Case Report: Myofascial Pain Syndrome

hello and welcome to the spine and nerve podcast my name is dr brian hovas and my name is dr nicholas carlos and thank you guys all for listening we are going to be wrapping up our month-long discussion and dive into myofascial pain syndromes and so if you have not already listened to the prior two episodes we did an introductory episode and then actually dove into some recent literature talking about some neuroinflammatory markers in the spectrum of myofascial pain syndromes specifically looking at things like fibromyalgia and so please refer back to those if you want a bit a little deeper dive into some of the science and background thought process behind this but today we're going to dive into a case report and so dr k had a very interesting case that kind of ties a lot of this together and i think will be a good launching point for us talking about some of the options that we have as we start thinking about treating these patients and helping them uh get back to as normal life as possible and and enjoying things again so uh dr k take it away yeah so as dr hobas said you know in terms of this format of uh you know going over the basic science of the topic and then uh having a journal article and then a patient case presentation so this specific patient is a 36 year old woman she works in the operating room as a surgical tech predominantly for spine cases so for any any of us who have been in operating room for spine cases we know those are very long arduous cases this patient's otherwise healthy and she's presenting with chronic and worsening moderate to severe bilateral neck and shoulder region pain with intermittent radiating symptoms into her upper limbs but in variable patterns i just want to go over the physical exam and then we'll talk about uh i won't necessarily go immediately into the diagnostic workup that she had because we'll talk briefly about how we'd want to approach this uh both from a treatment and a diagnostic perspective but on physical exam she did have uh multiple taught bands in the cervical paraspinal and periscapular region with palpable trigger points which if we remember uh you know would be defined by uh reproducing uh so exquisitely tender uh uh spots that uh reproduce her symptoms um uh with a palpable twitch at times uh and you know pain um they would shoot to a distant location and like i said would reproduce some of her symptoms as well she did have decreased range of motion of her cervical spine and no clear neurologic deficits on a neurologic exam so you know what i think a couple of uh key points uh from this presentation because i think it's in terms of a presentation of uh a significant component of myofascial pain for the patient this is a fairly common presentation in terms of the age group so as we know you know the 20 to 50 year old range women tend to have a little bit increased risk of having this myofascial pain presentation um so we have a middle-aged uh you know young middle-aged woman here um and her job obviously uh you know stressful and uh requiring being in uh potentially less than ergonomic you know less than ideal uh positions for sustained periods of time so she definitely has you know multiple risk factors now when we think about the management here as we've brought up over and uh over and over again in terms of how we strategically go about approaching these type of situations we think about our algorithm of lifestyle modifications activity modifications therapies medical equipment medications procedures surgery diagnostic work further diagnostic work as well as consults and so i think in her case starting with the diagnostic workup because whenever we have a situation like this you know uh she's young otherwise healthy but we want to make sure you know even if we have a strong suspicion that this is predominantly myofascial pain we want to make sure we rule out other disease processes so you know in her case after a thorough physical exam a thorough neurologic exam making sure we don't find any neurologic deficits and also in our history making sure we don't hear any red flag you know signs or symptoms after doing that from a diagnostic workup perspective especially considering you know she does have some radiating symptoms into the upper limbs we wanted to make sure we got imaging of the neck in terms of a cervical x-ray and um considering the chronic and refractory nature of her symptoms and how much it was impacting her in terms of her ability to do her work we also felt it was reasonable to get an mri uh as well as a emg nerve conduction study to rule out uh any uh neurologic compromise at the level of the cervical spine so bottom line after we did that diagnostic workup her x-ray mri and emg nerve conduction study all came back largely within normal limits just a little bit of straightening of the cervical spine which we oftentimes see uh in the setting of chronic uh increased muscle tension so you know that's our case presentation and like i said um you know that was the initial diagnostic workup so now in terms of thinking about the treatment options i think dr hoban hobez and i will kind of go back and forth here from a treatment perspective but you know like i said when we think through that algorithm we brought up you know starting with lifestyle modifications unfortunately you know obviously we can do the best we can but with her uh position and what she has to do on a day-to-day basis