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PubMed1988

Documentation of myofascial trigger points.

Two basic diagnostic features of myofascial trigger points (TPs), namely, local tenderness and alteration of tissue consistency (such as in taut bands, muscle spasm), can be documented quantitatively by simple hand-held instruments. A pressure threshold meter (algometer) assists in location of TPs and their relative sensitivity. A side-to-side difference exceeding 2kg in comparison with normal values indicates pathologic tenderness. The effect of treatment can be quantified. Pressure tolerance, measured over normal muscles and shin bones, expresses pain sensitivity. Myopathy is suspected if muscle tolerance drops below bone tolerance. Tissue compliance measurement documents objectively and quantitatively alteration in soft tissue consistency. Muscle spasm, tension, spasticity, taut bands, scar tissues, or fibrositic nodules can be documented. The universal clinical dynamometer is used as part of a physical examination to quantify weakness. Thermography (heat imaging) demonstrates discoid shaped hot spots over TPs. Muscle activity, spasm, or contraction is visualized as increased heat emission in the shape of the active muscle.

Compliance↗
PubMed1991

Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study.

A trigger point is frequently found over the iliac crest at 7 to 8 cm from the midline in low-back-pain syndromes. Previously, this was described as either a painful insertion site of the iliolumbar ligament or pain in the distribution of the cutaneous dorsal ramus of the first or second lumbar nerve. The authors performed 37 dissections, and they report their anatomic findings. The iliac insertion of the iliolumbar ligament is inaccessible to palpation, being shielded by the iliac crest. The dorsal rami of L1 or L2 nerve roots, however, cross the crest at 7 cm from the midline, and this distance closely correlates with the dorsal projection of the iliolumbar ligament insertion. These rami are superficial and dorsal to the crest, easily accessible to palpation. In two of the 37 dissections performed, some rami were found to be narrowed as they crossed through an osteofibrous orifice over the crest, thus being susceptible to an entrapment neuropathy. The authors conclude that the trigger point sometimes localized over the iliac crest at 7 cm from the midline likely corresponds to elicited pain from a cutaneous dorsal ramus originating from the thoracolumbar junction rather than from the iliac insertion of the iliolumbar ligament.

Back Pain↗
PubMedDate not supplied

Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response.

This study was designed to investigate the effects of injection with a local anesthetic agent or dry needling into a myofascial trigger point (TrP) of the upper trapezius muscle in 58 patients. Trigger point injections with 0.5% lidocaine were given to 26 patients (Group I), and dry needling was performed on TrPs in 15 patients (Group II). Local twitch responses (LTRs) were elicited during multiple needle insertions in both Groups I and II. In another 17 patients, no LTR was elicited during TrP injection with lidocaine (9 patients, group Ia) or dry needling (8 patients, group IIa). Improvement was assessed by measuring the subjective pain intensity, the pain threshold of the TrP and the range of motion of the cervical spine. Significant improvement occurred immediately after injection into the patients in both group I and group II. In Groups Ia and Ib, there was little change in pain, tenderness or tightness after injection. Within 2-8 h after injection or dry needling, soreness (different from patients' original myofascial pain) developed in 42% of the patients in group I and in 100% of the patients in group II. Patients treated with dry needling had postinjection soreness of significantly greater intensity and longer duration than those treated with lidocaine injection. The author concludes that it is essential to elicit LTRs during injection to obtain an immediately desirable effect. TrP injection with 0.5% lidocaine is recommended, because it reduces the intensity and duration of postinjection soreness compared with that produced by dry needling.

Adult↗
PubMed2000

Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles.

