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There is no known means of preventing myositis and treatment results are highly variable. In some cases, the symptoms are highly responsive to corticosteroid therapy, the first treatment method typically used. At other times, symptoms do not respond to any treatments. In many cases, general physicians refer patients to specialists, particularly rheumatologists (physicians who specialize in inflammatory diseases), for treatment. If left untreated and the disease becomes severe and progressive (worsening), it can be fatal.

Treatment of myositis is highly individualized. Physicians typically attempt to predict treatment outcomes according to a variety of points. These include:

* Age (in children). Children usually respond better to treatment than adults. Younger children tend to respond better than teenagers.

* Duration of disease before diagnosis and treatment. Responsiveness is best with early therapy, particularly within three to six months of the onset of symptoms.

* Severity of muscle weakness. Typically, the more severe the muscle weakness, the more resistant the myositis is to treatment.

* Dysphagia (difficulty swallowing). When dysphagia is present, the myositis is usually more resistant to treatment.

* Involvement of cardiac or respiratory muscles. When myositis affects the heart or the muscles involved in breathing, treatment is typically less effective.

* Form of myositis present. Different forms of myositis respond differently to treatment. Myositis associated with cancer is typically responsive only to the effective treatment of the cancer. Myositis associated with medications or infections typically goes away when the drug is removed or the infection is treated. Inclusion body myositis (IBM) is particularly unresponsive to treatment.

Pregnancy may worsen the signs and symptoms of myositis, and active myositis may increase the risk of premature birth or stillbirth. This risk is greatly reduced when the disease is in remission. Physicians usually recommend that the patient ensure that the disease is controlled before attempting to conceive. Many pharmacological agents are best avoided during pregnancy. However, if absolutely necessary, corticosteroids may be used throughout the pregnancy with close supervision by a specialist.

Restricting strenuous activities when inflammation is most intense often helps with pain and healing. When symptoms are less severe, physical therapy and rehabilitation may prove helpful. Physical therapists can teach a patient how to be aware of positioning to reduce the risk of pressure sores in bed or wheelchairs and can recommend exercises, including low-impact activities (e.g., walking, swimming) and active or passive range of motion exercises to prevent or improve joint contractures (when the joint remains in a bent position). Occupational therapy may be prescribed if myositis hinders the patient’s performance of daily activities.

Certain nutritional concerns exist for myositis patients. Protein in the diet is important for muscle growth and healing. Calcium is important for strong bones. During corticosteroid therapy, the diet needs to be low in salt and sugar.

Several medications may be used to treat myositis. Typically, the first medications attempted are corticosteroids. These may help to relieve muscle and joint pain and swelling, improve muscle strength, and control fever and rash. Corticosteroids are generally given in pill forms and in high doses. Muscle enzyme levels in the blood are monitored during treatment to determine if the corticosteroid treatment is working and to catch any signs of relapse. In general, if corticosteroids are started earlier in the course of the disease, they work faster and more effectively. Usually 90 percent of patients attain some response with corticosteroids, and 50 to 70 percent of these attain complete remission.

After about four to 12 weeks on the initial high dose of corticosteroids, the muscle enzyme levels have usually returned to normal and muscle strength has returned. At this time, the dose is gradually reduced. Most adults continue taking a low dose for many years or even indefinitely to Osteoporosis involves the bones becoming thin, brittle and more prone to fracture, causing pain.prevent a relapse. Most children, however, are able to stop corticosteroid therapy entirely without fear of further relapses after about two years. Prolonged use of corticosteroids has been associated with complications including diabetes and osteoporosis, and may affect children’s bone development. Usually corticosteroids are tapered slowly after prolonged use; stopping corticosteroids abruptly can make a person very sick.

In some cases, intravenous corticosteroids are used as an alternative to pill form. When using this method, the corticosteroids are typically administered for three consecutive days weekly or monthly as needed.

Not all forms of myositis respond well to corticosteroids. In cases of inclusion body myositis (IBM), corticosteroids may have no effect or only stabilization or slight improvement of muscle strength.

