Transcript Rehabilitation of Neck Pain and Myofascial Pain Syndrome

Rehabilitation of Neck Pain
and
Myofascial Pain Syndrome
復健醫學部
楚恆毅醫師
Objectives of this lecture
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To have a basic understanding of the
following conditions: cervical strain/sprain,
cervical radiculopathy and myofasical pain
dysfunction syndrome in terms of clinical
presentations, physical examinations and
priciple of treatment from a rehabilitative
perspective
Introduction and epidemiology
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Cervical axial pain: pain in all or part of a
corridor extending from the lower occipital region
down to the superior interscapular region
Cervical radicular pain: pain involving the
shoulder girdle and distally, in the upper limb
General prevalence from 9-18%
Increases with age
Radiculopathy: Annual incidence of 83.2/10000
and with peaks at 50-54 years of age for
radiculopathy
Pathophysiology of cervical pain and
the significance of referral patterns
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7 vertebrae and 8 roots
C0-1: 10° of flexion and 25° of extension
C1-2: responsible for 40-50% off all cervical
axial rotation; 45° in all direction
Functional anatomy of the joints, discs, roots
and other related ones
Dermatomes and areas of radicular pain
Disc herniations and degenerations
Injury
Common Clinical Disorders
Definition of Cervical strain and
sprains
Strain: a musculotendinous injury
produced by an overload injury due to
excessive forces imposed on the cervical
spines
 Sprain: overstretching or tearing injuries of
spinal ligaments
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Epidemiology of
Cervical strain and sprains
85% of neck pain results from acute,
repetitive or chronic injuries
 Most common cause of neck pain in noncatastrophic sports injuries
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Pathophysiology of Cervical strain
and sprains
Acceleration-deceleration injuries
 Partial/complete muscle tears and
hemorrhage
 Anterior longitudinal ligament
 Disc injury
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Diagnosis of Cervical strain and
sprains
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Symptoms: pain, soft tissue swelling, regional
muscle spasm, LROM
Thorough history and physical examination:
Spurling’s test
Headaches?
aggravating factors
Range of motion
Neurological signs
Plain radiography
Treatment of Cervical strain and sprains
Medication: NSAID, muscle relaxants
 Local injection with steroid, prolothrerapy,
shock-wave therapy, PRP therapy
 Physical modalities: PRICE,
superficial/deep heat therapy, TENS
therapy, cervical traction?
 Programs of therapeutic exercise
stretching and strengthening ex
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Shockwave therapy
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During Shockwave therapy, a highintensity sound wave interacts with
the tissues of the body
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This leads to a cascade of beneficial
effects such as neovascularisation
ingrowth, reversal of chronic
inflammation, stimulation of collagen
and dissolution of calcium build-up
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Stimulation of these biological
mechanisms creates an optimal
healing environment
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As the injured area is returned to
normal, functionality is restored and
pain is relieved.
Platelet rich plasma injection
therapy
Cervical radiculopathy and
radicular pain
Definition of Cervical radiculopathy
and radicular pain
• A pathologic process involving
neurophysiologic dysfunction of the
nerve root
• The seventh (C7; 60%) and sixth (C6;
25%) cervical nerve roots are the
most commonly affected
Pathophysiology of Cervical
radiculopathy and radicular pain
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Herniated intervertebral
disk (HIVD)
Inflammatory response
Cervical spondylosis:
ligamentous hypertrophy,
hyperostosis, disk
degeneration and
zygapophyseal joint
arthropathy
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Intervertebral discs are located between the
vertebral bodies of C2-C7
The discs are composed of an outer annular
fibrosis and an inner nucleus pulposus and serve
as force dissipators, transmitting compressive
loads throughout a range of motion (ROM)
The intervertebral discs are thicker anteriorly and
therefore contribute to normal cervical lordosis
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The foramina are largest at C2-C3 and progressively
decrease in size to the C6-C7 level
The nerve root occupies 25-33% of the foraminal space
The neural foramen is bordered anteromedially by the
uncovertebral joints, posterolaterally by facet joints,
superiorly by the pedicle of the vertebra above, and
inferiorly by the pedicle of the lower vertebra. Medially,
the foramina are formed by the edge of the end plates
and the intervertebral discs
The nerve roots exit above their correspondingly
numbered vertebral body from C2-C7. C1 exits between
the occiput and atlas, and C8 exits below the C7
vertebral body
Diagnosis of Cervical radiculopathy
and radicular pain
Thorough history and physical
examination
 Locations of pain regarding different level
of C spines
 Exacerbating factors
 Imaging studies: X-ray, CT scan, MRI,
bonescan (if necessary)
 Electrodiagnostic evaluation
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Red flags !!
