Trigger points have been implicated in a variety of pain phenomena, including muscle pain (myalgia), muscular (non-joint) manifestations of arthritis, muscle inflammation (myositis or myofascitis), and inflammation of the white fibrous tissue that comprises muscle sheaths and fascial layers of the whole muscle, joint, tendon, ligament system (fibrositis or myofibrositis). Trigger points, particularly those found in the upper regions of the back and shoulders, are often associated with palpable nodules of fibrous tissue. Physiologically, they form a self sustaining cycle of pain, more spasm, more pain. This vicious cycle may be interrupted at the sensory (afferent) or at the motor part of the mechanism. Trigger point compression, dry needling or injection of an anesthetic solution will intervene at the sensory level, possibly by stimulating brainstem production of enkephalins and endorphins. The result is a palpable softening of tense muscle tissue, signaling muscle relaxation and pain relief which may last for days.
Myotherapy: The Trigger Point Compression Technique
Myotherapy, the trigger point compression technique, was developed and reported by Bonnie Prudden in 1980. A well known physical fitness expert, Prudden was familiar with the trigger point injection technique long promoted by Janet Travell, White House physician during the Kennedy administration. