Introduction
Myofascial Pain Syndrome (MPS) is characterised by the presence
of myofascial trigger points (TrPs), which are tender, hypersensitive
points in skeletal muscles contained within palpable taut bands.
You can feel them as painful lumps of thickened tissue, like nodules
or small peas. Pressure on an active TrP produces local pain at
the TrP site and often produces distant referred pain (or abnormal
sensation) that is similar to a patient's usual symptom.
This pain pattern is usually similar from patient to patient
and is typical of each muscle. In fact, a specialist in the treatment
of myofascial pain can usually predict the location of active
TrP's from the patient's symptoms, without even touching the patient.
Such a TrP hurts whenever you use the involved muscle, e.g., driving,
eating, and combing the hair. An active TrP causes symptoms even
when the muscle is at rest. A latent TrP doesn't hurt at all,
unless you press it and you might not even know it's there.
Symptoms
TrPs typically cause muscle weakness, incoordination and dysfunction
before they cause pain. Symptoms include illegible handwriting,
poor grip strength, buckling knees, and weak ankles. TrPs can
compress blood vessels, lymph vessels and nerves, because these
structures pass through the fascia ("the endless web"), leading
to numbness, tingling, burning, electric shock like sensations,
coldness, skin discolouration and swelling. Other associated symptoms
may include stiffness, muscle tightness, muscle cramps, localised
sweating, chest pain, dizziness, tinnitus, pelvic pain, diarrhea,
nausea, goose bumps, runny nose/eyes, eye strain, jaw pain and
headaches.
The vast majority of Repetitive Strain Injuries (RSI) in IT professionals
is accounted for by MPS. However MPS can affect anybody, including
housewives, children and the elderly.
Factors that aggravate MPS
According to Travell & Simon's seminal text on Myofascial Pain
and Dysfunction, and similar medical textbooks, the following
factors are known to typically aggravate Myofascial Trigger Points
(MTrP's):
- Strenuous use of the involved muscle. Judging the precise
movement that produces pain is one way of diagnosing Myofascial
Pain Syndrome (MPS). This may indicate the muscle harbouring
the TrP's.
- Forcible, passive stretch of the muscle, e.g., traction,
conventional stretching
- Sustained or repeated contraction of the involved muscle,
e.g., while lifting weights or doing isometric or strengthening
exercises
- Local pressure on the TrP's, e.g., a vigorous massage
- Keeping the affected muscle immobile in a shortened position
for a long time, e.g., after sitting in a fixed position, driving,
sleeping, and by using neck collars, back belts/corsets and
braces
- Sitting under the cold draft of the air conditioner or an
open window
- Cold, damp weather
- Viral infections, sore throat, respiratory infections, etc.
- Chronic allergies, including food allergies
- Excessive, uncompensated emotional stress or psychological
tension
- Depression
- Sleep disturbances
- Hypothyroidism
- Nutritional deficiencies, especially folic acid and pyridoxine
deficiency
- Smoking, caffeine, and alcohol
- Anaemia
- Recurrent bouts of hypoglycemia
- Hyperuricaemia (high uric acid levels)
Some situations when TrP's suddenly get activated include accidents,
falls, direct blow to the muscle, sudden lifting of heavy weight,
twisting movements, intramuscular injections, appendicitis, heart
attack, being bed bound for a prolonged period, operations and
infections. An interesting observation is that muscles supplied
by a compressed nerve following a slipped disc can develop TrP's
(post-disc syndrome). Unless these TrP's are identified and treated
even surgical removal of the disc (discectomy) may be unsuccessful
in relieving pain.
Gradual development of TrP's is usually due to incorrect posture,
abnormal bone structure (short leg, tilted pelvis, short upper
arms, etc.), poor body mechanics and ergonomic issues related
to work station set up, job design, etc.
