What is myofascial pain syndrome

Myofascial pain syndrome is a chronic (long-lasting) pain disorder. Myofascial pain syndrome is defined as pain that originates from myofascial trigger points in skeletal muscle ¹. In myofascial pain syndrome, pressure on sensitive points in your muscles (trigger points) causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain. Myofascial pain syndrome is prevalent in regional musculoskeletal pain syndromes, either alone or in combination with other pain generators.

Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension.

While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens.

Myofascial pain syndrome can be divided into the acute and chronic forms. Patients with acute myofascial pain syndrome have pain in 1 or 2 local regions. Symptoms usually begin after traumatic events or overuse activities. Acute myofascial pain syndrome frequently resolves spontaneously or after simple treatments. However, some patients progress to chronic myofascial pain syndrome. Chronic myofascial pain syndrome are usually worse in prognosis, and the symptoms can last for 6 months or longer ². Patients with chronic myofascial pain syndrome have more widespread pain than the acute form. Pain intensity may fluctuate. Almost all of the chronic myofascial pain syndrome patients have some perturbating factors.

Myofascial pain syndrome involves about 9 million people in the United States ³. Myofascial pain syndrome is usually found in the population aged from 27 to 50 years. The gender difference in myofascial pain syndrome incidence remains unclear.

Treatment options include physical therapy and trigger point injections. Pain medications and relaxation techniques also can help.

Figure 1. Myofascial pain syndrome trigger points chart

[Source ⁴ ]

Myofascial pain syndrome vs Fibromyalgia

Both myofascial pain syndrome and fibromyalgia are chronic pain disorders, meaning they cause pain that lasts for long periods of time and can be difficult to manage. Myofascial pain syndrome involves mainly muscular pain; whereas, fibromyalgia includes more widespread body pain, along with other symptoms, such as headaches, bowel problems, fatigue and mood changes. There aren’t any specific tests available that can definitively diagnose myofascial pain syndrome or fibromyalgia. Both are diagnosed clinically.

Fibromyalgia also called fibromyalgia syndrome, is a long-lasting or chronic disorder that causes aches and pain all over your body. If you have fibromyalgia, you have pain and tenderness throughout your body that involves both muscles (myalgia) and joints (arthralgia). People with fibromyalgia often experience aches and pain all over their body, fatigue (extreme tiredness that does not get better with sleep or rest), sleeping, mood and memory problems. Fibromyalgia affects both sides of your body — above and below the waist. Furthermore, the pain may move — a process called migratory phenomenon — from one part of the body to another over time. The discomfort of fibromyalgia usually is felt as both joint and muscle aches and pain, without any redness or swelling caused by inflammation.

Fibromyalgia affects more women than men ⁵. The pain, extreme tiredness, and lack of sleep that fibromyalgia causes can affect your ability to work or do daily activities. Treatment can help relieve pain and help prevent flare-ups of symptoms.

Sometimes you may have two or more chronic pain conditions at the same time as fibromyalgia, such as:

• Chronic fatigue syndrome.
• Endometriosis.
• Irritable bowel syndrome.
• Interstitial cystitis.
• Temporomandibular joint dysfunction (TMJ).
• Vulvodynia.

Researchers believe that fibromyalgia causes pain because the disorder affects the way the brain processes pain signals, amplifying painful sensations. Fibromyalgia may be caused by a problem in the brain with nerves and pain signals. In other words, in people with fibromyalgia, the brain misunderstands everyday pain and other sensory experiences, making the person more sensitive to pressure, temperature (hot or cold), bright lights, and noise compared to people who do not have fibromyalgia.

Fibromyalgia affects as many as 4 million Americans 18 and older ⁵. The average age range at which fibromyalgia is diagnosed is 35 to 45 years old, but most people have had symptoms, including chronic pain, that started much earlier in life.

