Myofascial Trigger Points Pathophysiology and Evidence Informed Diagnosis and Management Contemporary Issues in Physical Therapy and Rehabilitation

References • 1 8 9 1 84. Tschopp KP, Gysin C. Local injection therapy i n 1 07 patients with myofascial pain syndrome of the head and neck. ORL 1 99 6;58:306- 3 1 0 . 1 85. Ling FW, Slocumb j c . U s e of trigger p o i n t injections in chronic pelvic pain. Obstet Gynecol Clin North Am 1 993;20:809-8 1 5 . 1 86. Padamsee M , Mehta N, White G E . Trigger point injection: A neglected modality i n t h e treat­ ment ofTMJ dysfunction. ] Pedod 1 987; 12 :72-92. 1 87. Tsen LC, Camann WR. Trigger point injections for myofascial pain d u ring epidural analgesia for labor. Reg Anesth 1 997;22:466-468. 1 88. Ney jP, Difazio M, Sichani A, Monacci W, Foster L, jabbari B. Treatment of chronic low back pain with successive injections of botulinum toxin over 6 months: A prospective trial of 60 patients. Clin] Pain 2006;22 :363-369. 1 89. jaeger B, Skootsky SA. Double-blind, controlled study of different myofascial trigger poi nt injection techniques. Pain 1 987;4(suppl):S292. 1 90. Cummings TM, White AR. Needl ing therapies in the management of myofascial trigger point pain: A systematic review. Arch Phys Med RehabiI 200 1 ;82:986-992. 1 9 1 . Wheeler AH, Goolkasian P, G retz SS. A randomized, double-blind, prospective pilot study of botu l i n u m toxin injection for refractory, u n i lateral, cervicothoracic, paraspinal, myofascial pain syndrome. Spine 1 998;23 : 1 662- 1 666. 1 92. M ense S. Neu robiological basis for the use of b o t u l i n u m tox i n i n pain therapy. ] Neurol 2004;25 1 (suppl l):I 1 -I7. 193. Reilich P, Fheodoroff K, Kern U, M ense S, Seddigh S, Wissel j, Pongratz D. Consensus state­ ment: Botulinum toxin in myofascial pain. ] Neurol 2004;25 1 (suppl 1 ) :136-138. 1 94. Lang AM. Botu l i n u m toxin therapy for myofascial pain disorders. Curr Pain Headache Rep 2002;6:355-360. 195. Kern U, Martin C, Scheicher S, Mu ller H. Langzeitbe handlung von Phantom- u nd Stumpfschmerzen mit Botulinumtoxin Typ A Uber 12 Monate: Eine erste klinische Beobachtung. [German; Prolonged treatment of phantom and stump pain with Botulinum Toxi n A over a period of 12 months: A preliminary clinical observation.] Nervenarzt 2004;75: 336-340. 1 96. Gobel H, Hei nze A, Reichel G, Hefter H , Benecke R. Efficacy and safety of a single botu l i n u m type A toxin complex treatment (Dysport) for the relief of u p p e r back myofascial pain syn­ drome: Results from a randomized double-blind placebo-controlled multicentre study. Pain 2006; 1 25:82-88. 1 97. Aoki KR. Review of a proposed mechanism for the antinociceptive action of botulinum toxin type A. Neurotoxicology 2005;26:785-793. 1 98. Aoki KR. Pharmacology and i m m u n o l ogy of botu l i n u m n e u roroxins. Int Ophthalmol Clin 2005;45(3):25-37. 1 99. Peng PW, Castano ED. S u rvey of chronic pain practice by anesthesiologists in Canada Can ] Anaesth 2005;52(4):383-389. 200. Gunn Cc. Transcutaneous neural sti m u lation, needle acu puncture and \"the Ch'I\" p henom­ enon. Am] Acupuncture 1 9 76;4: 3 1 7-322. 20 1 . Gunn Cc. Type IV acu p u ncture points. Am] Acupuncture 1 977;5 ( 1 ):45-46. 202. Gunn CC, Ditchburn FG, King M H, Renwick GJ. Acupuncture loci: A proposal for their clas­ s i fi cation according to t h e i r r e l at i o n s h i p to known n e u ral s t r u c t u res. A m ] Chin Med 1976;4: 1 83- 1 95. 203. Gunn CC, Milbrandt WE. Tenderness at motor points: An aid i n the diagnosis of pain in the shoulder referred from the cervical spine. ] Am Osteopath Assoc 1 9 77;77(3): 1 96-2 1 2 . 204. G u n n c c . Motor points and moror li nes. A m ] Acupuncture 1978;6:55-58. Copyrighted Material

