Trigger Points: Difference between revisions
No edit summary |
No edit summary |
||
| Line 8: | Line 8: | ||
== Definition/Description == | == Definition/Description == | ||
A Trigger Point (TrPt) is a hyperirritable spot, a palpable nodule in the taut bands of the skeletal muscles' fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness, local twitch response and referred pain which usually responds with a pain pattern distant from the spot | A Trigger Point (TrPt) is a hyperirritable spot, a palpable nodule in the taut bands of the skeletal muscles' fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness, local twitch response and referred pain which usually responds with a pain pattern distant from the spot<ref name=":0">Simons DG, Travell JG, Simons LS. Travell & Simons' myofascial pain and dysfunction: upper half of body. Lippincott Williams & Wilkins; 1999.[https://en.wikipedia.org/wiki/Myofascial_trigger_point][https://en.wikipedia.org/wiki/Referred_pain]</ref><ref name="Fernandez 2007">Fernández-de-las-Peñas,C.etal. Myofascial trigger points and sensitization: an updated pain model for tension-type headache,Cephalalgia, 2007, 27, 383–393</ref><ref name="David 2002">DAVID J. ALVAREZ, Et al. Trigger Points: Diagnosis and Management, AMERICAN FAMILY PHYSICIAN 2002 , 65, 4, 653-660</ref><ref name="Davidoff 1998">Davidoff, RA. Trigger points and myofascial pain: toward understanding how they affect headachesCEPHALALGIA 1998,18, 436-448</ref><ref name="Eduardo 2009">Eduardo Vázquez Delgad, et al. Myofascial pain syndrome associated with trigger points: A literature review. (I): Epidemiology, clinical treatment and etiopathogeny Med Oral Patol Oral Cir Bucal. 2009 Oct 1;14 (10):494-498.</ref>. | ||
'''Jump sign''' is the characteristic behavioural response to pressure on a TrPt. Individuals are frequently startled by the intense pain. They wince or cry out with a response seemingly out of proportion to the amount of pressure exerted by the examining fingers. They move involuntarily, jerking the shoulder, head, or some other part of the body not being palpated. A jump sign thus reflects the extreme tenderness of a TrPt. This sign has been considered pathognomonic for the presence of TrPts<ref name="Davidoff 1998" />. | '''Jump sign''' is the characteristic behavioural response to pressure on a TrPt. Individuals are frequently startled by the intense pain. They wince or cry out with a response seemingly out of proportion to the amount of pressure exerted by the examining fingers. They move involuntarily, jerking the shoulder, head, or some other part of the body not being palpated. A jump sign thus reflects the extreme tenderness of a TrPt. This sign has been considered pathognomonic for the presence of TrPts<ref name="Davidoff 1998" />. | ||
| Line 121: | Line 121: | ||
'''Examination''' | '''Examination''' | ||
<div> | <div> | ||
Examination through palpation can be performed standing, sitting or lying down. What we look for | Examination through palpation can be performed standing, sitting or lying down. What we look for are: | ||
* nodules (small or big ones) or lumps (one or several of them next to each other), | |||
* muscle stiffness and tight bands in the muscle like a string of a guitar, | |||
* temperature of the skin right above TrPs can be warmer or cooler, | |||
* compression of the TrP will elicit pain and will provocate twitch response, jump sign and worsening symptoms and strengthening of the pain locally and remotely - referrad pain map. The pain perception may also be delayed a few seconds<ref name="Davidoff 1998" />. <br>There have to be the ROM examination as well as postural examination. No laboratory test or imaging technique has been established for diagnosing TrPs<ref name="David 2002" />.<br> | |||
== Outcome Measures == | == Outcome Measures == | ||
| Line 136: | Line 133: | ||
== Medical Management == | == Medical Management == | ||
Pain management: | |||
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol(acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, and additionally NSAIDs reduce inflammation (swelling and irritation)<ref>Persons O. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-46.[https://www.webmd.com/pain-management/guide/pain-management-treatment-overview#1]</ref>.If over-the-counter drugs do not provide relief, doctor may prescribe muscle relaxants, anti-anxiety drugs (Valium), antidepressants (Cymbalta), prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (codeine), hydrocodone and acetominophen (Vicodin). | |||
Also, local anestethic injections should be considered, performed by physicians<ref name="Davidoff 1998" />. | |||
== Physical Therapy Management == | == Physical Therapy Management == | ||
The exact location of the trigger point should be palpated. Massage can cause the soft tissue back and that the different sarcomeres in the muscle of each other loose. <ref name="Arne 1998">Arne, N., et al. ‘Treatment of myofascial trigger-points with ultrasound combined with massage and exercise – a randomised controlled trial’., 1998, 77 pg. 73-79</ref> ''(Level of evidence 2b)'' | |||
