Cervical Myofascial Pain


Article Author:
Jeffrey Touma
Todd May


Article Editor:
Adam Isaacson


Editors In Chief:
Laura Stanley
Diana Peterson
Chantal Prewitt


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/10/2019 4:09:23 PM

Introduction

Myofascial pain is defined as a musculoskeletal disorder that causes pain in the area of a muscle in the body, and its surrounding connective tissue known as fascia.[1] The pain can be local or regional, and can also be characterized by multiple trigger points. Trigger points are highly sensitive muscle foci that are painful to touch and refer pain to the surrounding area. Specifically, in the cervical region, muscles commonly involved include the rhomboids, trapezius, levator scapulae, supraspinatus, and infraspinatus. The pain can be acute or chronic and likely occurs due to overuse, postural changes, or muscle trauma.

Etiology

The causes of myofascial pain syndromes are not fully understood. Overuse or trauma to the neck musculature, as well as stress and postural mechanics, can all lead to myofascial pain in the neck.[2] The clinical scenarios leading to this diagnosis can range from patients in motor vehicle accidents, to those who recently started a repeating overhead activity like painting a ceiling, to patients who work at a desk all day and have improper mechanics when using their computer. Some systemic connective tissue diseases may also lead to myofascial pain syndrome.

Epidemiology

Myofascial pain is extremely common in both the United States and worldwide, and it is the cause of many healthcare visits. Most people will experience a trigger point in their lifetime. As many as 20% of patients seen in orthopedic clinics have myofascial pain. More than 80% of patients who frequent pain management centers have a myofascial pain component to their condition. The cervical region is a very common place for diagnosis of myofascial pain. Cervical myofascial pain occurs in males and females, but there is an increased incidence in females. Myofascial pain occurs more frequently as patients age through midlife. The incidence declines gradually after middle age.

Pathophysiology

The pathophysiology of myofascial pain, in general, is not well understood. Patients may be more likely to develop trigger points if they have taut bands within the muscles; although, these taut bands are also common in asymptomatic individuals.[3] These bands can have latent trigger points that are then brought on by several factors, including stress or postural changes. New trigger points can also develop after injury or trauma. The most accepted theory states that there is an increase in acetylcholine abnormally, leading to increased muscle tension and the formation of the taut bands that constrict blood vessels. This leads to hypoxia causing tissue distress and activation of nociceptors, leading to autonomic modulation, which in turn causes increased acetylcholine release, thereby starting the cycle over.

History and Physical

The history of a patient presenting with the cervical myofascial syndrome can vary greatly. Patients can sometimes present with a history of acute trauma, or the pain may be insidious. Symptoms may be worse with repetitive tasks, certain movements, or even certain postural positions throughout the day. The pain can be nagging or acute, and it can be local or radiate out from the neck to the surrounding area. The range of motion of the cervical spine may be limited and painful, and the patient may also complain of some tightness or a local twitch response, similar to a spasm. Generally, the area is tender to palpation and can be described as deep, and constant. On physical exam, poor posture may be noted, with slumped shoulders or decreased cervical lordosis. No atrophy should be noted in cervical musculature. On palpation, finding trigger points in the area of pain is very likely. A trigger point is an area of hyperirritability that radiates pain when palpated. A taut band may be noted in the skeletal muscle or surrounding fascia. [4]Limitation of the range of motion of the cervical spine may be associated. The neurological exam, including strength, sensation, and reflexes of the upper extremities will be normal.

Evaluation

This is a clinical diagnosis. There are no imaging or laboratory tests that are diagnostic. However, imaging such as MRI or x-ray may be utilized if there is a suspicion for a more serious medical condition related to the neck, especially if treatment does not resolve the symptoms.

Treatment / Management

Multiple different treatments and modalities can be utilized to manage cervical myofascial pain syndrome. Typically these treatments include physical therapy, trigger point injections, medications, physical modalities and botulism toxin injections. [5] Physical therapy uses exercise and modalities to restore balance to the muscles and surrounding tissue areas. Therapists focus on targeted stretching and strengthening of affected muscles to correct the mechanical and postural deficiencies that may be causing or exacerbating the problem. Modalities including myofascial release, massage, ultrasound, and phonophoresis, along with an exercise program are aimed to decrease pain and prevent further injury. Various medications can also be prescribed, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and muscle relaxants. They should be used as an adjuvant to exercise or physical therapy because they are not usually effective alone. Botulism toxin type A inhibits acetylcholine release at the neuromuscular junction and may reduce muscle contractions, which can decrease pain levels. Trigger point injections or dry needling can both be equally effective in treating trigger points and is used commonly in clinical practice. [4]Trigger point injections involve injecting saline, steroid, or a local anesthetic into the specific trigger point palpated. Dry needling utilizes a similar technique, but no medication is injected into the area and is similar to acupuncture.[6] Osteopathic manipulation therapy has also been shown to be effective.[3]

Differential Diagnosis

Differential diagnosis includes cervical muscle strain, thoracic outlet syndrome, spondylosis, cervical disk disease, radiculopathy, muscle spasm, and fibromyalgia.

