myoActivation®, a Structured Assessment and Therapeutic Process for Adolescents With Myofascial Dysfunction and Chronic Low Back Pain: A Case Series.

Chronic low back pain (CLBP), described as pain that persists for over three months in the lumbar region [ 1 ], is a common and disabling health issue worldwide [ 2 ]. CLBP is not isolated to the adult population: 49% of high school students aged 14-19 years old experience one or more low back pain episodes [ 3 ]. Ongoing chronic pain in adolescents can have debilitating consequences for physical, psychological, and social functioning [ 4 ] with an associated loss of mobility, inability to participate in physical activities, decreased sleep quality, difficulty concentrating on schoolwork, school absenteeism, social isolation, and family stress [ 5 , 6 ]. Anxiety and depression are also known to be highly comorbid in people with a lived experience of chronic pain [ 7 ]. Non-specific CLBP [ 8 ], where a known remedial cause for pain has been excluded, can impact day-to-day functioning in up to 13% of adolescents [ 3 ]. This leaves them not only with unresolved pain and suffering but also with diagnostic uncertainty. These patients are often discharged from subspecialty care and advised to seek allied health alternatives, such as physiotherapy or psychology support. Individuals with chronic pain may experience stigma, be dismissed by peers or medical providers, and are often given the impression that the pain is “all in their head” [ 9 ]. Overlooked causes for pain and inadequate pain management may result in ongoing painful movements, fear of movement (kinesiophobia), a deconditioned physical status, illness-related distress, poor psychological functioning, and/or a general mistrust of the medical system [ 10 ]. Myofascial dysfunction and pain Myofascial dysfunction is a significant yet often unrecognized contributor to CLBP in the pediatric population [ 11 ]. Myofascial dysfunction and pain (MFD&P) can be diagnosed by identifying postural anomalies, muscle trigger points, scars, fascia in tension, or a combination of these findings. Trigger points (palpable pain points) can exist in muscles and fascia. Muscular trigger points are irritable nodules, located predominantly near the motor end plates in taut bands of skeletal muscle [ 12 ], which can develop in response to trauma, injury, surgery, repetitive microtrauma, poor posture, muscle overuse, or overload [ 13 , 14 ]. Fascial trigger points are palpable painful densities, often located near active muscle trigger points. Scars also contribute to defective fascial sliding, leading to distorted biomechanics and chronic pain. Scars are common in the pediatric population and are significant contributing factors to MFD&P, even when they appear to look “normal” [ 15 ]. The 3P conservative interdisciplinary approach The Complex Pain Service (CPS) at British Columbia Children’s Hospital provides assessment and management to pediatric patients with chronic and/or complex pain. Patients are referred to the CPS by a healthcare provider, family doctor, nurse practitioner, pediatrician, or subspecialty physician; patients are discharged from CPS when they meet their functional goals. The CPS utilizes an interdisciplinary pain care approach, which is now considered a standard of care for pediatric complex pain. This approach is more effective than single-discipline treatments or outpatient non-interdisciplinary rehabilitation [ 16 ]. Conservative management includes the 3P (physiotherapy, psychology, and pharmacology) approach, designed to help youth living with chronic pain achieve the goal of changing from a pain-centered life to a function-centered life. All CPS patients, regardless of their pain location and presentation, are initially managed with this 3P approach. In addition to seeking support from a physiotherapist, psychologist/therapist, and pharmacologist, patients diagnosed with MFD&P are also advised to engage in massage therapy and optimize supplements (magnesium bis-glycinate, vitamin K2, vitamin D3, and omega 3) designed to promote relaxation of muscles in sustained contraction and support an anti-inflammatory environment [ 11 ]. These conservative measures are trialed for four to six weeks. If a patient’s pain improves with initial conservative management such that functional goals can be achieved, then no added interventions are required. If repeat examination after this period reveals that there is still a myofascial component to pain, appropriately selected patients are offered myoActivation. Written information about MFD&P and myoActivation is given to the patient and family at this time. Objectives In this case series, we explore the journey from CPS admission to discharge of patients in whom myoActivation was incorporated as part of their CLBP management. The purpose of this case series is to 1) illustrate the utility of the myoActivation assessment to diagnose a myofascial component in CLBP, 2) identify some of the myofascial tissues likely contributing to MFD&P for adolescent CLBP, and 3) provide preliminary data of myoActivation therapy as a useful tool in adolescent CLBP multidisciplinary management. These study findings were previously presented as a meeting abstract at the 2024 Society for Pediatric Pain Management (SPPM) Annual Scientific Meeting on April 11, 2024.

