Indian Journal of Physical Medicine and Rehabilitation. April 2003; Vol. 14: 5-8.

A Study on the Role of Needling and Infiltration in Fibromyalgia and Myofascial Pain Syndrome

Dr RK Ghatak, MBBS, DCH, DSM, MD (PMR), Assistant Professor,
Department of PMR, Medical College, Kolkata

Dr A Ballav, MBBS, DGO, DTM&H, MD (PMR), Professor and Head,
Department of PMR, IPGMER, Kolkata

Dr AK Palit, MBBS, DCH, MD (PMR), MO, Department of PMR,
Burdwan Medical College, Hospital

Address for Correspondence : Dr. R.K. Ghathak, A-11/523, Kalyani Distt-Nadia, West Bengal, Pin-741235. Ph. : (033) 582-6264

Abstract

Patients with muscle pain, localised or generalised, is a common presentation in Physical Medicine and Rehabilitation department. It produces much morbidity to the patient and responsible for loss of working days of the individual .The study aims to findout a simple treatment which can be applied in outpatient basis even in rural setting . 30 patients, 15 each of fibromyalgia and myofascial pain syndrome, were considered for the present study. Age of the patients ranges from 18 - 55 years. Each patient was treated , once or twice, with needling and infiltration of 1% lignocaine in the tender spot / trigger point in right or left upper trapezius muscle. Patients were followed for one month. Clinical response was measured for subjective improvement by visual analogue scale as well as for objective improvement by pressure algometer. Like some former studies sustained improvement was noted mainly in myofascial pain syndrome. Thus it is worthy of trying needling and infiltration in myofascial pain syndrome cases.

Key Words : Muscle Pain - Fibromyalgia and Myofascial Pain Syndrome - Needling and Infiltration.

Introduction

Muscles make up 40% of the mass of human body. The forces muscle generate and mechanical stresses they are subjected to are tremendous . Muscle pain is a universal experience. The muscle pain syndrome, however, have yet to achieve universal acceptance in the medical community.1

Myofascial pain is considered to be one of the important causes of pain.2 Muscle pain may be generalised or localised. It produces substantial morbidity and socio-economic impact. Simon3 indicates that about 30% of patients attending a general medicine clinic with a chief complaint of pain are found to have myofascial pain. Common denominator of muscle syndrome is negative laboratory finding particularly absent evidence of inflammation.4 Cases can be divided into myofascial pain syndrome with regional pain and fibromyalgia with widespread pain and systemic feature.5 Trigger point is a criterion for myofascial pain syndrome and sustained pressure (10 seconds) or penetration by a needle of the trigger point causes referral of pain to defunite sites . There may or may not be a palpable nodule at the site. Often trigger point is located within a taut band.6 Criteria for fibromyalgia are widespread aching for 3 month , pain above and below the waist, pain on both right and left side of the body along with axial pain and presence of 11 out of 18 tender points on digital palpation with an approximate force of 4 kg.7 Pressure on tender spot produces pain without radiation .

The present study aimed to know the efficacy of needling and infiltration, a simple procedure which can be done in outpatient department in remote rural setting , in patients with muscle pain

Materials & Methods

The study was carried out in the department of Physical Medicine and Rehabilitation , Medical College Kolkata between Jan 1999 and Dec 1999. 30 patients , in the age group of 18-55 years , having localised or generalised muscle pain along with chronic neck pain were confidered for the present study . Table 1 shows the distribution of the patients .

Inclusion criteria :

1. Muscle pain , localised or generalised , along with chronic neck pain .

2. Muscle pain present for more than 3 months.

3. Age above 18 years .

4. Patients giving consent to be included in the study .

Exclusion criteria :

1. Association with other rheumatic diseases .

2 . Preganancy.

3 . Patients refusing injection.

4 . Past history of hypersensitivity to lignocaine.

5. Bleeding disorders or patients under anticoagulant.

6 . Presence of local or systemic infection.

