Myofascial Pain Syndrome PDF

MUSCULOSKELETAL PHYSIOTHERAPY I UniT 2: Myofascial Pain Syndrome Madrid, February 2023 DEFINITION MPS “Set of signs and symptoms caused by myofascial trigger points (MTrPs)” Simons DG et al 2002. 2 DEFINITION MTrP “Hyperirritable area in skeletal muscle associated with a palpable nodule locate...

MUSCULOSKELETAL PHYSIOTHERAPY I UniT 2: Myofascial Pain Syndrome Madrid, February 2023 DEFINITION MPS “Set of signs and symptoms caused by myofascial trigger points (MTrPs)” Simons DG et al 2002. 2 DEFINITION MTrP “Hyperirritable area in skeletal muscle associated with a palpable nodule located in a taut band formed by muscle fibres. It is painful on stimulation and may give rise to characteristic referred pain, referred pressure hypersensitivity, motor dysfunction and autonomic phenomena". Location:  Muscle tissue  Fascia associated 3 DEFINITION MTrPs • The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. • Any MTrP must be distinguished from cutaneous, ligamentous, periosteal, or any other nonmuscular TP. 4 Historical Review • Century XVI: Guillaume de Baillou => “soft-parts rheumatism” or “nonarticular rheumatism”. • Century XVII: Thomas Sydenham (father of English medicine) => “Rheumatism”. • 1816: Balfour=> “patients with painful spots on palpation/compression and referred pain”. 5 Historical Review • 1841: Valleix => “only pressure/compression discovers exactly the extension of trigger points or painful points”. • 1843: Froriep => Associated/linked “rheumatism” with muscular painful points. • 1938: Kellgren=> introduced the concept of “referred pain”, which was specific to each muscle. 6 Historical Review • 1942: Travell and Rinzler => “ The miofascial genesis of pain” => They described 32 muscles with MTrPs. • 1983: Travell y Simons => • They published “The Myofascial Pain and dysfunction. The trigger point Manual”. • *Nowadays this is the referent academic book about MPS and MTrPs. 7 CONFUSION ABOUT RELATED DIAGNOSTIC TERMS Sciatic syndrome Muscular Rheumatism Tension Headache MPS Muscle spasm Tennis elbow Valleix´s points Fibromyalgia 8 CLASSIFICATION SPONTANEOUS PAIN MOTOR DYSFUNCTION (Muscle weakness + (according to clinical activity) ACTIVE MTrP LATENT MTrP YES NO YES YES Restricted ROM) * * fatigability, inhibition, in/discordination, stiffness… 9 CLASSIFICATION • According to location:: - Central MTrP - Insertional MTrP * According to their hierarchy (clinical): - Key or primary MTrP: responsible for the activation of other PGMs. - Satellite or secondary MTrP: central MTrP neurogenically or mechanically induced by the activity of a key or primary MTrP - Associated MTrP: 2 coexist without hierarchy. 10 CLASSIFICATION • Active TrPs: produce a clinical complaint (usually pain) that the patient recognizes when the TrP is digitally compressed, since the compression increases the spontaneous pain. Active TrPS SPONTANEOUS PAIN Latent TrPs NO SPONTANEOUS PAIN 11 CLASSIFICATION • Latent TrPs can produce the other effects characteristic of a TrP including increased muscle tension and muscle shortening (but do not produce spontaneous pain). • When the Latent TrP is digitally compressed is triggered the referred pain (that the patient recognizes) 12 CLASSIFICATION Digitally compression Active TrPS Increase Referred pain Latent TrPs Trigger Referred pain 13 CLASSIFICATION • ACTIVE TrPs – LATENT TrPs VS Clinically Relevant TrPs ¿¿ Is it possible to change the concept?? CLASSIFICATION • Clinically Relevant TrPs: A TrP that regardless of being active or latent, should be treated because of its importance in the clinical picture of the patient. • So….. Which TrPs should we treat???? 