Another Great Imitator – Trigger Points, Pain and Dysfunction

Another Great Imitator – Trigger Points, Pain and Dysfunction

I wrote earlier about Lyme Disease and its status as the Great Imitator in Medicine.  Lyme Disease mimics (or causes) many diseases, cutting across many medical specialties, thus complicating diagnosis and treatment.  Myofascial Trigger Points are the Great Imitators of Physical Medicine - that is, the symptoms associated with Myofascial Trigger Points (“TPs”) mimic many other medical ailments and, more often than not, are overlooked and untreated.  The good news is that Trigger Point Therapy is relatively easy to do for trained practitioners and often provides near immediate relief.  The bad news is that very few practitioners have thorough training in Trigger Point Therapy.   

Myofascial:   Myo means muscle.  Fascia refers to a sheath-like connective tissue that surrounds and separates all muscles and organs, holding everything in place.  If everything else were sucked out of your body except the fascia, you would still be recognizable as a mummy-like image of yourself.

In laymen’s terms, Trigger Points are small tender knots in a taut band of muscle that can be found by skilled physical examination.  Applying the proper pressure to an active Trigger Point actually reproduces the symptoms associated with that Trigger Point.  Active Trigger Points are well known for causing pain – either right at the Trigger Point’s location, or referred pain, up to several inches away from the Trigger Point.  Aside from pain, Trigger Points can also cause restricted range of motion, dizziness, tingling, nausea, stiffness, sweating, bladder issues, numerous other functional disorders, and autonomic phenomena.  As such, Trigger Points are the Great Imitators of Physical Medicine. 

Physical Medicine:  Practitioners of Physical Medicine specialize in restoring optimal function to people with injuries to the muscles, connective tissue, ligaments, or the nervous system – as opposed to Internal Medicine, which is the diagnosis and treatment of organic and other diseases.

Trigger Points are extremely common and become a painful part of nearly everyone’s life at one time or another.  In one study at a medical center pain clinic, a neurologist examining 96 patients found that 93% had at least part of their pain caused by Myofascial Trigger Points, and in 74% of the patients TPs were considered to be the primary cause of pain.  There are over 400 muscles in the human body and any of them can develop Trigger Points causing pain and dysfunction.  Still, Trigger Points receive very little attention in medical training and in most acupuncture training programs, as well.  It’s no wonder that they are frequently overlooked and missed.  The dry needling & acupuncture treatment of Trigger Points are becoming a hot topic in Physical Medicine today with turf wars as to which discipline is best suited to provide the best care. 

The One Begets the Many . . . Sometimes

Additionally, Satellite Trigger Points may be generated as a result of the pain associated with a Primary Trigger Point.  For example, a TP in the low back can cause pain in the buttocks muscles – in turn, this can generate additional TPs in the buttocks (gluteal muscles) as a response to that pain.  These Satellite Trigger Points can cause additional pain symptoms elsewhere in the back or down the leg.  A successful treatment requires that all the Trigger Points be treated.  This illustrates the importance of a thorough exam in this work.  Trigger Point Therapy can be time consuming – and fascinating.

Trigger Points are Presidential

Trigger Point Therapy was extensively researched and developed by the late Dr. Janet Travell and her colleague, Dr. David Simons.  Dr. Travell was JFK’s personal physician in the Whitehouse.  JFK suffered from chronic pain and back issues.  Dr. Travell kept him up and running, so to speak, and was considered indispensible by the Kennedys.  Drs. Travell and Simons ‘mapped’ the locations of hundreds of Trigger Points and documented the symptoms caused by each Trigger Point - including pain, dysfunction, and autonomic phenomena.  Together, they wrote the comprehensive, two volume textbook:  ‘Myofascial Pain and Dysfunction: The Trigger Point Manual,’ a classic of physical medicine. 

Life Causes Trigger Points

Trigger points can be activated by overuse or overloading a muscle, i.e. shoveling snow or strenuous repetitive motions.  Even sleeping in an awkward position or habitually holding a phone between your neck and shoulder can activate trigger points.  There is evidence that viral illness can activate trigger points.  Nerve compression (sciatica, carpal tunnel, etc.) and organic disease can also contribute to the activation of trigger points, as can emotional distress and sports injuries.  

Treatment Options

Doctors trained in TP Therapy generally treat TPs by inserting a hypodermic needle and injecting lidocaine into them.  Acupuncturists trained in TP Therapy treat TPs with much thinner, flexible, less invasive acupuncture needles – which are safer, just as effective, and without the painful pinch associated with hypodermic needles.  The acupuncturist uses a special technique to elicit a twitch response from the muscle bypassing the need for lidocaine.  Some physicians are adopting the acupuncture needle now for this kind of work, recognizing the safety and comfort advantages to this approach. 