* Predisposing and perpetuating factors in chronic overuse or stress on muscles must be eliminated, if possible<ref name="Fernandez 2007" />. | |||
* Posture training and education about good and bad postures and initiate with it in ADL and lifestyle<ref name="Davidoff 1998" />, | |||
* ultrasonography, heath, ice, diathermy, laser in reducing pain<ref name="Davidoff 1998" /><ref name="Fernandez 2005" />, | |||
* stretch of tight and shortened muscle, | |||
*ischemic compression <ref name="Fernandez 2005" /><ref name="Eduardo 2010" />and TrPt pressure release<br>The terms “ischemic compression” and “myotherapy” have been used to describe treatment in which ischemia is induced in the TrPt zone by applying sustained pressure. However, this principle is questionable, since the nucleus of the trigger point intrinsically presents important hypoxia . Simons et al. described a similar treatment modality, though without the need to induce additional ischemia in the TrPt zone (TrPt pressure release). The aim of this technique is to free the contracted sarcomeres within the TrPt. The amount of pressure applied should suffice to produce gradual relaxation of the tension within the TrPt zone, without causing pain.<ref name="Eduardo 2010" /> yet both techniques show imitate significant improvement of the ROM after treatment.<ref name="Grieve 2011">Grieve R, et al. The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial. J Bodyw Mov Ther. 2011 Jan;15(1):42-49</ref><ref name="montanez 2010">Montañez-Aguilera FJ. Et al. Changes in a patient with neck pain after application of ischemic compression as a trigger point therapy. J Back Musculoskeletal Rehabil. 2010;23(2):101-104.</ref> | |||
== Other managements == | == Other managements == | ||
These are other possible therapies written in literature. Note: not all of theme have strong scientifically evidence | These are other possible therapies written in literature. Note: not all of theme have strong scientifically evidence. A lot of the researches are not placebo-controlled and immediate effects after treatment may occur due to placebo-effects<ref name="Fernandez 2005" /><ref name="Eduardo 2010" />. | ||
* Dry Needling, | |||
* Acupuncture, | |||
* Laser therapy and Ionophoresis - mostly used as antidolorific treatments in physical therapy, | |||
* Prolotherapy (injecting solutions in region of TrPs: lidocaine, glycerine, phenol...) | |||
* Spray and Stretch, | |||
* Stretch and Release Techniques (some of them: MET, Taping, Reciprocal inibition, Postisometric relaxation...)<br> | |||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | ||
Revision as of 17:42, 24 June 2018
Original Editors -Sean Wauters
Top Contributors - Sean Wauters, Milijana Delevic, Mathilde De Dobbeleer, Admin, Kim Jackson, Aminat Abolade, Jonathan Wong, Lizzie Cotton, WikiSysop, Uchechukwu Chukwuemeka, Lucinda hampton, 127.0.0.1, George Prudden and Benjamin Desmedt
Definition/Description[edit | edit source]
A Trigger Point (TrPt) is a hyperirritable spot, a palpable nodule in the taut bands of the skeletal muscles' fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness, local twitch response and referred pain which usually responds with a pain pattern distant from the spot[1][2][3][4][5].
Jump sign is the characteristic behavioural response to pressure on a TrPt. Individuals are frequently startled by the intense pain. They wince or cry out with a response seemingly out of proportion to the amount of pressure exerted by the examining fingers. They move involuntarily, jerking the shoulder, head, or some other part of the body not being palpated. A jump sign thus reflects the extreme tenderness of a TrPt. This sign has been considered pathognomonic for the presence of TrPts[4].
Local twitch response - defined as a transient visible or palpable contraction of the muscle and skin as the tense muscle fibers contract when pressure is applied. Coursed by needle penetration or by transverse snapping palpation[2][3].
Referred pain, also called reflective pain, is pain perceived at a location other than the site of the painful stimulus. Pain is reproducible and does not follow dermatomes, myotomes, or nerve roots. There is no specific joint swelling or neurological deficits[3][4]. Pain from a myofascial trigger point is a distinct, discrete and constant pattern or map of pain with no gender or racial differences able to reproduce symptoms - referred pain map[6].
(Radiating pain is slightly different from referred pain; for example, the pain related to a myocardial infarction could either be referred or radiating pain from the chest. Referred pain is when the pain is located away from or adjacent to the organ involved; for instance, when a person has pain only in their jaw or left arm, but not in the chest)[1][2][3][4][7].