15 CLASSIFICATION • It is necessary treat latent myofascial trigger points if they have influence in clinical picture because they are able to cause: - Limitation of ROM and pain. - Muscle fatigue, weakness and muscle cramp. (Celik y Yeldan, 2011). Fatiga (Ge y cols.,2012) - local tenderness (Mense, 2010), muscle activity CLASSIFICATION. LATENT MTrP • Sensory disturbances: – Hyperalgesia (Mense, 2010). • Autonomic phenomena Referred pain (Xu et al., 2010) (Zhang et al.,2009; Kimura et al., 2009) • Clinical Relevance – Transformation into active MTrPs (Ge y Arendt-Nielsen, 2011) – Trigger point relevant in pain conditions (Gerwin, 2014) 17 DIFFERENCE ACTIVE vs LATENT MTrP • Active MTrP: - volume than the latent. • Active MTrP : - pressure pain threshold (PPT) and PH. sust. P, bradicinina, serotonin, noradrenalin, CGRP,… - Shah JP, Phillips TM, Danoff JV, Gerber LH. “An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle” J Appl Physiol (1985). 2005 Nov;99(5): CLASSIFICATION MPS • MPS is considered within “idiopathic muscle diseases” or unknown => as Fibromyalgia. • It belongs to the group of secondary chronic musculoskeletal pain. * (ICD-11, WHO) “ * arises from bones, joints, muscles, spine, tendons or related soft tissue”. 19 PREVALENCE • Latent MTrPs: Between 45-65% according to different clinical studies (Sola et al, Drewer,…). • Active MTrPs in patients with musculoskeletal pain: Between 21% (Frölich et al) in patients with lumgogluteal pain and 93% (according Gerwin) in patients with general pain. Gerwin RD: A study of 96 subjects examined both for fibromyalgia and myofascial pain. Musculoske Pain 3. (Suppl 2J.121, 1995 20 PREVALENCE – Latent MTrPs (in asymptomatic) by muscle…: – Upper trapezius: 78.8% (Lucas et al, 2008) – Any muscle of the shoulder girdle: 72% (Mutlu et al, 2016) • 77.3% pectoralis minor. 71,5 serratus anterior… – Any muscle of the lower limb: 70% (Zuil-Escobar, 2015). Gastrocnemi: 30-40% 21 PREVALENCE • Active MTrPs found in patients diagnosed with another disease: - Fibromyalgia……99%. Leblebici 2007 - Distrofia Simpático Refleja… 82%. - Knee osteoarthritis…. 75% Mayoral 2013 - Cervicogenic cephalea (headache)……. 100%. 22 PREVALENCE 100% prevalence of active PGMs in: – Tensional headache (Fernandez de las Peñas et al, 2010) – Mechanical cervical pain (Fernandez de las Peñas et al, 2007) – TMJ disorders(Fernandez de las Peñas et al, 2010) – Mechanical shoulder pain (Bron et al, 2011) – Subacromial síndrome/impigement (Alburquerque-Sendin et al, 2013) – Tennis elbow (Fernandez-Carnero et al, 2007) 23 SOCIAL IMPACT MPS High Prevalence. High Severity. High Cost 24 CLINICAL CARACTERISTICS (I)  Referred pain in specific patterns for each MTrP. Can be activated: Indirectly: Directly * Being ANTAGOnist. * Being AGOnist. * “Satellite MTrP”. 25 SCALENE MUSCLES 26 CLINICAL CHARACTERISTICS (I) ACTIVATION MTrP. • Directly: - Acute and/or cronic muscle overload. - Direct impact trauma. - Overwork fatigue. - Radiculopathy: Compression nervous syndrome or MTrP activated by radicular affectation. - Cooling. 27 CLINICAL CARACTERISTICS (I) ACTIVATION MTrP. • Indirectly: - Visceral Disease: Angina pectoris => MTrP Pectoralis Major. - Arthritic joints or joint disfunctions. - Emotional Distress: + Overload in accesory respiratory muscles. + Postural actitude. + Decrease pain threshold… 28 CLINICAL CHARACTERISTICS (I) ACTIVATION MTrP. Indirectly: They are activated from other MTrP: ♦ MTrP in agonist muscles => Weakness. ♦ MTrP in antagonist muscles => Restriction of Range of Motion. ♦ “Satellite MTrP” (Secondary or associated) => In zone of referred pain of another MTrP. 29 CLINICAL CHARACTERISTICS (II)  MTrP provokes symptoms in prescribed area (metameric relation????).  Symptoms are more durable than the cause.  Symptoms range (vary) their irritability during the day or the hours. 30 CLINICAL CHARACTERISTICS (II) • MTrP not only causes pain, it can also provokes other different symptoms like….. lacrimation, photophobia, excess of sweating,… Kimura, 2009 • ¡¡Vegetative component is very important!! • Increased likelihood of muscle spasm or cramps (Ge et al, 2008). 