Muscular factor in the development of musculoskeletal pain. Treatment options

The importance of the muscular factor, which is traditionally considered in myofascial pain syndrome (MFPS), in the development and maintenance of musculoskeletal pain (MSP) is actively discussed. The hypothesis of the leading role of myofascial trigger points (MTPs) in muscle pain remains debatable. Probably, muscle pain is secondary to the underlying disease. The MTP phenomenon is considered as an area of secondary hyperalgesia resulting from neurogenic inflammation in muscles that were not initially structurally and physiologically damaged. According to these ideas, MFPS is a complex form of neuromuscular dysfunction, which is represented by soft tissue damage with the development of peripheral and central sensitization as a result of neurogenic inflammation, changes in the functioning of limbic system structures. MFPS is a clinical diagnosis, based on the presence of painful spasmodic muscles, painful muscle indurations, active trigger points with zones of reflected pain. The sensitivity and specificity of clinical tests for MFPS have not been determined. Currently, there are no proven universally accepted criteria (such as biomarkers, electrophysiological evaluation, imaging, diagnostic blocks, etc.) for objectifying or quantifying MTPs. Nonpharmacological interventions with the most proven effectiveness include therapeutic exercises and psychotherapeutic techniques, other methods are of secondary importance. The effectiveness of aceclofenac (Aertal®) and the muscle relaxant tolperisone (Mydocalm®) in the of MSP treatment is discussed. It is noted that a new form of tolperisone – Mydocalm®-Long 450 mg - can reduce the frequency of drug administration, provide a proven and predictable therapeutic effect, and increase treatment adherence.

1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014 Feb;(260):1-161.

2. Camilloni A, Nati G, Maggiolini P, et al. Chronic non-cancer pain in primary care: an Italian cross-sectional study. Signa Vitae. 2021;17(2):54-62. doi: 10.22514/sv.2020.16.0111

3. Latina R, De Marinis MG, Giordano F, et al. Epidemiology of chronic pain in the Latium region, Italy: a cross-sectional study on the clinical characteristics of patients attending pain clinics. Pain Manag Nurs. 2019 Aug;20(4):373-81. doi: 10.1016/j.pmn.2019.01.005. Epub 2019 May 15.

4. Malik KM, Beckerly R, Imani F. Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care. Anesth Pain Med. 2018 Dec 15;8(6):e85532. doi: 10.5812/aapm.85532

5. Treede R, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP classification of chronic pain for the international classification of diseases (ICD-11). Pain. 2019 Jan;160(1):19-27. doi: 10.1097/j.pain.0000000000001384

6. Perrot S, Cohen M, Barke A, et al; IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: chronic secondary musculoskeletal pain. Pain. 2019 Jan;160(1):77-82. doi: 10.1097/j.pain.0000000000001389

7. Puntillo F, Giglio M, Paladini A, Pathophysiology of musculoskeletal pain: a narrative review. Ther Adv Musculoskelet Dis. 2021 Feb 26;13:1759720X21995067. doi: 10.1177/1759720X21995067

8. Graven-Nielsen T. Fundamentals of muscle pain, referred pain, and deep tissue hyperalgesia. Scand J Rheumatol Suppl. 2006;122:1-43. doi: 10.1080/03009740600865980

9. Bordoni B, Sugumar K, Varacallo M. Myofascial Pain. 2022 Feb 12. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

10. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392-9. doi: 10.1093/rheumatology/keu471. Epub 2014 Dec 3.

11. Stecco C, Stern R, Porzionato A, et al. Hyaluronan within fascia in the etiology of myofascial pain. Surg Radiol Anat. 2011 Dec;33(10):891-6. doi: 10.1007/s00276-011-0876-9. Epub 2011 Oct 2.

12. Quintner J, Cohen M. Referred pain of peripheral nerve origin: Analternative to the 'myofascial pain' construct. Clin J Pain. 1994 Sep;10(3):243-51. doi: 10.1097/00002508-199409000-00012

13. Butler D. The Sensitive Nervous System. Australia: Noigroup Publications; 2006.

14. Fischer BD, Adeyemo A, O'Leary ME, Bottaro A. Animal models of rheumatoid pain: experimental systems and insights. Arthritis Res Ther. 2017 Jun 30;19(1):146. doi: 10.1186/s13075-017-1361-6

15. IASP. Myofascial pain. 2017.

16. Shah JP, Thaker N, Heimur J Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. 2015 Jul;7(7):746-61. doi: 10.1016/j.pmrj.2015.01.024. Epub 2015 Feb 24.

17. Li L, Stoop R, Clijsen R, Hohenauer E. Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review. Clin J Pain. 2020 Dec;36(12):955-67. doi: 10.1097/AJP.0000000000000875

18. Chiarotto A, Clijsen R, Fernandez-de-Las-Penas C. Prevalence of Myofascial Trigger Points in Spinal Disorders: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2016 Feb;97(2):316-37. doi: 10.1016/j.apmr.2015.09.021. Epub 2015 Oct 17.

19. Dunning J, Butts R, Mourad F. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug;19(4):252-65. doi: 10.1179/ 108331913X13844245102034

20. Vining R, Potocki E, Seidman M, Morgenthal AP. An evidence-based diagnostic classification system for low back pain. J Can Chiropr Assoc. 2013 Sep;57(3):189-204.

21. Petersen T, Laslett M. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord. 2017 May 12;18(1):188. doi: 10.1186/s12891-017-1549-6

22. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008 Jan;89(1):16-23. doi: 10.1016/j.apmr.2007.10.018

23. Lluch E, Nijs J, De Kooning M, Van Dyck D. Prevalence, Incidence, Localization, and Pathophysiology of Myofascial Trigger Points in Patients With Spinal Pain: A Systematic Literature Review. J Manipulative Physiol Ther. 2015 Oct;38(8):587-600. doi: 10.1016/j.jmpt.2015.08.004

24. Dommerholt J, Shah JP, Ballantyne JC. Myofascial Pain Syndrome. 4th ed. Baltimore: Williams & Wilkins; 2010.

25. Turo D, Otto P, Shah JP, et al. Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain. Ultrason Imaging. 2013 Apr;35(2):173-87. doi: 10.1177/0161734612472408

26. Sikdar S, Ortiz R, Gebreab T, et al. Understanding the vascular environment of myofascial trigger points usingultrasonic imaging and computational modeling. Annu Int Conf IEEE Eng Med Biol Soc. 2010;2010:5302-5. doi: 10.1109/IEMBS.2010.5626326

27. Do TP, Heldarskard GF, Kolding LT. Myofascial trigger points in migraine and tensiontype headache. J Headache Pain. 018 Sep 10;19(1):84. doi: 10.1186/s10194-018-0913-8

28. Lin I, Wiles L, Waller R. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86. doi: 10.1136/bjsports-2018-099878. Epub 2019 Mar 2.

29. Borg-Stein J, Iaccarino MA. Myofascial pain syndrome treatments. Phys Med Rehabil Clin N Am. 2014 May;25(2):357-74. doi: 10.1016/j.pmr.2014.01.012. Epub 2014 Mar 17.

30. Babatunde OO, Jordan JL, Van der Windt DA, et al. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017 Jun 22;12(6):e0178621. doi: 10.1371/journal.pone.0178621

31. Hill JC, Garvin S, Chen Y, et al. Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial. BMC Fam Pract. 2020 Feb 11;21(1):30. doi: 10.1186/s12875-019-1074-9

32. Ramirez-Velez R, Hormazabal-Aguayo I, Izquierdo M, et al. Effects of kinesio taping alone versus sham taping in individuals with musculoskeletal conditions after intervention for at least one week: a systematic review and meta-analysis. Physiotherapy. 2019 Dec;105(4):412-20. doi: 10.1016/j.physio.2019.04.001. Epub 2019 Apr 8.

33. Cagnie B, Castelein B, Pollie F. Evidence for the Use of Ischemic Compression and Dry Needling in the Management of Trigger Points of the Upper Trapezius in Patients with Neck Pain: A Systematic Review. Am J Phys Med Rehabil. 2015 Jul;94(7):573-83. doi: 10.1097/PHM.0000000000000266 34. Soares A, Andriolo RB, Atallah AN, da Silva EM. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD007533. doi: 10.1002/14651858.CD007533

34. Zhang Q, Fu C, Huang L. Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome of the Trapezius: A Systematic Review and MetaAnalysis. Arch Phys Med Rehabil. 2020 Aug;101(8):1437-46. doi: 10.1016/j.apmr.2020.02.013. Epub 2020 Mar 28.