If Trigger Points sound kind of mysterious . . . they are.  It is still not understood exactly how Trigger Points form, or cause symptoms – just that they do.  The mechanism for Trigger Point phenomena is likely related to the properties of fascia (connective tissue) surrounding muscles and organs.  Trigger Point Therapy, done properly, is a labor intensive, skilled craft.  It takes years of practice to become truly adept at it.  If there were a profitable drug to treat TPs, there would no doubt be more research into fascia as a source of pain and dysfunction. 

Acupuncture, Trigger Points, and Fascia  . . .

Some modern theories of acupuncture postulate that the therapeutic actions of acupuncture are due to the stimulation of fascia in key locations.   A 1977 paper by Melzack, Stillwell, & Fox found that over 90% of mapped Trigger Points coincide with acupuncture points, and the referred symptoms frequently coincide with mapped acupuncture meridians.  Is it possible that Dr. Travell unknowingly discovered aspects of Acupuncture without any pre-existing knowledge of Acupuncture?   

Acupuncture Points are located on Acupuncture Meridians – think of the NYC Subway Map – imagine Acupuncture Points as the subway stations and Acupuncture Meridians as the subway routes.  The meridians help the acupuncturist navigate the body.   

Miracle Cures or Placebo?   . . .  Neither - just Trigger Point Therapy

One of the common refrains I hear from patients is, “I’ve tried everything else, can acupuncture help me.” Every acupuncturist has their success stories that they like to include in website testimonials.  To the patient who has seen numerous doctors and practitioners without benefit, a successful acupuncture treatment can feel like a miracle (well, a minor miracle).  The majority of so-called Acupuncture Miracle Treatments in my clinic were simply successful Trigger Point Therapy treatments.  The fact that TPs sometimes cause such unusual symptoms makes some of the cases sound more fantastical than they really are.  

Some of my more interesting 'quick fix' cases include:

·      A patient with elbow pain radiating down the arm that was found to be caused by a TP in the serratus muscles over the ribcage.  The patient had been painting indoors, using an overhead roller with repetitive motion over the course of a weekend.  The guilty TP was nowhere near where I was expecting to find a source of elbow pain.

·      A middle-aged woman able to avoid knee surgery after coming in to 'try' acupuncture for injuries sustained in a kayaking accident.  I treated a TP on her upper thigh that turned out to be the cause of referred aching pain in her knee.  

·      An elderly male patient with an active TP on his upper thigh that made it difficult for him to raise his leg and navigate stairs.  Treatment immediately corrected his range of motion.  Like acupuncture points, some TPs have useful names - this one is called the “knee buckler.”  

·      A patient with a suspected chronic sinus infection, despite numerous rounds of antibiotics.  Her ‘sinus’ pain turned out to be caused by a TP in the pytergoid (jaw) muscle that produces pain over the sinus area.  The TP was probably caused by the irritation from earlier sinus infections. 

·      A few patients with TPs in the Sternocleidomastoid muscle (on the neck) that mimics migraine headache pain behind and around the eye.  There are a handful of other TPs that may cause similar headache pain around the eye.  I call them the usual suspects.

·      A 30 something male patient with a TP in the gluteus minimus (hip) muscle that refers pain down the leg that might be mistaken for a pinched nerve despite not having any nerve impingement.  Treating the muscle easily resolved the pain. 

·      A middle-aged man with a TP on the torso that caused Esophageal Reflux-like belching.  Stimulating the point made him belch reflexively, as well, during the treatment. 

Location, location, location

You can see why it would be easy to overlook Myofascial Trigger Points as a cause of symptoms in these patients – even for healthcare practitioners familiar with Trigger Points.  You won’t find them if you don’t look for them, and finding them is the first step in helping these patients to feel better. 

In health,

Tim Rhudy, M.S., L.Ac.

 

NOTE:  Trigger Points can occur in the presence of organic disease.  It is always recommended that a patient see a physician to rule out the presence of serious disease.

 

Some Journal-based Articles on Myofascial Trigger Points:

http://www.ncbi.nlm.nih.gov/pubmed/20673246

Comparison of acupuncture to injection for myofascial trigger point pain.

http://www.ncbi.nlm.nih.gov/pubmed/18160923

Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients--a randomised trial.

http://www.jabfm.org/content/23/5/640.full

Dry Needling in the Management of Musculoskeletal Pain

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC152827/

Cardiology and Myofascial Trigger Points

http://www.ncbi.nlm.nih.gov/pubmed/69288   

Trigger points and acupuncture points for pain: correlations and implications.

http://www.ncbi.nlm.nih.gov/pubmed/23756457

Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis.

http://www.ncbi.nlm.nih.gov/pubmed/15628774

Trigger point acupuncture treatment of chronic low back pain in elderly patients--a blinded RCT.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC152826/

The President's physician.

http://www.tsca.edu/site/prospective/c/programs/acupuncture-physical-medicine/

Acupuncture Physical Medicine

https://www.amazon.com/Myofascial-Pain-Dysfunction-Trigger-Manual/dp/0683083635?ie=UTF8&*Version*=1&*entries*=0

Travell and Simons, Myofascial Pain & Dysfunction:  The Trigger Point Manual