This retrospective case series explores the journey to discharge of eight pediatric patients with MFD&P and CLBP who received myoActivation as a part of their interdisciplinary care with the CPS. Their median (range) age was 16.5 years (15.7-19.4) with a weight of 57.9 (46.5-73.6) kg, and they presented with a range of diagnoses, comorbidities, and specific pain locations (Table 1 ). kg: kilograms, y: years, m: months Before the CPS admission, the patients had experienced chronic pain for a median (range) of 4.3 (1-8) years with a self-reported average pain intensity of 7.5 (4-9) out of 10. All patients had undergone medical investigations to exclude a remedial cause of chronic pain. Prior to the CPS assessment, many had trialed various pharmacological and non-pharmacological techniques for their pain, such as prescribed medications, over-the-counter medications, massage therapy, physiotherapy, chiropractic treatments, or acupuncture (Table 2 ). The patients were referred to the CPS between March 2020 and December 2021, in the first two years of the COVID-19 pandemic. CPS: complex pain service, MRI: magnetic resonance imaging The majority of patient histories revealed previous physical trauma (surgery, fracture, or fall on the coccyx) (Table 3 ), and all were taking prescribed or over-the-counter medications for pain at the time of their initial assessment (Table 4 ). All experienced negative impacts on their quality of life: sleep disturbance in 8/8 (100%), school absence in 8/8 (100%), and low mood in 6/8 (75%). All patients were asked to identify their specific treatment goals at their initial assessment with the CPS. Each patient had different self-reported explanations for pain, including “endometriosis” (Patient 1), “scoliosis surgery” (Patient 2), “Ehlers-Danlos syndrome” (Patient 3), “somatic symptom disorder and post-traumatic stress disorder” (Patient 4), and spine-related conditions, like “prolapse disk” (Patient 5), “scoliosis” (Patient 6), “underdeveloped lumbar, bulging (oversized) disk impeding on nerve system, narrow spinal column with lower than average spinal fluid” (Patient 7), or “spondylolysis and obsessive-compulsive disorder” (Patient 8). BID: bis in die/twice daily, PRN: pro re nata/as needed, QD: quaque die/once daily Patients may have some missing discharge information as clinical record-keeping focused on important aspects and some questions have been omitted by their healthcare provider at the time. Based on their initial myoActivation assessment findings, including initial BASE test results, combined with their TiLT (Table 3 ), pain history, medical history, and classical examination, all cases were diagnosed with a myofascial component to their pain (Table 5 ). Patients were given education and written information about MFD&P at the time of their diagnosis. The most common co-morbid diagnoses were anxiety disorders (generalized anxiety disorder, panic attacks, and/or obsessive-compulsive disorder) (Table 5 ). BASE: Biomechanical Assessment and Symmetry Evaluation, ROM: range of motion, CPS: Complex Pain Service The patients included in this series trialed a median (range) of 15 (8-83) weeks of conservative management (Figure 2 ). After this period, two of these patients reported feeling better, but all reported some ongoing chronic pain. myoActivation re-examination indicated a persistent myofascial component in their pain profile, so the patients were offered myoActivation. CPS: Complex Pain Service Image credits: Jessica Luo (Created on  www.canva.com ) Patients in this series attended a median (range) of three (2-5) myoActivation sessions over two (1-10) weeks. For these eight cases, the most commonly activated/released muscles were the iliopsoas (n = 7), paraspinal muscles (n = 7), abdominal wall muscles (rectus abdominus and lateral abdominal wall muscles) (n = 7), quadriceps (rectus femoris/vastus lateralis and vastus medialis) (n = 4), quadratus lumborum (n = 4), and the gluteal muscles (gluteus medius and gluteus maximus) (n = 2). The most commonly treated fascia was at the iliac crest (n = 4) and coccyx (n = 3). The most common scars released were knee scars (n = 5). All eight patients had scars released (Table 6 ). There were no complications of myoActivation in any of these patients. The median (range) time between their final myoActivation session with the CPS and discharge from the CPS was 24 (5-52) weeks. Upon discharge, changes were reported in physical and mental well-being: pain improved for 7/8 (88%), physical functioning for 5/8 (63%), sleep for 6/8 (75%), school attendance for 5/8 (63%), and mood for 4/6 (67%). Each patient reported improvement in at least one of the quality-of-life domains. Initial goals of CPS care were achieved for 7/8 (88%) patients at discharge (Table 7 ). Changes in medication can be found in Table 4 . For the cases, the total duration of care with the CPS was 12 (7-25) months. CPS: Complex Pain Service