A detailed history was taken and thorough physical examination was done to divide the patients into fibromyalgia (The American College of Rheumatology 1990 Criteria)8 and myofascial pain syndrome ( Simons AG 1990)9. Baseline investigation for RA factor , C- reactive protein, haemogram and radiological investigation viz. X-ray cervical spine were done.

Irrespective of diagnosis, fibromyalgia or myofascial syndrome, local needling and infiltration of 1% lignocaine with 24G needle was done in tender spot / trigger point on right or left upper trapezius muscle . Each patient was asked to follow advice regarding neck exercise and posture care. A second needling and infiltration was done in some cases at the same site after one week of the 1st needling and infiltration. (Table 2)

Concurrent therapy :

Patients were advised to avoid any medication for pain during the study.

Patients were followed at one week and one month after the 1st needling and infiltration and evaluated for subjective improvement by Visual Analogue Scale (VAS) of 100 mm and objective changes of pressure threshold of tender spot / trigger point by Pressure Threshold Meter (Algometer).

Results and Analysis

Fig. 1 compares the changes in Visual Analogue Scale readings as a result of needling and infiltration in patients with fibromyalgia and myofascial pain syndrome. In cases of fibromyalgia although slight improvement was noted at 1wk 90.67 ± 14.43 but at 1 month pain returned to pretreatment level (100). In cases of myofascial pain syndrome, mean Visual Analogue Scale readings were 100 cm. at the time of 1st injection, at 1 wk 41.33±17.27 and at 1 month 16.67±15.43. Thus following needling and infiltration persistent significant subjective improvement was noted only in patients with myofascial pain syndrome.

Fig 2. shows changes in readings of pressure Algometer as a result of needling and infiltration in patients with fibromyalgia and myofascial pain syndrome. In fibromyalgia slight improvement was noted at 1 wk , as slight greater pressure was needed to elicit tenderness at tender spot ( 4.46 ± 0.74 as compared to 4 at 1st visit ). But at 1 month followup, pretreatment level returned i.e. tenderness could be elicited with a pressure of 4 kg/cm 2. But in cases of myofascial pain syndrome, there was gradual improvement during the study period . At 1 wk mean pressure required to elicit tenderness at trigger points was 3.53± 0.74 and at 1 month the value was 5.06±0.70 both of which were greater than the corresponding reading at 1st visit 2.06 ±0.79 .

Thus in fibromyalgia, though slight improvement was noted at 1 wk but ultimately patients returned to pretreatment level at 1 month. In cases of myofascial pain syndrome, there was gradual improvement even at 1 month.

Table 1 : Showing characteristics of patients.

  Fibromyalgia Myofascial pain syndrome
1. Age of the patients 30.13 ±11.35
(18 - 55 years )		 32.27 ± 10.27
(20 - 48 years )
2. Sex F=12, M=3 F=11, M=4
Duration of illness 7± 2.62
(3 - 12 months ) 		 7.06 ±2.46
(3 - 11 months )

  Table 2 : Number of needling and infiltration required .

One Injection Two injections
Fibromyalgia   5 patients 10 patients
Myofascial Pain Syndrome 12 patients 3 patients

Table 3 : Shows mean value ± standard deviation of readings of visual analogue scale and pressure algometer in cases of fibromyalgia.

At entry At 1 week At 1 month
Visual Analogue Scale 100 90.67±14.38 100
Pressure Algometer 4 4.46± 0.74 4

Table 4 : Shows mean value ± standard deviation of readings of visual analogue scale and pressure algometer in cases of myofascial pain syndrome.
At entry At 1 week At 1 month
Visual Analogue Scale 100 41.33±17.27 16.67±15.43
Pressure Algometer 2.06± 0.79 3.53± 0.74 5.06± 0.70

Fig . 1 : Comparison of Visual Analogue Scale readings as recorded during the study in fibromyalgia and myofascial pain syndrome patients.

(Not Available)

Fig . 2 : Comparison of readings of Pressure Algometer as recorded during the Study in fibromyalgia and myofascial pain syndrome patients .

(Not Available)

Disscussion

Though patients with muscle pain is a common experience in Physical Medicine and Rehabitation department, there is no single treatment protocol that can control the disease process and naturally the patients search for alternative treatment.

