Our Lady of Fatima University

College of Physical Therapy

120 McArthur Highway, Marulas, Valenzuela City

Myofascial Pain Syndrome (MPS) with Intellectual Challenges

Abanto, Errik Jon C.

Aurelio, Margreth

Bautista, Kouji

Casinillio, Carla

Cristobal, Camille

Luciano, Roselyn

Marimla, Christian

Sinco, Edward

Vergara, Darren

Villasenor, Joey

October 9, 2019
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

INTRODUCTION

Myalgia is the general term for pain in a muscle or muscles. Human body is composed of

650 muscles that contributes to almost half of the body's weight (Finley,2019). Majority of those

muscles are voluntary which means that individual can contract and relax his muscle depending

on the demand of his or her physical activity. However, frequent and high demand of muscle use

may lead to pain, weakness or fatigue. Moreover, overuse, injury and other factors might stress

the muscle which may lead to pathologic condition of the muscle.

Myofascial Pain Syndrome has been characterized as “pain” in the fascia. Fascia is the

internal connective tissue that wraps around the organs, providing support and holding parts

together. The conventional definition of myofascial pain syndrome (MPS) is characterized by

regional pain originating from hyperirritable spots located within taut bands of skeletal muscle,

known as myofascial trigger points (MTrPs). Patients can demonstrate pain in one or more body

regions associated with referred pain to a site not associated with the pain source.

In some research, Myofascial pain Syndrome can have a drastic effect on the human

body. It causes several complaints from the patient aside from having chronic pain. Some

patients suffer from sleep deprivation, anxiety, fatigue, depression, and more. Researchers said

that Myofascial pain syndrome can lead to Intellectual challenges due to this suffering along with

Myofascial Pain Syndrome. Treatment is possible through physical therapy and other invasive

techniques that includes needles.

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

REVIEW OF RELATED LITERATURES

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is a chronic pain syndrome that originates from the

muscle and surrounding fascia. In this condition, the muscle has sensitive points that causes pain

when pressure is applied into it which is called referred pain (Mayo Clinic, 2019). This is

primarily resulted from traumatic events, ergonomic factors, structural factors such as scoliosis

and systemic factors such as vitamin deficiency (Tantanatip, A. & Chang, K., 2019).

Individuals who have MPS experience a regional pain primarily caused by the taunt

bands in muscle fibers in skeletal muscles referred as myofascial trigger points (Borg-Stein, J., &

Iaccarino, M. A., 2014).

Myofascial Trigger Points

To further understand the relevance of trigger point in the illness, (Bron, C. &

Dommerholt, J.D., 2012) defined it as tender spots in specific taunt bands of hardened muscle

which results to local and referred pain. It is composed of contraction knots that appears as a

segment of a muscle fiber with contracted sarcomeres and an increased diameter. In addition, it

prevents full lengthening of the muscle, weakens the muscle and mediates a local twitch

response of muscle fibers when stimulated.

Formation of trigger points may originate from acute trauma or microtrauma that exposes

the muscle fiber into frequent stress. Thus, patients who have trigger points may have a

decreased range of motion in the affected area (Alvarez, D. J., & Rockwell, P. G., 2002). Also,
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

this can cause pain and discomfort in the muscle. However, severe and persistent muscle pain is

referred as myofascial pain syndrome (Mayo Clinic, 2019).

Anatomy and Pathophysiology of Myofascial Pain Syndrome

Myofascial pain Syndrome can affect any skeletal muscles in the body. Skeletal muscle

accounts for approximately 50% of body weight, and there are 650 muscles in the human body.

It is responsible for many cases of chronic musculoskeletal pain and the diagnosis is commonly

missed (Finley, 2019). The condition affects both the muscles (myo) and the connective tissues

(fascia) that covers and join the muscles. MPS can either cause pain in a single muscle or a group

of muscles.

Despite of the limited knowledge about the pathophysiology of MPS, Bron &

Dommerholt (2012) stated that the theory of energy crisis of muscle fibers might provide a better

understanding how this illness occur. According to them, the repetitive or prolonged muscular

activity can cause overloading of the muscle fibers which lead to muscle hypoxia and ischemia.

