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    9

    Regional myofascial pain: diagnosis

    and management

    Mike Cummings*

    Medical Director

    5 Lime Terrace, London W7 3HE, UK

    Peter BaldryEmeritus Physician

    Millstream House, Old Rectory Green, Fladbury, Pershore, Worstershire WR10 2QX, UK

    This chapter defines and describes the condition that is known by the term myofascial triggerpoint pain syndrome. An outline is given of the current state of knowledge of the pathophysi-ology 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 termsand the reliability of the clinical diagnosis is discussed.

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

    Key words: myofascial pain; myofascial trigger point; needling therapy; physical therapy.

    INTRODUCTION

    Definitions

    The term regional myofascial pain is used clinically in at least two distinct ways. First it isused synonymously with the terms myofascial pain syndrome and myofascial triggerpoint pain syndrome to describe the specific clinical manifestation of a rather ubiquitousform of muscle pain that is derived from myofascial trigger points and which can be as-sociated with a number of other sensory, motor and autonomic phenomena. Secondly,

    * Corresponding author. Tel.: 44 2085799607.

    E-mail address: mike.cummings@btinternet.com (M. Cummings).

    1521-6942/$ - see front matter 2006 Elsevier Ltd. All rights reserved.

    Best Practice & Research Clinical RheumatologyVol. 21, No. 2, pp. 367e387, 2007

    doi:10.1016/j.berh.2006.12.006

    available online at http://www.sciencedirect.com

    mailto:mike.cummings@btinternet.comhttp://www.sciencedirect.com/http://www.sciencedirect.com/mailto:mike.cummings@btinternet.com
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    the term regional myofascial pain is used by clinicians to refer to soft tissue pain in gen-eral, particularly in circumstances where a more specific diagnostic category, such astendinopathy or enthesopathy, is not apparent. This chapter is concerned with themore specific use of the term, i.e. with the myofascial trigger point pain syndrome.

    MYOFASCIAL TRIGGER POINT PAIN SYNDROME

    Former misconceptions concerning the cause of this syndromes pain

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

    Guillaume de Baillou (1538e1616), when Dean of the medical faculty at the Univer-sity of Paris, introduced the term muscular rheumatism for it. At the beginning of the19th century two British physicians Balfour1 and Scudamore2 expressed the opinion

    that the pain arises as a result of inflammation developing in the fibrous connectivetissue in skeletal muscle. A view that continued to prevail in Britain throughout thatcentury and one that was to lead Sir William Gowers, in 1904, during the course ofa lecture, given at what was then called the National Hospital for the Paralysed andEpileptic, London, to conclude that as muscular rheumatism develops as a result ofinflammation of the fibrous tissue in muscle we may conveniently follow the analogyof cellulitis and term it fibrositis.3 This name was then widely employed for someyears but once it became evident that there were no convincing histological changesto support the hypothesis the term was eventually abandoned and replaced by thenon-committal one of myalgia.

    The evolution of present day concepts

    It was the French physician Francois Valleix who, in 18414, was the first to observethat the pain in this disorder emanates from well defined focal points of tendernessand which were thus called by him les points douloureux.

    The next to support this view was the German physician Cornelius who, in 19035,called them nervenpunkte and went so far as to conclude that the nerve endings atthese sites are in a state of hyperactivity because of the effect on them of such factorsas altered weather conditions, physical exertion and emotional upsets.

    It may, therefore, be seen that by the beginning of the 20th century some of themore enlightened physicians had come to appreciate that what hitherto had beenvariously called either muscular rheumatism or fibrositis occurs as a result of thedevelopment of increased activity in nerve endings at specific points of tenderness.A view endorsed by Sir William Osler who, in the 1909 edition of his textbook ThePrinciples and Practice of Medicine6, when discussing the disorder, stated it is by nomeans certain that the muscular tissues are the seat of the disease. Many writers claim,perhaps correctly, that it is a neuralgia of the sensory nerves of the muscles.