This case series describes the journey to discharge of eight adolescent patients with complex pain that included CLBP. We illustrate how myofascial dysfunction was a significant contributor to their pain presentation and that myoActivation was an integral part of their assessment and interdisciplinary pain management. Like many people with a lived experience of chronic pain, the adolescents in this case series had unique and complex contributing factors impacting their pain profiles. These cases had experienced a median of four years of pain prior to CPS clinic admission and had sought care from general practice or subspecialty physicians. Interdisciplinary pain management addressing all the components of the biopsychosocial model is recognized as the gold standard of care for managing complex presentations [ 16 , 19 ]. Prior to CPS admission, all patients in this series trialed multiple therapeutic modalities (Figure 2 ). After the CPS initial assessment, they underwent a median of four months of conservative interdisciplinary pain management, incorporating a combination of physiotherapy, massage therapy, psychology, self-management strategies, and pharmaceutical or nutraceutical interventions. Despite this conservative management, our patients continued to experience chronic pain, and all were offered myoActivation. At discharge, almost every patient in this case series reported improvements in pain and achieved their self-reported initial CPS goals. myoActivation proved to be an effective tool in assessment and management when chronic pain and functioning did not improve with many other trialed modalities. The positive patient outcomes and lack of complications in this series suggest that myoActivation, as an adjuvant to interdisciplinary care, is a feasible therapeutic strategy for appropriately selected pediatric patients with myofascial dysfunction and CLBP. myoActivation has several distinct differences to other needling modalities, such as intramuscular stimulation (IMS) or acupuncture. myoActivation targets active muscular trigger points, fascia in tension, and scars, not just muscles. The stimulus for myoActivation differs significantly due to needle type, insertion techniques, and tissue responses compared to other modalities. myoActivation uses cutting tip needles, which leads to a minimally traumatic stimulus that may trigger a spinal reflex, inducing muscle relaxation. myoActivation needles incorporate a syringe filled with saline but devoid of any pharmacologically active chemicals and do not utilize electrical stimulation. myoActivation and IMS both target myofascial or muscular trigger points [ 20 , 21 ], but the fine gauge hypodermic needles used for myoActivation are quickly inserted and withdrawn, not left in place. IMS and acupuncture may have in-situ needles in the body for 10-45 minutes and may be manipulated to stimulate muscle twitching and promote healing [ 22 , 23 ]. myoActivation principles dictate that the site of perceived pain is often not the true source of pain. For IMS, the site of pain is often the area targeted for treatment. After remedial causes for CLBP were excluded for patients in this series, myofascial dysfunction was determined to be a contributing component. The myoActivation assessment identifies myofascial sources of pain for all patients by considering each patient’s lifetime trauma, the mechanisms of any identified injuries, postural observations, and systematized BASE movement tests. This provides some diagnostic certainty and hope for targeted therapy especially when the classic medical examination revealed a normal neuromuscular examination. myoActivation examination is not only useful to diagnose myofascial dysfunction but also to show changes with subsequent myoActivation examinations. To recognize myofascial dysfunction, it is important to understand that many factors contribute to its development, such as genetics, nutrition, immune function, lifestyle, environmental factors cultural influences, ergonomic factors (e.g., overuse athletic activities, abnormal posture), structural factors (e.g., spondylosis, scoliosis, osteoarthritis), and lifetime physical impacts to the body (medical conditions, fractures, injuries and surgeries) [ 24 ]. When the skin is injured, the healing process leads to the formation of scar tissue. Remodeling of the scar and the deposition of type 1 collagen increases the strength of the tissue but decreases its elasticity. The subsequent reduced mobility and flexibility impacts not only the skin but also the underlying fascia and muscle. Scar tissue is associated with increased nerve density, neuropeptides, and nociceptors in scarred tissues. Scars were determined to be a contributing factor for all pain profiles within this case series: each patient had scars released, even in the two patients