Ep 218: Putting the horse before the myofascial pain cart, with Dr Chad Cook

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] Myofascial pain syndrome is common, affecting somewhere around one in every five people. Yet there's plenty of debate about what causes myofascial pain syndrome, how to diagnose it and even whether myofascial pain syndrome is a primary condition. Today, Professor Chad Cook from Duke University, North Carolina joins me to discuss whether it's even possible to differentiate myofascial pain syndrome from other pain conditions and the implications for you, the clinician. Let's get into it.

[00:00:52] Professor Chad Cook, welcome to JOSPT Insights. Claire, thanks for having me back. It's been a long time. It is always a pleasure to have you on the podcast, Chad. Today, myofascial pain syndrome, why is it so hard to get clarity on myofascial pain syndromes? Well, I actually think there are a lot of reasons and I'll try to limit it to just a few. The first, and I think the biggest, is we don't have a clear direction from our diagnostic oversight body, the World Health Organization.

[00:01:20] And as your listeners probably know, the WHO, they're the folks that have created the International Classification of Disease or the ICD codes, the diagnostic codes. If you use the search strategy within the ICD-11 system, it pushes you toward primary pain, musculoskeletal disorders, but it doesn't have a specific diagnosis. I think that's the first reason.

[00:01:42] The second is most of the staunch advocates for myofascial pain syndrome are in the complementary and integrative medicine field. And they don't always coincide that well with traditional medicine. In my experience, individuals in this field often will put the treatment first and then create a diagnosis to match the assumptions around that treatment.

[00:02:06] But even if you go outside the WHO and just look at the complementary and integrative health researchers, they will typically not agree on what the diagnostic criteria is either. So there's some confusion among those that really support this diagnosis. Next, in the areas around a clinical diagnosis of this are built on assumptions that haven't stood up that well.

[00:02:32] Trigger points are a classic problem because of reliance on palpation, poor inter-rater reliability, and the fact that trigger points on imaging and EMG are fairly similar on a person who's in pain and who's not. And the last thing I think is one of the problems is, and we've especially seen this on X or Twitter, is that everybody seems to be an expert on myofascial pain syndrome.

[00:02:58] They're either completely all in and I believe all the assumptions around it, or they're completely all out and don't believe any of the components actually exist, that there's not a clinical presentation related to myofascial pain syndrome. The viewpoint which just came out, there was a lot of social media buzz around it. And one of the reasons we actually wrote the viewpoint is because there have been 52,000 papers published on myofascial pain syndrome.

[00:03:25] And in just the last two years, there have been 25 NIH grants toward this condition, either as a direct or an indirect measure. So we felt it was really important to get that out there and actually show there are some controversies with it. But my mind is still boggling from the, what did you say, 50,000 papers in the last couple of years? 52,000 papers and just listed on PubMed.

[00:03:54] And a majority of those are trials, are comparative trials. So somehow their inclusion criteria involves myofascial pain syndromes, and they'll compare different approaches to one another. It's quite interesting. And we actually called it in the paper, putting the cart before the horse, that you're doing all of this comparative effectiveness research around something that is a somewhat notable controversial diagnosis. We will link to your viewpoint, Chad, in the show notes.

[00:04:23] So listeners can go and find a link directly to explore some of these issues in more depth and find references to explore them in more depth than what we can possibly fit into today's podcast. I guess where I want to take our conversation first is where you have these very polarized views. There's often a kernel of truth in both, and something in the middle is about where things sit.

[00:04:46] So where do you sit on myofascial pain syndrome, and how do we interpret this very conflicting information and the fact that it seems that quite a few people are clearly getting funding to do this research? So there must be something there. I guess the other thing is, for clinicians out there in practice, some of what we're describing might really resonate with what they observe in clinical practice. So how do we make sense of all of this, Chad? Yeah, that's a great question. I actually think there is a clinical presentation there.

[00:05:14] And, you know, I'm not sure that it's a distinct diagnosis, but there is certainly a clinical presentation where we see referred pain that potentially has origin from muscle or fascia. And it can be very debilitating. I mean, we see it in our patients. I've had a couple of recent frozen shoulder, had costochondritis, and I had referred pain. I'm not sure it was myofascial referred pain, but the referred pain was as bad as the condition.

[00:05:39] And for individuals who deal with this on a daily basis, it is notable enough that you would want to manage it right. So clinicians are seeing this clinical presentation. Clinicians are being taught to identify trigger points. And we know that there is a tremendous amount of anecdotal data suggesting that things like trigger points and acupuncture will work on a subset of populations that just don't get better with traditional care.

