Myofascial pain syndrome (MPS) is a chronic painful condition caused by localized adhesion contractures of the myofascial membrane.
(1) Localized muscle pain: chronic persistent soreness, swelling or dull pain, pain with tightness or heavy pressure, can occur in the lower back, back, sacrum, buttocks, legs, knees, soles, neck, shoulders, elbows or wrists.
(2) Ischemic pain: pain can be induced by local cold or general fatigue or cold weather, waking up with pain during late night sleep, stiffness and pain in the morning, relieved after activity but often aggravated after long working hours or in the evening, and pain can also be aggravated when inactive for a long time or overly active or even in bad mood.
(3) Fixed pressure point: During physical examination, the patient is found to have tension, spasm, bulge, contracture or stiffness in one side or local muscle. The location of the pressure point is often fixed near the starting point of the muscle or at the intersection of two groups of muscles in different directions, and painful hard nodes or painful muscle cords may be felt deep in the pressure point.
(4) There may be a history of local or adjacent injury, and the onset is more frequent in women than in men.
The diagnostic criteria for MPS in the United States are.
1. There are fixed painful areas and pressure points on the attachment points of tendons or on the muscle belly. Pressing on the painful point may cause regional dispersed pain not distributed according to the nerve root sensation.
2.The pain worsens when the temperature decreases or when fatigue is present.
3.Treatment to increase blood flow to the muscles may reduce pain.
4.Exclude local occupying or destructive lesions.
The principles of treatment for MPS are.
(1) Remove the cause: such as anti-rheumatoid, anti-inflammatory, loosening the scar ;
(2) improve blood supply: exercise, massage, heat therapy (infrared, laser, cupping, acupuncture), etc. effective but not healing, high recurrence rate ;
(3) Anti-inflammatory and analgesic: can reduce the symptoms and improve the quality of life;
(4) Elimination of tenderness points: the application of minimally invasive techniques to loosen local adhesions can prevent recurrence and aggravation of MPS, with good long-term effects. Minimally invasive treatment techniques include Kawasaki block for acute pain, small needle separation for those with limited pain in the chronic phase, intensive warm mass needle release for those with widespread pain, radiofrequency thermal coagulation release for dangerous areas, and so on.
(5) Physical exercise: anti-gravitational muscle exercise.
(6) Antigravity treatment.
Muscles and ligaments are the power base of various human activities, and their end devices are their respective muscles attached to the bones at the power transmission hub that drives the bones and joints, and also the parts where stresses are concentrated and intersected, so they are highly susceptible to injury. Repeated injury to the local muscle, when the injury healed can leave scars or adhesions, scar tissue can reduce the number of local blood vessels or small diameter, the occurrence of local microcirculation blood flow regulation ability to reduce the muscle blood supply and anaerobic work ability to lose. The local ischemia of the muscles causes pain due to stimulation of the peripheral nerves, and the patient is unable to tolerate prolonged physical activity or even activity. For example, long-term incorrect posture or psychological depression can cause physiological contracture at the level of local muscle segments, long-term repeated muscle spasms cause muscle ischemia, sterile exudation, scar formation, local myofascia is often subjected to postural loading and extreme tension, fatigue causes postural injury, repeated exertion causes micro-tearing muscle damage, and pain-causing substances appear around the microvascular reaction zone of myofascia. Rheumatoid myositis, ankylosing spondylitis or viral myositis cause peripheral nerve compression due to muscle swelling, which may form nociceptive sensitive points or painful muscle sclerosis for a long time and experience a complex intertwined reaction process of long-term local irritation, inflammation, healing, hyperplasia or scarring, with painful local tissues and calcification of inflammatory exudate deposits and development of myoclonus. Hypoxia or lack of energy metabolism may be secondary to a decrease in local blood flow and is an important mechanism of CMPS painfulness that can cause muscle dysfunction and tissue destruction, therefore any means of improving microcirculation to the muscles and nerves even local massage or walking can provide some relief from the painful symptoms of CMPS. Pathological features of painful nodules: (i) a bundle of muscle fibers in a muscle surrounded by a sterile inflammatory myofibrils that are stiffer. (ii) A lesioned dermal nerve. (iii) Hyperplastic inflammatory fatty connective tissue, closely connected to deep fascia. (iv) The site where the motor nerve enters the muscle. Painful nodules mostly occur in the supraspinal ligaments, interspinous ligaments, posterior laminae, supraspinatus, intertransversus, occipital ring fascia, levator scapulae, trapezius, rhomboids, psoas, sacrospinous, and so on.
The release of local adhesions of myofascia is the basic technique for eliminating the tenderness point of MPS. Patrick believes that the key to needling is the mechanical destruction of the pain trigger point and not in what potion is injected, and advocates that the injection allows the needle tip to repeatedly explore the area to separate the tissue and mechanically destroy the pain trigger point. Surgical separation of myofascia was popular in the 1950s, and although effective, it is now largely replaced by minimally invasive techniques. At present, MPS can be used: saline injection at the point of pain (Kawasaki therapy), steroid injection (closure therapy), which can be used to dissolve local nodal tissue, microethanol or phenol glycerin injection to separate myofascial adhesions by destroying local tissue cellular proteins, small needle knife therapy to directly cut or peel the myofascial scar point, and burning of moxa on the pierced needle bar to make the needle channel The intensive warm needle therapy with the coagulation of cellular proteins and the growth of capillaries. Radiofrequency thermal coagulation therapy, which is being explored, is also similar to the intensive warm needle therapy mechanism and is particularly suitable for myofascial release in areas containing important nerves, such as the neck or buttocks. Eighty-five percent of patients with chronic pain disorders have primary or secondary CMPS, such as osteoporosis, disc herniation, cervical spondylosis, posterior branch syndrome, osteoarthritis, or ankylosing spondylitis. Pain relief in the myofascial component is an important part of the overall treatment plan, so it is important to clarify the diagnosis and plan and understand the patient before treatment begins. Elderly or frail patients with myofasciitis in multiple parts of the body, often accompanied by hypertension, diabetes, cardiopulmonary, cerebrovascular, mental or psychological disorders, should be treated in a planned and comprehensive manner.
