Myofascial pain can either be acute or chronic. Acute myofascial pain that involves only one or two muscles can be treated. And you can use various stretching techniques, trigger point injection, spray and stretch, deep tissue massage and stretch and things will resolve. For example, here we have a trigger point in the Master Muscle that's causing pain to be referred into the lower molar teeth and causing toothache. If this trigger point developed acutely after a long dental appointment, or after a chronic dental infection. And no other secondary muscles have developed trigger points, then simple just jaw stretching should take care of the pain. So early or acute myofascial pain is of short duration, it is, it has a clear onset. Very few muscles are involved. There are very few perpetuating factors, and there are no behavioral or psychological problems. Now if, however, you end up getting a patient that has a chronic pain problem, pain that's been around for more than, ma, four months often times, ten, 12, 13 years people have had these pain complaints. Then we find satellite trigger points in distant muscles. So, for example, here we have upper trapezius trigger points that start to develop satellite trigger points in the masseter and temporalis muscles. And then we have the masseter muscle trigger point setting up its own referral patterns and we have the temporalis trigger point also referring pain. And so, the pain picture becomes much more complicated, and chances are very good that a more comprehensive approach to treatment will be necessary. The more chronic the problem and the more muscles that are involved, the more important it will be to take a management approach to address the pain. So chronic myofascial pain problems usually have a long complex history. There are multiple diagnosis and associated symptoms. There are multiple muscles with myofascial trigger points. There are multiple perpetuating factors. And there are multiple behavioral and psychological issues. So the truth is, while we can treat acute pain, we can use injections, medications and we can use procedures, we have to manage chronic pain using behavioral change self efficacy and compliance. Those are requirements. And myofascial pain, when it becomes chronic, is like any chronic pain condition. You need to address a lot of different factors. And in myofascial pain, the best mantra is the principle of management, which is to identify and control all the perpetuating factors and then apply specific myofascial trigger point therapies. Now I think in module three we discussed all the details of the perpetuating factors. The most important aspect of man, managing chronic myofascial pain is the identification and the control of the perpetuating factors. The clinical importance of controlling perpetuating factors is greatly underestimated. For example, chronic muscle overload will, over time, result in the development of trigger points. And continued muscle overload will cause the trigger points to re-develop and reactivate over and over again even if they've been treated with excellent sprain stretch or perfect trigger point injection. Now, psychological stress was shown experimentally to increase the spontaneous electrical activity found in the trigger points themselves. This increased spontaneous electrical activity means increased referred pain. Therefore, understanding the stresses a person is under and teaching or learning healthier techniques of coping with stress will help to reduce trigger point activity and hence the referred pain as well. And specific strategies for controlling psychological factors are discussed in a separate module in this course. Underlying disease or inflammation is not only a causative factor but, if left untreated or poorly managed, will cause perennial reactivation of associated trigger points. This include medication overuse as a perpetuating factor in headaches as well. Lastly any kind of comprise of the energy metabolism of the muscles such as metabolic endocrine or nutritional inadequacies. Inadequacies will aggravate and perpetuate myofascial trigger points. So inadequate hormone and vitamin levels result in increased irritability of the muscles and poor response to therapy. In your initial history and physical, it was really important to take the time to identify all of the perpetuating factors in a particular patient's pain history. Once you've identified all of the perpetuating factors, a plan for controlling each of the perpetuating factors is imperative before embarking on specific myofascial trigger point therapies. What are some of the myofascial trigger point therapies? Today we'll discuss a little bit about myofascial Spray and Stretch and trigger point injections, the two most common treatments associated with myofascial trigger point pain. Myofascial spray and stretch involves the use of a cold or vapocoolant spray to be applied over the muscle containing the trigger point and into the referred pain site in order to relax the muscle and allow the trigger point to be stretched. The main ingredient to treating myofascial pain is to stretch the muscle out. Here's your trigger point, here's a latent trigger point, here is no trigger point. So what we really want to achieve, is to get the trigger point to be at very least, latent, and at the very best, completely gone. So, the key to getting it to this point is stretch. How we facilitate stretch is all the different therapies that have been invented around myofascial pain. So the spray and stretch is the application of cold spray over the muscle containing the trigger point, and then into the referred pain site. And the ideas that as you're stretching the muscle, you stretch the trigger point. Stretch do hurt and there's reflex contraction. If you apply the cold spray, while the cold spray is being applied, the muscle kind of goes, well, well, wait. The skin, the spinal cord doesn't let the painful sensations from the stretching of the trigger point through. And all of a sudden the muscle can stretch out. So it's a distraction, the cold spray is a distraction. The cold alarm hits the spinal cord faster than the pain from the stretch and therefore, the muscle can stretch out. Here we have an example of. Sprain stretch technique for the upper trapezius muscle. the upper trapezius most of us have trigger points in the upper trapezius. What you want to do anchor the arm have the patient sitting comfortably in the chair and have the well support so they can relax. And you want to also have them in pretty decent posture, because if you're going to