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Indications and Treatment of Myofascial Pain Lisa DeStefano, DO Associate Professor and Chair Department of Osteopathic Manipulative Medicine College of Osteopathic Medicine Michigan State University

Common Myofascial Pain Syndromes

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Greater Occipital Nerve Impingement Sites

. 1: Origin of the third occipital nerve and proximal connection with the greater occipital nerve. . 2: Greater occipital nerve as it courses inferior to the inferior oblique muscle. . 3: Greater occipital nerve coursing through the semispinalis capitis muscle. . 4: Greater occipital nerve exiting the aponeurosis of the trapezius muscle. . 5: Greater occipital nerve traveling with the occipital artery. . 6: Origin of the greater occipital nerve and relationship to the descending branch of the occipital artery. . 7: Suboccipital nerve relation to the vertebral artery and the descending branch of the occipital artery and this nerves interconnection to the greater occipital nerve. . 8: Relationship between the third occipital nerve and the C2‐C3 joint complex.

Common Treatment Approaches • MFR • MET • Soft Tissue Release • Counterstain • HVLA

Etiology of Head and Neck Myofascial Pain Syndromes

• Overuse • Posture –Head over the pelvis • Posture – Scapular function • Occlusion –how the teeth control for the proper placement of the mandibular condyle.

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Stabilization of the torsobegins with spinotransverse muscle transmission of force onto the epaxial fascia or vertebral aponeurosis.

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This then transmits tension into the serratus posterior superior and inferior, which then lifts the upper four ribs and sternum and lowers the lower ribs respectively.

In response a force‐ couple is generated between the serratus posterior inferior fascia, external oblique fascia, and the rectus sheath. This load then reconnects to the upward moment of the sternum.

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Evaluation and Observation

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Rational Treatment Approach

1. Optimize lumbopelvic stability 2. Optimize thorax stability on the pelvis 3. Optimize cervical stability on the thorax 4. Optimize cranial stability on the cervical spine

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For thorax stability, lower thoracic lordosis is imperative. • The deeper layers of the thoracolumbar fascia, which mechanically links the thorax and the lumbopelvic regions, support extension moments of the thoracolumbar junction thus allowing stable transfer of loads between the lumbopelvic region and the thorax. • In addition, extension of the lower thoracic spine allows for stiffness of the rib cage such that lateral bending forces are countered.

Thoracic stability –below the kyphotic apex

• Treatment is often focused at the lower thoracic and upper lumbar regions to assure segmental lordosis. • Balanced lordosis at the thoracolumbar region has been shown to contribute to the activity of the deep and superficial multifidus and internal oblique muscles which then contributes to the tension throughout the vertebral aponeurosis.

Thoracic stability –below the kyphotic apex

• Superior tension in this fascial system contributes proprioceptive feed forward neural input to the lower trapezius musculature. • Manipulation at and above the apex of the thoracic kyphosis again optimizes the passive transfer system, in particular for loads that are derived from the upper extremity and cervical spine.

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Lower Thoracic INR

• Once the segment of dysfunction (FRS) is localized contact the transverse process of the segment using the thenar eminence and/or scaphoid of both hands. • Move the hands slowly to move the vertebral unit towards the “feather edge” of its planes of restriction. • From this position ask the patient to slowly and gently press one leg into the table as you monitor for an internal load that matches the load that your hands have generated. • Wait and monitor for release.

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Lower Thoracic INR

• Pt. seated on their heels 1‐2 feet from a stool or bench, elbows together and resting on the stool or bench, hands clasped and chin resting on forearms, as if praying. • Operator stands straddling patients legs from posterior, and springs along the patients’ 7th‐12th transverse process’ bilaterally seeking for restriction. • Once the restricted segment is determined, a posterior to anterior fascial release is imposed over the restricted segment. • INR is utilized by asking the patient to use their abdominal muscle to balance your forces by pulling their umbilicus inwards, with breathing; paying careful attention that the patient does not change the position of their spine. • Wait for a release.

Thoracic Stability –above the kyphotic apex

• Reversal of the upper thoracic kyphosis is common in scapular dyskinesis, and suggests loss of passive tension above the apex of the kyphosis. • This tension system stabilizes the upper thorax, cervicothoracic junction, and upper rib cage in preparation for upper extremity load; when it then employs a force couple with the rhomboids, serratus anterior, external oblique, abdominal musculature and fasciae across the body to the contralateral ilia.

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Cervical Stability • Thoracic kyphosis also is accompanied by scapular dyskinesis with subsequent facilitation of the levator scapulae and upper trapezius musculature placing detrimental load onto the cervical spine.

Thorax stability is imperative for cervical dynamic stability. • The posterior cervical muscles to be countered by the deep cervical flexors creating a stable yet mobile column on which the cranium is supported. • An increase in thoracic kyphosis is generally accompanied by an increase in the cervical lordosis, a decrease in the deep cervical flexor muscle tone and facilitation and pain in the anterior cervical musculature.

Cervical Thoracic Junction

. Thumbs on the anterior surface of C6 . Fingers posteriorly along and on the spinous process of C7, posterior first rib and transverse process of T1‐2. . Ask the pt. to bite their teeth together. . Monitor for muscle facilitation.

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Cervico‐Trigeminal Reflex

• Contact the costovertebral joint of T3 bilaterally. • While watching your thumbs, ask your patient to bite their teeth together. • Watch for rotation and extension of the segment.

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CT Junction INR

• Thumbs on the lateral body of C6. • Fingers posteriorly along and on the spinous process of C7, posterior first rib and transverse process of T1‐2. • Using both hands position the CT junction just into the feather edge of its restrictive barrier, in multiple planes. • Ask the patient to pull the back of their tongue posteriorly (facilitating the deep cervical flexors to match the load that you have generated with your hands), and breath easy. • Wait for release.

Seated Posture

• Patient seated, feet flat on the floor. • Instruct patient to roll their pelvis forward until the weight of their body is onto their ischial tuberosity’s or “butt bones” or “sit bones” and to relax their “butt muscles” and back muscles.

Seated Posture

• From this position instruct the patient to fire their transversus abdominus and external oblique muscles. The external oblique’s fire with terminal exhalation. • From this position, instruct the patient to breathe by expanding their lower rib cage, rather than by pushing out their lower abdomen.

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Seated Posture

• From this position and while breathing, start from L5 and instruct the patient to toggle each of the five lumbar segments and the lower four thoracic segments forward slightly, ultimately placing the thorax over the pelvis.

Seated Posture

• From this position instruct the patient to relax their shoulders and scapula onto the thorax. • Finally, from this position, instruct the patient to move the 4th cervical segment, or apex of the cervical lordosis, posteriorly without tilting their head downward…. and breathe.

Home Stretches

• Latissimus Dorsi • Scalenes • Sternocleidomastoid • Levator Scapulae • Pectoralis

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