Musculoskeletal Pain Syndromes
There are a group of people with idiopathic back and leg pain for whom no correlated underlying abnormality can be found ( Lawrence 1977 ). Most complain of muscular tenderness and pain ( Kalimo et al 1989 ). Most have associated spasm and focal tenderness, with loss of range of motion. There are no associated neurological signs. The back pain is typically local, but radiates diffusely upward and diffusely into the hips and upper thighs ( Macintosh & Bogduk 1987 ). The problem may be isolated to the lumbar spine or be a part of the larger syndrome called ‘myofascial pain’ ( Mense 1991 ). Diagnosis is made by history and through the non-specific physical findings which typically are loss of range of motion, local pain and tenderness in muscles or at muscular insertions and the presence of focal areas of myositis ( Panjabi et al 1982 ). Imaging studies typically are normal or have non-diagnostic spondylotic abnormalities. Treatment consists of anti-inflammatories, local passive therapy measures for focal areas of abnormality, and a long-term exercise programme ( Bell & Rothman 1984 , Basmajian 1989 , Bigos et al 1994 ).
There is much debate concerning the basis for these symptoms. Some experts believe that this is an inflammatory disease and eventually will become as well defined as rheumatoid arthritis. Others believe that these symptoms are non-specific and have no underlying unifying diagnosis. Still others suggest that these symptoms are largely psychosomatic and frequently are a part of somatization. Currently available data do not allow a precise definition of this symptom complex. Symptomatic therapy is all that is available now. It does appear that the co-morbidities associated with the chronic pain syndrome appear with uncommon frequency in patients with these diffuse myofascial complaints. As in all such patients, these co-morbidities should be defined carefully and treated individually ( Waddell et al 1980 , 1987a).
The myofascial pain syndrome generates one of the controversial treatment programmes in the chronic back pain field. These are patients who undergo prolonged courses of multiple injections of the so-called trigger points. Sometimes these trigger points are not treated by direct injection, but acupuncture and various forms of other local direct treatments are employed repetitively as the areas of tenderness in muscle are identified. As yet, there are no controlled studies demonstrating the value of local measures for these specific areas of tenderness. Most clinicians expert in the management of back pain recognize that the occasional local treatment of these foci of pain and tenderness is beneficial. The controversial issue occurs when these treatments are both multiple and prolonged. As an adjunct to a vigorous general rehabilitation programme, many of these local measures appear to have value. There is little or no convincing evidence that they are useful as independent prolonged treatment plans.