Myofascial Pain Syndromes and Trigger Point Injection Therapy

Dr John Whiteside MBBS, BSc

Perpetuating Factors

Introduction

In order to understand perpetuating factors you need to understand the global nature of myofascial trigger points. Skeletal muscle is the largest single organ of the human body. It accounts for more than 40% of the total body mass. As we progress through life taut bands develop within skeletal muscle as a normal part of the aging process. Along each taut band is a more sensitive region that is designated as a trigger point. Trigger points can exist in different stages of sensitivity. If they are very sensitive they are active. If they are not very sensitive they are latent.

Active myofascial trigger point

• Refers a pattern of pain at rest or at motion.
• Usually refers pain on direct compression.
• Mediates a local twitch response.
• Tender to palpation.
• Prevents full lengthening of muscle.Weakens the muscle.

Latent myofascial trigger point.

• Clinically quiescent with respect to spontaneous pain.
• May refer pain.
• Tender to palpation.
• Prevents full lengthening of muscle.
• Weakens the muscle.
• They accumulate from all of the vast number of physical things that happen to us.
• If all our trigger points remain latent we gradually become stiffer and weaker.
• If some become active we experience myofascial pain.

Prevalence

In general practice it is my experience that approximately 70% of all pain is primary Myofascial in origin. The remaining 30% has another cause but is normally associated with a secondary myofascial pain syndrome.The ratio will depend upon two things.

• The group of patients being examined
• The experience of the examiner.

Sports Injuries

Almost all are due to taut bands.
Muscle tearing is sometimes present as an associated event.
The associated muscle tear is self limiting.
Treatment should be directed at the taut band not at the tear.

Treatment of all sports injuries.

• Heat ASAP.
• Never ice.
• Stretch.
• Ischaemic pressure / massage. 
• Mobilization.

The Pain Management Industry

The pain management industry internationally has been directing itself at "part of" "30 % of" the problem. This is why it is called a pain management industry. " We cannot remove your pain but we can teach you how to manage it."

It is my opinion that as myofascial therapy becomes a routine part of the day to day work of health care professionals then we will become a pain treatment industry.

Reasons why myofascial therapy fails.

The interdisciplinary myofascial team is not sufficiently skilled.
Treatment is being directed at a secondary myofascial pain syndrome.
Perpetuating factors are present.
Perpetuating Factors: Any physical, chemical or psychological factors that act to increase trigger point activity in that individual, at that particular time.

The following notes provide brief practical information about some of the perpetuating factors.

The detail of this subject is in chapter 4 of vol.1. of the Trigger Point Manual.

Leg Length Discrepancy (LLD)

The problem of leg length discrepancy (LLD) and the method of assessment is covered in detail in chapter 4 of vol. 1 and chapter 4 of vol. 2 of the Trigger Point Manual.

Trigger points in the quadratus lumborum muscle must be released before an accurate measurement of LLD can be made.

The following is the protocol used at my clinic.
At the initial assessment
Assess LLD
Assess quadratus lumborum bilaterally for trigger points.
If the quadratus lumborum muscles are not shortened and if no confident diagnosis of LLD can be made, do not proceed to a trial of correction.
If a provisional diagnosis of LLD is made, with or without tight quadratus lumborum muscles, reschedule the patient for a separate session to begin a trial of correction.

Release quadratus lumborum using procaine injection, spray & stretch, & heat. Re-assess the LLD. Proceed to a trial of correction. If a LLD can be confidently diagnosed an initial trial correction can be made in the office be cutting a heel raise from sheets of ethyl vinyl acetate (EVA). EVA can be purchased in different thickness from 1mm upward. Using scissors, Stanley knife, and glue the heel raise can be made to the thickness required by sticking appropriate layers together.

To assess the thickness required I use test boards made to exact thickness. I have the patient stand on a large board and then put smaller test boards under the foot. These are made up to thickness of 1mm, 2mm (x 2), 5mm and 1cm.

With patience and trial and error an estimate can be made of the LLD "theoretically" to an accuracy of 1 mm. In practice this is quite unrealistic, but the method produces a starting point and the EVA heel inserts can be thickened or diminished by 1mm steps as required. This simple method is valuable in simple cases. If the LLD is large or if correction by heel raise alone is not producing the desired result then a more rigorous approach is needed. Review by podiatrist who makes up an orthotic to correct the bio-mechanical factors at the ankle and foot level without adding a heel raise.