31 CLINICAL CHARACTERISTICS (II) 32 CLINICAL CHARACTERISTICS (III) Contraction against resistance  Pain Stretching  MTrPs provoke stiffness + weakness. ( NO provoke atrophy). * Because atrophy is the loss or wear of muscle tissue, due to disuse or neurogenic causes.  Limitation of mobility/elongation due to existence of taut bands (within the muscle) the 33 CLINICAL CHARACTERISTICS (III)  MTrPs refers deep referred pain zone. pain + dysesthesias in • Dysesthesia ≠ Paresthesia (both are sensory disturbance like tingles, numbness,…) => painful/ irritating ???  If we palpate a muscle with MTrPs we´ll feel the existence of taut bands and tight muscle. 34 CLINICAL CHARACTERISTICS (III) 35 CLINICAL CHARACTERISTICS (IV)  MTrP is palpated inside a taut band (nodule or hyperirritable spot).  If you press or compress MTrP is produced the “jump sign”.  Snapping palpation (sudden/fast) triggers “Local Twitch Response” (LTR). => Pathognomonic Response of MTrPs * Pathognomonic: Clinical sign or symptom that if it is presented ensures the patient has a particular disease 36 CLINICAL CHARACTERISTICS (IV)  Moderate or mantained pressure applied on a MTrP, triggers or pain/refereed symptoms. * Remember the difference between Latent and Active MTrP!!!!  Possible panniculosis (can be treated with skin rolling or suction cups). 37 CLINICAL CHARACTERISTICS (IV) CLINICAL CHARACTERISTICS (V) • MTrPs can induce motor activity in other muscles (referred pain). • EMG studies in MTrPs show spontaneous electrical activity (SEA). Ge, 2011 39 ESSENTIAL DIAGNOSIS CRITERIA (Classic) Travell y Simons  Taut band palpable (if muscle accessible).  Exquisite spot tenderness of a nodule in a taut band.  Patient's recognition of current pain complaint by pressure on the tender nodule (identifies an active trigger point)..  Painful limit to full stretch range of motion 40 CONFIRMATORY OBSERVATIONS • Visual or tactile identification of local twitch response. • Imaging of a local twitch response induced by needle penetration of tender nodule. • Pain or altered sensation (in the distribution expected from a trigger point in that muscle) on compression of tender nodule. 41 CONFIRMATORY OBSERVATIONS • Relief the pain after infiltration/ inyection (corticoid and/or local anesthetic). • Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band. 42 DIAGNOSIS CRITERIA • There is currently some controversy about the reliability of diagnostic criteria.… • Although according to international consensus (2017)… 43 PERPETUATING FACTORS “Factor/s that prevents the healing of a Myofascial Pain Syndrome despite of making a proper or correct treatment”. * The CLINICAL IMPORTANCE of factors that perpetuate myofascial trigger points (MTrPs) is generally underestimated. 44 PERPETUATING FACTORS - We should suspect its presence when… 1. The MTrP´s treatment doesn´t modify or change the symptoms. 2. Exist an improvement of clinical process, without total resolution of itself. 3.They are produced relapses frequently. 45 PERPETUATING FACTORS  Mechanical Stress: -Structural inadequacies: asymmetries, scoliosis,… -Postural stresses: Misffiting furniture, poor posture, inmobility,… - Constriction of muscle: pressure from the strap of a ponderous purse, tight shocks,… 46 PERPETUATING FACTORS  Nutritional inadequacies: deficiencies of vitamins B1B6-B12, folic acid, vitamin C, calcium, potasium,…  Metabolic and Endocrine inadequacies: Thyroid alterations, hypoglucemia, hyperuricemia (gout),… 47 PERPETUATING FACTORS  Psycological anxiety,… factors: hopelessness, depresion,  Chronic infections: viral disease (herpes simplex), bacterial infection, parasites,…  Others: -toxic habits (smoking, alcoholism) - Allergic rhinitis. - Impaired sleep. - Nerve Impingement. 48 Natural History of MPS BANDA TENSA PGM LATENTE Estrés PGM ACTIVO Recuperac. Espontánea Persist. Sin Progresión Factores Perpetuación SDM 49 NATURE OF THE MTrPs. Pathogenesis • ♦ Energy Crisis Hypothesis. • ♦ Muscle Spindle Hypothesis. • ♦ Neuromuscular junction Hypothesis. • ♦ Neuropathic Hypothesis. • ♦ Integrated Hypothesis. • ♦ Pain- spasm- pain cycle Hypothesis. • ♦ Fibrotic Scar Tissue Hypothesis. 