What is It?
Myofascial pain is the ache and tension that occurs within your muscles (myo) and connective tissues (fascia) that attach muscles to your joints. As summarised in an earlier article, myofascial pain syndrome is chronic muscle pain that can be isolated to a region of your body; or, the pain may radiate to other ‘unrelated’ areas (known as referred pain). This biochemical and mechanical dysfunction that causes pain is due to chronic contracted muscle fibres, called Trigger Points. Makes sense, they trigger pain.
A trigger point is not a muscle spasm. Whereas a spasm is an abrupt contraction involving the entire muscle, the contrasting trigger point will contract only a minute section of muscle.
Also, a trigger point is not muscle strain or torn tissue, as empirical studies of trigger points have never demonstrated this. Although, a muscle injury can predispose you to developing a trigger point in the future.
How does it Happen?
Myofascial trigger points (MTrPs) are pressure sensitive areas (knots/nodules) within your muscles. Fibres within your muscle become tight through repetitive contraction, such as your calf during a long run, standing for long periods at work, an injury to your muscle, or muscle tension brought on by stress. Activation of your MTrPs creates a pain disorder that is ongoing, and grows worse across time. Physiotherapy and regular use of relaxation techniques are ideal methods to ease your pain.
Myofascial pain has two stages; active (painful) and latent (non-painful dormancy unless pressed). In the active phase, the muscle containing the trigger points is weakened due to less flexibility as the muscle is ‘tight’. Muscles in the nearby area are relied on more to compensate for the weakened muscle, and so more muscles become stressed, slowly tightening across time.
Latent trigger points can exist for years, even after a muscle injury has healed. The MTrPs can be activated when you over-stress your muscles, expose them to cold drafts, exhaust the muscles or you become ill such as with an infection.
A trigger point complex happens in the endplate zone of a muscle fibre. There is a tightening of the band and the local ‘twitch response’ is activated. Thus, myofascial pain is comprised of 3 components;
- Sensory- pressure stimulation, twitch response, local and sometimes referred pain
- Motor- action potential of the nerve and endplate ‘’noise’
- Physical- sensory and motor components combined to create a taunt band
‘Noise’ in the pain process is due to excess leakage of ACh at the endplate. As the sarcomere shortens, sensitising substances are released by the nerve and an energy crisis can occur rendering the muscle dysfunctional. Local ischemia and hypoxia ensue, creating pain.
The spinal cord can play a part in maintaining pain when activation of the relevant dorsal horn neurons, releases substance P and calcitonin gene-related peptide. In turn, pain signalling increases to other receptors connected to the identical dorsal neuron horns. This is known as centralised sensitisation. Increased sensitisation of nociceptive neurons within the central nervous system react to both normal and sub-threshold afferent stimulation. This alters the conduction of electrochemical signals along the nerve. Thus, motor stimulation decreases (sympathetic stimulation) and the muscle weakens.
Pain signals from the peripheral nervous system activate hormone release in the hypothalamus, which activate the anterior pituitary to release ACTh (adrenocorticotropic hormone). End organs, such the adrenals then release cortisol to deal with the pain, and ongoing exposure to cortisol can affect your body’s joints and even lead to osteoporosis (as well as other serious medical conditions). As cortisol levels can increase in a short time following stress (such as that caused by triggered fibres). Within the muscle with the trigger point, the ACTh receptors increase, and so the area is now much more sensitive to pain, and rapidly degenerating due to atrophy.
As the affect muscle has its fibre bands tighten, your postural alignment changes and your muscle tissue undergoes further changes. The bands become hypertonic (stiff/contracted) and develop into trigger points (MTrPs). Due to the muscle becoming more sensitised, the nociceptors (pain receptors) are more prone to be activated by the slightest pressure, because their threshold for activation has been lowered.
Inflammation develops your muscle that is experiencing ongoing pain. Mechanosensitisation maintains the spontaneous activation of Aβ fibres & C-fibres in the muscle, so that it is hypertonic. In turn, dorsal root ganglia continue to fire, which leads to a pain cascade within the CNS (centralised sensitisation) and chronic pain cycle.
Illnesses linked to Myofascial Pain
Many illnesses have trigger points as an underlying cause:
- Tension headaches
- Lower back pain
- Neck pain
- Referred pain
- Temporomandibular pain
- Forearm and hand pain
- Postural pain
- Sinus pain
- Sore throats
- Poor sleep patterns
- Decreased recovery sleep
- Pain that awakens you at night
- Ongoing muscle aches and soreness
Who can help?
Physiotherapy and massage are two valuable methods to treat trigger points and myofascial pain. The therapists at Bodyharmonix are trained in biomechanics to recognise the signs and symptoms of myofascial trigger points (MTrPs). Using palpitation and their honed clinical judgment, our bodyworkers can identify the most likely cause of your tender spots and areas of deeper pain.
We encourage good communication between our therapists and clients. And we pride ourselves on our patience in answering your questions and delivering education to aid your self-management of trigger point pain. Also needed, is your patience with yourself in the pursuit of pain management and eventually, if possible, elimination of myofascial pain.
Firstly, our physiotherapists and massage therapists will take your full medical history, including your pain history. Your reported and manually identified pain, as well as referred pain, are mapped for our records. We will also try to determine the ergonomic of your everyday workstations, in your home, your office or other workplace, as these contribute to the workload placed on your muscles.
Your quality of sleep will also be assessed and we will do our best to make suggestions that could improve your sleep recovery. Nutritional recommendations may also be made depending on your reported daily dietary intakes, and the physical activities you regularly participate in. If necessary, we may refer you to your GP for blood tests to enable our therapists to make the most viable nutritional suggestions to you.
