Thursday, June 3, 2010

Are FM Tender Points really Myofasical Trigger Points?

Fibromyalgia is a central nervous system state of sensitization, whereas myofascial pain due to trigger points is a peripheral neuromuscular problem (outside the CNS, nerve to muscle). Trigger points are myofascial areas of knotted up muscle fibers in a taut band of muscle. They are EASILY felt unless behind bone or other muscles, or the band of muscle affected is too tight, in which case "specific myofascial therapy," such as TrP myotherapy, TrP injection, Frequency Specific Microcurrent, is necessary to loosen the muscle to locate the trigger point (TrP).

M = Myofascial
TrP = Trigger point, synonymous with
MTrP = Myofascial trigger point
FM = Fibromyalgia
CMP = Chronic myofascial pain

Myofascial TrPs are palpable, rendering an objective measurement of disease. And, thanks to the work of scientists dedicated to explaining myofascial trigger point (MTrPs) we know that there is irritability and pain associated with the excessive endplate noise at the MTrP, (Kuan, et. al, 2007) and that certain biochemicals are present. (Shah, et. al, 2007) When these TrPs are treated with pressure therapy, injections, or dry needling, the "twitch response" is visualized by the practitioner and felt by the patient. This has not been described in the “tender point model” of FM, or the present diagnostic criteria set by the American College of Rheumatology (ACR).

Let me interject the newer study “The Predetermined Sites of Examination for Tender Points in Fibromyalgia Syndrome Are Frequently Associated with Myofascial Trigger Points.” (Ge HY, et al. 2009), suggests that possibly all FM patients also have CMP (chronic myofascial pain from trigger points. This study and others like it brings question, "Were the ACR patients screened for the presence of myofascial trigger points?" "Did the examiners know enough about TrPs to know to look for them or that they cause significant pain, dysfunction and referral of symptoms?" "Did they know presence of these TrPs provides criterion that takes FM out of the subjective complaints only arena?" This is a question that I personally would like to see answered. What we know for certain right now is that FM, and CMP, can and often do co-exist in the same patient, yet paradoxically not all patients with myofascial trigger points have FM, they are two separate entities.

As I have described before, and backed by solid research, FM is a central sensitization problem brought on by a dysfunction of the HPA (hypothalamus-pituitary-adrenal) axis. Chronic myofascial trigger points and pain (CMP) is a peripheral nerve to muscle problem(Hong and Simons, 1998). FM, CFID, migraine, IBS, irritable bladder and several other common co-existing conditions that escape me right now, also have a strong central nervous system component. As an example, the pain of a cervicogenic migraine, is helped a great deal by myofasical therapy. (DeLaune, 2008). These patients may not have FM, but there is also a strong centralization issue in Migraine, whether they meet the current FM diagnostics or not.

A new application of ultrasound imaging and vibration soloelastography includes 2 dimensional greyscale and vibration sonoelastography imaging of a myofascial trigger point [in the upper trapezius] and specifically identifies MTrPs from surrounding tissue, more objective criteria. This new science will be a helpful tool to the clinician for evaluating palpable myofascial TrPs. In addition, the study also shows that as many as 85-93% of chronic pain patients seen in pain management clinics have myofascial trigger points (MTrPs). This does not mean that they all have FM, but if their TrPs are perpetual, meaning they are perpetuated by even a light breeze, and not chronic, meaning they are not responding to therapy, they certainly could have an undiagnosed FM component.

When any centralization disorder, like FM, co-exists with CMP from TrPs, the peripheral message of painful trigger points to the brain keeps the brain in a hypersensitive state," causing a “wind up” phenomenon and dysfunction of the HPA-axis (also seen in CFID/CFS/ME) is off and running. Think about the patient that has FM, CFID, CMP, migraine, IBS, and irritable bladder. You may be one, I am.

In disturbs me that so much misinformation is being disseminated, well intended, but could lead to a misdiagnosis and inappropriate treatment. It is this misinformation that causes unnecessary frustration to both the doctor and the patient.

"It's not about the rough ride, remembering life is like a safari. Sometimes I have to look for that, but I always find it, so I must be certain, it is always there for the taking." - Celeste

S. Sikdar, J.P. Shah, E. Gilliams et al. 2008. “Assessment of myofascial trigger points (MTrPs): A new application of ultrasound imaging and vibration soloelastography.” Arch Phys Med Rehab 89(11): 2041-2226.

T.S. Kuan, Y.L. Hsieh, S.M. Chen, J.T. Chen, W.C. Yen, C.Z. Hong. “Re: The myofascial trigger point region: correlation between the degree of irritability and the prevalence of endplate noise.” Am J Phys Med Rehabil. 2007 Dec;86(12):1033-4; author reply 1034.

J.P Shah, S. Parikh, J. Danoff, L.H.Gerber,” Re: The myofascial trigger point region: correlation between the degree of irritability and the prevalence of endplate noise.” Am J Phys Med Rehabil. 2007 Mar;86(3):183-9.

HY Ge , Y Wang, B. Danneskiold-Sams√łe , et. Al., “The Predetermined Sites of Examination for Tender Points in Fibromyalgia Syndrome Are Frequently Associated With Myofascial Trigger Points.” Pain. 2009 Nov 13.

C. Z. Hong and D. G. Simons, “Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points,” Archives of Physical Medicine and Rehabilitation 79, no. 7 (1998): 863–72.

D. M. Niddam, R. C. Chan, S. H. Lee, T. C. Yeh, and J. C. Hsieh, “Central representation of hyperalgesia from myofascial trigger point,” NeuroImage 39 (2008): 1299–1306.

D. G. Simons and S. Mense, “Diagnosis and therapy of myofascial trigger points,” Schmerz 17, no. 6 (2003): 419–24.

C. Z. Hong, “New Trends in myofascial pain syndrome,” Zhonghua Yi Xue Za Zhi (Taipei) 65, no. 11 (2002): 501–12.

D.G. Simons, J.Travell, and L. S. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed. (Baltimore: Williams and Wilkins, 1999.)

V. DeLaune, Trigger Point Therapy for Headaches and Migraines: Your Self-Treatment Workbook for Pain Relief. (Oakland: New Harbinger, 2008.)

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