1 90 • Chapter 8 Tri gger Po i n t Dry N e e d l i ng 205. B i rch S. Trigger poim: Acup u nctu re poim correlations revisited. ] Altern Complement Med 2003;9:9 1 - 1 03. 206. Melzack R. Myofascial trigger poims: Relation to acupuncture and mechanisms of pain. Arch Phys Med RehabiI 1 9 8 1 ;62: 1 1 4- 1 1 7. 207. Dorsher P. Trigger poims and acupuncrure points: Anatomic and clinical correlarions. Med Acupunct 2006; 1 7( 3) : 2 1 -25. 208. Kao M], Hsieh YL, Kuo F], Hong C-Z. Electrophysiological assessment of acupuncture poi ms. A m ] Phys Med RehabiI 2006;85:443-448. 209. Hong C-Z: Myofascial rrigger poims: Pathophysiology and correlarion with acupuncture poims. Acupunct Med 2000; 1 8( 1) : 4 1 -47. 2 10. Audette ]F, B inder RA. Acupuncture in the managemem ofmyofascial pain and headache. Curr Pain Headache Rep 2003;7(5 suppl):395-40 1 . 2 1 1 . Melzack R, Srillwell OM, Fox EJ. Trigger poims and acu puncture poims for pai n : Correlations and implications. Pain 1 977;3:3-23. 2 1 2. Simons DG, DommerholrJ. Myofascial pain syndromes: Trigger poin ts. ] Musculoskel Pain 2006 (in press). 2 1 3. Travell ] G , S i m o n s D G . Myofascial Pain and Dysfunction: The Trigger Point Manual. Vo l 2 . Baltimore, M D : Williams & Wi lkins; 1 992. 2 1 4. Ge HY, Madeleine P, Wang K, Arendt-Nielsen L. Hypoalgesia to pressure pain i n referred pain areas triggered by spatial summarion of experimental muscle pain from unilareral or bilateral trapezius muscles. Eur] Pain 2003;7:53 1-537. 2 1 5 . New Mexico Statutes Annotated 1 978. Chapter 6 1 : Professional and Occu pational Licenses. Article 1 4A: Acupuncrure and Oriental Medicine Practice. 3: Definitions, 1 978. 2 1 6. Linde K, Streng A, Jurgens S, H o p p e A, Brinkhaus B, Win C, Wagen p feil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D. Acupuncture fo r patients with migraine: A randomized controlled rrial. ]AMA 2005;293:2 1 1 8- 2 1 25. 2 1 7. Melchan 0, Streng A, Hoppe A, B rinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, H u mmelsberger ], lrnich 0, Weidenhammer W, Willich SN, Linde K. Acupuncture in patients with rension-eype headache: Randomised controlled trial. BM] 2005;33 1(75 1 3):376-382. 2 1 8. Scharf H P, Mansmann U, Streitberger K, Wine S, Kramer J, Maier C, Tram pisch H], Victor N. Acu p u ncture and knee osteoarth ritis: A rhree-armed random ized trial. Ann Intern Med 2006; 1 4 5 : 1 2-20. Copyrighted Material

Chapter 9 Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report Tamer S. Issa) P� BSc) OP� DCS Peter A. Huijbregts, P� MSc, MHSc) OP� DCS, FAADMP� FCAMT Introduction Headaches are one of the most common reasons people seek medical attention. They co nstitute the leading cause fo r neurology visits, acco unting fo r o ne-third of ou tpatie nt visits. I No data are available on the p revalence of h eadache as a cause fo r orthopaedic physical therapy visits; however, Boissonnault2 reported headache as a comorbidity i n 22% o f patients presenting fo r o u tpatient physical and occupational therapy services. Most relevant to the physical therapist are those headaches that to some extent have (or may have) a neurom usculoskeletal etiology, because those are the headache types that co uld logically be expected to benefit from physical therapy (PT) diagnosis and man­ agement. The Inte rnational Headache Society (IHS) has long aimed to improve upon the understanding, diagnosis, and management of h eadache disorders. The IHS pub­ lished the first internationally accep ted and clinically useful headac he classification system in 1 988 with the first edition of the International Classification ofHeadache Disorders (rCHD); a second edition (ICHD-II) was p ublished in 20043. The ICHD-II has classified hundreds of di fferent types of headaches into two categories: primary headaches and secondary headaches. P rimary headaches