OBJECTIVES: To determine the interexaminer reliability of palpation of three characteristics of trigger points (taut band, local twitch response, and referred pain) in patients with subacute low back pain, to determine whether training in palpation would improve reliability, and whether there was a difference between the physiatric and chiropractic physicians. DESIGN: Reliability study. SETTING: Whittier Health Campus, Los Angeles College of Chiropractic. PARTICIPANTS: Twenty-six nonsymptomatic individuals and 26 individuals with subacute low back pain. INTERVENTION: Twenty muscles per individual were first palpated by an expert and then randomly by four physician examiners. MAIN OUTCOME MEASURES: Palpation findings. RESULTS: Kappa scores for palpation of taut bands, local twitch responses, and referred pain were .215, .123, and .342, respectively, between the expert and the trained examiners, and .050, .118, and .326, respectively, between the expert and the untrained examiners. Kappa scores for agreement for palpation of taut bands, twitch responses, and referred pain were .108, -.001, and .435, respectively, among the nonexpert, trained examiners, and -.019, .022, and .320, respectively, among the nonexpert, untrained examiners. CONCLUSIONS: Among nonexpert physicians, physiatric or chiropractic, trigger point palpation is not reliable for detecting taut band and local twitch response, and only marginally reliable for referred pain after training.

Adult↗
PubMed2004

A proposed experimental model of myofascial trigger points in human muscle after slow eccentric exercise.

BACKGROUND: The purpose of this study was to develop an experimental model of myofascial trigger points to investigate their pathophysiology. METHODS: Fifteen healthy volunteers who gave informed consent underwent repetitive eccentric exercise of the third finger of one hand (0.1 Hz repetitions, three sets at five minute intervals) until exhaustion. Physical examination, pressure pain threshold, and electrical pain threshold of the skin, fascia and muscle were measured immediately afterwards and for seven days. Needle electromyogram (EMG) was also recorded in a subgroup of participants. RESULTS: Pressure pain thresholds decreased to a minimum on the second day after the exercise, then gradually returned to baseline values by the seventh day. On the second day, a ropy band was palpated in the exercised forearm muscle and the electrical pain threshold of the fascia at the palpable band was the lowest among the measured loci and tissues. Needle EMG activity accompanied with dull pain sensation was recorded only when the electrode was located on or near the fascia of the palpable band on the second day of exercise. CONCLUSION: These results suggest that eccentric exercise may yield a useful model for the investigation of the myofascial trigger points and/or acupuncture points. The sensitised nociceptors at the fascia of the palpable band might be a possible candidate for the localised tender region.

Adult↗
PubMedDate not supplied

Raymond L. Nimmo and the evolution of trigger point therapy, 1929-1986.

Dr. Raymond L. Nimmo (1904-86) was the definitive chiropractic pioneer in the now widely accepted field of soft tissue and trigger point therapy. This article explores how Nimmo was able to make the radical conceptual leap from moving bones to working with muscles that move the bones. Also discussed are the neurophysiological explanations that Nimmo evolved in the 1950s for the trigger point phenomenon, formulations that are still regarded as highly sophisticated half a century later. Finally, the article describes how Nimmo, with a basic chiropractic education absent much of the background in the biological and physical sciences of today's preparation, was able to combine his clinical experiences and intellectual formulation to arrive at a theory that became widely accepted.

Chiropractic↗
PubMed2005

Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis.

OBJECTIVES: To investigate the test-retest reliability of the following clinical diagnostic characteristics of myofascial trigger points: taut band, spot tenderness, jump sign, pain recognition, referred pain and local twitch responses (LTRs). DESIGN: Test-retest reliability study. SETTING: This study was undertaken in an outpatient physiotherapy department. SUBJECTS: Fifty-eight patients (31 males and 27 females) with rotator cuff tendonitis were recruited into this study. INTERVENTION: Rotator cuff muscles were assessed by an expert for the presence or absence of the main clinical diagnostic characteristics of trigger point assessment. The process was then repeated three days later by the same expert. MAIN MEASURES: Outcomes included the presence or absence of: a taut band, spot tenderness, jump sign, pain recognition, referred pain and LTRs. RESULTS: Kappa values between testing situations for the taut band, spot tenderness, jump sign and pain recognition were 1. Kappa scores for referred pain ranged between 0.79 and 0.88 and for the local twitch response between 0.75 and 1 depending on the muscles under investigation. CONCLUSIONS: The presence or absence of the taut band, spot tenderness, jump sign and pain recognition was highly reliable between sessions. Referred pain and local twitch response reliability varied depending on the muscle being studied.

Adult↗
PubMed2004

Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome.