Sometimes, corticosteroids may not be effective or may even worsen myositis conditions. In these cases, other drugs may be prescribed, including:

* Immunosuppressive drugs. May be employed as initial treatment in patients with indicators of poor prognosis (e.g., those with a delayed diagnosis or with difficulty swallowing) and those at significant risk of corticosteroid side effects. Immunosuppressive drugs may also be used with corticosteroid therapy.

* Intravenous immune globulin (IVIG). Contains large quantities of many antibodies and may be given when other drugs are not effective. IVIG has shown some cases of great improvement or even full remission. It may provide even greater benefit when patients also have difficulty swallowing. IVIG is usually given for two to five consecutive days a month for as long as nine months. However, the costs of this treatment are very high and relapse is common once treatment has stopped.

* Antimalarial drugs, including DMARDs (disease-modifying antirheumatic drugs). May be used to treat rash in dermatomyositis. Typically, the medications for myositis treat pain, inflammation and muscle weakness, not rash. There are some cases where adverse reactions to antimalarial drugs may be confused with the rash and weakness of dermatomyositis itself.

When these drugs prove ineffective, a number of other medications and therapies may be used, such as alkylating agents (cancer drugs), blood plasma exchange or radiation therapy. These drugs and therapies have shown mixed results in studies and may not be effective.

In addition to medical treatment, some physicians may recommend certain complimentary or alternative pain therapies, including acupuncture or thermotherapy (heat therapy). However, these treatments remain controversial and unproven.

In cases of dermatomyositis, the use of sunscreen helps with the prevention and management of photosensitive rashes.

When dysphagia (difficulty swallowing) is involved with myositis, it increases the risk of inhaling food or liquids into the lungs (aspiration), which can cause pneumonia. In some cases, feeding tubes may be necessary. Speech therapists may offer advice about aspiration risk and precautions (e.g., elevation of the head of the bed, semisolid diets).

Dermatomyositis may be accompanied by calcinosis (deposits of calcium and phosphate in the fat layer beneath the skin), particularly in children who do not receive prompt treatment. This can be medically treated in its early stages, but once calcinosis becomes established, it is highly resistant to treatment. In some cases, deposits may need to be surgically removed, particularly if they interfere with joint function, persistently drain, or are painful or infected.

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Early diagnosis leads to early treatment and better chances of recovery. Physicians will perform a physical examination, evaluate the patient’s medical history and request laboratory and imaging tests. Other possible conditions that could be causing the symptoms will be evaluated and ruled out. When diagnosing children, many physicians avoid using painful or invasive tests.

If a child demonstrates typical muscle weakness, elevated muscle enzymes in the blood and (in the case of dermatomyositis) characteristic rash, these tests may not be needed. In adults, proximal (closer to the body’s midline) muscle weakness on physical examination, elevated levels of enzymes derived from muscles, myopathic changes on electromyography and muscle biopsy evidence of inflammation are diagnostic criteria for polymyositis.

Physicians typically look for certain criteria before diagnosing a patient with myositis. These criteria include:

* Muscle weakness at shoulder or hips
* Increased levels of muscle enzymes in the blood
* Characteristic muscle tissue changes observed under a microscope
* Abnormal electrical activity in the muscles measured by electromyography
* In the case of dermatomyositis, characteristic rash

Physical examination pays particular attention to strength testing. Physicians typically hold a patient’s arm or leg and have the patient move it while mild resistance is applied. This can help the physician determine the degree of muscle weakness that is present.

Several tests are particularly helpful in the diagnosis of myositis. These include:

* Muscle biopsies. A small piece of muscle tissue is removed and examined for abnormal proteins and enzyme deficiencies. Muscle biopsy is the definitive test for myositis and may reveal abnormalities such as damage, inflammation, disease or infections. The particular form of myositis present can typically be identified by small differences in inflammation patterns. Muscle biopsy is particularly useful in diagnosing inclusion body myositis (IBM). Muscle biopsy is essential for establishing the diagnosis of polymyositis.