stretch the upper trapezius you want to be able to bend the neck to the side. And if they're in crummy posture and their head is forward, you can't really stretch the upper trapezius. So you need them comfortably seated in a chair. You also need them to be warm. Warm muscles stretch, cold muscles don't. I have somebody in a thin gown and an air conditioned examination room and they are cold, they're not going to be able to relax and stretch, so it's very important to have a warm patient. One of the techniques that I like to use is to take a hot pack and put it on their stomach, that way the warmth of the hot pack penetrates in through the abdomen and is transported to through the rest of the body through the abdominal aorta and the patient starts to get nice and warm, once you have a warm patient. The application of cold spray is very effective because you have warm skin cold spray and you can relax and the trigger plot will stretch. The application of the direction fo the spray is very also important. We want to go in one direction only and the spray application should be. About one to two inches per second. It's not really fast, it's nice slow spray, and it's only in one direction. So you're only going in one direction and it's usually over the trigger point and into the referred pain pattern. So if the pain, in the in the case of the upper trapezius muscle for example, the refered pain is usually into the temple, the back of the neck, the angle of the jaw. And so the ref, and the muscle is here so you would spray form the muscle and into the referred pain sites. And, up into the forehead. So you can see the referred pain pattern on this diagram. The idea behind this is that the inclusion of the pain referral pattern somehow also allows the muscle to relax more effectively. The spray is applied, but you want to apply. Apply maybe three sweeps of the spray and not too many, not too close together, because we don't want to chill the muscle. We only want a surprise effect. We only want the skin to be cold. We don't want any of the underlying subcutaneous tissues or the muscle to get cold. So we just want to apply enough spray to get the reaction we need in order to stretch. If we apply too many sweeps of cold spray, then it penetrates the subcutaneous tissues and the muscle and it takes a long time for those tissues to warm up again and then cold muscles. Don't stretch. So we need to make sure that we're just, we have a warm patient, warm muscles and the only application of cold is to the skin. You can apply the spray first and then stretch. There is no reason to spray and stretch at the same time. So typically I will take the spray, apply the pattern, and then have the patient help me by breathing. So an inhalation and then stretch with exhalation. So I can spray, put the bottle down, inhale. Exhale and stretch, and that will allow you to get a good stretch of the muscle. There are many varied techniques for specific muscles that can be looked up in Trevell and Simon's books and also in other published articles and textbooks that will describe various techniques. Specific muscles. There has been a study that was done to show that spray and stretch, and stretch actually do re, reduce the pain associated with myofascial trigger points, and also reduces the sensitivity of the trigger point. Here we have a study that was done on patients. They were their own controls, they had unilateral pain that was referred from the upper trapezius muscle. We evaluated the trigger point sensitivity on both sides. The active side and the latent side. And we had the patients rate their pain before and after the spray and stretch procedure. So in this. Chart here you can see that the before the spray and stretch procedure they had, a visual analog scale rating of about 35, and then after the spray and stretch. The proceed procedure their pain went down to maybe ten or less than ten on a visual analog scale. So that was the referred pain. Before the procedure you can see that the active trigger point, the one that was treated, was much more sensitive, tolerated less pressure than the control side which had a latent trigger point. After the spray and stretch procedure. The trigger point on the treated side became less sensitive than the untreated controlled side which was latent. So that shows that stretching reduces the sensitivity of the trigger points, and also reduces the referred pain. Here's another study that we did on patients with bilateral pain where we again used them as their own controls. But they had pain on both sides. And again we see that after the spray and stretch procedure they had less pain. On the treated side, the sensitivity of the trigger point went down. They were able to tolerate more pressure. On the untreated side. There was essentially no change. In the spray and stretch technique it's important to remember that stretch is what we're going after. Stretch is the action, spray is the distraction. So it's a very valuable technique to use for myofascial trigger points. The other technique I'm going to describe this. Today is trigger point injections. Trigger point injections include injecting perhaps saline, perhaps local anesthetic or nothing. We can also use dry needling. The importance of the trigger point injection technique is the impaling of the trigger point with the needle. What is injected is really not important. The technique itself involves. Finding the trigger points specifically and precisely is very important to isolate the trigger point and to actually get the needle into the trigger point. In this diagram on the right, you can see. The operator trying to stabilize the trigger point between two fingers before inserting the needle. Some people think oh, you just inject the muscle with a bunch of local anaesthetic and that's it. It's the law of mass action. Well, it's not. If you want to have an effective trigger point injection you need to actually impale the trigger point. And you can do that with an acupuncture needle or a, hypodermic needle But the important thing is to get into the trigger point. If you do actually get into the trigger point you will get a twitch response. And the twitch response tells you you actually nailed it. And the twitch response is your most, your high, highest likelihood. Predictor of an excellent clinical response. So you really want to get into the trigger point. And once you've hit one trigger point you want to then pepper the area withdraw the needle not through the skin but just out of the muscle and redirect it out of the muscle and redirect so that you