Tamer Issa, PT, DPT, OCS

Program Directors

Jan Dommerholt, PT, DPT, MPS, DAAPM Robert Gerwin, MD, FAAN President, Myopain Seminars Vice-President, Myopain Seminars

Based on the work of

• Janet Travell

• David Simons Travell Simons • Karel Lewit

• Chan Gunn

• Peter Baldry

• Beat Dejung Lewit Dommerholt Gunn • Robert Gerwin

• Jan Dommerholt

• among others

Baldry Dejung Gerwin

1 „Re-Discovery“ of Trigger Points

Janet Travell (1901-1997) David Simons (1922-2010)

Travell & Simons’ Myofascial Pain and Dysfuncon: The Trigger Point Manual

• Comprehensive myofasical trigger point reference (translated into >10 languages) • Vol. I: Upper Half of Body • Vol. II: Lower Half of Body • Worldwide interest of researchers and clinicians in a wide range of speciales • Rapidly increasing number of basic research studies and clinical trials in the field of myofascial pain

Orthopedic Manual Therapy

• a specialized area of physiotherapy / physical therapy • for the management of neuro-musculo-skeletal condions, • based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeuc exercises

www.ifomt.org/ifomt/about/standards

2 IFOMT - Educaonal Standards

a high level of skill in other manual and physical therapy techniques is required to mobilize the arcular, muscular or neural systems

www.ifomt.org/ifomt/about/standards

IFOMT - Educaonal Standards

knowledge of various manipulave therapy approaches as pracsed within physical therapy, medicine, osteopathy and chiropracc

www.ifomt.org/ifomt/about/standards

Muscle Dysfuncon

Few arcles about muscle dysfuncon in the medical literature Few lectures about muscle dysfuncon at this conference Focus on muscle injury, muscle repair mechanisms, motor control, or on muscle recruitment

3 Manual Therapy Training

Manual therapy educaonal programs place a strong emphasis on:

Joint Dysfuncon

Mobilizaons & Manipulaons

with limited classroom educaon devoted to muscle pain and muscle dysfuncon

Structural Lesion Model of musculoskeletal pain

Immobilization: shortened sarcomeres, los of total protein, mitochondria, soluble enzymes, loss of extensibility

Muscle pain follows joint injury or dysfuncon

Nerve pain follows nerve injury or dysfuncon

This philosophical model is based on assumptions that are not necessarily supported by scientific evidence

If pain is a puzzle, we should not throw away pieces of the jigsaw just because we are obsessed with a preconceived single soluon

Patrick Wall

4 Muscle Pain in History

• French physician Guillaume de Baillou (1538 – 1616) published “Liber de Rheumasmo:” “muscular rheumasm” • Thomas Sydenham (1624 – 1689), the “Father of English Medicine” published “Observaons Medicae” in 1676: “Rheumasm”

Muscle Pain in History

• Brish physician Balfour (1816): “paents as having a large number of nodular tumours and thickenings which were painful to the touch, and from which pains shot to neighbouring parts”

Muscle Pain in History

• French physician François Valleix (1841) published “Traité des Neuralgies; ou Affecons Douloureuses des Nerfs:” “it is only with the aid of pressure ….. that one discovers exactly the extent of the painful points”

Valleix's points: painful pressure points in the course of nerves

5 Muscle Pain in History

• German physician Strauss (1898) described “small, tender and apple sized nodules and painful, pencil- sized to lile-finger-sized palpable bands.”

Muscle Pain in History

• Lange F and Eversbusch G, Die Bedeutung der Muskelhärten für die allgemeine Praxis. Münch. Med. Wochenschr. 68: 418-420, 1921 • Lange M, Die Muskelhärten (Myogelosen). München: J.F. Lehmann's Verlag, 1931

Myofascial pain is a disnct clinical enty (according to 88.5% of physician members of the American Pain Society)

6 How common are MTrPs?

• Research has shown that MTrPs are commonly associated with facet joint dysfuncons, disc herniaon, osteoarthris, tension type headache, etc. Dommerholt, J. and T. Issa, Differenal diagnosis: myofascial pain, in Fibromyalgia syndrome; a praconer's guide to treatment, L. Chaitow, Editor. 2003, Churchill Livingstone: Edinburgh. p. 149-177.

