Myofascial Pain


Introduction

  • Virtually all pain has some myofascial origins.  It may be the primary source of the pain or it may just be a contributing factor.  Either way the pain can be improved by controlling the myofascial element.

  • "...studies suggesting that trigger points are a component of up to 93 percent of the pain seen in pain clinics, and the sole cause of such pain as much as 85 percent of the time. (1999:12;Gerwin 121;Fishbain 181 - 197)"   (from The Trigger Point Therapy Workbook pgs 17-18 2001)

Background

  • In August 2004, my wife developed a severe incapacitating headache.  It was nonstop and after several days I took her to the emergency room fearing a brain hemorrhage.  The doctors excluded life-threatening causes, gave her narcotics, and said it was a "tension" type headache.  The narcotics did not work and put her to sleep.  We saw a neurologist who gave her too much ibuprofen. The ibuprofen gave her a severe gastritis but no real headache relief.  Flexeril put her to sleep but not real pain relief.

  • We went to a chiropracter who gave her some significant relief decreasing her pain from a 10 to a 4 or 5.  The pain did come back though.  We went several times with some non-permanent relief.  We were on the right track but not precise enough.

  • We then went to a massage therapist and a physical therapist/massage therapist with more relief decreasing the pain down to a 2 - 3.  My wife did the recommended stretching but no permanent pain relief and no temporary complete pain relief.

  • During this time we went to a pain management physician who would inject a posterior occipital "trigger point".  He could not guarantee success so we held this treatment in reserve.

  • During all this, I was trying to duplicate daily/hourly whatever good the various therapists seem to produce.  I also bought the trigger point manual as a guide.  As we experimented I seemed to be getting better results that lasted longer than any of the above.

  • Eventually, we did eliminate the headaches.  My wife still has neck / shoulder pain with terrible "trigger points" which we can mechanically treat / stretch.   Part of the time they cause her no pain but they never disappear.  She appears to store her stress in these muscles and unfortunately life is not stress free.  We can keep the pain down and do not let it reach the headache stage.  She had headaches off and on throughout her entire life.  She no longer gets headaches.

  • Later I learned many of my physician colleagues believe in "trigger points" and some do inject them.  I believe they are the most significant cause of pain over all other causes.  I improved my neck pain and hip pain.  I improved my daughter's back pain.  "Lumbago" and "Sciatica" are commonly caused by "trigger points".  Many people suffer needlessly.  The best reference available is Myofascial Pain and Dysfunction - The Trigger Point Manual Vols 1 and 2 by David Simon, Janet Travell, and Lois Simons.  It is expensive - about $200 for the two volume set.  It will probably confuse the novice and the The Trigger Point Workbook is a better book to read first.

  • My "hobby" has helped several people and I hope the information on these web pages will do the same.

Basic Information

  • What is a "trigger point" ?  Spot tenderness in a muscle with usually a palpably tense band of muscle fibers.  Pain on compression can be excruciating.  This local pain is one way to recognize you are "on" the trigger point.

  • There are 3 signs and symptoms of active trigger points.  1 - referred pain, 2 - limited range of motion, 3 - muscle weakness.  Referred pain means the pain induced by trigger points usually does not occur near the trigger point but at a more distant site.  If you work / massage the area that hurts, it will never get better as it usually is not the trigger point.   The only way to successfully deal with trigger points is with a map of trigger points, muscles, and pain locations.  The other two symptoms are more subtle and may not be recognized by the patient.  They don't realize how limited they are until they compare themselves with a normal person.

  • Many common pain syndromes may have an underlying trigger point etiology.   Claire Davies in The Trigger Point Therapy Workbook says he had begun to wonder if "carpal tunnel" really existed as he saw so many cases due to trigger points.  An example list from Travell & Simons is here.

Treatment

  • Trigger points may be inactivated by several different methods listed below.

  • Ischemic compression: Push/compress the trigger point for 40 to 60 secs.  Use enough force to cause pain on a scale of 6 to 7 with 0 as no pain and 10 as unbearable pain.  This pain is short-lived and the relief provided will last much, much longer.  This should be done 5 to 6 times per day.  Or use as needed.  Better results with more frequent usage.

  • Stripping Massage: Compress the trigger point and stroke in one direction with short firm strokes.  Apply 10 - 12 strokes in one session.  This should be done 5 to 6 times per day.  Same pain level.

  • Ple: Best reserved for a physician.  The material injected is not critical though many physicians use xylocaine/lidocaine and possibly a steroid.  Saline works just as well.  A dry needle also works.  The tough part is penetrating the trigger point with the needle.

  • Spray and Stretch:  Very effective but you really have to know what you are doing.  Use a cold spray to lightly anesthetize the involve muscle (entire length) and then stretch through the trigger point.  Immediately reheat the muscle and move it through a full range of motion.  Effective but takes practice and Simon and Travells book.

  • Stretching with various techniques to assist:  Postisometric relaxation, reflex augmentation, reciprocal inhibition, contract-relax, hold-relax.  I have used postisometric relaxation coordinated with breathing and it does work.  On inhalation, isometrically contract the muscle to be stretched, on exhalation, stretch the muscle and trigger points.  Take baby steps and continually stretch the muscle gaining a little stretch with each breath.  

  • Ischemic compression with concominant stretch:   My favorite.  It takes no special tools or setup.  I believe ischemic compression gives the best, quickest short term pain relief.  However, not as long lasting as other methods.  Stretch gives the best long term relief and prophylaxis.  Stretching all your life is the best pain prevention.  Active trigger points cannot be stretched without some ancillary help.  Cold, compression, heat - all will enable stretching of trigger points.  

  • All of the above work.  It depends on the practitioner and their individual preferences and skills.

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