Fibromyalgia and myofascial pain is characterized by chronic, palpably painful areas within muscle and perhaps tendon insertions, and in ligaments. Commonly affected sites in patients during neurorehabilitation include the sub-
occipital musculoligamentous tissues; upper trapezius, levator scapula, supraspinatus, and medial scapular rhomboid muscles; the upper outer buttocks; tissues around the sacroiliac joints; and the transverse and interspinous ligaments from C-3 to T-1 and L-1 to S-1. The original, if scientifically unexamined notion from Travell and Simons, was that taut bands or nodules developed local twitch responses and that pain could radiate from pressing on trigger points. The reproducibility of such findings by different examiners has usually failed.131 Rheumatologists have tried to formalize criteria for a diagnosis by consensus, but the exercise led to rather circular reasoning. A committee decided that a diagnosis of fibromyalgia requires widespread pain involving 3 or more body segments and at least 11 of 18 designated tender points.132 Proponents of myo-fascial trigger spots suggest that spinal mechanism causes the problem and the release of acetylcholine causes a local twitch on abnormal muscle end plates.133 Just how muscle fiber sources of pain persist and how palpably tender areas come to be associated with headaches and cervical and lumber pain is far from clear. Often, however, approaches that focus on and manipulate tender areas will reduce pain.
Physical treatments include injection into tender areas, tissue stretching and range of motion, postural education, exercise conditioning, and strengthening. Local injection of short-acting anesthetics such as procaine, with or without a steroid, often helps painful trigger points, tender areas, and taut bands asociated with myofascial pain. A review of needling with and without injecting the muscle could not support or refute any efficacy; the design of nearly all trials is poor.134 Injection of as little as 1 mL of 1% procaine does eliminate a palpably tender area in some patients. The local anesthetic presumably alters C-fiber activity. Physical therapy should follow. A randomized trial showed that for cervical myofascial pain, neck stretches combined with either ultrasound or tender point injections into the trapezius muscle are both better than no treatment.135
Neck and back pain that persist for more than 3 months and interfere with attendance affect at least 10% of working people across Western countries.136 Interventions have proliferated. A variety of educational and physical therapies have been studied for managing chronic neck and back pain without radiculopathy. Thera peutic exercise appears to be most useful.137,138 A randomized trial of strengthening, stretching, relaxation, and education about back care for 6 weeks was superior to usual primary care physician management with pain still comparatively reduced at 1 year.139
Recent randomized trials with good designs add to the potential armamentarium of interventions, although all of these results require confirmation by additional trials. For low back pain, osteopathic manual care and standard medical care produce equivalent results;140 bipolar magnets were no better than sham magnets;141 low energy laser treatment 3 times per week for 4 weeks is modestly better than sham treatment;142 40 units of botulinum toxin injected into 5 paralumbar sites is better than placebo for up to 8 weeks of less pain;143 neuromuscular electrical stimulation and TENS for 5 hours per day at 2-day intervals is better than placebo stimulation;144 percutaneous electrical nerve stimulation with acupuncturelike needles in the paraspinal muscles reduces the need for opioid analgesics more than sham treatment, TENS, or exercise;145 and facet injections with methylprednisolone are no better than placebo in patients who reported less pain after the facet was injected with local anesthetic.146 Back schools and cognitive and behavioral interventions are useful, although the specific elements of value are uncertain.147 Evidence about the efficacy of acupuncture is equivocal. Of interest, physical therapy, chiropractic manipulation, and provision of an educational booklet produced similarly good outcomes in patients with acute low back pain.148 Similar approaches for chronic, nonradicu-lar neck pain generally reveal no advantages to any modality other than stretches and exercise. Traction has no apparent value based on multiple studies. The loads and EMG levels induced in cervical and shoulder girdle muscles increase markedly with head-forward pos-tures.149 These tense postures are common in stressed people. Thus, these muscles and their related structures may fatigue from overuse and become a source of pain. Simple exercises that reduce an exaggerated cervical lordosis and increase cervical flexion and rotation, postural education about positions that increase cervical dysfunction, and passive joint mobilization techniques are often used with success. Improved head and neck positioning was associated with reduced neck pain in one con trolled trial.150 Too often, physical therapy is limited to ultrasound, hot packs, and a little massage, which are unlikely to help the patient with chronic neck pain or tension headache. Tricyclic antidepressants and stress management with cognitive coping and relaxation techniques improve the control of tension headaches and the combination is better than placebo or either treatment alone.151
Antidepressant modulators of monamines and serotonin, muscle relaxants such as cy-clobenzaprine, metazolone, and methocar-bamol, and centrally acting adrenergic agonists such as tizanidine, along with medication and psychotherapy for depression, may supplement therapeutic exercises and stretches.
The Cochrane Library (www.update-soft-ware.com/cochrane.htm) routinely updates its studies about clinical trials for the management of neck and low back pain.
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