myofacial pain dysfunction syndrome anindya

Presented by : Dr. Anindya Chakrabarty

Content

Introduction

History

Definition

Characteristics

Pathophysiology

Symptoms

Physical examination

Goal of treatment

Management protocol

Introduction

It is a muscular pain disorder – most common diagnosis causingchronic pain but one of the most least understood.

Complex symptomatology, concomitant disorders and frequentbehavioral & psychosocial contributing factors make the disorderdifficult to recognize

As the name suggest it has three part

Myofascial – muscular & connective tissue origin

Pain – an unpleasant sensational & emotional experience

Dysfunction – deviated from normal function

Syndrome – collection of various symptoms

History

Costen – 1934 – indicate TMJ pain due to occlusal etiology

Schwartz – 1956 – coined term TMJ pain dysfunction syndrome – blamed the

spasm of masticatory and perimasticatory musculature.

Laskin – 1969 – termed as MYOFASCIAL PAIN DYSFUNTION SYNDROME –

implicated Psychophysiological theory for such incident.

Definition

A pain disorder, in which unilateral pain is reffered from the trigger points

in myofascial structures, to the muscles of the head and neck. Pain is

constant, dull in nature, in contrast to the sudden sharp, shooting,

intermittent pain of neuralgias.

Pain may range from mild to intolerable

Prevalence

Common persistent pain in head & neck region

50% of chronic head & neck pain

20-50% of people has this type of pain

Types of myofascial pain

disorder

6 distinct group

Myositis

Muscle spasm

Myofascial pain dysfunction (Trigger Point Pain)

Fibromyalgia

Muscle contracture

Muscle pain secondary to connective tissue disorder

Functional Neuroanatomy and Physiology of the

Masticatory System

Two major components:

(1) neurologic structures

(2) muscles.

MUSCULAR COMPONENT

MOTOR UNIT

consists of a number of muscle fibers that are innervated by one motor neuron.

Each neuron joins with the muscle fiber at a motor endplate.

Depolarization causes the muscle fibers to shorten or contract.

fewer the muscle fibers per motor neuron, the more precise the movement.

MUSCLE

Hundreds to thousands of motor units along with blood vessels and nerves are bundled together by connective tissue and fascia to make up a muscle.

Muscles are necessary to overcome this weight and mass imbalance.

MUSCLE FUNCTION

3 potential functions

isotonic contraction

Isometric contraction

Controlled relaxation

eccentric contraction

lengthening of a muscle at the same time that it is contracting

Muscles

Precise and complex balance of the head and neck muscles must exist to maintain

proper head position and function. A, Muscle system. B, Each of the major muscles acts

like an elastic band. The tension provided must precisely contribute to the balance that

maintains the desired head position. If one elastic band breaks, the balance of the entire

system is disrupted and the head position altered.

Neurological structure

Neuromuscular Function

Function of the Sensory Receptors

Reflex Action

Reciprocal Innervation

Regulation of Muscle Activity

Influence from the Higher Centers

Reflex action

Myotic / Stretch Relex

Nociceptive reflex

MYOTIC REFLEX

Nociceptive reflex

Pain modulation in trigeminal nerve

The degree of suffering relates more closely to the patient’s perceived threat of

the injury and the amount of attention given to the injury

Pain modulation means that the impulses arising from a noxious stimulus, which

are primarily carried by the afferent neurons from the nociceptors, can be altered

before they reach the cortex for recognition.

This alteration or modulation of sensory input can occur while the primary neuron

synapses with the interneuron when it initially enters the CNS or while the input

ascends to the brainstem and cortex.

it is important to distinguish the differences among four terms:

nociception, pain, suffering, and pain behavior

Mechanism of pain modulation

Non painful cutaneous stimulation system

It has been postulated that if the larger fibers are stimulated at the same time as the smaller ones, the larger fibers will mask the input to the CNS of the smaller ones

The descending inhibitory system assists the brainstem in actively suppressing input to the cortex.

