Continuing Education Activity

Cervical myofascial pain is a musculoskeletal disorder that causes pain in the area of a muscle in the body and its surrounding connective tissue. Proper diagnosis can lead to effective treatment for the patient. This activity outlines the evaluation, and treatment of cervical myofascial pain, and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the pathophysiology of cervical myofascial pain.

• Outline the typical presentation of a patient with cervical myofascial pain, as well as the physical exam findings expected.

• Outline treatment options for patients with cervical myofascial pain.

• Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with cervical myofascial pain.

Introduction

Myofascial pain is defined as a musculoskeletal disorder that causes pain in the area of a muscle in the body, and its surrounding connective tissue known as fascia.[1] The pain can be local or regional, and can also be characterized by multiple trigger points. Trigger points are highly sensitive muscle foci that are painful to touch and refer pain to the surrounding area. Specifically, in the cervical region, muscles commonly involved include the rhomboids, trapezius, levator scapulae, supraspinatus, and infraspinatus. The pain can be acute or chronic and likely occurs due to overuse, postural changes, or muscle trauma.

Etiology

The causes of myofascial pain syndromes are not fully understood. Overuse or trauma to the neck musculature, as well as stress and postural mechanics, can all lead to myofascial pain in the neck.[2] The clinical scenarios leading to this diagnosis can range from patients in motor vehicle accidents, to those who recently started a repeating overhead activity like painting a ceiling, to patients who work at a desk all day and have improper mechanics when using their computer. Some systemic connective tissue diseases may also lead to myofascial pain syndrome.

Epidemiology

Myofascial pain is extremely common in both the United States and worldwide, and it is the cause of many healthcare visits. Most people will experience a trigger point in their lifetime. As many as 20% of patients seen in orthopedic clinics have myofascial pain. More than 80% of patients who frequent pain management centers have a myofascial pain component to their condition. The cervical region is a very commonplace for diagnosis of myofascial pain. Cervical myofascial pain occurs in males and females, but there is an increased incidence in females. Myofascial pain occurs more frequently as patients age through midlife. The incidence declines gradually after middle age.

Pathophysiology

The pathophysiology of myofascial pain, in general, is not well understood. Patients may be more likely to develop trigger points if they have taut bands within the muscles; although, these taut bands are also common in asymptomatic individuals.[3] These bands can have latent trigger points that are then brought on by several factors, including stress or postural changes. New trigger points can also develop after injury or trauma. The most accepted theory states that there is an increase in acetylcholine abnormally, leading to increased muscle tension and the formation of the taut bands that constrict blood vessels. This leads to hypoxia causing tissue distress and activation of nociceptors, leading to autonomic modulation, which in turn causes increased acetylcholine release, thereby starting the cycle over.

History and Physical

The history of a patient presenting with the cervical myofascial syndrome can vary greatly. Patients can sometimes present with a history of acute trauma, or the pain may be insidious. Symptoms may be worse with repetitive tasks, certain movements, or even certain postural positions throughout the day. The pain can be nagging or acute, and it can be local or radiate out from the neck to the surrounding area. The range of motion of the cervical spine may be limited and painful, and the patient may also complain of some tightness or a local twitch response, similar to a spasm. Generally, the area is tender to palpation and can be described as deep, and constant. On physical exam, poor posture may be noted, with slumped shoulders or decreased cervical lordosis. No atrophy should be noted in cervical musculature. On palpation, finding trigger points in the area of pain is very likely. A trigger point is an area of hyperirritability that radiates pain when palpated. A taut band may be noted in the skeletal muscle or surrounding fascia.[4] Limitation of the range of motion of the cervical spine may be associated. The neurological exam, including strength, sensation, and reflexes of the upper extremities will be normal.

Evaluation

This is a clinical diagnosis. There are no imaging or laboratory tests that are diagnostic. However, imaging such as MRI or x-ray may be utilized if there is a suspicion for a more serious medical condition related to the neck, especially if treatment does not resolve the symptoms.

Treatment / Management

Multiple different treatments and modalities can be utilized to manage cervical myofascial pain syndrome. Typically these treatments include physical therapy, trigger point injections, medications, physical modalities, and botulism toxin injections.[5] Physical therapy uses exercise and modalities to restore balance to the muscles and surrounding tissue areas. Therapists focus on targeted stretching and strengthening of affected muscles to correct the mechanical and postural deficiencies that may be causing or exacerbating the problem. Modalities including myofascial release, massage, ultrasound, and phonophoresis, along with an exercise program are aimed to decrease pain and prevent further injury. Various medications can also be prescribed, including nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and muscle relaxants. They should be used as an adjuvant to exercise or physical therapy because they are not usually effective alone. Botulism toxin type A inhibits acetylcholine release at the neuromuscular junction and may reduce muscle contractions, which can decrease pain levels. Trigger point injections or dry needling can both be equally effective in treating trigger points and is used commonly in clinical practice.[4] Trigger point injections involve injecting saline, steroid, or a local anesthetic into the specific trigger point palpated. Dry needling utilizes a similar technique, but no medication is injected into the area and is similar to acupuncture.[6] Osteopathic manipulation therapy has also been shown to be effective.[3]

Differential Diagnosis

Differential diagnosis includes cervical muscle strain, thoracic outlet syndrome, spondylosis, cervical disk disease, radiculopathy, muscle spasm, and fibromyalgia.

Prognosis

Prognosis greatly varies in this syndrome. Patients generally have good relief with proper treatment, but it is also possible to have chronic symptoms, or for symptoms to recur. It is necessary to find the underlying cause of the problem so that focused treatment can be delivered. Early interventions seem to lead to better outcomes.

Deterrence and Patient Education

Patient education plays a large role in the management and treatment of this syndrome. Focused exercise and attention to a correct sitting posture, as well as proper body mechanics, in general, are necessary for better outcomes through the recovery process. The patient may also be required to participate in a home exercise program for continued benefit.

Enhancing Healthcare Team Outcomes

The diagnosis and management of cervical myofascial pain are complex and best done with an interprofessional team that includes a pain specialist, physical medicine specialist, social worker, physical therapist, specialty care nurse, neurologist, and the primary care provider. There is no ideal treatment for this disorder and all presently available treatments have limitations. Relapse and remissions are common. The key is to educate the patient on changes in lifestyle such as proper posture, weight loss, discontinuation of smoking and limiting stress. For mild cases, the outlook is good but those who chronic pain tend to have a poor quality of life. Specialty care nurses in orthopedics, pain management, and rehabilitation may be involved. They can faciliated communication between the team members, monitor patients, arrange follow up, and provide education to patients and their families. Pharmacists review medication, drug-drug interactions, and educate patients.[7][8][9] (Level V)