The Great Controversy:
Odds are, you may be experiencing a trigger point as you read this or have experienced one sometime in your life. But what exactly is a trigger point? Like many things in life, a myofascial trigger point is a very complex phenomenon that is undeniably concrete but still difficult to explain. Even experts have wavering opinions on the origins, physiology, biology, and best treatment of these tender spots of muscle. Throughout the arguments and debates, the one thing that remains evident is that a painful problem exists. Trigger points may not be the formal medical description for this condition, however, the word seems to trigger controversy. For that reason, and for the sake of simplicity, common knowledge, and discussion, I will merely use the phrase “trigger points” as a label for this unexplained experience.
A trigger point is a sensitive spot of irritated muscle that produces a sensation of perceived discomfort. These tender points of muscle are a very common cause of muscle pain that annoy and complicate daily life. The pioneers of trigger point research, Dr. Travell, M.D. & Dr. Simmons, M.D., define a trigger point as such
(1) “A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena.” (From Travell JG and Simons DG: “Myofascial Pain and Dysfunction: The Trigger Point Manual,” Williams & Wilkins, Baltimore, 1983, pg. 31.)
It is also theorized that once a trigger point develops, blood may be choked off from that area, leading to a lack of oxygen, causing them to become acidic. This can turn into an ongoing cycle of further pain and irritation. (27)
Until recently, I have been naive to the heated debate about trigger points. Experts, researchers, and self-proclaimed philosophical thinkers have questioned the biology, pathology, physiology, and even existence of trigger points, as well as the best treatment for this conundrum. I will give my humble opinion on the drama in the last section of this article, but first I will give more information about myofascial trigger points.
Everything in the body is interconnected by way of a certain connective tissue, called fascia. Fascia envelopes and connects every structure in the body, including muscles, organs, nerves, and blood vessels. (2) “Fascia is the biological fabric that holds us together, the connective tissue network”. Fascia is important when discussing muscle pain and trigger points because this tissue surrounds each muscle and may be influenced or have an influence on trigger points and its perceived pain. Fascia that envelopes specifically muscle is called myofascia (myo = muscles, fascia = the connective tissue that envelopes the muscle). Hence, the names myofascial release and myofascial pain being related to trigger points.
Muscle pain is important because most of the medical complaints seen by physical therapists consists of some variation of pain, with myofascial pain being a major culprit of most cases. The most common areas of myofascial pain are found in the neck, shoulders, and upper back. Research (5 & 6) has also shown that the trigger points could be a component of headaches. Aside from those popular areas, myofascial restrictions can often hide themselves in places like the pec minor, hip flexors, quads, lower back, and feet. A possible cause of trigger points can be joint instability–if joints are too mobile, the surrounding muscles are overworking to keep that joint in place, causing overuse and fatigue, making it easy for trigger points to develop. Just like a car that is overused with too many miles eventually breaks down, sooner or later, you can count on your muscular system to wear out too.
Trigger points are not only a problem on their own, but they can also make complicated health issues worse. Lower back pain from a herniated disc leads to a compensated posture that may give rise to trigger points. An amputation due to trauma or diabetes will lead to altered biomechanics from a compensated gait pattern. The new gait pattern will lead to new muscle activation and/or an overuse of muscles, which can give rise to trigger points as well.
This research study (14) Etiology of Myofascial Trigger Points states, “In spite of a lack of well-designed studies, the best available evidence supports that TrPs develop after muscle overuse…Whether overuse mechanisms are the crucial initiating factor or persistent nociceptive input remains a point of debate and further study.” A trigger point may occur the same way in stroke or spinal cord injury patients, with altered posture being a factor, as well.
Myofascial pain is complicated for another reason. Not only can MTrP obscure the underlying issue, it may also mimic other referred pain patterns. (7) Myofascial pain syndromes — the great mimicker states, “An understanding of these pain problems, produced from trigger points in muscles and ligaments, is important in order to differentiate myofascial pain syndromes from more dangerous diseases and to avoid unnecessary and expensive diagnostic procedures.” This makes MTrP easily mistaken for another diagnosis or vice versa.