* Blood tests. Certain enzymes tests may indicate elevated levels of creatine kinase for some forms of myositis. This indicates muscle damage and may be used to help rule out other conditions. An ANA test can identify the presence of antinuclear antibodies, which may be present in some forms of myositis. Complete blood count and sedimentation rate tests are typically normal in myositis patients and may be performed to rule out other conditions. There are a few other autoantibodies that can be measured in blood (e.g., Anti-Jo1, Ati SRP).

* Electromyography (EMG). A thin electrode is inserted into a muscle and electrical activity is measured as the patient relaxes or tightens the muscle. Although EMG can be painful, it reveals abnormal muscle function and may be used to assist in ruling out other conditions.

* MRI is an imaging test used in pain diagnosis, to guide treatment and to monitor for relapse.MRI (magnetic resonance imaging). Images of the muscle are generated using magnetic and radio waves. MRI can demonstrate areas of muscle inflammation and, because large areas can be accessed, sampling errors may be avoided. This is a nonpainful and noninvasive or minimally invasive procedure.

Certain other conditions may have symptoms similar to those seen in myositis. It is important to rule these out as the cause of the symptoms so that the proper condition may be treated. These conditions include:

* Viral infections
* Scleroderma
* Systemic lupus erythematosus (SLE)
* Muscular dystrophy
* Various other myopathies (muscle diseases)
* Exposure to toxins
* Drug reaction
* Hypothyroidism

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Symptoms of myositis typically develop slowly, over a period of weeks to months. Progression may be so gradual that people do not notice the disease for years. However, children usually develop symptoms more quickly than adults. Symptoms often vary in intensity and occur in periods of flare-up and remission. Symptoms are usually symmetrical (occur equally on both sides of the body).

Symptoms are highly individualized and variable. Some people may experience mild weakness that causes little or no detriment. For others, myositis may be a relentless downhill course resulting in confinement to a wheelchair or bed. Spontaneous, long-lasting remission is rare but may occur.

Symptoms of myositis include:

* Muscle weakness. Muscles close to the center of the body, particularly the neck, shoulders, upper arms, hips and thighs, are more often affected. The throat and esophagus may also be affected, but other internal organs and muscles of the hands, feet, eye and face are not usually affected. Weakness may be accompanied by warmth, pain or inflammation in the muscle. In advanced stages of the disease, the muscle may atrophy (deteriorate). Many activities may become very difficult, including:

- Lifting arms above shoulders
- Climbing stairs
- Getting out of a chair
- Getting into and out of automobiles
- Raising the head from a pillow
- Getting up off of the floor

* Difficulty swallowing (dysphagia). Muscle damage to the upper part of the esophagus may lead to dysphagia and food regurgitation. In some cases, food may be misdirected into the lungs, possibly leading to pneumonia. Any instances of dysphagia may indicate the need for immediate assistance.

* Shortness of breath and cough. Rarely, the lungs may be affected by weakness, causing shortness of breath and cough. This may indicate the need for immediate medical assistance.

* Raynaud syndrome. This peripheral vascular disorder, marked by discoloration of the fingers and toes accompanied by tingling sensations, may occur in any form of myositis.

* Myocarditis (inflammation of the heart muscle). Rarely, the heart may be affected by inflammation and weakness. This may lead to heart failure or arrhythmia (irregular heartbeat).

* Gastrointestinal abnormalities. Bleeding ulcers in the intestine or stomach may cause abdominal pain and black or bloody bowel movements. This is more common in children than in adults.

* Contractures. Muscles may shorten and cause a joint to remain in a flexed (bent) position. This may occur due to scarring during healing or to lack of exercise. It is seen more often in children than adults.

* Vasculitis. The blood vessels that lie under the skin and in the muscles may become inflamed. In some cases, these inflamed vessels may lead to open sores in the skin that may be as small as a pencil point or as large as a silver dollar. These sores may be deep or just on the surface and may last from a few days to several months. They typically go away with treatment. Vasculitis with or without open sores occurs in children more often than in adults.

* Lipodystrophy. Abnormal redistribution of fat may occur with myositis. It occurs in children more often than adults.

