INCIDENCE OF MYOFASCIAL PAIN SYNDROME IN CEREBRAL PALSY PATIENTS POST MULTILEVEL SURGERY: A RETROSPECTIVE STUDY

*Gayatri Ajay Upadhyay, **Ajay Kumar Upadhyay, ***Krishna N. Sharma

ABSTRACT Background: Pain after multilevel surgery is a recognized complication found to have an adverse impact of cerebral palsy patients quality of life, increasing psychosocial distress. There have been case reports about myofascial pain syndrome emerging as a cause of postsurgery pain. Myofascial pain syndrome characterized by myofascial trigger points in palpable taut bands of skeletal muscle that refers pain a distance and that can cause distant motor and autonomic effects. Objective: The goal of the current study was to document andanalyze MPS following multilevel surgeries in children with cerebral palsy. Design: Retrospective study. Setting: D.L.S. Institute for Health & Wellness, Mau, U.P, India Methodology: One hundred and ten children with cerebral palsy who underwent multilevel surgeries were studied retrospectively to document myofascial pain syndrome post operatively and determine risk factors that would correlate with myofascial pain syndrome. The diagnosis of MPS was made by a rehabilitation specialist using the Simons Criteria (Simons et al., 1999), that required 5 major and at least 1 of 4 minor criteria to be satisfied12. Results:56 out of the 103 patients with complications (54.36%) experienced MPS, the majority having onset within the first 6 months after surgery. The commonest complain of pain in post multilevel surgeries cerebral palsy patients were because of Myofascial Pain Syndrome. Conclusion: Myofascial Pain Syndrome is a potential cause of pain in cerebral palsy patients undergoing multilevel surgeries having onset within the first 6 months after surgery.

Keywords: Myofascial pain syndrome, incidence, prevalence, cerebral palsy, multilevel surgery, pain
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INTRODUCTION

type is common. It affects

of

surgery

performed.

Sometimes

Cerebral

palsy

complications can occur following surgery. However, individuals may experience

approximately 3 per 1000 children. Lever arm dysfunction and deformities due to muscle tightness (spasticity) occurs in up to half of the more severely affected children, and many of these children require major surgery.

complications and discomforts differently. After bony surgery the management of pain is very difficult, as spasticity tends to increase and causes painful spasms which are difficult to control. The identification of the level of pain can be challenging because most of these children are unable to communicate verbally. There is a high emotional and financial burden on the families of these children. Families describe high levels of emotional distress around the time of surgery, particularly when their child is in pain. Difficulty with pain control post operatively may delay discharge from hospital and parental return to work. It causes disrupted sleep for the child and family and may delay the child's return to school. Myofascial Pain Syndrome (MPS) following Multilevel Surgeries in cerebral palsy children has not been documented in the literature. This study is the first to describe fully the myofascial pain experience of children with cerebral palsy undergoing multilevel surgeries type of major surgery. The goal of the current study was to document and analyse MPS following multilevel surgeries in children with cerebral palsy. The MPS is defined as the signs and

Orthopedic surgery has a major role to play in minimizing the impairments and activity limitations associated with the development of musculoskeletal pathology in children with cerebral palsy (CP)1. Orthopedic procedures have been designed to address the various components of the progressive

musculoskeletal pathology including tendon lengthening, osteotomies, procedures.2,3,4 tendon and More transfers, joint recently, rotational stabilization multilevel

surgery have come up in which multiple levels of musculoskeletal pathology, in both lower limbs during one operative
2-5

procedure,

requiring only one hospital admission and one period of rehabilitation. described as This is variously surgery, gait-

multilevel

improvement surgery and, most frequently, single-event multilevel surgery to distinguish it from the birthday syndrome approach of the past.
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Complications with surgical procedures are common. addressing Since multilevel surgeries in

musculoskeletal

problems

symptoms caused by active myofascial trigger points (MTPs). An MTP can be defined as a hyperirritable nodule of spot tenderness in a palpabletaut band of skeletal muscle. The spot
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multiple levels, the extent of complications are also high. The amount of discomfort and problems following surgery depends on the

Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014

is a site of exquisite tenderness to palpation, that refers pain adistance, and that can cause distant motor and autonomiceffects.6 MTPs are considered to be localized muscle

electromyographic (EMG) examination,11 by ultrasound technology (grayscale 2D

ultrasound, vibration sonoelastography, and Doppler),12 or by sophisticated microdialysis techniques assaying characteristic biochemical markers.13 Central hypersensitization

contractures occurring at dysfunctional motor endplates. TABLE 1. Recommended Criteria for

associated with MTP activation is objectively visualized on functional magnetic resonance imaging studies.14 In the clinical setting, MTPs are identified by physical examination.36 Recent studies have shown that clinicians with adequate training in muscle palpation techniques have a high degree of reliability in identifying MTPs, not only in the same muscle, but the same trigger point within the muscle. Thus, the most widely used diagnostic criteria7 (Table 1) have shown a good overall inter rater reliability.15-17The examiner in this study has had extensive experience in MTP examination and

Identifying Myofascial Trigger Points.7 Palpable taut band Exquisite spot tenderness of a nodule in a taut band Patients recognition of current pain complaint by pressure on the tender nodule Painful limit to full stretch range of motion was assessed in each patient, but was considered confirmatory, although not

necessary to the diagnosis of MPS MPS indicates myofascial pain syndrome.

treatment. The objective of this study was to assess the incidence of MPS retrospectively 5 years after multilevel surgeries.

