MYOFASCIAL PAIN: A REVIEW Shelley Pullen* SUMMARY Myofascial pain syndrome is pain and/or autonomic phenomena referred from active myofascial trigger points with associated dysfunc­ tion. It has been said to affect human well-being and productivity even to the extent of driving some people to suicide. A literature review of myofascial pain is presented. An interesting historical view of muscular pain is discussed. PART ONE: HISTORICAL OVERVIEW INTRODUCTION Sincc ancient times pain, in particular muscular pain, has provided clinicians with one challenge after the next. Over the centuries muscular pain and its treatment has been described and documented and theories have been both devised and rejected time and again. In a quest for understanding and managing this pain clinicians have documented their clinical work and researched this subject exten­ sively over the years. So today, the quest continues for perfect understanding and the revelation o f new knowledge in this field. Myofascial pain has only in the past few decades begun drawing attention worldwide. This review aims to consolidate some o f the literature on myofascial pain as we continue to strive for excellence in the field of muscular pain. Sheon (1986)1 emphasised that this “soft tissue rheumatism” resulted in significant disability costs and that it remains poorly recognised by practitioners and researchers because the objective findings o f the disorder are few. About ten years ago Anders^ maintained, that the most common problem faced by most physicians is that o f myofascial pain. It was stressed that this may present as a primary complaint or as a crippling adjunct to any number o f other problems. Voluntary (skeletal) muscle is the largest single organ in the body comprising approximately 40% o f the body weight. This contractile tissue is extremely subject to wear and tear. This is the major cause o f muscular pain including myofascial pain. As a result the import­ ance o f myofascial trigger points has been described in the literature on acupuncture, anaesthesiology, dentistry, general practice, ortho­ p a e d ic s, p aed iatrics, physiotherap y, reh abilitation m ed icin e and rheumatology. BRIEF HISTORICAL VIEW OF MUSCULAR PAIN O f the earliest literature relating to trigger points Froriep (1843) used the term “muskelschwiele” meaning “muscle callouses” which was obviously describing the palpable bands o f trigger points. By 1898 Strauss3 concluded that no anatomical study had succeeded in finding a “callus” o f deposited connective tissue which would account for the hard cords palpable in hard muscles. At this time Helleday (Sweden) was emphasising the importance o f tender points in mus­ cles. In 1904 Gowers introduced the term “fibrositis” attributing the local tenderness and palpable hardness to inflammation o f fibrous tissue because o f sensitivity to cold, the sensation o f stiffness and circulatory disturbances3. On the other hand Stockman3 (1904) attributed these symptoms to connective tissue hyperplasia and illus­ trated this histologically. The book "Fibrositis” was published by Llewellyn .and Jones3 in 1915. It combined the theories o f Gowers and Stockman and in­ cluded descriptions o f gout, rheumatoid arthritis and myofascial pain syndromes. But in subsequent biopsy studies, it was established that not all o f these conditions show inflammatory pathology o f the connective tissue. 3 In Germany Schade (1919) reported persistent muscle harde­ ning during deep anaesthesia and after death and he described this as an increase in muscle colloid viscosity and introduced the term “myogelosis”. F Lange and Everbush3 in the same year described these palpable hardenings as "muskelharten”. M Lange3 (1931) later used the ideas o f “muskelharten" and "myogelosis” to treat his patients using fingers, knuckles or a blunt wood probe to apply forceful massage which was therapeutically effective. In 1931- his book 4 presented the history and concept o f myogelosis and described many pain syndromes associated with specific tender points. In 1939 Kellgren3 reported that many o f his patients experienced referred pain in areas remote from the tender points. Until then, few clinicians recognised this and subsequently this has become an im­ portant basic characteristic o f trigger points. H e demonstrated this by injecting an irritant into the muscle which caused pain not only locally but also resulted in referred pain at a distance. Three authors, from different continents identified a specific muscle with a patient's pain, rather than a group o f muscles. Each author reported specific muscle syndromes o f the body in a number o f patients. Amongst these authors Gutstein,3 (Polish), described the tender points as “myalgic spots”. He also described the referred pain patterns o f muscles and the patient’s reaction to palpation o f the tender point which was later termed the “jump sign”. In all his subsequent papers up until 1957 he attributed the myalgic spots to local constriction o f blood vessels due to overactivity o f the sympath­ etic fibres supplying the vessels. Michael Kelly, an Australian, wrote a series o f papers between 1941 and 1963 . He persistently described the “nodule” and the distant referral o f pain from the affected muscle. His concept was that fibrositis was a functional, neurological disturbance originating at the myalgic lesion, which was due to a local rheumatic process. He envisioned no pathology, but rather that a central nervous system reflex disturbance caused the referred pain. In 1942 Travell and co-authors3 proposed that any fibroblastic proliferation was secondary to a functional disorder and that patho­ logic changes occurred only if the condition was chronic. In 1976 Travell summarised her concept3 as follows: A feedback mechanism between the trigger point and central nervous system was responsible for the self-sustaining characteristic o f the trigger points. In 1934 and 1941 Kraus3 promoted vapocoolant spray as a treat­ ment for trigger points. In 1970 he wrote a book5 which emphasised the importance o f exercise in the treatment o f patients with back pain due to trigger points. Regarding the pathophysiology o f trigger points, Awad (1973, America) and Fassbender and Wegner (Germany)3 reported ultra- microscopic findings in biopsies o f muscles. These included abnor­ malities o f the contractile elem ents in muscle. 