Other symptoms include:

- Low-grade fever
- Fatigue
- Unexplained weight loss
- Myalgia (muscular pain and stiffness)
- Malaise (general unwell feeling)
- Irritability
- Nasal voice or loss of voice
- Stunted growth in children

Dermatomyositis may have any of the general symptoms of myositis, but is characterized by the addition of skin abnormalities. A brown coloration or pale discoloration and scarring or shriveling may develop after any rashes fade. Skin abnormalities that may be seen in dermatomyositis include:

* Heliotrope rash. Shadowy reddish-purple rash on the face, particularly the nose, cheeks and eyelids. Rash on the eyelids is usually accompanied by edema (swelling).

* Gottron sign. Pink or purple rash that may be scaly, smooth or raised. This may appear anywhere on the body, but typically occurs on the knuckles, elbows, knees and ankles.

* Smooth erythema (discolored inflammation). Smooth, violet-colored inflammation. May appear on the backs of the shoulders and neck (shawl sign) or on the front of the neck and upper chest (V sign).

* Rash affecting the fingertips. The bed of the fingernail may become red and the area around the nail may swell.

* Calcinosis. Deposits of calcium and phosphate in the fat layer beneath the skin. These may be as small as a period or as large as a pebble and small deposits may join together to form larger lumps.

Several symptoms of inclusion body myositis (IBM) occur and develop differently from other forms of myositis. The characteristic muscle weakness in the trunk may be accompanied by muscle weakness in the limbs and some facial muscles for IBM patients. Asymmetric weakness occurs more commonly in IBM than in other forms of myositis, but still does not occur more often than symmetric weakness. For IBM patients who experience difficulty in swallowing, this may be the first complaint, preceding muscle weakness by as many as seven years.

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The cause of myositis is not known. Most researchers agree that the muscle degeneration characteristic of myositis results from an autoimmune response, in which white blood cells and autoantibodies attack the muscles. However, it is not known what initiates this response. Many researchers speculate that a genetic predisposition to viral or drug complications may cause myositis.

Possible causes and risk factors include:

* Family history. A genetic predisposition to myositis seems to exist, at least in some families and particularly in the juvenile manifestations. Certain genes involved in the immune response may play a role. For example, studies have shown that a defect in the tumor necrosis factor alpha gene may increase risk of myositis in children. Another possibility of increased risk for children involves the presence of a mother’s cells in the blood of a child in many cases of juvenile myositis. The genetic makeup of the mother may cause a transfer and/or persistence of maternal cells in the blood of the fetus that somehow makes the child more susceptible to myositis.

* Cancer or connective tissue disorder. Autoimmune reactions against cancer and various connective tissue disorders (e.g., rheumatoid arthritis, scleroderma, systemic lupus erythematosus) may be directed against the muscles as well.

* Viruses. Myositis may occur during or just after a viral infection. Certain viruses may trigger an autoimmune reaction that does not stop with recovery from the virus. With no virus left to attack, the white blood cells and autoantibodies may, in some instances, turn their attack on healthy body tissues. The connection between viral infection and myositis has not been proven. Some of the viruses that may have links to myositis include the Coxsackie B virus, the echovirus and the human immunodeficiency virus (HIV).

* Drug complications. The use of antibiotics is common in the three months preceding onset and diagnosis of myositis in children. It has been suggested that an abnormal reaction in the immune system may cause these antibiotics to attack healthy muscles.

Recent research indicates that, in children with dermatomyositis, a protein called heat shock protein 60 (HSP60) triggers an immune reaction. Further research would be needed to show if this finding may be useful in diagnosis or treatment.

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Myositis occurs in a variety of forms:

* Polymyositis. This is the most common form of myositis, affecting many symmetrical muscular systems, usually near the trunk (e.g., shoulder or pelvic girdle). Generally, when the term “myositis” is used to refer to a chronic condition rather than short-term muscle inflammation, it is referring specifically to polymyositis.

* Dermatomyositis. When a rash accompanies polymyositis, the condition is called dermatomyositis. Photosensitive (sensitive to light) rashes usually appear, along with muscle weakness and other symptoms. In children, dermatomyositis is much more common than polymyositis. Sometimes its characteristic rash may lead to a diagnosis of dermatomyositis without the accompanying myopathy (muscle disease).

