Trigger Points – Myofascial Pathology or a Fight Starter?
By Aran Bright
Trigger points are a core principle in musculoskeletal pain. Since Travell and Simons instigated the concept it has been fundamental to any professional in musculoskeletal health. But trigger points have become more than a cause of myofascial pain – they lead to some of the most heated arguments amongst doctors, physios, massage therapists and scientists.
What Can We Agree On?
There isn’t a huge amount the experts agree on about trigger points, but here are some commonly agreed theories on what a trigger point is:
- A point in a muscle that is hypersensitive to touch
- A feeling of a nodule or band of muscular tightness
- Pain referral that can be aching, deep, burning and variable in sensation.
Many experts also agree that recognition of pain is important in identifying a trigger point that could be described as “active”.
However, no one seems to agree that a referral pattern is predictable and consistent from one person to the next.
Here’s a more detailed description of what some experts agree on.
It does appear that trigger point locations tend to be consistent from one person to the next, which brings us to the main topic of debate …
What Is A Trigger Point (apart from something that starts epic social media arguments)?
There are two main camps:
Muscle lesion – this model is based around concepts such as motor end plate hyperactivity causing continued muscle spasm or micro tears in the muscle structure, leaking calcium ions and triggering local contracture. (This is most likely the birthplace of the most horrendous of myths around “calcium balls” that need “breaking up” to “release” the muscle.) This is where the concept of ischemia or poor blood flow to muscle comes from: essentially, if the muscles spasm, it chokes the local area of blood flow. (Source)
Neuropathy – the main opponents to the muscle lesion model of trigger points contend that the muscle lesion model is, at best, a hypothesis that has never been conclusively proven. It appears that the best evidence around trigger points tends to be either sonographic or electromyographic, which is hardly conclusive as to what the physiology of a trigger point actually is. As far as this author can tell, no one has ever actually “seen” a trigger point, except through ultrasound imaging.
What is contended by the opponents to the traditional model of trigger points is that we should be considering other potential causes for trigger points that are more directly related to the nerves themselves, such as a neuritis (nerve inflammation) or peripheral nerve sensitisation.
The best summary to better understand the opposition to the muscle lesion model is the Critical Evaluation of the Trigger Point Phenomenon.
Why Does It Matter?
It is tempting to think, who cares? Most experts agree that trigger points are real, they hurt, and we can make them better with massage or whatever method we choose to treat them. There is some truth to this but, if we assume that there is some muscle lesion or dysfunctional motor end plate, then we should be choosing the most effective method in our toolbox to address it. Likewise, if the problem is more a product of the nervous system, then we should be choosing the method that is most suited to this physiology.
To demonstrate this point let’s explore one of the hot treatment approaches right now.
Dry Needling
Dry needling is definitely not new – any acupuncturist reading this will quite possibly be throwing things and screaming “4000 YEARS!” Dry needling is a product of Travell and Simons who actually proposed using hypodermic injection of anaesthetic into the site of a trigger point. At some point, someone got either cheap or lazy and started using thinner filiform acupuncture needles, and dry needling was born.
The theory behind dry needling is that the needle penetrates the muscle lesion and destroys the motor end plate. This is typically performed with a perforating or thrusting technique of the needle that is often quite painful and invasive.
Now, if it is truly the case that there is a muscle lesion, then should it also be the case that deep dry needling should be superior to, say, a thumb?
Well, here is where things get tricky. On the surface, the evidence does seem to suggest that dry needling is better than other approaches. For example, a systematic review of trigger point dry needling by Gattie, Cleland and Snodgrass in the Journal of Orthopaedic and Sports Physical Therapy states:
“Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period.”
Reading deeper into the article, you will discover this statement in the conclusion:
“Although findings of this review provide very low– to moderate quality evidence for the effectiveness of dry needling for reducing pain and improving PPT when compared to other physical therapy interventions during the immediate to 12-week follow-up period, the small effect sizes and the varied study populations and comparison interventions utilized do not support a strong recommendation of dry needling over other physical therapy interventions.”
