neurodynamic mobilizations, joint mobilizations, orthotics, or postural re-education32o,323 Patients with chronic myofascial pain syndrome usually present
with poor
postures and muscle imbalances with both adaptively shortened and lengthened muscles.
muscles will not correct muscular imbalances and abnormal posture, and may cause further aggravation of active myofascial trigger points, and increase pain and
dysfunction. Overstretching must be avoided as this may trigger myofascial trigger points. Prior to initiating isotonic training and conditioning programs, abnormal
postures must be corrected. Already during the pain-control phase of the program, patients can correct their postures and muscle imbalances by gently stretching
shortened muscles, improving neural mobility, and restoring basic function. Correction and prevention of abnormal postures require a comprehensive program to
include exercises to restore normal dynamic vertebral stabilization and mobility, motor control, muscle balances, strength, endurance, and breathing patterns. Many
patients are aerobically deconditioned, which, combined with poor posture, may cause adaptive shortening of the auxiliary respiratory muscles, such as the scalenes,
restricted chest expansions, and paradoxical breathing. Paradoxical breathing should be corrected with
functional abdominal breathing305,323, Certain work tasks or activities of daily living may predispose a patient to chronic musculoskeletal overload, increasing the
risk of myofascial dysfunction. Considering activity-related aspects of myofascial pain syndrome will enhance treatment outcomes. Modifying the workplace or the
patient's work habits can be critical.
continues to be exposed to certain workplace or other stress factors without modification of the conditions, the potential cause of myofascial dysfunction may not be
addressed adequately. Throughout the treatment process, much attention should be paid to educating the patient regarding the etiology, perpetuating factors, and self-
management. In patients with chronic myofascial pain, psychosocial issues must be assessed and addressed as outlined in the section
Muscle Pain Syndromes 125
on fibromyalgia. Patients must learn to modify their behaviors and avoid overloading the muscles without resorting to total inactivity.
SOFT TISSUE LESION AND MECHANICAL DYSFUNCTION
Def inition and Characteristics of Soft Tissue Mechanical Dysfunction
Fibromyalgia, with its lack of specific diagnostic findings and diffuse pain patterns, represents one end of a spectrum of pain severity and complexity and soft tissue
mechanical dysfunction represents the other end. dysfunction, where mechanical pathology exists and can be diagnosed, afflicts the greater portion of patients with
acute pain. There is usually overuse or direct trauma to the tissue that causes inflammation. A partial or full tear, as in a hamstring tear or "pull," gastrocnemius tear,
tennis elbow, or de Quervain's disease, for example, are forms of soft tissue mechanical dysfunction. Facet hypomobility or hypermobility, muscular or movement
imbalances, discogenic pathologies, and sacroiliac joint dysfunction, for instance, all represent mechanical dysfunction characterized by soft tissue lesions. These
dysfunctions can be medically diagnosed and evaluated for specific pathologies. Treatment can commence based on evaluative findings and the condition and
reactivity of the tissue. Once soft tissue mechanical dysfunction becomes more subacute or chronic, clinicians should consider whether myofascial trigger points have
become the main factor and, if so, alter the treatment strategy accordingly.
The specific evaluation process for soft tissue mechanical dysfunction requires a systematic approach. Looking for reproduction of pain based on palpation, muscle
contraction, or stretch helps to localize the dysfunction to a specific lesion. The purpose is to identify and define areas of somatic dysfunction and to localize a lesion
site. Somatic dysfunction can be defined as impaired or altered function of related components of the somatic system (body framework), skeletal, ar
