Myofascial pain syndrome is a chronic condition associated with the formation of local seals in the muscle tissue in the form of trigger (pain) points. Pain is provoked by palpation of points, movement, lead to limitation of the motor range, muscle fatigue. Diagnosis is carried out by examination and palpation, according to indications, radiography, studies of somatic organs are carried out. Treatment includes a combination of pharmacotherapy (NSAIDs, muscle relaxants, blockades) and non-drug methods (reflexology, massage, exercise therapy, post-isometric relaxation).
General information
Myofascial pain syndrome (MBS) begins its history since 1834, when the phenomenon of painful cords localized in the muscles was first described. In the future, this symptom complex was associated with rheumatic muscle damage, inflammation of fibrous tissue, increased colloid viscosity in the muscles. According to these ideas, the disease was called “myofascitis”, “fibrositis”, “myogellosis”. The modern term “myofascial syndrome” was first used in 1956 in the fundamental work of American physicians J. G. Travell and D. G. Simons. Pathology is widespread, it is one of the most frequent causes of chronic pain. Middle-aged people are most susceptible to the disease. In men, myofascial pain syndrome is observed 2.5 times less often than in women.
Causes
The occurrence of MBS is associated with the presence of limited painful seals in the muscle — trigger points. A single point has a diameter of 1-3 mm, grouped points create a trigger zone with a diameter of up to 10 mm. The formation of trigger points occurs under the influence of overstrain and traumatization of muscles. Predisposing factors are:
- Diseases of the spine. Osteochondrosis, spondyloarthrosis, spinal injuries are a source of pain impulses that provoke an increase in the tone of the parotid muscles. An additional factor provoking MBS is the forced position resulting from pain, leading to muscle overstrain.
- Anomalies of the musculoskeletal system. Curvature of the spine, shortening of the lower limb, asymmetry of the pelvis, flat feet lead to uneven load on the muscles of the body. Trigger points appear in congested areas, and myofascial syndrome occurs.
- Forced pose. Working in a fixed position, immobilization of the limbs, the monotonous position of the bed patient lead to static muscle overload. In conditions of constant overload, the MBS is formed.
- Stereotypical movements. Repetitive monotonous motor acts occur with the contraction of certain muscles. Overload of the latter leads to the formation of seals.
- The load on untrained muscles. As a result, there is microtraumatization, muscle overstrain. Repeated inadequate loads cause myofascial syndrome.
- Bruise. The direct traumatic effect on the muscle causes a violation of the structure of individual myofibrils. The consequence is dysfunction of some muscle fibers and compensatory hyperfunction of others. The latter leads to overload, provoking MBS.
- Somatic diseases. The internal organs are closely related to the corresponding muscle groups. Somatogenic pathological impulses cause local tonic contraction in skeletal muscles, the prolonged existence of which leads to the formation of a trigger point.
- Emotional overstrain. Repeated or chronic stress, anxiety, and other psychoemotional reactions are accompanied by increased muscle tension. Emerging muscle-tonic conditions that persist after an emotional outburst can provoke myofascial pain syndrome.
Pathogenesis
The result of overloads and micro-injuries of muscle tissue is a microscopically detectable violation of the permeability of the myocyte membrane, the release of calcium ions, damage to proteins that form the skeleton of the cell. Excess calcium increases the contractility of myofibrils. Prolonged muscle contraction is accompanied by an increase in intramuscular pressure, which causes deterioration of microcirculation. Muscle contraction occurs with the expenditure of ATP, which requires a period of relaxation to replenish its reserves. In conditions of prolonged muscle load, compensatory mechanisms are triggered: ATP is replenished at the expense of available reserves, produced by anaerobic glycolysis. The load exceeding the capabilities of the muscle (including due to lack of training) leads to a breakdown of compensatory mechanisms — a steady contraction with the formation of a trigger point. The resulting pain syndrome supports the spastic state of muscle fibers. A vicious circle is formed: pain — muscle tension — pain. The spread of pain impulses along the nerve trunks causes the phenomenon of distant pain.
Classification
In clinical practice, it is important to distinguish between active and latent trigger points. Active points are a source of acute pain during movement and palpation, they can go into a latent state. Latent points are palpationally painful, activated by the influence of provoking factors. Taking into account the state of trigger points , there are three main forms of MBS:
- Acute — trigger points are active, cause a constant pain syndrome, which increases with movements.
- Subacute — pain accompanies motor acts, disappears at rest.
- Chronic — trigger points are in a latent state, there is some discomfort in the corresponding area.
Understanding the etiology of the disease is necessary for an adequate choice of therapeutic tactics. Accordingly, in practical neurology, the classification of MBS is used according to the etiological principle, which includes two main groups:
- Primary — occur due to muscle damage (injury, overload).
- Secondary — formed against the background of diseases of the joints, spine, somatic organs.
Symptoms
The disease is characterized by the gradual development of pain symptoms against the background of constant overload of the affected muscles. Myofascial pain is felt by the patient as deep, moderately intense. At first, pain occurs during muscular exertion (movement, maintaining a certain posture), then it takes on a permanent character, remains at rest, increases with the work of the muscles concerned. Remote pain is often observed — painful sensations are localized in the parts of the body associated with the affected area. When the shoulder girdle is affected, distant pain is sometimes detected in the hand, lumbar muscles — in the leg. MBS in the muscles of the trunk can simulate cardiac, epigastric, renal, hepatic pain. In some cases, the removed pain has the character of paresthesia.