As per criteria for selection of patients, laboratory results were negative except degenarative changes in cervical spine in older patients .

Local needling and infiltration is ineffective in tender spot of fibromyalgia but effective in myofascial pain syndrome (Schneider MJ)10. This is also found in our study where initial improvement was noted in some cases of fibromyalgia (5 out of 15) but even in those cases signs and symtoms ruturned to the pretreatment level at the conclusion of the study. But in all cases of myofascial pain syndrome, substantial improvement of signs and symtoms were noted at the end of the study . Schneider MJ concluded that fibromyalgia and myofascial pain syndrome are two different clilnical conditions that require different treatment plans.Fibromyalgia is a systemic disease process and requires multidiciplinary treatment approach including psychotherapy, low dose antidepressant medication and a moderate exercise programe . Myofascial pain syndrome, on the otherhand, is a condition that arises from the referred pain and muscle dysfunction caused by trigger points which often respond to local treatment . Hong - CZ11 studied to know the effects of injection of local anaesthetic agent and dry needling in the myofascial trigger point of upper trapezius muscle . Improvement was assesed by measuring subjective pain intensity, the pain threshold of trigger point and range of motion of cervical spine . Improvement was noted with both dry needling and injection of local anaesthetic agent .The author concluded injection of local anaesthetic agent is preferable as it produces less postinjection soreness.

Conclusions

Muscle pain is a common presentation of patients in Physical Medicine and Rehabilitation department. By careful history taking , physical examination and laboratory investigation cases can be divided into myofascial pain syndrome with localised symptom and fibromyalgia with diffuse ache and systemic affection.

Presence of taut band , nodule and trigger point help in diagnosis of myofascial pain syndrome and presence of multiple tender points distributed around the whole body along with systemic complaints points to fibromyalgia.

It is worthy of trying local needling and infiltration in cases of myofascial pain syndrome. In cases of fibromyalgia the procedure is of no value and other treatment modalities can be tried.

References

  1. Physical Medicine and Rehabilitation . Ed. Randall. L. Braddam. W. B. Saunders Company. 1st . Ed . 1996 P. 893.

  2. Fishbain DA , Goldberg M , Meargher BR et . al: Male and female chronic pain patients categorised by DSM-111 psychiatric diagnostic criteria. Pain 26 : 181 -197, 1986.

  3.  Simon DG :Clinical and etiological update of myofascial pain from trigger points. Journal of musculoskeletal pain 4 : 93-121, 1996.

  4. Andrew A. Fischer : New developments in diagnosis of myofascial pain and fibromyalgia. Physical Medicine and Rehabilation Clinic of North America. Feb 1997 .

  5. Physical Medicine and Rehabilitation. Ed. Randall L . Braddam. W. B. Saunders Company. 1st Ed. 1996. P. 908.

  6.  Physical Medicine and Rehabilitation . Ed . Randall L . Braddam. W. B. Saunders Company. 1st Ed. P. 900.

  7. Physical Medicine and Rehabilitation. Ed. Randall L. Braddam. W. B. Saunders. 1st Ed. 1996 . Table 42-4 . P 907 .

  8. ACR 1990 . The American College Of Rheumatology 1990 criteria for classification of fibromyalgia - Physical Medicine and Rehabilitation . Ed .Randall L . Braddam. W. B. Saunders Company. 1st Ed. 1996. P 907.

  9. Simons : Clinical criteria for myofascial pain syndrome . Table. 42 - 2 . Physical Medicine and Rehabilitation. Ed. Randall L. Braddam. W. B Saunders Company. 1st Ed. 1996. P 902.

  10.  Schneider MJ : Tender points / fibromyalgia VS. Trigger points / myofascial pain syndrome : a need for clarity in terminology and differential diagnosis. J - Manupulative - Physiol - Ther. 1995. July - August ; 18 (6) : 398-406.

  11.  Hong-CZ : Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am-J-Phys-Med-Rehabil. 1994 July-Aug ; 73(4) :
    256-63    .

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