From the Book

Chapter 15

Myofascial Pain

Treatment Considerations

Nonsurgical

Patients with myofascial pain benefit from a multidisciplinary approach. The first and sometimes most important aspect of treatment is to evaluate the patient and to assure him that he does have real physical pain. Too often, patients with myofascial pain have sought numerous medical opinions, have been told that nothing is wrong, and then begin to doubt themselves, the medical profession, or both.

Routine physical therapy often exacerbates myofascial pain. Physical therapy is too often a simplistic combination of ultrasound, electrical stimulation, and cookbook-type exercises. If the abnormal tension, contractility, and hyperresponsiveness of the musculature are not addressed, then exercises can worsen the pain.

Skilled hands-on therapy, including spinal manipulation, physical therapy with a focus on myofascial release and craniosacral technique, and acupuncture can help to reshape the maladaptive muscular response of myofascial pain. This type of treatment in and of itself can be extremely beneficial.

Patients often benefit from medication. One of the most successful medications for myofascial pain is amitriptyline, which is an old-fashioned antidepressant medication that nonspecifically increases the availability of norepinephrine and serotonin (see Chapter 5). This medication promotes sleep, and patients with myofascial pain are often sleep deprived. Amitriptyline generally is prescribed in a low dose, 10 mg to 25 mg, which is lower than the therapeutic dose required to treat depression.

Anticonvulsants sometimes are useful in treating myofascial pain, especially when the pain has a burning component and when the pain has become severe. The choice of anticonvulsant depends on other symptoms that the patient is experiencing. Some anticonvulsants help to promote sleep, some anticonvulsants are associated with weight loss, and others are associated with weight gain. Newer-generation antidepressant medications also serve as a useful adjunct in treating myofascial pain, because very often an associated anxiety, depression, or both are present. In addition, numerous well-designed scientific studies have demonstrated the efficacy of newer-generation antidepressant medication in alleviating neuropathic pain.