Hi this is Dr. Andrea Furlan here and
today we're going to talk about myofascial pain.
Well myofascial pain is very very common what happens is: Is muscle pain. And
muscles we have everywhere in the body. We have morel muscles than we
have bones. And normal muscle doesn't hurt. If we apply a little bit of
pressure to a muscle and it hurts it's because something is wrong. Another
problem is also that a lot of people don't know that they have myofascial
pain. They have pain in the back, in the neck. in the shoulders, and they think
it's a problem with the nerves, the bones, the tendons, and it's not. It's a problem
with the muscles. So let's talk about it today. Today we're going to talk about
muscle pain. And the medical term is: myofascial pain. Myo comes from muscle.
fascial comes from the fascia. Fascia is the membrane around the muscles. Muscle pain is very different from skin pain. So for example if we have an injury
to our skin we know exactly where it happened, and this is because the skin is
so innervated, it's our protective system, and the skin has receptors for pain,
for pressure, for heat, cold, and we know exactly where it is the injury, With
muscle it's different because muscles they don't have a lot of receptors for
pain. So if a muscle is hurting, the pain is vague, is diffused, and
hard to localize. So what are some of the causes of muscle pain? Muscles can hurt
for a variety of reasons. One of them can be inflammatory process, we call this
Myositis, and then we have to find out what is causing the Myositis. But that's
not so common in pain clinics. Another one can be injury to the muscle, if there
is a hemathoma or bleeding inside of the muscle, that can cause a severe acute
pain. Myopathies are genetic or hereditary conditions that affect the
muscles but they are not usually a cause of pain or chronic pain. It can also be
a side effect of medication for example some of the
medications used to lower cholesterol it can also be withdrawal of some
medications for example if a person is using opioids every day, and they skip
one dose they may have muscle aches all over their body because that's a symptom
of opioid withdrawal. Muscle pain can also be radiating from other areas of
the body, so if a person has a nerve injury at the level of the spine we call
that radiculopathy, they may have been radiating to the muscles and the problem
is not really the muscles but that's where they feel the pain. It can also be
deficiency of some vitamins or nutrients one of them is vitamin D, and it can also
be some hormonal problems like problems with the thyroid can also cause some
muscle pain. And finally there are some chronic infections for example urinary
infection, that is ongoing untreated that can also lead to chronic muscle pain.
However in pain clinics the most common types of muscle pain is either
fibromyalgia or myofascial pain syndrome. Fibromyalgia I will not explain in this
video here because I did another video just dedicated to fibromyalgia, but in
summary fibromyalgia is not a disease of the muscle it's a disease of the pain
system, the person will feel pain all over the body and all the muscles of
their body but that's because the threshold to feel pain is lower in
fibromyalgia, so what a person that doesn't have fibromyalgia would tolerate
a lot of pressure to the muscles without having pain, in fibromyalgia that same
pressure will trigger a pain and that's because the treshold
is lower, and we need to fix the pain system instead of fixing the muscles. And
it's interesting that exercises, exercising the muscles of the body, all
over the body is one of the treatments of the pain system, because that will
and healthy impulses to the brain and we'll retrain the brain again how to
feel pain normal again. So even though fibromyalgia is not a disease of the
muscles, exercising the muscles, moving the muscles is one of the treatments for
fibromyalgia. But today we're going to talk about myofascial pain and
myofascial pain is a pain that is localized in the muscle, so normal muscle
doesn't hurt, if we apply pressure, or if we move it. But if the person is moving
the muscle and it's hurting, or if we apply pressure and the person feels pain,
that's not normal, maybe it is my facial pain syndrome. So
what's going on in the muscle that causes this myofascial pain syndrome? Well, it's not the whole muscle that is hurting, in fact if we apply pressure to
the muscle, the whole muscle, we may find that there are some areas of the muscle
that the person will not feel pain. But when we are moving our finger and we
applying pressure, for example, and we find one point that is very tender, and
the person will say well that's my pain you found my pain, then we call that a
trigger point. What's going on inside of the trigger point? The trigger points a
very tiny, tiny area of the muscle, what's going on is that that tiny area is
contracted, there is no blood flow if there is no blood flow there is no
oxygen, if there is no oxygen that area cannot relax because the muscle needs
oxygen to relax, so it's squeezing the nerve endings and it's squeezing the
receptors for pain. There is no blood flow there is no oxygen, it cannot relax by
itself, so it's perpetuating itself. And what are some of the causes of myofascial
pain? So it could be repetitive movements, it could be a bad posture,
it could be exposure to a cold environment, it could be other trigger
points that are activating trigger points in other muscles. We'll talk about
that. It could be emotional stress, we all carry some stress in our muscles, We
