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6NAUKi MEDYCZNE i NAUKi O ZDROWiU - MEAM^HCKME
HAYKM
REHABILITATION OF MYOFASCIAL PAIN SYNDROM IN OVERTENSION RELATED DISEASES
Petya Kasnakova, PhD
Medical University Medicl college Plovdiv
ABSTRACT
Myofascial pain syndrome (MPS) is connected with the presence of pain points /trigger points/, combined with trophic changes and functional complaints. MPS includes several diseases, varied in their etiology and clinical symptoms - insertionitis, bursitis, periarthritis, tendovaginitis, etc., characterized by pain and damaged joint function, without affecting the joint cavity. Rehabilitation therapy is structured depending on the locality and gravity of the process.
Key words: myofascial pain syndrome, rehabilitation therapy.
Introduction:Myofascial pain syndrome is defined as a chronic localized pain syndrome. The main feature determining MPS are the myofascial trigger points in the muscles, having a typical pattern in which the pain spreads. Trigger points are described as hyperirritable points in taut bands of miscle fibres. The pain in these areas is described as dull, deep and constant. In additio, trigger points contribute to increasing the pain,reducing flexibility in stretching the contracted muscle, and weakening the muscle strength. Periarthritis of the shoulder joint is a common clinical syndrome with polyetiological genesis. Strain in the shoulder joint usually results in the development of degenerative processes[5,6].Of 1700 cases, 38% were cases of insertionitis of the shoulder (W.Becker 1978). Minor ruptures occur mostly in the area of the muscle-tendon attachment to the bone, called insertions. First, insertionosis is observed, and later, in the event of an aseptic inflammation, insertionitis develops. This condition is common in cases of chronic strain, usually work-related. Degenerative changes result. The condition may be complicated and become chronic with the so called frozen shoulder syndrome. Bursitis is an inflammation of the synovial sacs. Most often it affects the shoulder bursa, the prepatellar bursa and the bursa at the Achilles tendon. When all the soft tissues in the area of the joint are affected, the condition is called periarthritis. Periarthritis of the shoulder joint is the most common [3,5].The syndrome is characterized by pain and restricted movements in the shoulder joint.
The rehabilitation therapy of the forms of the myofascial pain syndrome is a complex one - medicamentous treatment, physiotherapy - electro therapy, cryotherapy, medicinal massage -myofascial relief and drainage, kinesitherapy, ergotherapy and mechanic therapy, depending on the progress of the condition, the stage and the functional insufficiency.
In general, the treatment is not surgical, and in most forms it requires a lot of effort on behalf of the medical rehabilitation team. Physical therapy constitutes the main form of treatment; it consists of a set of exercises, specially selected and adapted to the stage of the condition. These exercises are to be done persistently, competently and regularly. Persistence and cooperation on the part of the patient are essential. The classical methods of therapy include rest, changes to the way of movement, non-steroid anti-inflammatory products and
physiotherapy. The last may involve warming up, cooling, ultra sound, electrostimulation, massage, etc., but therapeutic exercise is the distinctive feature of the effective remedial scheme.
The aim of the observation is to monitor the recovery of the function of the shoulder joint in patients with myofascial pain syndrome who have applied our combined rehabilitation methods, in terms of alleviating the pain, improving the flexibility of the shoulder joint, overcoming the muscle imbalance, overall strengthening of the affected upper limb.
Subjects and methods: The subjects of this research are 20 patients with myofascial pain syndrome of the shoulder joint in the period 2014-2015, treated by students during their practical training at the university training facilities of the Department of Physical and Rehabilitation Therapy at 'St. Panteleymon'Hospital, 'Plovdiv' Hospital, Medical Centre 1, Medical Centre 2 and Medical Centre 5 in Plovdiv. The said patients underwent complex rehabilitation therapy including kinesitherapy, massage, physical therapy. 11 of the subjects are men, and 9 - women, at an average age of 57.9. The rehabilitation schedule was implemented within 7-10 days, and at the beginning and at the end of the therapy periods the necessary tests and measurements were performed. The procedures were administered once a day, each lasting for 4050 minutes.
Methodological instructions:Myofascial pain syndrome is connected with the presence of typical trigger points in combination with vegetative-vascular and vegetative trophic changes, as well as functional complains. The physical therapy complex is structured depending on the location and gravity of the process[5].
