For Deactivating Myofascial Trigger Points And Improving Range Of Motion

Myofascial pain is a major cause of morbidity and has a considerable economical impact causing much absence from work and a large number of consultations in primary care and at pain clinics.

According to the authors who first introduced the basic concept of the myofascial trigger point (MTP), Janet Travell (1901-1996) and David Simons, several clinical features can be observed.10 The reader will permit me to list some of the most important:

1. MTP is a hyperirritable locus or a point of maximal tenderness located within a taut or palpable band of skeletal muscle.

2. Its compression may elicit local pain and/or referred pain that is similar to the patient's usual clinical complaint (pain recognition). Dr Travell said 'the more hypersensitive the MTP, the more intense and constant is the referred pain and the more extensive is its distribution'.

3. The pattern of referred pain from MTPs is predictable because it is specific for each individual muscle in the body.

4. The compression across the muscle fibers or snapping palpation may elicit a local twitch response which consists of a brisk contraction of the muscle fibers in or around the taut band.

5. Patients with MTPs may have associated localized autonomic phenomena, including vasoconstriction, pilomotor response, hypersecretion, etc.

6. Active MTPs show spontaneous pain or pain in response to movement. Latent MTPs show pain or discomfort only if elicited by compression. According to Dr Travell, a latent MTP can be activated directly by overload of the muscle, overwork, fatigue, chilling; or indirectly by other factors, for example visceral diseases and emotional distress.

7. Both active and latent MTPs may cause stiffness, weakness of the muscle and limited range of movement.

The treatment and subsequent disappearance of a majority of active and latent MTPs seems of great importance in a rehabilitation program. Among the different techniques proposed are the classical 'stretch and spray' and injections with a small amount of local anesthetic or simply with dry needles. According to Melzack et al,11 acupuncture points and MTPs show a high degree of correspondence between both the spatial distribution and the associated pain patterns. In my opinion ear acupuncture can show an analogous correspondence, and the best way to prove this was to identify the auricular points which best could modify the clinical features of MTPs with needle contact.

A series of 52 consecutive patients with chronic pain syndromes involving the neck, the shoulder girdle and the arm was examined. The exclusion criteria for my evaluation were: psychiatric disorders, cognitive impairment, intake of analgesics, psychoactive drugs and corticosteroids administered less than 12 hours previously.

All patients were examined sitting or lying down and each painful area was palpated in order to individuate the tender points and the MTPs. Every tender spot was marked with ink and the following four characteristics were recorded for each one: (i) tenderness within a palpable band; (ii) irradiation of pain at distance from the pressed point; (iii) local twitch response; (iv) pain in response to movement and/or limited range of motion.

The 52 patients totalled 142 tender spots (average 2.7); 81 (57%) spots had at least two clinical features which could be considered typical of an MTP.

After the search for MTPs, the tenderness of the auricle on the same side as the pain was tested with PPT and every sensitive point was marked with ink. NCT was then performed on every point and the result of this stimulation was checked after 1 minute on each tender spot of the body. No more than three attempts were made to test a singular MTP, to avoid the therapeutic effect of the palpation itself.

Of the 81 MTPs, 53.1% completely lost any tenderness during the minute following NCT, the local twitch response was no longer obtainable, and range of motion improved. Only a reduction of tenderness was seen in 30.9% of the total, but in the majority of cases the typical features of an MTP could no longer be evoked. In 16%, however, the tenderness of the trigger area was unchanged despite the three attempts made.

Thanks to this study I could represent the MTPs of some muscles on the ear: some of them are represented on the lateral surface, as for example the sternocleidomastoid, the pectoralis major and the biceps brachii (Fig. 8.6A). The majority of muscles, however, are represented on the medial surface, such as the splenius capitis, the upper trapezius, the levator scapulae, the triceps brachii and the latissimus dorsi (Fig. 8.6B). Furthermore, some muscles have a double representation on

Fig. 8.6 Representation of the myofascial trigger points (MTPs) of some muscles of the neck, shoulder girdle and arm on the lateral surface (A) and on the medial surface (B). (A) 1 = masseter; 2 = sternocleidomastoid; 3 = supraspinatus (represented both on lateral and medial surface); 4 = biceps brachii; 5 = pectoralis (dark pink). (B) 1 = splenius capitis; 2 = trapezius; 3 = levator scapulae; 4 = triceps brachii; 5 = latissimus dorsi (pale pink).

both surfaces, such as the supraspinatus and the deltoid. The representation of other muscles not belonging directly to the neck and shoulder girdle may, however, be overlapping, such as the masse-ter and the sternocleidomastoid. The following case studies describe how best to correlate an auricular point with the corresponding MTP.

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