Myofascial Pain Syndrome

Managing Myofascial Pain

The primary treatment for myofascial pain involves releasing the trigger points, which can be accomplished by stretching the affected muscle. One treatment, the “spray and stretch technique” involves stretching the muscle in conjunction with topical application of vapocoolant sprays. A sudden drop in the skin temperature is thought to be associated with a localized anesthetic effect, which allows the affected muscle to be stretched. Massage of the trigger points may also provide pain relief. Provoking factors such as poor posture and repetitive work should be avoided.

Nonpharmacologic Management

In addition to spray and stretch and massage, other nonpharmacologic approaches include osteopathic manipulation, application of heat or ice, ultrasound, exercise, TENS, acupuncture, and biofeedback. Reports of treatment effectiveness are based more on empirical clinical experience than data from controlled trials.

Pharmacologic Management

NSAIDs have no demonstrated efficacy in relieving myofascial pain, but some patients report benefit. TCAs or other analgesic antidepressants may provide some benefit. Opioid analgesics may be an option if adjuvant analgesics are not effective, particularly if the pain is severe. While these drugs seldom eliminate the myofascial pain completely, any reduction in pain may potentiate the effects of other medications, facilitate adjustments in lifestyle and improve the patient’s functional status.

Trigger point injections are reserved for patients who do not obtain relief from muscle stretching or when manipulation of trigger points produces twitching and referred pain.⁷⁸ Either a local anesthetic (i.e., 0.5% lidocaine; 0.5% bupivicaine) or a dry needle is inserted into the trigger point after isolating it by palpation. How these treatments work is not known, as the analgesic effect usually outlasts the anticipated effects of local anesthetics. Controlled studies have primarily focused on the different substances injected; for example, one study randomized patients to undergo dry needling (63% improvement rate) or trigger point injection with lidocaine with and without a steroid (42% improvement rate).⁷⁹ Given these outcomes, it is possible that the critical factor is not the substance injected, but rather manipulation by the needle.⁷⁸