Factors that relieve MPS
To avoid trampling on sensitive toes, I will confine discussion
of the modalities that have been shown to be consistently successful
in relieving Myofascial Trigger Points (MTrP's) by quoting directly
from Travell & Simons' text on Myofascial Pain and Dysfunction,
and similar authoritative medical textbooks. Methods other than
those mentioned below may be promising or may have had anecdotal
success but cannot be considered recommended therapy based on
current medical knowledge.
Myofascial pain syndrome (MPS) is responsible for directly causing
up to 85% of all pain conditions in all age groups and in all
professions. MPS also accounts for the vast majority of Repetitive
Strain injuries seen in Computer professionals.
Myofascial TrP pain is decreased by the following modalities:
- By a very short period of rest.
- By slow, steady passive stretching of the involved muscles,
especially under a warm shower.
- By application of moist heat on the TrP (and NOT at the site
of pain). However, patients will need to be shown exactly where
the TrP's are located.
- By short periods of light activity with movement (not by
isometric contraction or strengthening exercises).
- Specific manual therapy or myotherapy: Trigger point pressure
release, Myofascial release (MFR), Muscle Energy Techniques
(MET) and Positional Release Techniques (PRT).
- Clinician administered Spray and stretch.
- Clinician administered TrP injections.
Trigger point pressure release
(or TrP therapy) is done as
a painless but uncomfortable barrier-release technique to release
the contraction knot in the muscle. The amount of pain felt by
the patient should not exceed 7 on a scale of 10 at the time of
treatment (0 = no pain; 10 = maximum pain). Digital pressure or
tools can be used to achieve TrP release; however, a very high
order of manual skill and experience is required to achieve this.
This technique relies entirely on accurate identification of MTrP's
by means of palpation. With proper instruction, this can be achieved,
in certain cases by patients themselves, using rubber balls and
self massage devices.
Having evaluated where a restricted area exists, Myofascial
release (MFR) techniques can be added to improve flexibility
and restore musculoskeletal balance. MFR is a hands-on soft tissue
technique that facilitates a stretch into the restricted fascia.
During MFR a sustained gentle pressure is exerted in the line
with fibre direction of the tissue being treated, which engages
the elastic component of the elastico-collagenous complex, stretching
this until it commences, and then eventually ceases, to release.
Muscle Energy Techniques (MET)
are soft tissue manipulative methods in which the patient, on
request, actively uses his muscles from a controlled position,
in a specific direction, with mild effort against a precise counterforce.
Positional Release Technique (PRT)
involves positioning an area or the whole body in such a way as
to invoke a physiological response, which helps to resolve musculoskeletal
dysfunction. The beneficial results seem to be due to a combination
of neurological and circulatory changes, which occur when a distressed
area is placed in its most comfortable, its most easy, most pain
free position. (As described by Chaitow, 1996)
Clinician-administered spray and stretch
involves sweeping a stream of vapocoolant spray over the muscle
in a series of parallel sweeps that start at one end of the muscle
and continue over the muscle belly to include the referred pain
pattern. This is followed by a myofascial release maneuver or
sequential isometric contraction and relaxation (Lewit technique).
Spray and stretch produces an immediate increase in pain threshold
accompanied by improved range of motion. Travell and Simons state,
"Spray and stretch is the single most effective non-invasive method
to inactivate acute trigger points (TrP's)." This needs to be
maintained by a home-exercise programme of appropriate stretches
and self-care of the injured area.
TrP injections are used as
a method of directly inactivating TrP's particularly those refractory
to myotherapy, a situation common in chronic, neglected MPS. The
TrP is penetrated with a fine needle, eliminating the TrP as a
painful focus. It is not necessary to inject drugs during TrP
injection, and steroids in particular are strongly not recommended.
Botulinum toxin has been proposed as a method for resistant MPS,
but further investigation is needed to define whether it has a
place in the management of Myofascial Pain Syndrome (MPS). A TrP
injection is not the same as acupuncture.