for a job you know it's not like a desk job where you can get a sit-to-stand station um which obviously are is very useful when you do have those type of occupations in terms of optimizing the workplace uh because as long as there's that sub-optimal uh posture biomechanics in terms of you know head forward positioning and uh maybe not having things at the the perfect level um when you're typing or working on the computer or talking on the phone um but obviously in this specific case for this patient we don't have that luxury because she's in the operating room and it's a little more difficult to have ergonomic evaluation and implementation in that setting in terms of therapies you know very much so from a physical therapy standpoint the flexibility stretching range of motion and myofascial release techniques are going to be critical in these situations but as always emphasizing to the patient that what they learn in the in the therapy sessions is going to be critical to continue long term because those 8 or 12 sessions that are authorized by the insurance and that they're able to do sure can be helpful but it's really the home exercise program that they maintain long term that's going to be the foundation of anything we do and i you know whatever not just myofascial pain but any pathology we're dealing with we always emphasize that to patients that you know regardless of the medication procedure or even minimally invasive surgery that we do the foundation remains that uh consistent you know home exercise program that they're doing at home um so then moving to uh medications you know from an oral medication standpoint uh you know there can be some utility especially if you look at the literature you know oral not shockingly oral non-steroidal anti-inflammatory medications have some decent data in terms of treating myofascial pain uh and obviously we've brought up before things like baclofen or tarzaniting the thing we you have to be careful about with medications like back within tasanidine especially during the daytime for these patients is any compromise to their you know making them a little more drowsy or compromising their ability to do what they need to do at a high level occupation um so that's you know where the oral and anti-inflammatories may come into play however in a young person like this we don't want to get them in a situation where they're taking 800 tid of ibuprofen for years and years we want to be cautious with that and the potential systemic side effects of that so as dr hobes and i brought up before this is where topical medications can really be uh utilized and helpful um we've we've mentioned before the studies that show that for most topicals the systemic uptake is going to be uh you know drastically uh different compared to obviously oral administration just as an example you know for diclofenac typically most studies are going to show that you have less than five percent uh systemic circulation of the diclofenac compared to if that was to be administered orally when you're given it topically um so from from a topical standpoint obviously we have you know topical lidocaine topical uh non-steroidals in the form of diclofenac but you know definitely compounded topicals when viable you know when practical for the patient can be very powerful you know in terms of combining uh local anesthetics sodium channel blockers with anti-inflammatories and potentially some other substances we brought up cbd topical cbd in the past as well um so yeah just just to emphasize you know in these specific situations when we think about the pathophysiology which we've reviewed in detail in terms of myofascial pain the topicals can definitely serve a strong purpose yeah i mean i think one of the things that we continuously emphasize with patients as we're talking about this myofascial pain syndrome is like we've referred to in the prior episodes uh you know there's there is this large component of central and peripheral sensitization uh that's that's happening for a lot of these patients uh and so it is you know it is more than you know muscle pain or tight bands and things along those lines there there's so much uh it's so much deeper than that for many of these patients that have been living with this for a long time and so it's not always going to be a one-stop shop for you know just do this and it's going to be fixed right and so um you know unfortunately or unfortunately there there are not a lot of phenomenal uh things in the more invasive realms of of medicine right there's no great surgical intervention uh you know i'd say that uh we're still evolving some of the interventional options you know i mean i think that there probably is going to be in the future some role for things like peripheral nerve stimulation um but that it's it's still evolving in terms of of the literature you know and then you already brought up the challenges with a lot of the medications um you know you know we've talked before about you know even just neuropathic agents and you know the number needed to treat to be able to you know get benefit from from these patients uh and then the the risks of it especially for somebody who does have a job that requires her to be on top of her game at all times and so you know really focusing on that earlier end of the spectrum right where you have things like physical therapy chiropractic you know massage therapy acupuncture topical ointments exercises stretches postural