Specialty Care National Program

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 2

Specialty Care National Program Mini-Residency – Pain Management

February 10-12, 2015

IMAGING STUDIES Magenetic Resonance Elastography Thermography

Ultrasound

Referred Pain

• Dorsal horn sensitization spreads to adjacent

myotomes, via antidromal mechanisms

involving substance P, causing referred pain.

• Predictable patterns.

• Can mimic radicular pain, nerve

entrapment, intrinsic joint disease or even

visceral referred pain.

• Follow “anatomy trains”, or acupuncture

meridians, rather than dermatomes.

Piriformis Syndrome

• Due to local pressure on sciatic nerve.

• History of direct trauma or prolonged sitting.

• Internal rotation exacerbates symptoms.

• External rotation relieves pressure on nerve.

• Patients may undergo laminectomy but have persistent symptoms.

Other Conditions Associated with Trigger Points

• Iliotibial band syndrome

• Temporomandibular disorder

• Lateral epicondylitis

• Achilles tendonitis

• Rotator cuff tendonitis

• Radiculopathy

Etc.

Infraspinatus

• Strain from reaching

backwards.

• Mimics C4

radiculopathy,

glenohumeral

arthritis, rotator cuff

tear, subacromial

bursitis.

Active vs. Latent Trigger Points

• Active – spontaneous pain, may cause pain

with movement, or limit range of motion.

• Latent – pain elicited with palpation. Latent

trigger points can influence muscle activation

patterns, which can result in poorer muscle

coordination and balance.

Location of Trigger Points

• Central – within a taut band.

• Attachment – at tendinomuscular junction.

Other Classifications

• key trigger point – has pain referral pattern along a pathway that activates a latent satellite trigger point on the pathway, or creates it.

• Successfully treating the key trigger point will often resolve the satellite, either converting it from being active to latent or completely treating it.

• primary trigger point – biomechanically activates a secondary trigger point in another structure.

• Treating the primary trigger point does not treat the secondary trigger point.

Superficial Paraspinal Muscles

• TrP may be a satellite of a key TrP in

the latissimus dorsi.

• Due to sudden overload or traumatic

event, or repeated contraction over a

period of time;

• Quick awkward movement combining

bending and twisting of the back,

especially when muscles are fatigued;

• Almost any factor that contributes to a

significant gait deviation can activate

TP’s in iliocostalis;

• Also associated with prolonged

immobility – sitting, bedrest, etc.

• Mimic inguinal hernia, cholecystitis,

splenic, or even appendiceal pain.

Quadratus Lumborum • Acute trauma – lifting,

twisting strain.

• Deep, aching low back

pain at rest, severe

pain in unsupported

standing or sitting.

• Deep trigger points

refer to SI joint.

• Superficial trigger

points refer to hip, iliac

crest, groin.

• Mimics radiculopathy,

hip OA, trochanteric

bursitis, hernia, etc.

Scalenes

• Associated with

“whiplash” injury.

• Referral pattern in the

distribution of the fifth

cervical nerve root

dermatome and myotome,

with spillover into the

adjacent root distributions.

• May be associated with

Thoracic Outlet Syndrome

– compressing brachial

plexus, axillary vessels, or

lymphatics.

Palpation of Trigger Point

Left: Skin pushed to one side to begin

palpation (A). The fingertip slides

across muscle fibers to feel the cord-

line texture of the taut band rolling

beneath it (B). The skin is pushed to

other side at completion of movement.

This same movement performed

vigorously is snapping palpation

(C).Right: Muscle fibers surrounded by

the thumb and fingers in a pincer grip

(A). The hardness of the taut band is

felt clearly as it is rolled between the

digits (B). The palpable edge of the

taut band is sharply defined as it

escapes from between the fingertips,

often with a local twitch response (C).

Local Twitch Response

A: Palpation of a taut band

(straight lines) among normally

slack, relaxed muscle fibers

(wavy lines). B: Rolling the band

quickly under the fingertip

(snapping palpation) at the

trigger point often produces a

local twitch response that

usually is seen most clearly as

skin movement between the

trigger point and the attachment

of the muscle fibers.

MPS Diagnosis

• Consider myofascial pain when there is regional

pain without any findings on imaging studies.

• Sometimes, persistent myofascial pain may be a

muscle response to an underlying structural

spine or visceral problem.

• Palpate for taut bands and trigger points.

• MPS may be associated with weakness and

autonomic signs (warmth, erythema,

piloerection).