Soft tissue disorders are often diagnosed as scapulohumeral periarthritis. This, however, is not enough to develop the appropriate treatment and rehabilitation plan. The diagnosis has to be detailed and clearly specified, the rehabilitation potential has to be evaluated, a functional assessment - diagnosis of the dysfunction, has to be made, and kinesiological and pathokinesiological analyses have to be performed, through:
- Examining the flexibility of the shoulder girdle - The overall flexibility and mobility in the shoulder girdle are to be examined, as well as the flexibility of the scapulohumeral joint
itself, with a fixed scapula [8].For the purpose of assessing the contractures, it is important to differentiate the motions in the shoulder girdle from those in the shoulder joint, since the restrictions in the scapulohumeral joint can be compensated through increased movements in the scapulothoracic joint;
- Goniometry of the shoulder joint: extension and flexion; abduction and adduction; external and internal rotation;
- Manual muscle testing in the Lovett method (0-5) for a quantitative assessment of any motor deficit present. In case of suspected peripheral nerve damage, MMT is to be performed to establish if the muscle function is impaired. In addition to
examining the motions and flexibility of the shoulder joint, the motions of the shoulder blade are also to be examined. [1];
- Local status - presence of pain; the pain arc syndrome -surmountable pain during motion - the so called syndrome of Cyriax, is often observed;
- Hand grip strength test - for measuring muscle strength.
Results and discussion:
The objectives and tasks of the rehabilitation therapy were focused towards overcoming or curbing the dysfunctions and disabilities of the patients.
Fig.1 Shows a break-down of the examined patients by gender.
We performed the first measurements and examinations at the beginning of the treatment(xl), and repeated them at the end of the therapy (x2)of the twenty patients - n=20.
Data on the act:
Table 1 Shows the results from the active range of motion during goniometry of the affected limb at the shoulder girdle.
Table1
: range of motion
Motion Number - n X1 X2 d=X2-X1
Flexion 20 50,60 160,00 100,50
Extension 20 20,00 40,00 20,00
Abduction 20 40,50 140,50 100,00
Adduction 20 10,00 25,00 15,00
Internal rotation 20 35,50 65,50 30,00
External rotation 20 25,00 75,00 50,00
The analysis of the obtained results shows that at the end of the remedial course of therapy the range of motion increased, although it is still not within the physiological normal range of motion. This shows that the therapeutical complex provides a good initial basis for functional recovery, but the time
Changes in MMT
is insufficient and the shortened period is limited by pain syndromes.
The results from the manual muscle testing are presented in Table 2.
Table2
the shoulder girdle
Motion Number- n X1 X2 d=X2-X1
Flexion 20 2,00 4,00 2,00
Extension 20 2,00 4,50 2,50
Abduction 20 1,50 3,50 2,00
Adduction 20 2,50 4,50 2,00
Internal rotation 20 3,00 4,50 1,50
External rotation 20 2,00 4,00 2,00
The analysis of the obtained results shows that the pain is and at the end of the treatment the patients did not regain their considerable and obstructs movements; the muscles are weak, muscle strength to the extent they had expected. They have to
continue their rehabilitation therapy in order to achieve good The results from the hand dynamometry are presented in results. Table 3.
Table 3
Changes in muscle strength
Number - n =20 X1 X2 d=X2-X1
Affected limb 3,50 14,50 11,00
Unaffected limb 34,00 41,00 7,00
The analysis of the obtained results shows that muscle strength was not restored to its normal values. Continuous rehabilitation therapy is needed so that the limb could be used adequately. At the beginning of the therapy, the grip strength is reduced - a
Pain asse
mere 3,50 kg, whereas that of the healthy limb is 34,00 kg. The strength of the muscles stabilizing the shoulder is inadequate. Table 4 shows a subjective assessment of the pain in motion.
Table 4
ment (0-3)
Number - n Examinations Degree of pain
20 X1 0 1 2 3
Number - % Number - % Number - % Number - %
- - - - 2 10 18 90
X2 1 5 3 15 16 80 -
The data show that at the beginning of the therapy the patients had 90% of strong pain when moving. At the end of the procedures the level of pain decreased to moderate and mild.
Physical therapy yielded good effect. A combination of cryotherapy, remedial gymnastics and slight myofascial and drainage massage, with IC and LFPEF, is recommended. Intraarticular aplication of corticosteroids, as well as topical application of corticosteroids, NSAIDs and Procaine (Lidocaine) [5,10], also yields good results.