are the most com mon headache type and have no other underlying cause. They include migraine headache (MH), tension­ type headache (TTH) , cluster he adache and additional trigemi nal auto n o m i c cepha­ lalgias, and o ther p ri m ary h e adac hes. Secondary headaches are cl ass ified according to their causes and are c l assifi e d into 1 0 separate c atego ries. Of the p ri mary headaches, mounting evidence in the scientific li terature indicates that TTH a n d-to Courtesy ofJohn M. Medeiros, PT, PhD, Managing Edi[Or of the Journal ofManual a·nd Manipulative Therapy 191 Copyrighted Material

192 • Chapter 9 Physical Th e rapy Diagn osis a n d M a nagement a lesser extent MH-may have an underlying neurom usculoskeletal contribution. Secondary headaches with a neuromusculoskeletal etiology include cervicogenic headache ( CGH), occipi tal neu ralgia (ON), and headache associated with temporomandibular disorder (TMD). TTH is the most com mon yet least studied of the primary headaches4. , s It was once thought to be primarily psychogenic, but now there is evidence of a neurobiological com­ ponent. Recent studies aimed at understanding the etiology and mechanism ofTTH have looked at the role of muscle contraction, the significance ofpericranial muscle tenderness, and the combined influence of these peripheral inputs with central etiologic features.6, 7 Pericranial muscle tenderness is the most well-documented abnormality found in TTH 6-8 It has been proposed that in patients with chronic TTH, prolonged nociceptive stimuli from pericranial myofascial tissue contribute to supraspinal facilitation leading to central sensitization, which in turn results in an increased general pain sensitivity 6, 7,9 Central sensitization arises fro m the amplification of receptiveness of central pain-signaling neu­ rons to input from low-threshold mechanoreceptors and is clinically characterized by the presence of hyperalgesia and/or aUodynia. lOl,l Table 9-1 lists the ICHD-II diagnostic cri­ teria for some of the TTH forms. It has been hypothesized that part of the continued periphe ral nociceptive input leading to central sensi tization i n patients with TTH originates i n myo fascial trigger points (MTrPs) . Referred pain originating in these MTrPs may also contribute to the clinical presentation of patients with TTH. 12- 1S An MTrP is defined as a hyperse nsitive nodule wi thin a tau t band in skeletal muscle, which is painful on compression and which may cause characteristic referred pain, tende rness, or auto nomic phenomena. 12-14, 16- 18 Myofascial trigger points can be found i n a specific muscle or group of muscles and can limit the flexibility of the affected muscles . 12 Active MTrPs cause clinical symptoms of pain and restricted motion, whereas latent trigger points may not contribute to pain but still influence muscle fatigue and mobility I2-14, 16 -19 Several muscles of the head and neck have referral pain patterns into the h ead that can cause or contribute to pain distribution p atterns commonly associated not only wi th TTH but also with MH and secondary headaches such as CGH, occipital neuralgia, and TMD. Other trigger-point-related symp­ toms include tinnitus, eye symptoms, and torticollis. 12-2 1 MH is a common disabling headache with a strong genetic basis. This headache type can be divided into two categories: migraine with or wi thout aura (Table 9-1). The pathophys­ iology ofMH is believed to be a neurovascular disorder of the trigeminovascular system in which a dysfunctional vasodilation in the brains tern mechanically irritates sensory fibers of the trigeminal nerve, resulting in the release of inflammatory substances and the activation of meningeal nociceptors. Release of substance P and calcitonin gene-related peptide fur­ ther contributes to vasodilation and neurogenic inflammation, leading to an increased activation of neurons in the trigeminal ganglion and subsequent transmission of pain sig­ nals to the brai n. During the progression of an MH episode, the spinal and supraspinal ner­ vous cen ters become sensitized, resulting in increased pain and sensitivity to stimuli.22 Copyrighted Material

