Management of Myofascial Trigger Point Pain (PDF)

BMAS March 21/2/02 1:02 PM Page 2 Papers Management of Myofascial Trigger Point Pain Peter Baldry This paper is based on a lecture given at the BMAS Spring Scientific Meeting, Bournemouth 2001 Peter Baldry Summary emeritus consultant Successful management of myofascial trigger point (MTrP) pain depends on the practitioner finding all physician of the MTrPs from which the pain is emanating, and then deactivating them by one of several currently [email protected] used methods. These include deeply applied procedures, such as an injection of a local anaesthetic into MTrPs and deep dry needling (DDN), and superficially applied ones, including an injection of saline into the skin and superficial dry needling (SDN) at MTrP sites. Reasons are given for believing that DDN should be employed in cases where there is severe muscle spasm due to an underlying radiculopathy. For all other patients SDN is the treatment of choice. Following MTrP deactivation, correction of any postural disorder likely to cause MTrP reactivation is essential, as is the need to teach the patient how to carry out appropriate muscle stretching exercises. It is also important that the practitioner excludes certain biochemical disorders. Keywords Myofascial trigger points, deep dry needling, superficial dry needling. Introduction may be obtained from carefully noting the For the successful management of myofascial distribution of pain and by observing which trigger point (MTrP) pain it is essential to first movements are restricted as a result of it. identify all of the MTrPs from which the pain is The search should be carried out by means of emanating, and to deactivate them by one or other the palpating finger being drawn across each part of several methods currently employed. of a muscle in a manner similar to that employed Following this, measures should be adopted as when kneading dough. necessary to prevent reactivation of the MTrPs. In Some authorities advocate the use of flat addition, treatment should be started as early as palpation for any muscle where only one of its possible, before pain-perpetuating changes take surfaces is accessible for palpation, and pincer place, in particular spinal cord neuroplasticity palpation where both sides of the muscle are (central sensitisation). accessible, such that it is possible to grasp it between the fingers. The difficulty with Systematic Search for Pain-Producing MTrPs employing the latter technique, however, as Sir The identification of all of the active MTrPs is Thomas Lewis pointed out over 50 years ago,1 is mandatory, because if only one of them is that normal healthy muscle is extremely tender overlooked the persistence of a certain amount of when firmly squeezed. Because of this, it is my pain is inevitable. personal preference to use flat palpation for all It is therefore necessary to locate MTrPs not muscles. When doing this the pressure applied only in the primarily affected muscles, but also in with the examining finger must be very firm their synergists and antagonists (secondary MTrPs). (approximately 4kg), or the characteristic ‘jump’ In addition, it is necessary to search for any (involuntary flexion withdrawal) and ‘shout’ (the satellite MTrPs that may be present in the primary utterance of an expletive) reactions at an active or and secondary MTrPs’ zones of pain referral. latent MTrP site will not be elicited. It cannot be Guidance as to where to look for these MTrPs emphasised too strongly that one of the ACUPUNCTURE IN MEDICINE 2002;20(1):2-10. 2 www.medical-acupuncture.co.uk/aimintro.htm BMAS March 21/2/02 1:02 PM Page 3 Papers commonest reasons for MTrPs being overlooked body for therapeutic purposes had been a long is that palpation has been carried out too gently. established practice, first in China, and then in When palpating a superficially placed muscle Japan, reached Europe in the 17th century, in the manner just described it is often possible to principally as a result of the Dutch physician feel a MTrP-related taut band. Should this be Willem ten Rhijne.6 Whilst working as a medical ‘snapped’, by drawing the examining finger officer on the staff of the Dutch East Indies across it at a TrP (trigger point) site in a manner Company in Java, he wrote a book describing what similar to that employed when plucking a violin he had observed. string, a transient contraction of the muscle fibres His contemporaries in the Western World, may be evoked. This local twitch response may be however, viewed this type of treatment with either visible, or felt under the examining finger, considerable incredulity, particularly as, by that or both. time, renaissance anatomists such as Vesalius, When pressure is applied for about 10-15 had, during the course of dissecting the human seconds to a pain-producing MTrP it is possible to