Anatomy and Etiology[edit | edit source]
Trigger points develop in the myofascia, mainly in the center of a muscle belly where the motor endplate enters (primary or central TrPs)[6]. Those are palpable nodules within the tight muscle at the size of 2-10 mm and can demonstrate at different places in any skeletal muscles of the body. May be present even at babies and children. Presence of TrPs is directly associated with myofascial pain, somatic dysfunction, psychological disturbance and restricted daily functioning[8].
Causes - Usually, TrPs happened due to:
- aging,
- an injury sustained by a fall, by stress or birth trauma.
- a lack of exercise - commonly in sedentary persons between 27,5-55 years of which 45% are men[9],
- a bad posture[10] - upper and lower crossed pattern, swayback posture, telephone posture, cross-legged sitting,
- muscle overuse and respective micro trauma - weightlifting,
- cronical stress condition - anxiety, depression, psychological stress trauma,
- vitamins deficiencies - vitamin C, D, B; folic acid; iron;
- sleep disturbance,
- joint problems and hypermobility.
Classification of TrPs[edit | edit source]
Primary / Central AND Secondary / Satellite Trigger Points
- Primary or Central TrPs are those that cause severe pain locally at the pressure with irradiation according to referred pain map. Usually are based around center of a muscle belly.
- Secondary or Satellite TrPs arise in response to existing central trigger points in surrounding muscles. They usually spontaneously withdraw when the central TrP is healed. Can be present in form of a cluster.
Active AND Inactive /Latent Trigger Points
- Active TrP is any point that causes tenderness and referral pain pattern on palpation. Almost always central TrPs are active and some satellite TrPs are also active (but non necessarily all of them). Inactive TrPs can evetually become active if there is a provocating factor.
- Inactive or Latent TrPs can develop in anywhere and under fingertips feel like lumps, but are not painful. Can increase stiffness of the muscles.
Diffuse Trigger Points
- Commonly happen in case of sever postural deformity where initially primary TrPs are multiple, so secondary multiple TrPs are only a response of a mechanism, called diffuse.
Attachment Trigger Points
- Arise in tendo-osseouss junctions which become very tender. If not treated, degenerative processes of adjacent joint can spring up.
Ligamentous Trigger Points
- Even ligaments can develop trigger points. Presence of TrPs in anterior longitudinal ligament of the spine can result in neck instability. Some knee pain syndrome are successfully healed when treated ligamentum patellae and fibular collateral ligament.
Pathogenesis and Theories[edit | edit source]
Little is known about the formation of TrPs. There are some theories written in literature who try to explain the formation, sensitization and manifestation of TrPs, but few of them have strong evidence[2][3][4][11][12].
Under normal conditions, pain from TrPs is mediated by thin myelinated (Ad) fibres and unmyelinated (C) fibres. Various noxious and innocuous events, such as mechanical stimuli or chemical mediators, may excite and sensitize Ad fibres and C fibres and thereby play a role in the development of TrPs[2].
Integrated Trigger Point Hypothesis (ITPH) is the present working hypothesis. When sarcomeres and motor endplate become overactive for a number of different reasons, pathological changes start at cellular levels. This turns on permanently sarcomeres leading to a local inflammatory response, loss of oxygen supply, loss of nutrient supply, endogenous (involuntary) shortening of a muscle fibers, and increased metabolic demand on local tissues[13]. Electrophysiological investigations of TrPs reveals phenomena which indicate that the electrical activity arises from dysfunctional extrafusal motor endplates rather than from muscle spindles[14][15].
Polymodal theory explains the existence of polymodal receptors (PMRs) throughout the body which under certain constant, pathological stimuli turn into trigger points[16].
Radiculopathic theory explains direct relationship between problems on nerve roots which lead to local and distant neurovascular signals and trigger points creation[17].
Peripheral and Central Sensitization - Central sensitization is a phenomenon, together with peripheral sensitization, which helps understanding chronic or amplified pain. There is central sensitization after intense or repetitive stimulus of the nociceptor present in the periphery, leading to reversible increase of excitability and of synaptic efficacy of central nociceptive pathway neurons. Manifested as hypersensitivity to pain (called tactile allodynia and hyperalgesia secondary to puncture or pressure). These CNS changes may be detected by electrophysiological or imaging techniques[18].
Differential Diagnosis[edit | edit source]
- Fibromyalgia - characterized by diffused fatigue and aches all over the body. More often in women, does not involve joints but does involve all other tissues (muscle, bone, tendon, ligaments and fat) and can develop tender points. Tender points are discrete areas of tenderness over soft tissues that cause local pain and are tender to palpation but patients do not present jump signs when pressed nor referred pain maps[4]. These two pain syndromes may overlap in symptoms and are difficult to differentiate without a thorough exam by a skilled physician[3][9]. (Level of evidence B). Although they may be concomitant and may interact with one another[9].