50 NATURE OF THE MTrPs. Physiopathology • There is no scientific evidence that fully justifies the pathophysiology of MTrPs… • The existing hypotheses are mainly divided into: – Peripheral origin: neuritis, radiculopathy, integrated hypothesis,... – Central origin: Allodynia or central modulation 51 NATURE OF THE MTrPs. Physiopathology • The question also arises as to whether the MTrP is a primary peripheral (nociceptive) source or whether it is the result of activation by central sensitisation... (Fdez de las Peñas and Dommerholt, 2014). • - Primary peripheral => 2nd central sensitisation (treatment of MTrPs decreases central sensitisation) • - Primary central sensitisation: referred pain implies central sensitisation and if this ,the sensitivity of the MTrPs is increased. (Srbely et al 2010) 52 NATURE OF THE MTrPs. Physiopathology • Of all the pathophysiological hypotheses, the one with the most evidence and scientific consensus is the Integrated Hypothesis, which arises from the union of the Energy Crisis Theory and the concept of the neuromuscular junction. • The other hypothesis put forward have either been discarded (fibrous scar) or simply explain a partial aspect of the pathophysiology of MTrPs… 53 ENERGY CRISIS CONCEPT • The energy crisis concept was introduced in 1981 and was recently updated. • What is the “energy crisis concept”… “An hypothesis which postulates a vicious cycle of events that appears to contribute significantly to MTrPs” 54 ENERGY CRISIS CONCEPT • The function of the sarcoplasmic reticulum (SR) is to store and release ionized calcium that induces activity of the contractile elements, which causes sarcomere shortening… • And then…. 55 ENERGY CRISIS CONCEPT • 1. An initiating event such as trauma or a marked increase in the endplate release of acetylcholine can result in excessive release of calcium from the SR. • 2. This calcium produces maximal contracture of a segment of muscle which creates a maximal energy demand and chokes off local circulation. 56 ENERGY CRISIS CONCEPT • 3. The ischemia interrupts energy supply which causes failure of the calcium pump of the sarcoplasmic reticulum, completing the cycle… 57 HYPOTHESIS (I): ENERGY CRISIS (Travell 70´s) Excessive release of Calcium from the SR Mantained contractured of the sarcomeres Metabolism Local Ischemia Failure reuptake of Calcium into Sarcoplasmic Reticulum. ENERGY CRISIS In these areas (ischemic and hypoxic) the muscle releases cytokines and neurotransmitters => PH acidity and activation nociceptors 58 HYPOTHESIS (I): ENERGY CRISIS (Travell 80´s) 59 HYPOTHESIS (II): NEUROMUSCULAR JUNCTION CONCEPT  MTrP in EXTRAfusal fibers.  EMG recognition of MTrP as potential miniature plate.  This hypothesis argues that EMG spikes spread over 2.6 cm… whereas in Muscle Spindle the EMG spikes up to 1 cm (Simons)  Botulinum Toxin (type A) tests… acts only on the neuromuscular junction, effectively denervating that muscle cell 60 HYPOTHESIS (II): NEUROMUSCULAR JUNCTION CONCEPT Innervation Muscle Spindles => Noradrenalin. Innervation EXTRAfusal fibers => Acetylcholine • The toxin would not be effective if the MTrP was in the muscle spindle. HYPOTHESIS (III): HYPOTHESIS INTEGRATED (Simons 1997) Energy Crisis Hypothesis Neuromuscular Dysfunction Hypothesis • an abnormal increase in the production and release of acetylcholine packets from the motor nerve terminal under resting condition… 62 HYPOTHESIS (III): HYPOTHESIS INTEGRATED (Simons 1997)  1. Sustained depolarization of the postjunctional membrane of the muscle.  2. Endplate dysfunction.  3. Excessive release of ACh. in endplates.  