Management of Myofascial or Failed Back Surgery Pain Syndrome - Essay Example

Management of Myofascial Pain Syndrome as a Component of Failed Back Surgery A Systematic Review of the Literature Management of Myofascial Pain Syndrome Introduction Failed Back Surgery Syndrome is defined as persistant or recurring pain after one or more surgical procedures. FBSS is seen in 10-40% of patients that undergo back surgery in the United States. It can occur whether or not the surgery is considered successful. This literature review will cover a general overview of FBSS. It will then focus on the components of deconditioning, myofascial pain syndrome, and mechanical low back pain. Treatments available for these conditions with a focus on manual hands on, BIAS positions of symptom relief, DIM, core stabilization and functional phase programs will be reviewed. Failed Back Surgery Syndrome When diskectomy fails to improve a patients pain it is listed in the surgical literature as failed back surgery syndrome according to Fishbain and Cutler, (2007). There is some controversy in the literature as to what the definition actually should be. Fishbane et. al (2007) tells us that there is much disagreement as to the definition of FBSS and reviews all of those definitions in his study. Though there is disagreement most will agree that all of these patients have two similarities. These are that patients have chronic low back pain and they have one or more failed back surgeries (Fishbain et al. 2007), Slipman, Shin, Isaac, et. al (2002) however, presents us with a study that states that there are a myriad of reasons for the pain that these patients have. They used 42 exclusion criteria and finalized their study with the most common diagnosises being identified as spinal stenosis, internal disc disruption syndrome, recurrent/retained disc, and neural fibrosis. They felt that 95% of these patients could be told why they have pain. Collella (2003) also reviews the various issues that often cause this pain. There is a belief that one of those is the formation of scar tissue in the area of the surgery causing pressure on the nerve root. Other theories include that the original disease may have reoccurred, there are complications, there is an altered posture, depression, anxiety, sleeplessness, or deconditioning. Collella (2007), believes that the most common cause is improper selection of the patient for surgery. It is felt that these patients are not good candidates because of poor trunk strength and deconditioning as well as obesity and lack of activity. Peter Ulrich (2008) agrees and discusses the fact that deconditioning is often the issue in his physicians review of the findings. Deconditioning Duque, I., Parra JH, Duvallet, A. Et al (2009) completed a study on the effect of deconditioning on back pain with 70 patients. All 70 patients were of normal weight as to not confuse the study results. The conclusion was that physical fitness of patients who had chronic low back pain are comparable to that of a healthy but poorly conditioned adults. Gautsche, Hildebrandt & Cadosch (2009) agree in their resultant study on acute back pain assessment and management. Gautsche et.al. (2009) states that 90% of all adults will experience at least one episode of back pain in their lifetime. The difference in the patient that will determine whether it will be chronic or not depends on the patients conditioning and core strength. According to this study deconditioning can lead to more severe problems such as cauda equine syndrome, cancer, infection and fracture. Haig AJ, Geissel ME, Michael, B et al. (2006) developed a multidisciplinary assessment protocol using a qualitative approach to decision making. This study performed in the University spine program determined that the final framework for assessment should include physical deconditioning, psychosocial issues, potential for cure, and dozens of subcategories. Observational studies of patients with deconditioned core muscles were done by Smeets, Wade, &Hedding et al. (2006) showing evidence of the fact that deconditioned extensore muscles caused back pain symptoms. This was further discussed by Jenkins in his study of the transverses abdominis reconditioning to decrease back pain caused by deconditioned muscles. Koftolis & Samnabis (2003), reviewed the role of exercise in the natural cause of acute, subacute, chronic and post surgical categories of back pain and proved that this decreased the effects of back pain because of lowering the effects of deconditioning. Further information with support of the theory that deconditioned core muscles increase back pain is present in the study done by Warburton (2005) on disuse and physical reconditioning of lower back muscles. Estadt (2004), reviews actually patients and their cases and what methods were used, which we will discuss later in the paper, but for this point these cases were patients with deconditioned muscles about the abdomen and back. In each case improvement of these deconditioned muscles improved the patients's back pain. Myofascial Pain Syndrome An overview of myofascial syndrome is published by Yap (2007). Briefly he informs of the facts that the skeletal muscles are the largest organ in the body and that pain and dysfunction may happen to any of these large muscle groups but that when it occurs in the back, it is especially debilitating to patient's lifestyle. This syndrome almost always includes tautbands, trigger points, tender spots, and sensitized spinal segments. There is a lack of flexibility and balance to the muscles and all of this may affect not only the ability for the patient to perform ADL's but maintain balance. Stefanidi, Skoromets, & Dukhoovihova (2007) review myofascial back pain as a consequence of functional disorganization between flexors and extensors of the body. This causes contradictory information to be sent to the CNS. They trialed treatment by manual relaxation of the flexors which significantly decreased pain in 48% of cases while at the same time improveing CNS messaging. Regional Anderson and associates (2008). Report a two year perspective study of a general working population. It was considered a cohort study of 5,604 workers from industrial and service companies. They used Cox regression analysis to analyze data. Their conclusion was that very few workers are free of back pain and regional back pain is the number one complaint. The transition from minor pain to severe pain depended on an individuals health related factors. Regional pain was also studied by Schmidt, Raspe, Pfingsten et. al. (2007) in their population ibased cross-sectional study. Epidemiology of the prevalence and severity of back pain in Germany is the leading health problem. The results of this study show a substantial minority of 8% had disabling back pain. Those with lower educational levels had the most severe pain. There is the suggestion at the end of this study that a more thorough