* Inclusion body myositis (IBM). Only recently distinguished from polymyositis, IBM is characterized by a particularly gradual onset and progression of symptoms. Most patients have symptoms for about five to six years before diagnosis. This disease predominantly affects men over 50 years of age and tends to be more dangerous than polymyositis. It is resistant to treatment and often leads to severe disability, leaving patients wheelchair-bound or bedridden. IBM may lead to death, usually due to respiratory complications.

Myositis may also occur in association with other conditions or diseases. In many cases, if the associated condition can be Lupus is a chronic autoimmune disease that can cause joint pain and inflammation (arthritis).treated or stopped, the symptoms of myositis subside. Myositis may occur in association with:

* Connective tissue disorders (e.g., lupus, scleroderma)
* Cancer
* Viruses, including HIV
* Certain medications

Because the term myositis broadly refers to muscular inflammation, the term may be applied to a range of conditions unrelated to the three myopathies described above. For example, myositis trichinosa is a parasitic disease caused by eating undercooked meat, myositis ossificans is a condition that causes bone-like hardening in soft tissues, and the destruction of muscle by necrotizing fasciitis (“flesh-eating bacteria”) may be referred to as necrotizing myositis.

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In general terms, myositis is simply muscle inflammation that tends to be painful and tender and that does not issue pus (is nonsuppurative). However, myositis is often used to refer to any of a number of related inflammatory myopathies (muscle diseases), such as polymyositis, dermatomyositis and inclusion body myositis (IBM). These are rare, chronic connective tissue diseases involving the immune system. They are characterized by symmetrical (occurring on both sides of the body equally) pain, inflammation, weakness and degeneration of the strong muscles close to the torso, particularly those of the shoulders and hips.

Most researchers believe that the weakness and muscular degeneration of myositis is the result of the white blood cells and autoantibodies attacking healthy tissues. This attack is particularly concentrated on the small blood vessels in the muscles and leads to degeneration of the muscle.

Myositis may occur at any age, but onset typically occurs either between the ages of 5 and 15 years or between 30 and 60 years. There are numerous differences between myositis affecting children and adults. Polymyositis and dermatomyositis are more common in women. Inclusion body myositis (IBM) is more serious and occurs more often in men. The diseases occur more frequently among people with medical conditions that affect the immune system, such as autoimmune disorders or human immunodeficiency virus (HIV).

On rare occasions, myositis can be life-threatening. Complications leading to infection, respiratory failure or inability to eat due to difficulties with swallowing are the usual causes of deaths related to myositis.

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Also called: Idiopathic Inflammatory Myositis

Myositis may refer to a number of muscle diseases, including polymyositis, dermatomyositis and inclusion body myositis (IBM). These are all rare conditions characterized by pain, inflammation, weakness and degeneration of the muscles, particularly those close to the torso. Most researchers suggest that myositis may be similar to autoimmune disorders, in which white blood cells and antibodies attack healthy tissues.

Myositis may affect children or adults. It typically affects women more often than men and African Americans more often than whites. In some instances, myositis can be fatal.

Polymyositis is the most common form of myositis. It affects many muscle systems, usually near the trunk. Dermatomyositis includes all of the muscle weakness characteristics of polymyositis as well as a rash. Inclusion body myositis (IBM) is similar to polymyositis but involves more muscle in the limbs. IBM is resistant to treatment. Myositis may also be associated with other conditions, such as cancer, viral infections and rheumatoid arthritis.

The cause of myositis is not known. Many researchers believe that genetic factors may trigger the white blood cells and antibodies in the blood to attack muscles after a viral infection or use of certain medication.

Symptoms of myositis usually develop slowly and may range from mild to severe in intensity. Weak muscles are the primary symptom and often lead to other symptoms, such as difficulty swallowing or shortness of breath. Other less serious symptoms include fever, fatigue and weight loss.Electrodiagnostics assess muscle function (e.g., electromyography [EMG], nerve conduction study).

Diagnosis of myositis relies on physical examination and tests. Physicians look for signs of weak muscles. Typically, blood tests, muscle biopsies and electromyography (EMG) are used to rule out other conditions as the cause of the patient’s symptoms.

