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.
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next time when I post a new video. Thank you for watching. Bye