Introduction and defition

Refers to an area of exquisite tenderness in a palpable taught band. MTrPs can be active or latent. MTrPs can exist in other conditions such as whiplash injury, osteoarthritis; or on their own. In this case, they may compound symptoms of a pre-existing condition even after it has resolved. They may exist in absence of any medical condition of tissue injury. MTrPs involve local myofascial tissues, the central nervous system (CNS), and systemic biomechanical factors. There is a relationship between MTrPs and nearby articular dysfunction.

Myofascial pain syndrome (MPS) results when MTrPs cause sensory, motor and autonomic symptoms.

Characteristics of MTrPs

A MTrP contains three components:

• Sensory- mainly pain and muscle inhibition
• Motor- mainly muscle weakness
• Autonomic: MTrP in the head and neck would result in lacrimation (tears), coryza (nasal discharge) and salivation

The clinical picture of MTrPs

Myofascial trigger points can be divided into:

• Active MTrPs: Active MTrPs result in localised pain, referred pain and other abnormal sensations (paresthesia). They are present within a taught band of a muscle and give rise to a jump sign on palpation
• Latent MTrPs: This is a dormant area. A patient may present a nodular area in a taut band that does not usually produce pain on palpation. Later on, a latent trigger point may cause pain, if subjected to pressure, just like the active trigger point.
• Secondary MTrPs: This is a hyperirritable point in a muscle that becomes active as a muscular overactivity of another muscle
• Satellite MTrPs: A hyperirritable spot that becomes active because the muscle harbouring it is located within the region of another MTrP.

Essential criteria

During physical assessment, the following are an essential criteria for diagnosing MTrPs: Palpable taut band in muscle Spot tenderness of a nodule in band Patient's recognition of current pain complaint to pressure on nodule Painful limit to stretch motion.

Confirmatory criteria

Visual or tactile identification of local pathology

1. Observation of a local twitch response induced by needle penetration of a tender nodule
2. Altered sensation or pain on pressure on nodule along the area of expected distribution

Relationship between MTrPs and joint dysfunction

Due to a positive feedback loop, there is a close relationship between MTrPs and nearby joint dysfunction. For example, the following is commonly noted in clinical practice:

• Semispinalis capitis MTrPs with occipito-atlantal joint dysfuntion
• Semispinalis capitis MTrPs with occipito-atlantal and atlanto-axial dysfunctions
• Splenius MTrPs with upper thoracic articular dysfunctions

It is not uncommon to notice reduced range of motion (ROM) in a muscle crossing a joint if it has a MTrP. The MTrP exerts continuous compression on the articulation. This chronic compression results in soft tissues becoming more sensitive. It is this continuous sensitive that causes pain in the area. This then further activates MTrPs and the subsequent muscle tension. In the end, this positive feedback loop worsens articular distress. Muscle energy techniques (METs) to the dysfunctional muscle or fascia crossing the articulations can be used to indirectly treat articular dysfunctions. Specific techniques include strains-counter-strain (positional release) as well as myofascial release.

• Press and stretch

  This is a technique which starts with palpation of the MTrP with a single fingerpad while lengthening the affected muscle to a point of tissue resistance. Then it is followed by pressing the MTrP with a slow increase in pressure untill the finger encounters local tissue resistance (a barrier). Then the barrier is held untill the tension is released. This sequence is repeated in all other MTrPs found.

• Dry needling
• Vapacoolant and stretching
• Thermal treatment with ultrasound and infrared laser
• Articular methods
• Patient education
• ACh- or VsCC-attenuation techniques such as medications, herbs and nutrition

The pressing and stretching helps restore abnormally contracted muscle fibres to their normal resting length. Pereviously deep digital pressure was recommended. However, nowadays additional ischaemia is no longer recommended. Gentle digital pressure called trigger point pressure release is recommended. The best treatment for MTrPs and articular dysfunction must include patient education.

Treatment

Press and stretch. This is a technique which starts with palpation of the MTrP with a single fingerpad while lengthening the affected muscle to a point of tissue resistance. Then it is followed by pressing the MTrP with a slow increase in pressure untill the finger encounters local tissue resistance (a barrier). Then the barrier is held untill the tension is released. This sequence is repeated in all other MTrPs found. Dry needling Vapacoolant and stretching Thermal treatment with ultrasound and infrared laser Articular methods Patient education ACh- or VsCC-attenuation techniques such as medications, herbs and nutrition The pressing and stretching helps restore abnormally contracted muscle fibres to their normal resting length. Pereviously deep digital pressure was recommended. However, nowadays additional ischaemia is no longer recommended. Gentle digital pressure called trigger point pressure release is recommended. The best treatment for MTrPs and articular dysfunction must include patient education.

Importance of patient education

Patient education in the treatment of MTrPs is very important and some of the things a patient must know include:

• Disorders of poor posture perpetuate MTrPs and therefore good posture is encouraged.
• Biomechanical stress to the cold muscle is the one of the main reasons for the formation of MTrPs
• Avoiding excessive coffee intake and tobacco in order to reduce muscle hyperactivity
• Dietary intake of adequate vitamins and minerals since their deficiency has clinically demonstrated MTrP perpetuity. According to unpublished data by Simons, keeping blood vitamins to the mid-normal range increased effectiveness of manual and injection treatment of MTrPs and prevented a relapse of symptoms. Keeping vitamins and minerals below the mid-normal range resulted in a relapse of the MTrPs. Maintaining normal levels of blood haemoglobin is necessary to achieve last results from treatment of MTrPs. Keeping normal levels of magnesium, calcium and other trace elements is vital to muscle function.

Intake of herbal remedies and essential oils, mainly those containing linalool (a monoterpene that inhibit release of acetylecholine), has also been proven to be effective in relieving musculoskeletal pain. The herbal remedies include:

• Rosemary
• Piper methystium (Kava kava)
• Skullcap
• Passionflower
• Valerian
• Rose
• Marijuana