Referred pain is often a symptom of trigger points. Referred pain is the discomfort that radiates from a lesion and causes perceived pain at another point in the body. David G Simmons, M.D. makes a great analogy between trigger points and referred pain. (4)“The pain and tenderness referred by a trigger point is usually projected at a distance, much as the trigger of a gun that is located one place causes the bullet to impact elsewhere.” These hidden tender spots may also be caused by poor posture and faulty biomechanics, which leads to the theory of tensegrity.
Trigger points are often referred to as shortened or tight muscles. However, it can be argued that trigger points are not necessarily short, but are a product of muscles being fixated to a direction (Naudi Aguilar). Since the body is interconnected, the structures that are embedded in fascia have influence on other structures. When a muscle develops a form of dysfunction, like a trigger point, other structures in the body are susceptible to change as well. This phenomenon of stress on one point of the muscular system affecting another is called tensegrity. Thomas Myers states, (3) “Fascial continuity suggests that the myofascia acts like an adjustable tensegrity around the skeleton – a continuous inward pulling tensional network like the elastics, with the bones acting like the struts in the tensegrity model, pushing out against the restricting ‘rubber bands’.” Tensegrity may explain abnormalities, like upper cross syndrome, flat feet (pes planus), and piriformis syndrome, as well as other biomechanic defaults. Whether a trigger point is the chicken or the egg in regards to tensegrity is up for debate. However it is logical to think that the theory of tensegrity may explain the muscle pain patients experience and why they seek the guidance of physical therapists.
How do I know if I have a trigger point? David G Simons M.D. explains 5 characteristics of a trigger point. (4). https://www.ncbi.nlm.nih.gov/books/NBK219241/
- The initial onset of pain and its recurrences is of muscle origin (David G. Simons 1987).
- Reproducible spot tenderness occurs in the muscle at the site of the trigger point pain.(David G. Simons 1987).
- Pain is referred locally or at a distance on mechanical stimulation of the trigger point. This referred pain and tenderness projects in a pattern characteristic of that muscle and reproduces part of the patient’s complaint. Patterns of referred pain are frequently different from those expected on the basis of nerve root innervation (Travell and Rinzler, 1952; Travell, 1976).
- There is palpable hardening of a taut band of muscle fibers passing through the tender spot in a shortened muscle (Simons, 1976).
- A local twitch response of the taut muscle occurs when the trigger point is stimulated. (David G. Simons 1987)
There is plenty of evidence (16,17,18) saying that therapists cannot manually deform the muscle to make change. If muscle tissue change is not the cause, why do people feel significantly better after “myofascial release” of “trigger points”?. A theory of why, is that there is a neurophysiological effect taking place.
(15) Robert Schleip states,”Fascia, nevertheless, is densely innervated by mechanoreceptors, which are responsive to manual pressure. Stimulation of these sensory receptors has been shown to lead to a lowering of sympathetic tonus, as well as a change in local tissue viscosity. Fascia and the autonomic nervous system appear to be intimately connected.”
Wellens states, (23) “A simple explanation for a good part of the effectiveness of manual therapy could be that the novel stimulation introduced in the CNS by manual therapy may help the brain down regulate the perceived threat of current stimuli and thus decrease the pain by means of descending inhibition and other peripheral and central mechanisms (which include a placebo response).”
The NE can be explained at length, but for brevity, I will give a brief explanation. The effects of NE could be a combination of the central and peripheral nervous systems. Muscles are innervated by mechanoreceptors that respond to manual pressure and decrease the sympathetic tone in the muscle. Another theory could be that the gate control theory (19) is in effect. Afferent neurons receive information from external stimuli, then relate that information to the brain. Only so much information can run through neurons at a time, therefore, the newly received information from a mechanism, such as manual therapy techniques, may be another cause of decreased pain. Manual therapists should not take to heart that they cannot change the structure of fascia or muscle; if they could, our bodies would be too frail to function. A proper understanding of meaning behind the label trigger points and how manual therapy really is working is necessary for honest patient education and will help us treat more effectively.