4. Excessive release of Calcium ions from SR… ENERGY CRISIS CONCEPT 63 INTEGRATED HYPOTHESIS Endplates Dysfunction (video) 64 INTEGRATED HYPOTHESIS Energy Crisis (video) 65 INTEGRATED HYPOTHESIS (objetivables items) • EMG: SEA, motor plate noise (Ge, 2011). • Elastography: Observation of taut bands, and contraction evidenced (Sikdar, 2009). • ECO Dopler: difference in retrograde blood flow between active and latent MTrPs. Hypoxia due to capillary contraction (Sikdar, 2009).. • Ultrasound: Confirm that the volume of the active MTrP is > than the latent (Jay Shah 2009). • * Higher concentration of sensitising substances (Psubstance) and more acidic pH in active MTrP compared to latent MTrP (Sha, 2008). Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue. Siddhartha Sikdar, Ph.D., Jay P. Shah, M.D et al. Arch Phys Med Rehabil. 2009 November; 90(11): 1829– 1838 INTEGRATED HYPOTHESIS (objetivables items) NATURE OF THE MTrPs. Physiopathology  Of the other hypotheses suggested…  Muscle spindle concept:  Different studies (Hubbard and Berkoff, 1993; Gervitz et al 1994) tried to show that MTrP was located in intrafusal fibres... since the higher the vegetative stress, the higher the MTrP EMG activity..... • ¡¡¡ INFLUENCE OF ANS (vegetative) ON MTrP ACTIVITY!!! * Complementary evidence for the integrated hypothesis (Ge et al 2006) 68 NATURE OF THE MTrPs. Physiopathology • The Neurogenic Hypothesis, without being exclusive, is based on the MTrP "being part of a dysfunction of the PNS (radiculopathy)" (Gunn 1980, 1998), or that MTrPs would be "neurogenic manifestations of pathologies 1a in the same neurological segment" (Srbely 2010). NEUROMUSCULAR JUNCTION CONCEPT 69 NATURE OF THE MTrPS. Structure • Taut band. • Contraction of sarcomeres in MTrP. • Elongation of neighboring sarcomeres. • “Sarcomere is a structure with constant volume”. 70 NATURE OF THE MTrPS. Structure. • “Sarcomere has constant volume”. • If it´s shortened => “fattens”. • If it´s lengthened => “thins/slim down” MTrP structure (video) 71 PALPATION MTrP (perpendicular)  FLAT PALPATION - Accessible muscles against a firm underlying structure, such a bone. - Muscle in slight stretch. - Palpation of Taut bands. - Example: Infraspinatus.  DEEP PALPATION - Deep muscles. - Palpation of regions of muscle tension. - Example: Iliopsoas.  PINCER PALPATION -Examination of a part by holding it in a pincer grasp between the thumb and finger. Example: Sternocleidomastoid 72 PALPATION MTrP 73 MYOFASCIAL PAIN SYNDROME TREATMENT 74 PHASES OF THE MPS TREATMENT • 1ª Phase: Pain control - Treatment of the active and latent MTrPs (clinically relevants!!!). • 2º Phase: Control of the etiological factors and perpetuating. - Mechanical and/or postural. - Systemics and/or metabolic. - Neurodinamic. - Muscle conditioning…. 75 TECHNIQUES OF MPS TREATMENT • CONSERVATIVES • INVASIVES 76 RULES FOR THE TREATMENT OF MPS • 1º. Treating proximal MTrPs before than the distals. • 2º First treat the medial MTrPs, before than the laterals (multifidi). • 3º If exist any restriction of mobility like “comparable sign” in the muscle => treat the MTrPs within the muscle. RULES FOR THE TREATMENT OF MPS • 4º. First we will treat the muscles which we find “tight”(although they would be asymptomatic) => they will be antagonists of the symptomatic muscles. • 5º. => Among 2 MTrPs in the same muscle => first we will treat which is in the center of the muscle RULES FOR THE TREATMENT OF MPS TECHNIQUES OF THE CONSERVATIVE TREATMENT MTrPs 1. STRETCHING 1.1.- Analytical 1.2.- Spray and Stretch 2. MASSAGE THERAPY 3. THERMOTHERAPY 4. ELECTROTHERAPY 5. COMPRESSION Tech 5.1.- Ischemic Compress. 5.2.- Intermittent Comp. 5.3.- Trigger point pressure release. 6. MUSCLE ENERGY TECHNIQUES 6.1.- Lewit 6.2.- Mitchell 7. INHIBITORY Techniques 7.1.- Jones 7.2.- Chaitow 8. SWISS APPROACH 80 TREATMENT Techniques 1. STRETCHING 1.1.- ANALYTICAL   30” (if use an active stretching= 10”) With muscle contraction ??? 1.2.- Spray and stretch   Stretching => Action of cold = Distraction. Gate Control theory… “non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain”… Melzack and Wall 1965. 