training um you know man i you know i for the for patients like this that have been dealing with pain for you know five to ten years they've been in and out of you know various treatment modalities i love pool therapy right i mean i think there's so much to you know getting in the pool being able to you know move in a slightly less painful manner because of the the water being able to provide some buoyancy so that you don't have the pressures of you know all of the different anatomic structures on you and so i think that when we start focusing them on those earlier components so they don't think that there's a magic wand somewhere farther down the treatment algorithm and then we start thinking about you know emphasizing the consistency emphasizing the consistency emphasizing the consistency these are things that we have to think about our posture at all times we have to you know think about our home exercise program and our stretching and and staying on top of you know if we're utilizing topical ointments you know it's it's using them consistently because it's we have to continue to fight against that central and peripheral sensitization that's happening um and then just continuing to build on it right i mean i know one of uh one of our mentors in one of our attendings when we were in residency had the greatest spiel in the world on uh on myofascial pain especially kind of that uh neck and perry scapular pain because he dealt with it right so he had this phenomenal thing where he would go through uh you know ergonomic evaluation with a patient and talking about how to properly set up your desk and how to set up your workstation so that you can try your best to be able to keep your you know your head back and your ears over your shoulders so that you're not putting too much stress on that musculature as it's trying to support our our heavy heads um yeah yeah no definitely yeah a shout out to dr shin uh awesome person an awesome doctor but uh yeah so uh you know that i think what you brought up is a good segue to one of the things we want to discuss here towards the end in terms of what are the interventional options uh for you know for this for this disease process and you know as you mentioned we had gone into great detail with with myofascial pain um the myofascial tissue you know is specifically prone although it takes a little bit of uh you know initially it may be a little bit more resistant to the um to the development of this chronic pain situation but ultimately the myofascial tissue is uh very susceptible to the development of central and peripheral sensitization and we talked about the objective findings that we see in in terms of the biochemical uh meiloo at uh you know in the muscle tissue itself seeing you know abnormally high levels of substances including you know substance p uh cgrp calcitonin gene related peptide uh amongst others and seeing changes at the level of the dorsal horn and we talked about the interplay between the uh the primary ethers from the myofascial tissue uh going to certain laminas where the wide dynamic range neurons tend to be present and then that contributing to the diffuse uh and referred patterns of myofascial pain and the difficult nature of treating it and we talked about the um the changes that can occur even in terms of uh uh apoptosis and loss of inhibitory neurons so the bottom line is i think when we because dr hubbard was mentioning consistency i think that's the huge educational component to when you're telling a patient look we think that myofascial pain is playing a huge role here uh when you know not by any stretch of the imagination minimizing the uh what they're going through in fact we're emphasizing how critical you know significant and consistent therapies are because this this process that has occurred you know has now deep roots in the nervous system and we have to have a long-term and consistent plan to try to have a positive impact on that um when we talked about the pathophysiology one of the things we talked about was that increased calcitonin gene-related peptide and some of the consequences of that include uh increased acetylcholine in that junction that neuromuscular junction uh an abnormally high amount of it an impairment of acetylcholinesterase and increased acetylcholine receptors on the postsynaptic junction junction and the theory that that consequently leads to this vicious cycle of continued muscle contraction which obviously can ultimately be very painful and decreased range of motion uh and like i said create that vicious cycle so that brings us to the thought process of okay do trigger point injections have value because when you're utilizing the needle you're trying to mechanically disrupt that vicious cycle and the end plate and and trying to get it back to a more normal healthy state um so i just wanted to bring up i know this isn't journal club but i didn't want to bring up uh one article that i thought was uh particularly relevant for us so this was a article published by dr king and colleagues out of md anderson in houston texas it was a recent literature review published in the journal of anesthesiology and pain therapy in november of last year 2020 and the reason i bring this up is because obviously when we think about myofascial pain we think about trigger points and we think about trigger point injections i think there's so many different providers who do that uh you know primary care physicians and nurse