Trigger Points in Myofascial Pain: A Leading TrP Dry Needling Expert's Viewpoint

“Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective.” This is the title of a narrative review published in PM&R in 2015 (Shah JP et al, 2015).

A Leading Expert in MtrP & MPS

The leading author of the review is Jay P Shah, MD, a senior staff physiatrist in the NIH Clinical Center. Dr Shab is a well-known lecturer on the evaluation and treatment of myofascial and musculoskeletal pain with dry needling, TENS and acupuncture.

The review discussed the evolving role of the MTrP in myofascial pain syndrome (MPS) from both a historical and scientific perspective.

I summarized the key points of the review as below.

Confusing & Controversies

Although the clinical study of muscle pain and MTrPs has proliferated over the past two centuries, the scientific literature often seems disjointed and confusing.

Much of the terminology, theories, concepts, and diagnostic criteria are inconsistent, incomplete, or controversial.

The accumulating imaging and biochemical data suggest that the soft tissue around the MTrP, neurogenic inflammation, sensitization, and limbic system may all play a role in the development of MPS.

The Finding of Referred Pain

In the mid 1900s, J.H. Kellgren in Britain, by injecting saline into various anatomical structures such as fascia, tendon, and muscle in healthy volunteers, was able to chart zones of referred pain in neighboring and distant tissue.

The Birth of MTrP Bible Book

Largely influenced by Kellren's work, the U.S. physician Janet Travell (and Rinzler) coined the term “myofascial trigger point” in the 1950s. Travell eventually accomplished a 2-volume book, Myofascial Pain and Dysfunction: The Trigger Point Manual, co-authored with David Simons. This book became the TrP & myofascial pain bible in health care community.

Who Are The Bible Followers?

The bible followers include physical therapists, allopathic and osteopathic physicians, chiropractors, dentists, pain specialists, massage therapists, and myofascial trigger point therapists.

Among the various allopathic medical specialties, physiatrists currently have the most comprehensive working understanding of MTrPs. This is, in part, because physiatrists see MPS and the MTrP as related to muscle and musculoskeletal dysfunction.

A Disorder With A Very Narrow Scope

MPS is a pain syndrome involving muscle and fascia. The term “MPS” implies a condition distinguished from other soft tissue pain such as fibromyalgia, tendonitis, or bursitis.

Pathogenesis of MPS: Unknown

The pathogenesis of MTrPs and MPS, including muscle overuse and mechanical difficulties, remains neither proven nor disproven.

Does MTrP Diagnose MPS? Possibly

The MTrP remains central to its diagnosis, and possibly its successful treatment.

Identification of TrP: No Accepted Criteria

Although the MTrP is a common physical finding, besides the use of palpation, there are currently no accepted criteria (e.g., biomarkers, electrodiagnostic testing, imaging, etc.) for identifying or quantitatively describing MTrPs.

Anything for Sure? No, All Remain Speculative

Over the past few centuries, most investigations have been hampered by a lack of objective diagnostic techniques that could record more than simply their presence or absence. As a result, theories of the MTrP pathogenesis, pathophysiology, and contribution to the diagnosis of MPS have been speculative.

Unaswered Questions

Many questions remain to be answered.

• What is the etiology and pathophysiology of MPS?
• What is the role of the MTrP in the pathogenesis of MPS?
• Is the resolution of the MTrP required for clinical response?
• How does a tender nodule progress to a myofascial pain syndrome?
• Which musculoskeletal tissues are involved and how do these change in response to treatment?
• There are more...

The Core of Key Points

To date, the pathogenesis and pathophysiology of MTrPs and their role in MPS remain unknown.

A Key Question

“According to Travell and Simons, MTrPs are central to the syndrome—but are they necessary?” Asked Dr Shah in the review.

Dr Shah did not answer this key question he asked. His final words in the review was: “Proper treatment of MPS requires identification and targeting of the mechanisms and pathophysiology of perpetuating factors in order to obtain sustained relief.”

Then, The Right Answer to The Key Question?

The right answer is “hidden” in an ancient healing art – the acupuncture widely practiced 2000 years ago in China, which is recorded and described in Chinese medicine classic Huangdi Neijing. I call it Neijing acupuncture.

Dr Shah mentioned acupuncture a few times in the review, by seeing it as one modality, among many others, for myofascial pain relief with an effect no better than manual massage. Obviously, the acupuncture he mentioned is not Neijing acupuncture. The latter works for pain (any pain not limited to myofascial pain) like a magic wand or magic bullet: precisely take away the pain at any spot on the body, with instant effect at above 95% certainty, no MTrP as defined in the MPS bible book involved.

In my oncoming posts, I will discuss how to use the magic bullet – Neijing acupuncture to magically treat any of MPS conditions described in the myofascial bible book, without bothering anything about MtrPs. Interested readers, stay tuned.

References

Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. 2015 Jul;7(7):746-761.

Travell JG, Rinzler SH. The myofascial genesis of pain. Postgraduate Medicine. 1952;11:434–452.

Travell JG, Simons DG. Myofascial pain and dysfunction : the trigger point manual. Williams & Wilkins; Baltimore: 1983.

#triggerpoints #trp #myofascialpain #dryneedling #painrelief #acupuncture