Common Neck Problems, MPS &

Fibromyalgia

CRISTEL ADDUN
TRINITY ALMEDA
DENZEL ALFONSO
CHRISTIAN AMIHAN
Introduction
Neck Pain & Upper Limb Pain
CERVICAL AXIAL PAIN CERVICAL RADICULAR PAIN
 Epidemiology
The prevalence of neck pain with or without upper limb pain ranges
from 9% to 18% of the population
Cervical pain is more frequently encountered in clinical practice than
low back pain and traumatic neck pain becomes chronic in up to 40%
of patients, with 8% to 10% experiencing severe pain.
The occurrence increases in workplace.
Related Anatomy
Common Clinical Disorders
 Cervical Strain and Sprains
Cervical strain vs Cervical Sprains
Cervical strains and sprains injuries account for approximately 85% of neck pain
resulting from acute, repetitive, or chronic neck injuries.
The incidence is higher in women.
Individuals aged 30 to 50 years old.
These injuries are the most common type of injury to motor vehicle occupants.
 Pathophysiology
Differing pathomechanisms are causal in cervical strain and sprain injuries,
depending on the nature of the abnormal stress applied to the cervical spine.
Physiologic forces acting on a relatively normal cervical spine result in typical
soft tissue strain seen in nonathletes. In individuals with thoracic kyphosis and
consequential cervical lordosis and extension, strain occurs in the levator
scapulae, superior trapezius, sternocleidomastoid, scalene, and suboccipital
muscles.
Traumatic blows often incurred in sporting injuries can result in a more acute
cervical strain or sprain.
 Diagnosis
Cervical strain and sprain injuries can be associated with headaches. These
headaches are typically sharp or dull and localize to the cervical or shoulder
girdle musculature. The patient can also report neck fatigue or stiffness that
lessens with gradual activity. Aggravating factors include passive or active
motion.
Decreased cervical range of motion can be detected on gross examination. This
occurs because of muscle guarding and splinting to avoid pain. Palpation of the
involved region is usually uncomfortable or moderately painful. The most
commonly involved areas are the upper trapezius and sternocleidomastoid
muscles
 Treatment
Initial care includes controlling pain and inflammation to curb the injury
response, mitigate deconditioning, and facilitate active participation in a
functional restoration program. Nonsteroidal antiinflammatory drugs (NSAIDs)
and acetaminophen (paracetamol) aid in controlling pain and nurturing
restorative sleep patterns
Physical modalities such as massage, superficial and deep heat, electrical
stimulation, and a soft cervical collar can be used in the treatment program
Cervical Radiculopathy and Radicular
Pain
Cervical radiculopathy is a pathologic process involving neurophysiologic
dysfunction of the nerve root.64 Signs and symptoms of cervical radiculopathy
include myotomal weakness, paresthesias, sensory disturbances, and depressed
muscle stretch reflexes.
Cervical radicular pain represents a hyperexcitable state of the affected nerve
root.
Cervical radiculopathy, on the other hand, involves reflex and strength deficits
marking a hypofunctional nerve root as a result of pathologic changes in nerve
root function.
 Pathophysiology
Cervical nerve root injury is most commonly caused by cervical intervertebral
disk herniation (CIDH).
Cervical spondylosis (or degenerative osteoarthritic changes) is manifested by
ligamentous hypertrophy, hyperostosis (bony overgrowth), disk degeneration,
and zygapophyseal joint arthropathy.259 Hypertrophy of the zygapophyseal
joints and uncovertebral joints results in intervertebral foramina stenosis and
nerve root impingement.
 Diagnosis
Patients with acute CIDH-related radiculopathy typically report a history of axial cervical pain
that is then followed by an explosive onset of upper limb pain
Cervical radicular pain can masquerade as a deep dull ache or sharp lancinating pain. It can
occur in a number of locations.
Exacerbating factors include activities that raise subarachnoid pressure, such as coughing,
sneezing, or Valsalva maneuvers.
 Treatment
The primary objectives of treatment of cervical radiculopathy include the resolution of pain,
improvement in myotomal weakness, avoidance of spinal cord complications, and prevention of
recurrence.
 Whiplash Syndrome
Whiplash (hyperflexion-hyperextension) should be conceptualized as having
three components. The whiplash event is the biomechanical effect incurred by
the occupants of one vehicle when struck by another vehicle. The whiplash
injury is the impairment, or injured structure, resulting from the whiplash event.
The whiplash syndrome is the set of symptoms arising from the whiplash injury
MUSCLE PAIN SYNDROMES
 Brief Background
Myofascial Pain Syndrome (MPS) and Fibromyalgia Syndrome (FMS)
most frequently described muscle pain syndromes
Cause:
1. Myofascial Trigger Point (MTrP) a local lesion containing sensitized
(centrally or peripherally) or persistently irritated nociceptors, with
associated phenomena (e.g: taut band, referred pain, local twitch response
[LTR])
Etiology and Classification of
Muscle Pain
Pathophysiologic Considerations in Muscle Pain
Can be elicited by any irritation of the pain pathway from the muscle to
the cerebral cortex
Peripheral sensitization of nociceptors in the muscle or central
