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Myofascial trigger points: fact or myth? Let the battle continue

The concept of myofascial trigger points keeps on inspiring researchers and clinicians. With the recent publication of an interesting review article in Rheumatology, the concept is really challenged. Quintner, Bove & Cohen critically examined the evidence for the existence of myofascial trigger points and for the vicious cycles that are believed to maintain them. They found little evidence supporting their presence or sustaining vicious cycles. Myofascial trigger points are labelled as ‘inventions’ and the authors argue that the clinical phenomena of myofascial trigger points can be explained by known neurophysiological phenomena.

Is it really that bad? Are myofascial trigger points no more than an invention for a clinical phenomenon? We asked international experts to provide arguments supporting or refuting the concept of myofascial trigger points.

First, Rafael Torres Cueco (University of Valencia, Spain) argues against their existence, and is clearly on the side of Quintner, Bove & Cohen. Rafael explains: “I think that it is really imperative to battle with that old fashion concept. I have lectured in the concept on a physiotherapy conference many years ago, and I feel that I have treated to many patients following this principle. Today I am convinced that myofascial pain and myofascial trigger points are clinical expression of central sensitization rather than local (muscular) dysfunctions. I no longer treat trigger points.”

Barbara Cagnie (Ghent University, Belgium) provided arguments supporting the concept of myofascial trigger points. She provided us with the following comments:
Quintner, Bove & Cohen are acknowledged for their criticism regarding myofascial trigger points and although they are right in stating that the working hypotheses of myofascial pain syndrome caused by trigger points are still unknown, I think it is too radical to conclude that the theory should be discarded.
I just quote some sentences and try to extrapolate this to neck pain patients, which is my specific area of expertise.

Quintner et al. state that ‘The phenomena of muscle pain and tenderness in the absence of obvious disease are well recognized but poorly understood’. The absence of obvious disease is quite regular in neck pain patients. About 85% of the neck pain patients suffer from ‘nonspecific neck pain’, which means that there no clear structure can be pointed as the source of pain. The recognition of trigger points in myofascial pain syndrome has been a great help in finding underlying dysfunctions in patients with neck pain. Nowadays, it is more common to speak in terms of dominant dysfunction patterns as specific ‘diseases’ are lacking. A dominant myofascial dysfunction may be one of those patterns.

The authors further mention that ‘physical examination cannot be relied upon to diagnose a condition that is supposed to be defined by that physical examination. That is, the pathognomonic criterion for making the diagnosis of myofascial pain syndrome is unreliable.’ As is with a lot of tests within the field of physiotherapy, there is no single test that has both a specificity and/or sensitivity of 100%. The use of a cluster of tests is more reliable than one test alone. Clinically, in case of a dominant myofascial dysfunction, this may be a combination of pain and stiffness in the muscle, with provocation while lengthening the muscle; referred pain; presence of triggerpoints and muscular imbalances. However, more research is needed to validate this set of clinical indicators.

Quintner et al. highlight that “Travell and Simons composed anatomical charts of trigger points and their characteristic pain referral patterns. However, it appears that their diagrams had ‘sometimes been chosen arbitrarily, there being no accepted standard.” I agree that the flow charts of Travell and Simons are still accepted as the gold standard and I also question the validity of these charts. I think a lot of research is lacking with respect to the referred pain patterns. However, nowadays, different validated methods exist to define referred pain patterns.

Quintner et al. conclude that “the vast majority of studies and meta-analyses do not support the prediction from myofascial pain syndrome theory that focal treatment of trigger points is effective.” The problem within our profession is indeed the fact that a pragmatic approach is used when treating patients. Treatments are rarely performed in an isolated fashion. This gap between how we work in clinical practice and how scientific research is done, hampers making firm conclusion about the effect of treatment of trigger points. However, a recent systematic review on neck pain revealed that there is moderate evidence for ischemic compression and strong evidence for dry needling to have a positive effect on pain intensity. This pain decrease is greater compared to active range of motion exercises (for ischemic compression), and no or placebo intervention (ischemic compression and dry needling), but similar to other therapeutic approaches (Cagnie et al, 2014).

References

Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology

Cagnie B, Castelein B, Pollie F, Steelant L, Verhoeyen H, Cools A. Evidence for the Use of Ischemic Compression and Dry Needling in the Management of Trigger Points of the Upper Trapezius in Patients with Neck Pain. A Systematic Review. Accepted in American Journal of Physical Medicine & Rehabilitation

Further reading

http://rheumatology.oxfordjournals.org/content/early/2014/12/03/rheumatology.keu471.abstract

http://www.ncbi.nlm.nih.gov/pubmed/23206963

http://www.ncbi.nlm.nih.gov/pubmed/23801002