[00:06:08] So you said a kernel of truth. I actually believe that. But I'm not sure it's the grand thing that has been described in the literature. But I do think there's a clinical presentation there where it might be useful for clinicians to recognize certain features.

[00:06:24] So then I guess the next step is how would you recommend people go about recognizing those features, if not to make a diagnosis to help direct some of the treatment that they might think about using to help the person who's in pain? Yeah, it's a hard one for me because, again, you know, the traditional diagnosis of myofascial pain syndrome, I'm not sure I buy that. I do think it's a clinical presentation.

[00:06:50] I think the International Association of Study of Pain has some nice supportive documents on their website. And they will outline that through the traditional diagnostic criteria, which is the presence of myofascial trigger points, a local twitch response, comparable pain reproduction if you put pressure on those trigger points, some limited range of motion, and then the characteristic referred pain from that.

[00:07:16] And they will describe that as a clinical presentation to indicate that they all don't need to be present. And there's a lot of variability with that. Some are going to be more significant than others. But that's likely, I think, the best first place to start when diagnosing these. I think the challenge is, you know, we know a lot more about the pain experience now than what we did before.

[00:07:40] You know, if we had a purely reductionist biomedical view, we would say that it's purely coming from the muscle and the fascia and that, you know, that should be addressed. I'm not sure that's the only component to it. There are probably some central mechanisms, peripheral mechanisms. There may even be inflammatory components that contribute. I would use that as a starting point. I think that's what's most traditionally used.

[00:08:04] And the other thing that I would look for is those really troublesome patients that we've all dealt with, especially the sports population. There may be a place for things such as dry needling or acharacteristic treatment approaches, especially when traditional care hasn't been enough to nudge that person back to where they need to be. And is myofascial pain syndrome a primary or a secondary disorder in this case, Chad? And I guess why would it matter to figure out is it primary or secondary?

[00:08:34] Yeah, this is a great debate question that the six authors had. And we're lucky that we all agreed on the same thing. We believe it's a secondary pain disorder. It's been couched as a primary pain disorder. But I really firmly believe it's a secondary pain disorder. I think there is probably an underlying reason why we're seeing the myofascial referred pain, which, by the way, I think is a better description than myofascial pain syndrome.

[00:09:04] And it's probably why it's dying on the vine. I think that myofascial referred pain is probably reflective of something else, whether that's a comorbidity or an overuse injury or something. With respect to that, I think if we recognize that, then some of our treatment approaches will benefit that population. But I always recommend a very careful evaluation to assure that we're not missing the primary problem, the cause of the issue.

[00:09:35] What is known about the etiology of myofascial referred pain if we use that term instead of myofascial pain syndrome? The historical etiology involves excessive neuromuscular acetylcholine, which leads to ischemia, which causes an abnormal contraction of the sarcomeres so that the person will spasm within that muscle.

[00:09:59] That falls within line of the primary condition or if it's a primary disorder. Other individuals claim that it's more of a secondary complication of comorbid conditions or it's overuse or muscle trauma or even a secondary complication from psychological distress. I think the latter is probably as accurate as the former.

[00:10:24] If you look at the laboratory tests on what is actually happening at that trigger point, there's a lot of inconsistencies. There's a lot of really poor research in that area too. There's some suggestion that there is some neuroimmune components that are built into that. But again, the research is really weak in that area.

[00:10:47] So if we put the diagnosis, what we talked about around diagnosing or really, I think, identifying myofascial referred pain as opposed to creating another diagnostic category with the etiology or questions around the etiology, what causes this problem? How do we then go about managing the pain? How would you recommend listeners approach managing myofascial referred pain?

[00:11:15] So if somebody actually believes they're dealing with someone with myofascial pain and they're working with somebody, that person in front of them, the first thing I would do is I would really put some effort into differentiation between myofascial pain and fibromyalgia. They're often co-occurring, but when they're separate, they present very differently. And we'll start with fibromyalgia. It's much more common theoretically than myofascial pain syndrome. So it's going to be more widespread.

[00:11:44] It's going to be more centrally mediated. You're going to have additional problems with sleep and fatigue and co-occurring cognitive-related symptoms. Those things are not present with myofascial pain syndrome if you're working with an individual. Pain tends to be more regional. It's going to be more local. It's going to be easier to reproduce. And it's often related to a distinct activity.