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Weakness of limbs such as impaired fine motor
or coordination abilities of hands or gait change
Progressive neurological deficits
Muscle atrophy
Symptoms of neurogenic bladder such as
incontinence
Severe, unusual pain such as nocturnal pain,
obvious knocking pain along spines
Combined with other systemic condition such as
fever
Treatment of Cervical radiculopathy
and radicular pain
Physical medicine and rehabilitation
 Medications: oral NSAIDs, local injection
with steroid
 Stabilization and functional restoration
 Invasive procedures
 surgery
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IMMOBILIZATION
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For patients with acute neck pain
secondary to radiculopathy, a
short course (one week) of neck
immobilization may reduce
symptoms in the inflammatory
phase
Although the effectiveness of
immobilization with a cervical
collar has not been proven to
alter the course or intensity of the
disease process, it may be
beneficial in some patients.
TRACTION
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Continuous VS intermittent
Home cervical traction units may decrease radicular
symptoms.
In theory, traction distracts the neural foramen and
decompresses the affected nerve root, reduced the
pressure in discs, helps open the facet joints and release
the tight neck muscles
Typically, eight to 12 lb of traction (1/8 to ¼ body weight)
is applied at an angle of approximately 24 degrees of
flexion for 15- to 20-minute intervals
Traction is most beneficial when acute muscular pain
has subsided and should not be used (or with extreme
caution) in patients who have signs of myelopathy
A recent systematic review of mechanical traction for
neck pain of more than three months duration, with or
without radicular symptoms, found insufficient evidence
to recommend for or against its use in the management
of chronic symptoms
PHYSICAL THERAPY AND MANIPULATION
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restoring range of motion and overall
conditioning of the neck musculature
In the first six weeks after onset of pain, gentle
range-of-motion and stretching exercises
supplemented by massage and modalities such
as heat, ice, and electrical stimulation may be
used
As the pain improves, a gradual, isometric
strengthening program may be initiated with
progression to active range-of-motion and
resistive exercises as tolerated
Myofacial Pain Dysfunction
Syndrome (MPDS)
Terminology: muscle pain versus
myofascial pain
Muscle pain: widespread, aching pain that
appears to emanate from muscles
together with tenderness over the muscles
 Myofacial pain: a more complex term, a
regional pain syndrome characterized by
the presence of myofascial trigger
points( TrPs), taut band, slow twitch
responses and referred pain
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regionalized aching and poorly localized pain in the
muscles and joints
sensory disturbances, such as numbness in a
characteristic of distribution
the type of pain felt is characteristic of the muscle
involved
An acute onset may occur after a specific event or
trauma (eg, moving quickly in an awkward position),
while chronic pain may result from poor posture or
overuse
disturbed sleep. Persons with cervical and periscapular
myofascial pain may have difficulty finding a comfortable
sleeping position
They may or may not be aware of muscle weakness in
the affected muscles and may have a tendency to drop
things.
Trigger points
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focal point tenderness
reproduction of pain upon trigger point palpation
hardening of the muscle upon trigger point
palpation (taut band)
pseudo-weakness of the involved
muscle, referred pain, and limited range of
motion following approximately 5 seconds of
sustained trigger point pressure under the load
of 4 kg
Slow twitch response
End plate
Management of MPDS
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Physical modalities
Massage therapy using trigger-point release
techniques
Physical therapy involving gentle stretching and
exercise is useful for recovering full range of
motion and motor coordination
Once the trigger points are gone, muscle
strengthening exercise can begin, supporting
long-term health of the local muscle system
Management of MPDS
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Anti-depressants (primarilySNRiIs), anticonvulsants such
as pregabalin (Lyrica), and msucle relaxants such as
Baclofen
Myofascial release, which involves gentle fascia
manipulation and massage, may improve or remediate
the condition
Dry needling/acupuncture
Trigger point injections using local anaesthetic such as
Lidocaine or plus steroids; Botulinum toxin
Posture evaluation and ergomatics
Yoga,Taichi
Trigger point release by therapeutic ex
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Trigger point
therapy involves
the use of various
other techniques
including active
contract/relax and
postisometric
relaxtion,
vapocoolant spray
and stretch and
ultrasound.
Dry needling injection
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Trigger points are created at the muscular
endplate
This endplate becomes dysfunctional, creating a
localized contracted state (with more Ach)
The needle disrupts the dysfunctional endplates
forcing the body to repair them
The needling process also stimulates certain
nerves to block pain sensations
Compared to acupuncture
Thank you for your attention.
Any questions or thoughts?