A critical review of myofascial/trigger point treatment

[Cora]

Well, what my husband thinks ( he is an emergency medicine physician ) is that there are so many sub sets of contributing factors to our pain, and he uses the word heterogenous a lot when we look at "our"population of chronic pelvic pain. So, we often discuss ok, there are women that may have had congenital issues with their bladder, multiple surgeries,, IC, infections, scar tissue from terrible grade 4 tears during childbirth, men who may have had prostatitis that triggered PN irritation or pelvic floor irritation... trauma directly to the PN, true entrapment. his concern is that surgery is indicated to help the true sub-set of proven entrapment. If I were proven to be entrapped, he certainly worries about the surgery itself, and possibly having more complications that would result in a lower quality of life. Like many doctors, he often says, "It's best to avoid the hospital whenever you can." He has tremendous frustration at not being able to help me more and get some straight forward answers. He has certainly seen his share of surgical successes, surgical complications and with this surgery in particular, he has concerns, like we all do that there is not a very large "N" out there. As an ER doctor, he sees so many different forms of chronic pain, and generally speaking, he just thinks medicine has a poor understanding of it, and a very judgmental attitude towards it. And much of the literature bears that out. So, for example, if you are African American and walk into an ER and say you are in pain, before you even get examined, the staff will judge you as a drug seeker. But, back to this topic. My own gyn says that during certain surgeries they have to be very careful not to snag the PN, so I don't really know why entrapment is so disputed. Now in my own family, we have wondered if there is a structural susceptibility, as I had a relative who had very similar pain after a long bike ride. He has made some life-style changes, but I do think he has symptoms still, but they have calmed down. I have had a total of 2 other relatives who have had symptoms after increased cycling, so it's intriguing as to what the predisposition would be. Now, in terms of my plans, I think we gauge things as what would do more harm, and what is my quality of life right now, versus potential surgery? Right now, despite times when I am really down from the pain or a flare, if I can still hike an hour a day, and do my ADL's as they say... I probably won't run off and get tested, cuz I just personally don't want surgery right now. I have a few other health issues that could be compounding things. But, as far as centralized pain goes, RDS/CRPS ( which I know is different) I think neurologists are giving this much more attention now, even as an explanation of centralized pain, neurotransmitters, substance P levels, etc. I think turning off the generator is correct- and that is ultimately what probably starts the cascade into centralized, or chronic pain. My background as a nurse is in pediatric endocrinology and pediatric neurology, and I have had my share of seeing people in all types of pain from neuropathy. Of interest too, my husband wonders, if there is a genetic susceptibility to neuropathy. I once had an acute reaction to a medicine that gave me a periperhal sensory neuropathy. It resolved after a year, but is there something that differentiates those that develop central pain and those that don't, despite the generator? The bottom line, from his point of view, is that he is puzzled that there aren't more urologists, gyn's out there, that are taking a much more formal look- from a fellowship perspective, from an academic perspective. It is good to see it being discussed at meetings etc, but it sure has taken a long time. This always then leads into a more philosophical discussion about medicine in general- the pressure that dr.s are under to see a patient ever 15 minutes, to do procedures to bring in money, ... Something has been truly lost in medicine and he'll say sometimes " I remember when dr.s used to stop each other in the hallway to talk about cases, to share knowledge, and now it's all about billing, reimbursement etc... I know I've rambled here, but Ezer, I was just thinking about this earlier on a walk- I've worked with a doctor who invented a laser technique to get to inoperable brain tumors, there is the gamma knife out there now for neuro-surgery... I think many doctors today don't think beyond their 15 minutes with the patient, and I do think there have been biases out there towards pelvic pain patients. I actually had a colleague of his at a party ask me how I was doing? I told him a little bit about what I had and ya know what he said "Can't ya just use a vibrator to fix it ?" As my husband also often says: Dr's today, at least many of them, wants things to fit in a neat little diagnostic box, and then when they don't... many can get pretty apathetic. What he thinks to is that we all struggle because this diagnosis is just not that well differentiated... is it straightforward Pn or PNE, is it PFD? I mean, you should see the strange pain patterns that can evolve from a chest pain/cardiac event, gastric pain.. so our nerves do send out so many different messages. As many have stated here before, there has to be growth in the diagnostic criteria and better much better differentiation which the testing and imaging is doing, right ? Or lets say.. you go through 12 weeks or maybe even 6 months of PT and get well. I know, we need those studies and reports. These are the kinds of discussions we have and the bottom line is before I had this, my husband who is a very smart doctor, had no clue. Guess what, now he does, and although he can refer this concern back to the patient's doctor, not much else he can do beyond that. ( He does give out website addresses though, including this one.) So, these are the concerns of a doctor spouse. Must be others around here too.
Cora

[Cora]

well, I meant to preview, but I hit submit, so you are getting this totally unedited. Hope it's understandable

[Cora]

one more p.s. - to sum it up, what is concerning to my husband , is how there seems to be a lack of 'body of knowledge" to draw from and make decisions, and I think that is what gets us all wound up at times, when we have to go searching for what happened with Hibner's patients, or Rhonda's... etc..