sensitization in the central nervous system (CNS)
 Sensory
unit
Dorsal root ganglion
plus the peripheral
nerve fibers (the
peripheral axon and
the centrally
extended dendrite)
and the supplied
nociceptors
 Location of pain = Law of projection
The cerebral cortex can perceive pain at a certain site via
transmission of stimuli from the corresponding sensory unit to the
dorsal horn of the spinal cord, and then via the spinothalamic tract
to the thalamus and brain
Intensity of pain
determined by both the spatial and temporal summation of
action potentials generated by the sensory unit
Character of pain
based on the simultaneous stimulation on two or more
different sensory units with different entities
Pain pathway for muscle pain is different from skin
After the first synapse with the dorsal horn cell in the spinal
cord, the nociceptive information from muscle is largely
mixed with information from other tissues
Dorsal horn cells receives information from muscles are
convergent neurons
Spinothalamic tract - is the main ascending pathway for
muscle pain in the spinal cord
 Neuroplasticity - CNS has the ability to react to a short-
duration input of noxious stimulation with a long-lasting
deviation from normal synaptic function
Increased muscle sensitivity can be manifested as:
1. Hyperalgesia increased pain intensity evoked by a
noxious stimulus
2. Allodynia pain evoked by an innocuous stimulus
3. Increased size and number of referred pain areas with
associated somatosensory changes
Referred pain
can be elicited by a strong stimulation to a sensory unit
with spread to the sensory pathways of different sensory
units at the spinal cord (or higher) level of the CNS
Peripheral sensitization (nociceptor sensitization)
occurs when there is an increase of excitability in the nociceptors
of a sensory unit as a result of peripheral irritation
 Central sensitization
occurs when there is an increase of excitability of the spinal
dorsal horn neuron (or higher center) for a long period. This is
why a mild stimulus to a sensory unit can cause a cortical
perception of severe pain in its receptive field
Etiologic Classification of Muscle Pain
Based on its site along the pain pathway, muscle
pain can be divided into five categories:
1. Peripheral irritation or sensitization of the nociceptors in
the muscle
2. Irritation of the peripheral nerves involved in the
transmission of pain messages to the CNS
3. Irritation of the pain pathway in the CNS
4. Central sensitization in the spinal cord or a higher CNS
center
5. Systemic decrease of the pain threshold
Peripheral irritation or sensitization of the
nociceptors in the muscle
The muscle tissues can be injured by a sudden powerful
overcontraction or stretch (strain) or by an external agent
(e.g., contusion, wound, burn)
Acute inflammation of injured tissues can irritate the
muscle nociceptors.
An incompletely repaired acute lesion or a chronic
repetitive minor trauma can cause chronic inflammatory
reaction in the muscle tissues
The inflammatory substances can cause direct biochemical
irritation or peripheral sensitization of muscle nociceptors
Muscle soreness or pain can also occur after overactivity or
doing unaccustomed exercise
The proposed causes of this include excessive production of
lactic acid and minor injury to the muscle fascia.
Many muscle diseases (myopathies) can also result in either
direct compression or biochemical irritation of the muscle
nociceptors to elicit muscle pain.
 Irritation of the peripheral nerves involved in
the transmission of pain messages to the CNS
Neuropathic pain
Other tissues (e.g., skin, ligament, joint capsule, and tendon)
can also be painful if supplied by the same irritated nerve
Direct trauma or chronic entrapment of the sensory nerves
that supply a muscle can cause pain in that muscle
Examples include severe carpal tunnel syndrome with thenar
muscle pain, as well as radiculopathy with soreness or pain in
the innervated muscles
Irritation of the pain pathway in the CNS
Central Pain
Many CNS lesions can cause pain in the muscles when the
central sensory pathway is affected by the lesion. The muscle
and other tissues (e.g., skin, ligament, joint capsule, and
tendon) that are supplied by the same irritated neural
pathway can also be painful
Central sensitization in the spinal cord or a
higher CNS center
A muscle can be painful without having a local lesion or a CNS
lesion in its pain pathway as a result of a lesion that is remote
from this muscle via central sensitization
When the pain intensity in the remote lesion is strong enough,
the pain message can spread to the pain pathway of that
muscle
The remote lesion can be at another muscle or in other
tissues such as tendon, ligament, bursa, joint, or bone
It can also be induced by an increased excitability of a certain
site in the pain pathway as a result of an unknown cause
can cause referred pain, hyperalgesia, and allodynia
an important mechanism for the activation of an MTrP
 Systemic decrease of the pain threshold
considered to be a consequence of central sensitization
exact mechanism is still not clear
Any irritation or sensitization of the muscle nociceptors or the
muscle pain pathway can result in muscle pain
Causes of muscle
pain
Classification System of Soft Tissue Pain