In order for an individual to sleep, the brainstem and descending inhibitory system must completely inhibit sensory input (e.g., sound, sight, touch) to the cortex. Without a well-functioning descending inhibitory system, sleep would be impossible.

Transcutaneous electrical nerve stimulation (TENS) is an example of the nonpainful cutaneous stimulation system masking a painful sensation.

Constant subthreshold impulses in larger nerves near the site of an injury or other lesion block the smaller nerves’ input, preventing painful stimuli from reaching the brain.

Intermittent painful stimulation system

the stimulation of areas of the body that have high concentrations of

nociceptors and low electrical impedance. Stimulation of these areas may

reduce pain felt at a distant site.

Two basic types of endorphins have been identified:

(1) the enkephalins and (2) the betaendorphins.

This is the basis for acupuncture:

A needle placed in a specific area of the body having high concentrations of

nociceptors and low electrical impedance is twisted approximately two times a second

to create intermittent low levels of pain.

The stimulation causes the release of certain enkephalins in the cerebrospinal fluid,

and this reduces the pain felt in tissues innervated by that area.

Runner’s High – by Beta-endorphin

Psychologic modulating system

conditions that seem to intensify the pain experience are anxiety, fear,

depression, and despair.

Certainly the amount of attention drawn to an injury, as well as the

consequence of the injury, can greatly influence suffering.

CENTRAL EXCITATORY EFFECT

First explanation suggests that if the afferent

input is constant and prolonged, it continuously

bombards the interneuron, resulting in an

accumulation of neurotransmitter substance at

the synapses. If this accumulation becomes

great, neurotransmitter substance can spill over

to an adjacent interneuron, causing it also to

become excited.

second explanation of the central excitatory

effect is that of convergence. single interneuron

may itself be one of many neurons that converge

to synapse with the next ascending interneuron.

As this convergence nears the brainstem and

cortex, it can become increasingly difficult for

the cortex to evaluate the precise location of the

input.

ETIOLOGY OF MPDS

TISSUE INJURY

Major trauma

Exposure to extreme temperature

PHYSICAL STRESSES

Extreme fatigue

Repetitive micro trauma (Clenching & Bruxism)

Other disease processes

Psychological factors

- Pipe smoking

- Sleeping on stomach with mandible supported by forearm.

- Teeth clenching or grinding

- Jaw thrusting, tip sucking, tongue thrusting.

- Nail, pen / pencil biting

- Constant chewing of tobacco or gum

Occlusal factor

Developmental occlusal disharmony

Acquired occlusal disharmony

Iatrogenic occlusal disharmony

THEORIES OF MPDS

Neurophysiological hypothesis

Repetitive strain theory

Central hypothesis

Central biasing mechanism

DIGAMMATIC RERESENTATION OF ETIOLOGY OF MPDSPSYCHOPHYSIOLOGIC THEORY OF MPDS

(Modified by LASKIN in 1969)

PATHOPHYSIOLOGY OF MUSCLE PAIN

Muscular shortening(Calcium excess shortening)

Prolonged sustained and muscular contraction

Disruption of delicate sarcoplasmic reticulum

Release of free calcium ions that are stored within SR

Act on sarcomeres containing

actin-myosin complex

Shortened muscles experience increase in metabolic

demands due to more actin and myosin

Depletion of ATP

(Muscular fatigue)

Actin myosin binding intensified

(ATP depletion shortening)

Mechanical interruption of blood flow through

this area of biochemical derangement

Vasoconstriction decrease of oxygen in the affected muscular fibres (shift to anaerobic metabolism)

Anaerobic metabolism causes propagation of decreased

pH & accumulation of Nocigenic and Spasmogenic

by-products called the “BIOGENIC AMINES” like serotonin,

histamines, kinins & prostaglandins

Activation of group III and group IV

muscle nociceptive fibres

PAIN

Pain and further exaggerated central response (reflex response phenomenon) creates increased accumulation of

biogenic amines & intensified vasoconstriction

Local twitch response & jump signs of myofascial trigger points

CLINICAL FEATURES

Trigger point are present

Presence of zone of reference

Generally present at the end of tiresome day

Limitation of motion of the jaw

Chronic, focal or regional muscle Pain as discomfort (unexplained nature)

Continuous, dull to sharp ache in region of TMJ, preauricular or post auricular

areas and at the angle of mandible

Joint noises – grating, clicking, snapping etc.