With this, the intracellular pumps are dysfunctional due to energy depletion. Hence, the

intracellular calcium increases induces sustained muscle contraction which results in the

development and formation of taunt bands. Apart from energy depletion, inflammatory

mediators caused by muscle injury contribute to pain and tenderness of the affected muscles.

Other than this hypothesis, there are many theories such as neurogenic inflammation,

sensitization and limbic dysfunction that are proposed to relate to MPS.

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Apostol et al.,(2009) also correlates MPS to increased released of Acetylcholine at

dysfunctional motor end plate of neuromuscular junction. They also added that contracted fibers

cannot relax, leading to pain, stiffness and fatigue. Though Bron & Dommerholt (2012) and

Apostol et al.,(2009) have the same hypothesis regarding its pathophysiology, further analyzation

is needed to fully understand and provide a comprehensive explanation behind this syndrome.

Causes of Myofascial Pain Syndrome

Myofascial pain can also refer to as trigger points. It is usually the result of a muscle injury,

excessive strain as well as excessive fatigue on the muscle groups. These are some of the

common initiating factors of the Myofascial Pain Syndrome.

Development of myofascial pain depends on multiple predisposing and causative factors:

– Genetics (temperament, intelligence, cognitive/emotional characteristics, gender)

– Environment (trauma, chronic repetitive muscle strain, physical/sexual/emotional status, poor

posture, diet, education, income, coping skills)

– Stochastic (hormonal, systemic disease, neuromuscular lesions, age of trauma)

– Nutritional (vitamin D, B complex, iron)

These triggering and predisposing factors can cause the development of latent myofascial trigger

points, which subsequently can be activated.

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Sensitive areas of tight muscle fibers can form in your muscles after injuries or overuse. These

sensitive areas are called trigger points. A trigger point in a muscle can cause strain and pain

throughout the muscle. When this pain persists and worsens, doctors call it myofascial pain

syndrome (MayoClinic).

Myofascial Pain Syndrome in relation to Intellectual Challenges

Myofascial pain syndrome is a chronic pain that may occur whenever trigger points are

being activated. Since myofascial pain syndrome severely affects the physical well-being of

individual, it is also essential to know its underlying effect when it comes to human’s cognitive

status. Spindler et al.,(2018) agrees that chronic pain can influence the cognitive functioning of

individuals specifically on his or her number sense. They also claimed that chronic pain affects

the spatial numerical processing of people who have this kind of condition.

Due to the development of the Myofascial Pain Syndrome, It can bring a lot of symptoms along

with it. Myofascial pain syndrome is not just a pain in the muscle or muscle groups and the

connective tissue.

Pain in these areas can cause secondary cause like:

o Poor Sleep

o Fatigue

o Weakness

o Depression
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

o Fatigue

In a research conducted to childhood intelligence and its link to pain problems like

musculoskeletal chronic pain. It shows that children who got higher score on the intelligence test

are less likely to have or suffer from chronic widespread pain. Their hypothesis is that men and

women who scored lower on the test of intelligence in childhood would have an increased risk of

chronic widespread pain in midlife and can affect mental health or lifestyle.

Apart from that, MPS can also contributes to sleep deprivation due to pain and activation

of trigger points when trying to fall asleep (Mayo Clinic, 2019). Moreover, frequent insufficient

sleep brings harmful effects in the human brain in such a way that individual might decreased his

or her alertness, attention and lead to poor decision making and memory (Costa & Pereira, 2019).

This is due to the fact that the brain is resting and preparing for the activities the next day

(National Heart, Lung and Blood Institute, 2018).

Another research founds that missing sleep which is a cause of Myofascial pain syndrome can

result to health risk like declining cognitive thinking, weakened memory support, fatigue, stress,

and more. Disturbances to healthy sleep patterns can cause your IQ to drop by five to eight

points.

