulinum toxin. Eur J Neurol 1997; 4 Suppl. 2: S71–3Google Scholar
  92. 92.
    Hobson D, Gladish D. Botulinum toxin injection for cervicogenic headache. Headache 1997; 36: 253–5CrossRefGoogle Scholar
  93. 93.
    Wheeler AH. Botulinum toxin-A, adjunctive therapy for refractory headaches associated with pericranial muscle tension. Headache 1998; 38: 468–71PubMedCrossRefGoogle Scholar
  94. 94.
    Cheshire WP, Abashjan SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain 1994; 59: 65–9PubMedCrossRefGoogle Scholar
  95. 95.
    Yue SK. Initial experience in the use of botulinum toxin A for the treatment of myofascial related muscle dysfunction. J Musculoske Pain 1995; 3 Suppl. 1: 22Google Scholar
  96. 96.
    Wheeler AH, Goolkasian P, Gretz SS. A randomized double-blind prospective pilot study of botulinum toxin injection for refractory, unilateral, cervicothoracic paraspinal, myofascial pain syndrome. Spine 1998; 23: 1662–7PubMedCrossRefGoogle Scholar
  97. 97.
    Wheeler AH, Goolkasian P, Gretz SS. Botulinum toxin A for the treatment of chronic neck pain. Pain 2001; 94: 255–60PubMedCrossRefGoogle Scholar
  98. 98.
    Porta M. A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Pain 2000; 85: 101–5PubMedCrossRefGoogle Scholar
  99. 99.
    Freund BJ, Schwartz M. Treatment of whiplash associated with neck pain with botulinum toxin-A: a pilot study. J Rheumatol 2000; 27: 481–4PubMedGoogle Scholar
  100. 100.
    Royal MA, Gunyeu I, Bhatia B, et al. Botulinum toxin type A in the treatment of refractory myofascial pain [abstract]. Neurology 2001; 58 Suppl. 3: A350Google Scholar
  101. 101.
    Lang AM. A pilot study of botulinum toxin type A (botox), administered using a novel technique, for the treatment of myofascial pain. Am J Pain Med 2000; 10: 108–12Google Scholar
  102. 102.
    Wheeler AH. Botulinum toxin injection technique for treatment of headaches. Aesthetic Surg J 2002; 22: 65–8CrossRefGoogle Scholar
  103. 103.
    Schneider P, Moroni E, Bitttner C, et al. Physical therapy and botulinum toxin type A in patients with cervical associated headache according to IHS-criteria: double-blind placebo-controlled study [abstract]. Neurology 2001; 58 Suppl. 3: A349Google Scholar

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Authors and Affiliations

  1. 1.Pain and Orthopedic NeurologyCharlotte Spine CenterCharlotteUSA

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