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MPDS- Multifactorial Etiology and Varied Pathophysiology: A

Review
Anshul Chaturvedi1, Ahmed Anwar Khan1, Rahul Srivastava2, Ashutosh Shukla3, Bhuvan Jyoti4

describing specific referred pain patterns of many muscles

ABSTRACT and spinal ligaments following injections of hypertonic sa-
line. In 1952, Travell wrote the first of many articles intro-
Temporomandibular joint (TMJ) diseases and disorders refer ducing the myofascial genesis of pain illustrated by specific
to a complex and poorly understood set of conditions, mani- referred pain patterns of over 30 muscles.6 Travell (1901 -
fested by pain in the area of the jaw and associated muscles.
1997) has been referred to as the pioneer in the treatment of
Myofascial pain syndrome is a chronic pain disorder which
musculoskeletal pain through the recognition of MTrPs. She
produces the pain by pressure on sensitive points in muscles
coined the term “myofascial pain syndrome” to describe pain
(trigger points) and causes pain in seemingly unrelated parts
as a result of trigger points in muscle, tendon, skin, fascia,
of body.
This article highlights the possible etiology, clinical features,
and ligaments (the term “trigger point” was introduced by
investigations and recent treatment of myofascial pain dys- Steindler in 1940).7
function syndrome.
CAUSE
Keywords: Myofascial pain, temporomandibular joints, trig-
ger points Central nervous system plays significant role. Combination
of both central and peripheral factors makes the condition
difficult to manage. The following conditions are clinically
related to myofascial pain:
INTRODUCTION
Protracted local muscle soreness
Myofascial pain is a regional myogenous pain condition Muscles that experience continued muscle soreness may
characterized by local areas of firm, hypersensitive bands lead to development of myofascial trigger points and myo-
of muscle tissue known as trigger points. This condition is fascial pain.
also referred as myofascial trigger point pain. Myofascial
trigger point pain was first described by Travell and Rinzler Local factors
in 1952.1 Certain local factors that influence muscle activity such as
A myofascial trigger point (MTrP) is clinically defined as a habits, poor posture and chilling seem to affect myofascial
hyperirritable spot in skeletal muscle that is associated with pain.
a hypersensitive palpable nodule in a taut band. The spot is
painful on compression and can give rise to characteristic Systemic factors
referred pain, referred tenderness, motor dysfunction, and Certain systemic factors may precipitate to myofascial pain
autonomic phenomena.2 e.g. fatigue, poor physical condition, hypovitaminosis and
In 1969 Laskin published a paper and stated that there are viral infections
many patients with muscle pain complaints in which the
cause is not the occlusal condition and described the impor- 1
Intern, 2Reader, Department of Oral Medicine & Radiology, 3Sen-
tance of emotional stress and other factors. After this article ior Lecturer, Department of Oral and maxillofacial surgery, Rama
dental professionals began using the term myofascial pain Dental college Hospital and research centre, Kanpur, 4Dental Sur-
dysfunction syndrome.1 geon and Consultant- Oral Medicine and Radiology, Department
of Dental Surgery, Ranchi Institute of Neuro-Psychiatry and Allied
Historical Aspect of Myofascial Pain Syndrome sciences, Ranchi, Jharkhand, India.
Myofascial trigger points (MTrPs) are the principal charac-
teristic of MPS. During the past nearly 200 years, numer- Corresponding author: Anshul Chaturvedi, Intern, Rama Dental
ous authors have described MTrPs in the English, German, College Hospital and Research Centre, Kanpur, U.P, India
Dutch, and French medical literature, illustrating that muscu-
loskeletal pain due to MTrPs is very common.3,4 Already in How to cite this article: Anshul Chaturvedi, Ahmed Anwar Khan,
1816, British physician Balfour described MTrPs as “nodu- Rahul Srivastava, Ashutosh Shukla, Bhuvan Jyoti. MPDS- multi-
lar tumours and thickenings which were painful to the touch, factorial etiology and varied pathophysiology: a review. Internation-
and from which pains shot to neighbouring parts.”5 In 1938, al Journal of Contemporary Medical Research 2016;3(1):19-25.
British rheumatologist Kellgren published a seminal paper
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Chaturvedi et al. MPDS- Multifactorial Etiology and Varied Pathophysiology

Increased emotional stress • Pain is usually of dull and deep quality.