No methods of preventing myositis are known. The effectiveness of treatment varies among individuals. Corticosteroids are typically given in high initial doses. When symptoms go away, the dose is gradually reduced. Although adults usually continue taking corticosteroids for a long time or indefinitely, children typically stop therapy after two years. If corticosteroids do not work, other drugs may be used.

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Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about myofascial pain syndrome (MPS):

1. What is your experience in diagnosing and treating patients with MPS?
2. Can you recommend a physical therapist experienced with MPS treatment?
3. Should I make any changes to my living and working environments?
4. What kind of fitness regimen should I consider?
5. Are there changes I should make in my diet?
6. Are there any complementary treatments that may be helpful for me?
7. How will any of my pre-existing conditions affect MPS?
8. How might I reduce the likelihood of symptom flare-ups?
9. Can you refer me to a counselor or support group for MPS?
10. Is my MPS curable?
11. Can you refer me to a pain management specialist?

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By eliminating factors that contribute to the musculoskeletal pain, patients with myofascial pain syndrome (MPS) have reported vast improvement and prevented recurrent activation of trigger points. This can be done by:

* Correcting physical asymmetries. Some people are born with gait disturbances, such as one leg that is slightly longer than the other. Leg-length discrepancy due to an anatomically shorter limb or a locked sacroiliac joint can also lead to significant myofascial back pain. The asymmetry caused by these anatomic variations may be corrected with the use of heel lifts, dynamic insoles or buttock lifts.

* Using good posture. Good posture minimizes stress and improves efficiency in the use of muscles. Correcting poor body posture and alignment is an important component of treating patients with MPS.

* Proper ergonomics and body mechanics. Certain jobs and work activities (e.g., data entry, construction, assembly-line workers) are associated with an increased risk of developing cumulative trauma that leads to musculoskeletal disorders, including MPS. Modifying the workplace or the patient’s work habits is important in reducing pain and discomfort. However, in some cases patients may need to change careers.

* Nutrition. Getting proper nutrition ensures that the body has what it needs to function and heal. Deficiencies in vitamins C, B1, B6, B12 and folic acid have been linked to MPS. In addition, eating a well-balanced diet is believed to help improve symptoms of pain, depression, fatigue and headaches.

* Relaxation techniques. Psychological stress may aggravate MPS symptoms by activating TrPs. Relaxation and stress management techniques may be employed to manage stress and pain. Deep breathing, visual imagery and relaxing audio may be used as effective tools for relaxation.

* Exercise. Regular exercise has been shown to decrease pain and increase endurance and is essential for long-term recovery of MPS. A rehabilitation program should include postural and strengthening exercises as well as aerobic conditioning. Posture-enhancing exercises improve musculoskeletal alignment, thereby enhancing balance and promoting relaxation. Strengthening and aerobic conditioning improve not only strength and endurance, but also blood circulation in the muscles.

Muscle soreness may be minimized with relaxation, heat, steady breathing and drinking adequate water. Stretching prior and after exercising is also extremely important to lengthen muscles and maintain their length, help muscles relax, improve ability to move muscles and decrease pain.

* Limiting or avoiding alcohol consumption and cigarette smoking.
* Getting enough rest. Striving for restful sleep is important in the treatment of MPS. Sleep deprivation can be a major factor in the continuation of musculoskeletal pain. Patients are encouraged to get seven to eight hours of sleep each night. A healthy sleep regimen is crucial to improving sleep and includes going to bed at the same time every night, avoiding exercise three hours before going to bed and limiting caffeine and sugar intake before bedtime.

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The prognosis for myofascial pain syndrome (MPS) is good if treatment is started before symptoms become acute and aggravating factors, such as poor posture or excessive muscle overload, are eliminated. Other conditions, including many that are symptoms of or occur simultaneously with MPS (e.g., migraines, depression, anxiety, diabetes, fibromyalgia, insomnia) should be treated, as they may aggravate other MPS symptoms when uncontrolled.