Especially, we at Bodyharmonix strive to provide you with the most appropriate training program that can be incorporated into your daily life. Educating you on self-care is vital to giving your body the support it needs to heal and to create new biomechanical patterns. The level of self-management you provide yourself is a function of numerous complex factors:
- Lifestyle choices
- Workplace factors
- Family history
- Type of MTrPs and length of time it’s existed
- Your physical health
- Your fitness levels
- Existence of musculoskeletal abnormalities
- Your nutritional state Nutrition (vitamin and mineral deficiencies, poor diet etc.)
- Your sleep patterns
- Existence of other medical conditions
- Your treatment compliance
We at Bodyharmonix seek to help you to determine which factors can be controlled, eliminated or at least better managed.
At this point, it’s important to note, that a muscle weakened and tense due to trigger points, cannot be strengthened. As it’s hypertonic it is already over-contracted.
As such, many undergoing Trigger Point Therapy will experience a healing crisis at first; fatigue, feelings of nausea, pain patterns shift or pain relief is only temporary. However, many will experience immediate pain relief from simply one therapy session. If your body requires many treatments to see real change, be assured that realigning your dysfunctional musculature patterns takes time. Fascia does not stretch in the same way that muscles do, and this is one of the reasons your therapists sets you bodywork ‘homework’.
You can read more about how Trigger Point Therapy works to release MTrPs in our earlier article, Key Benefits of Dry Needling.
Thus, the ability for your body to change its biomechanical functioning is highly dependent on…You.
Dr Travell: Mother of Trigger Point Therapy
Dr. Janet G. Travell lived from 1901-1997 lead the way into bodywork that focused on treating myofascial pain.
Whilst a student at Beth Israel Hospital in New York her study area was arterial diseases, she was also a research fellow, from 1939-1941. Her studies intrigued her interest in musculoskeletal pain and she began experimenting in novel aesthetic methods for relieving muscle spasms. It was her use of procaine injections and the use of vapocoolant sprays locally at sites of muscle pain, that were revolutionary in the treatment of myofascial pain.
Dr. Travell, unbeknown to any involved, was one of three therapists across three continents (Gustein-Good of Germany, and Michael Kelly of Australia) who independently and coincidentally published their studies of treatment of myofascial pain. Each focused on ‘cardinal’ characteristics of the musculoskeletal dysfunction; bands of hardness or nodules that could be palpated manually; intense pain local to the area of the hardened band; referred pain that was exhibited by manual palpitation of an area distant to the nodule; and pain relief with the use of massage.
Simultaneously, these researchers determined the existence of MTrPs, though they identified the trigger points by different names. It was Travell’s pioneering work that became known across the globe, to influence physicians and therapists and to help thousands of people experiencing myofascial pain.
In 1955 the USA Senator John F. Kennedy was not healing from his back surgery. His orthopaedic surgeon requested the help of Dr. Travell. Identifying the true cause of Kennedy’s ongoing pain as muscular, Travell used minimal doses of procaine to relax his lumbar muscles. Due to the effectiveness of her treatment regime, which included modified shoes to compensate for the shortness of one leg, Kennedy could resume his place in the political arena. In 1960 Kennedy won the presidential race and went on to appoint Travell the position of Personal Physician to the President. This was a watershed moment in science as the first female physician to the president. Her dedication to her role saw Travell overseeing the ergonomics of Kennedy’s daily activities, making recommendations such as using a rocking chair to help with pain relief.
In turn, Travel was asked to consult for companies such as John Deere, who introduced a tilt to their tractor seats so that a driver could better brace themselves using their feet and sit more efficiently as they travelled across uneven ground. The seat also included support for the lumbar region of the spine. A pioneering feat.
Dr Travel remained in her role at the White House until 1965, having also provided her services to President Lyndon Johnson. However, whilst serving at the White House, she became an Associate Clinical Professor in Medicine at The University of George Washington. Later, she was appointed an Emeritus of the university. She published over 100 empirical journal articles and was the co-author (with Dr David Simons) of the two-volume, Myofascial Pain and Dysfunction: The Trigger Point Manual (1983).
Her papers, almost 14 meters of document, were donated in 1998 to the Gelman Library University Archives. Permission is granted to research studies that meet the criteria of the donors for use of the literature.
Dr. Travell continued to lecture, publish and present at conferences until her death at 95-years-old.
Argoff, C. E., Turk, E. C., Benzon, H., Rathmell, J. P., Hurley, R. & Wu, C. L. (2013).
Practical Management of Pain. Maryland Heights, Missouri: Mosby.
Edge-Hughes, L. (n.d.). Myofascial Trigger Points [pdf].
Leffingwell, R. (2002). John Deere: The Classic American Tractor. http://bit.ly/2vkpC2D
Mense, S., & Gerwin, R. D. (2010). Muscle Pain: Diagnosis and Treatment. New York:
Springer Science & Business Media
National Association of Myofascial Trigger Point Therapists (1997). Myofascial Trigger
Point Therapy – What Is It? http://www.myofascialtherapy.org/myofascial-therapy/index.html
Strauss, S. L. (1997-2017). “The Mother of Myofascial Trigger Point Knowledge.”
Tennant, F. (2013). The Physiologic Effects of Pain on the Endocrine System.
Wilson, V. P. (2003). Janet G. Travell, MD: A daughter’s recollection. Texas Heart Institute
Journal, 30(1), 8-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC152828/