Developed by Russell
1. Localized pain focal muscle pain
2. Regional pain myofascial pain syndrome
3. Generalized pain fibromyalgia
 Myofascial Pain Syndrome
defined as a regional pain syndrome characterized by muscle
pain caused by MTrPs
includes a regional muscle pain syndrome of any soft tissue
origin that is associated with muscle tenderness
Includes any pain phenomenon that is due to the activation of
latent MTrPs that can be secondary to pathologic conditions
such as chronic repetitive minor muscle strain, poor posture,
systemic diseases, and neuromusculoskeletal lesions (such as
strain, sprain, enthesopathy, bursitis, arthritis, spinal disk lesion,
etc.)
 Association of Myofascial Pain and Other
Lesions (The Underlying Pathologic Lesions)
Although myofascial pain can be suppressed by an
myofascial pain therapy, such as an MTrP injection, the
pain often recurs a few days or weeks later if the related
pathologic lesion is not eliminated

The MTrPs can be inactivated permanently when the

underlying etiologic lesion is completely eliminated,
unless reinjured
The underlying pathologic lesions are usually found in other
regions remote to the activated MTrP which is due to central
sensitization.

Overuse or inappropriate use of a muscle can activate the

MTrP as a result of peripheral sensitization

Repetitive use of a muscle can reduce the pain threshold of

the MTrP
The number and pain intensity of MTrPs were significantly reduced after physical therapy or
surgery for lumbar disk herniation

Active MTrPs has a association with cervical disk lesions, cervical facet lesions, cervical
radiculopathy, lumbar disk lesions, osteoarthritis of knee, teres minor tendinitis, lateral
epicondylitis, floating kidney, septic arthritis, and herpes zoster

Spinal adjustment and local injection of a cervical facet can effectively relieve the pain
caused by MTrPs

Facet nociceptors and MTrP nociceptors might be connected in the spinal cord and might use
the same nociceptive pathway to the higher center: Suppressing the facet pain suppresses
the MTrP pain
Compression of the related level facet joint can elicit pain in
the MTrP regions, but needle stimulation to the associated
MTrP can rarely induce pain in the correlated facet joint
Facet Dysfunction - one of the important causes of the
activation of MTrPs
It less frequently occurs as a consequence of primary muscle
lesion
Activation of MTrPs can cause pain to avoid any movement
that could interfere with the healing process of the primary
lesion
Muscle pain important defense mechanism to avoid further
injury before complete healing of the etiologic lesion
Myofascial Pain Syndrome Controversies
lack of a set of specific diagnostic criteria
This set of agreed-on specific diagnostic criteria is
required if different clinicians are to be able to agree
on when it is present (with acceptable interrater
reliability)
Acceptable interrater reliability of many of the
indicators of MTrPs appears to be obtainable only
after the examiners have undergone special training
The electrophysiologic and morphologic findings of
MTrPs cannot be part of the criteria for the diagnosis
because they are expensive and time consuming

The practical diagnostic procedure still has to depend

on a palpatory examination, which requires special
clinical skills
 Myofascial Trigger Point
most tender (hyperirritable) circumscribed spot in a
palpable taut band of skeletal muscle fibers (Travell and
Simons)
Pressure stimulation of a typical MTrP can elicit pain,
referred pain, and LTR (brisk contraction of the muscle
fibers in its taut band)
pain elicited by compression of the spot is familiar to the
patients pain recognition
Latent MTrPs are tender but not spontaneously painful. It can be
identified in most normal adult skeletal muscles but not in newborns
or babies less than 1 year old

Active MTrPs are painful spontaneously or in response to

movement of the involved muscle and are often so painful on
palpation that the patient jumps (the jump sign)

