Managing Myofascial Pain Syndrome

Sorting Through the Diagnosis and Honing Treatment

James M. Daniels, MD, MPH; Tim Ishmael, MD; Robert M. Wesley, MA

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 10 - OCTOBER 2003  Read About Mycoplasma  Part -2

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Shiatsu. This technique has many names, including ischemic acupressure and mild therapy. To perform the technique, the clinician uses the thumb to apply a slow, gentle, firm pressure to the trigger point. It is very important that light pressure be applied initially and slowly intensified over approximately 1 minute; application of sudden forceful pressure will actually aggravate the patient's symptoms. A second minute of maximal pressure is applied, at which time the examiner's thumb is slowly released from the trigger point. Clinicians familiar with this technique often describe a feeling of the muscle "giving way" beneath their fingers during this second minute. Once pressure is released, the skin blanches briefly, and a reactive hyperemia follows that may last several hours. This technique has no known complications other than local ecchymosis in some patients.

Spray and stretch. Not all patients can tolerate ischemic acupressure, so some practitioners may employ a spray and stretch technique with vapocoolant. The pain signal sent by the stretched muscle is overridden by a nerve impulse to the posterior horn of the spinal column. Following identification of the trigger point, the physician places the patient in a comfortable, relaxed position. To prepare the patient, physicians may often use a heating pad or moist heat on the area for approximately 5 to 10 minutes. One end of the muscle is anchored either by one of the examiner's hands or by immobilizing the patient's distal appendage. The skin is then sprayed with repeated parallel sweeps of vapocoolant over the length of the muscle in the direction of the pain pattern (figure 2). It is important that the vapocoolant container be held approximately 12 in. (30 cm) from the skin at a 30° angle to the plane of the skin. Parallel sprays are made using unidirectional sweeps over the most tightly stretched muscle fibers and then over the rest of the muscle. Sweeps should be slow and even and cover about 4 in./sec (10 cm/sec). The spray should be overlapped slightly, but no more than two passes should be made over the same area.

After the first sweep of spray, pressure is applied to take up muscle slack; this pattern is continued as additional sweeps of spray are applied. The sweeps are extended to cover the referred pain pattern of the muscle. These steps are repeated two or three times until the skin becomes cold to the touch or when range of motion reaches its maximum. Reapplication of heat is followed by several cycles of full range of motion of that muscle. Some physicians suggest using the vapocoolant over a slightly larger area than that of the referred pain pattern. If the patient says the spray is too cold, the dispenser can be held closer to the skin than the usual 12 in. (30 cm). If a colder than usual spray is desired, distance can be increased to 18 in. (46 cm). The skin should be transiently cooled and not the underlying muscle. Passive stretching is gradually applied to get the joint to extend to its full range of motion, but the muscle should not be overstretched. The muscle should then be promptly returned to its shortened length.

Coolant use and ice stroking. In the past, the most widely used vapocoolant was ethyl chloride, but this has been replaced by fluoromethane, which is nontoxic, is nonflammable, and does not irritate the skin. Unfortunately, fluorocarbons have been implicated in degradation of the upper atmosphere ozone layer and will no longer be manufactured. A temporary medical exception was granted for fluoromethane until a suitable substitute is developed, and one such spray is available (Fluori-Methane Spray and Stretch, Gebauer, Cleveland, 1-800-321-9348). The concentrated stream from a vapocoolant dispenser is far superior to the usual diffuse spray from a standard spray can. Physicians should be careful when using fluoromethane. Although the spray will not damage most tissues that are accidentally sprayed, the conjunctiva may be damaged if the spray hits a patient's eye.

Some patients with cold-induced asthma or other respiratory conditions may not tolerate vapocoolant spray near the face unless the clinician covers the patient's nose with a small cloth or hand.This difficulty has led to the development of a technique called ice stroking, which may replace spray for these patients. Water is frozen in a plastic or paper cup with a stirring stick, such as a tongue depressor, placed in the cup to provide a handle to hold the ice. The bottom of the cup is then torn back and an edge of ice is applied to the skin in a unidirectional stroke following the same patterns as for the spray. The patient's skin must remain dry, because dampness alters the rate of change in skin temperature. Some clinicians cover the ice with thin plastic wrap or have an assistant follow along with a small towel to blot the skin. It is imperative to move along at a rate so that the ice cools just the skin and not the underlying tissues.¹

These techniques can be easily mastered in a short time. The only contraindications to these methods would be if the patient has Raynaud's phenomenon, cold urticaria, or hypersensitivity to one of the cooling agents.

Battling Underdiagnosis

MPS is a common disorder that may be underdiagnosed. It is imperative that the physician has determined that the patient has no other condition that mimics MPS. Some of the simple techniques described for treating MPS can be easily learned by patients to provide pain relief and restore function without the additional cost of supervised physical therapy and medications.

References

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Dr Daniels is associate professor of family and community medicine in Southern Illinois University School of Medicine's family practice residency program and program director of the care sports medicine fellowship program in Quincy, Illinois. He has a certificate of added qualifications in primary care sports medicine. Dr Ishmael is a family practice physician in private practice in Litchfield, Illinois. Mr Wesley is director of research and program development in the department of family and community medicine at the Southern Illinois University School of Medicine in Springfield, Illinois. Address correspondence to James M. Daniels, MD, MPH, 612 N 11th St, Suite B, Quincy, IL 62301;