Treatment of Muscle Pain

1
Treatment of Muscle Pain

• Martin K. Childers, DO, PhD
• Associate Professor
• Department of Neurology
• Wake Forest University Health Sciences

2
Historical perspective

• 1900 Muscular rheumatism (Adler)
• 1915 Fibrositis (Llewellyn Jones)
• 1918 Muskelrheumatismus, Myalgie (Schmidt)
• 1931 Muscular indurations (myogelosis) (Lange)
• 1938 First experimental report of referred pain
  from hypertonic saline injections. (Kellgren)

3
Historical perspectives

• 1941-1975 Palpable nodules of muscle called
  fibrositis (Kelly)
• 1983 No inflammatory component identified
  (Reynolds) thus fibrositis faded as diagnosis.
• 1942-1993 Janet Travel publishes 15 papers and 4
  books using the term Trigger Points.

4
Clinical characteristics of MTrPs

• Diagnostic history
• Regional pain
• Onset with sudden muscle overload
• Onset with sustained contraction in shortened
  position
• Onset with repetitive activity
• Physical exam
• Taut band
• Focal spot muscle tenderness
• Pressure-elicited referred pain pattern
• If active, pressure elicits symptoms recognised
  as familiar
• Other clinical features
• Local twitch response, difficult to elicit
• Prompt release of taut band with specific therapy

Simons, J Electromy Kines, 2004.
5
Contraction-disk complexes

• A 2 muscle fibers crossing the upper left of the
  figure show multiple contraction disks whose
  centers appear as white bands without any
  discernible structures (arrows). Areas with
  abnormally contracted sarcomeres are marked with
  arrrowheads. The fiber to the lower right shows
  undisturbed sarcomere length. B left boxed area
  in A at a higher magnification to show the
  abnormally contracted sarcomeres. C right boxed
  area in A exhibiting normal A band spacing.

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Differential Diagnosis of muscle pain

• Lower limb
• Trochanteric bursitis
• Piriformis syndrome
• Sacroiliac joint syndrome
• Radiculopathy

7
Differential Diagnosis of muscle pain

• Lower limb
• Trochanteric bursitis
• Piriformis syndrome
• Sacroiliac joint syndrome
• Radiculopathy

8
Differential Diagnosis of muscle pain

• Lower limb
• Trochanteric bursitis
• Piriformis syndrome
• Sacroiliac joint syndrome
• Radiculopathy

9
Differential Diagnosis of muscle pain

• Lower limb
• Trochanteric bursitis
• Piriformis syndrome
• Sacroiliac joint syndrome
• Radiculopathy

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Differential Dx (cont)

• Upper limb
• Cervical dystonia
• Rotator cuff tear
• Epicondylitis

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Differential Dx (cont)

• Upper limb
• Cervical dystonia
• Rotator cuff tear
• Epicondylitis

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Differential Dx (cont)

• Upper limb
• Cervical dystonia
• Rotator cuff tear
• Epicondylitis

13
Differential Dx (cont)

• Fibromyalgia
• Polymyositis
• Influenza
• Medications (statins)

14
Differential Dx (cont)

• Fibromyalgia
• Polymyositis
• Influenza
• Medications (statins)

15
Treatment

• Correction of muscle shortening
• Stretching
• Strengthening of affected muscles
• Correct faulty posture
• Aerobic conditioning
• Medications

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Treatment (cont)

• Medications
• NSAIDS
• Ibuprofen, etc
• Muscle relaxants
• Low dose cyclobenzaprine
• Baclofen
• Tizanidine
• Tricyclic antidepressants
• Botulinum toxin

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Treatment (cont)

• Trigger point injections

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Lumbar Epidural Steroid Injections (ESIs)

• Martin K. Childers, D.O., Ph.D
• Associate Professor

19
What is an ESI?

• A shot of a long-lasting corticosteroid (e.g.,
  triamcinolone, betamethasone) and an anesthetic
  (e.g., lidocaine, bupivacaine). Delivered into
  the epidural space of the spine, between the
  protective covering (dura) of the spinal cord and
  vertebrae

20
What is the Rationale for an ESI?

• Inhibit inflammation (phospholipase A2)
• Decrease pain
• Inhibit neural transmission of C-fibers
• Reduce capillary permeability

21
What are the Risks of ESIs?

• Bleeding bruising
• Allergic reaction
• Contraindications
• Infection at the site of needle stick
• Systemic illness
• Bleeding disorder or fully anticoagulated
• History of allergy to injected solution

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What Benefits might your patient receive from a
Lumbar ESI?

• Pain relief
• 60-75 some relief of leg pain and/or LBP when
  Lumbar ESIs properly placed
• Use of fluoroscopy for confirmation of needle
• Delayed effect of steroid
• Compounds of betamethosone sodium phosphate and
  acetate (short and long-acting roids)

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Are Lumbar ESIs effective?

• Recent research supports efficacy of lumbar
  transforaminal ESIs in sciatica or spinal
  stenosis
• Lutz et al
• Botwin et al
• Riew et al

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A Comparison Study

• Lutz et al prospective randomized study (2002)
  N48
• 2 groups.
• transforaminal lumbar ESI vs. saline injection in
  paraspinal muscle.
• Follow-up 16 months.
• patient satisfaction, the Rolland-Morris scale,
  and pain reduction.
• Success rate transforaminal ESI 84, saline
  injection 48.

25
A Review Study

• Botwin et al transforaminal ESI (retrospective
  study) in patients with sciatica from lumbar
  spinal stenosis.
• N34 patients who did not respond to NSAIDs and
  oral analgesics received average of 1.9 ESIs.
• F/up 1 year 75 50 pain reduction, 60
  improved walking duration, and 50 increased
  standing tolerance.

26
A Randomized Study

• Riew et al prospective, randomized,
  double-blinded trial (n55) for sciatica.
• Patients no response to 6 weeks of conservative
  treatment.
• 2 groups lumbar ESI bupivacaine vs.
  bupivacaine only. Up to 4 ESIs given.
• F/up 2-3 years.
• 23 of ESI patients got surgery vs 67 of
  bupivacaine only patients. (P

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How Safe is a lumbar ESI?

• 0.5-1 bachache, headache, nausea, vomiting,
  vaso-vagal rxn
• 0.02-0.01 epidural hematoma
• Others nerve injury, meningitis, mild
  hypothalamic-pituitary-adrenal axis suppression
  reported 1-3 months after 3 ESIs with 80 mg
  Aristacort in 7 ml 1 lidocaine

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How are Lumbar ESIs Done?

• Translaminar
• Transforaminal
• Caudal
• Use of fluoroscopy miss 30-40 of the time
  without fluoro guidance. New standard of care

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Translaminar ESI
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Transforaminal ESI
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For more information

• Myofascial pain emedicine article on the web
  http//www.emedicine.com/PMR/topic84.htm
• To schedule an appointment
• 336-716-8100