BACKGROUND: Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. Several methods have been recommended for the inactivation of trigger points (TrP). OBJECTIVES: This prospective, single-blind study was proposed to compare TrP injection with botulinum toxin type A (BTX-A) to dry needling and lidocaine injection in MPS. METHODS: Eighty-seven trigger points (cervical and/or periscapular regions) in 23 female and six male patients with MPS were treated and randomly assigned to three groups: lidocaine injection (n=10, 32 TrP), dry needling (n=10, 33 TrP), and BTX-A injection (n=9, 22 TrP). OUTCOME MEASURES: Clinical assessment including cervical range of motion, TrP pain pressure threshold (PPT), pain scores (PS), and visual analog scales for pain, fatigue, and work disability were evaluated at entry and the end of the 4th week. Additionally, depression and anxiety were evaluated with the Hamilton depression and anxiety rating scales, and quality of life was assessed using the Nottingham health profile (NHP). The subjects were also asked to describe side effects. INJECTION PROCEDURE: One milliliter of 0.5% lidocaine was administered to each TrP in the lidocaine injection group, 10-20 IU of BTX-A to each TrP in the BTX-A group, and dry needling to each TrP in the last group, followed by stretching of the muscle groups involved. The patients were instructed to continue their home exercise programs. RESULTS: Pain pressure thresholds and PS significantly improved in all three groups. In the lidocaine group, PPT values were significantly higher than in the dry needle group, and PS were significantly lower than in both the BTX-A and dry needle groups. In all, visual analog scores significantly decreased in the lidocaine injection and BTX-A groups and did not significantly change in the dry needle group. Disturbance during the injection procedure was lowest in the lidocaine injection group. Quality of life scores assessed by NHP significantly improved in the lidocaine and BTX-A groups but not in the dry needle group. Depression and anxiety scores significantly improved only in the BTX-A-injected group. CONCLUSIONS: Injection is more practical and rapid, since it causes less disturbance than dry needling and is more cost effective than BTX-A injection, and seems the treatment of choice in MPS. On the other hand, BTX-A could be selectively used in MPS patients resistant to conventional treatments.

Adult↗
PubMed2004

High-power pain threshold ultrasound technique in the treatment of active myofascial trigger points: a randomized, double-blind, case-control study.

OBJECTIVE: To study what effects a high-power, pain-threshold, static ultrasound technique applied to acute myofascial trigger points of the upper trapezius has on pain and on active cervical lateral bending. DESIGN: Double-blind randomized trial. SETTING: Physical therapy unit of a private general hospital. PARTICIPANTS: Seventy-two adults with acute pain on 1 side of the neck, admitted to the outpatient unit during 1999 and 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Visual analog scale and goniometric measurement of active lateral bending of the neck performed daily after treatment sessions and length of treatment (number of therapy sessions). RESULTS: High-power ultrasound applied to the trigger points before stretching the muscle was more effective (P<.05) than conventional ultrasound, and it also significantly (P<.001) decreased the length of therapy. CONCLUSIONS: High-power, pain-threshold, static ultrasound technique may be considered in the treatment of patients with acute myofascial pain syndrome, with the understanding that this technique demands more concentration and communication between the patient and the therapist.

Adult↗
PubMed1981

Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.

Myofascial trigger points (TPs) in a muscle are usually activated by acute or chronic overload of the muscle. They are identified by objective and subjective findings. Objective signs include a palpably firm, tense band in the muscle, production of a local twitch response, restricted stretch range-of-motion, weakness without atrophy, and no neurologic deficit. Subjectively, the patient reports stiffness and easy fatigability, spontaneous pain in a distribution predictable for that TP, an exquisite deep tenderness specifically at the TP. Sustained pressure on the TP induces referred pain in the predicted pattern. Some muscles are likely to produce additional objective and subjective autonomic concomitants. Laboratory and radiographic findings are negative. The affected muscle is treated by passive stretch while a jet stream of vapocoolant spray is applied over it, or by injection of the TP with a local anesthetic. A case report describes in detail the treatment of a patient who, for 13 years, had suffered from a medically enigmatic, intense right facial pain with severe dysfunction and who is now pain-free, with a full schedule of unrestricted activities 23 years later.