practitioners physician assistants obviously interventional pain doctors you know it's a very common procedure to do and so understanding the research out there i think is is helpful and essentially one of the thoughts that you know comes up all the time uh you know i remember through residency fellowship i heard all sorts of different opinions from different attendings in regards to this i'd be interested to hear dr hoviz's approach as well but you know the question is what injectate to use do you use local anesthetic to use normal saline to use local anesthetic wistero to use botox and so you know as always when we're thinking about what to utilize for the patient of course there's the art of medicine every patient is different and you know what works well for each patient obviously needs to be taken into account as well but especially in terms of that initial choice that you make we want it to be you know as evidence-based as possible and so uh that is what the this article attempted to do so essentially the purpose was to compare the efficacy of normal saline versus botulinum toxin a versus local anesthetic versus uh look on a set with and without a steroid and ultimately 13 studies met their uh inclusion criteria of essentially evaluating the safety and efficacy of these different injectates comparing them and as this review acknowledges there is absolutely conflicting data currently out there and there is research including that by dr uh cardis and colleagues demonstrating that there are potentially superior results with local anesthetic versus normal saline in certain trials that being said at this time when you look at the totality of the evidence and synthesize all of the research that's out there ultimately there is currently no consistent significant differences in outcomes between the different injectates so the conclusion at least of these authors in this recent review was that when you're deciding on what substance to use that you ultimately take into account the potential side effects and cost and so that's why they advocated for the initial utilization of normal saline for their uh how they approach their trigger point injections and of course like i said i think that we you know continue to need more evidence and studies and i think that it does become somewhat patient dependent uh and also what you've seen in your own clinical practice but i think this this research is valuable and especially if you are trying to figure out okay what do i want to start with in this uh in these patients because when we think about you know uh especially if we're using utilizing uh botulinum toxin um uh botox you know there it obviously is a significant cost associated with that obviously there are certain conditions um that you know botox has really good evidence for example you know in terms of uh treatment decreasing the uh frequency and the severity of headache migraine headaches you know obviously uh botulinum toxin has really good evidence there but in terms of treating a simple uh i don't wanna say that in terms of uh treating in terms of i know we just emphasize how it's not simple but in terms of treating uh myofascial pain and trigger points um uh at least based upon the current evidence in terms of head-to-head comparisons there's no clear definitive evidence currently that botox would be superior to normal saline and or local anesthetic chronic anesthetic with steroids yeah i mean i think this is where a lot of that art starts playing in right i mean the challenge with looking at studies like these and you know trying to put all studies together for trigger point injections is that there's generally a range and spectrum of patients that you're treating right yeah i mean i think i think what this really says is the best place to start is with the cheapest medications possible because a lot of people respond to trigger points right so whether that's normal saline i tend to use local anesthetic just because we have local anesthetic readily available and you know it's usually already open in multi-dose vials so that we can easily utilize that for patients um and then slowly working up you brought up earlier the steroid conversation and i think that most people i shouldn't say most people i think many people within the pain and uh physiatry worlds uh would kind of die on the soapbox of saying no ster no steroid with trigger point injections and you kind of really kind of hearken that home because i i personally have not seen any literature that would suggest that there is a role for steroids in that process um or anything that would suggest that it you know can provide any you know more significant longer-term benefit i think the challenge becomes when you start thinking about botox and and and for the record i don't use botox i'm uh in this setting and i it's not something that is a part of my personal clinical practice um but if you're thinking about the central and peripheral sensitive sensitization process and we're thinking about some of the theoretical ways that botox works especially in smaller dosing when we're not thinking about it purely as a way of you know inhibiting muscles from firing there's a lot of science behind the fact that botox can work on that peripheral sensitization process and so i think we have to understand that you know when you're trying to draw multiple studies looking at trigger point injections you're looking at a wide spectrum of patients and so you know i've