Prognosis

Prognosis greatly varies in this syndrome. Patients generally have good relief with proper treatment, but it is also possible to have chronic symptoms, or for symptoms to recur. It is necessary to find the underlying cause of the problem so that focused treatment can be delivered. Early interventions seem to lead to better outcomes.

Deterrence and Patient Education

Patient education plays a large role in the management and treatment of this syndrome. Focused exercise and attention to correct sitting posture, as well as proper body mechanics, in general, are necessary for better outcomes through the recovery process. The patient may also be required to participate in a home exercise program for continued benefit.

Enhancing Healthcare Team Outcomes

The diagnosis and management of cervicall myofascial pain is complex and best done with a multidisciplinary team that includes a pain specialist, social worker, physical therapist, mental health nurse, emergency department physician, neurologist and the primary care provider. There is no ideal treatment for this disorder and all presently available treatments have limitations. Relapse and remissions are common. The key is to educate the patient on changes in lifestyle such as proper posture, weight loss, discontinuation of smoking and limiting stress. For mild cases, the outlook is good but those who chronic pain tend to have a poor quality of life.[7][8][9] (Level V)


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Cervical Myofascial Pain - Questions

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A 48-year-old male with no past medical history presents with right-sided neck pain for 2 weeks. He said it started after painting his ceiling for multiple hours. He denies any numbness, tingling, or weakness in his arms. On physical exam, which would not be an expected finding?



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Which of the following patients would be expected to resolve after targeted trigger point injections, followed by multiple physical therapy sessions?



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A 46-year-old female with no past medical history presents with left-sided neck pain with non-specific radiation across the scapula and into the posterior arm. On physical exam, the patient has no neurologic deficits and diffuse tenderness to palpation in the lower cervical paraspinals. Which of the following is not an appropriate treatment for the condition described above?



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A 31-year-old female office worker presents for an initial visit with neck pain that is made worse when she is typing on her computer during the day and when she is driving. She denies any inciting event but does state the pain got worse after a long car ride where she was driving. She denies any radiating pain down her arms and denies numbness and tingling in the arms. What is an appropriate diagnostic tool to diagnose her condition?



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A 38-year-old female presents with persistent, dull, deep pain in the left side of her neck. She states she has had the pain for multiple months, but it recently started to worsen. She has tried ibuprofen which reduces the pain a little. On physical exam, there are multiple hyperirritable areas in the muscle belly of the trapezius when palpated. The neurologic exam is normal. What other symptom would the patient likely say she has that would help confirm the diagnosis?



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An 81-year-old male presents with nonspecific pain in the right side of his neck without any inciting event. X-ray of the cervical spine is negative. The provider notes the patient is neurologically intact and also notes a taut band of muscle where the patient complains of his pain. What may be the cause of his pain?



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Cervical Myofascial Pain - References

References

Kashyap R,Iqbal A,Alghadir AH, Controlled intervention to compare the efficacies of manual pressure release and the muscle energy technique for treating mechanical neck pain due to upper trapezius trigger points. Journal of pain research. 2018;     [PubMed]
Tabatabaiee A,Ebrahimi-Takamjani I,Ahmadi A,Sarrafzadeh J,Emrani A, Comparison of pressure release, phonophoresis and dry needling in treatment of latent myofascial trigger point of upper trapezius muscle. Journal of back and musculoskeletal rehabilitation. 2018 Dec 14;     [PubMed]
Giamberardino MA,Affaitati G,Fabrizio A,Costantini R, Myofascial pain syndromes and their evaluation. Best practice     [PubMed]
Aker PD,Gross AR,Goldsmith CH,Peloso P, Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ (Clinical research ed.). 1996 Nov 23;     [PubMed]
Esenyel M,Caglar N,Aldemir T, Treatment of myofascial pain. American journal of physical medicine     [PubMed]
Alvarez DJ,Rockwell PG, Trigger points: diagnosis and management. American family physician. 2002 Feb 15;     [PubMed]
White PF,Elvir Lazo OL,Galeas L,Cao X, Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management. F1000Research. 2017;     [PubMed]
Iaroshevskyi OA,Morozova OG,Logvinenko AV,Lypynska YV, Non-pharmacological treatment of chronic neck-shoulder myofascial pain in patients with forward head posture. Wiadomosci lekarskie (Warsaw, Poland : 1960). 2019;     [PubMed]
Ahmed S,Khattab S,Haddad C,Babineau J,Furlan A,Kumbhare D, Effect of aerobic exercise in the treatment of myofascial pain: a systematic review. Journal of exercise rehabilitation. 2018 Dec;     [PubMed]

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