Muscle disorders/tx Flashcards
Characterized by the presence of Trigger Points (TPs) in any voluntary
muscle which cause referred pain and referred tenderness and may
be active or latent. (3)
TPs evoke referred pain which usually originates from a distant site
rather than the site of the pain complaint.
ACTIVE TPs: are painful to palpation or spontaneously produce local
pain OR refer pain and autonomic symptoms (i.e. erythema) to
remote areas in reproducible patterns characteristic of each muscle.
LATENT TPs: exhibit local tenderness but do not currently cause
spontaneous clinical pain or symptoms. (1)
Myofascial pain syndrome
___ trigger point: are painful to palpation or spontaneously produce local
pain OR refer pain and autonomic symptoms (i.e. erythema) to
remote areas in reproducible patterns characteristic of each muscle.
ACTIVE TPs:
___ trigger point:exhibit local tenderness but do not currently cause
spontaneous clinical pain or symptoms.
LATENT TPs
An irritable locus within a taut band of skeletal muscle or fascia which when stimulated
elicits referred pain & tenderness (“secondary hyperalgesia- increased sensitivity to
normally painful stimuli outside & surrounding a zone of primary hyperalgesia”). (1)
Referred pain from myofascial trigger points is dull and aching, usually deep, and can range
from discomfort to incapacitating pain
Myofascial trigger point
increased sensitivity to
normally painful stimuli outside & surrounding a zone of primary hyperalgesia
secondary hyperalgesia-
“stimulation of specialized nerve endings designed to transmit
information to the central nervous system concerning potential or actual tissue
damage
Nociception:
“a specialized nerve ending that senses painful or harmful sensations”
Nociceptor:
described a means where the CNS may switch
on Nociception by stimulating the “on” cells which causes activation of the Trigeminal
Nucleus nociceptors.
Is chronic, continuous muscle pain (myalgia) that is aggravated by function and refers
pain beyond the boundary of the masticatory muscle being palpated
Central mediated pain
The most elusive and difficult to diagnose since it refers
pain to other locations in the mouth and in the face and
head & does Not always follow Cranial Nerve Distributions-
(CN XI with active SCM trigger point refers to CN V in face
and head)
Myofascial pain
Diagnostic Criteria: (must be present)
Regional dull, aching pain aggravated by mandibular function when muscles
of mastication are involved.
Trigger points have a characteristic pattern of pain referral & alters the pain
complaint on palpation or spontaneously.
> 50% pain reduction occurs with vapocoolant spray or local anesthetic
injection (trigger point injection) using 1% Procaine without vasoconstrictor.
Myofascial pain
increased response to a stimulus that is normally painful
hyperalgesia
TMJ and ear pain are referred to by what 4 muscles?
MASSETER (deep)
LATERAL PTERYGOID
MEDIAL PTERYGOID
STERNOCLEIDOMASTOID (clavicular)
Toothache:
Referred by: what 3 muscles?
TEMPORALIS
MASSETER (superficial)
DIGASTRIC (anterior)
Diagnostic Criteria: (must be present)
1. Muscle pain reported by patient in the jaw, temple, ear or pre-auricular area in the last 30 days
2. Pain is aggravated by jaw movement or parafunction (i.e. bruxism)
3. Muscle palpation exam causes report of localized muscle pain at palpation site
May be present:
1. Limited range of mouth opening MAY be present
Secondary to:
Ischemia
Bruxism
Fatigue
Metabolic alterations
Delayed onset muscle soreness from overuse
Protective splinting
Myalgia
Diagnostic Criteria must be present: (5)
1. Local muscle pain following injury (non-infective) or infection (infective)
2. Edema, erythema, &/or increased temperature over the muscle
May be present:
1. Serologic tests may reveal elevated enzyme levels (i.e. creatine kinase), markers
of inflammation & the presence of an autoimmune disease.
2. Diffuse tenderness over the entire muscle.
3. Increased pain with jaw use if masticatory muscles involved.
4. Limited range of motion of unassisted mandibular movements secondary to pain.
myositis
Diagnostic criteria Must be present(5)
1. Acute onset of pain at rest & with function.
2. Immediate report of limited range of jaw motion <40mm for vertical opening
3. Continuous involuntary muscle contraction
4. EMG will Confirm elevated electromyographic activity compared to the
contralateral unaffected muscle.