You may have to see several doctors before getting a diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, also are symptoms of many other conditions, such as myalgic encephalomyelitis/chronic fatigue syndrome, rheumatoid arthritis, and lupus. Doctors try to figure out if fibromyalgia or another health problem is causing your symptoms.

Diagnosing fibromyalgia is a two-stage process. First, because many other disorders can mimic the symptoms of fibromyalgia, it’s important that those be ruled out. Blood tests and other diagnostic tests should be performed to confirm that the pain is not the result of another condition, such as arthritis, lupus, a connective tissue disorder or a thyroid disorder.

The second step in fibromyalgia diagnosis is assessing an individual’s symptoms using a tender point count and validated survey criteria, such as the Widespread Pain Index and Symptom Severity Scale. In most cases, if the pain is widespread, has lasted for three months or more, is not associated with an underlying medical condition that could cause the pain, and meets the validated survey criteria, then the diagnosis of fibromyalgia is made.

Treatment for fibromyalgia may include:

• Medicine to treat your pain. The Food and Drug Administration has approved three medicines to treat fibromyalgia: pregabalin, duloxetine, and milnacipran. Your doctor may also suggest pain relievers or antidepressants to treat certain symptoms or to prevent flare-ups.
• Talk therapy. Counseling sessions with a trained counselor can teach you different skills and techniques you can use to better control your pain. This type of therapy can be either one on one or in groups with a therapist. Living with a chronic condition like fibromyalgia can be difficult. Support groups may also give you emotional support and help you cope.

Your doctor or nurse may also suggest taking steps at home to relieve your symptoms.

You can take the following steps at home to help relieve your symptoms:

• Getting enough sleep. Most adults should try to get seven to eight hours of sleep every night. But fibromyalgia can make it hard to fall asleep and stay asleep. Talk to your doctor about any sleep problems you have and ways to treat them. Your doctor may recommend:
  • Going to bed at the same time and getting up at the same time every day
  • Not drinking caffeine, alcohol, or eating spicy meals before bedtime
  • Not taking daytime naps
  • Doing relaxing activities, such as listening to soft music or taking a warm bath, that prepare your body for sleep.
• Reducing stress. Stress can trigger a flare-up of fibromyalgia symptoms. Strategies such as meditation, massage, and talk therapy may help. Get tips on relieving stress.
• Getting regular physical activity. Pain and fatigue may make exercise and daily activities harder to do. But studies show that for many women with fibromyalgia, regular physical activity can reduce pain.11 Any activity, even walking around your home or neighborhood, can help relieve your symptoms.
• Start at a very low level, and slowly increase the amount of activity you get.
• Trying complementary or alternative therapies. Some women say their symptoms got better from trying complementary or alternative therapies, such as:
  • Physical therapy
  • Massage
  • Myofascial release therapy
  • Acupuncture
  • Relaxation exercises
  • Tai chi
  • Yoga

Myofascial pain syndrome causes

Sensitive areas of tight muscle fibers can form in your muscles after injuries or overuse. These sensitive areas are called trigger points. A trigger point in a muscle can cause strain and pain throughout the muscle. When this pain persists and worsens, doctors call it myofascial pain syndrome.

Nowadays, the exact pathophysiology of myofascial pain syndrome is still unknown ². Many researchers try to find scientific evidence and formulate hypotheses. One of the most accepted theory is energy crisis of muscle fibers. Repetitive or prolonged activity can cause overloading of the muscle fibers which lead to muscle hypoxia and ischemia. In addition, intracellular calcium pumps are dysfunctional due to energy depletion. Intracellular calcium increase induces sustained muscle contraction which results in the development of taut bands. Moreover, inflammatory mediators caused by muscle injury contribute to pain and tenderness of the affected muscles. Other than this hypothesis, there are many theories such as neurogenic inflammation, sensitization and limbic dysfunction that are proposed to relate to myofascial pain syndrome ².