[00:12:09] So I would spend some time in differentiating those two so that you know that you're actually working with something that's distinct from fibromyalgia. Second, I would, as we talked about, look for something primary with that patient. Look for the underlying cause that's related to this. And again, I had referred pain with my two conditions. I don't know what type it was. It may have been somatic. It may even have been radicular. It may be myofascial. I could not even tell because it's such a messy canvas to work with.

[00:12:39] And I'm a person that's paid to identify those. So look closely at the primary condition that may be contributing to these. I think that's a really important consideration. There are a lot of treatment options, which I think is nice. And I am very patient-centered in my approach. So I will talk to patients about, you know, let's talk about the options. We know that exercise modification is probably one of the best things that a person can do. It's often an overuse type of situation.

[00:13:09] Body awareness therapies have done fairly well in the literature. And that would be things like stretching, yoga, or tai chi. Aerobic and resistant exercises are also recommended. And then more passive-related components like soft tissue manual therapy, virtual reality has been recommended. TENS, pain neuroscience, so people actually understand what they're dealing with. And then the two biggies are probably acupuncture and dry needling.

[00:13:37] The last thing I want to mention, though, is lifestyle modification. And you've probably recognized how much we see in the literature recently that even with low back pain, some lifestyle contributions are beating what we normally do with treating. Certainly, lifestyle modifications would be something that we would look at in this population. They are often heavily influenced by stress. It's a particular problem with females from 20 to 40. That's often a concomitant problem.

[00:14:05] I would definitely look for those things and try to help that person out on how they can manage that. And Chad, while you've got our listeners here and people who are invested in doing the best they can for patients, and often complex pain syndromes, and it can be really hard, as you explained, to tease out what's going on. What are the things that you would encourage people to gravitate towards or think about?

[00:14:32] And what are the things that people really might want to think about leaving behind? Where this area is headed, and what are the beliefs that we really need to say, no, that's in the past? You know, you mentioned there's a kernel of truth in all things. And we're probably maturing out of a term called myofascial pain syndrome, or at least some of us are. You know, the average clinicians are recognizing that it's probably something different, and our very reductionist view about this is probably not accurate.

[00:15:02] Not everybody has gone that direction. I know the funding sources are still really hot on this particular area, but I think the lay clinician has moved away from some of the traditional paradigms. I think we run the risk, though, of killing something potentially beneficial. And I mentioned there are anecdotal examples of people that have really struggled, and the management has just not gotten them over the hump,

[00:15:28] and then they receive something like dry needling, and it's really made a big difference. And I know a lot of your listeners are probably listening and saying, hey, I use this, and it works. And there probably are instances where it has been the thing that has really helped that person out. I wouldn't, just because somebody said something on a podcast or wrote a paper, or, you know, a bunch of vocal people on X, I wouldn't necessarily change what I'm doing.

[00:15:54] I would maybe change my communication with the patient, and the terms that I use, and what I look for in the literature. But if what you're doing seems to work, it probably is going to be just as effective as the next thing we call it. So that's kind of where I am with that. I'm really intrigued in what drove your authorship group, your author group, to write this viewpoint.

[00:16:20] What's behind the messages you're trying to get across to the JOSPT community? Yeah, I'll tell you. And the authorship group is multidisciplinary, and they had very different thoughts on myofascial pain syndrome. And the three areas that we identified were problematic. They were consensus-based. Everybody believed in those three areas, and they said they need to be, you know, we need to shore these up. The reason we wrote the viewpoint was because of the amount of publications that we've seen

[00:16:50] and the amount of funding that goes toward this condition. And it's concerning because we all delve, all six of the authors delve into some form of complementary and integrative care, especially when manual therapy is described that. So we all have a vested interest in doing the best we can and being as accurate as we can with respect to medicine. So the paper was really focused on that, and that's why we made the recommendations we did.

[00:17:17] We do think those recommendations would improve the current standing of myofascial referred pain and help us better understand it. But it was really more about our experiences in the integrative and complementary health environment and hoping to help shape things as we move forward. Well, I want to say a big thanks to all of you for putting the work in to write the paper,

[00:17:43] and a reminder for listeners that the link is in the show notes if they're interested to go and follow up. And as we mentioned earlier, find more resources, do some more deep diving into myofascial pain syndrome for their own reading. Chad Cook, it's been wonderful having you on the JOSPT Insights podcast again. Thanks for joining me today. It's always a pleasure, Claire. Thank you. Thanks for listening to this episode of JOSPT Insights.

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[00:18:41] Talk with you next time.