who did not self-report any scars. Scars are often overlooked but play a crucial role in the development and perpetuation of MFD&P as their presence can have significant biomechanical consequences by restricting the flexibility of the scarred skin and the underlying soft tissues [ 15 ]. When scars are released, even at sites distant from the area of complaint, the reduction of scar-related tension can improve pain, flexibility, and range of motion [ 15 , 17 , 18 ]. The fascial system is defined as “a three-dimensional continuum of soft collagen containing loose and dense fibrous connective tissue that permeates the body. It incorporates elements such as adipose tissue, adventitia, neurovascular sheaths, aponeurosis, deep and superficial fascia, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula, septa, tendons, visceral fascia, and all the intramuscular and intermuscular connective tissues including endo-/peri-/epi-mysium. The fascial system surrounds, interweaves between, and interpenetrates all organs, muscles, bones, and nerve fibers, endowing the body with a functional structure and providing an environment that enables all body systems to operate in an integrated manner" [ 25 ]. As the fascia interweaves and envelopes every structure within the body, it creates structural continuity that provides form and function to the human body [ 26 , 27 ]. It varies in thickness, function, composition, and direction depending on its location and purpose [ 26 ]. It is innervated and has proprioceptive and nociceptive properties [ 27 , 28 ]. Injury reduces the flexibility of the fascia. The subsequent defective fascial sliding generates anomalous tension, disorders of intermuscular interaction, and active trigger points in muscles leading to progressive immobility and pain [ 29 ]. Half of the patients in this study received fascial release at the iliac crest, further exemplifying how myofascial tissues at and around the pelvis can play an important role in CLBP, this is supported by other work focussing on the psoas muscle fascia [ 30 ] and the thoracolumbar and lumbar fascia [ 31 , 32 ]. For patients in this series, the myofascial tissues around the pelvis were important. The most activated muscles in our case series were the iliopsoas, abdominal wall muscles, and paraspinals. Previous studies have outlined the significance of the pelvic muscles in low back pain presentations [ 33 , 34 ] and intramuscular stimulation has been shown to be beneficial for CLBP [ 35 ]. Our patients in this series showed improvements in pain, not just from release around the pelvic muscles but also at peripheral or distant sites including the release of fascia and scars (i.e., the release of knee scars). The muscles, fascia, and skin are intricately connected within the myofascial system where myofascial release results in improvement of pain, flexibility, and range of motion [ 18 ]. These results strengthen the myoActivation principle that the site of perceived pain is often NOT the true source of pain. Limitations The small sample size restricts the ability to generalize these findings to a broader population. Our participants were all female patients, which introduces a gender bias, limiting the applicability of these results to male patients. The patients were treated by a single myoActivation clinician, which may influence the reproducibility of outcomes. The myoActivation process is structured but myoActivation clinician experience and learning have benefited from insights gained from past patients; therefore, the impact of myoActivation may have varied from the beginning of the study period compared to the end of the study. There was a relatively long time in CPS care (admission to discharge), as well as the time between the final myoActivation session and CPS discharge, which may be explained by the concurrence of the COVID-19 pandemic and its impact on in-person assessments at the time. Another contributing factor is the fear that pain will return, especially after so many years of lived experience with chronic pain: patients may request a long follow-up time to be sure they continue to feel better before they are finally discharged.

This case series provides preliminary evidence that myoActivation may be a clinically useful non-pharmacological tool in the assessment and management of appropriately selected adolescents with MFD&P and CLBP. myoActivation assessment can help diagnose MFD&P, and myoActivation treatment can help adolescents move from a pain-centered life to a function-centered life, even after years of pain. Myofascial dysfunction should be considered as a diagnostic category, not just for patients with CLBP but for any patient with a chronic pain presentation. Prospective longitudinal research is required to establish robust evidence confirming the clinical efficacy of this approach as a component of interdisciplinary care.

