262 What's the Point?
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Dynamic Chiropractic – April 22, 2011, Vol. 29, Issue 09

What's the Point?

By Warren Hammer, MS, DC, DABCO

Most clinicians in the soft-tissue world work on some type of point. It could be a tender point, a myofascial trigger point (active and latent), an acupuncture point or what are currently being called "Stecco" points.

Some of the many techniques used to treat these points include friction massage, Graston technique, active release, ischemic compression, myofascial release, fascial manipulation, Nimmo, dry needling, gua sha, structural integration (Rolfing), active isolated stretch, pulsed ultrasound, low-level laser, mechanical vibration, reciprocal inhibition techniques, and varieties of massage, to name just a few. These points are found in and even define conditions such as myofascial pain syndrome, fibromyalgia, fibrositis, regional pain syndrome, chronic pain syndrome, chronic fatigue syndrome, tendinopathies, temporomandibular joint syndrome, migraines and many others.

One of the criteria for fibromyalgia in 1990 per the American College of Rheumatology was that there had to be at least 11 of 18 specific tender points. The presence of these points is questionable since many believe fibromyalgia is a controversial diagnosis to begin with. Trigger points seem to be the most commonly used term. They are usually defined as hyperirritable nodules located within a taut band of skeletal muscle.1 Palpation of the active trigger point will elicit pain directly over the affected area and cause radiation of pain toward a zone of reference and a local twitch response. A local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle and skin as the tense muscle fibers (taut band) of the trigger point contract when a firm pressure is applied perpendicular to the muscle. A latent trigger point does not cause spontaneous pain or refer.

Tender points differ from trigger points in that the former are only painful at the site of palpation and do not refer pain. They often occur in the insertion area of muscles instead of the taut bands of muscle bellies. Therefore, tender points are more frequently found in a fibromyalgia-like situation than in a myofascial pain syndrome.2

Travell and Rinzler noted that fascia referred pain similar to the underlying muscle and used the term myofascial trigger point.3 Stecco, et al.,4-5 and others have demonstrated numerous free endings and mechanoreceptors in fascia. While there are no studies to prove that there is a direct relationship between fascia and trigger points, I have heard clinicians who use fascial techniques6 remark that upon releasing the fascia, the trigger points disappeared.

Myofascial trigger point (MFTP) evidence regarding causation and histology is under investigation. There are several hypotheses regarding MFTPs. Simons described an "energy crisis" that maintains an initial sustained contracture at the muscle fibers near an abnormal endplate.1 Excessive acetylcholine (Ach) release from the motor endplate may cause sustained sarcomere contracture and diminish capillary flow. This may result in less adenosine triphosphate (ATP), causing muscle fiber contracture, thereby not allowing Ca2 + to the sarcoplasmic reticulum and the restoration of a polarized membrane potential.1

There is a neural reflex theory whereby taut bands and MFTPs are viewed as somato-somatic reflexes. For example, primary joint dysfunction of C2-C3 may cause secondary reflex muscle dysfunction in the cervical paraspinals innervated at that level.6 Another theory regarding causation of MFTPs refers to prolonged postural maintenance creating continuous muscle contraction. For example, the computer posture characterized by the elbows not resting (elevated) causes the cervical and upper trapezius muscles to continually contract. These low-level static exertions can lead to muscle damage and disturbance of Ca2+ homeostasis, contributing to MFTP pain.7

Shah1 has used microanalytic techniques to evaluate the biochemical milieu of MFTPs. He has found an elevation of inflammatory mediators, neuropeptides, catecholamines and cytokines in the vicinity of MFTPs that cause pain and inflammation. These chemicals stimulate nociceptors located in sensory receptors in the fascia surrounding muscle fibers.8-9

Stecco10 has found points on the body and related them to particular acupuncture points. It's almost like combining Eastern and Western medicine. He has created what he calls fascial manipulation, which has been taught in Europe for over 10 years and is currently being taught in the U.S. These points are found to be densified on palpation, tender to the patient and either in the belly of the muscle or near the retinaculum and tendons near the joint. All of these points are on acupuncture meridians. Some of these points could be classified as MFTPs.

Dorsher11 recently published data suggesting substantial anatomic, clinical and physiologic (referred pain to meridian) overlap of myofascial trigger points and acupuncture points, particularly in the treatment of pain disorders. He found a strong correlation between the locations of trigger points and classical acupuncture points, finding that 92 percent of the 255 trigger points correspond to acupuncture points, including 79.5 percent with similar pain indications. According to Dorsher, "[M]yofascial referred-pain data provide independent physiologic evidence of acupuncture meridians. The acupuncture tradition provides pain practitioners with millennia of accumulated clinical experience treating pain (and visceral) disorders and offers the potential for novel pain treatment approaches and understanding of pain neurophysiology."

References

  1. Shah JP, Gilliams BA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodywork & Movement Ther, 2008;12:371-384.
  2. Alvarez D, Rockwell PG. Trigger points: diagnosis and management. Amer Fam Phys, 2002;65(4):653-660.
  3. Travell JG, Rinzler SH. The myofascial genesis of pain. Postgraduate Med, 1952;11:434-452.
  4. Stecco C, Porzionato A, Lancerotto L, Stecco A, Macchi V, Day JA, De Caro R. Histological study of the deep fasciae of the limbs. J Bodywork Mov Ther, 2008 Jul;12(3):225-30.
  5. Bednar DA, Orr FW, Simon GT. Observations on the pathomorphology of the thoracolumbar fascia in chronic mechanical back pain. A microscopic study. Spine, 1995;20(10):1161-4.
  6. Personal communication on 02/21/2011 with Michael Schneider, DC, PhD.
  7. Treaster D, Marras WS, Burrr D, et al. Myofascial trigger point development from visual and postural stressors during computer work. J of Electromyography and Kinesiology, 2006;16:115-124.
  8. Langevin H. Potential Role of Fascia in Chronic Musculoskeletal Pain. In: Audette JF, Bailey A. Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. Humana Press, Totowa, 2008:123-132.
  9. Corey S, Bouffard N, Langevin H. "Immunohistochemical Characterization of the Mouse Subcutaneous Perimuscular Fascia Plexus." Presented at the First International Fascia Research Congress, 2007.
  10. Stecco L, Stecco C. Fascial Manipulation - Practical Part. Piccin Nuova Libraria S.p.A., Padova, 2009.
  11. Dorsher P. Myofascial referred-pain data provide physiologic evidence of acupuncture meridian. J Pain, 2009 Jul;10(7):723-31.

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