35. Lederer AK, Maly C, Weinert T, Huber R. Tissue Stiffness is Not Related to Pain Experience: An Individually Controlled Study in Patients with Chronic Neck and Back Pain. Evid Based Complement Alternat Med. 2019 Dec 21;2019:1907168. doi: 10.1155/2019/1907168

36. Laimi K, Mäkilä A, Bärlund E. Effectiveness of myofascial release in treatment of chronic musculoskeletal pain: a systematic review. Clin Rehabil. 2018 Apr;32(4):440-50. doi: 10.1177/0269215517732820. Epub 2017 Sep 28.

37. Low Back Pain and Sciatica in Over 16s: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2020 Nov. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11822/

38. Osteoarthritis: care and management. NICE Clinical Guidelines, No. 177. London: National Institute for Health and Care Excellence (NICE); 2020 Dec 11. ISBN-13: 978-1-4731-0426-6

39. Wong JJ, Cote P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017 Feb;21(2):201-16. doi: 10.1002/ejp.931. Epub 2016 Oct 6.

40. Qaseem A, Wilt TJ, McLean RM, Forciea MA Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-30. doi: 10.7326/M16-2367. Epub 2017 Feb 14.

41. Nasonova VA, Karateev AE. Symptomatic therapy for pain in rheumatic diseases: a place of aceclofenac. Sovremennaya revmatologiya = Modern Rheumatology Journal. 2009;3(3):58-65. doi: 10.14412/1996-7012-2009-560 (In Russ.).

42. Karateev AE, Tsurgan AV. Aceclofenac: the experience of Russian studies. Sovremennaya revmatologiya = Modern Rheumatology Journal. 2017;11(4):89-94. doi: 10.14412/1996-7012-2017-4-89-94 (In Russ.)

43. Parfenov VA, Gerasimova ON. Treatment of nonspecific back pain in outpatient practice. Spravochnik poliklinicheskogo vracha. 2013;(1):48-51 (In Russ.).

44. Kukushkin ML, Brylev LV, Laskov VB, et al. Results of a randomized double blind parallel study on the efficacy and safety of tolpersione in patients with acute nonspecific low back pain. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2017;117(11):69-78. doi: 10.17116/jnevro201711711169-78 (In Russ.).

45. Karateev AE. Evaluation of the population safety of nonsteroidal anti-inflammatory drugs in the framework of the Pan-European SOS program: focus on aceclofenac. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2020;12(2):109-13. doi: 10.14412/2074-2711-2020-2-109-113 (In Russ.).

46. Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gastrointestinal complications: a systematic review and metaanalysis of observational studies (the SOS project). Drug Saf. 2012 Dec 1;35(12):1127-46. doi: 10.2165/11633470000000000-00000

47. Parfenov VA, Isaykin AI. Bol' v nizhney chasti spiny: mify i real'nost' [Pain in the lower back: myths and reality]. Moscow: IMA-PRESS; 2016. P. 84-9 (In Russ.).

48. Kukushkin ML. A modern view on the mechanism of action of Mydocalm. Rossiyskiy zhurnal boli. 2012;(2):15-9 (In Russ.).

49. Caron J, Kaye R, Wessel T, et al. An assessment of the centrally acting muscle relaxant tolperisone on driving ability and cognitive effects compared to placebo and cyclobenzaprine. J Clin Pharm Ther. 2020 Aug;45(4):774-82. doi: 10.1111/jcpt.13165. Epub 2020 May 10.

50. Parfenov VA, Bogdanov EI, Laskov VB, et al. Multicenter, randomized, double-blind study of the efficacy and safety of prolonged release tolperisone hydrochloride 450 mg (Mydocalm® Long, once daily) and tolperisone hydrochloride 150 mg (three times daily) for acute non-specific lower back pain. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(6):14-22. doi: 10.14412/2074-2711-2021-6-14-22 (In Russ.).