81 Spray and stretch 1º Apply TREATMENT Techniques the spray on the relaxed muscle. 2º Stretch the muscle + apply the spray (on the muscle + referred pain zone). 3º Increase the stretching and repeat the step 2… 4º 3 applications of the spray (in total) and then moist heat. (15-20 min.)  Consider/ take into account… … Contraindications 82 Spray and stretch TREATMENT Techniques TREATMENT Techniques 2. MASSAGE THERAPY  Kneading.  Vibration.  Longitudinal stretching or Deep longitudinal friction.  Fascial Massage.  Percussion and stretching technique.  Neuromuscular technique (NMT) in MTrP + Referred Pain zone. 84 TREATMENT Techniques 3. THERMOTHERAPY  Moist heat (15- 20 min). 4. ELECTROTHERAPY  TENS  Diadinámicas (DF 5´+ LP5´)  US  Combination therapy  Laser (TMJ) (Uemoto et al 2013)  Biofeedback 85 TREATMENT Techniques 5. COMPRESSION TECHNIQUES  Compression MTrP Pain thershold Relaxation of the taut band + MTrP  After compression techniques should stretch.  Associated with other techniques  Advantages:  Effectiveness.  No Contraindications.  Minimally invasives.  Self-enforcing. 86 TREATMENT Techniques 5.1.- ISCHEMIC COMPRESSION Travell 1º Place the muscle in slight stretch. 2º Locate MTrP. 3º Compress until the patient feels pain. 4º Maintain pressure. 5º When the patient stops feeling pain turn to compress. 87 5.1.- ISCHEMIC COMPRESSION Repeat step 5 again until a maximum time of 90”-120”. (No consensus), or until, despite increasing the compression, we are not able to reproduce the referred pain again.  At the end you must perform a stretching technique. • useful technique when the patient is able to correctly feel the variations in the intensity of the referred pain 88 5.2.- INTERMITTENT COMPRESSION TREATMENT Techniques 1º Compress MTrP until the pain appears (local or referred). 2º Maintain pressure 5” 3º Relaxing pressure 5” 4º Compress 5”  5 – 6 repetitions.  Pression and Intensity ALWAYS EQUAL. In 3rd – 4th rep referred pain disappears. In 4th - 5ªth rep local pain or disappears. • useful technique in very irritable MTrPs 89 TREATMENT Techniques 5.3.- TRIGGER POINT PRESSURE RELEASE  Similar to “ischemic compression”.  Difference: WE DON´T LOOK AT THE (PATIENT) REFERRED PAIN. 1º Identified MTrP. 2º Compress until the patient feels pain. 3º We wait that the muscle tension 4º We increase the intensity of pressure until the patient feels pain again. 90 5.3.- TRIGGER POINT PRESSURE RELEASE Repeat step 4 again until a maximum time of 90”-120”. (No consensus), or until, despite increasing the compression, we don´t feel muscle tension under our fingers.  At the end you must perform a stretching technique. • * useful technique when the patient is not able to correctly feel the variations in the intensity of the referred pain 91 TREATMENT Techniques 5.4.- COMPRESSION MTrP + CONTRACTION • Location of MTrP and compression to trigger local pain and / or referred. • Ask concentric or isometric contraction (5-6 sec) of the muscle to treat. • Maintenance of these contractions until the disappearance of symptoms. • useful technique when the patient only feels pain in an specific movement. 92 6. MUSCLE ENERGY TECHNIQUES TREATMENT Techniques techniques that take advantage muscle contraction 6.1.- POST-ISOMETRIC RELAXATION (LEWIT)  Objective: Active Relaxation of the muscle (NO ELONGATION).  Combine 4 elements:  Smooth/easy isometric contraction.  Breathing.  Eye movements.  Gravity. 93 6.1.- POST-ISOMETRIC RELAXATION (LEWIT) • We have to combine the 4 elements at the same time: • Isometric contraction (25% of maximum intensity during 10 seconds), against the gravity force, while the patient is inhalating and looks to the side the contraction occurs. • Then the patient has to relax the contraction, exhalate and looks to the other side. • We repeat this cycle 10 times (contraction-relaxation). 94 TREATMENT Techniques 6.2.