Miyofasyal Ağrı Sendromu ve Fibromyalji Sendromu: Algoritmik Yaklaşım
Özet
Miyofasyal Ağrı Sendromu (MFAS) ve Fibromiyalji Sendromu (FMS), birbirine benzeyen ancak temelde birbirinden farklı en yaygın görülen kas-iskelet sistemi rahatsızlıklarındadır. MFAS, periferde bir enerji krizinin neden olduğu kas dokusunda lokalize olarak tanımlanırken; FMS esas olarak merkezi sinir sistemi duyarlılığı ile karakterize sistemik bir bozukluktur. MFAS belirli hassas/tetik noktalardan yayılan ağrıya neden olurken, FMS daha çok yorgunluk, uyku bozuklukları ve bilişsel sorunlara neden olabilmektedir. Etkin bir tedavi için her iki durumunda klinik olarak iyi tanınması gerekmektedir. Tedavi stratejileri, temel olarak hasta eğitimi ve fizik tedavi ile başlayan ihtiyaca göre farmakolojik müdahaleler veya enjeksiyonlara kadar giden algoritmik bir yol izler. Sonuç olarak, bu kaynak klinisyenlere günlük pratikte sıklıkla karşılaşılan bu iki klinik durumu çok daha kolay bir şekilde tanımasına ve tedavi edebilmesine imkan sağlamaktadır.
Myofascial Pain Syndrome (MPS) and Fibromyalgia Syndrome (FMS) are the most common musculoskeletal disorders, which are similar but fundamentally different from each other. MPS is defined as localized in muscle tissue caused by an energy crisis in the periphery, while FMS is primarily a systemic disorder characterized by central nervous system sensitivity. MPS causes pain radiating from specific tender/trigger points, while FMS can cause fatigue, sleep disorders, and cognitive problems. Effective treatment requires good clinical recognition of both conditions. Treatment strategies follow an algorithmic path, starting with patient education and physical therapy, and progressing to pharmacological interventions or injections as needed. Ultimately, this resource enables clinicians to more easily recognize and treat these two clinical conditions, which are frequently encountered in daily practice.
Referanslar
Dua A, Chang KV. Myofascial Pain Syndrome. 2025 Apr 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29763057.
Steen JP, Jaiswal KS, Kumbhare D. Myofascial Pain Syndrome: An Update on Clinical Characteristics, Etiopathogenesis, Diagnosis, and Treatment. Muscle Nerve. 2025;71(5):889-910.
Urits I, Charipova K, Gress K et al. Treatment and management of myofascial pain syndrome. Best Pract Res Clin Anaesthesiol. 2020;34(3):427-48.
Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a treatment review. Pain Ther. 2013;2(1):21-36.
Zhai T, Jiang F, Chen Y et al. Advancing musculoskeletal diagnosis and therapy: A comprehensive review of trigger point theory and muscle pain patterns. Front Med (Lausanne). 2024 Jul 10;11:1433070. doi: 10.3389/fmed.2024.1433070.
Saxena A, et al. Myofascial Pain Syndrome: An Overview. J Pain Palliat Care Pharmacother 2015;29(1):16-21.
Testa M, Barbero M, Gherlone E. Trigger points: Update of the clinical aspects. Eur Med Phys. 2003;39:37–43.
Gerwin, R.D. (2010). Myofascial Pain Syndrome. In: Mense, S., Gerwin, R. (eds) Muscle Pain: Diagnosis and Treatment. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-05468-6_2
Cao QW, Peng BG, Wang L et al. Expert consensus on the diagnosis and treatment of myofascial pain syndrome. World J Clin Cases. 2021:26;(9):2077-89.
Fernández-de-Las-Peñas C, Dommerholt J. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med. 2018:1;19:142-50.
D. G. Simons, J. G. Travell, and L. S. Simons, “Myofascial Pain and Dysfunction: The Trigger Point Manual,” in The Upper Half of Body, vol. 1, 2nd ed. (Lippincott Williams & Wilkins, 1999).
Li X, Wang R, Xing X et al. Acupuncture for Myofascial Pain Syndrome: A Network Meta-Analysis of 33 Randomized Controlled Trials. Pain Physician. 2017;20(6):E883-E902.
Rathbone ATL, Grosman-Rimon L, Kumbhare DA. Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain. 2017;33(8):715-29.
Rathbone AT, Kumbhare DA. Re: Signs and Symptoms of Myofascial Pain: An International Survey of Pain Management Providers and Proposed Preliminary Set of Diagnostic Criteria. Pain Med. 2016;17(3):620.
Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF et al. Dry Needling Versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Pain Med. 2022:2;23(3):515-25.
V. Toopchizadeh, B. Izadseresht, B. Eftekharsadat et al. “Effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) Modality for Treating Myofascial Pain Syndrome: A Systematic Review and Meta-Analysis,” Journal of Research in Clinical Medicine 2024:16;12(1):14.
A. Manca, E. Limonta, G. Pilurzi, et al. Ultrasound and laser as stand-alone therapies for myofascial trigger points: a randomized, double-blind, placebo-controlled study. Physiother Res Int. 2014;19(3):166-75.
M. G. Fagundes, J. R. S. Albuquerque, E. J. S. Silva et al. The Effects of Low-Level Laser in the Treatment of Myofascial Pain Syndrome: Systematic Review. BrJP 6 (2023): 83–89.
C. Avendaño-López, Á. Megía-García, H. Beltran-Alacreu, et al. Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Am J Phys Med Rehabil. 2024:1;103(2):89-98.
Liu C, Wang Y, Yu W, Xiang J, Ding G, Liu W. Comparative effectiveness of noninvasive therapeutic interventions for myofascial pain syndrome: a network meta-analysis of randomized controlled trials. Int J Surg. 2024:01;110(2):1099-1112.
Hong, CZ. Considerations & recommendations regarding myofascial trigger point injection. J Mus Pain 1994;2: 29-59.
Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620-34. doi: 10.2519/jospt.2013.4668. PMID: 23756457.
Liu L, Huang QM, Liu QG, Ye G, Bo CZ, Chen MJ, Li P. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944-55. doi: 10.1016/j.apmr.2014.12.015. Epub 2015 Jan 7. PMID: 25576642.
P. Ramaswamy, C. Saikiran, M. Swathi, B. M. Raj, and P. Lakshmisasi, “An Evaluation of Wet and Dry Needling Techniques for Treating Myofascial Pain in Trapezius Muscle–A Meta-Analysis,” Saudi Journal of Oral Sciences 2024;11(2):84–90.
Raeissadat SA, Rayegani SM, Sadeghi F et al. Comparison of ozone and lidocaine injection efficacy vs dry needling in myofascial pain syndrome patients. J Pain Res. 2018:29;11:1273-9.
Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting-a review of the literature. Pain Pract 2008;8: 269-76.
Fleckenstein J, Zaps D, Ruger LJ, Lehmeyer L, Freiberg F, Lang PM, Irnich D. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey. BMC Musculoskeletal Disor. 2010;11:32.
Haviv Y, Rettman A, Aframian D, Sharav Y, Benoliel R. Myofascial pain: an open study on the pharmacotherapeutic response to stepped treatment with tricyclic antidepressants and gabapentin. J Oral Facial Pain Headache. 2015 Spring;29(2):144-51. doi: 10.11607/ofph.1408. PMID: 25905532.
Clauw DJ. Fibromyalgia: an overview. Am J Med. 2009;122(12 Suppl):S3-S13. doi: 10.1016/j.amjmed.2009.09.006. PMID: 19962494.
Staud R, Smitherman ML. Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep. 2002;6(4):259-66. doi: 10.1007/s11916-002-0046-1. PMID: 12095460.
Harris RE, Sundgren PC, Pang Y, Hsu M, et al. Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia. Arthritis Rheum 2008;58:903-7.
R. Staud and M. Domingo, “Evidence for abnormal pain processing in fibromyalgia syndrome,” Pain Medicine. 2001;2(3):208–15.
S. Greenfield, M. A. Fitzcharles, and J. M. Esdaile, “Reactive fibromyalgia syndrome,” Arthritis and Rheumatism, 1992;35(6):678-81.
Bellato E, Marini E, Castoldi F, Barbasetti N, Mattei L, Bonasia DE, Blonna D. Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat. 2012;:426130.
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46(3):319-29.
Chinn S, Caldwell W, Gritsenko K. Fibromyalgia pathogenesis and treatment options update. Curr Pain Headache Rep. 2016;20(4):25.
Sarzi-Puttini P, Atzeni F, Salaffi F, Cazzola M, Benucci M, Mease PJ. Multidisciplinary approach to fibromyalgia: what is the teaching? Best Pract Res Clin Rheumatol. 2011;25(2):311-9.
Bidonde J, Busch AJ, Schachter CL, Overend TJ, Kim SY, Góes SM, et al. Aerobic exercise training for adults with fibromyalgia. Cochrane Database of Systematic Reviews 2017;6(6):CD012700.
Rao SG, Clauw DJ. The management of fibromyalgia: Drugs Today (Barc) 2004; 40: 539-54.
Tzellos TG, Toulis A, Goulis DG, Papazisis G, Zampeli VA, Vakfari A, Kouvelas D. Gabapentin and pregabalin in the treatment of fibromyalgia: A systematic review and a meta-analysis. J Clin Pharmacy Therap. 2010;35:639-56.
Kia S, Choy E. Update on treatment guideline in fibromyalgia syndrome with focus on pharmacology. The Biomedicines 2017;5(2):20.
Häuser W, Urrútia G, Tort S, Üçeyler N, Walitt B. Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia syndrome. Cochrane Database of Systematic Reviews. 2013, Issue 1. Art. No.: CD010292.
Ormseth MJ, Eyler A.E, Hammonds CL, Boomershine CS. Milnacipran for the management of fibromyalgia syndrome. J Pain Res. 2010;3:15-24.
Nishishinya B, Urrútia G, Walitt B, Rodriguez A, Bonfil, X, Alegre C, Darko G. Amitriptyline in the treatment of fibromyalgia: A systematic review of its efficacy. Rheumatology 2008;47:1741-46.
Holman AJ. Pragmatic consideration of recent randomized, placebo-controlled clinical trials for treatment of fibromyalgia. Curr Pain Headache Rep 2008;12:393-8.
Samborski W, Lezanska-Szpera M, Rybakowski JK. Open trial of mirtazapine in patients with fibromyalgia. Pharmacopsychiatry 2004;37:168-70.
Bourgaize S, Newton G, Kumbhare D, Srbely J. A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia: implications for differential diagnosis and management. J Can Chiropr Assoc. 2018;62(1):26-41.
Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Arthritis Res Ther. 2009;11(4):R120. doi: 10.1186/ar2783. Epub 2009 Aug 10. Erratum in: Arthritis Res Ther. 2009;11(5):415. PMID: 19664287; PMCID: PMC2745803.
Referanslar
Dua A, Chang KV. Myofascial Pain Syndrome. 2025 Apr 13. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 29763057.
Steen JP, Jaiswal KS, Kumbhare D. Myofascial Pain Syndrome: An Update on Clinical Characteristics, Etiopathogenesis, Diagnosis, and Treatment. Muscle Nerve. 2025;71(5):889-910.
Urits I, Charipova K, Gress K et al. Treatment and management of myofascial pain syndrome. Best Pract Res Clin Anaesthesiol. 2020;34(3):427-48.
Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a treatment review. Pain Ther. 2013;2(1):21-36.
Zhai T, Jiang F, Chen Y et al. Advancing musculoskeletal diagnosis and therapy: A comprehensive review of trigger point theory and muscle pain patterns. Front Med (Lausanne). 2024 Jul 10;11:1433070. doi: 10.3389/fmed.2024.1433070.
Saxena A, et al. Myofascial Pain Syndrome: An Overview. J Pain Palliat Care Pharmacother 2015;29(1):16-21.
