1/15 myofascial trigger point

UTI:

feels like lower back referral pain (need to rule this out)

active trigger point of right SCM with elbow flexion with weights

harder and heavier on the right side compared to the left

local twitch response (LTR)

is a brisk transient contraction of the palpable taut band of muscle fibers elicited by mechanical stimulation of the trigger point

identify yellow flags

patients that only think about their pain

active TrPs

produce a clinical complaint (usually pain) that the patient recognizes when the TrP is digitally compressed; pt familiar with pain and should be able to reproduce it

when thumb blanches...

should be 4 kg of force, press down on muscle; need a certain amount of pressure to create an effect (normally this force won't hurt but if they have an active trigger point it will)

symptoms

-History (trauma present, home life, family support, family hx, angina, non-msk pain patterns, gradual or sudden onset, MVA) -Aggravating and relieving factors (feels better with rest and ice/heat if it's muscle pain) -Limited ROM (pre-test and re-test after treatment) -Weakness -Other non-pain symptoms -Depression (because of the chronic pain; impacts their job and how they function in society) -Sleep disturbance -Prognosis -over the counter pain medications

most commonly involved active trigger points

-Upper trapezius: can refer to forehead for mimicking HAs -Scalenes- could have compression of TOS -SCM - affect swallowing -Levator scapula - affect scapulohumeral rhythm -Quadratus lumborum - mimick LBP, feels like kidney issues

nature of trigger points

1. Electrodiagnostic Characteristics of Trigger Points - active locus, spontaneous electrical activity (SEA) 2. Histopathological chracteristics of Trigger Points - muscle indurations from stretched sarcomeres to compensate for the contracted muscles 3. Integrated Trigger Point Hypothesis - Energy Crisis Component - Calcium is continually released continued contraction hypoxia and ischemia (muscle is not getting enough blood and oxygen)

integrated trigger point hypothesis

1. Energy Crisis Component -(-) motor unit action potential in the taut band -TrP's are activated by muscle overload -Sensitization of nociceptors in the TrP (locally palpate) and does better with therapeutic intervention -Effectiveness of therapeutic techniques 2. Clinical Correlations: -Taut band -Palpable nodule -Spot tenderness -Enthesopathy - tendon is into the bone (gets super tight) -Myoglobin response to massage (desensitization to the area)

clinical characteristics of trigger points - diagnostic testing

1. Needle EMG - "spike activity" vs. "noise activity" 2. US imaging - "local twitch response" 3. Surface EMG -3-fold problem: --Increase responsiveness - hyperactive --Delayed relaxation - cannot relax (due to constant contraction) --Increase fatigability (get tired easily) 4. Algometry- induction of a specific pain level in response to a measured force applied to skin 5. Thermography - visualization of skin T changes over large areas of the body (increased temp to the area)

differential diagnosis

1. Non-myofascial tenderpoints - visceral pain patterns -rule out organ stuff (kidney issues) -will not be able to reproduce pain if visceral 2. Musculoskeletal diseases - Tendinopathy, arthritis, bursitis 3. Neurological d/o (disorder) - weakness 4. Systemic diseases 5. Psychogenic pain - everything creates pain that doesn't follow a pattern

trigger point exam diagnostic criteria

1. Palpable tender nodule and taut band* -Flat palpation - use of fingertip -Pincer palpation - grasping the muscle belly with the thumb and index finger -Deep (probing) palpation - muscles inaccessible from flat and pincer palpation 2. Referred pain 3. Local Twitch Response 4. Central and Attachment Trigger points 5. Key and Satellite Trigger Points

patient examination

1. Patient mobility and posture 2. Neuromuscular functions -Restriction of movement - functionally shortened muscle -Weakness - static vs dynamic -Distorted weight perception - loss of weight appreciation (SCM) -Weak DTR's - hyporeflexia 3. Referred tenderness 4. Cutaneous and subcutaneous signs - skin sensitivity 5. Compression test- SCM trigger point - pain with swallowing 6. Joint Play - general hypomobility *pts should have more muscle power with static testing than with dynamic testing

referred pain (tenderness)

1. Patient's pain history - show me with one finger where your pain is; mark on a body chart and mark with X's where the pain is 2. Drawing the pain pattern 3. Initial Interpretations of pain patterns -Pain referred from Myofascial TrP's is characterized as steady, deep and aching -Pain referred from TrPs are reproducible and predictable -Directions of referral ---Peripheral ---Central ---Local -expect the patient may have multiple trigger points, have them rank the one that is the most bothersome -if you are able to deactivate one of the main ones, it makes the other easier

considerations for myofascial TrP

1. Referred pain (tenderness) 2. Symptoms 3. Activation and Perpetuation of Trigger Point -activate TrP: current life situation right now 4. Patient Examination 5. Trigger Point Exam 6. Trigger Point Release/Treatment 7. Corrective Actions - home program

activation and perpetuation of trigger point

1. Sudden Onset -MVA (WAD) -Falls -Fracture -Sprains 2. Gradual Onset -Sustained posture -Poor work habits

clinical characteristics of trigger points - physical findings

1. Taut band - nodule or rope-like indurations 2. Tender nodule - highly localized, exquisitely tender 3. Recognition - can elicit 'referred pain' pattern 4. Referred sensory signs- tenderness 5. Local twitch response - palpation triggers a transient 'twitch response' 6. Limited ROM- muscles in constant state of contraction (AROM and PROM) 7. Painful contraction - pain with resistance testing - will be strong but painful

essential criteria

1. Taut band palpable 2. Exquisite spot tenderness - with dry needling, there will be a twitch when you've hit the spot 3. Patient's identification of current pain complaint by pressure on the tender nodule 4. Painful limit to full stretch ROM

confirmatory criteria

1. Visual or tactile identification of local twitch response 2. Imaging of a local twitch response by needle penetration 3. Pain or altered sensation on compression of tender nodule 4. EMG activity - active nodule/taut band

importance

1. Voluntary skeletal muscle is the largest single organ of the human body (50 % BW) - Anatomical Nomenclature Committee - lists 200 paired muscles in the human body 2. Severity (pain and LOM) 3. Cost - lost of time @ work - Workman's Compensation?

prevalence

Myofascial trigger points are extremely common and become a painful part of nearly everyone's life at one time or another; trigger points are constant contractions in the muscle

clinical characteristics of trigger points - symptoms

active and latent trigger points

angina

appears to refer pain to the left side toward the shoulder

clinical characteristics of trigger points - diagnostic criteria

both essential and confirmatory criteria

active trigger points...

can cause referral pain patterns; the patient's familiar pain they can recognize once you put pressure on it; can reproduce the patient's pain; patients can also be very prone to getting trigger points

latent TrPs

can produce the other effects characteristics of a TrP including increased muscle tension and muscle shortening (but do not produce spontaneous pain); press on side but not as bad - not really impacting their ADLs as much as an active TrP

local twitch response: grips

digital pressure grip or pinch grip (the muscle)

energy crisis component

slide 14 1. Spontaneous release of acetylcholine 2. Increase muscle tension 3. Local hypoxia (tissue distress) 4. Release of nociceptive chemicals 5. Sacroplasmic reticulum dysfunction 6. Autonomic modulation constant state of contraction

pain in the upper traps

slide 6; local pain and referral patterns to the front of the head as well; refers behind the ear as well; TMJ trigger points could be here as well (they could say they have a tooth ache problem but really it's a trigger point); need to differentiate these