• 80% of 1096 subjects involved in low-velocity collisions developed acve trigger points (MTrP) Schuller, E., W. Eisenmenger, and G. Beier, Whiplash injury in low speed car accidents. J Musculoskeletal Pain, 2000. 8(1/2): p. 55-67.

Muscle Pain in History

Vecchiet et al: acute pain following exercise or sports parcipaon is oen due to painful MTrPs (1993)

Myofascial pain is the most commonly overlooked diagnosis in chronic pain paents (Hendler & Kozikowski, 1993) •

Myofascial Pain and Whiplash

100% of chronic whiplash paents have myofascial

pain

Gerwin and Dommerholt, 1998

7 MTrPs have been idenfied with

• pelvic pain and other urologic syndromes • radiculopathies • most pain syndromes • joint dysfuncon • post-herpec neuralgia • disk pathology • tendonis • complex regional pain syndrome • craniomandibular dysfuncon • nocturnal cramps • migraines • phantom pain • tension-type headaches • carpal tunnel syndrome • Barré Liéou syndrome • computer-related disorders • neurogenic pruritus • whiplash associated disorders • etc. etc. • spinal dysfuncon

Dommerholt J, Bron C, and Franssen J: Myofascial trigger points; an evidence- informed review. J Manual & Manipulative Ther, 2006:14(4):203-221

Definions

• Latent MTrP: Pain only with excessive smulaon

• Acve MTrP: Pain with physiologic smulus

• Satellite MTrP: In the referred pain region

Since no specialty claims skeletal muscle as its organ, it is oen overlooked David G. Simons, MD

8 “In this age of specializaon, few clinicians are broad enough to see the whole paent and his/ her problem .... understanding with the delicate interplay between the paent's mind, body, environment is a paramount importance in helping a paent overcome an illness.”

Janet G. Travell, MD (1901 - 1997)

Misconcepons… –Oen characterized as chronic –Regional or Widespread –Confused with Fibromyalgia –Psychological

Contracle Acvity

1. Electrogenic sffness: muscle tension coming from electrogenic muscle contracon, based on observable EMG acvity in normals who are not completely relaxed

The term electrogenic refers to the fact that the a-motor neuron and the neuromuscular endplate are acve under these condions.

9 Contracle Acvity

2. Electrogenic spasm that specifically idenfies pathological involuntary electrogenic contracon

Contracle Acvity

3. Contracture arising endogenously within the muscle fibers independent of EMG acvity

Simons DG, Mense S, Understanding and measurement of muscle tone as related to clinical muscle pain. Pain 75(1): p. 1-17, 1998

Dysfunconal Motor Endplate

10 Myofascial Trigger Points

Acetylcholine • Excess acetylcholine • Insufficient acetylcholinesterase • More and more sensized acetylcholine receptors (i.e. the ryanodine receptor) • Excess calcitonin-gene-related pepde • Low pH

Tissue O2 – measurements in MTrPs

Brückle, W., et al., Gewebe-pO2-Messung in der verspannten Rückenmuskulatur (m. erector spinae). Z. Rheumatol., 1990. 49: p. 208-216.

Trigger Point Endplate Noise

11 • Neuromuscular jier is produced by fluctuaons in the me for endplate potenals at the neuromuscular juncon to reach the threshold for acon potenals • With a dysfunconal neuromuscular juncon, muscle fibers of the same motor unit may not always fire in the same sequence causing jier

European Journal of Pain 12 (2008) 1026–1030

• Paents with MTrPs had a significantly increased mean consecuve difference (MCD = jier) in the trapezius and levator scapulae muscles compared to controls • At least part of endplate dysfuncon may be the result of disintegraon of spinal motor neurons

European Journal of Pain 12 (2008) 1026–1030

• Posive correlaon between jier and the duraon of myofascial pain • Supports the development of progressive neuronal degradaon with axonal neuropathy in more chronic cases of MTrPs

European Journal of Pain 12 (2008) 1026–1030

12 Microdialysis System

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987

Microdialysis of MTrPs with 0.3 mm Acupuncture Needle

Delivery tubes Fluid in

Fluid out Solute exchange surface – dialyzer membrane set 0.2 mm from the needle tip