Myofascial syndrome occurs with a decrease in the motor range, increased fatigue of the involved muscle. A number of patients consider such symptoms as muscle weakness. Unlike true paresis, pseudo-weakness is not accompanied by atrophic muscle changes. MBS is most often observed in the muscles of the neck, upper arms, and lumbar region. With cervical localization, the disease proceeds with headache, dizziness, tinnitus is possible. Secondary MBS often remains unnoticed behind the symptoms of the main pathology: arthralgia, vertebrogenic cervicalgia, lumboishialgia, gastritis pain.
Complications
Myofascial syndrome is not life-threatening for the patient, but it can significantly reduce his ability to work. Chronic pain physically exhausts the patient, adversely affects the psycho-emotional sphere, leads to sleep disorders. Insomnia aggravates the state of fatigue, negatively affects performance. The quality of life decreases, it becomes difficult for the patient to perform daily professional, household duties.
Diagnostics
The detection of MBS is carried out clinically, additional studies are necessary to determine the secondary nature of the disease, to establish causal pathology. Diagnostic difficulties are associated with low awareness of therapists, neurologists, vertebrologists, orthopedists regarding MBS. The main stages of diagnosis:
- General inspection. It makes it possible to identify skeletal anomalies, curvature of the spine, posture disorders. Palpation makes it possible to determine the myofascial nature of pain — its intensification / occurrence when probing the affected muscle. At the same time, compacted trigger points are palpated, pressing on which provokes the patient’s flinching — a symptom of a “jump”. Pressure on the point for several seconds causes the appearance of distant and reflected pain.
- Neurological examination. Primary myofascial pain syndrome proceeds without neurological changes: sensitivity, muscle strength, reflex sphere are preserved. Neurological symptoms indicate the presence of another disease, does not exclude concomitant MBS.
- X-ray examination. Radiography of the spine can reveal curvature, osteochondrosis, spondyloarthrosis, radiography of joints — arthrosis, signs of arthritis.
- Examination of somatic organs. It is necessary to exclude/identify a somatogenic variant of MBS. Taking into account the symptoms, electrocardiography, chest x-ray, gastroscopy, consultations of narrow specialists are prescribed.
Differential diagnosis is carried out with fibromyalgia, radicular syndrome, myositis. Fibromyalgia is characterized by widespread pain throughout the body, combined with paresthesia. Root syndrome is characterized by hypesthesia, decreased muscle strength, hyporeflexia, trophic changes in the innervation zone of the affected root. With myositis, the pain covers the muscle diffusely, has a nagging character.
Treatment
MBS therapy is carried out by a neurologist, an algologist, a chiropractor with the participation of a masseur, a reflexologist, a physical therapy doctor. Treatment is aimed at relieving pain, transferring active pain points to a latent state. With secondary myofascial syndrome, therapy of causal pathology is necessarily carried out. Pharmacotherapy is necessary in the acute period, it allows you to eliminate the pain syndrome. It is carried out against the background of a gentle motor mode using:
- Nonsteroidal anti-inflammatory drugs (ketoprofen, diclofenac sodium). The drugs have an anti-inflammatory, analgesic effect.
- Muscle relaxants (tolperizone, baclofen). Muscle relaxants slow down the processes of muscle arousal, relieve tonic tension, which promotes relaxation of spasmodic muscle areas.
- Medical blockades. Corticosteroids, NSAIDs, and local anesthetics are injected into trigger points. Blockades have a pronounced analgesic effect.
- Antidepressants (fluoxetine, amitriptyline). They are used in the combined treatment of long-term MBS. Eliminate the symptoms of depression, have analgesic effect.
Non-drug methods complement pharmacotherapy, are necessary to achieve stable remission, prevention of subsequent exacerbations. These include:
- Reflexology. Acupuncture, acupressure are carried out in order to relieve pain. Piercing the pain point relieves the spastic state of the trigger area. Acupressure has a similar effect.
- Massage. Initially, myofascial massage is indicated, aimed at relaxing the affected muscle. During the rehabilitation period, classical massage is performed to improve nutrition and strengthen muscle tissue.
- Manual therapy. Methods of post-isometric relaxation (PIT), myofascial releasing are used. The procedures are carried out in courses, have a pronounced relaxing effect.
- Physical therapy. Classes begin after the pain subsides. The exercises are aimed at training the muscle, increasing its resistance to stress. A visit to the pool is recommended.
Prognosis and prevention
Myofascial pain syndrome is a chronic disease. In most patients, complex therapy makes it possible to achieve a latent state of pain points. The subsequent retention of latency is achieved by eliminating provoking factors, regular physical therapy sessions, periodic massage courses. Primary prevention of MBS begins with childhood, provides for the formation of correct posture, habituation to a healthy lifestyle, sports, timely correction of musculoskeletal abnormalities. Secondary prevention includes getting rid of excess weight, proper organization of professional activities, daily physical therapy classes, compliance with the daily routine.