Myofascial pain may be exacerbated by increased emotion- • The pain diffuse in nature
al stress. When individual is experiencing higher levels of • The incidence and severity of pain vary with the stim-
emotional states, such as fear, anxiety frustration or anger the ulus.
following major modifications of muscle activity can occur: • Associated restriction in movement may be present.
• An increased emotional stress excites the limbic struc- Although pain is increased with function of involved mus-
ture and hypothalamus activating the gamma effer- cle, the amount of pain reported usually less than with local
ent system. Increased gamma efferent activity comes muscle soreness.10,11
contraction of the intrafusal fibres, resulting in partial
stretching of muscle spindle. When spindles are par- MUSCLE TENDERNESS
tially stretched, less stretching of the overall muscle is
needed to elicit a reflex action. This affects the myo- In myofascial pain, the tenderness termed trigger points is
tactic reflex and ultimately results in increase in muscle deep localized and about 2-5 mm in diameter. In many in-
tonus. Muscles also become more sensitive to external stances, the patient may be aware only of referred pain and
stimuli which leads to further increases in muscle tonici- not even acknowledge the trigger point. Referred pain is
ty. These conditions lead to an increase in intra-articular wholly dependent on its original source, palpation of an ac-
pressure of TMJ. tive trigger point increase such pain.9
• The increased gamma efferent activity may also in- Trigger point may present in an active or latent state. In ac-
crease the amount of irrelevant muscle activity. The re- tive state it produces central excitatory effects. Therefore
ticular formation, with influence from the limbic system when trigger point is active a tension type headache is com-
and hypothalamus can create additional muscle activity monly felt. In latent state patient does not report headache
unrelated to the accomplishment of specific task. Often complaint. In this state trigger point is no longer sensitive
these activities assume the role of nervous habits such to palpation and therefore does not produce referred pain.
as biting on the finger nails or on pencil, clenching the These types of trigger points are difficult to find by palpa-
teeth together or bruxism. tion.1

Constant deep pain CLICKING NOISE

Constant deep pain input can create central excitatory effects
in remote sites. If central excitatory effect involves an ef- There will be recurrent clicking in temporomandibular joint
ferent (motor) neuron, two types of muscle effects can ob- at any point of jaw movement and there may be crepitus es-
served: pecially with lateral movements.12
• Protective co-contraction.
• Development of trigger point. LIMITATION OF JAW MOVEMENT
When trigger point develops it becomes a source of deep pain
and can produce additional central excitatory effects. These There may be limitations of jaw movement with variable jaw
secondary trigger points are called satellite trigger point.1 deviation or locking but rarely severe trismus is seen. Patient
who clench or grind their teeth during working hours, the
CLINICAL FEATURES symptoms tend to worsen toward evening and some times
have psychogenic basis. People with night time habit of
1. Females more affected than males with ratio of 4:1. clenching or grinding the teeth may awake with joint pain
2. Affects primarily young women (age 20 to 40 years). that abates during the day.12
3. Presence of trigger points which present as local areas of Sometimes myofascial pain of head and neck is misdiag-
firm, hypersensitive, bands of muscle tissue. nosed due to additional signs and symptoms which are oc-
4. There are four cardinal sign and symptoms: casionally reported with more severe cases and coincidental
• Pain pathologic conditions and are often associated with myofas-
• Muscle tenderness. cial trigger point. Additional symptoms are increased fatiga-
• Clicking or popping noise in TMJ. bility, stiffness, subjective weakness, numbness, hyperesthe-
• Limitation of jaw movement.8,9 sia, teeth sensitivity, excess lacrimation, increase salivation,
nausea and vomiting. Numerous otologic symptoms such as
PAIN ear pain, tinnitus, diminished hearing, dizziness, vertigo and
fullness in ear.13
Most common sites of pain in the masticatory system include
jaw pain, preauricular pain, ear ache, neck pain, facial pain, INVESTIGATIONS
and temple, frontal or occipital headaches.
• Pain has following characteristic: Diagnosis is made on the basis of clinical findings.