[ezer]

Great posts Cora. From 2006-2010 (after I quit doing PT) I was like you, managing as well as possible, and very undecided. But in January of this year my pudendal pain became absolutely unbearable and that is why I finally decided to look into surgery.

[Cora]

Ezer, I will keep you in my thoughts and keep up with your post-op progress.

Cora

[Charlie]

Yes thanks for sharing yours and your husbands views. It was interesting to read both of yours perspectives on it all.

well, I meant to preview, but I hit submit, so you are getting this totally unedited. Hope it's understandable

By the way Cora if you did ever want to edit your posts after you press submit there is an edit button on the top right of your posts. Your posts read fine though.

[Charlie]

One approach that may be effective for 'trigger points' (whatever they actually are) may be Dry needling. This approach is favored by Dr Chan Gunn, the founder and president of the Institute for the Study and Treatment of Pain in Vancouver. Gunn argues there is more evidence for this approach than say for example the press and hold technique.

Below is an extract from an interesting article about Dr Gunns theory . As I have said I am not questioning the existance of tight bands in muscles. I am questioning the approach of trigger point therapy in particular the press and hold approach ( ischemic compression along with it's arbitrary 30-90 second hold ) and also whether they are the primary cause of pain.

5.3. Radiculopathic model for muscular pain

Not all researchers agree with the theories of Travell and Simons. Most opposing theorists postulate a neurological cause as the primary stimulus and trigger points as a secondary phenomenon(Gunn, 1997; Quintner and Cohen, 1994). Gunn (1997) suggested a radiculopathic model for muscular pain and states that ‘myofascial pain describes neuropathic pain that presents predominantly in the musculoskeletal system’ (p. 121). The radiculopathic model is based on all denervated structures exhibiting super sensitivity. From clinical observations, Gunn (1997) states that neuropathic nerves are most commonly found at the rami of segmental nerves, and therefore represent a radiculopathy. If neural injury or compression and partial denervation are the site of origin of this pathology, he believes that it helps to explain the lack of pathology seen in muscle and the sensory, motor, and autonomic changes seen in myofascial pain syndromes.

Gunn (1997) suggests that myofascial pain most often relates to intervertebral disc degeneration with nerve root compression or angulation due to reduced intervertebral space and resultant paraspinal muscle spasm. This is described as a form of neuropathy. This neuropathy then sensitises structures in the distribution of the nerve root, causes distal muscle spasm, and contributes to other degenerative changes in tendons and ligaments within its distribution that are then perpetuated by the ongoing muscle shortening. Therefore, this theory is not only used to explain trigger point formation, but also conditions such as tendinopathy and enthesopathy.

Based on his theories, Gunn (1997) proposes that long lasting pain relief requires needle treatment to the shortened paraspinal muscles in order to reduce nerve root compression, as well as to trigger points more local to the site of perceived pain.

Quintner and Cohen (1994) argued that the reasoning behind traditional trigger point teaching is circular and excludes the possibility of a non-muscular origin of the pathology. They suggest that the characteristics of the pain from trigger points are not distinguishable from neural pain, and that a primary neurological cause is a much more likely explanation for the local and referred sensations of myofascial pain.

http://www.terapiamanipulativa.com.br/M ... points.pdf

[Griff522]

Charlie,

I'm just wondering what kind of PT you received. About 6 months ago I had pelvic floor PT. The therapist spent a lot of time telling me how weak my pelvic floor was using bio feedback. Well I'm thinking "lady, your pelvic floor would be weak too if you had been in pain for 6 months!". She did mostly MR along the nerve and the pain really never changed. I stopped going after two months.

Just recently, I went to be evaluated by a PT for SIJD. I don't think she found much SIJD but she did find other problems with my pelvis which HerMajesty is trying to help me understand. But I have felt a difference in the pain since this PT has adjusted my llium and worked on my tailbone issue.

I had a major fall on my tailbone as a child and I had always kind of known it was a problem but nerver had uncomfortable chronic pain from it. I had two BIG babies vaginally and I'm sure that has added a little damaged to the old pelvis too.

[Charlie]

Charlie,

I'm just wondering what kind of PT you received.

In answer to your first question as I have said I went to the A Headache in the Pelvis clinic. I tried to self treat for a short while after this. I personally feel unless you are regulary seeing a pelvic floor PT to guide you self treatment is a ridiculous approach. Indeed David Wise the person who runs the A Headache in the Pelvis clinic appears to contradict himself in his sales strategy. On the one hand he argues you must see Tim Sawyer (the supposed best Pelvic Floor PT in the world ever and the only person that can find those mystery trigger points) and then on the other argues that you can simply learn to self treat in a single week. It makes no sense.