The article goes on to state that the general “superiority” of dry needling is just over 1 point on the visual analogue scale. As an example, if someone received massage for a trigger point, they might see a pain reduction from 8 to 5, with dry needling, they would expect to see 8 to 4. Considering the extra muscle perforation and discomfort involved in dry needling, not to mention the risks, is that really worth it?
Does dry needling demonstrate clinically meaningful effects that would be an indication that there is a muscle lesion of some sort? The most generous conclusion would be that this is yet to be demonstrated.
An Alternative Approach
To avoid getting too much deeper into a science wormhole, the Gattie et al systematic review did demonstrate that manual techniques were effective in reducing myofascial trigger point pain.
The purpose of this blog is to hopefully open your mind as to why.
The best answer is, we don’t know.
Anyone stating with absolute certainty that they know what a trigger point is should be viewed with some scepticism.
We should be considering alternative explanations, and hopefully ones that don’t involve repetitive thrusting with sharp pointy things.
To provide you with some sense of what might be going on when you press on a trigger point and the pain is reduced, please consider two theoretical mechanisms that have undergone significantly more investigation than trigger point physiology and are much more broadly accepted by neuroscientists and scientists in general.
Descending Inhibition – this is the current mechanism that is proposed (and has been around for about as long as trigger points) for the effects of manual therapies such as massage. Basically, it is the “turning down” of nociceptive pathways at the level of the spinal cord.
It goes a little something like this:
Massage Therapist: *Presses firmly on tender trigger point*
Nerve Ending: *stimulated*, *sends message to the spinal cord along sensory nerve*
Sensory Nerve: *sends signal to brain*
Brain: *interprets message as pain*
Client: “Ouch.”
Brain to self: “Hmm, even though sensation is painful, it is occurring in a safe, therapeutic space.”
Brain to Sensory Nerve: “Thanks very much for that information but I am kinda busy soaking up this massage.”
Brain: *turns down the pathway to that sensory nerve at the spinal cord so it can still hear it but just in the background*
Brain: *goes back to “soaking up” massage*
Client: *experiences a “release” regardless of what actually happens to the muscle*
Diffuse Noxious Inhibitory Control – This is most likely what is going on when someone receives intense needling, extreme instrument assisted soft tissue manipulation or one of those torture sessions that some people confuse as massage.
Client: *receives intense sensation to the sensory nerves* “Ouch!”
Spinal cord: *fast tracks intense sensation to the brain*
Brain: “WTF!” *runs straight to internal medicine cabinet and grabs whatever it can find (generally a mixture of endogenous opioids)*
Brain: *gets drunk and ignores irritating sensory nerves*
Client: In some cases, the client will experience a reduction in symptoms.
Massage Therapist: *sees themselves as some kind of demi-god – kind of a mixture between Maui and Thor*
It would be appropriate at this point to apologise to any neuroscientists reading this, and encourage anyone who wants a better description of these two mechanisms to go here and here.
Summary
Trigger points are real, no one questions this, but what they are is unclear.
It is important that we consider all the options on the table as it is likely to be “a little from column A and little from column B”.
The mechanisms by which we treat trigger points should also be viewed with an open mind. Massage works, dry needling works, but the best methods are probably yet to be defined. Please remember: our best understandings of why massage and manual therapies reduce pain are functions of the nervous system, not fixing some part of a muscle.
References:
Article by Chang-Zern Hong, MD and David G. Simons, MD “Pathophysiologic and Electrophysiologic Mechanisms of Myofascial Trigger Points”
About the Author
Aran Bright started his career as a massage therapist in 2002 after graduating from the Australian College of Natural Medicine in Queensland. In 2006, Aran completed his Diploma of Remedial Massage and, in 2007, his Bachelor of Health Science in Musculoskeletal Therapy. Aran graduated from University of Queensland with a Graduate Certificate of Sports Coaching, completed a Certificate IV in Fitness and an Advanced Diploma of Myotherapy. He currently runs his own businesses, Bright Health Training and Brisbane Workplace Massage, with his wife, Sheree.
admin
30/05/2018 - 11:54 am
Huzzah! One for the ages … long may this post be recycled on social media. Thanks Aran. I am giving it 5 stars.
