surve - myofascial pain patterns for head and neck...
TRANSCRIPT
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
2
Disclosures
• I have no relevant financial disclosures with regard to this presentation.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
3
Outline
• Introduction• Myotomic patterns• Dermatomic patterns• Sclerotomic patterns• Conclusion
Myofascial Pain Patterns Head & Neck Disorders-
Surve
4
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
5
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
6
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
7
Introduction
• Remainder of history is unremarkable
• On physical exam, patient has tenderness to palpation of cervical spine and restricted range of motion
xx
x
Myofascial Pain Patterns Head & Neck Disorders-
Surve
8
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?
xx
x
Myofascial Pain Patterns Head & Neck Disorders-
Surve
9
Myotomic Pain Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
10
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
11
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
12
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
13
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
14
Trapezius
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
15
Sternocleidomastoid
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
16
Splenius Capitis/Cervicis
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
17
Suboccipitalis
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
18
Frontalis (A) / Occipitalis (B)
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
19
Temporalis
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
20
Lateral Pterygoid
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
21
Medial Pterygoid
Images courtesy of http://www.triggerpoints.net
Myofascial Pain Patterns Head & Neck Disorders-
Surve
22
Dermatomic Pain Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
23
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
24
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
25
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
26
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
27
Segmental Nerve Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
28
Peripheral Nerve Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
29
Sclerotomic Pain Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
30
Sclerotomic Pain Patterns
• Cervical facets are innervated by medial branch
Myofascial Pain Patterns Head & Neck Disorders-
Surve
31
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
32
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.
Myofascial Pain Patterns Head & Neck Disorders-
Surve
33
Sclerotomic Pain Patterns
Myofascial Pain Patterns Head & Neck Disorders-
Surve
34
Conclusion
Myofascial Pain Patterns Head & Neck Disorders-
Surve
35
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
Myofascial Pain Patterns Head & Neck Disorders-
Surve
36