Tuesday, August 7, 2012

Myofascial Trigger Points: My Paradigm Shift

Aaron Parr, PYII

"Skeletal muscle constitutes nearly half of our body weight, yet it is the only organ that is not linked to a specific medical specialty." (Dommerholt, 2011) 

There are many different thought processes on how to interpret and analyze a patient.  During my CRII rotation I had the opportunity to experience a new realm of physical therapy, which organized itself around a different constituent than I was normally familiar with: Myofascial Trigger Points (MTrP's) and dry needling.   I would like to point out that my current curriculum did well to prepare me for what MTrP's were, but until I stepped foot into the clinic it was hard for me to truly interpret its depth into a patient's pathology. 

MTrP's are defined by Simons et al as "a hyperirritable spot associated within a taut band of skeletal muscle"; Huijbregts furthers this by saying, "this spot is painful on compression and usually responds with a referred pain pattern distant from that point."  There is a lot more to the etiology and definition of trigger points, which has begun extensive study in the recent past due to an increase in focus on muscles and the neurology associated with, but I think it can be safely stated that MTrP's are painfully referring muscles.

So, with the knowledge of MTrP's etiology and definition, I went into the clinical thinking, "Ok, how involved can a referral pattern of pain be, and what truly is this dry needling thing?" 

Two words, “paradigm shift.”  The clinic dealt a lot with chronic pain patients, or rather patients with an etiology unknown and an aura of frustration and uncertainty surrounding their situation both from a patient's and clinician's point of view.  There is much to be discovered about the body, and chronic pain is as dark and mysterious an area as Mars, though we did just land on Mars, but the point has been made.  The patients seen were individuals commonly dragged through a system of trial and error, with error being the victor, but this is not surprising due to the nature of the pathology.  Even with the complexity of the patient's etiologies one thing was fairly common amongst them all, myofascial trigger points.  The hyper-irritable spots were identified and treated with many having positive pain decreasing/eliminating results (about 70% met their discharge goals from the treatment), and for the first time during the patient's extensive, extended, and numerous chronic pain treatments the muscles were indicated as a primary problem source and treated as such.

It should be noted that not everyone responded with success to this treatment, but also, no individuals regressed in their pathology or function because of the treatment.

The concept of muscular pain on the sensitization of central pathways and subsequent chronic pain is an interesting one, and will be something important to follow in the future, for now it should be noted that it has been established but needs further research.  Also, myofascial trigger points are not just for chronic pain treatments as success has been noted for all different types of musculoskeletal pathologies.  Remember, most injuries involve muscular tissue in some regard, and thus highly innervated and vascularized tissues are prime candidates for trigger points and pain referral patterns.

So, what did the clinical teach me?  I learned one needs to expand their approach to a patient and realize there is more to an injury than what meets the eye.  I understand that the clinic I was in saw a specific type of patient population, and so it should be noted dry needling and trigger point release is not indicated for everyone, but it should be an eye opener, at least for a student, into the multi-dimensional analysis and approach each patient requires and deserves.


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