Myofascial pain syndrome (MPS) is a disease that affects the chemical responses between nerve endings and muscle. It is thought that there is an excessive release of a neurotransmitter (a chemical messenger in the central nervous system) called acetylcholine.
Newer research suggests that chronic myofascial pain (CMP) from myofascial trigger points (MTrPs) may be at the root of muscle pain in fibromyalgia(FM). It is thought that the tender points on the tender point model, which has been used to diagnose fibromyalgia, may have been MTrPs all along. I suspect there are chronic fatigue syndrome (CFS/ME) patients that have chronic myofascial pain also, which might explain their myalgia (muscle pain).
Myofascial pain syndrome (MPS) is a chronic disorder in which sensory, motor, and autonomic symptoms are caused by myofascial trigger points (MTrPs). This condition may develop in muscles that are stressed, overused, or injured. Different from isolated incidental occurrences of trigger points (TrPs), which do not become a chronic problem, MPS develops when TrPs are apparent in several quadrants of the body and they have outlived their usefulness as a warning sign. (More on trigger points following). When accompanied by fibromyalgia, MPS can be triggered without muscle strain or injury. This hypersensitivity could be due to the cellular hypoxia (low oxygen) and poor cellular healing during sleep. It is a peripheral pain generator that keeps the FM brain in a hypersensitive state, called centralization.
Theories as to the cause of trigger points and how they affect muscle tissue and the body has been documented by early investigators, but the real pioneer for the study of chronic myofascial pain, MPS, as we know it today, is Dr. Janet Travell, later joined by Dr. David Simons.
Dr. Travell noted that by applying pressure to a trigger point (TrP), she could establish and predict the presence of referred pain patterns that remain consistent between patients. After successfully treating President Kennedy for previous bouts with myofascial pain and long-standing back problems, she was appointed as the first woman, and first non-military, White House physician. Dr. Travell and Dr. Simons have passed on, but they carried the torch a long way mentoring those willing to learn allowing research regarding myofascial medicine to continue.
The primary job of a skeletal muscle is to provide locomotion by attaching to other muscle and to joints.
When a muscle is shortened by the presence of a myofascial trigger point (MTrP), it causes dysfunction in the normal contraction and relaxation of the muscle, and it is not able to do the job efficiently or without pain. The muscle is made up of sarcomeres.
A sarcomere is a tiny unit of muscle fiber. Many of them lined up end to endform myofibrils, and thousands of myofibrils make up the skeletal muscle.
The sarcomere's job is to contract the muscle. Each one goes through three phases—resting, contracted, and stretched—and the impulse from one to the other is transmitted in a domino effect.
Myofascial trigger points (MTrPs) are an area of unnaturally shortened, thickened, sarcomeres in knotted, ineffective muscle fiber. These bound-up sarcomeres contract and stay that way weakening the rest of the chain of sarcomeres during a full-length stretch, which causes muscle unable to dysfunction.
It is extremely important to treat that myofascial trigger point so the sarcomeres can lengthen and contract normally.
A MTrP is a self-sustaining irritable area in a taut band of muscle fiber that is felt as a nodule or bump. This irritated spot causes gradual shortening of the muscle interfering with normal muscle function, and causing pressure on the surrounding nerves, lymph and blood vessels. Other related symptoms from untreated TrPs can result depending on trigger point location.
Myofascial trigger points can usually be felt with your fingers unless the muscle is too rigid or the MTP is behind bone or other muscle. The presence of MTPs has no relevance regarding the size of the muscle. Feel around your body, see if you note any of these nodules, press on them and see if they radiate pain or numbness. If they do, you have found a "trigger point."
A new application of ultrasound imaging in finding and treating TrPs is especially helpful. The physician can inject lidocaine (no steroids) and do some dry needling to watch for the trigger point release. When TrPs are treated, the muscle can return to its normal resting length and restore function to opposing muscles and joints. We can do the same with self treatment by applying pressure. You can read more about this in Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Pain.
Myofascial trigger points are described as active, latent, primary, secondary or satellite.
Active trigger point
Active MTrPs hurt without being touched, radiate pain, restrict motion, and can cause other symptoms depending on the surrounding nerves, lymph system, and blood vessels.
An active trigger point can elicit a visible local twitch response when adequately stimulated by compression or needle insertion. It can also produce referred motor and autonomic phenomena in the TrP referal zone, and can cause the reference zone to become tender, which most likely explains the tender points in the tender point model of FM, and why many patients have tender areas not related to the model.
Latent trigger point
A latent trigger point is a trigger point that causes pain only when it is compressed or manipulated. Latent TrPs also restrict muscle movement, cause stiffness, and cause weakness that persists for years after apparent recovery. They can go unnoticed only to be reactivated from a seemingly minor overstretching, overuse, or injury. Even chilling can cause transition from a latent trigger point (TrP) to an active TrP in the fibromyalgia patient.