Chronic pain causes a change in the information exchange with the insula. This is a key area in

the brain responsible for the perception of pain, and modifies the output of the hypothalamus,

causing a shift in the brain’s chemistry. As a result of the now ongoing amygdala response, there

are changes in cerebral circulation and a decrease in flow to other areas of the brain, potentially

affecting cognitive function.

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

CASE

Clinical Presentation and Diagnosis

 Pain Complaints

o Sharp aching pain in a muscle, tissue and joints

o Constant deep muscle pain

o knots underneath the skin

Myofascial pain Syndrome can be difficult to diagnose because the muscle trigger points may be

in a different place than the pain site (MayoClinic).

Severe, constant and dull facial muscle pain is often the first pain-related symptom of Myofascial

Pain Syndrome. The patient feels a constant pain in the affected area. Eventually, the pain might

turn chronic after 2-3 months. Such chronic pain will not respond to normal medication. In

addition, chronic pain caused by the Myofascial Pain Syndrome soon begins to affect the normal

life of the patient (LondonPainClinic).

This pain is often located in the jaw area, though it can spread to any of the body parts.

Aching/Stiffness

An individual affected by the Myofascial Pain Syndrome feels a strong sensation of pain or

stiffness in various parts of the body. These include the neck, shoulders, low back and hips.

However, in some cases, the pain and stiffness can even be felt in the whole body

(LondonPainClinic).
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Besides the stiffness, popping and clicking of the joints might also be felt.

Headaches

A headache is usually felt as an aching or throbbing pain in one or more areas of the head, neck,

face or mouth. There can be many reasons which can trigger off a headache (LondonPainClinic)

including:

 Stress, anxiety

 Fatigue

 Depression

 Arthritis in neck or spine

 Glaring or flickering lights

 Changes in weather

 Inherited abnormality in blood vessels

 Food-triggered (from nuts, yoghurts, lima beans etc.)

Sleep Problems

Myofascial Pain Syndrome often leads to development of sleep disorders. The patient

experiences mild to severe disturbances in their normal sleeping patterns (LondonPainClinic).

The most usual form of sleep disorders includes:

 Lack of sufficient sleep

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

 Having a non-restorative sleep

 Difficulty in lying down for longer hours

 Experiencing hot-flushes in sleep

Psychological Symptoms

In addition to the physical symptoms, Myofascial Pain Syndrome also exhibits certain signs of

psychological impact (LondonPainClinic).

The main amongst these are:

 Depression

 Loss of concentration

 Memory problems

 Behavioral disturbances

 Excessive mood swings

Other symptoms

There are a series of other symptoms associated with an episode of Myofascial Pain Syndrome.

These include:

 Fatigue

 Irritable Bowel Syndrome

 Numbness

 Fluid Retention
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College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

 Balance Problems

 Ear pain

 Blurred vision

 Reduced exercise tolerance

Physical Examination

During the physical exam, the doctor may apply gentle finger pressure to the painful area, feeling

for tense areas. Certain ways of pressing on the trigger point can elicit specific responses. For

instance, you may experience a muscle twitch (LondonPainClinic).

Muscle pain has many possible causes. The doctor may provide or order different test and

procedures to rule out other causes of muscle pain.

Treatment

The main goal in treating Myofascial Pain Syndrome is to eliminate trigger points which causes

the referred pain, reverse trigger point-induced weakness, restore normal muscle function, and

decrease pain. Conservative or less invasive modalities should be considered first before

advancing to more invasive treatment options (Trescot, 2019)

When treating MPS, it is important to identify and treat predisposing and perpetuating factors. If

the underlying pathology is not given the appropriate treatment, the Myofascial trigger points

cannot be completely and permanently inactivated. Treatment of active Myofascial trigger points
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

may be necessary in situations in which active Myofascial trigger points persist even after the

underlying etiologic lesion has been treated appropriately (LondonPainClinic).