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Chaturvedi et al. MPDS- Multifactorial Etiology and Varied Pathophysiology

Muscle spasm Trigeminal neuralgia Atypical odontalgia Pulpal pain

• Characterised by acute • In TGN there is parox- • There is pain in tooth or • Sharp oscillating, throb-
onset of pain in jaw, face, ysmal, unilateral sharp tooth side. bing tends to coarsen
ear or temples. pain, sudden electrical • Mandibular function does or improve in time and
• In muscle spasm there is lancinating pain confined not affect. local provocation of tooth
generalised tenderness of to distribution of one or • Patient will not have exacerbates pain.
muscle more branches of trigemi- trigger points. • Trigger point are absent.
nal nerve. • Clinical or radiographic
• TGN occur after four science of pathology
decade and peak in 5th present in tooth with
and 6th decades. pulpal pain and absent in
• Trigger zones are present MPDS.
and stimulated by touch,
in MPDS trigger points
are deep, localised and
2-5 mm in diameter and
produce pain on palpa-
tion.
• Trismus absent in TGN
Table-1: Differential diagnosis

Radiographic changes are not commonly present. and superior to zygomatic arch. Posterior region is palpated
Arthrography and MRI is seldom indicated.12 above and behind the ear. In sternocleidomastoid palpation
is done bilaterally near its insertion on the outer surface of
PRESENCE OF TRIGGER POINTS mastoid fossa behind the ear. The entire length of muscle is
palpated down to its origin near the clavicle.1,15
Trigger points are localized, firm, hyperirritable nodules that
are tender to palpation patients often describe as knots within MEASUREMENT OF STRESS
their muscles if sufficiently sensitized can be the referred pain
source. Trigger points are small in head and neck region i.e. A useful tool is Symptom check list 90(SCL-90). This evalu-
about to 2 to 10 mm and larger in shoulder region 10 to 20 ation provides an assessment of nine psychologic states:
mm. Trigger points become aggravated from muscle use, poor 1. Somatisation
sleep, psychological tension and emotional stress and their se- 2. Obsessive compulsive behaviour
verity can fluctuate as the contributing factor change. Manu- 3. Interpersonal sensitivity.
al palpation is a common method for identification of trigger 4. Depression.
zones. Rolling the finger over the muscle and feeling for firm, 5. Anxiety.
hyperirritable nodules within the muscle often identifies the 6. Hostility
trigger zone. It has been demonstrated to apply pressure di- 7. Phobic anxiety.
rectly to the trigger point to generate the referred pain.14 8. Paranoid ideation.
9. Psychotocism.
EXAMINATION OF MUSCLE OF Assessment of these factors are necessary when evaluating
MASTICATION chronic pain.16

Muscles should be examined for tenderness using digital pal- TREATMENT

pation. Muscles that should be included in examination are
medial and lateral pterygoid, masseter, temporalis, sterno- Treatment of MPDS is divided in to three categories by
cleidomastoid, and trapezius. Medial pterygoid muscles are Weinberg. These categories are:
checked by running a finger in an anterioposterior direction 1. Palliative therapy.
along the medial aspect of the mandible in the floor of the 2. Causative therapy.
mouth. 3. Adjunctive therapy.
Masseter muscle is examined by simultaneous pressing from One more category has been suggested by authors
inside and outside the mouth in the process of bimanual known as:
palpation. Lateral pterygoid examined by inserting a finger 4. Definitive therapy.
behind tuberosity region. In temporalis each of three areas
(anterior, middle, posterior) should be examined. The ante- PALLIATIVE THERAPY
rior region is palpated above zygomatic arch and anterior to
TMJ. The middle region is palpated directly above the TMJ This therapy includes procedures such as occlusal splint,

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Chaturvedi et al. MPDS- Multifactorial Etiology and Varied Pathophysiology

