Causing Most Of The World’s Pain, Anonymously – Myofascial Trigger Points
For centuries it has been afflicting man. It is intangible, mysterious and yet ubiquitous. Myofascial Trigger Points are the commonest cause of undiagnosed or misdiagnosed aches, pains and other puzzling symptoms. The daily clinical experience of thousands of physiotherapists, massage therapists and physicians verifies that most back, neck pain and headaches; which are recurrent and stubborn, caused by trigger points or muscles knots.
Jane, in her 40s, suffered from recurrent one-sided headaches over the eye, behind the ear and on top of the head. On days when she gripped with a bad attack of pain, she felt a spill of pain on her cheek, back molar teeth and the ear. It didn’t help to have occasional ringing in her ears and dizziness which she related to chronic sinusitis. Given her symptom complex over 2 years, she had seen several doctors, had scans, trigeminal nerve tests and medications.
She happened to talk to a friend who treated neck pain with us and mentioned; that she should give physiotherapy a shot for her headaches. On her first visit; trigger points in her Sternocleidomastoid muscle found. She surprised how the front of her neck never hurt. However, when I applied pressure on the trigger points in her neck it spread her pain in the exact location of her headache. Over the next few sessions, she excitedly reports that her cheek, teeth and ear pain had disappeared. It is perplexing to her that her sinus symptoms have cleared too!
What makes trigger points fascinating is how they often cause pain far away from the actual site where they exist, i.e. referred pain.
Symptoms Of Myofascial Trigger Points
Referred pain caused by trigger points do not fit into the more familiar dermatomal or myotomal patterns. This seen in radiculopathy. The referral patterns have been studied and well documented for hundreds of years. They are available as detailed trigger point charts. Each trigger point (TrP) has a predictable referral pattern with only slight variation. This heralding discovery by Janet Travell and David Simons who are pioneers in the area of Myofascial TrP provided the impetus in making their localization and treatment evidence-based.
An example of this far away pain referral is in a patient who presented with carpal tunnel syndrome. The median nerve, however, not involved when examined. Interestingly the muscle (subscapularis) in the armpit had a trigger point which was the culprit! Back pain almost always has a myofascial component. Besides the back muscles which can harbour trigger points, surprisingly pain in the low back can be due to trigger points in the stomach, buttock or calf muscles.
Besides musculoskeletal pain, myofascial trigger points can cause toothaches or earaches, e.g. from muscles in the jaw area.
Some of the other intriguing symptoms caused by trigger points are numbness or hypersensitivity. Autonomic symptoms such as increased perspiration or nasal secretions, hyperemia, nausea and dizziness may be associated with trigger points.
So What Are Myofascial Trigger Points?
A trigger point or a muscle knot, as it is often termed, is an area of contraction within a muscle. This can likened to a small patch of spasm in a muscle; and is different from the entire muscle being tight. Because of the local contraction, the blood flow to the immediate area stops resulting in a restriction of the blood supply (ischemia).
This leads to the accumulation of metabolic waste products and toxins which sensitize the trigger point causing it to send out pain signals and further increase contraction. Thus the local physiology of a trigger point involves a vicious cycle of a metabolic crisis.
Clinically trigger points, identified by examining signs, symptoms as well as by manual palpation. Usually, there is a taut band in the affected muscle, and along with this band, one can feel a hard nodule which is the trigger point. A twitch response, often elicited when pressure applied followed by a spread of the referred pain. For objective validity of trigger points research has used various tools – EMG, HiRes imaging ultrasound, algometry and tissue biopsy.
The recent use of Magnetic resonance elastography (MRE) imaging (which is a modification of MRI) and recovering small molecules in vivo from tissues has provided groundbreaking evidence in the existence, detection and chemical nature of myofascial trigger points.
How Do We Treat Myofascial Trigger Points?
While several methods are available in the treatment of trigger points, e.g.: dry needling, spray and stretch, manual compression is one of the most effective ways to treat trigger points. The therapist palpates the muscle and locates the TrP along with the taut band and applies pressure to deactivate the TrP. This followed by stretching the muscles using various techniques. Current research states that deactivating a TrP can normalize or reset processes in a muscle through gamma motor control; this will stretch an overactive muscle or improve functioning in a poorly functioning muscle.
The crux of treatment is identifying the causes which lead to the development of trigger points and correcting them. Faulty postures, bad ergonomics, a structural variation e.g. scoliosis or short leg, overuse and injury are a few. Parallel to releasing the trigger points we change muscle imbalances which stress muscles and create overuse in some. The fascial covering of a muscle treated with myofascial releases. This is to resolve strain patterns. Muscles will return to positions where trigger points will re-develop. This is unless all these factors are considered for treatment.
Myofascial Release is a form of hands-on therapy used to relieve pain and to relax muscles and tissue. “Myo” refers to the muscle, and “fascial” refers to the smooth tough tissue that covers all the muscles.
In a normal healthy body, the fascia is relaxed and soft. It can stretch and move without restriction. However, it becomes tight and restricted when our body experiences physical trauma or inflammation of the fascia. Trauma such as a fall, whiplash or habitual poor posture can have a cumulative effect over time to tighten the fascia.
Myofascial release is applied directly on the body and uses slow and sometimes deep pressure to restore the proper health of the fascia.
Myofascial release has been used effectively in the treatment of:
- Low back pain
- Neck Stiffness
- Sports injuries
- The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies
- Myofascial Pain and Dysfunction: The Trigger Point Manual by David Simons, Janet Travell, Lois Simons
- Archives of Physical Medicine and Rehabilitation, 2008
- New Views of Myofascial Trigger Points: Etiology and Diagnosis, Archives of Physical Medicine and Rehabilitation 2008
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- Temporomandibular Joint: Jaw Pain? Physiotherapy Can Help.
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