Myofascial Pain Evaluation and Treatment

Original Editor - Carin Hunter based on the course by Rina Pandya
Top Contributors - Carin Hunter, Jess Bell, Kim Jackson, Merinda Rodseth and Tarina van der Stockt

Treatment : Symptom Review

• Sore spots, sensitive to pressure, primarily in muscles.
• Dull, aching, and nagging pain.
• Deep muscle pain than joints.
• Limbs may feel a little weak, heavy, and stiff.
• Pain mainly occurs in a specific area with a fairly clear epicenter
• Crave massage, but it usually provides only temporary relief.
• Hot showers and baths are also appealing and almost always at least briefly relieving.
• Usually feels better with activity and exercise.
• Pain is not strongly or sharply linked to movement.
• There is no clear mechanism of injury, but flare-ups often occur in response to extremes of position, exercise, or temperature.
• Pain is mostly (episodic), but episodes can last a long time (weeks or months).
• Pain may move around a bit…even to the other side of your body! While uncommon, it’s a distinctive symptom of trigger points.

Treatment techniques

1. Instrument assisted soft tissue mobilization (IASTM)
2. Trigger point release
3. SFMA
4. Kinesiotaping
5. Dry needling
6. Foam Rolling
7. Exercises

1. Instrument assisted soft tissue mobilization (IASTM):

Instrument assisted soft tissue mobilization (IASTM) is a widely known and acknowledged treatment for myofascial restriction. IASTM uses specially designed instruments to provide to mobilize scar tissue and myofascial adhesions. One such example is the Graston technique ® .

Systematic review by Scott Cheatham and Matt Lee ( 2016) appraised the evidence assessing the effects of IASTM.

Methodology: databases: PubMed, PEDro, Science Direct, and the EBSCOhost collection. The search terms included individual or a combination of the following: instrument; assisted; augmented; soft-tissue; mobilization; Graston®; and technique.

Results: A total of 7 randomized controlled trials were appraised. Five of the studies measured an IASTM intervention versus a control or alternate intervention group for a musculoskeletal pathology. The results of the studies were insignificant (p>.05) with both groups displaying equal outcomes. Two studies measured an IASTM intervention versus a control or alternate intervention group on the effects of joint ROM. The IASTM intervention produced significant (P<.05) short term gains up to 24 hours.

IASTM uses specially designed instruments for deeper penetration and mechanical advantage to the clinician. Using instruments for soft tissue mobilization is theorized to increase vibration sense by the clinician and patient. The increased perception of vibration may facilitate the clinician’s ability to detect altered tissue properties (e.g., identify tissue adhesions) while facilitating the patient’s awareness of altered sensations within the treated tissues. ( Baker 2013, Lee, Lee et al 2014)

It is theorized that IASTM stimulates connective tissue remodeling through resorption of excessive fibrosis, along with inducing repair and regeneration of collagen secondary to fibroblast recruitment.(Howitt 2009, Strung 2014) This results in the release and breakdown of scar tissue, adhesions, and fascial restrictions.(Howitt 2009, Papa 2012)

There are various IASTM tools and companies such as Graston®, Técnica Gavilán®, Hawk Grips®, Functional and Kinetic Treatment and Rehab (FAKTR)®, Adhesion Breakers® and Fascial Abrasion Technique™ that have their own approach to treatment and instrument design (e.g., instrument materials, instrument shape).

The Graston® technique

•The Graston® technique contains a protocol for treatment that contains several components: examination, warm-up, IASTM treatment (e.g., 30–60 seconds per lesion), post treatment stretching, strengthening, and ice (only when subacute inflammation is of concern). (Technique G. Graston Technique: Frequently Asked Qustions. Graston Technique Website. 2016. available at: http://www.grastontechnique.com/FAQs.html. )

•Graston Technique® (GT) is a unique, evidence-based form of instrument-assisted soft tissue mobilization that enables clinicians to effectively and efficiently address soft tissue lesions and fascial restrictions resulting in improved patient outcomes.GT uses specially designed stainless steel instruments with unique treatment edges and angles to deliver an effective means of manual therapy. The use of GT instruments, when combined with appropriate therapeutic exercise, leads to the restoration of pain-free movement and function. The instruments also are used diagnostically to assess the kinetic chain, in an efficient manner using the principles of regional interdependence.

•Refer to : grastontechnique.com/clinicians/resources

Effects of the Graston® technique

Empirical and anecdotal evidence: based on patient and clinician experience and documentation)

•Separates and breaks down collagen cross-links, and splays and stretches connective tissue and muscle fibers

•Facilitates reflex changes in the chronic muscle holding pattern (inhibition of abnormal tone/guarding leading to pain reduction via improved sensory input)

•Alters/inhibits spinal reflex activity (facilitated segment)

•Increases the rate and amount of blood flow to and from the area (angiogenesis vs. immediate local increases in blood flow)

•Increases cellular activity in the region, including fibroblasts and mast cells

•Increases histamine response secondary to mast cell activity.

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•Graston Technique® is grounded in the works of Dr. James Cyriax, a British orthopedic surgeon

Conditions treated with the Graston® technique

•Achilles Tendinitis/osis (ankle pain)

•Carpal Tunnel Syndrome (wrist pain)

•Cervicothoracic Sprain/Strain (neck pain)

•Fibromyalgia

•Lateral Epicondylitis/osis (tennis elbow)

•Lumbosacral Sprain/Strain (back pain)

•Medial Epicondylitis/osis (golfer's elbow)

•Myofascial Pain Syndromes

•Patellofemoral Disorders (knee pain)

•Plantar Fasciitis/osis (foot pain)

•Post surgeries such as joint replacements, RTC repairs (once post-surgical protocol allows for soft tissue mobilization/manual therapy)

•Rotator Cuff Tendinitis/osis (shoulder pain)

•Scar Tissue/post-surgical scars (once completely closed)

•Patients demonstrating central and/or peripheral sensitization (only used in light stroking/brushing mode to desensitize)

•Shin Splints

•Trigger Finger

•Women's Health (post-mastectomy and Caesarean scarring)

2. Trigger Point Release

1. Primary / Central and Secondary / Satellite Trigger Points

•Primary or Central trigger points are those that cause severe pain locally at the pressure with irradiation according to referred pain map. Usually are based around the center of a muscle belly.

•Secondary or Satellite trigger points arise in response to existing central trigger points in surrounding muscles. They usually spontaneously withdraw when the central trigger point is healed. Can be present in the form of a cluster.

• Active Trigger Points: Any point that causes tenderness and referral pain pattern on palpation. Almost always central trigger points are active and some satellite trigger points are also active (but not necessarily all of them). Inactive trigger points can eventually become active if there is a provocative factor.
• Inactive or Latent Trigger Points: These can develop in anywhere and under fingertips feel like lumps, but are not painful. Can increase a stiffness of the muscles.
• Diffuse Trigger Points: Commonly happen in case of severe postural deformity where initially primary trigger points are multiple, so secondary multiple trigger points are only a response of a mechanism, called diffuse.
• Attachment Trigger Points: tendo-osseous junctions which become very tender. If not treated these can create degenerative processes of an adjacent joint.
• Ligamentous Trigger Points: Pay attention to the ligament for the presence of trigger points. Presence of trigger points in the anterior longitudinal ligament of the spine can result in neck instability. Some knee pain syndromes are successfully healed when treated ligamentum patellae and fibular collateral ligament.

●Reference: physiopedia