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Myofascial Pain: Overview of Treatment Options

The best course for patients with myofascial pain syndrome, a common yet underdiagnosed pain disorder, will be an integrated, multifaceted approach to treatment.
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Myofascial pain syndrome (MPS) is the chief complaint for patients presenting to orofacial pain centers.1 It is associated with pain and muscle stiffness and is characterized by the development of myofascial trigger points (MTrPs)—hyperirritable, palpable nodules in the skeletal muscle fibers.2 The abnormal release of acetylcholine, which shortens sarcomeres and produces a “contraction knot,” is thought to be the mechanism of MTrPs development.3

Myofascial pain is generally described as a taut or hard band within a muscle, with tenderness and referred pain that can be present either locally, regionally or secondary to some other condition. Myofascial pain is estimated to affect approximately 44 million Americans.4 The muscle pain can be acute or chronic and oftentimes presents as dull and achy.

Stimulation of MTrPs will cause referred pain that does not follow a dermatome or myotome distribution.5 In one study by Audette and colleagues, investigators found that unilateral needle stimulation produced bilateral motor unit activation.6 This helps explain the referred pain of MTrPs and how individuals with chronic myofascial pain have a lower threshold for pain via increased neuronal excitability and release of substance P, glutamate, bradykinin, and other substances.3

Diagnosis of MPS

The commonly accepted key diagnostic criterion for MPS is the presence of MTrPs.7 Active trigger points are defined by the presence of spontaneous pain at rest, as well as the association of a local twitch response and/or pain referral with manual or intramuscular needle provocation.8 MTrPs can be either active or latent, and stress, tension, and factors such as poor posture can cause a latent MTrP to become active, causing pain.9

While manual palpation is the most commonly employed clinical method to confirm the presence of MTrPs, the sensitivity and specificity of palpation to detect MTrPs has not been validated, and there is no known “gold standard” for identifying the presence of MTrPs.10,11

Other diagnostic methods may have promise for the diagnosis of MPS. These include both diagnostic ultrasound and the use of biomarker analysis. Diagnostic ultrasound is a safe, portable method of achieving high-resolution imaging of soft tissue. Unfortunately, while ultrasound may offer important diagnostic images of the structural properties of MTrPs, it has not yet been validated.12 Ultrasound was able to distinguish between active, latent, and normal sites in one study. 12

While biomarkers (such as bradykinin, substance P, calcitonin gene-related peptide, tumor necrosis factor- alpha, interleukin 1beta (IL-1beta), IL-6, IL-8, serotonin, and norepinephrine) may offer an objective test for the diagnosis of MPS, sample testing is not practical or necessary when nodules can be diagnosed by manual palpation.13,14

MPS, while very common in the specialty of pain management, can mimic many other musculoskeletal and visceral diagnoses.15,16 As noted, MPS presents as both acute and chronic muscle pain that may also be accompanied by a sensory component of paresthesia or dysesthesia; the underlying cause of MPS is not always obvious. Low back pain (LBP) is one of the common manifestations of patients with MPS. While LBP is a commonly reported symptom, in many cases, a specific diagnosis is not well established.17,18 MPS may be a common cause of LBP, and should be considered as part of any LBP differential diagnosis since it can be treated.19

Treatment of MTrPs

Given the interrelationship of chronic pain with biopsychosocial factors, directing awareness toward decreasing stress and anxiety can help alleviate myofascial pain. In a study conducted with 26 participants experiencing facial myofascial pain, pain intensity decreased by 73% (P < 0.05) with a group cognitive behavioral therapy (CBT) course.1 There were 2 to 5 people per session, with 3 sessions each lasting 2 hours. The course focused on habit reversal, relaxation techniques, and changing rumination and exaggeration of thoughts.1

While addressing mental health conditions is an important factor in a comprehensive care plan, many efficacious medical treatments are available to manage MPS (Table 1). All treatments are designed to “release” the MTrPs—whether by mechanical or chemical means. Since many of these treatments are conservative and cost effective, each will be discussed briefly. We have broken the treatments down into categories, starting with dry needling, which is the traditional treatment recommended by Janet G. Travell, MD, creator of the term MPS.2

Dry Needling/Acupuncture

Dry needling is not acupuncture. Dry needling is based on Western principles and should not be confused with traditional Chinese medicine techniques of acupuncture. Both, however, use filament needles. As noted, dry needling is a popular treatment method for addressing MTrPs as introduced by Dr. Travell.2

Most of the literature, however, discusses the role of acupuncture, which is performed by certified professionals trained in either Japanese or Chinese techniques. Acupuncture has been used for the treatment of myofascial pain because it inactivates the neural loop of the trigger point, reducing pain and muscular hypertonicity.20-22 Acupuncture stimulates points on the body typically along meridian lines to prevent or modify the perception of pain, or to alter physiologic functions.22 Acupuncture and electro-acupuncture, which is where an electric current passes through the needle, have been shown to effectively decrease the intensity of chronic myofascial pain.22,23


Electromedical methods to “release” myofascial trigger points include biofeedback, therapeutic ultrasound, transcutaneous electrical nerve stimulation (TENS), and laser therapy. Surface electromyographic (SEMG) biofeedback, one of the oldest biofeedback methods, has been a major modality to reduce pain and optimize muscle function for decades. By measuring muscle activity, patients can be trained to reduce muscle tension or increase weak muscle activity. Three electrodes are required to measure a single muscle area: 1 positive, 1 negative, and 1 reference electrode.24 SEMG biofeedback records muscle activity, turns it into visual or auditory cues, and helps the patient modify muscle tension accordingly.25

Biofeedback exhibits usefulness as a modality to diminish pain in a noninvasive and productive way.26,27 Patients with low back pain, for example, often present with impaired flexion-relaxation response.28 SEMG biofeedback and ultrasound imaging biofeedback have been shown to be effective in the treatment of myofascial lower back pain, with solid empirical evidence of positive beneficial effect.29 In a small study, SEMG was combined with assisted stretching to reduce pain in patient with low back pain.28

Last updated on: May 16, 2017
First published on: May 15, 2017
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