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Myofascial Syndrome

Treatment

Dr. Janet Travell developed a technique to map out myofascial pain regions and their associated trigger points; the technique is used to either inject a local anesthetic with a mild anti-inflammatory steroid solution into the trigger point or to break up the trigger point with a needle. The exact pathology of the trigger point is not entirely understood. It is clear, however, that treating the trigger point is responsible for resolving many types of pain patterns.

Janet Travell's work coincides with acupuncture points. The trigger points and associated pain radiation areas have been co-related by an acupuncture researcher. Eighty-seven percent of Dr. Travell's trigger points and their associated pain areas lie on acupuncture meridians and correlate with known acupuncture points. Additionally, acupuncturists describe a certain grabbing of the needle (taking Chi), which correlates with the twitch response described by Dr. Travell. When a trigger point is properly needled, there is a visible "grab" observed by the practitioner and a feeling of a grabbing or slight contraction around the needle experienced by the patient. These techniques had been utilized by the Chinese for thousands of years before finally being introduced by Dr. Travell into Western medicine (Travell 1983).

The acupuncture points He Gu (near the wrist where the thumb and forefinger join) and Yin Men (back of the thigh) were found to increase blood flow and reduce MFS-related pain (Wang 1998). Most studies, however, seem to indicate that although acupuncture is an effective short-term treatment for chronic pain due to MFS, there is limited evidence that acupuncture will be effective in the long-term, and further human studies need to be conducted (Fargas-Babjak 2001; Irnich 2001). One study on the use of amitriptyline in people with temporomandibular joint (TMJ) pain and MFS seemed to show that while the beneficial effects of these pain treatments reduced over time, muscular pain was still manageable more than 1 year after treatment (Plesh 2000). Amitriptyline is a tricyclic antidepressant drug with many side effects that preclude long-term use in most people.

For refractive cases of MFS, a homeopathic solution of traumeel and/or a mild narcotic called buprinorphine injected into the trigger point(s) may be employed. Dr. Travell's technique of injecting corticosteroids and/or local anesthetics into trigger points appears to be effective in reducing muscle pain. Japanese researchers conducted studies on 40 women with chronic lumbar, shoulder, or neck myofascial pain. Using Dr. Travell's technique, each woman was given an injection of diluted anesthetic or saline placebo, and their pain levels were measured. In another portion of the study, 21 outpatient volunteers were given different dilutions of different anesthetics in each shoulder. The researchers concluded that the most suitable type of local anesthetic is lidocaine or mepivacaine, and the most effective water-diluted concentration is 0.2-0.25% (Iwama 2001).

Trigger points may require multiple treatments that necessitate excessive amounts of steroids over time. Some physicians feel that local anesthetics may irritate the muscle tissue, and multiple injections into the same trigger point may aggravate the problem.

Buprenorphine, a mild narcotic with agonist and antagonist properties, has a very low addiction liability (if any), indicating it can be used for a long period of time without developing serious withdrawal symptoms. Buprenorphine acts rapidly on depression, reducing pain, and inducing sleep; thus, it is effective for conditions with multiple symptoms (eg, MFS) (Cathelin 1980).

Buprenorphine is available as an injectable, 0.3-mg ampule dose. The dosage is variable. Because buprenophine is poorly absorbed orally, larger dosages must be used. Oral buprenophine liquid is withdrawn or shaken from the ampule and held under the tongue as long as possible. Compounding pharmacies can make up buprenorphine for sublingual use as a troche (ie, lozenge). Both forms, the ampules and troches, are expensive. For pain that prevents sleep, start with 2-6 ampules sublingually or 0.5-2 mg as a sublingual troche. For treating depression-related pain throughout the day, begin with 2-6 ampules (or 0.5-2 mg as a sublingual troche) every 4-6 hours. As with most medications, begin with a low dose and increase slowly until the smallest dose that proves effective is reached. Do not be concerned about addiction.

Buprinorphine, when diluted and injected into trigger points, may have a local pain-reducing action or in some way help to directly break up the trigger point. Additionally, buprinorphine is a mild narcotic analgesic that makes repetitive injections more tolerable for the patient. The dosage of traumeel, since it is homeopathic, is not critical. One to 2 ampules a session may be adequate, depending upon the number of trigger points and volume of the solution. The proportion works out to 1 ampule per 10 cc of saline. Since buprinorphine has a systemic action and may produce drowsiness, no more than 2 ampules per session are usually used, again depending upon the volume. Some patients, especially those who are obese, may tolerate more than 2 ampules per session. The dilution is 1/2-2 ampules (0.15-0.6 mg) per 20 cc of saline depending upon patient response and the number of trigger points treated per session. It is advised to begin with the lower concentrations.

Injections are usually 2-4 cc per trigger point. The patient must be driven home after treatment due to the potential for sedation. For really difficult-to-treat trigger points, the Edegawa technique involves taking a 60-cc syringe filled with saline (salt water) and injecting it rapidly through an 18-gauge (large) needle. Anywhere from 10 cc to the full 60 cc may be used for a particularly recalcitrant trigger point. It is believed that rapid influx of saline pulls muscle fibers apart where they cross the trigger point, resulting in a breakup of the trigger point itself.

If saline injections fail, traumeel and buprinorphine may be added to the saline. This combination is recommended at the outset due to the safety of the two preparations, the possible direct actions of both agents on the trigger point, and the systemic pain-killing properties of buprinorphine. After all, multiple injections of large volumes of fluids into the muscle tissue are painful. The dilution is 6 ampules of traumeel and 1-2 ampules of buprinorphine per 60 cc of saline. Each trigger point may require anywhere from 10-60 cc of fluid as previously described. The amount must be found empirically. No matter how many trigger points are treated, it is suggested that no more than 3 ampules a per session of buprinorphine be used because ofdue to the potential for sedation. However, some patients, especially those who are obese, may require and tolerate more. There is no need to worry about addiction (see Life Extension’s Pain [Chronic] protocol for more information).