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Myofascial trigger points

Noninvasive treatment options

Research suggests that myofascial trigger points (MTP) are prevalent in all patient populations, and are not exclusive to people with chronic disorders of the musculoskeletal system (1). Skeletal muscle is the largest single organ of the human body, which provides ample potential sites for development of myofascial trigger points (1). MTPs have the capability to cause motor dysfunction through stiffness and restricted range of motion and to create pain. These impairments can greatly restrict activities of daily living.  

A myofascial trigger point is a hyperirritable area in skeletal muscle, or in muscle fascia, that is associated with a palpable nodule (2). Trigger points are commonly located by palpation. Criteria to help the practitioner to identify MTPs include: a tender spot on a taut muscle band, local twitch response elicited by palpation, referred pain or altered sensation, and restricted range of motion in the joint the muscle crosses (3). Trigger points can be categorized as either active or latent. Active MTPs cause pain with active muscle contraction or at rest.  Latent MTPs do not create pain but limit range of motion and produce weakness of the muscle (3). It is thought that trigger points may develop from trauma, repetitive microtrauma to muscles (overload), neuropathy of the nerve serving the affected muscle, postural faults or psychological stress (1,2). 

Subjectively, patients with MTPs will report poorly localized, regional, aching pain in tissues, stiffness, restricted motion and sleep disturbance. Upon objective examination, the clinician will observe disturbances of motor function caused by MTPs including weakness of involved muscle, loss of coordination, and decreased work tolerance of the involved muscle. MTPs can commonly be located inpostural muscles of the neck, shoulder, pelvic girdle and the muscles of mastication (1). If the MTP is not addressed then the patient will compensate with alternate muscles and activation sequencing to perform the activity. This substitution can further establish weakening and deconditioning of the involved muscle. 

Invasive treatment strategies such as Intramuscular Stimulation (IMS) and noninvasive techniques such as ischemic pressure, have been recognized for MTPs

The goal of treatment is to decrease trigger point sensitivity and restore range of motion and impaired movement patterns. A recent systematic review of the literature investigating myofascial trigger points and management conclude that manual therapies are useful in short term relief of trigger point pain (4). Specifically, it supports the use of ischemic pressure. Ischemic pressure is a technique, which involves application of gentle persistent digital pressure producing elimination of the trigger point. Pressure is applied and maintained until the clinician feels reduction in tension (5). Further, a study conducted by Hanten et al. found a home program of ischemic pressure and sustained stretching was effective in reducing MTP sensitivity and pain intensity (6). 

After locating and treating a trigger point, a therapist will provide explanation of predisposing activities including postural faults and biomechanical errors to prevent further perpetuation of MTPs. Follow up visits consist of correction of these elements by manual therapy and instruction in a variety of home-based exercises to correct compensatory patterns and deconditioning.

References:

1. Simons DG, Travell JG & Simons LS. Myofascial pain and dysfunction: The trigger point manual 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1999.
2. Lavelle DL, Lavelle W & Smith HS. (2007) Myofascial trigger points. The medical clinics of north America. 91: 229-239.
3. Hou CR, Tsai LC, Cheng KF, Chung KC and Hong CZ. (2002) Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 83:1406-1414.
4. Veron H and Scheinder M. (2009) Chiropractic management of myofascial trigger points and myofascial pain syndrome: A systematic review of the literature. Journal of manipulative and physiological therapeutics. 32:1. 14-24.
5. Simons DG. (2002) Understanding effective treatments of myofascial trigger points. Journal of bodywork and movement therapies. 6:2. 81-88.
6. Hanten WP, Olson SL, Butts NL and Nowicki AL. (2000) Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial triggers points. Physical Therapy. 80:10. 997-1003.