John Quintner
30/05/2018 - 3:37 pm
Aran, thanks for the honorable mention. As far as I am concerned, the fight has long been over. The myofascial pain/trigger point theorists have run out of ammunition and have exposed themselves to ridicule: https://blog.apsoc.org.au/2018/01/08/behold-the-mighty-trigger-point/
John Quintner
31/05/2018 - 7:52 am
Your assessment of “dry needling” is perhaps still somewhat generous, particularly when the practice is so firmly embedded within physical therapy culture.
In 1994, we wrote: “Inactivation of the TrP by physical or chemical means would be predicted if the TrP is indeed a site of primary hyperalgesia. However, reports of the efficacy of this approach are only anecdotal; inactivation has not been subjected to formal trial. Furthermore, the persistence of using the recommended approach in the face of clinical inefficacy, along with the continuing failure to reveal a reasonable anatomical or pathophysiological basis for so doing, is not only irrational, but also fails to acknowledge powerful placebo effects and the wider psychosocial context of chronic pain.”
These words ring true nearly a quarter of a century later!
Reference: Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.
Aran
31/05/2018 - 4:41 pm
Hi John,
I think I could certainly be a little guilty of being fast and loose with my interpretation of the data on dry needling. And the truth is I have yet to truly look at effect sizes in detail.
But so far I have seen a trend that would be consistent with massage, mobilisation and other “manual” therapies. Which makes one wonder if it may be the common non-specific effects at play here rather than the actual specific effects?
But what is really interesting is how needling has been embraced by allied health therapists, it’s as if the quasi surgical nature of it is really seductive. Even when the evidence for it is no better than say TENS, from what I can tell?
Jason Kiely
31/05/2018 - 6:04 pm
To add to the discussion or fight (lol), it would be good tease out the incidence of harm (if any) occurring from various MTrP protocols. Regarding Dry Needling, in my practice I have a few clients that I would describe as DN “refugees”, however from what they have discussed with me, I wouldn’t describe their experience as having created “harm”, more just ineffective and closer to torture than therapy.
My personal experience of DN, when I went through various phases of trying different approaches to DN, is that I appeared to make early gains in performance and ROM but the effect decreased over time but not the soreness. I remember limping/hobbling out of many DN sessions, that would last up to a week!
Looking back on some of those sessions, with my current understanding of the nervous system, and how “jacked-up” my sympathetic nervous system was at the time, I’d hazard a guess why the effect declined over time. Not sure how common that sort of experience is but I can’t see myself returning anytime soon for another bout of DN, and again I wouldn’t describe my experience as harmful, just ineffective and not worth the pain.
John Quintner
01/06/2018 - 8:16 am
Here is my most recent critique of the absurd practice of dry needling: http://www.fmperplex.com/2018/01/26/dry-needling-for-musculoskeletal-pain-the-new-homeopathy/
Aran Bright
01/06/2018 - 8:22 am
Hi Jason,
On the up side for DN the rate of adverse events seems to be relatively low compared to other invasive approaches, but my concern is why be so invasive if there is no discernible benefit over less invasive approaches?
I should confess at this point I do use dry needling on occasion, but there are few simple guidelines, there should be no pain at all, it is very rarely beyond 10mm deep and there is never any thrusting of the needle. My justification is that in some cases, such as acute lumbar pain, it is actually very gentle, and I believe it can be an effective way to trigger non-specific effects and reduce some pain. It actually tends to be more gentle than massage when used in this manner, in most cases.
But I think the point you make is relevant except I would add that pneumothorax is a very real and far too regular occurrence.