Tenderness to palpation of the muscles of mastication.

ASSOCIATED SYMPTOMPS

Neurologic GIT Musculoskeletal Otologic

Tingling

Numbness

Blurred vision

Twiches

Trembling

Lacrimation

Nausea

Vomiting

Diarrhea

Constipation

Indigestion

Dry mouth

Fatigue

Tension

Stiff joint pain

Tiredness

Weakness

Tinnitus

Ear pain

Dizziness

Vertigo

Diminished hearing

TRIGGER POINTS

Manifestations of abnormal muscles spindles

Nodes of degenerated tissues

Hyperirritable, localized point of tenderness in muscles

**Stimulation of trigger points produces local and referred pain

**Pathophysiology unknown although many theories proposed

MUSCLES INVOLVED REFERRED PAIN

1. Masseter

2. Temporalis

3. Medial pterygoid

4. Lateral pterygoid

5.Sternocleidomastoid

Preauricular, post auricular

region and mandibular body

Side of the head, masseter

origin, orbit maxillary teeth

Retromandibular region

Ear and TMJ

Ear, mastoid and anterior

cervical region

TEETH source

1. MAXILLARY INCISORS

2. MAXILLARY CANINES

3. MAXILLARY

PREMOLARS

4. MAXILLARY MOLARS &

MANDIBULAR MOLARS

ANTERIOR TEMPORAL MUSCLE

ANTERIOR TEMPORAL MUSCLE

INTERMEDIATE TEMPORAL

MUSCLE,SUPERFICIAL MASSETER

MUSCLE,

POSTERIOR TEMPORAL MUSCLE,

TRAPEZIUS MUSCLE AND

STERNO-CLEIDOMASTOID

MUSCLE

MUSCULAR SOURCES OF REFERRED PAIN TO THE TEETH

PAIN REFERENCE POINTS FOR MASSETER

MUSCLES (TRIGGER POINTS)

SUPERFICIAL LAYER MIDDLE LAYER

LOWER DEEP

PAIN REFERENCE POINTS FOR

TEMPORALIS (TRIGGER POINTS)

MIDDLE FIFRESANTERIOR FIFRES

MIDDLE FIFRES POSTERIOR FIFRES


MEDIAL PTERYGOID (TRIGGER POINTS)

BEFORE AND AFTER REMOVAL OF CONDYLE


LATERAL PTERYGOID (TRIGGER

POINTS)

BEFORE AND AFTER REMOVAL OF SUPERFICIAL MASSETER

STERNAL DIVISION

CLAVICULAR DIVISION

PAIN REFERENCE POINTS FOR STERNOCLEIDO-MASTOID (TRIGGER POINTS)


TRAPEZIOUS (TRIGGER POINTS)

UPPER RIGHT TRAPEZIUS

KEYS IN MAKING A DIFFERENTIAL

DIAGNOSIS

History

Examination

Mandibular restriction

Mandibular interference

Acute malocclusion

Loading of the joint

Functional manipulation

Diagnostic anesthetic blockade

Diagnostic imaging & Investigations

GENERAL HISTORY: which includes medical, surgical, psychological,

occupational and social background

SPECIFIC HISTORY: related to present complaint i.e. onset and type of

pain, aggrevating and relieving, severity of symptoms, associated

symptoms and medicines taken for the problem.