medications, home remedies (ice, moist heat application, ex- MUSCLE RELAXANTS
ercises and soft diet).
Most common muscle relaxants are metaxalone 400 to 800
MOIST HEAT AND ICE mg every six hours or chlorzoxazone 500 mg every six
hours. Other muscle relaxants are casrisoprodol, methocar-
Moist heat opens the capillary bed to promote increased bamol, orphenadrine and cyclobenzaprine.
blood flow; it also acts as muscle conditioner prior to ex-
ercise and physical therapy. Contraindications of heat ther- NONSTEROIDAL ANTI-INFLAMMATORY
apy include circulatory insufficiency, sensory or cognitive DRUGS
impairment, malignancy and inflammation. Application of
ice is quite effective for reducing muscle swelling and pain NSAIDS are commonly used for the pain control in cases of
especially in acute condition.17 MPDS. Ibuprofen should be used in doses of 400m.g four
times daily. Chronic long term use is cautioned against be-
OCCLUSAL SPLINTS cause of their systemic and gastrointestinal side effects. The
cyclo-oxygenase inhibitors rofecoxib (25-50 mg/day) and
Dental occlusal splinting and permanent occlusal adjustment celecoxib (100-200mg/day) has same analgesic effects with
have been the mainstays of TMJ disorder treatment. Occlu- reduced risk of gastrointestinal injury.
sal splint therapy may be defined as “the art and science of
establishing neuromuscular harmony in the masticatory sys- BENZODIAZEPENES
tem by creating a mechanical disadvantage for parafunction-
al forces Diazepam (5-10 mg/day) and clonazepam can be used in the
with removable appliances.” Occlusal splint is a diagnostic, patient with muscle pain accompanied by stress and sleep
relaxing, repositioning, and reversible device. According to disturbances.
the glossary of prosthodontic terms [8th ed.], “occlusal splint
is defined as any removable artificial occlusal surface used TRICYCLIC ANTIDEPRESSANT
for diagnosis or therapy affecting the relationship of the man-
Drug like amitryptylline is effective in management of
dible to the maxilla. It may be used for occlusal stabilization,
chronic pain in cases of MPDS. It has analgesic action in low
for treatment of temporomandibular disorders, or to prevent
doses, sedative effects and promotes restful sleep. The anal-
wear of the dentition.” A common goal of occlusal splint
gesic effect of TCAs is due to the serotonin and noradren-
treatment is to protect the TMJ discs from dysfunctional
aline reuptake inhibition at synaptic level in the central
forces that may lead to perforations or permanent displace-
nervous system (CNS). The blocking of these two amines
ments. Other goals of treatment are to improve jaw-muscle
increases their concentration and availability in the synaptic
function and to relieve associated pain by creating a stable
space of the nerve endings in the posterior horn of the spinal
balanced occlusion. Splint therapy is considered an adjunct
cord (involved in the transmission of pain) favoring or pro-
to pharmacologic therapy and most appropriate when noc- longing the inhibitory action in the transmission of pain. It
turnal parafunctional activities can be identified. Typically, can be started with dose as low as 10mg at night and dosage
a flat‑plane maxillary occlusal splint designed for bilateral can be increased to 75 to 100mg depending upon patient tol-
contact of all teeth is fabricated. Such splints are thought to erance.9,10
unload the joint by disarticulating the dentition and increas-
ing the vertical dimension of occlusion. By unloading the CAPSAICIN
joint, there will be a reduction in both synovitis and masti-
catory muscle activity. Therefore, the result is a reduction in Capsaicin cream (0.025% or 0.075%) can be use for pain
symptoms. These appliances may also change condylar posi- relief. It releases substance –P and pain related neuropep-
tion and the existing occlusal relationship, thereby reducing tides to reduce pain perception and inflammation and must
abnormal muscle activity and spasm. Most occlusal splints be applied multiple times per day for at least 2 weeks. Side
have one primary function that is to alter an occlusion so effects of the drug are local burning, warming and reddening
they do not interfere with complete seating of the condyles of the skin, these side effects diminish with time and even-
in centric relation.18 tually disappear.17

PHARMACOTHERAPY EXERCISE

Drug therapy should be used on fixed dose schedule rather Passive stretching i.e. keeping the muscle fibers relaxed
than as needed for pain. Following drugs can be used for while slowly stretching the muscle, preventing it from
treatment of M.P.D.S. tightening via the stretch reflex in conjunction with moist

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Chaturvedi et al. MPDS- Multifactorial Etiology and Varied Pathophysiology

heat(followed by application of ice) is beneficial for de- ple chronic muscle trigger points. The LA must be used in
creasing muscle and joint pain and for improving ranges of concentration less than that required for nerve block. This
movement.19 can remarkably lengthen the refractory period of periph-
eral nerves and limit the maximum frequency of impulse
COUNTER STIMULATION OF MUSCLE conduction.9,13

There are two methods for reducing muscular pain: ADJUNCTIVE THERAPY
1. Repetitive action on trigger point with a mode of coun-
ter stimulation. Consist of treatment modalities that augment and assist de-
2. Muscle rehabilitation through active and passive stretch- finitive or causative type of treatment for TMD.
ing and postural exercises to restore the muscle to nor-
mal length, posture and range of motion. PHYSIOTHERAPY
There are several methods for counter stimulation of mus-
cle to reduce trigger points. Common methods are spray and It is combination of physical therapy, massage therapy and
stretch, trigger point injection and acupuncture. Other meth- electro modalities. Both passive and active treatments are
ods like ultrasound, direct electrical stimulation are also use- commonly included as part of therapy. Posture therapy is
ful for muscle contracture. also useful to avoid forward head positions that are thought
to adversely affect mandibular posture and masticatory mus-
SPRAY AND STRETCH cle.9,17