3 Russian authors, Popelianski et al., have recently described a two-stage process causing myofascial trigger points: an initial neuro­ muscular dysfunctional stage and a subsequent dystrophic pathologi­ cal stage. These, hypothesis remain largely untested. Today the term “fibrositis” has been replaced to a large extent in the literature by the term “fibromyalgia” and Junus et a P in 1982 * BSc (Physiotherapy), MSc student, University o f the Witwatersrand Ithuseng Rehabilitation Centre, Ernest Oppenheimer Hospital, Welkom Physiotherapy, May 1992 Vol 48 no 2 Page 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) described the most common symptoms in patients with primary fibromyalgia. Travell and Simons3 define myofascial pain as “pain and/or autonomic phenomena referred from active myofascial trig­ ger points with associated dysfunction”. In the Dictionary o f R h eu­ m a tic D i s e a s e s , m y o f a s c i a l p a i n is d e f i n e d a s f o l l o w s : "Musculoskeletal pain or aching, diffuse or local, felt anywhere in the body. It is typically deep in character with boundaries that have no anatomical basis, and is often aggravated by movement” A myofas­ cial trigger point is defined by Travel and Simons3 as “a hyperirritable spot, usually within a taut band o f skeletal muscle or in the muscle's fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness and autonomic phenom e­ na”. Types o f trigger points include active, latent, primary, secondary, associated and satellite. Travell and Simons3 also stress that myofas­ cial trigger points should be distinguished from cutaneous, ligamen- BOOK REVIEWS REHABILITATION OF THE OLDER ADULT by Keith Andrews Reviewed by J C Beenhakker This book, reprinted in paperback in 1991, is written by a physician who believes that effective rehabilitation requires a well integrated, multi professional team. According to the author the main functions o f the book is to provide some practical ideas for management of specific disorders as well as to encourage further research into reha­ bilitation. The latter is facilitated by long reference lists at the end of each chapter. A good introductory chapter is given explaining what is meant by rehabilitation, the prevalence o f handicap and disability related to age in Great Britain, the need to set goals and involvement o f the carers. Chapter two briefly covers the physical modalities used in reha­ bilitation including heat, cold, ultrasound, ultraviolet radiations etc. This is superficially covered and many o f the references are old (only seven o f the 132 references are later that 1984). In the following chapters specific conditions are briefly discussed followed by som e of the modalities which could be used in the management o f these conditions. Again some o f this is out o f date and later research in these areas is not given. It is not clear at whom this book is aimed as it is very basic but it does give som e practical ideas o f how to adapt treatment to the individual both in hospital as well as at home. FOUNDATIONS OF PHYSICAL REHABILITATION A MANAGEMENT APPROACH by Doreen Bauer Reviewed by Trish Wallner This is a most enlightening approach to the difficult task of organising an effective and efficient rehabilitation service. It offers broad principles o f the management o f such a service that can be adapted to most situations. A n up to date account o f current thinking in the broad field o f rehabilitation is presented in a refreshing and clear manner. This book offers an opportunity o f understanding the foundations of tous, periosteal and non-muscular fascial trigger points. (In P art II c o n c e p ts and m a n a g e m e n t o f fib rom yalgia and myofascial pain will be -discussed) REFERENCES 1. Sheon RP. Regional myofascial pain and the fibrositis syndrome (fibromyalgia). Comprehensive Therapy 1986:12(9) :42-52 2. Anders ES. Myofascial trigger point therapy. Resident and staff physician 38-44 August 1981. 3. Travell JD and Simons MD. Myofascial pain and dysfunction. The trigger point . manual 1983. Williams and Wilkins. 4. Lange M. Die Muskelharten (Myogelosen). JF Lehmann's Verlag, Munchen, 1931. 5. Kraiiss H. Behandlung akteur Muskelharten. Wien Klin WW/i«juc/irl937:50:1356- 1357. 6. Simons DG. Fibrositis/Fibromyalgia: A Form of Myofascial Trigger Points? The American Journal o/.Wc^Wncl 986 81 (suppl 3A). 7. ARA Glossary Committee: Dictionary o f the rheumatic diseases. Volume 1: Signs and Symptoms. New York: Contact Associates International Ltd, 1983:44-62 rehabilitation in the complete sense o f the word and then explores elements such as service design, resources, staffing, time manage­ ment and service evaluation. Much is to be learned from this book by physiotherapists in South Africa currently searching for a way to offer a much needed, com ­ prehensive rehabilitation service in partnership with the disabled community. STROKE AND HEAD INJURIES: A GUIDE FOR PATIENTS, FAMILIES, FRIENDS AND CARERS by Mary Lynch and Vivian Grisogno Johan Murray (Publishers) Ltd. 1st Edition 1991 soft, 175 pp, illustrated. Reviewed by Leigh Hale An extremely comprehensive guide to anyone faced with the daunting task o f caring for a stroke or head-injured person at home. Subjects covered vary from washing and dressing the person, to ideas for mealtimes. The principle o f minimising spasticity is emphasised. The book covers the pathology o f stroke and head-injury, preven­ tion and first aid, hospital care (tests and procedures), the patient at home and at physiotherapy. It ends with seven case studies. The text is detailed but simply written. However, it would have benefited from more explanatory diagrams. It is best to bear in mind that the book was written in Britain, around their health care system, much o f which is unavailable in this country. The useful addresses at the end are all British. Physiotherapy, May 1992 Vol 48 no 2 Page 25 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )