Académique Documents
Professionnel Documents
Culture Documents
Trigger Points
David G. Simons
Four articles this quarter present major progress in new experimental data.
Hou et al. demonstrated in rabbits that motor endplate potentials [spontaneous
electrical activity] of trigger spots are partially dependent on increased cal-
cium channel permeability. Delaney et al. report an elegant way to measure
the effect of myofascial trigger point [TrP] massage on autonomic nervous
system activity. This opens a new research window through which to explore
the close relation between TrP activity and autonomic nervous system activ-
ity. Esenyel et al. present a randomized, controlled, unblinded comparison of
the results of ultrasound application and injection of TrPs and found that both
were equally and significantly effective. This is one of the very few scientific
papers that address the effectiveness of treating TrPs with ultrasound.
Pongratz reported a noteworthy histological study specifically of TrPs. In ad-
dition, the efficacy of needling TrPs is becoming firmly established, and one
review article presents in detail the importance of considering TrPs in patients
with symptoms of radiculopathy.
CLINICAL STUDIES
Infrared Skin Temperature Measurement Cannot Be Used to Detect
Myofascial Tender Spots: M. Radhakrishna, R. Burnham. Arch Phys
Med Rehabil 82: 902-905, 2001.
Summary
There is great need for an objective test to identifying myofascial trig-
ger points [TrPs] and hot spots of skin overlying TrPs have been recom-
David G. Simons, MD, is Clinical Professor [voluntary], Department of Rehabilitation
Medicine, Emory University, Atlanta, GA.
Address correspondence to: David G. Simons, MD, 3176 Monticello Street, Covington,
GA 30014-3535 [E-mail: loisanddavesimons@earthlink.net].
Journal of Musculoskeletal Pain, Vol. 10(4) 2002
http://www.haworthpressinc.com/store/product.asp?sku=J094
2002 by The Haworth Press, Inc. All rights reserved. 71
72 JOURNAL OF MUSCULOSKELETAL PAIN
Comment
Summary
Comments
TPT. The diagnostic criteria make it clear that part of the treatment was di-
rected specifically to TrPs and that part of it concerned less specific
myofascial pain in general. Several lines of evidence indicate that auto-
nomic activity can strongly influence TrPs and that TrPs can influence au-
tonomic activity. This is a groundbreaking contribution to what promises
to be a useful new tool for future TrP research.
ETIOLOGICAL MECHANISMS
Summary
Comments
Summary
Comments
TREATMENT
Summary
selected acupuncture sites and over, or into, four TrPs or into the four most
painful muscle tender points and stimulated four times in 15 minutes by
rotation. [Criteria used for identifying active TrPs were not stated.] Pre-
treatment compared to post-treatment McGill Pain Questionnaire re-
sponses were not statistically significantly improved, and only deep
insertions resulted in statistically significant improvement three months
after treatment. Immediately following eight treatment sessions, the su-
perficial group improved 36 percent and the deep group 59 percent. At
three months, the deep group progressed to 79 percent improvement,
which was significantly more improvement [P < 0.05] than seen in the su-
perficial group at that time. The statistically nonsignificant improvements
immediately following treatment were considered of considerable clinical
importance in this well-controlled study.
Comment
I agree. Too often we throw the baby out with the bath water. This
well-conducted study combined two different concepts of treatment that
leaves unanswered the question of whether combined therapy is more ef-
fective than either approach alone would be for inactivating TrPs. A num-
ber of clinicians find that combining acupuncture methods with specific
TrP treatment is more effective than either alone. From a TrP point of
view the study would have been strengthened if a specific measure of TrP
activity [such as algometry] had been included pre- and posttreatment.
Summary
sity [P < 0.001], increase in pain pressure thresholds [P < 0.001], and in-
creased range of motion [P < 0.05] at two weeks and at three months after
treatment. Controls showed no improvement at two weeks. Psychological
testing showed depression in 23 percent and high anxiety scores in 90 per-
cent of patients and showed no correlation with the three measures de-
scribed above. Psychological test results did correlate with the duration of
symptoms. Ultrasound and injection were found to be equally effective
and significantly better than just neck stretching exercises and to be inde-
pendent of the severity or duration of pain. Improvement lasted for at least
three months. Anxiety or depression did not limit the effectiveness of
these two treatments.
Comments
More detail as to the treatments administered would be desirable. The
authors found that psychological distress increased as the cause of the pain
remained unsuccessfully treated–maybe the pain and unsuccessful pain
treatments were driving the patient crazy. The favorable response to TrP
treatment in the presence of psychological distress is compatible with the
distress being the result of and not the cause of the persistent TrP pain.
This emphasizes the importance of prompt recognition and effective treat-
ment of the cause of the pain.