HISTORY TAKING

CRANIAL NERVE EXAMINATION Olfactory nv

Optic nv

Occulomotor/ Trochlear/ Abducent nv

Trigeminal nerve

Facial nv

Acoustic nv

Glossopharyngeal nv

Accessory nv

Hypoglossal nerve

EYE EXAMINATION

Testing gross vision

Diplopia or blurriness of vision is noted

Reddening of the conjunctivae should be recorded

Any tearing or swelling of the eyelids

EAR EXAMINATION:

CERVICAL EXAMINATION

EXAMINATION FOR

CRANIOCERVICAL

DISORDERS.

asked to look to the extreme

right and the extreme left

look upward fully

Look downward fully

bend the neck to the right and

left

MUSCLE EXAMINTION Location of muscle pathology

Evaluation of muscle tone

Location of trigger point

Evaluation of temperature change

Location of swelling

Muscles are palpated bilaterally and simultaneously with firm but gentle pressure for 1-2min. Main pressure is exerted with the middle finger of each hand

During palpation subjective pain should be noted.

Patient is asked question regarding unilateral / bilateral pain, tenderness is mild / moderate or severe.

Reference zone of the pain should be noted

Temporalis Examination:

Masseter Examination:

Sternocleidomastoid Examination:

Posterior Neck Muscle examination

FUNCTIONAL MANIPULATION

Medial Pterygoid Muscle

Lateral pterygoid Muscle

Interincisal distance

Maximal comfortable mouth opening Maximal mouth opening

Checking “End Feel”

Alteration in Opening pathway

Dental / occlusal examination

Occlusal discrepancies, prematurities, or interference should be noted.

Anterior open bite, collapsed bite, cross bite, reduced vertical dimensions,

wear facets, mobility of teeth missing and teeth should be checked.

Type of occlusion, skeletal, dentofacial should be checked

Examination of Articular joint

JOINT SOUND

either clicks or crepitation

click is a sound of short duration. If it is relatively loud, it

is sometimes referred to as a “POP”

Crepitation is a multiple gravel-like sound described as

grating

JOINT RESTRICTION

The dynamic movements of the mandible are observed

for any irregularities or restrictions.

Diagnostic Blocking

INDICATIONS:

It is essential when differentiating primary from secondary pains

useful to identify the pathways that mediate peripheral pain and to localize pain sources

when the source of pain is difficult to identify, local anesthetic blocking of related tissues is the key to

making the proper diagnosis

educate the patient to the source of his or her pain problem

GENERAL RULE

purpose of an injection is to isolate the particular structure that is to be blocked

clinician should have a sound knowledge of the pharmacology of all solutions that will be used

clinician should avoid injecting into inflamed or diseased tissues

clinician should maintain strict asepsis at all times.

TYPES

Muscle block

Nerve block

Intra capsular

Technique of Trigger Point Injection

AURICULO-TEMPORAL NERVE BLOCKING

Radiological investigation

Helpful in diagnosis of

Intra articular pathologies

Osseous pathologies

Soft tissue pathologies

Conventional Radiograph

Panoramic radiograph

Transcranial projection

Transpharyngeal projection

Transmaxillary projection

Recent advances

CT

MRI

CBCT

Bone scaning

Other Investigations

Electromyogram

Sonography

Sonography is the technique of recording and

graphically demonstrating joint sounds.

Many healthy joints can produce sounds during

certain movements

Presently sonography does not provide the clinician

with any additional diagnostic information over

manual palpation or stethoscopic evaluation.

Vibration analysis

Vibration analysis has been suggested to help in

diagnosing intracapsular TMD, and internal

derangements in particular

Measures the minute vibrations made by the condyle

as it translates and has been shown to be reliable.

the technique diagnoses up to 25% of normal joints

as derangements and misclassifies many deranged

joints as normal, especially if the joint sounds are not

audible or if the derangement has advanced to a

nonreducing stage

Thermography

Thermography is a technique that records and graphically

illustrates surface skin temperatures.

Various temperatures are recorded by different colors,

producing a map that depicts the surface being studied.

