What is the recommended treatment for myofacial pain syndrome?

Treatment of Myofascial Pain Syndrome

The recommended treatment for myofascial pain syndrome should follow a multimodal approach that includes physical therapy, pharmacological interventions, and interventional procedures, with manual physical therapy techniques being the first-line treatment option. 1

First-Line Treatments

Physical Therapy

• Manual physical therapy techniques should be offered as first-line treatment for patients with myofascial pain syndrome who present with pelvic floor tenderness or muscle trigger points 1
• Appropriate manual techniques include:
  • Maneuvers that resolve muscular trigger points
  • Techniques that lengthen muscle contractures
  • Release of painful scars and connective tissue restrictions 1
• Pelvic floor strengthening exercises (e.g., Kegel exercises) should be avoided in patients with myofascial pain 1
• Low-resistance exercise is recommended to improve joint stability by increasing muscle tone 1
• Physical therapy for myofascial release is often necessary to facilitate participation in exercise programs 1

Therapeutic Exercise

• Individually tailored exercise programs, including aerobic exercise and strength training, can benefit patients with myofascial pain 1
• Heated pool treatment with or without exercise is effective for myofascial pain 1
• Home exercise programs should be prescribed after initial instruction by a physical therapist 2

Second-Line Treatments

Pharmacological Options

• NSAIDs are recommended for symptomatic relief of myofascial pain 1
• Muscle relaxants (e.g., cyclobenzaprine) are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 3
  • Should be used only for short periods (up to two or three weeks) 3
• Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) may be beneficial for myofascial pain 1
• Anticonvulsants (gabapentin, pregabalin) can be considered for persistent pain 1

Local Therapies

• Topical treatments including lidocaine patches, capsaicin, and diclofenac patches may provide relief 1, 4
• Heat, cold packs, and medicated creams/ointments are recommended for myofascial pain 1

Third-Line Treatments

Interventional Procedures

• Trigger point injections may be beneficial for persistent myofascial pain 1, 5
• Dry needling can be effective for treating active myofascial trigger points 6, 5
• Botulinum toxin type A injections are supported by evidence for providing 8-12 weeks of relief for persistent myofascial pain 2
• Image-guided injections are recommended to ensure accurate placement 2

Other Modalities

• Transcutaneous electrical nerve stimulation (TENS) can be used as part of a multimodal approach 1, 2
• Acupuncture is recommended as an option for myofascial pain treatment, though evidence is limited 1, 7
• Instrument-assisted soft tissue mobilization has shown similar effectiveness to manual myofascial release techniques 8

Adjunctive Approaches

Behavioral Interventions

• Cognitive behavioral therapy may benefit some patients with myofascial pain 1
• Relaxation techniques, breathing exercises, and other behavioral therapies can be useful 1
• Psychosocial support and education should be provided 1

Treatment Algorithm

1. Begin with manual physical therapy and tailored exercise program
2. Add pharmacological treatment (NSAIDs and/or short-term muscle relaxants) if needed
3. Consider local therapies (heat, cold, topical medications)
4. For persistent pain, progress to interventional procedures (trigger point injections, dry needling)
5. Add adjunctive approaches (TENS, acupuncture, behavioral interventions)

Common Pitfalls and Caveats

• Failure to identify and treat underlying etiologic factors that may be activating trigger points will result in incomplete and temporary relief 6
• Pelvic floor strengthening exercises should be avoided as they may worsen myofascial pain 1
• Muscle relaxants should only be used short-term (2-3 weeks) as evidence for longer use is inadequate 3
• As myofascial pain syndrome enters the chronic stage, it becomes increasingly refractory to treatment, highlighting the importance of early intervention 5
• Cyclobenzaprine has not been found effective in treating spasticity associated with cerebral or spinal cord disease 3