tense our muscles. So it can also be because the muscles
are weak or they are short, and when a person tries to use that muscle, the
muscle is not ready to be used. So if a person develops a trigger point in one
muscle what happens is: that muscle will not want to work, will not want to be
contracted, will not want to be stretched, and what happens is the muscles around
that one will have to work overtime to compensate that muscle that is not
working properly, and then the other muscles around will start having trigger
points too. So the pain starts spreading, that's very common, that people tell me
the pain started here, but now I have pain the whole region here. So myofascial
pain is a region of the body that is hurting and the pain is diffuse, is
difficult to localize, and when we put pressure in those points we find the
pain, the pain that the patient is complaining about. How do we diagnose myofascial pain? So there is no imaging, no laboratory tests, no blood tests,
no electromyography, no muscle biopsy that can detect the trigger points. It's
basically with our fingers at this point in time, the best technique that we have
is palpating the patient, palpating the whole muscle. So, finding the taut bands, it
looks like a rope inside of the muscle and inside that taut band we find the
areas of tenderness, and the patient tell us: Wow, that's my pain! You found
my pain doctor! That's usually how we diagnose. I have a colleague of mine he
is developing a technique using artificial intelligence, he's teaching
the computer to read images of the muscle, and apparently the computer can
detect where are the trigger points so that's the future and maybe in a few
years from now I can update this video with that technique, but as of
today the best technique that we have is using our fingers. How do we treat myofascial pain? So basically there are two things we need to do: 1) is to treat
what is what caused myofascial pain, the perpetuating and the precipitating
factors, what's maintaining the myofascial pain. And second thing that we
need to do is how can we eliminate those trigger points. We're going to talk about
those separately. So for the underlying precipitating predisposing factors, one
thing that we need to see if there is a gait problem, if there is a posture
problem, or if the person is doing any repetitive movement, if there is any
joint instability, so we need to take some details about what's going on in
the life of the person, why they're having that myofascial pain. Also in some
cases it can be that there is a constant pressure or constriction of the muscles,
there can be a tight bra, it can be a a purse strap, I had a patient that she was
always having pain in the trapezius muscle here, because she was always
carrying a purse on that side, and it was a heavy purse it can also be a tight
belt, so anything that is putting pressure on the muscles could be
perpetuating the myofascial pain. It could also be some nutritional
deficiencies the person is not eating a proper diet, the person is deficient in
some vitamins, minerals, proteins, folate, vitamin D, so we need to see if that's
the case for that person. It can also be some metabolic or hormonal deficiencies,
so we need to see if there's any thyroid problem, diabetes, neuropathies. And also
if the person is not having any psychological distress, it's very common
in our society today that people are anxious, they have a depressed mood, and
if we don't treat the psychological aspect, the person is going to always
carry the stress in their muscles and it's not going to get better, they are
not going to get better. Sometimes can also be like a chronic infection it
could be a bladder infection, a intestinal, gastrointestinal infection
that we need to treat. It can also be a problem of sleep, the person is not
sleeping well, or is not sleeping this the amount of sleep that they require, so
we also need to talk about that, how are we going to improve their sleep. Another
thing is also could be a nerve impingement in an area that is then
innovating all those muscles in the area. So if we treat the nerve impingement
then the myofascial pain can get much better, and also we need to look at the
environment. Is the person working or living in a very cold environment, that
they are also contracting their muscles? That can also be perpetuating. So there
are many, many things that we need to see what is perpetuating those
trigger points, because if we don't treat those conditions, the pain will not go
away. And then how do we eliminate the trigger points? There are many techniques
that we can use to eliminate your points one thing is true: is if we use multi
modalities the elimination will be much faster and more efficient, and also if we
start treating the myofascial pain right in the beginning, when the myofascial pain
started. If I see patients they have myofascial pain for 10, 15, 20, 30 years, that's
going to be much harder. It's not impossible, but it's going to be much
harder. So what are some of the techniques that we use to eliminate
trigger points? The main one is going to be moving those muscles, doing exercises
with those muscles. And for muscle pain we have to think: we need to do four
types of exercise. What are those four types of exercise? Well, if the muscle
that has trigger point was weak, this means that we need to strengthen that muscle,
so the first one is the strengthening exercises. Also if that muscle that has
trigger point doesn't want to be used then the muscle gets shorter and shorter.
