Library
APS Bulletin • Volume 19, Number 1, 2009
Resource Reviews
John D. Loeser, MD, Department Editor
Fundamentals of Musculoskeletal Pain
Reviewed by James P. Robinson, MD PhD
Thomas Graven-Nielsen, Lars Arendt-Nielsen, Siegfried Mense (Eds.). Seattle: IASP Press, 2008. Hardcover, 496 pages. ISBN 978-0-93102-72-5. $90 nonmembers, $70 IASP members.
Musculoskeletal pain, which dwarfs all other kinds of chronic pain in prevalence, comprises a disproportionately low percentage of research papers published in pain journals or presented at pain conferences. Thus, it is heartening to see an ambitious book like this one, which focuses on musculoskeletal pain and reviews the basic science underlying it.
The greatest strength of the book is its detailed description of physiologic processes involved in pain emanating from muscles. This is not surprising, given the fact that the editors are internationally acclaimed pain researchers with many years of experience in the study of muscle pain. Some chapters provide detailed information about the neurology of muscle pain, including discussions of muscle nociceptors, central pain pathways, and descending pathways involved in pain modulation. Others summarize research on structures other than neurons that influence pain experience, including glial cells and cytokines. The scope of these basic science chapters is impressive—for example, they include thoughtful reviews of gender differences in pain and genetic influences on pain.
Part III of the book, “Effects of Muscle Pain on Motor Function,” is particularly interesting. Chapters in this section document the effects of musculoskeletal pain on muscle function at multiple levels, including muscle spindle activity, EMG activity in specific muscles, and more global movement patterns (kinesiology). Also, several of the authors postulate feedback loops, such that pain-induced patterns of muscle activation perpetuate or amplify an initial injury by creating abnormal loads on other musculoskeletal structures.
The book’s emphasis on mechanisms of muscle pain is entirely appropriate, given the editors’ expertise. However, with the exception of chapter 21, this book does not provide much information about the roles of other musculoskeletal structures—bones, joints, ligaments, tendons, and peripheral nerves—in musculoskeletal pain. The contributors do not offer insights into the relative importance of muscle injury/dysfunction versus joint/periarticular/nerve dysfunction in musculoskeletal disorders, or the interactions among these components of the musculoskeletal system. However, taken as a whole, the book suggests three ways in which muscle injury/dysfunction can contribute to chronic musculoskeletal disorders:
Muscle injury or dysfunction can be the primary cause of musculoskeletal pain, as in acute muscular injuries, chronic muscle overuse syndromes, and inflammatory myopathies.
Disorders involving other musculoskeletal structures (e.g., facet arthopathies) or various visceral structures (e.g., nephrolithiasis) can secondarily cause referred pain and hyperalgesia in nearby muscles.
Musculoskeletal or visceral pain can provoke abnormal muscle function, which, in turn, can perpetuate the painful condition by causing abnormal stresses on the musculoskeletal system.
It should be noted that there are significant disagreements among practitioners of musculoskeletal medicine about the relative importance of muscles versus other structures in the origin and maintenance of musculoskeletal pain. For example, proponents of myofascial pain assert that muscle pain and dysfunction play a key role in most musculoskeletal disorders, whereas many orthopedic texts do not even mention the words muscle pain or myofascial pain.
Given the divisions among physicians and the absence of definitive research on the mechanisms underlying many musculoskeletal disorders, it is understandable that the authors of this book were unable to draw convincing lines from basic research on muscle pain to the clinical realities of common musculoskeletal disorders such as nonspecific lower back pain or lateral epicondylitis. But this limitation does not detract from the important contributions that the book does make. Most importantly, it repeatedly emphasizes the importance of musculoskeletal pain, and makes a serious attempt to explicate the pathophysiologic processes that may underlie pain in important musculoskeletal disorders. It thus helps to put musculoskeletal pain on the map for pain researchers, and will stand as standard against which future attempts to understand the pathophysiology of musculoskeletal pain are judged. At the same time, it provides a detailed, current synopsis of the many neurologic, neuroendocrine, and humoral processes that subserve any kind of pain, and a state of the art review of the ways in which these processes contribute to pain emanating from muscles.
Any physician or researcher who is interested in understanding the biology underlying musculoskeletal pain should have this book in his/her library.
References
Canale, S.T. (Ed.). (2003). Campbell’s operative orthopaedics, 10th Edition. St. Louis: Mosby.
Greene, W.B. (Ed.). (2001). Essentials of musculoskeletal care (2nd ed.). Rosemont, Illinois: American Academy of Orthopaedic Surgeons.
Travell, J.G., Simons, D.G. (1992). Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins.
Dr. Robinson is Clinical Associate Professor of Rehabilitation Medicine in the Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