Other conditions which include muscle pain and trigger points:
- Musculoskeletal diseases
- Temporomandibular joint disorders
- Occupational myalgias
- Post-traumatic hyperirritability syndrome
- Joint dysfunction (osteoarthritis)
- Tendonitis and bursitis
- Neurological disorders
- Trigeminal neuralgia
- Glossopharyngeal neuralgia
- Sphenopalatine neuralgia
- Systemic diseases
- Sistemic lupus erythematosis (SLE)
- Rheumatoid arthritis
- Gout
- Psoriatic arthritis
- Infections (viral, bacterial, protozoan and parasitic and Candida albicans infection)
- Lyme disease
- Hypoglycemia and Hypothyroidism
- Heterotopic pain of central origin
- Axis II-type disorders
- Psychogenic pain
- Painful behaviors
- Prug reactions
Symptoms of Active Trigger Point[edit | edit source]
- a patient usually ask for help due to a chronic pain state (ex: headaches, aches everywhere, morning stiffness, TMJ syndrome, tinnitus...), which, in reality, is often away from the active trigger point,
- muscle weakness or imbalance, altered motor recruitment , in either the affected muscle or in functionally related muscles,
- changes in Range of Motion (ROM),
- painful movement and / or movement that sometimes can exacerbate symptoms,
- tension headaches, migraines, tinnitus, temporomandibular joint problems,
- postural abnormalities.
Diagnostic Procedures[edit | edit source]
Anamnesis
Anamnesis (a patient's account of their own clinical history) should be specific. The patient must be asked about fibromyalgia, as well as the presence of it in the family history of diseases. Also, the patient should be asked about his physical and daily activities in the presence and in the past as a lack of exercise and sedentary life may be a pathogenic factor. Furthermore, (chronic) muscle overuse, daily stress, medications (overuse), sleep disturbances have to be asked and examined in details.
Examination
Examination through palpation can be performed standing, sitting or lying down. What we look for are:
- nodules (small or big ones) or lumps (one or several of them next to each other),
- muscle stiffness and tight bands in the muscle like a string of a guitar,
- temperature of the skin right above TrPs can be warmer or cooler,
- compression of the TrP will elicit pain and will provocate twitch response, jump sign and worsening symptoms and strengthening of the pain locally and remotely - referrad pain map. The pain perception may also be delayed a few seconds[4].
There have to be the ROM examination as well as postural examination. No laboratory test or imaging technique has been established for diagnosing TrPs[3].
Outcome Measures[edit | edit source]
Fischer has proposed the use of a pressure threshold meter (algometer), as a means of quantitative documentation of TrPs, and for quantifying the effects of the physical therapy treatment. Pressure pain threshold and visual analogue scale (VAS) scores were the outcome measures more used in the analyzed trials. ROM also may be an outcome measurement for evaluating therapy[12].
Medical Management[edit | edit source]
Pain management:
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol(acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, and additionally NSAIDs reduce inflammation (swelling and irritation)[19].If over-the-counter drugs do not provide relief, doctor may prescribe muscle relaxants, anti-anxiety drugs (Valium), antidepressants (Cymbalta), prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (codeine), hydrocodone and acetominophen (Vicodin).
Also, local anestethic injections should be considered, performed by physicians[4].
Physical Therapy Management[edit | edit source]
The exact location of the trigger point should be palpated. Massage can cause the soft tissue back and that the different sarcomeres in the muscle of each other loose. [20] (Level of evidence 2b)
- Predisposing and perpetuating factors in chronic overuse or stress on muscles must be eliminated, if possible[2].
- Posture training and education about good and bad postures and initiate with it in ADL and lifestyle[4],
- ultrasonography, heath, ice, diathermy, laser in reducing pain[4][12],
- stretch of tight and shortened muscle,
- ischemic compression [12][9]and TrPt pressure release
The terms “ischemic compression” and “myotherapy” have been used to describe treatment in which ischemia is induced in the TrPt zone by applying sustained pressure. However, this principle is questionable, since the nucleus of the trigger point intrinsically presents important hypoxia . Simons et al. described a similar treatment modality, though without the need to induce additional ischemia in the TrPt zone (TrPt pressure release). The aim of this technique is to free the contracted sarcomeres within the TrPt. The amount of pressure applied should suffice to produce gradual relaxation of the tension within the TrPt zone, without causing pain.[9] yet both techniques show imitate significant improvement of the ROM after treatment.[21][22]
Other managements[edit | edit source]
These are other possible therapies written in literature. Note: not all of theme have strong scientifically evidence. A lot of the researches are not placebo-controlled and immediate effects after treatment may occur due to placebo-effects[12][9].