Procaine injections to trigger points in quadratus lumborum muscles bilaterally, followed by spray and stretch and heat. Immediately following the procaine injections the patient proceeds to the X-ray department. There an AP pelvic X-ray weight bearing is taken. This is done with the orthotics in situ.

The difference in the height of the femoral heads now provides an accurate measurement of the leg length difference. The patient is then reviewed as soon as possible by the podiatrist with the data from the X-rays. The orthotics are now adjusted with the appropriate heel raise. Follow-up reviews by the podiatrist and medical practitioner allow for fine adjustment of the orthotics.

Small hemipelvis

Assess patient in seated position. Release quadratus lumborum if possible before assessment. Advise patient on a trial of butt lift using a folded towel or a magazine.

Nutritional inadequacies

The prescription of nutritional supplements by the practitioner will depend upon three things. How much importance the practitioner places on this form of therapy.

There is a commonly held belief that by eating the Standard Australian Diet (SAD) sufficient nutrients are obtained to do all things in all circumstances. I strongly recommend the course run by the Australasian College of Nutritional and Environmental Medicine (ACNEM). This provides the supportive evidence for the prescription of nutritional Supplements. Details can be obtained by telephoning (03) 9589 6088

The patient's attitude to taking supplements and the cost of the program are influential factors.

Basic Vitamin Program

The rationale behind prescribing nutritional supplements is primarily to improve the efficiency of the body to neutralize free radicals. Damage by free radicals is thought to impair the capacity of the body to repair itself.

Anti-oxidants are substances that counter the oxidative process and formation of the potentially highly toxic free radicals.The main anti-oxidants are C,E,Selenium, Zinc and A.Listed below is a basic program that offers a good high dose anti-oxidant support at a cost of $7.00 to $10.00 per week.Basic Program $7.00 to $10.00 per week.

High dose multi B & multi mineral ( this will contain vitamin A)1 daily

Vitamin C 1gm daily, Vitamin E 500 IU daily, Zinc 20-30 mg of elemental zinc daily

Selenium 200 mcg daily. Sodium selenite drops.

Selenite B tablets -Vita Glow. Formula 33 Note: Increase vitamin C supplement according to the level of physical, chemical, and emotional stress. Patients should take 1g of C before & after sessions of injection therapy and increase to 1g four times daily for several days until post treatment soreness is gone. Athletes normally require 500 IU twice daily of vitamin E to assist tissue repair after training and decrease post training muscle soreness.

A higher dose multi B is often needed in the early stages of treatment. The brand name multi B preparations are balanced. Use thiamine as the parameter looking for 100-200mg daily in divided doses. This adds another $1.00 - $4.00 per day.

Magnesium 20 to 200mg of elemental magnesium per day (an extra $1-$15 per week)

Powerful muscle relaxant. Now used intravenously in many coronary care units.

Indicated where skeletal muscle is generally tight, exhibits tics or fibrillations, or cramps easily, or where cardiac palpitations are present. Excellent for athletes before & after intensive training sessions or competitions.

Metabolic & endocrine inadequacies

This topic is well covered in chapter 4 vol.1.

The most important perpetuating factor in this category is the pathology caused by oestrogen /progesterone imbalance in women.

I strongly recommend the book Natural Progesterone by John R Lee MD. This makes the treatment of this problem so simple and provides an efficient, natural way of removing this very common and powerful perpetuating factor. Details on the availability of natural progesterone cream are available by telephoning Michael Buckley, Pharmacist on (08) 9271 1956. Copies of the book by John R Lee MD can also be purchased from Michael.

Psychological factors

Stress is the most important perpetuating factor. "Neuropeptides such as endorphins, are released during different emotional states. The neuropeptides bind to opiate receptors which have been found to be present on the surface of virtually every cell in the body, including the immune and endocrine system. High levels of endorphins promote well being and improve immunity." Ref: Healing and the Mind, B Moyers, Doubleday 1993.

Infections: These act as powerful perpetuating factors.. I ask the patients not to come in for injection therapy if they have an active upper respiratory tract infection or gastroenteritis.

Allergies: Both environmental and nutritional allergies can act as perpetuating factor. A good history is important to diagnose environmental factors. Elimination and challenge diet is the only reliable way to diagnose food intolerance.