Testa M, Barbero M, Gherlone E. Trigger points: Update of the clinical aspects. Eur Med Phys. 2003;39:37–43.
Gerwin, R.D. (2010). Myofascial Pain Syndrome. In: Mense, S., Gerwin, R. (eds) Muscle Pain: Diagnosis and Treatment. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-05468-6_2
Cao QW, Peng BG, Wang L et al. Expert consensus on the diagnosis and treatment of myofascial pain syndrome. World J Clin Cases. 2021:26;(9):2077-89.
Fernández-de-Las-Peñas C, Dommerholt J. International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med. 2018:1;19:142-50.
D. G. Simons, J. G. Travell, and L. S. Simons, “Myofascial Pain and Dysfunction: The Trigger Point Manual,” in The Upper Half of Body, vol. 1, 2nd ed. (Lippincott Williams & Wilkins, 1999).
Li X, Wang R, Xing X et al. Acupuncture for Myofascial Pain Syndrome: A Network Meta-Analysis of 33 Randomized Controlled Trials. Pain Physician. 2017;20(6):E883-E902.
Rathbone ATL, Grosman-Rimon L, Kumbhare DA. Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain. 2017;33(8):715-29.
Rathbone AT, Kumbhare DA. Re: Signs and Symptoms of Myofascial Pain: An International Survey of Pain Management Providers and Proposed Preliminary Set of Diagnostic Criteria. Pain Med. 2016;17(3):620.
Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF et al. Dry Needling Versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Pain Med. 2022:2;23(3):515-25.
V. Toopchizadeh, B. Izadseresht, B. Eftekharsadat et al. “Effectiveness of Transcutaneous Electrical Nerve Stimulation (TENS) Modality for Treating Myofascial Pain Syndrome: A Systematic Review and Meta-Analysis,” Journal of Research in Clinical Medicine 2024:16;12(1):14.
A. Manca, E. Limonta, G. Pilurzi, et al. Ultrasound and laser as stand-alone therapies for myofascial trigger points: a randomized, double-blind, placebo-controlled study. Physiother Res Int. 2014;19(3):166-75.
M. G. Fagundes, J. R. S. Albuquerque, E. J. S. Silva et al. The Effects of Low-Level Laser in the Treatment of Myofascial Pain Syndrome: Systematic Review. BrJP 6 (2023): 83–89.
C. Avendaño-López, Á. Megía-García, H. Beltran-Alacreu, et al. Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Am J Phys Med Rehabil. 2024:1;103(2):89-98.
Liu C, Wang Y, Yu W, Xiang J, Ding G, Liu W. Comparative effectiveness of noninvasive therapeutic interventions for myofascial pain syndrome: a network meta-analysis of randomized controlled trials. Int J Surg. 2024:01;110(2):1099-1112.
Hong, CZ. Considerations & recommendations regarding myofascial trigger point injection. J Mus Pain 1994;2: 29-59.
Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620-34. doi: 10.2519/jospt.2013.4668. PMID: 23756457.
Liu L, Huang QM, Liu QG, Ye G, Bo CZ, Chen MJ, Li P. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944-55. doi: 10.1016/j.apmr.2014.12.015. Epub 2015 Jan 7. PMID: 25576642.
P. Ramaswamy, C. Saikiran, M. Swathi, B. M. Raj, and P. Lakshmisasi, “An Evaluation of Wet and Dry Needling Techniques for Treating Myofascial Pain in Trapezius Muscle–A Meta-Analysis,” Saudi Journal of Oral Sciences 2024;11(2):84–90.
Raeissadat SA, Rayegani SM, Sadeghi F et al. Comparison of ozone and lidocaine injection efficacy vs dry needling in myofascial pain syndrome patients. J Pain Res. 2018:29;11:1273-9.
Jeynes LC, Gauci CA. Evidence for the use of botulinum toxin in the chronic pain setting-a review of the literature. Pain Pract 2008;8: 269-76.
Fleckenstein J, Zaps D, Ruger LJ, Lehmeyer L, Freiberg F, Lang PM, Irnich D. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey. BMC Musculoskeletal Disor. 2010;11:32.