- Dry Needling,
- Acupuncture,
- Laser therapy and Ionophoresis - mostly used as antidolorific treatments in physical therapy,
- Prolotherapy (injecting solutions in region of TrPs: lidocaine, glycerine, phenol...)
- Spray and Stretch,
- Stretch and Release Techniques (some of them: MET, Taping, Reciprocal inibition, Postisometric relaxation...)
Recent Related Research (from Pubmed)[edit | edit source]
see tutorial on Adding PubMed Feed
Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=12__a65sE8_hVP0dHKXhC1m7eA01IRt4t6jbu7u8J7cg25: Error parsing XML for RSS
References[edit | edit source]
- ↑ 1.0 1.1 Simons DG, Travell JG, Simons LS. Travell & Simons' myofascial pain and dysfunction: upper half of body. Lippincott Williams & Wilkins; 1999.[1][2]
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Fernández-de-las-Peñas,C.etal. Myofascial trigger points and sensitization: an updated pain model for tension-type headache,Cephalalgia, 2007, 27, 383–393
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 DAVID J. ALVAREZ, Et al. Trigger Points: Diagnosis and Management, AMERICAN FAMILY PHYSICIAN 2002 , 65, 4, 653-660
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Davidoff, RA. Trigger points and myofascial pain: toward understanding how they affect headachesCEPHALALGIA 1998,18, 436-448
- ↑ 5.0 5.1 Eduardo Vázquez Delgad, et al. Myofascial pain syndrome associated with trigger points: A literature review. (I): Epidemiology, clinical treatment and etiopathogeny Med Oral Patol Oral Cir Bucal. 2009 Oct 1;14 (10):494-498.
- ↑ 6.0 6.1 6.2 Niel-Asher S. The concise book of trigger points: a professional and self-help manual. North Atlantic Books; 2014.[3]
- ↑ Ray BS, Wolff HG. Experimental studies on headache: pain-sensitive structures of the head and their significance in headache. Archives of Surgery. 1940 Oct 1;41(4):813-56.[4]
- ↑ Simons DG, Travell JG, Simons LS. Travell & Simons' myofascial pain and dysfunction: upper half of body. Lippincott Williams & Wilkins; 1999.[5]
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Eduardo Vázquez-Delgado. Et al. Myofascial pain associated to trigger points: A literature review. Part 2: Differential diagnosis and treatmentMed Oral Patol Oral Cir Bucal. 2010 Jul 1;15 (4):639-643
- ↑ Han SC, Harrison P. Myofascial pain syndrome and trigger-point management. Reg Anesth 1997;22: 89-101.
- ↑ Elizabeth A. et al. Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials European Journal of Pain 13 (2009) 3–10
- ↑ 12.0 12.1 12.2 12.3 12.4 Fernandez de las Penas, C., et al. Manual therapies in myofascial trigger point treatment: a systimatic review: Journal of Bodywork and Movement Therapies (2005) 9, 27–34
- ↑ Fernández-de-las-Peñas,C.etal. Myofascial trigger points and sensitization: an updated pain model for tension-type headache,Cephalalgia, 2007, 27, 383–393
- ↑ Simons DG. Clinical and etiological update of myofascial pain from trigger points. Journal of musculoskeletal pain. 1996 Jan 1;4(1-2):93-122.[6]
- ↑ Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams & Wilkins, 1999:11-93
- ↑ Kawakita K, Itoh K, Okada K. The polymodal receptor hypothesis of acupuncture and moxibustion, and its rational explanation of acupuncture points. InInternational Congress Series 2002 Aug 1 (Vol. 1238, pp. 63-68). Elsevier.[7]
- ↑ Gunn CC, Wall PD. The Gunn approach to the treatment of chronic pain: intramuscular stimulation for myofascial pain of radiculopathic origin. Churchill Livingstone; 1996.[8]
- ↑ Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011 Mar 1;152(3):S2-15.[9]
- ↑ Persons O. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-46.[10]
- ↑ Arne, N., et al. ‘Treatment of myofascial trigger-points with ultrasound combined with massage and exercise – a randomised controlled trial’., 1998, 77 pg. 73-79
- ↑ Grieve R, et al. The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial. J Bodyw Mov Ther. 2011 Jan;15(1):42-49
- ↑ Montañez-Aguilera FJ. Et al. Changes in a patient with neck pain after application of ischemic compression as a trigger point therapy. J Back Musculoskeletal Rehabil. 2010;23(2):101-104.