The type of PT that was employed at the clinic was ischemic compression on trigger points. It was extremely painful to receive and all it did was flare me up and make it worse. David Wise assured me this was a good sign. It was not and it led to no improvement. I think a lot of people mistake improvement when they compare the flare up after treatment to how they feel once the flare up has subsided. They have not really improved they have just recovered from the flare up. At the clinic I was also taught Paradoxical relaxation, a bizarre scene with David Wise monitoring our breathing and telling us all to relax our eyes, relax our forehead, relax our pelvis, etc. Paradoxical relaxation is just progressive muscle relaxation invented by Edmund Jacobsen. A technique which is taught throughout the country. I became pretty good at it and does help cope with pain but it is never going to cure you of it.

In terms of the PT there I do not believe in this approach at all. Even Travell and Simons (who developed trigger point treatment) dropped the idea of applying ischemic compression to trigger points. I was told this by a PT who treated me I saw after the Wise clinic. Right now there is probably someone consulting their trigger point map with their thumb inserted into them digging into their obdurater internus muscle when they could well have a pudendal nerve entrapped by their ligaments. I think this approach is insane and it is lamentable that people are spending thousands on extremely basic, unscientific treatment.

I then went to another PT who performed trigger point release and extensive connective tissue massage. I did not receive hardly any connective tissue at the AHIP clinic so I was hopeful this might be the breakthrough. They explained to me that they had seen many 'David Wise failures' so I was extremely hopeful. The trigger point release I had was described as barrier release. Less pressure was applied to the trigger point and I had to try and release my pelvic floor muscles at the same time. This PT was far superior to the standard of PT I received at the Wise clinic. I have to say with this approach I did experience relief but it was always temporary. I believed wholeheartedly in my therapists claim that I could make a full and complete recovery. My therapist also claimed an extremely high success rate so this kept me going for nearly a year.

The short term relief I received convinced me I could recover but it never lasted. I then became good friends with a highly qualified physical therapist and it was him I have to thank for really encouraging me to question trigger point theory and see the weaknesses in it. I have done further reading myself as well.

As I have said I really want to stress that I am not telling people not to try PT but I am encouraging people to question the science of this approach. People should also be aware of the fact that there is no evidence to support the type of PT I personally tried. Some people become angry when you say this. In some sense I can understand it as when you say stuff like this you take away people's sense of hope that PT will cure them. I should add that years ago I would look on at pudendal nerve sites with utter horror. Did n't these people know that they simply had trigger points and tough connective tissue? Now I realize that the treatment I was pursuing was completely lacking in evidence and maybe the people I was reading on the pudendal sites were not so crazy and naive after all. It's a shame that pudendal info ( the old site) is down as you could see from my old posts there that at one point I praise Dr Wise's contribution to pelvic pain. I was a fully fledged PT fan. Looking back I was just clinging onto hope.

David Wise appears to get angry when you say stuff like this as you threaten his reputation and profit. For instance on David Wise's website people have been told to ignore my posts as I am apparently psychologically ill and been told to seek help. People can make up their own minds on that. I don't feel my posts on the forum give that impression. I think it is concerning that a psychologist is using the tactic of labelling people mentally ill just because they dare to speak up against this methods.

I presume that the person that wrote the article I linked to is also mentally ill when they state

Trigger point therapy is essentially divided into invasive and non-invasive techniques. Non-invasive techniques are those that have been traditionally employed by physical and manual therapists. In recent years, there has been marked increase in the use of invasive therapies, in particular, dry needling to manage trigger points. Anecdotally, all therapies have their supporters. Scientifically, however, very few of them stand up to scrutiny.

Dr Gunn, Dr Quintner and Dr Cohen , all the pudendal nerve surgeons, etc must also be mentally ill

I recognize there are highly knowledgable, very caring PTs helping people. Maybe for some people PT is highly effective as their problem is only muscular. However I also wish PTs would recognize the limitations of their treatment for people with entrapments or other conditions.

I would also though not advise people to run away and have surgery. That is a big decision to make.

I had a major fall on my tailbone as a child and I had always kind of known it was a problem but nerver had uncomfortable chronic pain from it. I had two BIG babies vaginally and I'm sure that has added a little damaged to the old pelvis too.

It's interesting you say that. You should watch this presentation by Beco. He describes how both of these things can cause entrapments. Click on slide 15 if you would prefer not to plough through the whole presentation.

http://webcasts.prous.com/webcast_viewe ... NIgmTYI2E=

I also accept that the PT hermajesty has advised you to try may be beneficial. I have not tried that type of PT so it would be wrong of me to comment on it. To be fair I have never criticized the PT that hermajesty recommends. Although I do always feel weird referring to her as 'hermajesty', she is pelvic pain royalty!

Lastly everyone is different with pelvic pain. In my opinion beware any treatment provider who treats everyone the same. PT even trigger point theory may well work for some people.

[ezer]

I remember very well at the Wise clinic, there was always a particular "trigger point" to explain every pelvic pain situation. Some patients were trying to ask questions about bladder inflammation, PN, or SIJD but it was all dismissed.
By keeping in touch with other people after the clinic and speaking with other ex-Wise patients I found out that trigger point treatment was not the solution to their pelvic pain. At best it was pain management.
In subsequent years, I heard many grandiose claims from PTs about curing people. To me It almost seems that when a patient does not return, it is assumed that he or she is cured.