Finding the right physician is crucial in treating MPS because not all physicians have experience treating this type of pain disorder. It is recommended that patients seek care with a physician specializing in pain management, a growing medical specialty incorporating anesthesia and physical medicine and rehabilitation.

Treatment of MPS centers on reducing the musculoskeletal pain and improving muscular function. All treatment options, including those the individual can do on their own, should be discussed with a physician. These may include:

* Physical therapy. Therapists focus on correction of muscle shortening by targeted stretching and strengthening of the affected muscles, and correction of aggravating factors (e.g., improper posture and ergonomics). Modalities such as diathermy and ultrasound therapy can be used to reduce pain.

Therapists may also perform a spray and stretch technique. This involves spraying a muscle with a topical anesthetic to numb the area and then stretch out the painful, contracted muscle to reduce pain and stiffness. Many therapists use ice instead of the spray, because the spray is costly and ice usually is just as effective.

* Manipulation therapy. Myofascial release therapy involves working on tight, contracted muscles and TrPs to release or stretch out the problem areas. Massage therapists generally work lightly and progress slowly in doing deep muscle work. The results of massage can last a considerable time.

* Occupational therapy. This type of therapy can be helpful in assessing and setting up ergonomically correct workstations to prevent exacerbation and/or recurrence of symptoms. Properly set-up work sites can help to decrease aggravating factors, such as poor posture. Occupational therapists can also offer expertise on home modifications, task simplification and energy conservation to reduce fatigue and pain.

* Cryotherapy (cold therapy). Therapy using a cold substance can reduce pain and inflammation; however, prolonged use can injure skin.

* Thermotherapy (heat therapy). Heat therapy is usually used in rehabilitation to relieve joint stiffness. Moist heat, done by combining hydrotherapy with thermotherapy, penetrates deeper into the muscle and offers more relaxation than dry heat. Too much heat can cause burns. Heat should not be used on sensitive skin and may need to be avoided when using analgesics.

* Cognitive behavioral therapy. This form of psychological treatment can help people replace negative thoughts with positive ones and provide coping strategies.

* Injection therapy. Physicians may inject medication directly into the TrPs to relieve pain.  A physician may recommend trigger point injections only when other, less invasive methods fail to eliminate the pain. These treatments can be very effective in individuals who have long standing pain.

Other complementary and alternative medicine techniques can be tried in some patients:

* Dental appliances. A mouth guard worn at night can help in cases caused or exacerbated by clenching or grinding of the teeth.

* Biofeedback. Information about typically unconscious bodily functions (e.g., muscle tension and blood pressure) is used to help gain conscious control over those functions. Electrodes are placed on the muscles to identify which are in use. People can then try to consciously lower muscle tension in that area.

* Acupressure. Pressure is used on target points of the body to control symptoms.

* Acupuncture. Thin needles are inserted into target points of the body to ease pain and improve sleep patterns. Controversy remains as to its effectiveness, but some studies show significant beneficial results.

When used in conjunction with active treatment therapies, the use of certain medications may help alleviate symptoms. These include:

* Nonsteroidal anti-inflammatory drugs (NSAIDs). Usually used to treat inflammation, NSAIDs also help ease muscle aches and may help make patients more comfortable in exercising and returning to daily activities.

* Muscle relaxants. By reducing the ability of the muscles to contract, these drugs help alleviate muscle pain.

* Antidepressants. Used in lower doses when treating MPS than when treating depression unless the patient is also suffering with depression. Even at low doses, side effects are common, including dry mouth, weight gain, constipation and lack of concentration. Tricyclic antidepressants relax muscles and heighten the effects of endorphins and may be taken at bedtime to help promote restorative sleep. The U.S. Food and Drug Administration (FDA) has approved a  selective serotonin and norepinephrine reuptake inhibitor (SSNRI) to relieve some types of nerve pain.

Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration has advised that antidepressants may increase the risk of suicidal thinking in younger patients and all people being treated with them should be monitored closely for unusual changes in behavior.

For improvement to be significant, patients must adhere to an active medical treatment plan as outlined by their physician. In addition, patients should continue seeing their physician until symptoms have resolved or stabilized at maximum medical improvement.

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