Myofascial Pain Syndrome(MPS) 1. Definition of MPS ; regional pain syndrome accompained by trigger points 2. Trigger point vs Tender points
3. Muscle Pain ∙ muscle spasm ∙ muscle tension ∙ muscle deficiency (stiffness & weakness) ∙ trigger points 4. Myofascial Trigger Point(TPs) ; a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle's fascia ∙ localized tenderness ∙ presence of a taut band ∙ twitch response ∙ referred pain on palpation of a TPs 5. Incidence ∙ In chronic pain center : MPS were the cause of pain in over half of the patients ∙ Latent trigger points afflict nearly half the population by early childhood. ∙ Of patients with a pain complaint, myofascial trigger points caused the pain in 31% 6. Pathophysiology ∙ Sensitization of nerves at the TPs ∙ Referred pain - convergence projection - convergence facilitation - axon branching - sympathetic nerves ∙ Palpable band ∙ Metabolic distress 7. Diagnosis 1) History & pain patte군 ; reffered pain 2) Physical Examination ; restricted stretch range of motion "jump sign" local twitch response-confirmatory 3) Laboratory findings ; No laboratory or imaging test is diagnostic of MPs cf. thermography & MRI ◎ Clinical Features General symptoms; regional pain (muscle specific) poor sleep "swelling" stiff joints tinnitus paresthesia nausea constipation depression & anxiety fatigue Muscle shortening and decreased joint motion secondary to trigger points
Empirical Criteria Suggested for Diagnosis fo MPS
* All major criteria + at least 1 of minor criteria ◎ 7 Clinical feature of MPS caused by TPs 1) local tenerness 2) referred pain, tenderness & autonomic phenomenon 3) electrically quiet palpable band 4) local twitch response(LTR) 5) perpetuation of TPs by compromise of the muscle's energy supply 6) remarkable therapeutic effect by stretching 7) weakness without strophy 8. Differential Diagnosis ∙ Fibrositis-fibromyalgia ; regional, promary, secondary, concomitant ∙ Articular dysfunction ∙ Common pain diagnosis 9. Common pain diagnoses Examples) ∙ tension headache; SCM, U.trapezius, Post. cervicals ∙ thoracic outlet syndrome; Scalene, P.minor ∙ appendicitis; Rectus abdominis, iliocostalis ∙ angina pectoris; P. major & minor ∙ knee arthritis; Quadriceps, GCM ∙ Meralgia paresthetica; TFL, Sartorius 10. Stretch & Spray ; one of the simplest, quickest, least painful methods Purpose : to inactivate the TPs by restoring the muscle to its full stretch range of motion with minimal discomfort and without exciting feflex spasm cf. Fluori-Methane Comparison of Fibromyalgia Syndrome and MPS
11. Treatment 1) Stretch and spray; initial choice 2) Postisometric relaxation, ischemic compression 3) Injection 4) Massage 5) Ultrasound or electrical stimulation 6) Removal of perpetuating factors 7) Medication 8) Patient educaton 1) Postisometric relation ; voluntary contraction alternated with passive stretch for releasing tight muscles 2) Ischemic compression (thumb therapy) ∙ noninvasive & effective but painful ∙ Pressure is applied directly on the TPs with a steady moderately painful(tolerable) pressure. → TPs no longer painful (after 15 secs to 1 min. of pressure), the pressure is released and full active ROM performed. 3) Injection technique ∙ The Patient is positioned comfortably. ∙ Identify the primary TPs and bony landmarks. ∙ Skin preparation(sterilization) ∙ Injection method - single entry - multiple entry - combination ∙ Aspirate prior to injection 4) Massage ; Deep muscle massage (deep friction, or stripping massage) can effectively inactivate TPs. 5) Injection & Stretch ∙ selected initially when the TPs are inaccessible to stretch or because or restriction of ROM ∙ rationale; disruption of the self-sustaining trigger point mechanism - dry needing - isotonic saline injection - 0.5% procaine or 1% lidocaine injection 6) Contraindication to TPs injection ∙ presence of systemic or local infection ∙ bleeding disorderes or patients on anticoagulants ∙ pregnant woman ∙ who appear to be or feel ill after injection 7) Removal of perpetuating factors ∙ Mechanical perpetuating factor - anatomic variatoins; LLD, short upper arm - seated postural stress - standing postural stress; head-forward posture - vocational stress ∙ Systemic perpetuating factor - enzyme dysfuction - metabolic & endocrine dysfuction - chronic infection - psychologic stress |
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