Injection/Needle Therapy

Trigger point injections (TPIs) are part of the comprehensive treatment plan of patients with

MPS; however, they should not be the only treatment approach given the underlying

pathophysiology. Elicitation of a local muscle twitch response during TPIs appears to correlate

with the best result. TPIs are commonly performed by pain physicians and primary care

providers and are the second most common pain procedure after epidural steroid injections in

Canada. There is no difference clinically if the injectate contains local anesthetics alone or the

addition of nonsteroidal anti-inflammatory drugs, vitamins, or steroids. Ultrasound may be

considered in order to better visualize the surrounding anatomy (i.e., blood vessels, nerves,

pleura) and selectively inject desired muscles and fascial planes (Trescot, 2019).

Needle therapy includes:

 Acupuncture

 Dry needling

 Local anesthetic injections

 Botulinum toxin type A injections

Medication
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Currently, there are no FDA-approved medications for the treatment of MPS. Some medication

offers to ease the pain and effects of MPS but the medications doesn’t really treat it.

 Pain relievers. Over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB,

others) and naproxen sodium (Aleve) may help some people. Or your doctor may prescribe

stronger pain relievers. Some are available in patches that you place on your skin.

 Antidepressants. Many types of antidepressants can help relieve pain. For some people

with myofascial pain syndrome, amitriptyline appears to reduce pain and improve sleep.

 Muscle relaxants.

 Nonsteroidal anti-inflammatory drugs (NSAIDs). Not commonly used due to side

effects

 Sedatives. Clonazepam (Klonopin) helps treat the anxiety and poor sleep that sometimes

occur with myofascial pain syndrome. It must be used carefully because it can cause

sleepiness and can be habit-forming.

PHYSICAL THERAPY PRACTICE

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Ischemic compression

Ischemic compression is a mechanical treatment of myofascial trigger points that consists of

application of sustained pressure for a long enough time to inactivate the trigger points.

(Whiplash, 2012). It has been suggested that ischemic compression therapy using either 90 s low

pressure up to the pain threshold or 30 s stronger pressure up to pain tolerance can create

immediate pain relief and MTrP sensitivity suppression (Baldry 1993; Simons et al. 1999; Hou et

al. 2002). It is important to execute this technique correctly to avoid accidental activation of

latent trigger points. For maximum benefit, some form of stretching should follow ischemic

muscle pressure (Anders Jelvéus,2011)

Intervention

The pressure is performed with braced thumbs, long, or index fingers. The muscle tissue and

MTrP are slowly compressed until the athlete begins to experience identical referred pain. The

pressure is maintained until the pain subsides. When the pain is relieved, the MTrP is

compressed further until identical pain reappears. The process is repeated three or four times.

The therapist slowly releases the pressure during a 10 s period. The pressure is not reduced

unless it is too high, which is recognized by the pain either being uncomfortable to the athlete or

not decreasing in intensity (Anders Jelvéus2011)

Myofascial release therapy

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Myofascial release (MFR) therapy focuses on releasing muscular shortness and tightness.The

goal of myofascial therapy is to stretch and loosen the fascia so that it and other contiguous

structures can move more freely, and the patient's motion is restored. For this reason, myofascial

therapy is sometimes referred to as 'myofascial release' therapy. It may also be referred to as

'myofascial trigger point therapy' by others. Physical therapies usually combine the myofascial

releasing to a stretching exercise, this method helps to stretch the muscles in the muscle group to

provide better blood circulations. MFR technic was strongly effective on pain, disability and

emotional status, especially in a short period of treatment. Myofascial Release was specifically

designed to relax the fascia throughout the whole body. This is the benefit of a whole-body

approach that makes MFR such an effective treatment. Multiple studies show that myofascial

release can result in decreased pain, better posture, reduced symptoms, increased range of motion

and improved quality of life (Altindag O, Ozaslan S, 2014).

Interventions

gentle application of pressure or sustained low load stretch to the affected area. Progress is

gauged by the level of increased motion or function experienced, and/or decrease in pain felt by

the patient.
 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

Stretch and Spray Technique

Stretch and spray technique is one of the treatments in treating MPS (myofascial pain syndrome)

in Physical Therapy Practice. It involves spraying the trigger point in the muscle with a coolant

and then carefully stretching the muscle. It is commonly used implemented in treating cervical

myofascial pain. It requires the positioning of the patient in a well- supported, relaxed position

with the specific muscle to be sprayed on a maximal tolerable stretch. (Nielsen, 1978).