So we need to stretch the muscle, so that's the second type of exercise, we need to do stretching exercises. But also the muscles need oxygen, so we need to
pump oxygen to break those trigger points, and how do we pump oxygen to our
whole body is doing cardio, aerobic exercise, so that's the third type of
exercise. And then the last one that a lot of people forget: is we need to relax our muscles, and we need to learn how to do this. That's
the last type of exercise. So I tell my patients to remember the SSAR. Those
are the four types of exercises that we need to do for myofascial pain. Then, we
also have a lot of other things we can do to get rid of those trigger points
one of them is the modalities, we can use modalities such as the heat (can be
superficial heat or deep heat). It can also be application of ice. Some people
get better, they get better from the trigger points with applying ice.
Although I don't recommend that a lot, but if the person gets better I am okay
with that. Another one can be electrotherapy the application of
electricity: TENS, electrical muscle stimulation, so that helps the muscle to
contract, or the TENS that will help the endorphins of the nerve system to be produced in those are analgesics. It can also be application of laser, so all of these are what we call modalities.
Another thing is: we need to relax the muscles they can also be done with
relaxation techniques, biofeedback, CBT, it can be also helpful for CBT for sleep,
and CBT for anxiety, so that's excellent that if the person can relax their mind
with cognitive behavior therapy or any relaxation technique, meditation, or any other breathing exercises, that will relax their muscles. We can also use
manual therapies, things like a massage, manipulation, mobilization, those are
great for muscle pain. Then there are also things more invasive like putting
needles on people. These can be acupuncture, can be dry needling, it can
be injections. I do trigger point injections with lidocaine, it's a local
anesthetic and that's to help to break that area of the trigger points, because
the needle will go there and will make the blood flow to wash that area, and get
rid of all of that contraction, I need to do that very
occasionally not in every patient that has myofascial pain because myofascial
pain usually gets better with the other techniques that I just explained. I don't
use botulinum toxin for injections in the muscles for myofascial pain
because I don't want to make the muscle weaker. The muscle is already weak, we
need to strengthen the muscle, not to weaken the muscle, an botulinum
toxin makes the muscle more weak. Also, I don't use steroids for
injection in the muscle for a number of reasons. One of them is that there's no
inflammation inside of the muscle, inside of the trigger point, so there's no point
of injecting an inflammatory there, and also the steroids will be in less than
five minutes the steroid that we put in the muscle will be all over the body, and
then they may have systemic effects like increasing the blood sugars, and I don't
want to do that. So I don't inject steroids in the muscles. I may inject
steroids inside of a joint or close to a tendon, but not inside of the muscles.
In terms of medications: oral medications, or topical medications, we should avoid
things like opioids because they really don't treat myofascial pain and they may cause dependence and tolerance, we also should
avoid benzodiazepines, those are the sleeping pills. The person will sleep
better they will fall asleep better, but the quality of sleep will be so much
worse, if they take benzodiazepine, is not worthwhile, and they can also develop
tolerance and dependence. And I also should avoid baclofen. I see a lot of
people taking battlefield for myofascial pain, really I don't understand why.
Baclofen is a medication for spasticity, which is a deregulation from the brain
or spinal cord to the tone of the muscle, these people don't have spasticity, so I
don't know why people prescribe baclofen to them, maybe it's because of
the side effects that it caused some somnolence and sleepiness. But then we
may use some anti-inflammatories or muscle relaxants for a short period of
time to treat myofascial pain, and I use a lot of antidepressants like
tricyclic antidepressants: like amitryptiline or nortriptyline because those antidepressants, they have a lot of advantages: they relax the muscles, they
give a much better quality of sleep, and they also treat some mood disorders, they
treat the depression, so many of the patients will have chronic pain if they
have depression the tricyclic antidepressants may be a good option for
them. It's also important to remember that myofascial pain can be a recurrent
condition, you may treat the trigger points today and they may recur in a few
weeks or months or years from now. So the person needs to know how to do how, to
manage their pain, how to self manage so the pain will not become chronic and
also will not spread and become fibromyalgia. It's also important to note
that in almost every chronic pain condition, neuropathic pain, CRPS, even
fibromyalgia, arthritis, low back pain, there's always a component of myofascial
pain, of muscle pain. The myofascial pain can be compounding, can be aggravating,
and making it worse, so we should still treat try to treat the myofascial pain
component. So as you seen there are many different things we can apply to
eliminate the trigger points, and we should not use only one of them maybe we
need to use a combination of them to get rid of the trigger points, and we call
this the toolbox approach. I tell my patients you should have like a toolbox
where all of these tools are available to you, and maybe in different days
you're going to use 1 tool of your toolbox to manage your chronic pain. And please
remember that this video is only for educational purposes, it's not intended
to provide medical advice, if you think that you have a condition that is
causing you myofascial pain syndrome please consult your physician to get a
proper diagnosis in a treatment plan for you. And if you liked this video don't forget
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you for watching. Bye
