Myofascial Pain is a syndrome arising from soft tissues associated with trigger points that produce pain in discrete patterns. The pain is regional (as opposed to diffuse, generalized pain seen in Fibromyalgia), often with taut palpable myofascial bands. Pressure to these trigger points often elicits a referred pain pattern. Referred pain patterns have been well described by various authors. Symptoms can begin after injury, chronic strain, or without clear insult.
Treatment of myofascial pain can include physical therapy, massage, myofascial release techniques, transcutaneous electrical nerve stimulation (TENS), and trigger point injections (TPI). Trigger point injections, though commonly performed, vary widely by provider. One systematic review by Cummings and White showed little difference between “Dry Needling” and injection of local anesthetic. Additionally, the addition of steroid to TPI has not been shown to have increased benefit.
Fibromyalgia is a challenging medical condition with multiple core symptoms including multifocal pain, fatigue, insomnia, cognitive or memory problems, and psychological stress. Multiple disorders coexist with fibromyalgia including regional musculoskeletal pain syndromes, chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome or interstitial cystitis, headaches, vulvodynia, and pelvic pain. Pathophysiology of fibromyalgia is attributed to decreased descending analgesic activity and increased wind-up or temporal summation.
Diagnosis of fibromyalgia as defined by ACR requires widespread pain index (WPI) greater than or equal to 7 and symptom severity scale (SSS) score greater than or equal to 5 or WPI 4-6 and SSS score greater than 9, generalized pain of at least 4 out of 5 regions, duration of at least 3 months, no other diagnostic explanation for symptoms. Differential for fibromyalgia is hypothyroidism, polymyalgia rheumatica, autoimmune disorders (rheumatoid arthritis, SLE), Sjogren’s syndrome as well as less common disorders including hepatitis C, sleep apnea, Chiari malformation, celiac sprue.
Pharmacological treatments of fibromyalgia include tricyclic antidepressants (amitriptyline, nortriptyline), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), alpha 2 delta ligands (pregabalin, gabapentin). Non pharmacological treatments of fibromyalgia are also key to sustained remission including low intensity, low impact exercise programs, behavioral medicine programs including cognitive behavior therapy and psychological support. FDA approved drugs are pregabalin (lyrica), duloxetine (Cymbalta), and Milnacipran [SNRI] (Savella). Glutamate is increased in this patient population secondary to wind up.
Complex Regional Pain Syndrome (CRPS) is a constellation of symptoms describing persistent pain in a particular body region/extremity with varying degrees of autonomic dysfunction. CRPS has been divided in CRPS I (formerly reflex sympathetic dystrophy) and CRPS II (formerly causalgia). The primary difference between CRPS I and II is the absence (CRPS I) or presence (CRPS II) of nerve injury. CRPS I is associated with an inciting event (potentially minor) and the lack of nerve injury. The exact pathophysiology is an area of ongoing debate, but is felt to involve peripheral and central sensitization, release of inflammatory mediators, and some degree of sympathetic nervous system involvement.
The commonly accepted diagnostic criteria for CRPS was developed in 2007 and commonly referred to as the “Budapest Criteria”. While originally developed as criteria to assist research, they have largely become the clinical definition used in the United States for diagnosis of CRPS. Attempts to develop objective testing (sensory testing, doppler blood flow studies, triple phase bone scans) in CRPS has proved largely unsuccessful and CRPS remains a clinical diagnosis.
Pain after back or lumbar surgery may be known as failed back surgery syndrome or post Laminectomy pain syndrome. A number of causes may be attributing to back pain after surgery including build up of scar tissue, returning disc herniation, nerve root compression, failure of hardware, or worsening adjacent spine disease. Post-surgical back pain may be worsened by smoking, aggravated by depression, anxiety, lack of sleep resulting in the release of inflammatory mediators.
After careful review of medical history, physical examination, and imaging studies, treatment options that exist are epidural injections, nerve blocks, or radiofrequency ablation. Spinal cord stimulation is an advanced therapy that uses electrical stimulation to block pain signals and relieve pain.
Knee pain is complex secondary to the multiple moving components including ligaments, tendons, cartilage, and muscles. Pain can be attributed to osteoarthritis, tendonitis, damage to ligaments, degeneration of cartilage, and bursitis. If surgery is not an option, multiple treatments exist including cortisone injections, viscosupplementation, radiofrequency ablation, and regenerative therapies such as platelet rich plasma (PRP) and bone marrow aspirate concentration (BMAC).
There are many different types of headaches that exist, the primary headaches include migraine, tension type, and cluster headaches. Secondary causes of headaches include occipital neuralgia, vascular disease, spinal headache, pain originating from the cervical spine, stressors, infection, head injury, and serious causes such as a tumor must be ruled out. When oral medications are not helpful, interventions such as injections or other advanced therapies may be indicated.
Nerve related pain and pain due to neuropathy can be caused by trauma to nerves, disease and damage to the nervous system. Diabetes, infection, injury, and exposure to toxins may be other causes of neuropathic pain. Treatment include anticonvulsants, antidepressants, anti-inflammatory medications, and physical therapy. Advanced therapies to treat neuropathy is spinal cord stimulation, including dorsal column stimulation and DRG therapy. This therapy works by sending electrical impulses to nerves to reduce pain transmission and signaling to the brain.
Cancer pain can be caused by many different mechanisms, including direct compression of nerves by the cancer itself, or the medications used to treat the cancer. Cancer treatment such as radiation therapy and chemotherapy may cause nerve damage and nerve related pain. Pain from the cancer can be related to the type of cancer, location of tumors, and the stage of malignancy. Treatments include opioid medication, spinal cord stimulation and targeted drug delivery to alleviate suffering and improve life span.