Recent studies shows Infrared imaging measurements can

provide a useful, non-invasive and nonionizing examination for

diagnosis of MTPs in masticatory muscles.

Mandibular tracking device

If a jaw-tracking device is used, the exact movement of the

mandible can be recorded

Unfortunately, many intracapsular and extracapsular disorders

create deviations and deflections in mandibular movement

pathways.

A particular deviation may not be specific for a particular

disorder, this information should only be used in conjunction

with history and examination findings.

MANAGEMENT OF MPDS

Patients counseling

Physiotherapy

Pharmacotherapy

Occlusal therapy

Patient concealing

Explaining patient about parafunctional habits such as clenching and bruxism.

Soft diet

Avoiding tooth to tooth contact.

Avoid stressful forces.

Resting of the jaw.

Relaxation therapy

Bio-feedback therapy – yoga, deep breathing, meditation, hypnosis

PHYSIOTHERAPY

Heat application

Superficial:

Hot packs, paraffin and radiants (Infra Red) Hot

moist application of towels for 15-20 min for 4

times.

Hydrocollator:

pad filled with clay and heated in water both for

70°-80°, wrapped in a protected towel and placed

over the affected area for 15-20 mins

Deep Heat application:

delivered by diathermy, ultrasound or

phonophorosis

DIATHERMY

ULTRASOUND

PHONOPHORESIS

DIATHERMY

Short Wave Diathermy

In chronic conditions, there will be increase in blood flow.

Increase in oxygenation on application for 10 mins

Mega Pulse

Rest period between pulse raise allows dissipation of heat by

blood flow.

Time of application – 10 mins

60 micro second pulse

100 pulse / sec.

Regime: 3 times / week for 4 weeks

Ultrasound:

Heat is placed on the skin which has to be coated with an acoustic coupling gel

and moved in parallel or circular over lapping sweeps 0.7 to 1 volts / cm2 for 10

mins.

Regime: 3 times / week for 4 weeks.

Uses:

Altered cell membrane permeability

Intracellular fluid absorption.

Decreased collagen viscosity.

Vasodilation

Relax muscles and analgesia.

Phonophorosis:

Application of ultrasound instead of acoustic coupling gel. It uses a pad filled with an anesthetic

or steroid cream is placed over the treatment kit

LASER THERAPY

Cold laser therapy

cold or soft laser has been investigated for wound healing and pain relief

A cold laser is thought to accelerate collagen synthesis, increase vascularity of

healing tissues, decrease the number of microorganisms, and decrease pain.

increases capillary permeability

Time of application: 3min

Output: 4 joules / cm2

Cryotherapy / Cold therapy :

Ice packs application to the painful area 4 times a day for 20

min.

Ice should not be placed over skin not more than 5 to 7 min

It lowers thermal gradient in skin, interrupting massive

concentration of Histamines, thus lowering pain threshold in the

skin.

Acupuncture:

It is based on a complex relationship between energy through

channels or natural elements (wood, earth and water) and

positive and negative elements.

Energy flow is done merely by placing a needle into a specific

site and adding either electric or heat to the needle.

It has minimal effect on reducing pain therefore not

recommended as primary therapy. Its used as an alternative

therapy.

Use of vasocoolent sprays:

Cold encourages the relaxation of muscles that are

in spasm and thus relieves the associated pain.

Most commonly used – ethyle chloride and

fluromethen

Fluromethane or ethylchloride spray is applied to

painful area for 5 min. Muscles are then gently

stretched after that.

Electrogalvanic stimulations:

Delivers a wide range of intensity to activate the

injured muscles.

It stimulate local circulation, achieves excitability and

conductivity without painful heating.

Pulse at 80 cycles / sec for 10 min followed by

excessive for 5 min.

TENS (Transcutaneous Electrical Nerve

Stimulation)

Produced by a continuous stimulation of cutaneousnerve fibers at a sub-painful level

When a TENS unit is placed over the tissues of apainful area, the electrical activity decreases painperception

TENS uses a low-voltage, low-amperage, biphasiccurrent of varied frequency and is designed primarilyfor sensory counter-stimulation in painful disorders.

