Myofascial and Viscerosomatic Pain Syndromes
Robert Gerwin, MD, FAAN
Disclosure ď Ž
Nothing to Disclose
Learning Objectives
List 3 common types of viscerosomatic pain
Describe the gender effects of chronic visceral pain syndromes
Review treatment options for chronic visceral pain syndromes
What do these have in common?
A 25 y.o. man falls 10 ft, landing on his tail, and cannot sit down because of pain
A 37 y.o. woman has urinary frequency, painful voiding, and fibromyalgia
A 56 y.o. man has hemorrhoids, pain on defecating and on voiding, urinary urgency and painful intercourse
A young man has 2 years of burning penile tip pain, worse when voiding
A young woman with endometriosis has pelvic region pain despite 13 laparoscopic procedures for endometriosis and adhesions
Viscerosomatic pain (VSP): The forgotten entity
Not structural
Cannot be imaged
Diffuse & complex
No Treatment guidelines
Pelvic Pain Syndromes
Interstitial Cystitis
Irritable Bowel
Ureteral Lithiasis
Pain on Sitting Hamstring/adductors
Perineal/groin pain Obturator internus Pudendal nerve entrapment Prostatitis, vaginal pain
Visceral and Somatic Pain
Visceral Pain Referred to body wall Dull or sharp, poorly localized Referred pain may outlast initial visceral pain source
Somatic Pain Referred to body wall or to viscera Dull or sharp, poorly localized Referred pain may outlast initial cause of pain
Chronic Pelvic Pain
Perineal muscles: ischiocavernosis, bulbocavernosis, transverse perinei
Pelvic diaphragm: levator ani, coccygeus
Pelvic wall: obturator internus, piriformis
Referred Pain from Viscera: esophageal carcinoma; chronic obstructed urinary bladder
AV Apkarian in Gebhart Visceral Pain, 1995, IASP Press
Diaphragmatic Referred Pain
Segmental referral regional myofascial pain syndrome
shoulder
Liver, Gallbladder and right diaphragm: phrenic nerve, C3-5
Viscerosomatic Pain
Phrenic nerve: cervical nerve: innervates the diaphragm Referred pain C4-5 shoulder region
Hahn, McQuillan & Sheplock: Regional Anesthesia St. Louis 1996 Mosby
Referred Renal Pain
Renal Pain Referral Segmental Lumbosacral, low back, Distant segments: Lessening intensity
Hahn, McQuillan, & Sheplock: Regional Anesthesia St. Louis 1996, Mosby
Viscerocutaneous referral skin allodynia ď Ž
Response of gracile nucleus neurons to skin and urogenital stimulation ď Ž
Nearly 50% of cells that respond to skin brushing (Br) respond to uterine (RU, LU) or vaginal (Vdis) distention, vaginal shearing stimulation (Vsh) or cervical probing (CVX)
KJ Berkley and DH Hubscher in Gebhart, Visceral Pain 1995, IASP Press
Referred pain from colonic distention ď Ž
Acute visceral pain (balloon distention): wide distribution? poor localization
ď Ž
Body surface pain representation AV Apkarian in Gebhart Visceral Pain 1995 IASP Press
Central sensitization with colonic distention
Evidence for sensitization during repetitive colonic distention. Left: increase in intensity of visceral sensations induced by repetitive balloon inflation in the descending colon. Right: increased referral areas to thoracolumbar dermatomes from the 1st to the 10th distension. (Ness et al, PAIN (1990) 43: 377386
Viscerosomatic Pain:
Irritable Bowel Syndrome
Low
back pain Pelvic floor pain Levator ani muscle pain
Urinary Bladder Distention Referred
pain: suprapubic region
Repeated
distension
Hypersensivity Lower pain threshold increased cardiovascular responses (pseudo-affective reflex)
Ness TJ (1998) Pain 76: 61-69
Repeated bladder distention: increased responses to stimulation
TJ Ness PAIN 1998, 76:61-69
What Causes Visceral Pain?