- MUSCLE ENERGY TECHNIQUE (according to MITCHELL). “Stretching post – contraction”  Objective: Inhibit muscle spindles.  4 types of contractions:  Isometric.  Isotonic Concentric.  Isotonic Eccentric.  Isolitic  2 protocols:  Isometric.  Eccentric 95 6.2.- MUSCLE ENERGY TECHNIQUE (ISOMETRIC PROTOCOL) 1. Maximum stretching 2. Isometric Contraction 5” – 7”. 3. Relaxation 2” – 4”. 4. During the relaxation, we have to increase the stretch.  Repeat cycle 3 – 5 times. • It is the same as hold-relax technique of stretching Muscle Energy. Isometric Protocol. Iliopsoas (video) 96 6.2.- MUSCLE ENERGY TECHNIQUE ECCENTRIC PROTOCOL  Similar to the isometric protocol.  We have to perform 5 eccentric contractions (from shortening position to elongation position).  Difference: eccentric contractions NO MAXIMAL (the patient allows “we to win”) Eccentric Contractions triceps (video) 97 TREATMENT Techniques 7. INHIBITORY TECHNIQUES 7.1.- STRAIN/COUNTERSTRAIN (JONES TECHNIQUE) “Spontaneous Release by positioning technique”  Osteopathy treatment). technique (diagnosis and  Objective: Inhibit muscle spindles . 98 7.1.- STRAIN/COUNTERSTRAIN (JONES TECHNIQUE) 1º Palpate MTrP (local/referred). + trigger the pain 2º Place the muscle in NO pain position (usually is the shortening position). 3º 90” in this position (without maintaning pressure). Jones technique in Iliopsoas (video) 99 7.2.- INTEGRATED neuromuscular inhibition technique (CHAITOW - 1994) TÉCNICAS TTO 1º Ischemic or intermittent compression. 2º Jones 20” – 30” without pressure in MTrP. 2 ways to continue: 3º Excccentric ( 5 rep/times). 3º Isometric 7”-10” in NO pain 4º Massage+Thermot.+Repose 24h Position. 4º Analytical Stretching (*contraindic.) (*stiff) Chaitow technique in Upper Trapezius (method 1) (video) 100 TÉCNICAS TTO 8. ABORDAJE SUIZO (Swiss approach) 1º Sustained compression in MTrP + 10 contractions. 2º Ischemic compression or TrP pressure release. 3º Local stretching (MTrP) x Massage (10 repeats) 4º Fascial massage (kneading, skin rolling). 5º Manually releasing the fascia between two muscles. 6º Analytical Stretching (with/without cold spray). 7º Self-stretching. 8º Moist heat. *** Dry needling (deep/ superficial ??) at the beginning or end. 101 INVASIVE TREATMENT OF Myofascial Pain Syndrome 102 INVASIVE TREATMENT OF Myofascial Pain Syndrome • INFILTRATION CHEMICAL SUBSTANCES • DRY TECHNIQUES 103 INFILTRATION CHEMICAL SUBSTANCES • ANALGESICS. • CORTICOSTEROIDS (Betamethasone, Dexamethasone,…). • LOCAL ANESTHETIC (Mepivacaine, Lidocaine,...). • BOTULINUM TOXIN. 104 INFILTRATION BOTULINUM TOXIN A (BTA) • Chemical and localized denervation, very specific and irreversible. • Relaxation of the involuntary muscle contracture, slowly and progressively (= decrease pain)… • Start (1-5 days) - Maximum effect (2-3 weeks) – Duration (3-6 months). INFILTRATION BOTULINUM TOXIN A (BTA) • Functional reinnervation : - Reinnervation and hypertrophy of endplates. - Formation of new endplates. - Increase of muscle fibers inervated by an axon. 106 INFILTRATION BOTULINUM TOXIN A (BTA) DRY TECHNIQUES • DRY NEEDLING: - Superficial: The needle doesn´t reach the MTrP. - Deep: The needle goes through the MTrP. • PERCUTANEOUS ELECTROESTIMULATION OF THE MTrPs. • ELECTROACUPUNCTURE(wrong word/concept) • INTRATISSUE PERCUTANEOUS ELECTROLISIS (EPI). 108 DRY NEEDLING “Introduction of needles through the skin, without injecting or extracting any substance, seeking only the mechanical stimulation of their insertion and manipulation.” (Mayoral y cols, 2009) 109 SUPERFICIAL DRY NEEDLING • Needle in cutaneous and subcutaneous tissue. • TYPES: - Peter Baldry Technique (2001). - Fu´s subcutaneous needling => movement in subcutaneous layer and leave the catheter under the skin. 110 SUPERFICIAL DRY NEEDLING • Central analgesic mechanisms(Cagnie, 2013; Hsieh et al 2014): - Activation of the descending inhibitory system. - Segmental inhibition (Gate control theory). Beta fibres. A- - Endogenous opioid peptides. - Diffuse inhibitory control of pain. - Placebo... 