Background & Purpose: Chronic pain suffers have been shown to be comorbid with psychosocial impairments such as anxiety, depression and pain catastrophizing. Cognitive Behavioral Therapy (CBT) is a popular non-pharmacological treatment that has shown efficacious outcomes in reducing pain and disability levels in chronic pain suffers.
Myofascial pain syndrome is a pain condition within the soft tissue that is perpetrated by myofascial trigger points (MTrP). MTrPs are associated with greater disability, poorer sleep quality and altered muscle activation patterns. MTrPs are also correlated with the development of central sensitization and chronic pain syndromes. Dry needling (DN) and Spinal Manipulative Therapy (SMT) have shown to reduce pain and disability in MTrP. The purpose of this case report is to provide a treatment rationale and documentation of the efficacy of combining CBT, DN, SMT and exercise in the management of an individual with chronic myofascial pain syndrome.
Case Description: A 33-year-old male veteran was referred to therapy with a chief complaint of a constant, dull burning mid-scapular ache extending down to his lower back and up to his trapezius on the right side. He described this pain as 6/10 at current and constant, 5/10 at best with rest and pain medication and 10/10 at worst that occurs intermittently with prolonged sitting, walking and particularly forward-bending. Physical impairments included decreased and painful active range of motion, thoracic spine and rib hypomobility, and lumbar spine hypermobility with a positive prone instability test. MTrPs were identified along the T6-8 paraspinals, rhomboids at the medial border of the right scapula and lumbar segments L1-2 and L4-5. The patient was treated for nine 30-minute treatment sessions following a one-hour initial evaluation. DN was performed in 4/10 sessions; CBT, SMT and exercise were performed in every session.
Outcomes: Pain intensity and catastrophizing were measured by the Numeric Pain Rating Scale (NPRS) and Pain Catastrophizing Scale (PCS). Disability was measured by the Oswestry Disability Index (ODI) and the Patient Specific Functional Scale (PSFS). Active functional movement was measured using the Selective Functional Movement Assessment (SFMA). Following ten treatments, NPRS improved from 7/10 to 3/10, PCS improved from 31/52 to 16/52, and ODI improved from 72% to 8%. PSFS to return to golfing improved from a perceived ability of as a 7/10 ability and return to CrossFit activities as 8/10. SFMA multi-segmental flexion and rotation and overhead squat improved to functional painful while single leg stance improved to functional non-painful. Thoracic spine and rib mobility improved to a grade 3 without pain.
Discussion: Pain intensity, catastrophizing, disability and functional movement were all improved following nine treatment sessions. The outcomes of this case report suggest a multimodal treatment approach of DN, SMT, CBT and exercise may be beneficial for individuals with chronic myofascial pain.
Javate, Adam; Smith, Kayla; and Anderson, Matthew, "The Management of Chronic Myofascial Thoracolumbar Pain with Dry Needling, Spinal Manipulation, Cognitive Behavioral Therapy and Exercise: A Case Report" (2016). Physical Therapy Collection. 35.