Risk factors for myofascial pain syndrome

Myofascial pain syndrome is caused by a stimulus, such as muscle tightness, that sets off trigger points in your muscles. Factors that may increase your risk of muscle trigger points include:

• Muscle injury. An acute muscle injury or continual muscle stress may lead to the development of trigger points. For example, a spot within or near a strained muscle may become a trigger point. Repetitive motions and poor posture also may increase your risk.
• Stress and anxiety. People who frequently experience stress and anxiety may be more likely to develop trigger points in their muscles. One theory holds that these people may be more likely to clench their muscles, a form of repeated strain that leaves muscles susceptible to trigger points.
• Ergonomic factors (e.g., overuse activities, abnormal posture) ²
• Structural factors (e.g., spondylosis, scoliosis, osteoarthritis) ²
• Systemic factors (e.g., hypothyroidism, vitamin D deficiency, iron deficiency) ²

Myofascial pain syndrome symptoms

In people with myofascial pain syndrome, sensitive areas of tight fibers form within a muscle or an adjoining muscle group, typically due to muscular injury or overuse. As a result, a tender, painful knot develops in the muscle. When pressure is placed on that area, called a tender point or trigger point, it leads to deep, aching muscle pain.

Signs and symptoms of myofascial pain syndrome may include:

• Deep, aching pain in a muscle
• Pain that persists or worsens
• A tender knot in a muscle
• Difficulty sleeping due to pain

Myofascial pain syndrome complications

Complications associated with myofascial pain syndrome may include:

• Sleep problems. Signs and symptoms of myofascial pain syndrome may make it difficult to sleep at night. You may have trouble finding a comfortable sleep position. And if you move at night, you might hit a trigger point and awaken.
• Fibromyalgia. Some research suggests that myofascial pain syndrome may develop into fibromyalgia in some people. Fibromyalgia is a chronic condition that features widespread pain. It’s believed that the brains of people with fibromyalgia become more sensitive to pain signals over time. Some doctors believe myofascial pain syndrome may play a role in starting this process.

Myofascial pain syndrome diagnosis

There aren’t any specific tests available that can definitively diagnose myofascial pain syndrome. Myofascial pain syndrome is diagnosed clinically. Myofascial pain syndrome often can be identified based on symptoms and a physical examination. During the physical exam, your doctor may apply gentle finger pressure to the painful area, feeling for tense areas. Certain ways of pressing on the trigger point can elicit specific responses, such as a muscle twitch. Because muscle pain can have many possible causes, additional tests may be recommended to rule out other diseases or conditions before making a diagnosis of myofascial pain syndrome.

Your doctor may recommend other tests and procedures to rule out other causes of muscle pain.

While there is no lab test to confirm a diagnosis of myofascial pain syndrome, your doctor may want to rule out other conditions that may have similar symptoms. Blood tests may include:

• Complete blood count
• Erythrocyte sedimentation rate
• Thyroid function tests
• Vitamin D levels

Several diagnostic tools are available to assess the presence of trigger points, but there is no agreement on the results ⁶.

• Ultrasound imaging: Ultrasound is often used to analyze the thickness of the muscle nodule and the sliding of the various tissue layers as well as the stiffness of the trigger point. Some studies analyzed the trigger points with ultrasound elastography by Doppler variance, inducing with an external vibration instrument. The vibrations brought to light the less elastic area, with focal and hypoechoic images, and specific patterns of blood waves to the muscle; they also highlighted latent and active triggers ⁷.
• Micro-dialysis: This method is used to measure inflammatory molecules in active trigger points, such as bradykinin, substance P, tumor necrosis factor alpha, CGRP, interleukin 1 beta, serotonin, interleukin 6 and 8, norepinephrine ⁷.
• Electromyography: To evaluate the electrical activity of active and latent trigger points, with an immobile patient or with the patient actively moving the muscles, respectively. Generally, the latent trigger points have a wider electromyographic spectrum with active movement, compared to the musculature in the absence of latent trigger points. The active trigger points show a more active electric spectrum than the musculature in the absence of active trigger points and with higher contracted fatigue indices ⁷.
• Infrared thermography: This tool is used to assess skin temperature and trigger points areas, but there seems to be no consensus on results ⁷.
• Magnetic resonance imaging: Even with this diagnostic mode, there is no consensus on the validity of the results obtained ⁷.