Any pathological condition of the viscera
Renal colic Biliary colic Myocardial infarction Endometriosis Colitis Cystitis
Additional Visceral Pain Causes
Non-pathological visceral conditions
Bladder distention Colon distention Increase hollow-organ pressure Organ capsule pressure
Conclusion: Tissue injury is not necessary to produce pain
Causes of Visceral Hypersensitivity
Distention or traction
Anoxia, ischemia
Chemical irritants
Inflammatory conditions
potassium Kinins Prostoglandins, histamine, 5-HT
Dorsal Horn Cell
Dorsal horn cell afferent input
visceral input and muscle input Increased synpatic efficiency
Convergence is the rule
Viscera Cutaneous Deep tissues (viscerosomatic)
Neuromodulation of Pain
Midbrain Descending pain modulation: input from ascending STT A6 (locus coeruleus): noradrenergic inhibition system RVM: rostroventral medulla EA Mayer et al in Gebhart Visceral Pain 1995 IASP press
Effect of descending influences on dorsal horn neuron Removal of descending spinal influences increased the receptive field, the excitation by uterine distention, switch from probing the cervix, and increased the cardiovascular response to cervix probing.
KJ Berkley and CH Hubscher in Gebhart Visceral Pain, 1995, IASP Press
Dorsal Column Contribution to neuromodulation
Dorsal columns visceral nociception
Humans: affects pain awareness Midline dorsal column lesions reduce pelvic visceral pain decrease experimental colo-rectal distention pain
Houghten, et al (2001) Pain; Willis and Westlund (2001) Current Pain
Sex and Gender Effects
Chronic visceral pain syndromes more common in women
Hormone effects: peripheral and central Direct effect of estrogen, progesterone, testosterone on organ function Psychological and social factors, Age modified
Sex and Gender Effects Woman > Men IBS and IC Associated low back pain and pelvic floor pain: Abdominal pain migraine temporomandibular joint disease Fibromyalgia Endometriosis and dysmenorrhea
LeResche L (2000) in Fillingham, IASP Press, pp233-249
Urogenital Pain
Subjects: healthy menstruating women
Pressure pain, heat, and tactile thresholds
Decreased in referred pain zones (Abd, LB):
Ovulation:Pain, heat, tactile thresholds further decreased (lowered thresholds)
Bajaj P (2001) European J Pain 52: 135-144
Non-cardiac chest pain (NCCP)
Chest pain following CABG
56% Pain interfered with activity 72%
Mechanical allodynia: common
Eisenberg, Pulorak, Pud, Bar-El. PAIN 92:1-2
Non-cardiac Chest pain
Angina-like pain
Organic or psychological
Procaine injections into Pectoralis TrPs
Travell JG and Rinzler SH (1952) Postgrad Med 11: 452-434
VSP
Gastroesophageal reflux disease (GERD)
IBS
Colic (biliary, ureteral)
IBS
IC
Dyspareunia
Prostadynia
Thurston RC et al (2001) Pain 93: 95-100
Pelvic Pain
3 month prevalence: 15% of women 18-50 years old 60%: no dx. 55%: sexually active 88% pain before or after intercourse Sexual Abuse
Pelvic Pain Symptoms
Painful intercourse
Painful urination (pain relief on voiding)
Painful sitting
NOT INCONTINENCE; stress or urge incontinence and frequency
Surgical Management of Endometrial Pain Endometriosis: Surgery: fails CPP:15% of all hysterectomies 50% are unsuccessful
Referred Pain from Viscera Referred pain without hyperalgesia Referred pain with hyperalgesia muscle layer with MTrPs subcutaneous tissue skin