Solid information is hard to come by with trigger points. The science has missing pieces, is not fully explained or understood, and has been thrown out all together (8). However, muscle pain still exists, but the cause of trigger points and the best treatment for them seems to be the argument. Muscle pain is often overlooked by the general physician, but muscle is a huge part of the body. Beyond normal muscle tissue, muscle is also found in the heart, digestive system, and blood vessels. Even though muscle is everywhere, it is still arguably neglected by medicine. Muscle pain is not as serious as other complications, so the neglect is understandable.However, as physical therapists, muscle pain is our expertise. Because of the weak science refuting or standing for trigger points, myofascial pain is often thrown in as a last possible diagnosis despite its all too real presence.
For those looking for evidence-based and science-based research on trigger point therapy/myofasicial release, here are a few:
5). Systematic review of self myofasical release. The results show that SFMR increases muscle flexibility and reduces soreness without impeding athletic performance. The study comes to the conclusion that “SMFR appears to have a range of potentially valuable effects for both athletes and the general population, including increasing flexibility and enhancing recovery.”
9) “Acute Effects Of Self-Myofascial Release Using A Foam Roller On Arterial Function” says, “These results indicate that SMR using a foam roller reduces arterial stiffness and improves vascular endothelial function.” This may reduce oxygen deprivation in a trigger point that could be the cause for the painful sensation.
10) Literature Review: Effects of Myofascial Release on Range of Motion and Athletic Performance. “Overall, myofascial release techniques show an ability to improve range of motion and athletic performance, depending on the type of range of motion and mode of athletic performance. Further research needs to be conducted to find which muscle groups and joints benefit the most from myofascial release.”
11) Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. “The results suggest that myofascial release techniques can be a complementary therapy for pain symptoms, physical function, and clinical severity, but do not improve postural stability in patients with fibromyalgia syndrome.” According to this study, unless a person has fibromyalgia, myofascial release will be beneficial.
12) Myofascial Release as a Treatment for Orthopaedic Conditions: A Systematic Review. “The quality of studies was mixed, ranging from higher-quality experimental to lower-quality case studies. Overall, the studies had positive outcomes with myofascial release, but because of the low quality, few conclusions could be drawn. The studies in this review may serve as a good foundation for future randomized controlled trials.”
13) An acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force. “An acute bout of SMR of the quadriceps was an effective treatment to acutely enhance knee joint ROM without a concomitant deficit in muscle performance.”
14) Etiology of Myofascial Trigger Points.”In spite of a lack of well-designed studies, the best available evidence supports that TrPs develop after muscle overuse…Whether overuse mechanisms are the crucial initiating factor or persistent nociceptive input remains a point of debate and further study.”
With just that small pocket of research, there is much more with findings for or against myofascial therapy . If you need more research, feel free to search the reference section of any of these cited works and find the articles that best suit your argument. The research I pulled is biased towards the benefits of trigger points/ myofascial release therapy for the betterment of the most important part of physical therapy, the patient. It is understood that limitations and interpreting statistics should be taken into account to determine how significant the research really is. However, for the sake of this article, I will not delve to that depth. Why tooth fairies are so important in PT (21), does a great job in explaining that topic in more detail.
It is difficult for young clinicians to know what the best practice is because in this information age, anyone can find a study or opinion to support or counter any argument made. Once there is a substantial amount of solid evidence in agreement with one another, then it is time to adapt our thinking and practice to agree with evidence. Trigger point therapy should not be the end all be all for treatment and I highly doubt for any physical therapists that is the case. Manual therapy is only another tool in the toolbox to benefit the people we entered this great profession to help.
The Patient experience:
I enjoy implementing the scientific method to questioning everything and I do not claim to have the all the answers. I can only take what I have learned so far and apply it with logical thinking to make the best decisions possible for patients.