The technique is VERY effective at reducing and deactivating acute trigger points. This

technique is performed by using a vapocoolant spray applied to the affected muscle after

undergoing passive stretch. Vapocoolant sprays or "cold sprays" are delivered onto the skin to

alleviate pain problems in the body. In doing this treatment, apply the vapocoolant spray to the

region around the trigger point and the area of referred pain using parallel strokes in the same

direction. Some authors recommend first spraying, then stretching, and only then repeating the

spraying. This kind of treatment is especially effective for a wide range of complaints: trigger-

point therapy, myofascial pain syndrome, pre-injection anesthesia, muscle spasms, restricted

motion and minor sports injuries.

How to use Spray and Stretch Technique according to Charles Staley

 Place the body part in questions (with skin exposed) in a very mild stretch to start. Too

great a stretch may irritate the trigger point and activate a quasi-stretch reflex. Make sure

the person receiving the treatment is warm and their body is supported posturally as to

avoid unnecessary postural strain (Staley, 2019).

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

 Have your training partner, friend or significant other spray the Instant Ice from one

attachment of the muscle(s) towards the other. Very important: the stream should be

sprayed from 12 to 18 inches for maximum coldness and effect on the nervous system

(Staley, 2019).

 The closer the can is to the body the warmer it is when it hits the skin while the farther

away (up until 18 inches) the colder it will feel. Beyond 18 inches you lose your

aim/precision and get no further benefit of coldness. Additionally, Travell and Simons

report that applying the stream from an angle of 30 degrees (as compared to the surface

you're applying it to) works best (Staley, 2019).

 After spraying 3-5 streams parallel to each other (each stream traversing a slight lateral or

medial course to the previous one), you should gently stretch the muscle to its pain free

limit (Staley, 2019).

 Hold this stretch for up to 30 seconds or so making sure the person is breathing slowly

and deeply (preferably with their diaphragm muscle). The stretch will help to keep the

offending trigger points from coming back as fast. Of course, if you go do the activities

or assume the offensive static postures that caused the trigger points to activate in the first

place they'll probably return quickly (Staley, 2019).

 After performing the above steps, you should apply moist heat for up to 10 minutes to

promote healthy blood flow and further relax any shortened tissues left in the treated

muscle. A second dose of the spray and stretch can then be performed for further gains if

desired (Staley, 2019).

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

TPI (Trigger Point Injection)

Trigger point injection (TPI) may be an option for treating pain in some patients such as

Myofascial Pain Syndrome. TPI is a procedure used to treat painful areas of muscle that contain

trigger points, or knots of muscle that form when muscles do not relax.

It can be experienced or felt under the skin where it can irritate the nerves around them and

cause referred pain, or pain that is felt in another part of the body.

TPI is used to deal with many muscle groups, specially these in the arms, legs, decrease back,

and neck. In addition, TPI can be used to deal with fibromyalgia and tension headaches. The

method is also used to alleviate myofascial ache syndrome (chronic ache involving tissue that

surrounds muscle) that does now not respond to different treatments. However, the effectiveness

of TPI for treating myofascial ache is nevertheless beneath study.

A health care professional sticks a small needle into the trigger point of the patient in the TPI

protocol. The injection requires a local anesthetic or saline and a corticosteroid may be included.

The trigger point becomes removed with the injection and the pain is alleviated. A quick course

of counseling will often contribute to lasting relaxation. Injections are given in the office of a

doctor and usually only take a couple of minutes. In one visit, several sites can be injected. If a

person has an allergy to a certain drug, it is possible to use a dry-needle procedure (including no

drugs). (Web MD, 2019).

 Our Lady of Fatima University
College of Physical Therapy
120 McArthur Highway, Marulas, Valenzuela City

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