Personal Injury and Myofascial Pain

Dr. Mark K. Frobb is a pain management physician with a special focus on Orthopedic Medicine Rehabilitation. He was also the co chair of this Essential Soft Tissue Injury Conference put on March 30 -31 at the Vancouver Convention Centre by the Trial Lawyers Association of British Columbia in association with the Family Medicine of BC.  His presentation was one of the most informed and extensive addressing controversies and certainties alike.  His slides were excellent. Talking with him between sessions he was jovial and down to earth with a quick wit and astute ability to key into questions being asked him. He was a superb communicator. He is an executive member of the Medicolegal Society of British Columbia and President elect of the the Canadian Association of Orthopedic Medicine.
My notes do not do justice to his presentation. I was busy reading the slides and listening with rapt attention to his fascinating insights rather than taking notes. Therefore, they're really just a few things captured here and there.  The Trial Lawyers Association of BC provided a CD with the notes and other information relevant to the conference. Having attended another one of these conferences a few years ago I needed a wagon to carry home the vast collection of notes that different speakers had provided. I thought the CD was considerate given that some of us older sorts had had personal injuries and could well carry home a cd easier than all the binders of previous years.

Myofascial Pain: Relationship between Pain, Impairment and Function

Dr. Mark K. Frob

The Essential Soft Tissue Conference, March 30, 2012

Myofascial pain syndromes are characterized by regional muscular pain patterns typically involving groups of muscles which functionally control complex movements in a specific anatomical area.

14.4% of general population suffer from chronic musculoskeletal pain

myofascial pain syndromes in variaous studies account for 21 % to 93% of pain

History: Myofascial Pain Syndrome

-Dr. Janet Travel and Dr. David Simons 1977

• Dr. Janet Travel served Dr. J. F . Kennedy
• Dr. Janet Travel Clinical Professor of Medicine wrote on trigger points in 80 and 90

-Dr. David Simons - aerospace - work on weightlessness in space

Aerospace medicine

Together two of them - produced what remains the bible of myofascial pain

Myofascial Trigger Points (MTrPs)

taut muscle bands t latnt MTrp to active Mtrp

stress

24 to 54% of asymptomatic individuals have latent trigger points

MTrPs - palpable taut bands, equisitely tender, range of motion of taut muscle limitted

#1 cause - axial skeletal asymmetry

Poor Posture

-fatigue

-sleep deprivation

depression

otherwise radiculopathy, deficiency diseases, hypothyroid,

It presents with a story

Localized muscle tenderness

regionally referred pain

stiffness and limitation of range of motion

sensory distrubance - paresthesia

autonomic phenomena - sweating or decrease, temp changes

recognisable localized knot

‘jump sign’ - patient jumps when you touch

‘twitch response’  - muscle twitches when you touch it

muscle weakness without atrophy

Clinical investigation remarkable by it’s absence

No specific lab tests

infrared or liquid crystal thermography can show increased blood flow at trigger site

Electrical studies may show abn

But we don’t use them in clinical investigation - done as research

Treatment

Needling

drying needling - intramuscular stimulation

trigger point injections - local anesthetics, saline, sterile water, botulinum toxin, corticosteroids

neural acupuncture - injection at the acupuncture points - xylocaine

• if it’s going to work its going to work as first treatment

Massage

Stretching

electrical stimulation

TENS

EMG

etc

Has a rule - if you see benefit but it doesn’t keep getting better after three visits benefit may have peak

Medications

non steroidial anti inflammatory medication and cream

tricyclic antidepressants

Nociceptive VS

Central Pain ()Neuropathic)

20-30% of patients with chronic myofascial pain will have concurnet or comorbid central pain characterics

ie hyperalgeisa

Central Pain Characteristics and comorbidities as described by Dr. Gouw

Pharmacology of Neuropathic Pain

a variety of meds , including cannabinoids

Disability and Impairment

AMA Guides to the Evaluation of Permanent Impairment 5th edition

Activities of Daily Living

self care

communication

physical activitiy

sensory function

non-specialized hand activeity

travel

sexual function

Impairment

= loss of use oor derangement of any body part or organ system or organ function

only those impairments interfering with ADLS

not all impairments interfere with ADL

Disability

=alteratioon of an individual capacity to meet personal social or occupational demands statutory or otherwise

PAIN

-pain is subjective

-pain can exist without tissue damage and tissue damage can exist without pain

a patient can have a well established pain syndrome without identifiable organ deficit

eg migraine

Need to assess credibility and pain behaivour

Need to balance indivdiual self reports and clinical judgement of examiners

Pain Behaviours - non verbal behaviour

• primarily observed
• congruent with established conditions
• consistent over time and situation
• consistent with normal anatomy and physiology
• we’d like to find agreement among caregivers

CHRONIC PAIN DISORDER

-pain exists in more than one anatomic area and warrant clinical attent

-exists past expected treatment

-ccuases clinical distress and or impairment

-psychological factors

-symptons not intentially produced or feigned as in factitious disorder or malingering)

not better accounted by a mood, anxiety or psychotic disorder

Testing Instruments

clearly document history

use of pain related impairment worksheets (PRI’s)

Functional Capacity Evaluation -work simulations