What causes muscle pain between the shoulders after a Bone Marrow Transplant (BMT)?

Muscle Pain Between Shoulders After Bone Marrow Transplant

Muscle pain between the shoulders after BMT is most commonly caused by graft-versus-host disease (GVHD), which can affect almost any organ system including musculoskeletal structures, though other BMT-related complications including medication side effects (particularly corticosteroids), immobilization-related deconditioning, and treatment-related neuropathies must also be considered. 1

Primary Causes to Evaluate

Graft-Versus-Host Disease (GVHD)

• GVHD is increasingly recognized as a cause of pain syndromes affecting multiple organ systems, including musculoskeletal manifestations, as hematopoietic stem-cell transplantation use expands. 1
• GVHD-related inflammatory myopathy can present with severe muscle pain and weakness, often accompanied by other organ involvement. 2
• Muscle cramping is a debilitating painful condition known to occur with GVHD that often interrupts sleep. 1
• Chronic GVHD is the leading cause of non-relapse mortality in BMT survivors and directly impacts patient outcomes. 3

Corticosteroid-Induced Complications

• Immunosuppressive agents used to treat GVHD, particularly corticosteroids, can lead to painful complications including avascular necrosis and contribute to muscle weakness and muscle loss. 1
• Corticosteroids are a major factor responsible for muscle weakness in BMT patients alongside the underlying disease, pre-BMT therapy, and immobilization. 1, 3

Immobilization and Deconditioning

• Multiple factors contribute to muscle weakness including immobilization during BMT, which can manifest as interscapular muscle pain. 1, 3
• Patients lose weight particularly in the first 40 days after BMT, with weight loss having negative effects on clinical outcomes. 1, 3

Peripheral Neuropathy

• Peripheral neuropathy after BMT can produce motor disability with significant morbidity, particularly when occurring within the first few months post-transplant. 4
• Severe neuropathies may have demyelinating features characteristic of immunologically-mediated processes. 4

Diagnostic Approach

Clinical Assessment

• Look for concurrent GVHD manifestations in other organ systems (skin, gastrointestinal, liver) to support the diagnosis of GVHD-related musculoskeletal involvement. 1
• Assess for signs of inflammatory myopathy: severe muscle pain, weakness, and functional impairment. 2
• Evaluate medication history, particularly corticosteroid dosing and duration. 1
• Screen for nutritional deficits and weight loss, which should be monitored weekly during BMT. 1, 3

Laboratory and Imaging Considerations

• If inflammatory myopathy is suspected, myopathological analysis may show cell infiltration with necrotic and regenerative fibers, with expression of interferon-inducible proteins useful for identifying GVHD-related myopathy. 2
• Nerve conduction studies should be obtained if peripheral neuropathy is suspected to identify immunologically-mediated neuropathies. 4

Management Strategy

Address Underlying GVHD

• Controlling the underlying GVHD may be necessary to reverse musculoskeletal symptoms, as steroid therapy alone may not sufficiently control GVHD-related inflammatory myopathy. 2
• Concurrent immunosuppressant therapy may be required for adequate disease control. 2

Nutritional Support

• Initiate early nutrition support including counseling, oral nutritional supplements, enteral nutrition, or parenteral nutrition to avoid further loss of weight and body cell mass. 1, 3
• Delaying nutritional intervention can lead to further deterioration. 3

Physical Activity and Rehabilitation

• Encourage and support patients to perform muscle training and increase physical activity before, during, and after BMT, as aerobic exercise improves physical performance and reduces complications. 1, 3
• Daily ergometer training has been shown to result in higher maximal physical performance, less pain, and shorter hospital stays. 1
• Physical therapy with stretching exercises focusing on strengthening upper back muscles may provide symptomatic relief. 5

Pain Management

• Recognize that severe pain is a problem for most BMT recipients, with overall pain ratings averaging 4.5 on a 0-10 scale. 6
• Patients commonly report that medication works best to decrease pain, though nonpharmacologic techniques can be adjunctive. 6, 7

Critical Pitfalls to Avoid

• Do not attribute all post-BMT muscle pain to simple deconditioning without evaluating for GVHD, as this is a potentially life-threatening complication requiring specific immunosuppressive therapy. 1, 2
• Avoid delaying nutritional assessment and intervention, as early support is critical to prevent further deterioration. 1, 3
• Do not overlook medication-induced complications, particularly corticosteroid-related avascular necrosis, which requires specific imaging and management. 1
• Be vigilant for novel pain syndromes as new treatments are introduced in BMT protocols. 1