Hence, MPS is classified as a myopathy associated with disordered neuromuscular junction function.6,7 MTPs can be classified as active (symptom-producing) or latent (not spontaneously symptomatic). overload,6,7by leaving shortened position
6,7

METHODS Design: After IRB approval, a retrospective review was performed to identify myofascial pain syndrome as one of the potential cause of pain following multilevel surgeries during the post-surgical rehabilitation from 2008-

Latent MTPs

can be activated by acute or chronic the muscle in a long a

for

period

2013.By means of a specific physical therapy treatment of MTPs we achieved very good results in the control of pain of our patients. Patients: 110 cerebral palsy subjects who underwent Multilevel Surgeries were studied
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oftime,6,7by surgical scars8 or by surgical drains,9 among other causes. MTPs can be identified by the objective tests of magnetic resonance elastography,10 by specific

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for the complications following the surgery. The present study analyzed the complications during post-surgical rehabilitation following multilevel surgeries during a period of 5 years (2008-2013). All 110 children underwent multilevel surgeries followed by a postoperative immobilization period varied

complained of pain, the patient was again examined to determine the cause including assessment of active MTPs. The diagnosis of MPS was based on the major criteria proposed by Simons et al, shown in Table 1. RESULTS Complication causing pain during postsurgical rehabilitation following multilevel surgeries during a period of 5 years (20082013) was analysed. The commonest

between 2 weeks (upper limbs) to 6-10 weeks (lower limbs) and was followed by physical therapy for at least 6 months. Assessment: Each patient underwent pre operative and post operative assessment during all the phases of rehabilitation. In addition to the scheduled assessments each patient as well as their parents was instructed to report if they experienced pain. Aphysical therapists expert in diagnosis of MPS

complications causing pain were Myofascial Pain Syndrome (56, 54.36 %), Incidence of MPS The number of cerebral palsy patients with active MTPs was 56 out of 103 (54.36%). During these 5 years other pain conditions were also noted like post operative joint

performed the assessment. During the pre operative assessment,

stiffness,

pathological

fractures,

rickets,

demographic data were collected on all patients including age, sex, type of cerebral palsy, medical history, bony deformities, GMFCS Level, GMFM 88 and other details. Patient were also asked open question about whether they felt any pain. If they did, a physical examination was conducted to find the source of pain, including evaluation of active MTPs. Location, duration and intensity of pain were recorded. In post operative assessment, data were collected regarding the type of surgery performed, the duration of immobilization, any complication if any was noted and intervened and level of pain. If the patient
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osteoporosis and anterior knee pain. MPS developed mainly during six months period after surgery. The active MTPs were mainly found in Pectoralis Major, Trapezius and Sternocleidomastoid. DISCUSSION This will be the first published study to address the incidence of MPS among cerebral palsy post multilevel surgeries. The results of this study give an insight into incidence of this unreported pain syndrome in cerebral palsy patients after multilevel surgeries.

Complications with surgical procedures are common. Patients with cerebral palsy who undergo surgical reconstruction with

Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014

osteotomies

are

at

significant

risk

of

related to positioning of the shoulder during surgery, maintaining muscles in a shortened position after surgery, the surgical scar, the manipulation, and excision of forearm fascia during surgery or the adaptation of upper extremity movement after surgery. There are at least 2 possible reasons to explain the tightness that is often found in the major muscle after surgery: (1) Immobilization and (2) the positioning of the arm in abduction and external rotation during surgery. The patients efforts to inhibit movement causing pain through thoracic flexion and scapular

complications. The risk of complications following an osteotomy is significantly greater in the non-ambulatory population, and in a recent series a 69 percent complication rate was noted. Since multilevel surgeries in

addressing

musculoskeletal

problems

multilevel, the extent of complications are also high. The amount of discomfort and problems following surgery depended on the type of surgery performed. Sometimes complications occurred following surgery. However,

individuals experience complications and discomforts differently. Pain after any orthopaedic surgery is a recognized complication found to have an adverse impact on patient's quality of life, increasing psychosocial distress. We have noted many cases of myofascial pain

protraction may account for the high presence of MTPs in the pectoralis major, upper trapezius and sternocleidomastoid. The

pectoral tightness pulls the scapula into a protracted position, and the arm into internal rotation, increasing the risk of subsequent MTPs in shoulder rotators, and in scapula retractors, as well as in back and neck muscles. The diagnosis of MPS was made by a rehabilitation specialist using the Simons Criteria (Simons et al., 1999), that required 5 major and at least 1 of 4 minor criteria to be satisfied7. Although we achieved very good results in the control of pain of our patients by means of a specific physical therapy treatment of MTPs, the fact that we did not have a control group to evaluate the effectiveness of our treatment does not allow any conclusion to be drawn regarding this issue. Controlled studies with longer follow-up are needed to evaluate the effectiveness of different specific treatments of MPS in these patients to be
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syndrome as a cause of post-surgery pain. Myofascial pain syndrome is a regional pain syndrome characterized by myofascial trigger points in palpable taut bands of skeletal muscle that refers pain a distance, and that can cause distant motor and autonomic effects. 56 out of the 103 patients with complications (54.36%) experienced MPS, the majority having onset within the first 6 months after surgery. This high incidence supports the need for identifying and treating the often

underdiagnosed and misdiagnosed MPS found in these patients. Most patients with MPS had active MTPs in muscles of the shoulder girdle. This would be expected since the most likely activation factors in these patients would be

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certain about the real contribution of MTPs to

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