Adult↗
PubMed1999

The relationship between myofascial trigger points of gastrocnemius muscle and nocturnal calf cramps.

To support that myofascial pain syndrome (MPS) of gastrocnemius muscle is one cause of nocturnal calf cramps, quantitative assessment of the efficacy of trigger point (TrP) injection compared with oral quinine in the treatment of nocturnal calf cramps (NCC) associated with MPS of gastrocnemius muscle was designed. Twenty four subjects with NCC and gastrocnemius TrPs were randomly divided into two groups of twelve for each treatment. Patients in group 1 were treated with xylocaine injection at the gastrocnemius TrP, and 300 mg of quinine sulfate p.o. was prescribed for patients of group 2. The treatment period was four weeks with a follow-up 4 weeks later. Cramps were assessed quantitatively (in terms of frequency, duration, pain intensity, cramp index, and pain threshold of the gastrocnemius TrPs) before treatment, after treatment and at the end of the follow-up respectively. The outcome of treatment in both groups showed a statistically significant reduction in all quantitative aspects of cramps (95% confidence interval). Also the pain threshold of the gastrocnemius TrP was significantly increased in group 1 only when comparing the pre-treatment and at the end of follow-up. In comparing the two groups we found no statistical difference during the period of treatment. The benefit of both strategies lasted up to four weeks following cessation of the treatment but the outcome of all measures (except pain threshold) were found to be significantly better in the group treated with TrP injection. The results of this study support that gastrocnemius trigger point is one cause of NCC and show that the TrP injection strategy for NCC associated with myofascial pain is not only as effective as oral quinine during the treatment period but also better in the prolonged effect at follow-up.

Aged↗
PubMed1989

Effects of helium-neon laser irradiation on skin resistance and pain in patients with trigger points in the neck or back.

The purpose of this double-blind study was to ascertain the effects of helium-neon (He-Ne) laser irradiation on skin resistance and pain in patients with trigger points in the neck or low back. This study entailed a partial replication of a previous study by Snyder-Mackler and associates that determined the use of the He-Ne laser increased skin resistance overlying a trigger point. Twenty-four patients were randomly assigned to either a treatment or a control group and received three 20-second applications of laser irradiation or placebo "stimulation," respectively. Pretreatment and posttreatment skin resistance and pain measurements (via visual analog scale) were taken during each session. Results indicated a statistically significant increase in skin resistance (p less than .001) and a decrease in pain (p less than .005) following laser treatment. There was not a significant correlation between skin resistance and pain across subjects. These data substantiate the previous findings of Snyder-Mackler and associates and demonstrate a reduction in pain. Helium-neon laser treatment, therefore, may be an effective adjunct to conventional physical therapy of these patients.

Double-Blind Method↗
PubMed1996

Low level laser therapy with trigger points technique: a clinical study on 243 patients.

Among the various methods of application techniques in low level laser therapy (LLLT) (HeNe 632.8 nm visible red or infrared 820-830 nm continuous wave and 904 nm pulsed emission) there are very promising "trigger points" (TPs), i.e., myofascial zones of particular sensibility and of highest projection of focal pain points, due to ischemic conditions. The effect of LLLT and the results obtained after clinical treatment of more than 200 patients (headaches and facial pain, skeletomuscular ailments, myogenic neck pain, shoulder and arm pain, epicondylitis humery, tenosynovitis, low back and radicular pain, Achilles tendinitis) to whom the "trigger points" were applied were better than we had ever expected. According to clinical parameters, it has been observed that the rigidity decreases, the mobility is restored (functional recovery), and the spontaneous or induced pain decreases or even disappears, by movement, too. LLLT improves local microcirculation and it can also improve oxygen supply to hypoxic cells in the TP areas and at the same time it can remove the collected waste products. The normalization of the microcirculation, obtained due to laser applications, interrupts the "circulus vitiosus" of the origin of the pain and its development (Melzak: muscular tension > pain > increased tension > increased pain, etc.). Results measured according to VAS/VRS/PTM: in acute pain, diminished more than 70%; in chronic pain more than 60%. Clinical effectiveness (success or failure) depends on the correctly applied energy dose--over/underdosage produces opposite, negative effects on cellular metabolism. We did not observe any negative effects on the human body and the use of analgesic drugs could be reduced or completely excluded. LLLT suggests that the laser beam can be used as monotherapy or as a supplementary treatment to other therapeutic procedures for pain treatment.

