Trigger Points - An Overview of the Evidence Base
Dr. Jonathan Kuttner Presents an Overview of the Evidence Behind Trigger Point Therapy
Drs. Janet Travell and David Simons (1992) described a trigger point as, “A highly irritable localised spot of exquisite tenderness in a nodule in a palpable taut band of (skeletal) muscle”
These hyperirritable localized spots can vary in size, and have been described as “tiny lumps,” “little peas,” and “large lumps”; they can be felt beneath the surface, embedded within the muscle fibers.
If these spots are tender to pressure they may well be “trigger points.”
The size of a trigger point nodule varies according to the size, shape, and type of muscle in which it is generated.
What is consistent is that they are tender to pressure. So tender in fact (hyperalgesia) that when they are pressed, the patient often winces from the pain. This is often referred to as the “jump sign.”
Myofascial trigger points may well be implicated in all types of musculoskeletal and mechanical muscular pain. Their presence has even been demonstrated in children and babies.
Pain or symptoms may be directly due to active trigger points, or pain may “build up” over time from latent or inactive trigger points.
Studies and investigations in selected patient populations have been carried out on various regions of the body.
There is a growing amount of research evidence directly linking musculoskeletal pain to trigger points.
A high prevalence of trigger points has been confirmed to be associated with myofascial pain, somatic dysfunction, psychological disturbance, and associated restricted daily functioning.Embryogenesis
There is some evidence that myofascial trigger points may be present in babies and children (Davies 2004); they have also been demonstrated in muscle tissue after death.
Trigger points develop in the myofascia (hence the descriptor myofascial trigger points or MTPs), mainly in the center of the muscle belly where the motor endplate enters (primary or central).
However, secondary or satellite trigger points often develop in a response to the primary trigger point.
These satellite points often develop along fascial lines of stress, which may well be “built- in” at the time of embryogenesis. External factors—such as ageing, body morphology, posture, weight gain, or congenital malformation—also play a crucial role in trigger point manifestation and genesis.
In 1957, Dr. Janet Travell discovered that trigger points "generate and receive” minute electrical currents.
She determined experimentally that trigger point activity could be accurately quantified by measuring these signals with an electromyogram (EMG).
Local twitch response (LTR) in a rabbit tender spot. LTRs are elicited only when the needle is placed accurately within the trigger spot.
This is because electrical activity in a muscle in its resting state is “silent.” When a small part of the muscle goes into contracture, as with a trigger point, a small, localised spike in electrical activity occurs.
When needled with a monopolar teflon-coated EMG needle, trigger points have been demonstrated to elicit a local twitch response (LTR).
LTRs appear as high-amplitude polyphasic EMG discharges (Hong 1994, Wang & Audette 2000).
Trigger points have been reliably demonstrated by MRI's and there is an abundance of studies showing their efficacy.Some key questions do remain unanswered however:
What is the action of a needle that causes a muscle to contract?
Why is the twitch painful?
Why does the pain go away quickly?
Shah et al. (2003) performed a micro-dialysis experiment, in which two tiny microtubules were inserted (within a hollowed-out acupuncture needle) into the trigger point of the upper trapezius muscle.
Saline solution was pumped through one tubule, while the other aspirated the local tissue fluid exudate.
Nine subjects were selected for the study; of these, three were said to manifest active trigger points, three latent trigger points, and three no trigger points (control group).
To locate the trigger points, the subjects were first manually palpated, and then an algometer (pressure meter) was used to measure the amount of pressure required to elicit symptoms.
In each of the nine subjects the same zone of the upper trapezius was aspirated.
The results have thrown some more light on the internal pathophysiology within trigger points, suggesting localised tissue hypoxia, increased acute inflammatory cascade, and lowered pH (acidosis) (see Table above).
Notes to the Video
The video above is presented by Dr Jonathan Kuttner (MBBCH, Dip Sports Med, Dip MSM, FRNZCGP, FAFMM) who is a musculo-skeletal pain specialist and has spent the last 35 years working as a doctor and teaching in New Zealand.
He is the recipient of the NAMTPT Lifetime Award for Contribution to Myofascial Trigger Point Therapy and is regularly featured on national TV and radio.
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This trigger point therapy blog is intended to be used for information purposes only and is not intended to be used for medical diagnosis or treatment or to substitute for a medical diagnosis and/or treatment rendered or prescribed by a physician or competent healthcare professional. This information is designed as educational material, but should not be taken as a recommendation for treatment of any particular person or patient. Always consult your physician if you think you need treatment or if you feel unwell.