John Quintner
01/06/2018 - 1:57 pm
Hi Aran. You have mentioned the “Delphi Study” that was recently published in the journal Pain Medicine, accompanied by an editorial written by Dr Robert Gerwin, one of the most high profile of the MPS/TrP proponents. I reviewed both publications and, if you are interested, here is the link: http://www.fmperplex.com/2017/10/09/more-trouble-in-the-land-of-the-trigger-point/
Jason Kiely
01/06/2018 - 8:57 pm
Thanks Aran
Yer, I specifically stayed away from pneumothorax, as I don’t know the actual incidence and didn’t want to get ahead of myself but yes, I fully concur. At the moment I see the “economic” perspectives around DN dominating, which is why I think focusing on the potential “harm” caused, or if the benefit of DN reduces over time, (which was my experience), might make for a more convincing argument!…?
I fully agree with this, “why be so invasive if there is no discernible benefit over less invasive approaches?” When we have a vested interest in something working, it can be hard to tease out “real” over “non-specific” effects, hence why I’m very sympathetic to the plight of the average practitioner, with bills to pay etc., and not bothering to ask too many questions if customers seem happy and keep returning for more!
As you implied on the AMT Facebook group, the Trigger Point debate is not so much about the “phenomena” of MTrPs themselves but the implied physiological “causation”, which hence determines treatment approach. It is a subtle debate, and highly technical, and again I’m sympathetic to those therapists doing some good work and thinking the entire debate is intellectual bogus-ness (I want to use another phrase but this is “g-rated” channel lol). It is not bogus unfortunately!
The significance of this debate highlights the current divide between biomedical and biopsychosocial approaches to health care, for which many manual therapists are divided. Dave Nicholls has some of the best commentary I’ve read on this topic. He gets into the changing demographics, disease profiles and medico-socio-economic landscapes, and the potential problems for health care that lie not too far ahead. The Massage Therapy professions would seem to be well placed more generally to benefit in this zone!
John Quintner
04/06/2018 - 8:28 am
Aran, I hear via the virtual grapevine that some of your colleagues have reacted to my deliberately provocative offerings on your blog. It has been extremely hard for a few of us to dispel 30 years of conjecture being passed off to clinicians as established knowledge. Here is another offering designed to prove the point (ouch!): http://www.fmperplex.com/2016/05/14/to-kill-a-myofascial-trigger-point/
Aran Bright
04/06/2018 - 8:15 pm
Hi John,
I think the point where most people get #triggered, is they assume you are refuting the phenoma of trigger points. Which, as best I can tell, both you and Dr Cohen have not challenged, but instead the physiology of a trigger point.
I think once most people realise this then they get past their moment of cognitive dissonance, and see the new possibilities. Most massage therapists actually sit in a pretty good space once they let go of their “body mechanic” mindset, but it can take a little while. I am still certainly going through the process.
Many thanks for your thoughts and contributions, I look forward to reading more.
Aran
Aran Bright
04/06/2018 - 8:18 pm
Hi Jason,
This seems to be where the rubber hits the road, you gotta pay dem bills! And for some of us we might have been having relative success with cupping or needling or other “aggresive” approaches. So maybe we just gradually need to change course for business reasons as well as theoretical ones. I just hope that we are all willing to change, at least.
Btw, I will be in Perth soon, I hope we can catch up.
Aran
Gerhard Hassler
06/06/2018 - 2:35 pm
Great blog Aran !
Thank you for sharing your thoughts.
In my experience, your words make great sense.
My first approach to trigger points is usually Thomas Hendrickson’s “Wave Mobilisation Technique” interspersed with MET.
9 out of 10 that leads to a release and is gentle on the client.
🙂
John Quintner
07/06/2018 - 8:42 am
Aran, as you have observed correctly, Milton Cohen and I have never denied the existence of the clinical phenomena associated with the concept of the “trigger point”. But we have soundly refuted the hypothesis advanced by the late Drs Travell and Simons. Accordingly, all therapies/techniques that are, and have been, based on this flawed hypothesis cannot be defended on scientific grounds. These include “dry needling”, “myofascial release” etc. I am not familiar with “Wave Mobilisation Technique” and MET but they may well be in the same category. We have offered scientifically credible explanations for the clinical phenomena and encourage therapists to attempt to understand them and explain them to their patients.