Trigger Points and Myofascial Pain Syndrome

Deactivate Trigger Point

Ultrasound and stretch Ischemic compression (Nimmo)

syndrome

group of signs and symptoms that occur together and characterize a particular abnormality or condition

The distance between the short crossways lines (Z bands) within the fiber defines the ________ of the individual sarcomeres.

length

Flat palpation

muscle can be pressed against underlying bone - Fingertips remain in contact with overlying skin

A "_______ _______" is a trigger point (TrP)

muscle knot

Latent TrP =

no spontaneous non-palpated pain

History of trigger point

- Sudden onset = acute overload - Gradual onset = chronic overload Decreased length and strength of muscle • Taut palpable band Characteristic referred pain pattern

What symptoms accompany Fibromyalgia?

- chronic headache -55% IBS - "brain fog" -75% TMJ - fatigue - sleep disorders

• Painful contraction

- emphasized when contraction in shortened position

Energy is introduced into the fascia by what?

- muscular activity, Soft Tissue manipulation, - vibration or heat

• Restricted stretch range of motion

- shortened upon muscle length test

• Palpable tenderness

- tender nodule upon palpation

• Pincer Palpation

- 2 sides of the muscle are accessible - Muscle belly is grasped between fingers and thumb

Trigger Point Pressure Release

(replaces the term, ischemic compression)

TYPES of Trigger Points

1. Active 2. Associated 3. Attachment 4. Central 5. Key 6. Latent 7. Primary 8. Satellite (Previously termed Secondary TrP)

Trigger Point Pressure Release

1. Apply slowly increasing pressure over a trigger point un?la barrier of tissue resistance in encountered. 2. Maintain contact un? lthebarrie rreleases. 3. Increase pressure to reach new barrier to eliminate the trigger point and tension. 4. Con?nueun?lthetriggerpointdoesnotreleaseanyfurther or it completely releases.

Physiological Cause of a Myofascial Trigger point

1. Increased Ach released from motor nerve terminal. 2. Sustained Ca2+ released from sarcoplasmic reticulum. 3. Sustained sarcomere contraction. 4. Increased energy demand from sustained contraction & decreased energy supply from compression of local capillaries. 5. Energy crisis - leads to release of sensitizing substances that could interact with autonomic and sensory (nociceptive) nerves - causes failure of the Ca2+ pump of the sarcoplasmic reticulum. 6. Release of neuro-active substances contribute to excessive Ach release. 7. Self-sustaining vicious cycle established. Ach = acetylcholine Ca2+ = Calcium ion

Trigger Point (Trp) symptoms

Focal point of hyperirritable tissue • Tender constantly or to palpation - refer to grading scale for clinical documentation • May cause referred pain • Possible referred autonomic phenomenon - Skin flushing or hypersensitivity, localized sweating, shortness of breath (SOB), and more depending on location and reference SOB should always be investigated thoroughly

If fascia is immobilized then the ground substance solidifies, the collagen fibers are unable to slide across each causing what?

ADHESIONS & CROSSLINKAGE BETWEEN COLLAGEN FIBERS

Fibromyalgia Syndrome

Autoimmune predisposing factor Necessary Diagnostic Criteria: MUST HAVE11 out of 18 tender points: 1. Occiput - insertions of suboccipitals 2. Cervical- articular pillars of C5àC7 3. Second Rib near costochondral junction 4. Within 2cm distal of the lateral epicondyles 5. Medial jointline of the knee 6. Trapezius - distal and midline to upper border 7. Supraspinatus - superior to medial border of spine of the scapula near rhomboids area 8. Gluteal areas in the most lateral aspects (near gluteal tubercle and superior) 9. Greater trochanter - posterior

Grade 1 = Active TrP

CONSTANTLY painful (either LOCALLY or REFERRED)

MFPS:

Fatigue Accompanying Systemic Conditions May be Due to decreased activity/sedentary May be due to Nutritional Deficiencies Nervousness/Tension/Stress May have accompanying ANS Sx {flushing, sweating hypersensitivity, SOB}

Letter B-

Knot in a muscle fiber Mass of sarcomeres in the state of maximum continuous contraction The bulbous appearance of the contraction knot indicates how that segment of the muscle fiber has drawn up and become shorter and wider. The Z bands have been drawn much closer together

Trigger points have _________ _________ response to snap palpa?on

Localized twitch

MYOFASCIAL PAIN SYNDROME (MFPS or MPS) Definition

MFPS is sometimes used as a general term to describe a regional pain syndrome of any soft tissue origin.