Non-invasive technique for counter stimulation. It involves ELECTROTHERAPY

cooling the skin with fluoromethane, ethyl chloride, spray
and then gently stretching the involve muscle to perform Is a part of adjunctive therapy; modalities includes electro-
spray and stretch therapy. The cooling is done to allow the galvanic stimulation, ultrasound, low level laser and infra
stretching to take place without the pain leading to reactive red.
contraction or strain. The vapocoolant spray provides abrupt
cutaneous stimulation that temporarily reduces pain percep- ELECTROGALVANIC STIMULATION
tion in the area. It must be applied from distance of 18 inch.
It is applied in one direction from trigger points towards ref- It utilizes negative polarity over a painful, swollen area. The
erence zone in slow, even sweeps over adjacent parallel areas negative charge produces alkaline effect within the tissues,
at rate of about 10cm/second.13,16 denaturing proteins and produced vasodilatation of the cap-
illaries; this in turn permits the outward flow of metabolites
PRESSURE AND MASSAGE and tissue fluids. High voltage electrogalvanic stimulation
rhythmically pulsates the muscles to the level of fatigue
Increased pressure is applied to trigger point can also relieve causing muscle relaxation.17
pain. Pressure is increased to about 20 pounds and is main-
tained to 30 to 60 seconds. If this technique produce pain it TRANSCUTANEOUS ELECTRICAL NERVE
must be stopped since the pain can reinforce cyclic muscle STIMULATION (TENS)
pain.16
Mode of action of transcutaneous electrical nerve stimula-
TRIGGER POINT INJECTIONS tion (TENS) has been attributed to neurologic, physiologic,
pharmacologic and psychological effects. TENS supposedly
Intramuscular trigger point injection can be performed by in- blocks pain signals being carried over the small, unmyeli-
jecting local anaesthetic solution,saline or sterile water or by nated C fibers by forcing the large myelinated A fibers to
dry needling without depositing a drug or solution. carry a light touch sensation. It may provide pain relief by
Procaine diluted to 0.5% with saline has been recommended physiologic effects of rhythmic muscle movement. The fas-
because of its low toxicity to the muscle, but lidocaine (2% ciculation of muscle may result in an increase in circulation,
without vasoconstrictor) is also used with standard dental sy- a decrease in edema and a decrease in resting muscle ac-
ringe. Injections are often given to muscle group in series of tivity. The pharmacologic action of TENS may involve the
weekly treatments for 3 to 5 weeks; this may be continued stimulated release of endorphins which are endogenous mor-
with modification of the intervals between injections, de- phine like substances. The probable placebo effect of TENS
pending upon the response. in relieving pain should also be considered. It is thought to
Trigger point injections with LA are generally more com- increase the action of the modulation that occurs in pain pro-
fortable than dry needling or injecting other substances, al- cessing at the dorsal horn of the spinal cord and trigeminal
though acupuncture may be helpful for patient with multi- nucleus of brainstem.15

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Chaturvedi et al. MPDS- Multifactorial Etiology and Varied Pathophysiology

ULTRASOUND feedback, usually by monitoring the electrical activity of the

muscle with surface electrodes or by monitoring peripheral
It is a method of producing deep heat more effectively that temperature. The monitoring instruments provide patients
the patient could achieve by using surface warming. These with physiological information that allows them to reliably
mechanical vibrations produce heat and vasodilatation by change physiological functions to produce response similar
increasing the tissue temperature. Thus increasing metabol- to that produced by relaxation therapies.9
ic activity. Vibrations also decrease pain by activating large
myelinated peripheral neurons that attenuate pain or nocice- CONCLUSION
ption stimulation at spinal cord or trigeminal (pons) levels.9,17
Myofascial pain syndrome is a type of muscle pain syndrome
IONTOPHORESIS that has a defined pathophysiology that leads to the develop-
ment of characteristic taut or hard band in muscle that is ten-
Is a process in which ions in solutions are driven through der and that refers pain to distant sites. If it becomes chronic,
intact skin by using a direct current between two electrodes. it tends to generalize. Myofascial pain syndrome can resolve
It uses ultrasonic energy to drive a medication deep into the with ideal treatment regimens. However, many patients with
tissue. myofascial pain syndrome have symptoms for years. Out-
comes are best when a multifaceted treatment approach is
Low level laser done.
Laser therapy includes nitric oxide synthesis, which causes
the endothelial linings of capillaries to dilate, improving cir- REFERENCES
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Source of Support: Nil; Conflict of Interest: None

Submitted: 2-11-2015; Published online: 26-11-2015

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