Myofascial Trigger Points

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Definitions

Myofascial pain syndrome is defined as sensory, motor, and autonomic symptoms that are caused by myofascial trigger points. The sensory disturbances that are produced are dysesthesias, hyperalgesia, and referred pain. Coryza, lacrimation, salivation, changes in skin temperature, sweating, piloerection, proprioceptive disturbances, and erythema of the overlying skin are autonomic manifestations of myofascial pain.

Travell and Simons [1] defined the myofascial trigger point as “a hyperirritable

Etiology

Trigger points may develop after an initial injury to muscle fibers. This injury may include a noticeable traumatic event or repetitive microtrauma to the muscles. The trigger point causes pain and stress in the muscle or muscle fiber. As the stress increases, the muscles become fatigued and more susceptible to activation of additional trigger points. When predisposing factors combine with a triggering stress event, activation of a trigger point occurs. This theory is known as the “injury pool

Pathophysiology

There is no pathologic or laboratory test for identifying trigger points. Therefore, much of the pathophysiologic research on trigger points has been directed toward verifying common theories of their formation. Fig. 1 provides an example of the theory behind the formation of myofascial trigger points.

The local twitch response (LTR) has been described as a characteristic response of myofascial trigger points. LTR is a brisk contraction of the muscle fibers in and around the taut band elicited

Diagnosis

The diagnosis of myofascial pain is best made through a careful analysis of the history of pain along with a consistent physical examination [11]. The diagnosis of myofascial pain syndrome, as defined by Simons and colleagues [12], relies on eight clinical characteristics (Box 1). Identification of the pain distribution is one of the most critical elements in identifying and treating myofascial pain. The physician should ask the patient to identify the most intense area of pain using a single

Spray (freeze) and stretch

Travell and Simons [1] advocated passive stretching of the affected muscle after application of sprayed vapocoolant to be the “single most effective treatment” for trigger point pain. The proper technique depends on patient education, cooperation, compliance, and preparation. The patient should be positioned comfortably, ensuring that the trigger point area is well supported and under minimal tension. Position should place one end of the muscle with the trigger point zone securely anchored. The

Invasive techniques for management

Trigger point injection remains the treatment with the most scientific evidence and investigation for support. Typically, it is advocated for trigger points that have failed noninvasive means for treatment. Injections are highly dependent of the clinician's skill to localize the active trigger point with a small needle.

Various injected substances have been investigated. These include local anesthetics, botulism toxin, sterile water, sterile saline, and dry needling. One common finding with

The universal technique for injection

The patient should be positioned in a recumbent position for the prevention of syncope, assistance in patient relaxation, and decreased muscle tension. The trigger point must then be identified correctly. The palpable band is considered critical in the identification of the trigger point. This can be done with any of the three methods described above. The trigger point should be marked clearly. Then, the skin is prepared in a sterile fashion. Various physicians use different skin preparations

Local anesthetics

Local anesthetics are the substances that have been investigated most frequently for the treatment of myofascial trigger points. Local anesthetic injections were shown to improve measures on a pain scale, range of motion, and algometry pressure thresholds. The volume of local anesthetic injected also has been investigated, and small volumes are considered the most effective. Typically, less than 1 mL of local agent should be injected in a highly controlled manner. The primary use for a local

Summary

Myofascial pain syndromes are a widely recognized phenomenon among physicians and represent a common pain disorder in the American population. A myofascial trigger point is “a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle fascia. The spot is painful on compression and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena” [1]. Many treatment strategies, both invasive and noninvasive, have been recognized for myofascial

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