Lynsey McGovern owner of Archview Physiotherapy Pain and Sports Injury Clinic has a keen interest in the management of pain. Muscle pain or myofascial pain as she explains in the following article can be associated with any injury and therefor should not be ignored if resolution of a patients symptoms is the primary aim of treatment. The following article was published in the Chronic pain association of Ireland in 2009.
Muscle Pain – The elephant in the Room.
Over the last decade, words like myofascial pain and dysfunction have become familiar for both chartered physiotherapists and medical doctors in Ireland. Physiotherapists have, however, adapted to this new concept of pain more readily. Travell and Simons, both respected medical doctors, dedicated their lives to researching the area of myofascial pain anddysfunction, and, in doing so, devised a revolutionary approach to the treatment of muscle pain, which developed into what we now know today as – dry needling. Thanks to them, the medical world now has the ability to treat chronic pain safely, effectively – and without medication. Myofascial pain has been estimated to be present in 85%-93% of patients in chronic pain clinics and in 55% of patients with head and neck pain.
The aim of this article is:
To introduce, simply and in layman’s terms, the concept of myofascial pain to chronic pain sufferers.
What does myofascial mean? The term myofascial is used only when discussing muscles, and refers to the layer of soft tissue that covers the muscle – known as the fascia. Our bodies are made up of approximately 50% muscle but often muscle is ignored as a potential source of pain. So much so, in fact, that muscle has often been caused the “orphan organ”. When it comes to healing, we instinctively place our faith in medical professionals, GPs or consultants. And well we should. But bizarrely there is no doctor who specialises in the treatment of muscles. We have neurologists for our nerves; orthopaedic surgeons for our bones – but no myologists! Today, physiotherapists are perhaps the most qualified medical professionals in the area of muscles, and the role they play in chronic pain.
What is myofascial pain? Myofascial pain refers to specific points in the muscle, called trigger points. These points can give rise to local or referred pain. Each muscle has a referral pain pattern (trigger point pain patterns) just like myotomes (myotomes refers to all those muscles innervated from a particular segment of the cord) e.g. C5 nerves supplies the shoulder muscle. Therefore any disruption to the nerve root at this level may cause pain in the shoulder. The diagram above shows the ‘trigger point pain pattern’ from trigger points in the trapezius muscle of the neck. As you can seethese point can refer into the head and be a source of headaches. ‘X’ is only an indication where the trigger points may lie. A muscle can have many trigger points.
What are myofascial trigger points (MTrPs)? These particular points (TrPs) are explained by Travell and Simons as, “hyper-irritable spots in skeletal muscle that are associated as hypersensitive palpable nodules in tight bands.” In other words – skeletal muscle is the only type of muscle in which you can find trigger points. They are, in simple terms, knots which are embedded within very tight bands in the muscle. These specific points are painful on compression.
What effect can trigger points have on our bodies?
Research has shown that, at cellular level, there is chemistry at play on and around the points. Abnormal cellular calcium and acetylcholine are thought to be the kingpin of the trigger point at the neuromuscular junction (the point at which the nerve sends impulses into the muscle to cause it to contract). This imbalance is thought to have an effect on the spinal cord and cause pain.
Is there more than one kind of myofascial trigger point? Yes, there are two types of Myofascial trigger points (TrPs):
Latent trigger points – as in the variety which cause no pain – are sometimes to blame for motor dysfunction (muscle stiffness and restricted range of movement). These, thankfully, are far more common than active trigger points, which can bring with them a considerable amounts of pain. Some research in the area has shown that latent trigger points may be to blame for noctural (night) cramps in the calf muscle.
What causes myofascial trigger points? When answering this you have to look at a patient’s day-today life and well-being as a whole. A number of factors need to be considered, including:
Mechanical: e.g. postural, structural, biomechanical, ergonomical and leg length discrepancies.
Physiological: e.g general fitness, fatigue and sleep patterns
Medical: e.g. thyroid disease, medications, systemic influenza and infections
Metabolic: e.g. vitamin deficiencies like B1, B6, B12, folic acid and Zinc
Psychological: e.g. stress, fear avoidance issues, alcohol, drugs and psychological disorders. As there are many causes of myofascial pain, it is often necessary that a multidisciplinary approach to treatment be used – medical, medical specialty, physiotherapy, psychology etc.
What is Myofascial dysfunction? Myofascial dysfunction relates to muscles which are being hampered and kept from functioning correctly by trigger points. The muscle is unable to contract or relax properly unless the points are treated.
How can Myofascial trigger points be treated? Myofascial trigger points (MTrPs) can be treated by Dry Needling, but they can also be treated by manual means (hands on treatment), ice and stretching, electrotherapeutic modalities such as TENS, interferential therapy, ultrasound and exercise therapy. In my opinion, a combined approach of dry needling and physiotherapy works best. Unfortunately, only 150 Irish-based chartered physiotherapists are trained in the area of dry needling. Approximately 600 are trained in palpation, though, so can treat myofascial pain manually. However, it must be noted that in the majority of cases, manual treatment is slower to produce results.
Is dry needling acupuncture? No. Because needles are used in both treatments, the two are commonly mistaken. But that’s where the similarities end. The concept behind dry needling is very different. Acupuncture, for instance, is based on Chinese medicine where by needles are placed in chi points along meridian lines; whilst dry-needling is a western-based approach to treating pain. It is a scientifically proven and evidence based form of treatment which works by deactivating pain producing myofascial trigger points in muscle so that the muscles can function better. The clinical importance of myofascial TrPs to practitioners has been described in literature for chronic pain managers, dentists, orthopaedic surgeons, physiotherapists, rheumatologists and even veterinarians, yet, in general, trigger points receive very little attention as a major source of pain and dysfunction in modern medical text books. It is for this reason that all health care professionals need to be able to identify MTrPs as being a component to their patient’s pain, so that appropriate referrals can be made.
I sincerely hope this article has shed some light on the fact that pain is complex. There are so many factors contributing to pain, not just one. It is therefore so important that muscle pain is not ignored as it can often be present in chronic pain conditions.
N.B. Please be careful when seeking a physiotherapist or physical therapist for treatment in myofascial pain. Always ensure that they are members of the Irish Society of Chartered Physiotherapists (ISCP).