A latent MTrP can be evolve into an active MTrP. When an active MTrP
is suppressed with treatment, it is still tender but not painful because
it has become a latent MTrP.
Compression of the MTrP can reproduce or aggravate the
patients pain recognition, and inactivation of the MTrP can
relieve the pain and other symptoms
myofascial pain patient can have many active MTrPs. It begins
with the patient having only one active MTrP in the affected
muscle as a result of a soft tissue lesion
The pain region can expand to other regions and develop
additional active MTrPs if not appropriately treated or not
eliminated
Primary MTrP or key MTrP aka original MTrP
Secondary MTrPs or Satellite MTrPs occurs in the latter part
 Characteristics of Myofascial Trigger Points

Chief characteristics of
latent and active MTrPs:
The separation of active MTrPs into three categories (mildly,
moderately, and severe) is artificial
Common characteristics include taut band, spot tenderness,
referred tenderness, LTR, and restricted range of stretch
Latent MTrPs Referred tenderness, LTR, and restricted range
of stretch are not always elicited in latent MTrPs
Mildly Active MTrP it is painful, but the referred pain is often
not obvious
Moderately Active MTrP referred pain usually develops
Patients with severely active MTrPs typically show motor
dysfunction and autonomic phenomena
Change in symptom
severity is continuously
variable.
The degree of sensitized
nociceptors in an MTrP
region is the most
important factor in
determining the degree
of MTrP severity.
MTrPs are usually located within the end-plate zone because
end-plate noise (EPN) can usually be recorded
electromyographically
Central MTrP typical MTrP occurring in the end-plate zone
Attachment trigger point (A-TrP) trigger points in other
locations in the muscle or tendon attachment region. It does
not have all the characteristics of central MTrPs. It always
located at the end of a taut band. Pain, referred pain, and LTR
can be elicited, but EPN cannot be recorded from an A-TrP
region of muscle.
Clinical Characteristics of Myofascial Trigger Points
Painful or Tender Spot
most important characteristic of an MTrP
circumscribed spot in the muscle with pain or
tenderness. For most muscles, this spot can be
identified in approximately the same region in
different persons
The exact location of the MTrP in almost every
skeletal muscle
 Taut Band
Simons et al. considered that an MTrP is always found in a
taut band of skeletal muscle fibers, and a taut band is the
precursor of an MTrP
an essential component of the definition of an MTrP
Restriction of stretch with reduced range of motion can
occur in a muscle with one or more tense taut bands that
produced pain during stretch
different from muscle shortening caused by contraction
because no action potentials from the muscle fibers
 Referred Tenderness
occurs when a distant muscle has pain compression of an
MTrP
The occurrence of referred tenderness depends on two
factors:
1. Irritability of the MTrP
2. Pressure of compression
Referred Pain
occurs when spontaneous pain is referred to remote sites
from an MTrP
Spontaneous referred pain occurs in severe cases of MPS
Same area of muscle referred pain in different persons
 Local Twitch Responses
a sudden brisk contraction of a group of muscle fibers (usually in a taut
band) in response to snapping palpation (quick compression across
the muscle fibers perpendicularly of the MTrP)
occurrence of the LTR also depends on the irritability of the MTrP and
the pressure applied for eliciting LTR.
High pressure is required to elicit an LTR in an MTrP with low irritability
A needle tip can provide high pressure stimulation to the MTrP and
can elicit LTR much easier than using finger palpation
Motor Dysfunction
observed reduced muscle strength (weakness)
caused by an MTrP is neither a true neurogenic nor a
myogenic weakness

It is a pain-induced weakness and usually occurs only

in severe cases of myofascial pain. Disuse muscle
atrophy occurs rarely, mainly in cases of MPS with
persistent severe pain
Other motor dysfunctions related to MTrP include increased
responsiveness (muscle hyperactivity, referred muscle
hyperactivity, referred inhibition), delayed relaxation, and
increased fatigability (accelerated fatigability, delayed recovery

also called hyperresponsiveness muscle spasm and referred

muscle spasm and defined muscle spasm as involuntary
contraction (with electromyographic [EMG] activity) of a
muscle that is not dependent on posture.
Autonomic Phenomena
This is observed in extremely severe cases of MPS
(including abnormal sweating, abnormal tearing,
abnormal salivation, increased vasomotor response,
and increased pilomotor response)
The Basic Science of
Myofascial Trigger
Points
Studies on Taut Band
Studies on Myofascial Trigger Point Pain
Visual Analogue Scale (VAS)
- assess the effectiveness of a certain therapeutic
modality or technique for myofascial pain relief, subjective
pain intensity can be assessed with a numerical rating scale
- ranges from 0-10, with 0 representing no pain and 10
the worst pain that could be experience
Simons Integrated Hypothesis of
Myofascial Trigger Point
Three Essential features of MTrPs:
1. Excessive Ach release
2. Sarcomere shortening
3. release of sensitizing substance
 Excessive release of
acetylcholine in the
endplate

