hen Melvin Karges, M.D., a physiatrist at the Kansas City Spine Center specializing in physical medicine and rehabilitation, was a resident at the University of Kansas City Medical Center, he occasionally saw patients with tissue pain which didn't respond to conventional treatment.

"The conditions were referred to as arthritis of the muscle, fibrositis, or nerve entrapment syndrome-all incorrect terms. We also saw it misdiagnosed as rheumatology problems or simple muscle strain," he said of that experience a decade ago. "But now we use the term 'myofascial pain' because it effects the muscles and fascia, (which is the connective tissue found throughout the body.) We also know that it has its own etiology and treatments."

Elizabeth Hesse, a physical therapist at the Health and Rehabilitation Pavilion, who treats patients with myofascial pain syndrome, describes the fascia as a thin, fibrous-looking tissue below the skin that surrounds the muscles, bones, organs, and vessels, supporting and protecting them.

When this tissue is injured, it shortens and hardens, creating pain. Women may be susceptible to myofascial pain because of a reported difference in the elasticity of their connective tissue.

The pain, which can spread, may be initiated by an injury, surgery, repetitive motion stress due to work or sports, or even, over time, by poor posture. People who carry stress in their shoulders and neck are at greater risk for the syndrome because of tightened musculature.

"While middle-aged women have the highest incidence, we see myofascial pain in all ages of people," said Dr. Karges. "Too often, people simply learn to live with it, taking aspirin for the pain. Without treatment, the syndrome is chronic."

While much has been learned about the causes, diagnosis, and treatment of myofascial pain, its still poorly understood by many in the medical community, Dr. Karges said. It is not unusual, for example, to see a patient diagnosed as having a heriated disc in the lower back, only to find out it's actually myofascial pain syndrome.

Dr. Karges classifies myofascial pain three ways:

Local myofascial pain is suffered in one spot-perhaps in the arm after too much tennis.

Regional myofascial pain affects a larger area, such as the neck, shoulder and upper back. "We see it commonly after injury, overuse, or some kind of complication," Dr. Karges said. "It 's part of the overuse phenomenon brought on by our attempts to work as fast as machines can work. Problems set in, then the body tries to compensate and the pain spreads and gets worse."

Generalized myofascial pain, the third type of myofascial pain syndrome, appears throughout the body. Dr. Karges says there are identifiable trigger points located in the injured upper shoulder, mid-thoracic spine, achilles tendon, in the hip and elsewhere. Identifying them is part of diagnosing myofascial pain syndrome.

Successful treatment begins with getting full blood flow back into the injured area in order to start the healing process. This requires getting the muscles to relax or "release" so they will be receptive to treatment, and may be done with heat, ice, ultrasound, biofeedback or trigger point massage.

The second step involves stretching the fascia of the muscles to increase their range. Physical therapists manually break up the tissue tightness with their hands, a process that can be rough for both therapists and patients.

"Leaner people are easier to work on," observe Hesse, who along with two other therapists in the Rehab Pavilion, performs myofascial release, "and people with hard muscles are hard on my fingers. I may use my elbows or my shoulders to help out. It can be a real workout."

At the Rehab Pavilion, patients see a physical therapist three to five times a week for two to four weeks. Once they are pain-free and muscle range improves, they begin a gradual strengthening program and work on changing postural habits, body mechanics, or other activities that Biofeedback and muscle retraining/re-education may be part of this.

Occasionally, psychological intervention is necessary to assist with controlling the stress that can exacerbate myofascial pain syndrome. "We also know-although we can't yet pinpoint the reason-that sleep disorders typically accompany this syndrome. So a psychologist or sleep disorder specialist may be part of our team approach to treatment," Dr. Karges said.

Once strength is developed, the final phase is to help the patient achieve muscle conditioning and endurance throughout the body. Patients' maintenance conditioning programs typically include walking, running and swimming, along with stretch warm-ups before they begin exercise or work in order to get healing blood flow to the muscles.

Patients' jobs, which may have to be modified, can also become part of the endurance conditioning.

In an aggressive program, pain may get worse before it gets better. Complete healing can take up to a year.

According to Dr. Karges,..."there currently is no central location for syndrome. Industrial medicine folks are really interested in knowing as much as possible because this syndrome affects so many workers. But at the moment, when we discuss connective tissue disorders, we are like the blind men looking at the elephant: everyone has a different theory and a different description of what's going on. What we must strive for is a generalized approach."