Myofascial pain syndrome treatment

Treatment for myofascial pain syndrome typically includes medications, trigger point injections or physical therapy. No conclusive evidence supports using one therapy over another, but exercise is considered an important component of any treatment program. Discuss your options and treatment preferences with your doctor. You may need to try more than one approach to find pain relief.

Medications

Medications used for myofascial pain syndrome include:

• Pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) may help some people. Or your doctor may prescribe stronger pain relievers. Some are available in patches that you place on your skin.
• Antidepressants. Many types of antidepressants can help relieve pain. For some people with myofascial pain syndrome, amitriptyline appears to reduce pain and improve sleep.
• Sedatives. Clonazepam (Klonopin) helps treat the anxiety and poor sleep that sometimes occur with myofascial pain syndrome. It must be used carefully because it can cause sleepiness and can be habit-forming.

Physical therapy

A physical therapist can devise a plan to help relieve your pain based on your signs and symptoms. Physical therapy to relieve myofascial pain syndrome may involve:

• Stretching. A physical therapist may lead you through gentle stretching exercises to help ease the pain in your affected muscle. If you feel trigger point pain when stretching, the physical therapist may spray a numbing solution on your skin.
• Posture training. Improving your posture can help relieve myofascial pain, particularly in your neck. Exercises that strengthen the muscles surrounding your trigger point will help you avoid overworking any one muscle.
• Massage. A physical therapist may massage your affected muscle to help relieve your pain. The physical therapist may use long hand strokes along your muscle or place pressure on specific areas of your muscle to release tension.
• Heat. Applying heat, via a hot pack or a hot shower, can help relieve muscle tension and reduce pain.
• Ultrasound. This type of therapy uses sound waves to increase blood circulation and warmth, which may promote healing in muscles affected by myofascial pain syndrome.

Needle procedures

Injecting a numbing agent or a steroid into a trigger point can help relieve pain. In some people, just the act of inserting the needle into the trigger point helps break up the muscle tension. Called dry needling, this technique involves inserting a needle into several places in and around the trigger point. Acupuncture also appears to be helpful for some people who have myofascial pain syndrome.

Lifestyle and home remedies

Take care of yourself if you have myofascial pain syndrome. Self-care measures to keep your body healthy may make it easier for you to concentrate on coping with your pain. Try to:

• Exercise. Gentle exercise can help you cope better with pain. When your pain allows, get moving. Ask your doctor or physical therapist about appropriate exercises.
• Relax. If you’re stressed and tense, you may experience more pain. Find ways to relax. Meditating, writing in a journal or talking with friends can all be helpful.
• Take care of your body. Eat a healthy diet full of fruits and vegetables. Get enough sleep so that you wake rested. Take care of your body so that you can put your energy toward coping with your pain.

Coping and support

Having a chronic pain condition such as myofascial pain syndrome can be frustrating. Treatment may be only moderately successful for you. It may help to talk to a counselor about the challenges you’re facing. Online or in-person support groups also can be helpful by connecting you with people who understand what you’re going through.

Myofascial pain syndrome diet

Eat a healthy diet full of fruits and vegetables. Get enough sleep so that you wake rested. Take care of your body so that you can put your energy toward coping with your pain.

Myofascial pain syndrome prognosis

The prognosis of myofascial pain syndrome depends on symptom duration. In acute myofascial pain syndrome, symptoms usually resolve spontaneously or after simple treatments (heat physical modalities, stretching exercise, trigger point needling or local anesthetic injection). On the other hand, chronic myofascial pain syndrome last much longer than acute form. In a previous study, the average duration of symptoms was 63 months; the range was between 6 and 180 months. Chronic myofascial pain syndrome may become recalcitrant if the underlying medical condition is not corrected.

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