From a Clinical Perspective, Myofascial Trigger Points Describe a Phenomenon
An international panel of 60 clinicians and researchers was recently consulted to establish a consensus for identification of a myofascial trigger point (MTrPs). The panel agreed on two palpatory and one symptom criteria: a taut band, a hypersensitive spot, and referred pain (Fernández-de-Las-Peñas & Dommerholt 2018).
These clinical findings may be help clinicians investigate common pain patterns, such as:
• Neck Pain (Morikawa et al. 2017)
• Migraine Headaches (Landgraf et al. 2018)
• Tension-Type Headache (Fernández-De-Las-Peñas & Arendt-Nielsen 2017)
• Carpal Tunnel Syndrome (Meder et al. 2017)
• Low Back Pain (Takamoto et al. 2015)
• Chronic Pelvic Pain (Fuentes-Márquez et al. 2018)
Sore Spots Exist, but Their Etiology is Still Not Well Understood.
It has been demonstrated that patients benefit from hands on work aimed at MTrPs, but this may not always be due to reasons we once were taught. One issue is that ascribing patient’s pain solely to MTrPs or other tissue-driven pain problem is often an oversimplification of a complex process. When it comes to MTrPs there are a number of competing hypothesis, including, but not limited to:
- Cinderella Hypothesis - low-level, continuous muscle contractions overload tissues and makes “Cinderella” fibers susceptible to calcium dysregulation and subsequently sarcomere contracture (Bron et al. 2012).
- Expanded Integrated Hypothesis - the zone around a MTrP seems to be in an ischemic state resulting in a shortage of glucose and oxygen for metabolism and subsequent sarcomere contracture (Gerwin et al 2004).
- Neurogenic Inflammation - the release of inflammatory substances from the nerve axon, result in a lower the threshold for depolarization (Quintner et al. 2015).
- Central Sensitization - several studies support the hypothesis that persistent nociceptive input from MTrP contributes to the development of central sensitization and/or changes in the dorsal horn. In contrast, preliminary evidence suggests that central sensitization can also promote MTrP activity (Fernández-de-las-Peñas et al. 2014).
Stepping Back: What is the Big Picture?
The explanations used in the past of this observable phenomenon seem to be flawed in reasoning, but I do not think there is a need to abandon a multidimensional treatment approaches that provide patients with pain relief. What is needed is an updated explanation of myofascial triggerpoints aligned with the biopsychosocial model pain.
More to Explore
Arendt-Nielsen, L., Castaldo, M., Mechelli, F., & Fernández-De-Las-Peñas, C. (2016). Muscle Triggers as a Possible Source of Pain in a Subgroup of Tension-type Headache Patients? The Clinical Journal of Pain.
Bron, C., Dommerholt, J.D. (2012). Etiology of myofascial trigger points. Curr Pain Headache Rep.
Chen, Q., Wang, H., Gay, R. E., Thompson, J. M., Manduca, A., An, K., . . . Basford, J. R. (2016). Quantification of Myofascial Taut Bands. Archives of Physical Medicine and Rehabilitation. Archives of Physical Medicine and Rehabilitation.
Courtney, C.A., Fernández-de-Las-Peñas, C., Bond, S. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.
Fernández-de-las-Peñas, C., Dommerholt, J. (2014). Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep.
Fernández-De-Las-Peñas, C., Arendt-Nielsen, L. (2017). Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev Neurother.
Fernández-de-Las-Peñas, C., Dommerholt, J. (2018). International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain Med.
Fuentes-Márquez, P., Valenza, M.C., ... Ocón-Hernández, O. (2018). Trigger Points, Pressure Pain Hyperalgesia, and Mechanosensitivity of Neural Tissue in Women with Chronic Pelvic Pain. Pain Med.
Gerber, L.H., Sikdar, S., Aredo, J.V., Armstrong, K., Rosenberger, W.F., Shao, H., Shah, J.P. (2017). Beneficial Effects of Dry Needling for Treatment of Chronic Myofascial Pain Persist for 6 Weeks After Treatment Completion. PM R.
Gerwin, R.D., Dommerholt, J., Shah, J.P. (2004). An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep.
Gerwin, R.D. (2018). Trigger Point Diagnosis: At Last, the First Word on Consensus. Pain Medicine.
Grosman-Rimon, L., Clarke, H., ... Kumbhare, D. (2017). Clinicians' perspective of the current diagnostic criteria for myofascial pain syndrome. J Back Musculoskelet Rehabil.
Kumbhare, D.A., Ahmed, S., Behr, M.G., Noseworthy, M.D. (2018). Quantitative Ultrasound Using Texture Analysis of Myofascial Pain Syndrome in the Trapezius. Crit Rev Biomed Eng. https://www.ncbi.nlm.nih.gov/pubmed/29717675
Landgraf, M.N., Biebl, J.T., Langhagen, T., Heinen F. (2018). Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? - A prospective controlled observational study. Eur J Pain.
Nascimento, J.D.S.D., Alburquerque-Sendín, F., Vigolvino, L.P., Oliveira, W.F., Sousa, C.O. (2018). Inter and intraexaminer reliability in identifying and classifying myofascial trigger points in shoulder muscles. Arch Phys Med Rehabil.
Meder, M.A., Amtage, F., Lange, R., Rijntjes, M. (2017). Reliability of the Infraspinatus Test in Carpal Tunnel Syndrome: A Clinical Study. J Clin Diagn Res.
Mayoral Del Moral, O., Torres Lacomba, M., ... Sánchez Sánchez, B. (2018). Validity and Reliability of Clinical Examination in the Diagnosis of Myofascial Pain Syndrome and Myofascial Trigger Points in Upper Quarter Muscles. Pain Med.
Moraska, A.F., Schmiege, S.J., Mann, J.D., Butryn, N., Krutsch, J.P. (2017). Responsiveness of Myofascial Trigger Points to Single and Multiple Trigger Point Release Massages: A Randomized, Placebo Controlled Trial. Am J Phys Med Rehabil.
Morikawa, Y., Takamoto, K., Nishimaru, H., ... Nishijo, H. (2017). Compression at Myofascial Trigger Point on Chronic Neck Pain Provides Pain Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Front Neurosci. (OPEN ACCESS)
Nasirzadeh, Y., Ahmed, S., Monteiro, S., Grosman-Rimon, L., Srbely, J., Kumbhare, D. (2018). A Survey of Healthcare Practitioners on Myofascial Pain Criteria. Pain Pract.
Palacios-Ceña, M., Wang, K., ... Fernández-de-Las-Peñas, C. (2018). Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache. Cephalalgia.
Palacios-Ceña, M., Castaldo, M., ... ,Fernández-de-Las-Peñas, C. (2017). Relationship of active trigger points with related disability and anxiety in people with tension-type headache. Medicine (Baltimore). (OPEN ACCESS)
Quintner, J., Bove, G., & Cohen, M. (2015). A critical evaluation of the trigger point phenomenon. Rheumatology.
Rathbone, A.T., Grosman-Rimon, L., Kumbhare, D.A. (2017). Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain.
Simons, D.G. (2008). New views of myofascial trigger points: etiology and diagnosis. Arch Phys Med Rehabil.
Shah, J., Thaker, N., Heimur, J., Aredo, J., Sikdar, S., & Gerber, L. (2015). Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. Pm&r. (OPEN ACCESS)
Takamoto, K., Bito, I., Urakawa, S., Sakai, S., Kigawa, M., Ono, T., Nishijo, H. (2015). Effects of compression at myofascial trigger points in patients with acute low back pain: A randomized controlled trial. Eur J Pain.