Comments
Since lidocaine is an effective local anesthetic, reduction in local ten-
derness immediately following treatment is not surprising. An effect ob-
served several hours later would have told more about its effect on the
TrPs. Reporting change in the clinical pain coming from active TrPs
would be more relevant to clinical practice. Since dry needling of TrPs
without evoking twitch responses is ineffective (5) and injection of anes-
thetics is no more effective than dry needling (6), it is not surprising that
lidocaine iontophoresis would be ineffective for treatment of TrPs.
Comment
Summary
Comment
Summary
Comment
The proposed rationale presented for why the combination of these two
release techniques works is not convincing to this reviewer, but a number
of skilled clinicians find this combination of treatments very effective.
Literature Reviews 81
Summary
The objective is to treat the cause of the pain, not just the symptom.
First one locates myofascial trigger point [TrP] tenderness by palpating its
taut band. Digital pressure elicits a ‘jump’ or ‘shout’ reaction and repro-
duces the patient’s pain. A scholarly historical review and detailed de-
scription compares superficial [subcutaneous penetration only] and deep
[intramuscular penetration] dry needling techniques. The review con-
cludes with a hypothesis of pathophysiology to explain the effectiveness
of superficial dry needling and the importance of identifying strong, aver-
age, and weak responders to superficial needling.
Comment
This use of superficial dry needling for treatment of TrPs has been pre-
sented in this journal (7) and in a book (8). Clinically, this technique ap-
parently is frequently effective, but the neurophysiological mechanism by
which it inactivates an TrP remains obscure and deserves serious experi-
mental study. Modulation of sympathetic nervous system activity by the
procedure would be a likely place to start. The effect of this procedure on
the autonomic nervous system could be tested using heart rate variability
as the indicator (see Delaney et al., reviewed above). The results of
Ceccherelli et al., reviewed above, are relevant and indicate that deep dry
needling is clinically clearly more effective than superficial dry needling
of acupuncture points and trigger points.
Summary
Comment
This succinct focused review was written by and for physiatrists. It crit-
ically examines the state of the art and knowledge of myofascial pain
caused by Trps.
Summary
Comment
tivity Scores?: D.G. Simons. J Manip Physiol Ther 25(1): 77-78, 2002
[letter].
REFERENCES
1. Swerdlow B, Dieter JNI: An evaluation of the sensitivity and specificity of medi-
cal thermography for the documentation of myofascial trigger points. Pain 48:205-213,
1992.
Literature Reviews 85
2. Chen J-T, Chen S-U, Kuan T-S, Chung K-C, Hong C-Z: Phentolamine effect on
spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal
muscle. Arch Phys Med Rehabil 79:790-794, 1998.
3. Simons DG, Travell JG, Simons LS: Travell & Simons’ Myofascial Pain and Dys-
function: The Trigger Point Manual, Vol.1, Ed. 2. Williams & Wilkins, Baltimore, 1999,
pp. 57-82.
4. Mense S, Simons DG: Muscle Pain Understanding its Nature, Diagnosis, and
Treatment: Lippincott Williams & Wilkins, Baltimore, 2001, pp. 240-259.
5. Hong C-Z: Lidocaine injection versus dry needling to myofascial trigger point: the
importance of the local twitch response. Am J Phys Med Rehabil 73:256-263, 1994.
6. Cummings TM, White AR: Needling therapies in the management of myofascial
trigger point pain: A systematic review. Arch Phys Med Rehabil 82:986-992, July 2001.
7. Baldry P: Superficial dry needling at myofascial trigger point sites. J Musculoske
Pain 3(3):117-126, 1995.
8. Baldry PE, Yunus MB, Inanici F: Myofascial Pain and Fibromyalgia Syndromes.
Churchill Livingstone, Edinburgh, 2001.
9. Wu C-M, Chen H-H, Hong C-Z: Inactivation of myofascial trigger points associ-
ated with lumbar radiculopathy: surgery versus physical therapy. Arch Phys Med Rehabil
78:1040-1041, 1997 (Abstr).
10. Wu C-M, Chen H-H, Hong C-Z: Myofascial trigger points in patients with lumbar
radiculopathy due to disc herniation before and after surgery. J Surgical Association Re-
public of China 30(3):175-185, 1997.
11. Hsueh T-C, Yu S, Kuan T-S, Hong C-Z: Association of active myofascial trigger
points and cervical disc lesions. J Formos Med Assoc 97:174-180, 1998.
12. Chu J: Twitch-obtaining intramuscular stimulation: observations in the manage-
ment of radiculopathic chronic low back pain. J Musculoske Pain 7(4):131-146, 1999.
13. Gerwin RD, Shannon S, Hong C-Z, Hubbard D, Gevirtz R: Interrater reliability in
myofascial trigger point examination. Pain 69:65-73, 1997.
14. Zhu Y, Haldeman S, Hsieh C-Y J, Pingjia W, Starr A: Do cerebral potentials to
magnetic stimulation of paraspinal muscles reflect changes in palpable muscle spasm,
low back pain, and activity scores? J Manip Physiol Ther 23 (7): 458-464, 2000.