The remedial results in conditions of the shoulder joint depend on the applied methods and their correct combination in an efficient therapeutical complex: for example, cryotherapy with kinesitherapy, underwater gymnastics with postisometric relaxation, electrostimulation with active muscle contractions, etc. Orthopedic means ensure the functional rest of the kinematic chain, when needed.
In the moderate to severe stage, physiotherapeutic procedures, such as the listed below, are recommended:
Cryotherapy- widely used in shoulder joint conditions, especially those of traumatic or inflammatory nature. It is applied in the form of: cryomassage with an ice cube, diadynamic cruo-electrophoresis [10].
The local application of MF current within inhibiting parameters is also recommended. Ultra sound segmentary application paravertebrally at the level of C4 - C7. Pulse mode, labile methods with small doses - 0,2- 0,4 W per square centimeter, 3-4 minutes per field [5].
When developing individual therapeutic schedules, what should be kept in mind is the functional disturbances of the limb and the location of the problem. Kinesitherapy, with its wide variety and therapeutic methods (analytical gymnastics, postisometric relaxation in the Levit method, therapy from a position, stretching, muscle-inhibiting techniques, proprioceptive neuromuscular facilitation -diagonal and reciprocal inhibition, etc.) has to be included in the rehabilitation process from the very beginning of the
therapy to its completion. Rehabilitation methods have to be applied below the pain threshold, regardless of whether they are active or passive. Kinesitherapy should be preceded by the administration of pain-relieving or myorelaxing procedures, and in a chronic stage - by underwater gymnastics.
Kinesitherapy in the mild to severe stage includes:
- Therapy from position - a slight abduction of the shoulder, the wrist - higher than the elbow, the elbow - higher than the shoulder. Passive kinesitherapeutic techniques are contra-indicated, with the exception of some manual soft-tissue mobilizing techniques. It should be proceeded straight to muscle relaxation:
- Relaxing swinging exercises: fixed shoulder blade, hanging arm - the exercise of the pendulum, taking the arm to the side for swinging and relaxing exercises.
- PIR (postisometric relaxation) for the contracted muscles; PIR for trapezius; PIR for levator scapulae; PIR for the long head of biceps brahii.
- Relaxation techniques of PNF in the method of Cabat [4,7].
- Analytical active exercises are applied against gravity to pain for 10-20 min, twice a day, for the purpose of strengthening the muscles that are prone to inhibiting and extending.
The following are contra-indicated:1. Pain-causing kinesitherapy; 2. Redressing exercises; 3. Massage on the joint; 4. Local application of an irritating action; 5. Endogenic and exogenic thermal action simultaneously.
Kinesitherapy is allowed when the pain lessens. Exercises are strictly analytical. The patient is to be trained in relaxation techniques.
A good alternative in the treatment of myofascial pain syndrome is reflexive massage. At the beginning of the therapy, transversal massage in the J. Cyrax method is applied (1978) on the tendond of the affected muscles - transversely to the muscle fibres and the tendon. With the tip of his/her thumb and forefinger, the rehabilitation therapist applies pressure to the place 3-4 times, for 2-3 seconds until bearable pain is
experienced [12,13,14].
Findings and conclusions:
As a result of the complex rehabilitation therapy and the efficiency of the treatment program applied by the students, the active mobility and motor habits of the treated patients were restored, though not to their full range to enable the patients to be fit to work. The treatment should continue with subsequent courses of therapy or in home conditions, provided the patients are given clear instructions on the methods and techniques.
An excessively aggressive physio-rehabilitation therapy or an unadequate one are equally unsuitable, and pose an equal risk of consequential complications [2].
Any uncontrolled rehabilitation therapy - which is not under the supervision of a doctor specialized in physical and rehabilitation medicine - is always a precondition for deterioration of the condition of the patient; it may become chronic and lead to complications, regardless of how common or banal the condition of the patient may seem at first sight [2].
In cases of 'humeroscapular periarthritis', refractory to conservative treatment, a rupture of the rotator cuff is to be suspected, and the diagnostics is to be more comprehensive [9], which calls for surgical methods of treatment.
In conclusion, it can be claimed that the complex rehabilitation applied by us yielded good results in accordance with the severity of the motor dysfunctions.
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