Introduction • 193 TABLE 9�1 Competing Primary Headaches4 (Migraine, Tension�Type, New Daily Persistent) Type Diagnostic Criteria Migraine without A. At least five :macks fulfilling criteria B-D aura (l.l) B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully Typical aura with trcated) migrame (1.2.1) C. Headache has at least two of the following characteri.tics: 1. nli at 2. Pulsat ing yuality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine phY'ical activity (e.g., walking or climbing stair) D. During heada he at least one of the following: I. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not amihured [Q another di'order A. Atlea't two attack fulfilling criteria B-D B. Aum ollsi'ting of at least one of the following, hut no motor weakness: 1. Fully rever ihlt! visu;]lymprorns incl uding positive feature' ( g. ., f1ickt!ring Iighl1;, spots or lines) and/or negative features ( i.e\" loss of vision) 2. Fully reversible sensory 'ymptoms mcluding po\"tin: features (i.e., pins and needle) and/or negative features (j.e., numbness) 3. FuJly reversible dysphasic speech disturbance C. Atleast two of the following: l. Homonymous visual symptom' and/or unilateral sensory symptoms 2. Atleast one aura symptom develops gr adually over �5 min­ u tes and/or differem aura symptoms occur in slIccession over l!!5 minutes 3. Each symptom lasts l!5! and :560 minutes D. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follow alLra within 60 minures. E, ot att ributed ro another disorder (continued) Copyrighted Material

194 • Chapte r 9 Phys i c a l Therapy D i agn o s i s and M a n ag e m ent TABLE 9�1 Competing Primary Headaches4 (Migraine, Tension�Type, New Daily Persistent) (cont.) Type Diagnostic Criteria Chronic migraine (1.5.1) A. Headache fulfilling criteria C and D for 1.1 Migraine without aura �m :2:15 days/month for >3 months 8. Nor attributed to an ther disorder Probable migraine A. Attacks fulfillmg all but one of criteria A-D for).1 Migraine withOlll aura without aura (1.6.1 ) B. Not attributed to another disorder Infrequent episodic A. At least 10 epi odes occurring on < I day per month on tension-type average (< 12 days per year) and fulfilling criteria B-D headache (2.1) 8. Headache lasting from 30 minutes to 7 day� C. Headache has at least two of the following characteristics: 1 . Bilateral location 2. Pressing/tightening (nonpulsating) quality 3. Mild or moderate inten icy 4. Not aggravated by routine phY'i al activity such as walking or climbing stairs Frequent epi odic O. Both of the following: tension-type I. No nausea r vomiting (anorexia may occur) headache (2.2) 2. No more than one of phomphobia or phonophobia E. Not attributed to another disorder A. At least 10 epi'oJes of occurring on:2:1 but < 15 days per month for at lea't 3 months and fulfilling criteria B-D B. Headache lasting from 30 minutes to 7 days C. Headache has at least two of the following characteristics: 1. Bilateral location 2. Pressing/tightening (nonpulsating) quality 3. Mild to moderate intensity 4. Nor aggravated by mutin!! phy'ical activity 'uch as walking or climbing stairs D. Both of the following: L. No nausea and/or vomiting (anorexia may )occur 2. No more than one of photophobia and phonophobia E. Not attributed to another disorder (continued) Copyrighted Material