5. MAY be present:
6. Acute Malocclusion.
myospasm
Shortening of a muscle due to fibrosis of tendons, ligaments, or
muscle fibers
Usually not painful unless muscle is overextended
History of radiation therapy, trauma, or infection is often present
Diagnostic Criteria MUST be present:
1. Progressive loss of range of motion with unassisted and assisted
opening < 40mm causing a “hard end feel”
contracture
Pathophysiology
is poorly understood but
believed to involve a central
sensitivity syndrome
little evidence of peripheral
tissue abnormalities
may involve dysfunction of
autonomic nervous system
Associated Co-morbid Medical
Disorders:
TMD (10% of population)
Inflammatory & neuroendocrine
disorders
IBS, functional chest pain from
esophageal origin
Chronic pelvic pain
Headaches especially Migraines
Fibromyalgia
Widespread pain with bilateral
diffuse musculoskeletal aches &
stiffness both above & below
the waist for > 3 months.
Associated with exaggerated
tenderness in at least 11 of 18
specified anatomic sites.
Commonly shows up as
masticatory muscle pain.
May be associated with sleep
deprivation & depression.
Refer to a rheumatologist for
evaluation & treatment.
Tingling, numbness, tightness,
stiffness & swelling may affect
the jaw. Dizziness is common.
Toothache & gingival pain occur
commonly in fibromyalgia
patients.
Fibromyalgia
Diagnostic Criteria MUST be present:
1. Tenderness on palpation of at least 11 of 18 specified sites
2. Presence of wide-spread pain with concurrent masticatory muscle pain
3. Pain is bilateral and present above & below the waist
Fibromyalgia
Meds to tx ______
Effective:
Lyrica
Antidepressants (i.e. amitriptyline)
Savelle (SNRI)
Minimally Effective:
NSAIDs
Opioids
Benzodiazepines
Fibromyalgia
INVOLVES INVOLUNTARY, CHOREATIC MOVEMENTS
MAY involve the face, lips, and/or the jaw.
MAY cause traumatic injury to the tongue or oral mucosa
More common with advancing age, use of neuroleptic medications and/or
traumatic brain injury, psychiatric or certain neurologic disorders
Patient must provide a history of dyskinesia involving the orofacial region,
history and examination is positive for myalgia and arthralgia that worsens
with episodes of dyskinesia
Cranial nerve examination is positive for sensory &/or motor nerve
conduction deficit (i.e. Trigeminal nerve)
Orofacial dyskinesia
What can confirm dx of dystonia/dyskinesia?
Intramuscluar EMG
INVOLVES INVOLUNTARY, EXCESSIVE SUSTAINED MUSCLE CONTRACTIONS
MAY involve the face, lips, tongue and/or the jaw disappearing during SLEEP.
Painful & can make opening/closing of mouth difficult; can impair speech,
swallowing & chewing
Traumatic injury to the brain/head/neck can trigger transient or permanent
dystonia involving the MASTICATORY MUSCLES
More common with certain neurologic disorders (i.e. Parkinson’s Disease), or
adverse reaction to medications especially neuroleptic medications
Patient must provide a history of dystonia involving the orofacial region, history
and examination is positive for myalgia and arthralgia that worsens with
episodes of dystonia
Cranial nerve examination is positive for sensory &/or motor nerve conduction
deficit (i.e. Trigeminal nerve, Facial nerve)
Intramuscular EMG confirms the dystonia diagnosis
Orofacial dystonia
What is the max dose of aspirin?
4 g/day
What type of drug can be prescribed for pts on a longer term NSAID?
H2 blocker
Potent neurotoxin that inhibits acetylcholine (ACh)
on both afferent & efferent motor nerves
Weakens painful muscles & inhibits muscle
contractions
Interrupts pain cycle & may block peripheral
neurotransmitters (i.e. Substance P, glutamate, &
calcitonin gene-related peptide (CGRP)
Therapeutic injections have an average duration of
12 weeks before re-injection is necessary
Botox
