Postural Disharmony Causing Myofacial Pain: A Case Report and Review of Literature of the Treatment

Abstract

Myofacial pain, a chronic painful condition of muscle origin, has numerous precipitating factors, if undiagnosed or left untreated could lead to compromised function and poor quality of life. In this case report, a female patient giving a history of 10 years of pain in the head and neck region was eventually diagnosed with myofacial pain secondary to bowing posture. The patient was successfully treated with combination of treatment modalities (TENS therapy, exercises, occlusal splint, etc.), which resulted in relief from chronic pain and improvement in quality of life.

Introduction

Myofacial pain (International Classification of Disease—10 M79.1) is pain of muscle origin as described by myalgia with pain spreading beyond the site of palpation but within the boundary of the muscle when using the myofascial examination protocol as described in RDC/TMD 2014 [1]. The risk factors for masticatory myofacial pain are parafunctional habits, psychological factors, trauma, and now recently in addition, several authors have reported that postural problems involving the head and cervical spine can also cause TMDs (as the stomatognathic system and cervical spine can be considered as one) [2–7]. Here, we have discussed a case report on myofacial pain with complex clinical presentation of signs and symptoms.

Case Report

A 48-year-old female patient visited the dental outpatient department, with the chief complaint of pain in her lower left side of the face since 10 years. On elucidating detailed history of illness, she experienced continuous dull aching unilateral pain in the left side of her face; pain was radiating in nature to the cervical region but was present predominantly in the lower third of the face. Patient is married and has two children. She had a typical forward head inclination. She is a farmer in a nearby village, which explained her bowing posture. Her Hospital Anxiety Depression Score (HADS) stated her as borderline anxious and depressed which could be attributed to the chronicity of the pain. She gave us a visual analog score (VAS) for subjective analysis of pain as 8. On clinical examination, mouth opening was adequate with no signs of temporomandibular joint abnormalities. On palpation of cranio-cervical muscles such as masseter, temporalis, sternocleidomastoid, occipitalis, and trapezius, her pain was aggravated. This indicated the presence of trigger points in these areas (Fig. 1). On intra-oral palpation of masticatory muscles, patient presented with “jump sign” at the area of insertion of medial pterygoid muscle. Dental examination revealed angle’s class I molar relationship with normal overjet and overbite. Thus, on comprehending all the history and the examination, provisional diagnosis of chronic myofacial pain secondary to bowing posture was made.

Fig. 1.

Depicting the trigger points (X)

Patient was simultaneously started with acupuncture like—transcutaneous electrical nerve stimulation (AL-TENS) therapy and soft occlusal splint. AL-TENS therapy was given for eight sittings consecutively at the trigger points extraorally for 15 min each for individual TrP (Fig. 2), which was given with increasing frequency (2 Hz, 2.5 Hz, 3 Hz, 3.5 Hz, 4 Hz, 5 Hz…maximum up to 6 Hz) for each sitting in order to increase the pain threshold of the patient. Soft occlusal splint was given to the patient to be worn throughout the day and night for 4 weeks. The manual stretching of taut bands was done during each visit; along with this patient was also advised to perform physical stretching exercises (chin-to-chest stretch and lateral stretches of neck). Patient was conveyed about her bowing posture and its implication in the form of myofacial pain. She was asked to avoid forward bending and was trained to maintain a straight posture. She was instructed to consume soft diet and to perform hot and cold alternate external compressions at least twice daily until she got subsequent relief in symptoms. The VAS* with each visit was noted for subjective pain assessment, and it showed drastic improvement (Table 1). Patient’s posture was monitored during each visit, and objective assessment of the trigger points (TrP) was also evaluated to ensure treatment response. By the end of 15th day, her VAS was 1 with marked improvement in quality of life. Patient was further followed up after 6 months, and she was reported to be asymptomatic with normal findings in HADS.

Fig. 2.

Transcutaneous nerve stimulation (TENS) therapy given on the trigger points

Table 1.

Subjective assessment of VAS

Visit	Day	VAS
1	1	8
2	2	6
3	3	5
4	4	5
5	5	5
6	6	3
7	8	3
8	9	2
9	10	2
10	15	1

Discussion

One of the commonest types of TMDs is myofacial pain syndrome (MPS). Essentially, the term “myofacial pain” is used only when specific criteria are satisfied [8]. The three subjective criteria are as follows: (a) spontaneous, dull aching pain, and localized tenderness in the involved muscles; (b) stiffness in the involved body area; and (c) easily induced fatigue with sustained function. The four objective criteria are as follows: (a) a hyperirritable spot within a palpably taut band of skeletal muscle; (b) upon sustained compression of this hyperirritable spot, the patient reports new or increased dull aching pain in a nearby site; (c) decreased range of unassisted movement of the involved body area; and (d) weakness without atrophy and no neurologic deficit explaining this weakness. Of all the mentioned criteria, our patient was fitting into both objective as well as subjective findings [4].

The treatment of MPS should be targeted to eliminate the etiology rather than the symptoms. Low-voltage, low-frequency TENS stimulation (AL-TENS; frequency < 10 Hz) as used in our patient for consecutive 8 days is a neuromuscular stimulator, producing rhythmic contractions of the muscles in spasm, which may facilitate clearance of the waste products. It stimulates descending pain inhibitory pathway, thereby increasing the concentration of endorphins and promoting anti-nociceptive activity [9, 10]. The literature suggests the usage of soft oral splint which contributes for reduction in “abnormal muscle activity” and pain by restoring the patient’s original vertical dimension of occlusion (VDO) which has been reduced by tooth wear or loss of posterior teeth. Our patient had a significant abnormal HADS which can be attributed to altered quality of life due to sustained chronic pain [11, 12]. Psychological disorders are more common in patients with MPS. Prevalence of depressive symptoms in MPS patients, range from 23 to 54%, has been detected by many studies [13].

Forward head inclination or poor posture can cause muscle soreness. Hence, we employed stretch exercise program for masticatory muscle pain, that is, chin-to-chest stretching and lateral extension of the neck muscles [14]. As an adjuvant to mentioned therapies, we also advised the patient to apply alternate hot and cold compressions at the site of tenderness. These methods increase intramuscular blood flow, reduce muscle tension, and generally relieve muscle pain for a period of time [8].

Therefore, in such complex clinical cases where diagnosis can be subtle, a detailed history and proper clinical examination play a major role and lead to appropriate diagnosis. The clinician should also consider patient’s psychological status. Proper patient counseling should be done about the condition, along with the devised treatment plan to achieve maximum patient compliance toward the treatment. In the present case, multi-directional therapeutic approaches were taken into consideration. Thus, the specific therapeutic philosophy of intervention and the decision to institute treatment remain the decision of the clinician. Therefore, all the etiological factors should be considered in order to successfully deal with such complex clinical scenario with multi-directional holistic treatment approach.

It is suggested that future research needs to be performed to reach a specific conclusion with different postural issues contributing to myofacial pain.

Funding

None.

Compliance with ethical standards

Conflict of interest

None.