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Regional myofascial pain: diagnosis and management

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This chapter defines and describes the condition that is known by the term myofascial trigger point pain syndrome. An outline is given of the current state of knowledge of the pathophysiology of myofascial trigger points, including the latest details from needle microdialysis in near real-time. The clinical features of this pain syndrome are summarised in general terms and the reliability of the clinical diagnosis is discussed.

The clinical evidence for and against the common therapeutic interventions used in the management of myofascial pain is reviewed in detail and some tentative conclusions are reached with respect to needling therapies.

Introduction

The term ‘regional myofascial pain’ is used clinically in at least two distinct ways. First it is used synonymously with the terms ‘myofascial pain syndrome’ and ‘myofascial trigger point pain syndrome’ to describe the specific clinical manifestation of a rather ubiquitous form of muscle pain that is derived from myofascial trigger points and which can be associated with a number of other sensory, motor and autonomic phenomena. Secondly, the term ‘regional myofascial pain’ is used by clinicians to refer to soft tissue pain in general, particularly in circumstances where a more specific diagnostic category, such as tendinopathy or enthesopathy, is not apparent. This chapter is concerned with the more specific use of the term, i.e. with the myofascial trigger point pain syndrome.

Section snippets

Former misconceptions concerning the cause of this syndrome's pain

The cause for pain developing in the muscles of a seemingly otherwise fit person for centuries remained an enigma and, as a consequence of this there was for long no general agreement as to what to call the underlying disorder.

Guillaume de Baillou (1538–1616), when Dean of the medical faculty at the University of Paris, introduced the term muscular rheumatism for it. At the beginning of the 19th century two British physicians Balfour1 and Scudamore2 expressed the opinion that the pain arises as

Pain

This is by far the most common presenting complaint. Typically the pain is described as deep, aching and poorly localised. It is usually restricted to one quadrant of the body, although complex patterns from multiple MTrPs may give a wider distribution. It is important to determine the precise nature and pattern of the pain, as would be done when taking a standard medical history. Paraesthesia is not uncommon in association with the pain and often confirms in the patient's mind the false

Needling therapies

Needling of MTrPs is one of the most common treatments for myofascial pain in global terms. This is because of the use of acupuncture in the East. Acupuncture is also popular in the West, but not on such a scale, and is sometimes referred to as dry needling. Wet needling, or injection therapy, is perhaps more commonly applied in the West, with a variety of injected substances being used, ranging from the relatively innocuous physiological saline to the toxin derived from Clostridium botulinum.

Summary

The myofascial trigger point pain syndrome is a prevalent cause of regional pain and dysfunction. Good clinical skills in muscle palpation are needed to reliably identify the myofascial trigger points (MTrPs) from which the pain emanates. The common manifestations of this syndrome can be identified and treated with limited training, but the more complex and esoteric presentations require detailed knowledge of functional anatomy and factors that perpetuate the condition.

The pathophysiology of

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