Increase of muscle fiber Release of sensitizing

tension (energy crisis) substance
MTrP Circuit - Spinal Cord Mechanism of
Pain, Referred Pain, and Local Twitch
Response
Irritation or sensitization of nociceptors can cause spontaneous pain.
Central sensitization can also cause spontaneous pain without stimulation of the nociceptors
Central sensitization is the main cause of MTrP activation in a remote lesion.
Nociceptors in an MTrP region connect to a group of dorsal horn cells (sensory neurons) in the
spinal cord.
These MTrP-related sensory neurons are responsible for central sensitization and for
transmission of pain information to the brain.
The neutral network with connections among these MTrP-related sensory neurons is defined as an
MTrP circuit.
Diagnosis of Myofascial Pain
Diagnostic Criteria for the Myofascial
Trigger Point
In clinical Practice, the identification of MTrPs depends on manual palpation and clinical
judgement.
-spot tenderness
-taut band Most important
-pain recognition criteria for
diagnosis of MTrP
PT MANAGEMENT
I S CHE MI C COM P R ESSION T H E R A PY
T HE R MOTHERAPY
Hot packs
Ultrasound
R A N GE OF M OT I ON E X E RCISES
ST R ETCHING
E L EC T RO T HE RAPY
Interferential Current
Transcutaneous Nerve Stimulation
MA S SAGE
L A S E R T HE R APY
N E E DLING
Myofascial Trigger Point Injections
 FIBROMYALGIA

AMIHAN, J.C. 2.SEM 17-18 SEM 201 BSPT4Y2-1

 FIBROMYALGIA
Is a disorder characterized by widespread musculoskeletal pain (Braddom)
FM is a common type of nonarticular, chronic pain involving the musculoskeletal system (De Lisa)
Researchers believe the disorder amplifies pain by affecting the way the brain processes painful sensations
Even though it is a disorder of the soft tissues, the tender points can be found at some joint lines.
 EPIDEMIOLOGY
F>M
Prevalence of fibromyalgia is approximately 2% to 4% (Braddom)
2% to 12% in the general population and primarily involving middle-aged women (379,380)(De Lisa)
Working women with fibromyalgia who are hospitalized for chronic musculoskeletal issues were almost 10
times less likely to return to work and 4 times less likely to retain work 1 year posthospitalization
 ETIOLOGY
The etiology of FM is still unclear.
There is also an increased incidence of depressive and anxiety disorders associated with a common
pathophysiological pathway in neurotransmission in patients with FM.
 PATHOPHYSIOLOGY
The pathogenesis of FM is unknown, but evidence suggests that it may be secondary to abnormal
processing of sensory stimuli in which sensory input is amplified at the brain and spinal cord, thus leading to
an increased experience of pain.
 SIGNS AND SYMPTOMS
It is characterized by widespread muscular pain, headache, fatigue, sleep disturbances, and
memory/cognitive problems.
Diagnostic markers involving both sides of the body, above and below the waist, and axial skeletal system
It is notable that there have been concerns that the defined criteria are too subjective, and that FM should
be classified as a functional somatic syndrome and not a rheumatologic disorder
 DIFFERENTIAL DIAGNOSIS
HIV
Persons with HIV are often fatigued for a variety of reasons, including fibromyalgia, pulmonary dysfunction, anemia,
encephalopathy, endocrine dysfunction, myopathies, cardiomyopathy, psychiatric disorders, and depression.
Fibromyalgia is commonly seen, and the response to traditional measures is generally good

Myofascial Pain Syndrome (MPS)

It is characterized by fascial contraction and trigger points in the muscles, causing pain and decreased range of
motion.
DIAGNOSTIC TOOL
 PT MANAGEMENT
Low-intensity aerobic exercise (walking, biking, jogging)
Stretching
Massage
Deep breathing exercises
Relaxing activities (yoga, qi gong)
Electrical Stimulation
 PHARMACOLOGICAL MANAGEMENT
Anticonvulsants (pregabalin)
Tricyclic antidepressants (amitriptyline, desipramine)
Dual-action, SSNRIs (venlafaxine, duloxetine)
Atypical analgesics (tramadol)
 REFERENCES
DeLisas Physical Medicine and Rehabilitation, Principles and Practice 5th edition
Braddoms Physical Medicine and Rehabilitation 5th edition
Pictures from the internet