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005. 99: p. 1980-1987

• Norepinephrine • TNG – α • Interleukin 1, 6, 8, 12 • Substance P • Serotonin • Calcitonin Gene Related Pepde

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008

13 Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008

14 increased skill in idenfying and eliminang relevant trigger points: beer outcome

Three Interrater Reliability Studies

• Bron, C., Wensing, M., Franssen, J.L.M., et al., Interobserver reliability of palpation of myofascial trigger points in shoulder muscles. J Man Manipulative Ther. 2007; 15(4):203-215 • Gerwin, R.D., Shannon, S., Hong, C.Z., et al., Interrater reliability in myofascial trigger point examination. Pain. 1997; 69(1-2): 65-73 • Sciotti, V.M., Mittak, V.L., DiMarco, L., et al., Clinical precision of myofascial trigger point location in the trapezius muscle. Pain. 2001; 93(3): 259-66

Interrater Reliability Referred Pain Local twitch Taut Band

Trigger Point Tenderness Pain Rec.

Gerwin, R.D., et al., Interrater reliability in myofascial trigger point examination. Pain, 1997. 69(1-2): p. 65-73.

15 Clinical precision of myofascial trigger point locaon in the trapezius muscle

Excellent precision in manually diagnosing and locang a latent myofascial trigger point in the trapezius muscle

Experienced physical therapists can reach acceptable agreement in the diagnosis of MTPs in three shoulder muscles

16 1. Chen, Q., J. Basford, and K.N. An, Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon), 2008. 23(5): p. 623-9 2. Chen, Q., et al., Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil, 2007. 88(12): p. 1658-61

Characteristics of Myofascial Trigger Points

disturbed motor funcon

muscle sffness muscle weakness

restricted range of moon

17 Characteristics of Myofascial Trigger Points

vasoconstricon vasodilataon goose bumps local tenderness Referred Pain Peripheral Sensitization Central Sensitization

Peripheral Sensizaon

Myofascial TrPs Liberaon of Aδ and C fibers (referred pain algogenic Aβ fibers paern) mediators

Central Sensizaon

Sensizaon of 2nd order neurons in Increased pain Sensory cortex the dorsal horn transmission and thalamus and trigeminal nucleus caudalis

18 Unique Characteriscs of Muscle Pain

• Aching, cramping pain, difficult to localize and referred to deep somac ssues • Muscle pain acvates unique corcal structures • Inhibited more strongly by descending pain- modulang pathways • Acvaon of muscle nociceptors is much more effecve at inducing neuroplasc changes in dorsal horn neurons

Strong acvaon of the anterior cingulate cortex and periaquaductal gray (PAG) Pain. Pain. point trigger from myofascial evoked of pain modulation SH, RC, Lee DM, Chan Niddam Yeh JC, Central TC,Hsieh and Neurophysiol. humans in pain muscle and of skin acute processing Cerebral P,Svensson S, Beydoun Minoshima A, Morrow KL, TJ, Casey and 23 Myofascial Pain: 2007 (5): 440-8, 78

activates anterior cingulate cortex/ 1997 (1): 450-60, periaquaductal gray (PAG) → associated w/ affective-emotional pain component and w/ hightened attention to painful stimulus Cutaneous Pain: No involvement of ant. cing. cortex. . Clin J Clin . J

Muscle Nociceptors

Mense: The Pathogenesis of Muscle Pain Current Pain & Headache Reports 2003, 7:419-425

19 Radiculopathy? MTrP referred pain? Both?

• Taut band palpable (if muscle is accessible) • Exquisite spot tenderness of a nodule in a taut band • Paent’s recognion of current pain complaint by pressure on the tender nodule (idenfies an acve trigger point) • (Painful limit to full stretch range of moon)

• Local Twitch Response

• Referred Pain

• Autonomic signs and symptoms

20 Referred Pain

Gerwin, R.D., et al., Interrater reliability in myofascial trigger point examination. Pain, 1997. 69(1-2): p. 65-73

Studied pain phenomena by injecng various substances in muscles, tendons and periosteum

