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the latest synopsis of myofascial pain syndromes


Myofascial Pain Trigger Point

Dr. Bruno Bordoni recently wrote an article for STAT Pearls titled Myofascial Pain, in which he stated, “Different tissues work in harmony to make up the myofascial continuum. Thanks to the fascial tissue, all the muscles make up a network in constant connection, and it becomes an error to consider a muscular district as a separate entity.  It is impossible to intervene or come in contact with a muscle excluding the associated connective or fascia tissues.” 

He went on to talk about the fact that the liquid portion of both blood and lymph are actually fascia (HERE), that fascia has contractility (HERE), that it has conductibility (HERE), as well as the various ways it is organized and intertwined with numerous other tissues.  And of course he spoke of FASCIA AS A SOURCE OF PAIN.  Today we will not so much be discussing SCAR TISSUE / FIBROSIS, but the dreaded MYOFASCIAL TRIGGER POINT; the most common of the myofascial pain syndromes.

What’s just as interesting as calling trigger points a source of pain is that he referred to them a “source of functional limitation“.  In other words, these creatures (TP’s) are not only painful, they have the potential to alter the way you go about your normal day-to-day life.  Bordoni went on to talk about the various theories on why people get Trigger Points.  Here are some of the takeaways (trying to simplify some of this for my readers).

  • Trigger points are more prone to be found in red muscle (aerobic, slow twitch, postural) that white muscle (anaerobic, fast twitch, explosive movements).
  • Constant (repeated) microtrauma is a problem — probably one of the reasons that the consensus is that REPETITIVE INJURIES are usually harder to deal with than acute trauma.
  • This constant microtrauma to red fibers causes an increased need for cellular OXYGEN, which depletes cellular energy (ATP) and causes increased sensitivity to pain.  
  • In this environment, numerous chemicals, compounds, and elements (including the biomarkers we refer to collectively as “INFLAMMATION,”) causes both tissue STIFFNESS AND DENSITY, as well as the heightened pain sensitivity and low threshold to meet said sensitivity we saw in the previous bullet.  When this process happens in the central nervous system it’s known as CENTRAL SENSITIZATION.  As the famed neurologist and acupuncturist (he’s considered the father of modern dry needling techniques) Chan Gunn said, this can make fibrotic tissue over 1,000 times more sensitive to pain than normal tissue (HERE).
  • Thanks to the above-mentioned CS, as well as similar phenomenon occurring in the peripheral nervous system, areas of the nervous system begin firing on their own, sometimes almost perpetually, with an end result that there is “a constant local contraction of the muscle fibers“.  Mind you, I am not saying that the entire muscle is contracting, but instead, due to the fact that when an individual muscle fiber contracts it contracts at 100%, the individual fibers under the control of a specific nerve can be hyper-stimulated and contract until they finally run out of ATP.  The end result is that once this occurs, many people will get a short period of TP relief until the body replenishes it’s stores of cellular energy to start contracting again.
  • As the vicious cycle spins faster and faster, not only is there an increase in pain, but the FIBROBLASTS actually start converting to myofibroblasts, which dramatically changes the dynamics of the fascia.  In fact, Bordoni theorizes that the fascia, which acts as A SECOND NERVOUS SYSTEM, has the potential to itself start sending “looped” messages that play over and over again, causing further “spontaneous presence of local muscle contraction.
  • There is also an alteration of the hyaluronan or hyaluronic acid (HA) that, like most everything else seen in fascia, also thickens, becoming more viscous, creating a scenario where the various layers of fascia do not slide on each other (IT LOOKS LIKE THIS).  This seems to cause stretching of the nerve tissue in the fascia, creating still another reason for it “becoming constantly activated“.
  • If you throw altered BLOOD PRESSURE into this whole mess, the smallest blood vessels (the capillaries) become ischemic, starving their corresponding muscles for O2.  In a nation where we learned just last week that our COLLECTIVE BMI (body mass index) went up yet again, it’s just another nail in the proverbial coffin.
  • Because the internal environment of a trigger point is hypoxic (low oxygen), it’s also acidic.  For those of you who suffer from any sort of digestive issue, I suggest you read about the inverse relationship between the stomach and the body as far as acidity / alkalinity is concerned (HERE).
  • The end result is that there are several positive feedback loops (viscous cycles) that set themselves up, causing a release of neurotransmitters that stimulate contraction, based largely on inflammation, hypoxia, acidity, and the muscle contraction itself, “surging the sending of painful information to the nervous system.
  • Trigger points, if biopsied, contain cells, tissues, and biochemical markers that are different than normal surrounding tissues.  Not surprisingly, the tissues are themselves thickened (sometimes researchers refer to this as “DENSIFICATION“).

One of the theories that Bordoni specifically mentioned concerning myofascial pain syndromes has to do with altered neurological function of the nervous system as it relates to the SKIN.  “The concept of altered electrical activity of the skin and the afferents [sensory nerves] coming from the TPs could explain the altered emotional state in patients with the myofascial syndrome (anxiety and depression).” 

Interesting, considering ANXIETY and DEPRESSION are both considered to be “inflammatory” diseases (HERE). 

Furthermore, we saw confirmation of previous studies that various parts of the brains of people in chronic pain, and especially chronic myofascial pain, actually shrink and atrophy.  In fact, I’ve seen studies showing that this phenomenon can be so severe that over time, brain scans of those who have lived with chronic pain become almost indistinguishable from people with neurodegenerative diseases such as ALZHEIMER’S (HERE).

Although the books by TRAVELL & SIMONS were mentioned (Janet Travell was JFK’S PERSONAL PHYSICIAN), what I found most interesting was the lack of consensus as to what can be used to effectively image and / or successfully address myofascial pain syndromes — especially the chronic myofascial pain syndromes (“Currently, the causes of the presence of TPs are only speculative, as well as the correct evaluative and therapeutic approach.“). 

As far as treatment, Bordoni mentioned every single one of my ‘BIG FIVE,’ as well as “lidocaine patches, BOTOX, POSTURE-CONTROL EXERCISES, NUTRITION, THERAPY, CHIROPRACTIC ADJUSTMENTS [actually, he mentioned “Osteopathic Manipulation”], ultrasound, STRETCHING, DRY NEEDLING, YOGA, ACUPUNCTURE” and a number of others.  What wasn’t mentioned was, at least in my mind, even more interesting than what was.   Namely, any sort of bodywork, massage therapy, rolfing, TISSUE REMODELING, etc.

The paper’s theme was that the drugs are not going to be very helpful and can actually cause a myriad of SIDE EFFECTS when trying to affect myofascial pain syndromes.   It seems that Bordoni would agree that A SYSTEMIC APPROACH to trigger points has the potential to be much more effective than simply attacking these beasts in a purely local fashion.  If you appreciated today’s post, be sure to share it with others.  FACEBOOK is still an effective way to reach the people you love and care about most!


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