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PART THREE  EVALUATION OF THE PAIN PATIENT

have argued that this is extremely common in patients with persistent neck pain. For example, one recent study found evidence of myofascial pain in 100% of a cohort 224 patients treated for chronic neck pain by primary care providers. 41 But the quality of the data supporting the importance of myofascial pain in spi- nal disorders is questionable, 42 and the term myofascial pain is not even mentioned in comprehensive reviews of neck pain (e.g., Côté et al., 43 Hogg-Johnson et al., 44 Holm et al. 45 ). Again, it is beyond the scope of this chapter to resolve the conflicting views regarding the importance of myofascial problems among patients with chronic neck pain. But a few observations are worth making. First, there are no accepted diagnostic tests for myofascial pain. Clinicians rely on the history and physical examination to make the diagnosis. Sec- ond, clinicians should be aware that many neck pain patients will describe pain that suggests irritation of muscles and will report tenderness to palpation of neck and shoulder girdle muscles. Third, there is uncertainty about the appropriate interpretation of these symp- toms and reports during physical exams. Because pain that seems to be muscular is typically widespread and because CNS hypersensitivity is now recognized as at

least one contributor to the pathophysiology of myo- fascial pain, 46 symptoms that some physicians construe as indicators of myofascial pain could instead be con- strued as widespread “nonanatomic” pain, or as pain secondary to CNSS rather than peripheral nociception. 4. Widespread “nonanatomic” pain. As described earlier, physicians who practice musculoskeletal medicine try to explain symptoms following a musculoskeletal injury in terms of some structural lesion in joints, periarticular tissues, muscles, and nerves in the body region where the patient is symptomatic. 47 The first step in this approach is to elicit a patient’s symptoms and consider patho- physiologic processes that might reasonably account for them. But this approach founders when the symptoms of patients do not fit a pattern that suggests some dis- crete injury to a musculoskeletal structure. For example, Figure 23.2 is a pain drawing provided by a chronic pain patient who reported that she initially hurt her lower back pain when she lifted a heavy box on her job. Al- though the patient denied injuries other than her low back injury, the figure indicates that she was now expe- riencing widespread pain. In interpreting such figures, it is important to note that research has demonstrated that irritation of intervertebral disks and facet joints produces

FIGURE 23.2  Patient indication of pain location.