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CMP TREATMENTS

CMP TREATMENTS Many approaches can be used to treat myofascial pain syndrome. Often, a combination is necessary to obtain pain relief and full functional recovery. Treatment should begin with the least invasive and least traumatic approaches. Below are treatments used in CMP.

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Types of Treatments for CMP
  • Stretch & Spray
  • Trigger Point Injections
  • Massage Therapy
  • Exercise
  • Medication
  • Myofascial Release

  • Stretch and Spray

    The stretch and spray technique for relief of muscle pain was introduced in the 1940's by Simons and Travell (the originators of CMP research)1. Using an anesthetic spray as a distraction, the clinician passively stretches the muscle containing the trigger point to its normal maximum length, creating mild discomfort2. For best results, the patient should be in a comfortable, relaxed position and the stretch should be performed with a fluid motion.

    The recommended anesthetic spray is 15% dichlorodifluoromethane and 85% trichloromonofluoromethane (Fluori-Methane). It has replaced ethyl chloride because it is neither combustible nor potentially lethal. To obtain optimal cold stimulation, Fluori-Methane should be used at 10°C to 12°C while the muscle is being stretched. The spray should be directed at a 30° to 60° angle in sweeps parallel to the muscle fibers and toward the pain reference zone.

    Two to three sprays covering approximately 10 cm/sec are typically sufficient. Concern has arisen regarding Fluori-Methane's potential as a biohazard affecting the ozone layer, but because of its limited usage, it continues to be considered appropriate for medical treatment.

    After using the stretch and spray technique, moist heat should be applied to the muscle for 10 to 20 minutes, followed by active movement of the muscle several times through its full range of motion. The stretch and spray treatment may be repeated daily if improvement occurs and the pain has not resolved. Patients can see immediate results with this technique, which is typically applied for 1 to 2 weeks. However, if the muscle becomes sore, treatments should be stopped for 2 or days and then their effectiveness reassessed1.

    Most patients respond well to this technique. However, it's noted that in patients who have hyperirritable trigger points and other perpetuating factors, the treatment may cause increased local and referred pain3.



    Trigger Point Injections

    Injections are recommended for more chronic myofascial pain but should be avoided in the acute setting. It's reported that 75% to 80% of acute myofascial pain can be treated with less invasive methods, such as stretch and spray and nonsteroidal anti-inflammatory drugs (NSAID's)4.

    Technique is critical because it appears that pain relief is caused not by the medication but by the mechanical disruption of the trigger point. Dry needle injections (injections without medication, or "needling") are effective but more painful and not as well tolerated by the patient5-7.

    As with stretch and spray, it is essential that the patient be in a comfortable position during the procedure. The clinician should locate the most tender spot in the taut muscle-fiber band, fix it between his or her fingers, and inject it directly using sterile technique. Often, inserting the needle causes a local twitch response with some referred pain: This confirms that the injection is well placed. Pain relief may also occur in the absence of a twitch response. Injecting near the trigger point, instead of into it, may irritate the trigger point rather than quiet it.

    Because of its low side-effect profile, the recommended injection solution is procaine hydrochloride 0.5% dilution, which is prepared by mixing 1 part of 2% procaine with 3 parts of sterile normal saline. Only small amounts are needed: 0.5 to 1 mL per trigger point1. Corticosteroids provide no additional benefit because trigger points are not inflammatory lesions.

    Injection therapy may be repeated. However, if pain persists after two or three injections, underlying perpetuating factors may exist.



    Massage Therapy

    Massage by a massage therapist may be a valuable primary or adjunct therapy. Deep massage of the trigger point and surrounding tissue with 20 to 30 lb of force often provides relief.



    Exercise

    Exercise is critical for long-term recovery. A rehabilitation program should include stretching, postural and strengthening exercises, and aerobic conditioning. Stretching reduces the potential for trigger point reactivation. It should be both passive and active. Posture-enhancing exercises improve musculoskeletal alignment, thereby enhancing balance and promoting relaxation8. Strengthening and aerobic conditioning improve not only strength and endurance, but also blood circulation in the muscles.