21 J.H. Kellgren: Deep Pain Sensibility The Lancet, June 4,1949

Eology of Myofascial Trigger Points • Acute Overuse • Direct Trauma • Persistent Muscular Contracon (emoonal or physical cause), i.e,: poor posture, repeve moons, stress response • Prolonged Immobility • Systemic Biochemical Imbalance

Eology of MTrPs

low level muscle contracons uneven intramuscular pressure distribution direct trauma unaccustomed eccentric contractions eccentric contractions in unconditioned muscle maximal or submaximal concentric contractions

Dommerholt J, Bron C, and Franssen J: Myofascial trigger points; an evidence-informed review. J Manual & Manipulative Ther, 2006:14(4):203-221.

Gerwin RD, Dommerholt J, and Shah J: An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep, 2004. 8:468-475.

22 • Associated MTrP

• Afferent Input from Joints

• Afferent Input from Internal Organs

• Stress / Tension

Treatment Opons: Manual Techniques

• Trigger Point Compression with Acve Contracon • Manual Stretching of the MTrP • Myofascial Release • Muscle Play (Fascial Manipulaon) • Therapeuc Stretching (with or without cold spray) • Autostretching (Home Program)

Spray & Stretch Method

• Travell (1901-1997) promoted the Spray & Stretch method • Preferred fluori-methane • Ozone depleng

Simons, D.G., Travell, J.G., and Simons, L.S., Protecting the ozone layer. Arch Phys Med Rehabil. 1990; 71(1): 64

23 Spray & Stretch Method • The new Spray & Stretch product consists of hydrofluorocarbons with a carbon dioxide equivalent of 1,300 • Or a 1,300 greater greenhouse effect than carbon dioxide

“NONFLAMMABLE AND NON-OZONE DEPLETING”

Intramuscular Manual Therapy (aka PT Dry Needling)

Fine solid filament are used to release trigger points in muscle

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physiologicalprinciples Based on Western anatomical and Basedon Western

Dommerholt, J. and McEvoy, J., Myofascial Trigger Point Release Approach, in Orthopaedic Manual Therapy; from Art to Evidence, C. Wise, Editor., F.A. Davis: Philadelphia, in press.

Treatment Specificity

Efficient and effecve treatment method

Dry Needling Targets Myofascial Trigger Points

25 Differences between trigger point injecons and dry- needling/intramuscular smulaon Injecons Dry Needling

• Beveled hypodermic needle • Fine solid filament needle

• Substances injected • No substances injected (analgesics, Botox) • Usually lower gauge needle • Oen higher gauge needle size size

How does dry needling work?

Exact mechanisms unknown

Mechanical Results in disrupon of muscle fiber adhesions and increases circulaon to the region

How does dry needling work? Neurophysiological Local twitch response is a spinal cord reflex that results in immediate release in muscle hypertonicity Biochemical Local twitch response results in favorable biochemical effects (based on Shah’s research at NIH) which reduce pain

26 Possible Adverse Side Effects

• Soreness (typically 1-2 days)

• Slight bleeding/Hematoma

• Fague

• Lightheadedness or fainng due to anxiety, hunger or lack of sleep

• Pneumothorax

Benefits of Trigger Point Dry Needling

• Relief of acute and chronic muscle pain

• Release of muscle tension

• Maximizes muscle funcon

• Immediate improvement oen noted, otherwise 2-3 visits necessary for inial improvement

Maximize Benefits

Dry needling is never used in isolaon – Technique followed by so ssue work, myofasical release and cold/hot pack to minimize soreness and maximize connecve ssue flexibility

27 Maximize Benefits

Other contribung factors important to address – Presence of joint or spinal dysfuncon – Postural imbalances – Poor coordinaon of movement – Poor posture and improper body mechanics with daily acvies

Is it painful? • The inseron of the needle through the skin is rarely painful

• Needling of healthy muscle ssue is not painful whatsoever

• Elicing local twitch responses in the trigger point region does cause a cramping or aching pain and may refer pain to other parts of the body

But that could be a good thing!

Why have so many people sought this treatment despite the pain? • If the technique reproduces your pain, then we are well on our way to relieving your pain because we have accurately idenfied the source

28 Why have so many people sought this treatment despite the pain?

• Most are relieved that finally the source of pain has been found

Why have so many people sought this treatment despite the pain?