• Screen for endocrine abnormalities and

nutritional deficiencies.

MPS Diagnosis

• Screen for serious medical pathology

(Red Flags), and for psychological and social

factors that may delay recovery

(Yellow Flags).

• Use a numeric pain rating and functional

scale to determine severity of pain disability.

• Identify and manage perpetuating factors

(posture, repetitive actions, occupational

factors).

Myofascial Assessment

Symptoms

• Local and referred pain

• Pain with isometric

contraction

• Stiffness and limited ROM

• Muscle Weakness

• Myofascial holding pattern

• Paresthesia and

numbness possible

• Autonomic dysfunction

Physical Findings

• Local Tenderness

• Single or multiple

muscles

• Trigger points active

• Firm or Taut Bands

• LTR

• Muscle weakness

• Muscle Shortening

Collaborative Care Model

Biopsychosocial interdisciplinary team

approach with cognitive-behavioral components

encouraging

exercise and active participation

of the patient in the plan of care

MPS Treatment

• Treatment consists more in restoring muscle

balance and function through physical

techniques rather than with medication

management.

• Behavioral interventions are vital to success.

Treatments

• Behavioral management

• Physical Therapy

• Exercise

• Nutrition, including proper hydration.

• Posture correction

• Complementary/Traditional/Integrative Medicine

• Manual Therapies

• Needle Interventions

• Pharmacotherapy

Behavioral Management

• Depression – 50% comorbidity

• Stress management

• Relaxation techniques

• Mindfulness-Based Stress Reduction

• Cognitive behavioral therapy

• Chemical dependency treatment, including

nicotine.

• Anger management

• Biofeedback

Nutrition and Inflammation

• Typical American diet is pro-inflammatory –

high in simple carbohydrates and

hydrogenated fats.

• Ideally omega-6 to omega-3 should be < 4:1;

typical dietary omega-6:omega-3 is 10:1 or

greater.

Omega-3 Fatty Acids

Supplementing

EPA and DHA, 3

g daily, can

reduce

inflammatory

cytokines and

eicosanoids,

leading to

decreased

cardiovascular

disease,

improved mood,

and decreased

joint pain in RA.

Antioxidants

• Free-radical damage can trigger inflammatory

response, and is implicated in chronic pain,

cardiovascular disease, cancer, degenerative

neurologic disorders, etc.

• Pathways to scavenge free radicals are

nutrient-dependent.

• Plants provide numerous antioxidant

phytochemicals including flavenoids,

carotenoids, lycopene, tocopherols (vitamin

E), vitamin C, etc.

Nutritional Deficiencies

• Vitamin D

– if 25-OH vitamin D<18 ng/mL,

check PTH, serum and urine calcium,

calculate fractional excretion.

• Vitamin B12

– Screen for anemia.

– Check for elevated methylmalonic acid for

borderline low cobalamin (200-300 pg/mL).

– Consider Intrinsic Factor antibody testing.

• Iron - screen for anemia.

• Water!

Simple Dietary Guideline

• Michael Polan

• In Defense of Food

• “Eat food. Not too much. Mostly vegetables.”

Consider Mediterranean Diet

• Meets recommendations for anti-inflammatory

diet.

• Less restrictive than many other dietary

regimens.

• High in fruits, vegetables, fish, and

monounsaturated fats such as olive oil.

• Low intake of dairy products and red meat.

• May be effective for reducing pain in

rheumatoid arthritis.

Physical Rehabilitation

• Fitness program

– Gentle graded strength training

- Cardiovascular (aerobic activity)

- Flexibility

- Balance

• Body mechanics and posture

• Modalities

- Ice/Heat, Massage, TENS, Ultrasound, Laser,

Aquatic Therapy, etc.

Aerobic Exercise

• Start with 5 to 10 minute sessions, 50% of

maximum heart rate, 3 days/week.

• Goal of 30 minutes sessions, 75-85%

maximum heart rate, 5 days/week.

• Rule of thumb:

maximum heart rate = 220-age.

Posture

Anterior Pelvic Tilt

• Problem: Lack of support through the transverse abdominus, instability of lower two lumbar vertebra, leading to contracture of psoas & iliacus. Hip joints may be unstable due to stretched joint capsules as well.

• Exercise: Kneel on left knee, with right foot on the floor in front, knee bent. Press forward to stretch left hip. Tighten gluteus on left side. Reach upward with left arm and stretch to the right side. Hold for a count of 30 seconds. Switch sides, three repetitions on each side.