Physical Medicine and Rehabilitation for Myofascial Pain

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Myofascial pain (MP) is a common, painful disorder that is responsible for many pain clinic visits. MP can affect any skeletal muscles in the body. Skeletal muscle accounts for approximately 50% of body weight, and there are approximately 400 muscles in the body. MP is responsible for many cases of chronic musculoskeletal pain and the diagnosis is commonly missed. ^[1]

MP can cause local or referred pain, tightness, tenderness, popping and clicking, stiffness and limitation of movement, autonomic phenomena, local twitch response (LTR) in the affected muscle, and muscle weakness without atrophy. Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles; restricted range of motion (ROM); and a visible or palpable LTR to local stimulation are classic signs of MP. Over 70% of TrPs correspond to acupuncture points used to treat pain. ^[2]

An active TrP is an area that refers pain to a remote area in a defined pattern when local stimulation is applied. Satellite TrPs appear in response to a primary, active TrP and usually disappear after the primary TrP has been inactivated. Latent TrPs cause stiffness and limitation of ROM but no pain. Frequently, they are found in asymptomatic individuals.

Although MP and fibromyalgia have some overlapping features, they are separate entities; fibromyalgia is a widespread pain problem, not a regional condition caused by specific TrPs.

A taut band in a muscle may be necessary as a precursor to the development of a trigger point (TrP). Taut bands are common in asymptomatic individuals, but patients with them are more likely to develop a TrP. A latent TrP can develop into an active TrP for a number of reasons. Psychological stress, muscle tension, and physical factors, such as poor posture, can cause a latent TrP to become active.

The pathophysiology of myofascial pain is not well understood. Current research supports sensitization of low-threshold, mechanosensitive afferents associated with dysfunctional motor endplates in the area of the TrPs projecting to sensitized dorsal horn neurons in the spinal cord. Pain referred from TrPs, as well as LTRs, may be mediated through the spinal cord after stimulation of a sensitive locus. ^{[3, 4]}

In a study by Alonso-Blanco et al, a connection was found in women between the number of active myofascial TrPs and the intensity of the spontaneous pain and widespread mechanical hypersensitivity; nociceptive inputs from these myofascial TrPs may be linked to central sensitization. ^[5]

Work by Shah et al using a microdialysis catheter demonstrated an increase in biochemicals associated with pain, including protons (a more acidic environment), inflammatory mediators, neuropeptides, cytokines, and catecholamines in the tissue around active trigger points. Uninvolved control points showed lower concentrations of these compounds, but the levels were still higher than in subjects without myofascial pain syndrome. ^[6]

United States

Myofascial pain (MP) is extremely common, and almost everyone develops a trigger point (TrP) at some time. In the US, 14.4% of the general population suffers from chronic musculoskeletal pain. Approximately 21-93% of patients with regional pain complaints have MP. Studies have demonstrated that 25-54% of asymptomatic individuals have latent TrPs.

Myofascial pain (MP) is not a fatal condition, but it can cause significant reduction in quality of life (QOL) and is a major cause of time lost from work. Costs associated with MP sap millions, perhaps billions, of dollars from the economy.

No racial differences in the incidence of myofascial pain have been described in the literature.

Myofascial pain is distributed equally between men and women. ^[7]

Myofascial trigger points (TrPs) can be found in persons of all ages, even infants. The likelihood of developing active TrPs increases with age and activity level into the middle years. Sedentary individuals are more prone to develop active TrPs than are individuals who exercise vigorously on a daily basis.

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Jennifer E Finley, MD, FAAPMR Consulting Physiatrist and Sports Medicine Physician

Jennifer E Finley, MD, FAAPMR is a member of the following medical societies: American Academy of Medical Acupuncture, American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Dean H Hommer, MD Chief, Department of Pain Management, Brooke Army Medical Center

Dean H Hommer, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Healthcare Executives, American College of Sports Medicine, American Institute of Ultrasound in Medicine, American Society of Interventional Pain Physicians, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Physical Medicine and Rehabilitation for Myofascial Pain

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