My objective is not to sway you to believe in the theory of MTrP or not, and there very well could be conformation bias in everyone towards one side or the other on this topic. There is research supporting and refuting the existence of trigger points, however, most research will say that this is an ongoing investigation and more evidence is needed and encouraged. I am solely writing from the perspective of a person who entered the field of physical therapy not for his own ego to prove others wrong, but for the benefit of the patients. I attempt to use my knowledge and passion to impact lives in a positive way, even if that does happen to include “releasing trigger points” alongside other hard evidence-based treatment that will benefit the patient.
My concern is not the research; time and money will come and the best evidence-based and science-based practice will emerge. With current knowledge, we are not defying the hippocratic oath of first doing no harm and we may in fact be keeping the public out of the opioid epidemic by performing MTrP therapy. The patients may even argue they are getting better and have the most satisfaction from manual therapy (24) (consumer report 2013). To support that, Sulmasy in The Healers calling implies that touch is a deep human need (26). As physical therapists, patients almost always are coming to us from a place of vulnerability and pain. Therefore, relief from pain could be argued as an ethical obligation by PTs.
(20) Placebo, Nocebo, and Expectations: Leveraging Positive Outcomes states,”We have made great strides in published evidence and structured postprofessional programs… It is now time for our profession to take a proactive approach toward patient values. Therefore, let us embrace and enhance, rather than discount, the benefits of placebo and couple this with knowledge and shaping of patient expectations to maximize therapeutic outcomes.”
What is of utmost importance is the patient. Manual therapy techniques coupled with other therapies is making a difference, whether we fully understand these ambiguous but concrete trigger points or not. Patients want and care about results. In the real world, patients want you to acknowledge their chief complaint and want help to feel and function better, regardless of what we label the term.
So why go to school and be trained in science and evidence practice? What PT school is or is not teaching is another topic, which you can read about in (25) 10 things physical therapy school will not teach you.
Schools’ primary goal is to instill competence in its students in order to not harm the patients and to pass the board exam. However, school is not the end all be all of our learning. School, first and foremost, teaches us how to discern knowledge for ourselves. We become educated through school, but at times the education seems to take over common sense. We seem to forget why we do things and who we are doing them for.
For the most part, no one is going to come to you and ask you about the science. They’re going to ask you to make them feel better. If physical therapists can offer the client something that helps them function throughout the day but doesn’t have an established Random Contol Trial, is that the worst thing in the world?
In the age of evidence/science-based research, some are critiquing scientific research all together saying it is (28) losing credibility, and the results are biased towards whoever is funding the research. With that said, is it stepping on too many toes to say the patient may come before the research? Even orthopedic textbooks, like (29) Orthopedic Manual Therapy – An evidence based approach, uses the patient response model as the primary approach to therapy.
There are many things that have yet to be fully explained by science. There are also things we use everyday in society that an average person couldn’t explain the inner workings of. Yet they still use it. Why? Because it serves a purpose. If we cannot provide or understand the absolute cure for MTrP as of yet, at least we can provide care.
Clients have probably been living with this pain for weeks, months, or years so it is important to remind them that they will not be magically healed in 10 minutes. Self massage or self myofacial release are good ways to relieve pain caused by trigger points. Side note – self efficacy can be quite powerful in the pain experience. However, if self release techniques do not work, multiple sessions of therapy, coupled with corrective exercises are needed in order to completely fix the problem and avoid relapse. It is best to seek a professional, like a physical therapist, who is trained in myofascial release techniques.
To learn myofascial techniques, you will need a few items to get started, like a Theracane and a myofascial release ball (lacrosse or tennis balls work, as well). You can (22) watch my video to learn a view hacks when performing SMFR.
At the end of the day we are all in the same profession with many more problems to solve, like direct access, marketing, insurance rates, and legal scope of practice battles. Therefore, how to label trigger points shouldn’t be at the top of our concerns. With that said, we need to have each other’s backs, instead of tearing each other down. I’d rather have you on my team than my ego or opinions. Thank you for your attention.
Thank You for Your Attention.
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Edited: Ffrancesca Famorcan
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