It stimulate local circulation, achieves excitability andconductivity without painful heating.

Pulse at 80 cycles / sec for 10 min followed byexcessive for 5 min.

PENS (Percutaneous Electrical

Nerve Stimulation)

A new therapy for chronic pain sufferers that uses a low voltage electrical current delivered to the subcutaneous tissue or peripheral nerves to relieve chronic refractory neuropathic pain

It is a form of neurostimulation or neuromodultation that damping down overactive (sensitized) nerves that are causing pain

Does not destroy any nerves. It just makes them less sensitive to pain. A low voltage electrical current is delivered via a specially designed needle to a layer of tissue just below the surface of the skin close to the specific nerve, or to the nerve endings situated in an area that is painful

Some patients will have total pain relief, others experience prolonged pain relief for 3 months or more and others get relief for shorter periods of time

Manual therapy

Soft tissue mobilization

Joint mobilization

Muscle conditioning

Passive muscle stretching

Assisted muscle stretching

Resistance exercise

Postural training

PHARMACOTHERAPY

Anti inflammatory drugs:

NSAIDS: Reduces inflammation and provide pain relief both in the muscles and joints

for 14-21 days.

Aspirin 2 tab 0.3 to 0.6gm / 4th hourly

Piroxican 10-20 mg / 3-4 times /day

Ibiprofen 200-600mg / 3-4 times / day

Opoids: Pertazacine 50mg / 2-3 times /day.

Muscle relaxants:

It is used for short duration as they produce addiction.

Meprobamate 400mg TDS for 1 days.

Vallium 5-10mg 2-3 times /day.

It can be used as centrally acting eg Datrium, Succinyl colin, cusara, baclofin, and

peripherally acting.

ANTI ANXIETY MEDICATION:

Propylalcohol derivatives – Meprobamate 1200-1600 mg / day is divided doses.

Diphexyl methansis – Antilistamines are used in patients where benzyl diazapines are

contra indicated.

BENZODIAZEPIENES:

Alprazalam – 0.5mg 1-3 times / day

Diazepam – 2-5mg 1-4 times / day for 10 days

ANTI DEPRESSANT:

Amitriptyline 10-25 mg/day for 3 times

Fluoxitin 5mg / day

LOCAL ANAESTHETICS:

Procaine – 0.5%

Lidocain – 1%, 2%

Ethyl chloride spray or i.m.

Local anaesthetic at affected part give relief.

PCA (Patient Controlled

Analgesia) for MPDS

It is an effective method for administrating opiates to patient

for pain relief.

It gives patients a sense of control over pain

USE OF BOTOX

Botulinum toxin injections are currently the mainstay of treatment for most focal dystonias.

Neurotoxin botulinum toxin A, when injected into a muscle, causes a presynaptic blockade of the release of acetylcholine at the motor end plates.

End result is a muscle that can no longer contract (paralysis).

Normally takes 1 to 2 weeks for the effect to be clinically noticeable.

Normally, activity of the motor end plate is totally restored in 3 to 4 months

Approximately 25 U of botulinum toxin A is normally appropriate for each of these muscles.

The greatest number of motor end plates is found in the midbody of the muscle (halfway between the insertion and origin).

OCCLUSAL SPLINT

Purpose:

To create a balance joint tooth stabilization the mandible.

To reduce spasm, contracture and hyperactivity of musculature.

To restore vertical dimension

Types:

Stabilization splint

Relaxation splint

Stabilization Splint

12-18 hrs / 4-6 months

Fabricated over the maxillary teeth covering occlusal and incisal surface made up of acrylic

A flat platform perpendicular to mandibular incisors so the splint will disengage the teeth and

release the muscles

If patient doesn’t have relief at the end of 3 month re-evaluation should be done.

Splint reduces the load on the retrodistal area and therapy relieve pain.