• Despite word-of-mouth tesmonials, the fear of pain keeps many people from giving this treatment technique a chance

Tying It All Together

Incorporang Intramuscular Manual Therapy into an Orthopaedic Physical Therapy Approach

29 Physical Therapy- Case Study

• Issa, T., Huijbregts, P: Physical Therapy Diagnosis and Management of a Paent with Chronic Daily Headache: A Case Report. J Manual & Manipulave Ther. 14(4): E88 - E123, 2006.

• Purpose: Describe the physical therapy diagnosis and management of a paent with chronic daily headache

Physical Therapy- Case Study • 48-year-old female

• Medical diagnosis – Migraine headache without aura – Chronic tension-type headache

• Exacerbaon of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months.

Physical Therapy- Case Study • Symptoms – Bilateral headache – Neck pain – Le facial pain – Tinnitus – Jaw Pain

• Outcome measures: – Henry Ford Hospital Headache Disability Inventory (HDI) – Neck Disability Index (NDI)

30 Physical Therapy- Case Study

• Examinaon revealed the following impairments of the head and neck region: – Myofascial – Arcular – Postural – Neuromuscular

The Internaonal Classificaon of Funconing, Disability, and Health (ICF) Disablement Model

Biopsychosocial Framework

ICF- Health Condion

• Chronic Tension-Type Headache Associated with Pericranial Tenderness Headaches • Cervicogenic Headache • Probable Migraine Headache

• Impaired Joint Mobility, Motor Funcon, Muscle Performance, and Range of Moon Associated With Connecve Tissue Neck Pain Dysfuncon • Impaired Posture

31 ICF- Body Funcon & Structure (Impairments)

Acve MTrPs • Bilateral: Upper Trapezius, Sternocleidomastoid, Contribung To Splenius Capis, and Suboccipitals Myofascial Hypertonicity • Le: Masseter and Temporalis and Tenderness

• Le C0/C1 for FB and SBL Spinal Mobility • Le C1/C2 for RR Restricons • U/T and M/T for BB and axial extension

Decreased Muscle • Bilateral: Upper Trapezius, Sternocleidomastoid, Flexibility Cervical/Thoracic Paraspinals and Suboccipials

ICF- Body Funcon & Structure (Impairments)

Postural • Forward head posture with Dysfuncon craniocervical extension

• Related to busy home and work life, and Stress/Tension possible grieving over death of her mother earlier in the year

Craniomandibular • Myofascial Pain Disorder • Le Condylar Hypermobility

ICF- Acvity (Limitaons)

Funconal • Roune daily acvies, personal care, liing, work acvies, limitaons concentraon, reading, with: recreaonal acvies, driving

Emoonal • Handicapped, isolated, angry, tense, irritable, frustrated, insane, feelings of desperate, unable to maintain being: control

32 ICF- Parcipaon (Restricons)

• Less likely to socialize • Concerned about Restricons consequences on work, with life home, and relaonships situaons with others • Perceived difficulty achieving life goals

Physical Therapy- Case Study

• Treatment – Myofascial trigger point dry needling – Head and Neck musculature – Orthopaedic manual physical therapy – So ssue mobilizaon, cervical and thoracic spine mobilizaon, TMJ mobilizaon – Exercise therapy – Self-stretch, motor control and postural strengthening – Paent educaon – Postural awareness/correcon and self-management techniques

Physical Therapy- Case Study Outcomes – On the final visit, the paent reported no headaches during the preceding month

• HDI – 31% improvement in the emoonal score – 42% improvement in the funconal score – 36% improvement in the total score – exceeding the minimal detectable change for the total score

• NDI – At discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26% – Both improvements exceeded the minimal clinically important difference for the NDI

33 Thank you

Tamer S. Issa, PT, DPT, OCS

ISSA PHYSICAL THERAPY Myopain Seminars 4701 Randolph Rd. Suite G1 7830 Old Georgetown Road, C-15 Rockville, MD 20852 Bethesda, MD 20814 301.231.0095 301.656.0220 www.issapt.com www.myopainseminars.com [email protected] [email protected]

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