i have seen a lot of patients that have had trigger point injections with botox done by other providers that have had great success with it and they never responded to some of the kind of earlier steps of that intervention uh cascade yeah i think that's a great point and yeah to your point when you think about the pathophysiology of myofascial pain and the mechanism of action of botox it makes a lot of sense and like you said i think taking that stepwise approach maybe i start with local anesthetic and or normal saline but if their symptoms are refractory and i really you know after a thorough workup i really believe that this myofascial pain is the primary cause of their symptoms and then at that point i think it's reasonable to start to think about that in the refractory setting um a couple of things you had brought up in terms of sterile yeah you know i absolutely agree a couple of things to think about are that number one you know these are relatively superficial injections and so you definitely have to worry about a subcutaneous atrophy with the injection of the steroid and then plus these patients most likely may be getting oftentimes epidural steroid injections or joint injections you know if they're in that chronic pain setting and so you know in terms of just being aware of their overall steroid burden and trying to optimize uh you know that component of it i'm adding something to the trigger point injection that may most likely at least based on the best evidence probably not have a huge uh drastic uh uh change positive change in their outcome uh uh you know um potentially um potentially adding uh unnecessary risk for the patient um and then uh the other thing i would mention too i think that one of the take-home points from this article as well is that it's really that uh mechanical disruption of the trigger point with the needle um uh as well as diluting that abnormal biochemical milo that we brought up as well because you know normalcy and local anesthetic botox they're all going to accomplish that right the needle is going to have the mechanical disruption and then the substance is going to dilute so that seems to play a critical role as you brought up you know botox as well as local anesthetic has some good mechanism mechanisms of action to have a positive impact on that uh peripheral sensitization component of it but um yeah no i think all great uh points all right in closing i have i have one thing that i'd like to ask you as we uh released the last episode um there was actually somebody who took offense to the title and you titled it i i as you guys may have noticed our titles have gotten more professional over time that's because dr carvalhos thought that my jokes were stupid and uh told me not to name our uh our uh our podcast idiotic things um somebody took offense to our title oh really which was myofascial pain disorders right uh that are uh that was i think that was the the phrase that you had used uh in the title um and um and i wasn't quite sure where to take it because he was quite aggressive about saying how he didn't believe in that for that phrase um and my response was well this is this is common nomenclature right we're just utilizing you know myofascial pain syndromes obviously i'm if you're watching on video or holding up this paper it the paper utilizes myofascial pain syndromes uh in the title and so um you know i i would like your opinion on uh on that i think uh i think his take was obviously that there is a lot more that's going on here like we've emphasized extensively the central peripheral sensitizations um but i don't know i thought it was kind of strange to take offense to the title uh i guess i would have to understand what the offense uh what was the what was the reason for that but i think i think it was that just simply that he didn't believe that that nomenclature was befitting of the processes that uh the processes deserve a more um uh like a description that encompassed more of how severe debilitating it could be i i'm not sure it was it wasn't well explained okay got well no i mean as you know dr lovez knows i i always uh you know i always think i can be better i always want to learn so definitely you know open to learning more um yeah and unders i guess understanding another's point of view that's the beautiful thing about life in terms of you know communication and and uh understanding where people are coming from and yeah so um yeah i don't know if that you're always such a gentleman yeah it doesn't but that's okay it was a very politically correct answer i uh it's common nomenclature i'm sorry if anybody who's listened to this i don't think you could have possibly gotten this far in this episode and and have taken offense to us our nomenclature of it um but we discuss it as is discussed in the literature and we will use the common nomenclature uh to discuss uh but i think we've been very uh forward with saying talking about how much we believe in the central and peripheral sensitization of this and how this is much more complex than simply muscular pain um that's all i got man yep that sounds good all right guys you guys stay safe out there and listen to those legal disclaimers we will talk to you next time

Channel: Spine & Nerve

Views: 970

Rating: 4.8857141 out of 5

Keywords: spine & nerve, pain medicine, physiatry, physicians, medicine, medical education

Id: pDUxmIznLSY

Length: 29min 33sec (1773 seconds)

Published: Sun Mar 14 2021