Giamberardino, M.A., Affaitati, G., Iezzi, S., et al., Referred muscle pain and hyperalgesia from viscera. J Musculoskeletal Pain. 1999; 7(1/2): 61-69
Cutaneous hyperalgesia and TrPs
Courtesy John Jarrell, MD
Cutaneous hyperalgesia and TrPs
Courtesy John Jarrell, MD
FitzGerald, M.P. and Kotarinos, R., Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct. 2003; 14(4): 261-8
TrP Injections for Abdominal Wall Pain
89% early onset relief
77% some or complete relief at 2 weeks postinjection
(95% relief in subjects w/o GI sx’s)
Lidocaine +/- steriods
Nazareno J, Ponich T, Gregor J. Can J Gastroenterol 2005;19:561-65
Vulvadynia Vulvadynia is associated with profound hyperalgesia Wiping a moist cotton swab over the vulva produces stabbing neuropathic-like pain
Irritable Bowel Syndrome
IBS and FMS:
30- 70% of FMS have IBS;
30- 65% of IBS have FMS
IBS:
visceral hyperalgesia in FMS, cutaneous allodynia w/FMS Hypoalgesic w/o FMS
Veale D (1991) Brit J Rheum 30: 220-222
Experimental Ureteral Colic Rat
model
Referred muscle hyperalgesia Outlasted artificial stone
Giamberardino, MA (1995) Pain 61:459-469
Chronic Urologic Pain
Urinary colic Hypersensitivity: greatest in referred pain zone 90% of patients: hypersensitive in 1 of 3 body wall layers, 25% in all 3 body wall layers Also: biliary colic and dysmenorrhea TrP Inj with Procaine: relief of abdominal wall pain after renal colic Giamberardino M et al (1999) in Vecchiet & Giamberardino, pp61-69
Case Study: renal colic
65 y.o. man had persistent pain right flank pain 3 weeks after passing a kidney stone
Trigger point injections into the right abdominal oblique muscles eliminated his pain
Subsequent episodes of right abdominal wall and flank pain always signaled a stone. Post- passage TrP injections relieved his persistent pain after each attack
Painful Bladder Syndromes
IC
Differential Dx Infection
(chlamydia) Drug induced cystitis (cyclophosphamide) Sarcoid Biofilm infections
Interstitial Cystitis Pain
moderate to severe
Dull and aching or sharp and stabbing
worse with voiding, intercourse, exercise, tight clothing
perineal region (vagina, urethra)
suprapubic region
Interstitial Cystitis
Childhood abuse: 50%
normal sphincter control not learned
pelvic floor dysfunction
Pelvic floor trigger points
IBS co-morbidity
Pelvic Pain•Prostatitis in Men: Prostatitis •2 X106 OP visits/yr in US •8% of all visits to urologists urologi
•Most men have no UTI but have CPP-MPS syndrome •Chronic or acute bacterial infection: 5-10% of cases
Pelvic Floor Pain in Men
Chronic prostatitis
Non-infectious prostadynia: 30% of chronic prostatitis
Pelvic floor TrPs: prostatitis-like pain
Child abuse
CPP with prostatitis-like symptoms impaired sexual function Painful voiding Painful defecation
Doggweiler-Wiygul R (2001) World Journal of Urology,
Male Chronic Pelvic Pain Syndrome • Pain Symptoms:
• Penile •Peritoneal •Rectal •Testicular •Abdominal
Male Chronic Pelvic Pain Syndrome
Treatment
Uncertain Symptomatic relief No effective drug Rx including antibiotics Bioflavonoid: 1 study Thermotherapy Acupuncture
MTRP THERAPY
Chronic Pelvic Pain
Perineal muscles: ischiocavernosis, bulbocavernosis, transverse perinei
Pelvic diaphragm: levator ani, coccygeus
Pelvic wall: obturator internus, piriformis
Viscerosomatic Pain: Summary
Common
Under-recognized.
Mimics/causes MPS
MPS mimics viscerosomatic pain
MTrP Treatment Relieves visceral pain Improves visceral function