    It was not, however, until the 1930s that objective clinical support for this viewbegan to appear. One of the first clinicians to provide this was Hunter, a physician

    in Canada who, in 1933, described cases in which abdominal pain emanated frompoints of tenderness in anterior abdominal wall muscles.7

    Then in 1936, Edeiken & Wolferth, physicians at the University of PennsylvaniaMedical School, reported that among patients with coronary thrombosis under their

    368 M. Cummings and P. Baldry

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    care some had developed shoulder pain that could be reproduced by applying firmpressure to points of exquisite tenderness in muscles around the scapula.8

    The physician, however, who during the 1930s made the greatest contribution toour knowledge concerning the pathophysiology, diagnosis and treatment of what,currently, is called the myofascial trigger point pain syndrome was John Kellgren duringthe time he was working as a research assistant to Sir Thomas Lewis, the director of

    Clinical Research at University College Hospital, London.Lewis and Kellgren first carried out an experiment on healthy volunteer medical

    students. In this they injected pain-evoking hypertonic saline into muscles and ob-served that rather than the pain being experienced at the injection site it was feltsome distance away at what they called the zone of pain referral.

    Kellgren then turned his attention to patients with muscle pain.9 With respect tothese he said:

    A number of cases of fibrositis or myalgia have been investigated. Thedistribution of pain from normal muscles guided me to the muscles from which

    spontaneous pain may have arisen. Such muscles always presented tender spotson palpation and pressure on these spots reproduced the patients pain.

    He then went on to confirm that the pain arose as a result of nerve hyperactivity atthese tender points by showing that it could be alleviated, often for several days, byinjecting a local anaesthetic into the tissues at these tender sites.

    Janet Travells pivotal contributions to the subject

    During World War II, Kellgren served in the Royal Army Medical Corp. Following this

    he became Professor of Rheumatology at Manchester University, but his former studyof muscle pain was not renewed. Fortunately, however, during the 1940s, a youngAmerican physician, Janet Travell, decided to take up the study of the subject wherehe had left off. She did so having read how Kellgren had shown that widespread dullaching pain in muscle emanates from what an American orthopaedic surgeon had aptlycalled trigger points.

    Travells study of the subject led her to realise that pain in the disorder that hithertohad variously been called rheumatism, fibrositis, myalgia and a host of other synonymsarises not only from skeletal muscle itself but also from its fibrous connective tissue.She therefore, during the 1950s, in view of the Greek for muscle being myos, called the

    disorder the myofascial trigger point pain syndrome.Furthermore, she soon recognised that each muscle in the body has its own spe-cific pattern of myofascial trigger point pain referral and over the years, together withher colleague David Simons, published diagrams of these in two prestigiouspublications.10,11

    Prevalence of myofascial trigger points

    Myofascial trigger points (MTrPs) are recognised by many clinicians to be one of themost common causes of pain and dysfunction in the musculoskeletal system. They

    have been detected in the shoulder girdle musculature in nearly half of a group ofyoung, asymptomatic military personnel12 and with a similar prevalence in the masti-catory muscles of a group of unselected student nurses.13 Active MTrPs, those causingspontaneous pain, have been diagnosed as the primary source of pain in 74% of

    Regional myofacial pain 369

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    96 patients with musculoskeletal pain seen by a neurologist in a community pain medicalcentre14 and in 85% of 283 consecutive admissions to a comprehensive pain centre.15

    Of 164 patients referred to a dental clinic for chronic head and nec k pain, 55% were

    found to have active myofascial trigger points as the cause of their pain16, as were 30% ofthose presenting with pain to a university primary care internal medicine group practicefrom a consecutive series of 172 patients.17 A study of musculoskeletal disorders in vil-lagers from rural Thailand has demonstrated myofascial pain as the primary diagnosis in36% of 431 subjects with pain during the previous 7 days.18

    Essential clinical features of MTrPs

    The essential clinical features of MTrPs are:

    A tender point within a tau