We retrospectively reviewed clinical records of adolescents aged 13-19 years old within the CPS. Patients were included if they reported CLBP and underwent myoActivation between August 2022 and January 2023. Patients were excluded if they had not yet been subsequently discharged from the CPS. The University of British Columbia - Children’s & Women’s Health Centre of BC Research Ethics Board waived the requirement for individual consent in approving this retrospective study (H21-00951, 02-Jun-2021). Key features of the patients’ conditions, treatment techniques, and patients’ responses were extracted and described. Information was gathered from the referring physician’s referral letter, completed parent and child admission forms, and documentation from patient appointments with the CPS. Information extracted from these records, when available, included (i) demographics; (ii) preclinical information, such as pain, trauma history, medical history, previous investigations, diagnoses, medical and other therapies, goals of CPS care, and the impact of pain on function and quality of life; (iii) details of CPS care, such as clinic recommendations, assessment, and interventions, and details of myoActivation assessment and therapeutic interventions; and (iv) discharge information, including recorded improvements at discharge for pain, sleep, mood, physical function, school attendance and goals of CPS care. Microsoft Excel (Microsoft Corporation, USA) was used for data collection and descriptive analysis. Assessment and treatment approach: myoActivation® myoActivation® is an innovative, structured approach designed to resolve MFD&P [ 17 ] (see Intellectual Property: Patents & Copyrights). This process, described in detail below, employs (i) a unique injury history, known as the Timeline of Lifetime Trauma (TiLT), (ii) a structured assessment process, and (iii) a non-pharmacological, needling therapy. myoActivation treatment results in immediately observed and reported changes in pain, flexibility, and ease of movement [ 18 ]. myoActivation combines three well-established techniques for managing chronic pain: intramuscular stimulation, scar release, and fascial release. The needling component of myoActivation is much less invasive than acupuncture, which is also an established technique for the management of chronic pain, including in children. For appropriately selected patients, myoActivation is discussed during their appointments, and consent is obtained from both the primary caregiver and youth. myoActivation is not offered to youth with needle aversion or procedural anxiety. Timeline of Lifetime Trauma (TiLT) The TiLT is a unique, detailed injury history focusing on past injuries, fractures, surgeries, and the associated scars as far back as the patient and family can remember. The most significant contributor to MFD&P is often the injury or scar from the youngest age. The mechanism of injury is sought for each event to help elucidate which soft tissues may have been impacted by an injury. Structured Posture and Movement Assessment myoActivation assesses for postural anomalies and limitations in systemized movement tests. Posture assessment includes the determination of the patients' perceived weight on feet, head position, shoulder height, torso alignment, hip height, pelvic orientation, and knee and feet positioning; all as indicators of differences in the symmetry of the body. The standardized movements are known as Biomechanical Assessment and Symmetry Evaluation (BASE) tests (Figure 1 ). The most restricted or painful BASE test indicates to the myoActivation clinician the most likely area where soft tissues are impacting myofascial dysfunction. For example, if the most restricted or painful BASE test is extension arms down (EAD), then the tissues most likely to be impactful are the abdominal wall tissues. The myoActivation clinician would inspect and palpate the abdominal wall to determine if there were muscles in sustained contraction, fascia in tension, or scars. The information amalgamated from the TiLT, posture assessment, and the examination help to determine the important soft tissue or tissues (as there may be more than one area contributing) to each individual patient's MFD&P. The seven core tests include (left to right): balance (BAL), extension arms raised (EAR), extension arms down (EAD), flexion arms down (FAD), squat arms down (SAD), squat arms raised (SAR), and lateral arches (LA). The related tissues are described below each movement demonstration, in red text. Originally published by Bhatnagar et al. [ 17 ]. Image credits: Gillian R. Lauder with illustrations by Shona Massey Treatment: Non-pharmacological Needling Technique myoActivation intervention is a needling technique utilizing fine gauge hollow-bore, cutting-tip hypodermic needles to release; significant scars, muscles in sustained contraction (known as activation), and fascia in tension [ 15 , 17 ]. To prevent needle-related pain in pediatric patients, the clinician should always employ a variety of non-pharmacological techniques including distraction, modification of breathing techniques, music, virtual reality, or mobile devices. A topical anesthetic cream can be applied to the target sites (especially scars) an hour before the appointment to minimize needle pain. Vapocoolant spray is also a useful topical agent to minimize discomfort with needling. Electrical stimulation is not used for myoActivation. The BASE tests and palpation are repeated after each treatment to determine the next most dominant myofascial soft tissue(s) that need to be treated. This repeated treatment and assessment process is known as "catenated cycles" [ 17 ]. The number of catenated cycles in any one myoActivation session depends on individual treatment needs, tolerance, and response. Once the BASE tests are improved, the myoActivation clinician uses different regional tests to resolve other sources of myofascial dysfunction, such as neck pain or headaches. myoActivation sessions are usually spaced one to two weeks apart. Patients may require two to six sessions to completely unravel multiple sources of MFD&P. Side effects include discomfort at the site of needling, infection, bruising, light-headedness, post-care fatigue, muscle aches, emotional responses, and, extremely rarely, pneumothorax when needling around the lung fields.