surve - myofascial pain patterns for head and neck...

Myofascial Pain Patterns for Head and Neck DisordersSajid A. Surve, D.O.UMDNJ School of Osteopathic MedicineNeuroMusculoskeletal Institute

Learning ObjectivesBy the end of this presentation, participants will be able to:

• Correctly distinguish between referred pain patterns of different origins

• Appropriately refer patients to interventional pain management or perform injections on affected structures in myofascial pain

• Recognize the indications for Osteopathic Manipulative Treatment in myofascial pain

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Disclosures

• I have no relevant financial disclosures with regard to this presentation.

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Outline

• Introduction• Myotomic patterns• Dermatomic patterns• Sclerotomic patterns• Conclusion

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Introduction

• 45-year old male presents with 6 year history of headache following motor vehicle accident

• Restrained driver of sedan travelling 15-20 mph, rear-ended by another sedan travelling 25-30 mph

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Introduction

• Rates pain VAS 4/10 during flare-ups which occur 3-4 times per month. Otherwise pain-free

• Describes as throbbing, achy pain with no other associated symptoms

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Introduction

• Saw PCP, has been taking prescription naproxen intermittently, which helps

• Within 6 months of accident had x-rays and MRI of c-spine which were both negative

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Introduction

• Remainder of history is unremarkable

• On physical exam, patient has tenderness to palpation of cervical spine and restricted range of motion

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Introduction• What do we think about this

case?

• What is the treatment plan for this patient?▫ OMT?▫ Trigger point injection?▫ Spray and stretch?▫ Botox?▫ Something else?

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Myotomic Pain Patterns

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Myotomic Pain Patterns• Originally described by Travell, Simons, and

Simons in 1942

• 80 years later, still debate about exact diagnostic criteria

• General consensus describes trigger points as derangement of muscle or fascial tissue hallmarked by referral of pain in a predictable pattern upon direct palpation

Myburgh et al. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance.Arch Phys Med Rehabil. 2008 Jun ;89(6):1169-76.

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Myotomic Pain Patterns

• New imaging techniques are giving us greater insight into underlying pathology

• Diagnosis is still made from history and physical exam findings

• Number of treatment options have been considered, although few have solid evidence

Chen Q, Bensamoun S, Basford JR, Thompson JM, An K-N. Identification and quantification of myofascialtaut bands with magnetic resonance elastography. Arch Phys Med Rehabil 2007;88:1658-61.

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Myotomic Pain Patterns

Evidence-based beneficial treatments:• OMT• Trigger Point Injection / Dry Needling /

Acupuncture• TENS• Iontophoresis with indomethacin• Spray and Stretch

Annaswamy TM et al. Emerging concepts in the treatment of myofascial pain: a review of medications, modalities, and needle-based interventions.PM R. 2011 Oct ;3(10):940-61.

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Myotomic Pain Patterns

Botox is not considered an effective modality for myofascial pain

Soares A, Andriolo RB, Atallah ÁN, da Silva EMK, da Silva EMK. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD007533. DOI: 10.1002/14651858.CD007533.pub2

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Trapezius

Images courtesy of http://www.triggerpoints.net

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Sternocleidomastoid

Images courtesy of http://www.triggerpoints.net

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Splenius Capitis/Cervicis

Images courtesy of http://www.triggerpoints.net

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Suboccipitalis

Images courtesy of http://www.triggerpoints.net

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Frontalis (A) / Occipitalis (B)

Images courtesy of http://www.triggerpoints.net

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Temporalis

Images courtesy of http://www.triggerpoints.net

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Lateral Pterygoid

Images courtesy of http://www.triggerpoints.net

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Medial Pterygoid

Images courtesy of http://www.triggerpoints.net

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Dermatomic Pain Patterns

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Dermatomic Pain Patterns

• Neuropathic radicular pain related to entrapment of either nerve roots or peripheral nerves

• May be caused by canal stenosis, disc disease, or external pressure (peripheral nerves only)

• OMT indicated primarily as adjunct, HVLA contraindicated at level of entrapment

Chila et al. Foundations of Osteopathic Medicine, 3rd edition. LWW 2011. pp. 524

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Dermatomic Pain Patterns

• NSAIDs and TCAs indicated in cervical radiculopathy

• Opiates generally indicated through WHO guidelines

• Oral corticosteroids not well studied for radicular pain

Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353:392–399.

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Dermatomic Pain Patterns

• Low level evidence for cervical immobilization, traction, physical therapy in radiculopathy

• Acupuncture is recommended for both acute and chronic radiculopathy

Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005;353:392–399.

Council of Acupuncture and Oriental Medicine Associations. Acupuncture and electroacupuncture: evidence-based treatment guidelines. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=9343.

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Dermatomic Pain Patterns

• Moderate to high level evidence for cervical epidural steroid injection and selective nerve root blocks

• Moderate to high level evidence for peripheral nerve blockade in peripheral nerve entrapment

Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.Pain Physician. 2009 Jul-Aug ;12(4):699-802.

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Segmental Nerve Patterns

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Peripheral Nerve Patterns

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Sclerotomic Pain Patterns

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Sclerotomic Pain Patterns

• Cervical facets are innervated by medial branch

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Sclerotomic Pain Patterns

• In cervical facet disease (i.e. spondylosis) bony hypertrophy and sclerosis can produce referred pain which is independent from all other referral patterns

• OMT of limited use for improving referred pain, although indicated for compensatory changes

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Sclerotomic Pain Patterns

• Moderate to high level evidence for diagnostic cervical facet injections

• Moderate to high level evidence for radiofrequency ablation to medial branch

Manchikanti L et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.Pain Physician. 2009 Jul-Aug ;12(4):699-802.

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Sclerotomic Pain Patterns

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Conclusion

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Conclusion

• Different structures have different referral patterns

• Being cognizant of pain patterns will help to guide interventions

• OMT has indications for many causes of cervical myofascial pain

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