Understanding the different types of TrPs reinforces the need to be in tune with your body. However, knowing what kind of trigger point is not as important as knowing what they feel like when you run across them. Some cause pain regardless of whether you touch them (active), others will hurt only when you press on them (latent). Either way, you need to be treated. Treating all the types is necessary for optimal recovery. Don't be lured into thinking you can only treat active TrPs (the ones screaming out), even though the acute pain of a primary trigger point is dormant, it is still the villain.
A primary TrP is the one that starts the whole painful event. It can be active or latent. Treating other TrPs without treating the primary trigger point will not solve your problem. It takes someone specifically trained in Travell and Simons work or following a self treatment guide written according to Travell and Simons teachings. Being able to do both, therapist and self treatment, provides the best results. When not done properly, myofacial TrPs will easily reoccur leaving you and the therapist or doctor frustrated and you in pain.
Secondary trigger point
A secondary TrP is a trigger point that develops in a second compensating muscle. This second (or third, or fourth…) muscle is attempting to compensate for the malfunction of the muscle affected by the primary trigger point(s). Yes, you can have more than one TrP in a muscle. The location of each one in the same muscle is responsible for its own pattern of symptom referral.
Satellite trigger point
A satellite trigger point is a TrP located in the referral zone of the primary trigger point muscle. It can be active or latent.
Muscles can develop MTrPs because of accident, surgery, poor posture, repetitive motion, stress, or chronic tension; and can cause changes in balance, nausea, vision, hearing, heart palpitations, bowel and gonad related difficulties, urinary difficulties, and many other autonomic disruptions to the body.
A trigger point (TrP) has both a sensory and motor component. These are demonstrated by locating tenderness, locating a referred pain pattern, and demonstrating a local twitch response by mechanical stimulation. An active location is a site from which spontaneous electrical activity (SEA) can be recorded. This record is achieved much like heart electrical activity is recorded on an EKG. And now TrPs can be located for treatment with sonography.
Understanding why these disruptions occur is what guides scientists. The good news, unlike in fibromyalgia (FM) and chronic fatigue immunodysfunction (CFS/ME), trigger point treatment is precise and successful when done properly. For the severe FM patient, however, complete control may not be possible because of the dysfunctional feedback loop; however, having them treated by a specialist in Travell and Simons methods and learning self treatment can allow the patient to get out of the wheelchair and moving again.
Chronic Myofascial Pain Diagnostic Criteria
Diagnosis can sometimes be very complicated. The perpetuating factors that cause trigger points can, and do, vary among us, and TrPs can mimic many conditions.
A history of pain resulting from a muscular insult that has outlasted the causative event is the most significant characteristic of chronic myofascial pain disorder.
The pain or symptom referral pattern for the trigger point involved does not change either in the same patient or between patients.
A clear, concise history is an integral part of the diagnostic criteria. Let your doctor know how chronic myofascial pain (MPS) interferes with your function. An isolated event can cause severe disabling pain and dysfunction, but when successfully treated, it will not lead to a chronic myofascial pain state in the otherwise healthy individual. We are not certain why CMP occurs, but a central sensitization phenomenon such as fibromyalgia is suspected.
Chronic Myofascial Pain Symptoms
People who have chronic pain from TrPs have myofascial pain syndrome not fibromyalgia. The two may co-exist but are not interchangeable. Chronic myofascial pain can occur with other conditions such as migraine, TMJ, dysfunctional pelvic disorder, RLS etc. that seem to cluster with fibromyalgia.
It is possible to bring MPS under control with proper myofascial treatment, supervised exercise, medication, and avoidance of perpetuating factors. It is not a progressive disorder in that it does not continue to worsen once the TrPs are treated. Left untreated, however, the chances of their total eradication are decreased.
For help in learning to identify perpetuating factors, communicating with your physician and others, documenting, dealing with emotional and spiritual aspects of living with chronic pain, and juggling two or more of these disorders or co-existing conditions, please read our book, Integrative Therapies for Fibromyalgia, Chronic Fatigue Syndrome, and Myofascial Pain: The Mind-Body Connection.
Therapies and treatments for chronic myofascial pain from TrPs are aimed at restoring normal resting muscle fiber length; and maintaining adequate muscle strength, and endurance. Effective treatments include TrP injection and pressure therapy, active release therapy, myofascial release, and self treatment. We discuss many types of therapies ourbook. It is imperative that you understand MPS and TrPs in order to bring some of your painful symptoms under control. Myofascial trigger points are the greatest peripheral pain generator in fibromyalgia.If you have chronic myofascial pain, you must be committed to therapy. Successful treatment of trigger points will improve your life's quality. Refer to the Helpful Links regarding information on helpful self-treatment guides.
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