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I believe that myofascial pain is one of the most overlooked and ignored sources of acute and chronic pain, and at the same time, constitutes one of the most common causes of musculoskeletal pain. Myofascial pain is characterized by the presence of myofascial trigger points (TrPs). The activation of a TrP may result from different factors, for example, acute or sustained overload, repetitive muscle overuse, stress or other medical causes. In fact, muscle pain is commonly a primary dysfunction and is not necessarily secondary to other diagnoses. For instance, TrPs may occur in the
absence of other medical issues; however, TrPs can also be comorbid with underlying medical conditions, for example, knee osteoarthritis or irritable bowel syndrome, and also injuries such as whiplash. Although different definitions of TrPs are currently used among different disciplines, the most commonly accepted definition maintains that a TrP is a hyperirritable spot within a taut band of a skeletal muscle that is painful on compression, stretch and/ or contraction of the tissue which usually responds with a referred pain and/or sensation. As well as referred pain, other associated symptoms may also be present: for example, numbness, coldness, stiffness, weakness, fatigue, motor dysfunction, dizziness and autonomic responses. If any
*Department of Physical Therapy, Occupational Therapy, Rehabilitation & Physical Medicine, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcn, Madrid, Spain; cesar.fernandez@urjc.es
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One of the big concerns for myofascial pain is its correct diagnosis. Competent TrP diagnosis requires adequate manual skills, training and clinical practice to develop a high degree of reliability in the examination. There are several signs and symptoms that may be used for TrP diagnosis:
Presence of a palpable taut band in a
taut band;
Palpable local twitch response on snap-
stretching;
Jump sign.
In addition, there are several factors that may contribute to a correct diagnosis: proper identification of taut bands, experience of the examiner, proper positioning of the patient or the assessor, proper palpation technique, the amount of manual force exerted on the palpated point and the duration of force applied, and so on. Therefore, proper training of clinicians is clearly needed. Nevertheless, I should comment that recent studies have demonstrated the ability to visualize TrP taut bands by using magnetic resonance elastography and sonographic elastography, although future studies are needed to optimize these procedures for the clinical setting.
Are there many treatment options available for patients with myofascial pain and what are the major
Q
There are several intervention modalities, particularly nonpharmacological, aimed at eliminating myofascial TrPs: ultrasound, thermotherapy, laser therapy, electrotherapy, magnetic therapy, manual therapies and dry needling. Among these interventions, manual therapies and dry needling are the basic treatment options. There is scientific evidence supporting the use of most of these interventions; however, high-quality randomized trials are needed. In clinical practice, their effectiveness will depend on the patients features and the muscle, since in some cases, dry needling would be much more effective than manual therapies, whereas in others, it would be the opposite. It is important to analyze the clinical picture of the patient and the potential role of each intervention. In addition, it is important that clinicians not only treat the TrP, but also the perpetuating factors. There are no serious complications associated with TrP treatment techniques. In some cases, patients may feel a slight worsening of their symptoms (if the manual therapy was applied too strongly), but it should disappear within a few hours. Dry needling is also a relatively safe approach, if properly applied. In fact, safety guidelines in different countries are being developed for this purpose. Nevertheless, it is important to recognize that dry needling can induce some muscle soreness for 2448 h after treatment.
How important is it to obtain the correct balance of both pharmacological and nonpharmacological approaches to this condition?
Q
The main therapeutic arsenal is represented by nonpharmacological approaches; nevertheless, some patients can exhibit nutritional discrepancies related to the presence of myofascial pain, or other underlying medical conditions that are perpetuating muscle pain. In such cases, it is important that clinicians combine both pharmacological and nonpharmacological approaches. Finally, injections of local anesthetics or other substances may also be used for the management of myofascial pain.
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The topic of myofascial pain and fibromyalgia syndrome (FMS) is currently under debate, and the answer is not easy. I believe that myofascial pain and FMS are clearly two different clinical entities, but that they interact. Myofascial pain is characterized by TrPs, and FMS is characterized by widespread pain, sleep disturbances, fatigue, tenderness, cognitive difficulties and other somatic complaints. It is clear that a patient with myofascial pain and TrPs should not be diagnosed as a patient with FMS. However, a patient with FMS can also exhibit TrPs, and may therefore be suffering from myofascial pain. In recent years, we have published some studies demonstrating the presence of active TrPs in women with FMS, and that the referred pain elicited by TrPs was able to reproduce pain symptoms in FMS. However, the presence of TrPs in FMS does not mean that myofascial pain causes FMS; this would be completely wrong. In my clinical practice, I believe that patients with FMS should receive a multimodal approach including pharmacological, psychological and physical interventions. Obviously, patients with FMS exhibiting TrPs that appear to be clinically relevant for their symptoms should have such TrPs properly treated. If not addressed, the management of these patients would not be effective.
Can you describe any current research you are undertaking in the study of myofascial pain management?
Q
some randomized controlled trials looking at the effectiveness of including TrP treatment for patients with, for example, plantar heel pain or shoulder pain. In recent years, there has been an increasing interest in TrP pain. Several clinical and neurophysiological studies have been conducted and extremely important topics have been clarified. For instance, it is possible to visualize TrP with some imaging techniques, which is extremely helpful for research. Several clinical studies have demonstrated the relevance of TrP-referred pain in several chronic pain conditions. Furthermore, research from my friends Drs Hong-You Ge and Lars Arendt-Nielsen in Denmark has demonstrated the importance of latent TrPs. I believe that, in the words of the late Dr Simons: the TrP virus has emerged in the last years.
Can you identify any areas in the field of myofascial pain management that require further research?
Q
I think that current research should focus on different directions: To determine the effectiveness of TrP therapy in several chronic pain conditions;
To clarify the clinical and research diag-
My research group has demonstrated the relevance of TrPs in several chronic pain conditions: for example, tension-type headache, migraine, shoulder pain, lateral epicondylalgia, neck pain, whiplash and breast cancer. We have also conducted
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Roshaine Gunawardana, Editor, Pain Management r.gunawardana@futuremedicine.com
www.futuremedicine.com
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