Introduction • 195 TABLE 9�1 Competing Primary Headaches4 (Migraine. Tension�Type. New Daily Persistent) (cont.) Type Diagnostic Criteria Chronic tenslon-tYre A. Headache occurring on �15 day per month on average for headache (2 . .3) >3 months and fulfilling criteria B-D Chronic tension-type headache �lIctated B. Headache lasts hour' or may be continuou with pericranial C. Headache has at least two of the following characterbtics: [enderne�s (2.3.1) I. Bilateral location Chroni tension-type headache nut aJiSOCiated 2. Pressing/tightening (nonpulsating) quality with ricranlal 3. Mild to moderate intensity tenderness (2.l2) 4. Not aggravated by routine physical activity such a Cluster headache (3.1) walking or climbing stairs D. Both of the following: I. No more than one of photophobia, phonophohia, or mild nausea 2. Neither moderate or severe nausea nor vomiting E. or atlributed to another disorder A. Headache fulfilling criteria A-E for 2.3 Chronic tension-type Ileaaache B. Increased pericranial tenderness on manual palpation A. Headache fulfilling criteria A-E for 2.3 Chronic tension-type headache B. No incrcalied pericranial tenderne s A. At least five attack:. fulfilling criteria B-D B. evere or very severe unilateral orbital, 'upraorbital, anti/or temporal pain lasting 15-180 minute' if untreated C. Headache is accompanied hy atlea tone Qf the following: 1. Ip ilateral conjunctival injection and/or lacrimation 2, Ip ilateral l1al;al congestion and/or rhinorhoea .3, Ipsilateral eyelid edema 4, Ipsilateral forehead and facial wearing 5, lp 'ilateral milli� and/or pto i 6. A sense of restlessness or agitation (continued) Copyrighted Material

196 • Chapte r 9 Physical Therapy Diagn o s i s a n d Ma nagement TABLE 9�1 Competing Primary Headaches4 (Migraine. Ten ion�Type. New Daily Per i tent) (cont.) Type Diagnostic Criteria D. A((ack have a frequency from one t!very other Jay to eight per day E. Not artributctl (0 another dIsorder New daily per istcm A. Headache >3 mOnlh� fulfilling criteria B-D headache (4.8) B. Heauache i daily and unremilting from met or from <3 days from onset C. At least two of the following pain characteristics: 1. Bi later.lliocation 2. Prcssmg/tightening (nonrul aring) quality 3. Mild c>r moderate intensity 4. Not aggrav3teJ by routine physical activity such as walking or climbing tairs D. Both of the following: 1. No more than one of photophobia, phonuphohia, or milJ nau ea 2. Neither moJcrate or severe nau ea nor vomiting E. Nor attributed to another di order The proposed etiology of CGH is based on the convergence of afferent sensory input into the cervicotrigeminal nucleus from structures that are innervated by the first three spinal nerves or the trigeminal nerve. A subsequent \" misinterpretation\" of nociceptive signals orig­ inating in the cervical somatosensory structures as coming from the structures in the head innervated by the trigeminal nerve is thought to be responsible for this type ofheadache.23- 27 Musculoskeletal structures in the neck that are innervated by the first three spinal nerves that may refer pain into the head include the atlanto-occipital joints, joints and ligaments of the atlanto-axial joint, the C2-C4 zygapophyseal joints, the C2- C3 intervertebral disk, and muscles innervated by CI_ C3.23-29 Table 9-2 lists the diagnostic criteria for CGH. Temporomandibular disorder describes a variety of conditions affecting the temporo­ mandibular joint (TMJ) and the muscles of mastication.3o Symptoms include jaw and facial pain, limited TMJ mobility, joint sounds, tinnitus, and-most relevant to this case report­ headaches. 15, 1 6, 30,31 A classification of TMD i nto two subtypes provides a better under­ standing of the disorder and possible treatm e nt options3. o Arthralgia enco mpasses i mpai rments related to the joint bio mechanics, i n te rnal derangemen ts, dege nerative Copyrighted Material