regional study should be done related to educational levels. Regional pain is discussed in the light of chronic pain in a study by Geerkzen, Van WIlgen and Schrier et.al. (2008). Psychosocial inciting risk factors are also discussed. Different treatments are studied and discussed with the psychosocial components treated at the same time. The conclusions of the study show that most regional back pain does have a psychosocial component that needs further study for appropriate treatment. These results were further supported by Klein, and Eik (2002) in their study done with women with chronic low back pain. Along with the study of the back pain, they included a personality inventory. It was determined that the group of women with the worst back pain, also had poorer coping mechanisms and defense mechanisms in their personality structure. Endplate noise is significantly more prevalent in myofascial trigger points than other sites that are outside of a trigger point but still within the endplate according to a comparison study done by Simons, Hong, & Simons. The study compared motor endpoint potentials in active myofascial trigger points, end plate zones and taut bands of skeletal muscle to conclude with this result. Further testing was done by Finneran, Mazanec, and Marsolaes et. al (2003) in their study of people with low back pain under large array surface electromyography. These were studied against those without low back pain. This was a long term study and did show that the large array surface electromyography was a good way of evaluating low back pain and trigger point involvement. Trigger point pain was tested by Hong, Chen, Twyous et al. (1996) in an investigative study of the amount of pressure on a myofascial trigger point sufficient to initiate referred pain. The conclusion was that referred pain is an appropriate sign to indicate an active TrPl but not reliable sign for the identification of myofascial TrP. In contrast, Simons (2008 )studied several previous studies through review technique and found that there are actually 11 credible approaches to precipitating MTPs. Perle and Schneider (1996) studied the difference between tender points in fibromyalgia and trigger points in myofascial pain syndrome. The end result was that TRPs are both active and latent and are amenable to manual therapy such as the Nimmo technique and Lewitt technique and TEPs are not. There is always the naysayer. Cohen & Quintner (2008) specifically believe that myofascial pain has been studied enough and it is time to move on and just treat with the proven effective methods now. However, as we talk about treatment modalities, there is certainly still much controversy as to what works the best and it may be differential by patient. Treatment Modalities Bodane and Brownson (2002) do an excellent job of reviewing alternative medicine in the treatment of back pain. They review acupuncture, naturopathy, massage therapy, herbal remedies, and needling techniques in their belief that surgery should not be the first choice for patients with back pain. It is an excellent article to start the research process as it talks about and refers to much research that has been done. Gkolfinopoulos, V, Byfield, D, & McCarthy, PW (2002), in a study of low back pain and chiropractic practices give us an overview of most treatment modalities. This study was excellent in leading to the various practices most often used for treating back pain in a non-surgical way Myofascial pain syndrome: efficacy of different therapies by Esenyel, ALdemir, Gursory et al (2007) also does an excellent review of many of the treatment modalities present including stretching, trigger point therapy, visual analog scaling and others. Wilkey, Gregory, Byfield, and McCarthy (2008) managed a comparison of outcomes for regional back pain for patients treated by chiropractic services and those treated as hospital inpatients. The study was concluded with the suggestion that patients did better overall with chiropractic services instead of in hospital service. Different needling techniques have been studied by many. Dry needling of trigger points in a study by Ga, Choi, and Park (2007) is an excellent review of the comparison of dry needling with and without paraspinal needling in myofascial pain syndrome of elderly paitients. This was a single blinded randomized control trial and the results were positive. The dry needling technique with paraspinal needling resulted in more continuous subjective pain reduction than TrP dry needling alone. The suggestion from the study was that TrP dry needling and paraspinal dry needling is suggested to be a better method than TrP dry needling only for treating myofascial pain syndrome in elderly patients. Acupuncture technique is studied by Ga and associates (2007) comparing acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients. This was a randomized trial. Local twitch responses were elicited at least once in 94.4% of all subjects. Both groups improved, but there was no significant reduction of pain in the two groups. This brought the conclusion that there was no significant difference between acupuncture needling and lidocaine injection of trigger points for treating myofascial pain syndrome in elderly patients. Smith and Lopez (2001) discuss acupuncture technique and the history behind how it works. They continue by discussing how the patient might be able to get to a safe practitioner and how this technique might help in their pain relief. This is an excellent well done article with much information for the newer practitioner. Passive care and active rehabilitation was studied by Gluck in the attempt to describe the results of chiropractic care combined with rehabilitative exercise in patients that have failed back surgery syndrome. Treatment goals for this study were to increase flexibility, decrease pain, increase coordination, increase lower extremity and lumbar muscle strength and recondition the patient. Pelvic stabilization exercises abdominal strengthening exercises as well as the use of a rocker board and many other physical therapy modalities were used. The patients had improvement in daily activities as well as range of motion. Nimmo technique and Lewitt technique for trigger points. It is found that abdominal muscle activation also works well under these circumstances as found in a study of golfers and their back pain by Horton, Lindsay, and Macintosh (2001). They discovered during this study that the pain created from the constant use of the golf swing caused tight bands of pain for these golfers. This pain was relieved by strengthening the abdominal muscles causing a more stable core. Bibliography Anderson, JH, Haaki JP, Frost P. Risk Factors for more severe regional musculoskeletal symptoms: A two year perspective study of a general working population. Arthritis & Rheumatism. 40(6) 112-24. Bodane, C, and Brownson, K. 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