Elimination Diet

Foods Allowed: Rice, Wholegrain or white. All fruit,Vegetables except uncooked tomato potato. Fish: Any fish, fresh / frozen cooked, tinned tuna, salmon, sardines prawns, lobster, crabs. Eggs,Any Herbs & Spices, Herbal Teas,Nuts- Except peanuts,Olive Oil for cooking Honey,Soy Milk- I recommend the brands Soy King or Australia's Own Malt free. Distilled Water

Foods Excluded: Dairy, Gluten- Grains, bread, cereals, pasta.Uncooked Tomato, cooked or tinned is OK.Potato.Meat-Including chicken,Tea & Coffee,Alcohol,Peanuts,Junk foods / Confectionery / Refined Sugar, Tap Water,Yeast.

Sleep disorders

Active myofascial trigger points produce sleep disturbance. Sleep disturbance increases trigger point activity and lowers general health. The problem will not resolve until the pain is removed. I prefer melatonin as an hypnotic. More aggressive pharmaceutical medications may be needed in some cases. Melatonin is an S4 item and can be obtained from Richard Stenlake, Chemist, by telephone (02)

9387 3205. The dose for different ages is noted below.

Age Dose of Melatonin

40-50 0.5 - 1mg

45-55 1 - 2 mg

55-65 2 - 2.5 mg

65-75 2.5 - 5 mg

75 plus 3.5 - 5 mg

Melatonin is a natural hormone that is produced by the pineal gland in the brain and is responsible for the sleep wake cycle. Under natural lighting conditions the pineal gland begins the production of melatonin when it becomes dark and when it becomes light the melatonin production ceases. Melatonin is produced by the pineal gland in large quantities during youth and this explains why teenagers can sleep for long periods of time. As we get older the production of melatonin decreases and it becomes more difficult to complete a full nights sleep without waking frequently in the second half of the night. People in their 60's and older often state that they only need 5 to 6 hours sleep per night. They need more sleep than this but are unable to get it because their melatonin levels are too low. It is possible to restore sleep to its natural youthful levels by taking a melatonin supplement. The dose for your age needs to be calculated. Once this has been done a prescription is written and this is then sent to a pharmacist in Sydney (details are listed below). The pharmacist will keep the prescription including the repeats and you can telephone for further supplies as needed. To get started taking melatonin you need to be advised of the correct dose for your age. Make contact with the pharmacist in Sydney and check the cost of the prescription plus freight. Make sure you sign and date the prescription and then mail it to the chemist in Sydney. There are considerable individual differences with regard to the tolerance for melatonin. If you find that the dose you are taking leaves you to sleepy in the first few hours of the following day then a lower dose may be required. If you are waking early in the morning with the dose you are prescribed it is quite safe to increase the dose in a trial and error basis to find the dose that suits you best. Any questions that you have can be directed to me at the clinic.

Richard Stenlake, Chemist, 169 Oxford Street, Bondi Junction, NSW. 2022 .Tel 02 9387 3205, fax 02 9389 3821

Dental perpetuating factorsThe medical practitioner's role is to physically treat the muscles of mastication using the procaine injection technique. The dentist's role is threefold. Occlusal adjustment, preferably with an electromyograph. Use of an occlusal splint where necessary. In my opinion splint therapy should not be the treatment of first choice and provided only for a short time while the muscles of mastication are injected. Removal of mercury amalgams. Mercury is a toxic substance. Mercury amalgams in a solution of saliva produce an electric current. This is even more prominent when a gold filling is also present. This electrical activity increases the sensitivity of the trigger points in the muscles of mastication.

On Monday almost every patient you see with pain will have myofascial trigger points.

Finding the clinical material is easy. What do you do with the jungle of information called perpetuating factors?

Myofascial Pain Syndromes:

Simple-Tend to begin treatment immediately and see what happens. Sports injuries.

Complex- Tend to examine perpetuating factors, first and prepare a good therapeutic environment before beginning physical therapy. Workers Compensation. Motor Vehicle Accidents. Migraines. Chronic Pain & illness.

Simple problems: Require 30 minutes , Inject/stretch/heat and home stretches. Most will fully recover within 1 to 3 sessions. If not it may be necessary to look for perpetuating factors.

Difficult problems: The first 5 minutes of the history tells the story. Mainly primary myofascial pain within a healthy person. Begin treatment immediately.

Myofascial pain with high probability of perpetuating factors- Careful history and examination looking for perpetuating factors.