Haviv Y, Rettman A, Aframian D, Sharav Y, Benoliel R. Myofascial pain: an open study on the pharmacotherapeutic response to stepped treatment with tricyclic antidepressants and gabapentin. J Oral Facial Pain Headache. 2015 Spring;29(2):144-51. doi: 10.11607/ofph.1408. PMID: 25905532.
Clauw DJ. Fibromyalgia: an overview. Am J Med. 2009;122(12 Suppl):S3-S13. doi: 10.1016/j.amjmed.2009.09.006. PMID: 19962494.
Staud R, Smitherman ML. Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep. 2002;6(4):259-66. doi: 10.1007/s11916-002-0046-1. PMID: 12095460.
Harris RE, Sundgren PC, Pang Y, Hsu M, et al. Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia. Arthritis Rheum 2008;58:903-7.
R. Staud and M. Domingo, “Evidence for abnormal pain processing in fibromyalgia syndrome,” Pain Medicine. 2001;2(3):208–15.
S. Greenfield, M. A. Fitzcharles, and J. M. Esdaile, “Reactive fibromyalgia syndrome,” Arthritis and Rheumatism, 1992;35(6):678-81.
Bellato E, Marini E, Castoldi F, Barbasetti N, Mattei L, Bonasia DE, Blonna D. Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat. 2012;:426130.
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46(3):319-29.
Chinn S, Caldwell W, Gritsenko K. Fibromyalgia pathogenesis and treatment options update. Curr Pain Headache Rep. 2016;20(4):25.
Sarzi-Puttini P, Atzeni F, Salaffi F, Cazzola M, Benucci M, Mease PJ. Multidisciplinary approach to fibromyalgia: what is the teaching? Best Pract Res Clin Rheumatol. 2011;25(2):311-9.
Bidonde J, Busch AJ, Schachter CL, Overend TJ, Kim SY, Góes SM, et al. Aerobic exercise training for adults with fibromyalgia. Cochrane Database of Systematic Reviews 2017;6(6):CD012700.
Rao SG, Clauw DJ. The management of fibromyalgia: Drugs Today (Barc) 2004; 40: 539-54.
Tzellos TG, Toulis A, Goulis DG, Papazisis G, Zampeli VA, Vakfari A, Kouvelas D. Gabapentin and pregabalin in the treatment of fibromyalgia: A systematic review and a meta-analysis. J Clin Pharmacy Therap. 2010;35:639-56.
Kia S, Choy E. Update on treatment guideline in fibromyalgia syndrome with focus on pharmacology. The Biomedicines 2017;5(2):20.
Häuser W, Urrútia G, Tort S, Üçeyler N, Walitt B. Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia syndrome. Cochrane Database of Systematic Reviews. 2013, Issue 1. Art. No.: CD010292.
Ormseth MJ, Eyler A.E, Hammonds CL, Boomershine CS. Milnacipran for the management of fibromyalgia syndrome. J Pain Res. 2010;3:15-24.
Nishishinya B, Urrútia G, Walitt B, Rodriguez A, Bonfil, X, Alegre C, Darko G. Amitriptyline in the treatment of fibromyalgia: A systematic review of its efficacy. Rheumatology 2008;47:1741-46.
Holman AJ. Pragmatic consideration of recent randomized, placebo-controlled clinical trials for treatment of fibromyalgia. Curr Pain Headache Rep 2008;12:393-8.
Samborski W, Lezanska-Szpera M, Rybakowski JK. Open trial of mirtazapine in patients with fibromyalgia. Pharmacopsychiatry 2004;37:168-70.
Bourgaize S, Newton G, Kumbhare D, Srbely J. A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia: implications for differential diagnosis and management. J Can Chiropr Assoc. 2018;62(1):26-41.
Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Arthritis Res Ther. 2009;11(4):R120. doi: 10.1186/ar2783. Epub 2009 Aug 10. Erratum in: Arthritis Res Ther. 2009;11(5):415. PMID: 19664287; PMCID: PMC2745803.