body, failed to find evidence of channels reproduce the patient’s spontaneously experienced corresponding to those containing Qi (vital pain. It might be thought that it is worthwhile energy) that had been described by the Chinese. doing this routinely in order to confirm that the Consequently, Europeans took no further TrP is in an active phase. However, carrying this interest in acupuncture until the early 19th century, out at a number of MTrP sites is liable to cause the when, somewhat surprisingly, books recommending patient considerable discomfort. As Hong et al its use appeared in France, Italy, and England. have shown,2 this pressure-induced pain referral is In England, the London medical practitioner not confined to active MTrPs, for it may at times JM Churchill drew attention to the merits of dry be observed with latent trigger points. needling by writing about it in two books, the first My pragmatic approach therefore,3 is to avoid published in 18217 and the second in 1828.8 this test, for when, in the absence of any other It is obvious, from reading Churchill’s books, obvious pain-producing disorder, MTrPs with their that he restricted himself to treating the disorder characteristic ‘jump’ and ‘shout’ reactions are found, that he called rheumatalgia, which today is called in a region of the body affected by a persistent dull the MTrP pain syndrome. It is equally clear that he aching type of pain, and the latter is relieved by employed a strong acupuncture stimulus, for, from one or other of the MTrP deactivating procedures looking at the length of the flanged needles he to be discussed, it is reasonable to assume that the used (see figure 1), he clearly inserted them deeply pain must have been emanating from them. into muscle at points of maximum tenderness, and There is no general consensus as to the then left them in situ for five to six minutes. essential criteria for the diagnosis of the MTrP Although Churchill reported good results with pain syndrome. In view of this unfortunate state of this treatment, its use for the rest of the 19th affairs, and in an attempt to rectify it, the century was restricted to a few centres, seemingly International Myopain Society has been recently because no one could offer a plausible explanation engaged in conducting a large-scale multi-centre as to how it might work. One of its most study.4 Its findings are awaited with great interest. distinguished exponents, however, was Sir William Osler,9 who, in the 8th edition of his Treatment of Pain-Producing Myofascial student text book, published in 1912, at a time Trigger Points - Historical Review when he was Regius Professor of Medicine at Historically, the method which must take pride of Oxford University, wrote, place as having been the first to be employed, in “...For lumbago, acupuncture is in acute cases the 7th century A.D. by the Chinese physician Sun the most efficient treatment. Needles of from three Ssu-Mo, is dry needling, of what he called Ah- to four inches in length (ordinary bonnet needles, Shih points.5 Clearly, from his description of them, sterilised will do) are thrust into the lumbar they are what are currently referred to as MTrPs. muscles at the seat of the pain and withdrawn News that insertion of needles into the after five to ten minutes...” ACUPUNCTURE IN MEDICINE 2002;20(1):2-10. www.medical-acupuncture.co.uk/aimintro.htm 3 BMAS March 21/2/02 1:02 PM Page 4 Papers alleviated, by injecting 1% procaine (Novocain) into them. These extremely important observations were largely ignored in Britain, and might have been lost sight of completely had they not, together with those made by others,13;14 come to the attention of the American physician Janet Travell. Travell, from the 1940s onwards, made a life time study of the subject of myofascial pain, introducing this term and the term MTrP, and showing that each muscle in the body has its own specific pattern of MTrP pain referral. With respect to treatment, Travell was quick to realise that the analgesia produced by injecting procaine into a MTrP could not, as Kellgren had assumed, be due to its nerve blocking effect, as it lasted too long. In addition, she found that pain relief of a similar duration could be obtained by simply inserting a needle into the MTrP.15 She also found, however, that the latter is an extremely Figure 1 Needles employed by JM Churchill, painful procedure, and in order to suppress this from his book ‘A treatise on acupuncturation…’ ephemeral treatment-evoked pain, decided to published in 1821. continue to employ Kellgren’s method of injecting a local anaesthetic through the needle. From his description, he, like Churchill, was A disadvantage of using a local anaesthetic for clearly employing strongly applied deep needling, this or any other purpose is that it very occasionally at what today would be called MTrPs.

Load more