Acute Disease↗
PubMed1986

Effect of helium-neon laser on musculoskeletal trigger points.

Cold lasers have been proposed recently as a therapeutic tool for treating a wide variety of pathological conditions, including wounds, arthritis, orthopedic problems, and pain. These proposed therapeutic effects largely have been unsubstantiated by research. A randomized, double blind study was undertaken to ascertain the effect of a helium-neon (He-Ne) laser on the resistance of areas of skin overlying musculoskeletal trigger points. These areas usually demonstrate decreased skin resistance when compared with the surrounding tissue. Thirty patients with musculoskeletal trigger points were assigned randomly to either an experimental or a placebo group. In addition to standard physical therapy, each patient received three 15-second applications of a He-Ne laser or placebo "stimulation" from an identical unit that did not emit a laser. The results of a two-way analysis of covariance with one repeated measure showed a statistically significant increase (p less than .007) in skin resistance. This increase in an abnormal skin resistance pattern may accompany the resolution of pathological conditions.

Adolescent↗
PubMed2004

Travell trigger points--molecular and osteopathic perspectives.

The proposed etiology of Travell trigger points (TrPs) has undergone a fundamental revision in recent years. New research results suggest that TrPs are evoked by the abnormal depolarization of motor end plates. This article expands the proposed etiology to include presynaptic, synaptic, and postsynaptic mechanisms of abnormal depolarization (ie, excessive release of acetycholine [ACh], defects of acetylcholinesterase, and upregulation of nicotinic ACh-receptor activity, respectively). This working hypothesis regarding the etiology of TrPs has changed the approach to treating TrPs. As an example, Travell and Simons abandoned the application of ischemic compression to TrPs; instead the authors adopted several techniques associated with osteopathic medicine (ie, muscle-energy, myofascial, counterstrain; high-velocity, low-amplitude). Scientists are now proposing and reporting the results of new approaches using capsaicin, a vanilloid-receptor agonist, and ACh antagonists (eg, dimethisoquin hydrochloride, botulinum toxin, quinidine, linalool). The purpose of this article is to review these new concepts and describe new resulting approaches to the treatment of TrPs.

Biomechanical Phenomena↗
PubMed1981

Myofascial trigger point syndromes: an approach to management.

The treatment of myofascial trigger point (TP) pain syndromes is not difficult once the source of the problem has been determined. Whereas many modalities may be used, two of the most effective are spray-and-stretch and TP injection. These can be followed by deep massage, specific, manual resistive exercises, and an exercise program which the patient can follow at home. The goal of management is to inactivate the TPs and to restore shortened and stretch resistant muscles to their full range of motion. A number of such syndromes are discussed in terms of recognition and management.

Back Pain↗
PubMed1994

Neurobiology of the myofascial trigger point.

The clinical phenomenon of the MTrP is accessible to any clinician who takes the time to learn to palpate skeletal muscle gently and carefully, and who is willing to learn the functional anatomy necessary to understand the regional spread of MTrPs through functional muscle units (Travell and Simons, 1992). Yet despite the years of clinical study of MPS, the pathophysiology of the central feature, the trigger point, has remained elusive. Many investigators have contributed to the general understanding of the mechanisms of pain perception, but we owe a particular debt of gratitude to Dr Seigfried Mense of Heidelberg for his pursuit of the study of pain originating in muscle lesions. However, Dr Mense would be the first to caution us against the direct transference of the results obtained with an inflammatory lesion produced in the experimental animal to the pain of MTrPs in the clinic patient. Notwithstanding that, researchers in the field of pain have given us an understanding of the basis for the hyperalgesia, allodynia and the previously difficult-to-understand finding of referred pain zones that we see daily in our patients. Finally, the interesting initial observations of Hubbard and Berkoff (1993), suggesting that the muscle spindle may be associated with the trigger point, open yet another door in our understanding of the nature of MPS.

Animals↗