Pre fabricated rediant splint are also available.

Relaxation splint

It is used for disengagement of teeth and for only short period (upto 4 wks)

They are fabricated over the maxillary incisor teeth

A platform is added to disengage mandibular anterior

Differential diagnosisType Cause History C/F Treatment

Muscle splinting 1. Altered sensory input

2. Constant deep pain

3. Increased stress

1. Recent alteration in

local structure

2. Source of deep pain

3. Recent increase in

emotional stress

1. Decrease ROM

2. But may achieve

normal ROM on

request

3. No pain at rest

4. Pain with function

5. Muscle weakness

1. Correction of local

causes

2. Removal of source of

deep pain

3. Psychological

regulation

4. Soft diet

5. Analgesic

Local muscle

soreness

1. h/o previous muscle splinting

2. Local tissue trauma

3. Emotional stress

1. Pain begun after

several hr/day of an

event

2. Pain started by-

injection, long

standing mouth

opening

3. Increased emotional

stress

1. Decrease ROM &

velocity but normal

range not achieve on

request

2. Minimum pain at rest

3. Pain increase with

function

4. Muscle fatigue

1. Elimination of

constant deep sensory

input

2. Patient motivation and

emotional stress

management

3. Supportive therapy to

control algesia

4. Stabilization

appliance

Myospasm 1. Continue deep pain

2. Local metabolic factors

within muscle tissues

3. Idiopathic myospasm

mechanism

1. Sudden onset of

restricted jaw

movement

1. Marked restriction of

jaw movement

2. Acute malocclusion

3. Pain at rest


function

5. Affected muscle firm

and painful

6. Generalized muscle

tightness

1. Passive lightening/

stretching by manual

massage

2. 2% lidocaine without

vasopressor to stop

persistent spasm

3. Muscle rest

4. Reestablishment of

electrolyte balance

Type Cause History C/F Treatment

Myofascial pain 1. Continue deep pain

2. Increased emotional stress

3. Sleep disturbance

4. Local factors – habit, posture,

muscle strain, chilling

5. Systemic factors – nutritional

imbalance, fatigue, viral

infection

6. Idiopathic trigger point

1. c/o heterotropic pain

2. c/o headache or

muscle splinting

1. Slight decrease in

velocity and range of

motion of jaw

2. Presence of trigger

point

3. Presence of reference

zone

4. Heterotropic pain at

rest


function

6. On provocation pain at

refer zone

1. Eleminate source of

deep pain

2. Soft diet

3. Life style modification

4. Analgesic, antianxyti,

muscle relaxant

5. Spray and stretch

6. Massage

7. Injection/ theraputic

blocking

Chronic myositis 1. Mediated by CNS not by

masticatory system

2. While CNS exposed to

prolonged pain – brain

pathway of pain deranged –

antidromic effect of afferent

nerve

1. Constant, primary,

myogenous pain

2. Associated with

prolonged history of

muscle complain

1. Significant decrease in

velocity and range of

movement

2. Significant pain at rest

3. Pain increase with rest


tightness

5. Significant pain on

muscle palpation

6. May induce muscle

atrophy

1. Restricted muscle use

2. Soft diet

3. Slower chewing and

smaller bite

4. Avoid exercise or

injection – may

increase pain – due to

neurogenic

inflammation

5. Disengage the teeth by

relaxation splint

6. Prescribe NSAIDs

Fibromyalgia 1. Still not cleared

2. Alteration in musculoskeletal

input by CNS

1. Chronic & generalized

musculoskeletal pain

in ¾ quadrant of body

since 3 month or more

2. Presence of sleep

disturbances

3. Clinical depression

1. Generalized

myogenous pain

2. Decreased ROM

3. Presence of numerous

myofascial trigger

point


fatigue & weakness

1. Definitive therapy to

treat underling causes

2. NSAIDs helpful to

some extent

3. If sleep problem –

antidepressant can be

given

myofacial pain dysfunction syndrome anindya

Health & Medicine