Small needle knife: Small needle knife is a knife blade shaped like a silver needle, but with a thicker needle stem and a 0.8 cm wide tip. It was invented in the 1970s by Zhu Hanzhang, an orthopedic surgeon in Jinling, Jiangsu Province, and can effectively cut or peel away limited soft tissue adhesions or small nodules. The difference with previous acupuncture is that the mechanism of the small needle knife is used more for anatomical separation of myofascial adhesions in addition to the meridian stimulation and adjustment effect. The small acupuncture needle is firstly mechanical stimulation and separation, so that the local tissue mobility is enhanced and lymphatic circulation is accelerated, and the local scar tissue that has been cut is absorbed. Because of its simplicity and ease of use, it was once promoted rapidly in China. However, small needle knife treatment is a closed procedure, and should be used with caution in some areas containing important neurovascular or organ, such as cervical spine, pear-shaped muscle or Achilles tendon.
Intensive warm mass needle: In the 1960s, Shanghai orthopedic surgeon Xuan Zheren made a large number of chronic myofascial pain stripping procedures, which were not easily accepted by patients because they were too traumatic. In his rich experience in orthopedic myofascial detachment surgery, Xuan was inspired by Chinese medicine meridian warm needle therapy, he put silver needles intensively in the original diseased myofascial area that needed surgery, and the end of the needles were lit with moxa balls to add heat, the temperature of the body of the needles was greater than 100 ℃, 55 ℃ on the patient’s body surface, and 48 ℃ in the tip of the body, the tissue cells of the myofascial and bone surface adhesions occurred protein coagulation to achieve the purpose of separation. Instead of surgically separating the adherent myofascia, the new microvasculature grows through the needle holes, achieving an excellent cure rate of 90.6% for both acute and chronic MPS and a recurrence rate of 6.5% for 1-4 years. The local blood flow in the lesion area increased by 50-150% after intensive warm mass needle treatment, and still increased by 20-40% after 1 month, and the local temperature increased by 1.14℃, forming a cylindrical heat conduction bio-responsive zone centered on the warm needle channel, and the maximum area of the heat response zone was 2.4mm and 2.8mm radius when heated at 60℃ and 70℃.
mm, which not only maintains the normal skeletal muscle blood supply pathway but also promotes the growth of new capillaries into the myofascia and improves muscle blood supply. He believes that needling and heating has a deep thermal effect in the myofascia and periosteum of the diseased tissue, which can eliminate the primary inflammatory response of the soft tissue at the point of skeletal attachment, and the analgesic mechanism of the warm mass needle may be similar to laser perforation for myocardial infarction. In patients with refractory myocardial infarction angina pectoris that cannot be reversed by bypass surgery, the necrotic myocardium is revascularized by laser perforation of the blood perfusion pinhole, and 68% of the pinholes are still open 6 months after surgery. Precautions for intensive warm mass needle treatment: (1) be familiar with the anatomy and important tissues and organs of the hypodermic point/area, especially the location and course of nerves, blood vessels and muscles; (2) place needles at painful points, with each needle 1.5-2 cm apart; (3) leave needles on the bone surface: the needle tip must touch the bone and not cross the vertebral plate or transverse process; (4) prevent and control burns/burn; (5) provide adequate analgesia. Local anesthesia mound / full layer, dulcolax + gastrofacial, cortisone + tramadol + gastrofacial, epidural + morphine. However, Dr. Xuan also noted that when intensive warm mass needle treatment, moxa ball burning procedures are troublesome and time-consuming, and when ignited, it produces smoke pollution, open flame, burns the patient and other shortcomings are extremely to be reformed.
Radiofrequency thermal coagulation: the instrument will be a beam of about 300KHZ high frequency current through the electrode, so that the electrode around the tissue in the ion oscillation mass point friction heat generation, the formation of the required range of protein coagulation foci in the tissue and the occurrence of local cell destruction. We apply RF needles to reach and thermally coagulate the tender points of myofasciitis to achieve separation of tissue adhesions, loosen contractures and promote local tissue blood flow supply similar to intensive warm mass needles without their environmental pollution disadvantages. The radiofrequency instrument can also adjust the size and time of radiofrequency output power, precisely control the temperature, time, degree and range of thermal coagulation of local tissue heating, and can cauterize the local hyperplastic peripheral nerves. The instrument has a nerve stimulation function to identify the nature of the tissue where the needle tip is located and the important nerves within at least 3CM of the needle tip, which is especially suitable for treatment in myofascial areas containing important nerves such as the pear-shaped muscle area, near the intervertebral foramen and the root of the thigh. Radiofrequency thermocoagulation has some local pain after puncture, heating and treatment, and the application of analgesics is advocated for prevention and treatment. After rehabilitation, attention should be paid to educating patients to correct poor posture and strengthen muscle exercise to reduce MPS recurrence. The radiofrequency relaxation technique is flexible and controllable and can be better adapted to the specific situation of each patient, and the operation can be discontinued at any time when discomfort occurs during treatment. Therefore, radiofrequency treatment of CMPS, with the advantages of good analgesia and controllability, has shown good efficacy without serious side effects and deserves further study.