    Medication

    The use of medication for myofascial pain syndrome is somewhat debatable. NSAID's are beneficial as analgesics, especially to make the patient more comfortable while exercising and returning to activities of daily living.

    There is no evidence, however, for an anti-inflammatory effect for NSAID's in myofascial pain syndrome. Muscle relaxants are not particularly effective. If the patient suffers from sleep disturbance, low-dose tricyclic antidepressants may be effective in restoring sleep duration and quality. They may also diminish the pain. For more information about specific medications used in the treatment of CMP, check out the Drug Database.



    Myofascial Release

    Myofascial Release (MFR) is fast gaining recognition as the missing link in traditional healthcare. While MFR has existed in various forms for approximately 50-60 years scientific research and the use of electron microscopes has enabled therapists to refine this work and understand the nature of the fascial system and the important role to plays in health9. Myofascial (pronounced Myo-fashal) is derived from the Latin words 'myo' for muscle and 'fascia' for band. Fascia, sometimes called fibrous bands or connective tissue, is a 3D continuous web of microscopic hollow tubules that extends without interruption from the top of the head to the tip of the toes. Within these hollow tubules are continuous fibres of elastin and collagen surrounded by a fluid called the ground substance.

    Myofascial Release Therapy, like many alternative therapies, promotes the philosophy that the mind and body work together to maintain health. Effectively this supports the understanding that the mind and body are one and the same. The body has the ability to remember postural positions, actions and emotions without the brain reminding it to do so. Through out the body's fascial system flow microscopic cells containing energy which have the ability to retain memory.

    MFR also treats the injury at source allowing the patient to heal at the deepest level. Myofascial Release Therapy is a specialized physical therapy that affects and releases the restrictions within the fascial network. The therapy is an art form. The MFR therapist not only takes in to consideration what they see in the patients postural assessment but works directly with what they feel and sense from palpating and treating the body. Even though the patient may not feel much happening the experienced Therapist can actually feel the fascial restrictions, where they go to and subsequently feels the release of those restrictions during the session.

    Therapists are taught to feel and stretch slowly into the fascial network. Collagen means glue producer so therapists are taught to feel for this glue like texture which when dense, thick or hard defines a fascial restriction. The MFR technique is very different to that of massaging muscles, tendons and the ligaments of the body. A time component also exists, coupled with the fluidity of the therapists hands in applying pressure and moving though each and every fascial restriction. The time element is a vital factor, the fascia cannot be forced as it will naturally meet that force in return. Hence the MFR therapist provides a sustained, gentle, pressure for a minimum of 90 to 120 seconds allowing the fascia to elongate naturally and return to it's normal resting length restoring health and providing results that are both measurable and functional.



    Source(s):

    1. Simons DG, Travell JG: Myofascial origins of low back pain: 1: principles of diagnosis and treatment. Postgrad Med 1983;73(2):66-73

    2. Elizabeth W. Fomby, MD; Morris B. Mellion, MD. Identifying and Treating Myofascial Pain Syndrome. The Physician and Sportsmedicine, Vol 25, NO. 2, February 1997.

    3. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams & Wilkins, 1983

    4. Goldman LB, Rosenberg NL: Myofascial pain syndrome and fibromyalgia. Semin Neurol 1991;11(3):274-280

    5. Gunn CC, Milbrandt WE, Little AS, et al: Dry needling of muscle motor points for chronic low back pain: a randomized clinical trial with long-term follow-up. Spine 1980;5(3):279-291

    6. Hong CZ: Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response. Am J Phys Med Rehabil 1994;73(4):256-263

    7. Lewit K: The needle effect in the relief of myofascial pain. Pain 1979;6(1):83-90

    8. Simons DG: Myofascial pain due to trigger points, in Goodgold J (ed): Rehabilitation Medicine. St Louis, CV Mosby Co, 1988, pp 686-723

    9. What is Myofascial Release and Integrated Myofascial Therapy? Myofascial Release (MFR) is the core component of Integrated Myofascial Therapy. Myofascial Release UK & Ireland. (http://www.myofascialrelease.co.uk/what_is_mfr.htm)


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    Last Modified: 12/31/69 07:00 ET