can look for other trigger point nidices, little. Contracted muscles. And hit those as well and you may get repeated twitch responses as you, you do this. Once you've eliminated all the twitch responses in a particular trigger point site, you take the needle out and then post injection procedures are to apply pressure and hemostasis. And then you want to stretch the muscle, again, it's injection and stretch. The idea's we want to get the trigger point stretched out, and then we want to apply some heat to the area, and also give him, the patient, some instructions on home care. So here's an example of post-injection spray and stretch for the sternocleidomastoid muscle. The important thing is also to let your patients know what sensations to expect with a trigger point injection. It makes the procedure much easier and less stressful for them. If you allow the patient to know that finding, your going. Isolate the trigger point, find it. That's going to be a little uncomfortable. You can hold the trigger point and then as you go through the skin there might be a little pinch. Once you're in the muscle there's actually no pain until you find the trigger point. And which point there is typically either a twitch. Or at the very least, a deep aching pain. And the referred pain. The pain that's being treated. So often times patients will say, oh yes, I can feel that now. And I can feel my referred pain. And you can get a twitch response. And you should let them know that the muscle may twitch, and that that's normal. And that may feel a deep aching and that that's normal. And that they may feel their usual pain and that that's normal, that's part of what you want. After the trigger point injection you should let them know that for the rest of the day it might be a little sore, if they touch it it might be a little tender. Moving the muscle might be a little sore. And that's typical post injection soreness. It has been poked with a needle. Amelioration of those particular symptoms perhaps some Tylenol or some Ibuprofen and for a day. And, and typically that will resolve any post injection soreness problems. The benefit of using a local anesthetic for a trigger point injection is that it tends to reduce post injection soreness. So dry needling and saline or water tend to be associated with a slightly higher post injection soreness issues. The local anaesthetic of choice is Procaine or half percent Lidocaine. That is because those two local anaesthetics and the low concentration of the Lidocaine do not cause myotoxic effects, there are no changes in the muscle tissue on histologic examination. Any of the longer acting anaesthetics do cause myotoxicity. And hyaline degeneration of the muscle which does resolve, but with repeated injection, can cause fibrosis of the muscle. Any addition of epinephrine is completely contraindicated because epinephrine actually worsens all the myotoxic effects to a tremendous amount. The keys to success in terms of doing trigger point injections is careful patient selection you don't want to be injecting a very depressed patient or a patient whom history has shown that they have a lot of adverse reactions to various procedures. You want to make sure that you actually are treating a trigger point and not a myalgia. You want to make sure you choose the appropriate key trigger point sites. There are muscles, such as the trapezius, sternocleidomastoid, latissimus dorsi, teres major, that are typically key trigger point bearers. And the referred pain sites contain the ke, the satellite trigger points. So you want to make sure you're injecting key trigger points not satellite trigger points. Because the satellite trigger points will recur if the key trigger points aren't treated. And obviously skillful technique. Again remember very little local anesthetic is needed if any. You can use dry needling techniques. Many people do use dry needling techniques. They're very, very effective. And kitting the trigger point and getting the twitch response is really key in terms of a successful treatment outcome. So, again, the principles of management are to identify and control the perpetuating factors. And then use the spray and stretch or the trigger point injections. If you don't treat the perpetuating factors, these pains will come back and the trigger points will return. There are also physical therapy modalities other than spray and stretch and trigger point injections that can be used. There are various massage techniques. There's myotherapy, there's myofascial release, there's deep tissue massage, there's ischemic compression, there's various stretching techniques. You can teach patients just static stretches, you can teach them hold release techniques, contract release, Lewit techniques, you can also. Have them use what's called a Theracane to first apply ischemic compression to trigger points before stretching. Golf balls, tennis balls are really great little adjunctive tools to apply pressure to back trigger points lying on the floor. And then stretching. Also useful to teach patients how to breathe with stretching so that when they actually do their stretches they do them effectively. [NOISE] A big breath in [NOISE] and a long breath out goes a long way to stretching a muscle. And it's more important to stretch the muscle completely and adequately than to do a lot of repetitions because what you are really trying to achieve is to lengthen out the muscle and if somebody is trying to do multiple replica, rep, rep, rep, [LAUGH] multiple reps, then they may end up just doing things very quickly and not actually getting the full stretch. I work very hard up with my patient to actually get them to do long slow breathing and exhilarating with their stretching. Back to this idea that the management and prevention of mild pain is really equivalent to. Healthy living. We need to have good posture and body mechanics. We need to have stress management skills and make sure that our day is not stressful. That there's time management in there. That we take time out to meditate or relax. We need to eat nutritious and regular meals so that we have enough vitamins to support our body and our muscles and not to have low blood sugar episodes. We need to sleep well and sleep regularly ad we need to get regular exercise. Those are the things that are key to living well living healthy and preventing myofascial pain. And once you have a myofascial pain disorder learning to identify and control other perpetuating factors will allow you to beat the pain, get better, and stay better. And that's what the goal is. Thank you.