Letter A-

Muscle fiber in a normal resting state

Myofascia

Myofascia is a thin, almost translucent film that wraps around muscle tissue. It is the tissue that holds all the other parts together. It gives shape to and supports all of the body's musculatures. It wraps around muscle fibers, bundles of fibers, and the muscles themselves, and then goes on to form tendons and ligaments.

§ Grade 2 = Latent TrP

Only painful when palpated (either LOCALLY or REFERRED)

What surrounds trigger points?

Surrounded by ground substance - Primarily acid glycosaminoglycan (AGAGs) and water (H2O)

Letter C -

The muscle fiber that extends from the contraction knot to the muscle's attachment (to the sternum in this case). Note the greater distance between the Z bands the muscle fiber is being stretched by tension within the contraction knot. These overstretched segments of muscle fiber cause shortness and tightness in assessment of the "end feel" of a muscle.

MFPS =

The sensory, motor and autonomic symptoms caused by myofascial trigger points.

What is a TRP?

a small isolated patch of contracted muscle tissue in spasm.

Active TrP =

clinical complaint of pain (dull/diffuse/achy or referred)

Fascia can change from a gelatinous like substance to a more_______(watery) state

solute

If a TRP is left untreated what can happen?

àeventually a TrP left untreated may constrict the local blood supply to the area potentially creating a biochemical metabolic crisis

Causes of TRP due to direct stimuli

• Acute overload • Overwork fatigue • Repetitive Stress Injury • Posture • Radiculopathy • Gross trauma

• Taut band fiber

• Characteristic referred pain, tenderness and/ or dysesthesia (hyperesthesia, numbness, paresthesia)

Trigger Point formation in the Connective Tissue (Fascia) & extracellular matrix

• Composed of cells (including fibroblasts and chondrocytes) + • an extracellular matrix of collagen & elastic fibers • Surrounded by ground substance - Primarily acid glycosaminoglycan (AGAGs) and water (H2O) • Movement encourages collagen fiber alignment - Helps maintain the balance of AGAGs and H2O èlubricates & hydrates the Fascia

Physical Exam & Management of TRP.

• Exquisite, focal tenderness - Essential, but non-specific • Local Twitch Response • Reproduction of Complaint - specific and strongly diagnostic • Elimination of symptoms by therapy

Referred Phenomenon

• Occurs in a ZONE distant from Trigger Point • Sensory (pain & tenderness) • Motor (spasm) • Autonomic (vasodilation & hypersensitivity) • DDx Myofascial Pain Syndrome (MFPS) • DDx MFPS with Fibromyalgia

Causes of TRP due to indirect stimuli

• Other TrPs • Abnormal (Paradoxical) Breathing • Joint dysfunction • Emotional Stress • Nutritional deficiency (esp. H2O soluble vitamins) • Heart, gallbladder and other visceral disease

What happens to a muscle (in a real PERSON) when it has a myofascial trigger point ?

• Prevents full lengthening • Weakens the muscle • Mediates local twitch response • Generates referred phenomenon (maybe)

Symptoms of the TRP beyond pain

• Sometimes complaint of numbness/paresthesia • Increased muscle tension and shortening • Spasm of other muscles • Weakness of involved muscle - reflex motor inhibition without atrophy of the affected muscle • Loss of coordination by involved muscle • - abnormal proprioception from muscle and tendon • Decreased work load tolerance • Distorted weight perception of lifted objects• Sleep disturbances • Involved limb may feel cold compared to other side - reflex vasoconstriction • Abnormal sweating • Persistent lacrimation • Persistent rhinitis - aka coryza - inflammation of mucus membranes • Excessive salivation • Pilomotor activities • Imbalance • Dizziness • Tinnitus

The Twitch Response

• When a muscle band containing a TrP is snapped, a transient contraction occurs (like a ripple of contraction) • Not to be confused with a Jump Sign. - General involuntary pain response. • Actual JUMP away involuntarily like a reflex • Example - twitch response in horse - https://www.youtube.com/watch?v=s7R4IgLClUk