111 SUPERFICIAL DRY NEEDLING (According to Baldry) • Step 1: Measure the sensitivity of the MtrP to palpation (algometer preferably). • Step 2: Insert the needle 5-10 mm, and maintain it 3-5 seconds. Measure the sensitivity again and if the local sensitivity doesn´t low (decrease) • Step 3: Insert the needle again, and keep the needle 30 sec. without manipulating 112 SUPERFICIAL DRY NEEDLING (According to Baldry) • Step 4: If the local sensitivity doesn´t low (decrease) => I return to insert needle 2- 3 min. • Step 5: If the local sensitivity doesn´t low (decrease) => insert needle and “roll up”/”wind up” it (A- Delta) and keep it (needle) 10-15 min. • Variability of time according to sensitivity. 113 SUPERFICIAL DRY NEEDLING (According to Baldry) superficial dry needling (wind up) vastus lateralis (video) 114 DEEP DRY NEEDLING • Needle goes through the MTrP. • Needles (types): Specific needles for dry needling (different lengths and thickness). Length: From 12,5 mm to 75 mm. Thickness: 0,16 mm to 0,32 mm. • Trigger (reproduce) the referred pain, when you reach the MTrP 115 DEEP DRY NEEDLING • ¡¡¡¡¡¡Importance of the Local Twitch Response!!!!!!. (associated with the effectiveness of the technique). Hong 1994 • “Rod phenomenon”: the needle can be used as a “palpatory tool”. • Needle effect Lewit, 1979 => inmediate analgesia without hypesthesia, immediately after needling. • Therapeutic efficacy = infiltration. (Hong 1994)…….. If the LTR is produced when the needle is inserted 116 DEEP DRY NEEDLING DEEP DRY NEEDLING • Techniques: - “Fast-in and Fast-out technique”(Travell, Simons, Hong,…) => until LTRs disappear. - Lewit technique: 1 or 2 LTR. - Gunn technique: needle in multifidus related with the pain areas of the patient (metameric relation??). • There seems to be a greater clinical effectiveness or greater clinical relevance of the improvement when exhausting LTRs... (Fdez Carnero, 2017).… 118 DEEP DRY NEEDLING • Analgesic mechanisms : the same as the superficial dry needling +….. - “Washing” of sensitizing substances. (P substance, cytokines,…). (Hsieh 2012) - Mechanical destruction of the fibers and/or endplates affected. Further regeneration. (Domingo et al, 2013. Dry needling analgesic mechanisms (video) 119 CENTRAL EFFECTS DRY NEEDLING 120 DEEP DRY NEEDLING • Risks: - Pneumothorax. - Nerve injury, mioedema,… - Infection, bleeding,… - Vasovagal syncope, children??,.. • Absolute Contraindications: - Refusal by the patient. - Deep muscles in anticoagulated. Caution in AIDs (Acquired Immunodeficiency Syndrome) , transplanted and lymphadenectomy patients. 121 DEEP DRY NEEDLING • Post-needling Treatment: - Spray and Stretch. - Longitudinal stretching of the MTrP - Physical exercise / TENS (acup). - Moist thermotherapy. - Free Active Mobilizations - Self- Stretching (24-48h). - Ischemic Compression (Soo A Kim, 2013) DEEP DRY NEEDLING Deep dry needling trapezius muscle (video) 123 PERCUTANEOUS ELECTROESTIMULATION OF THE MTrPs. • Can be superficial or deep. • Tweezers clasped to the needles: - 1 needle each side of MTrP. - 1 inside of the MTrP and other outside. - The 2 needles in the MTrP. Dose: - 1-10 Hz, 40 mseg. - High intensity (tolerance). - Short application (10-20 min). 124 PERCUTANEOUS ELECTROESTIMULATION OF THE MTrPs. Percutaneous electroestimulation (video) 125 INTRATISSUE PERCUTANEOUS ELECTROLISIS (EPI/EPTE). • Ultrasound- guided application of a specifically designed and controlled continuous current through a needle. • The primary objective is to produce a nonthermal electrolytic ablation that induces a highly controlled inflammatory response. 126 INTRATISSUE PERCUTANEOUS ELECTROLISIS (EPI). • This activates the cell mechanisms involved in phagocytosis and the repair/regeneration of affected tissue. 127 INTRATISSUE PERCUTANEOUS ELECTROLISIS (EPI). EPI in Patellar tendon (video) 128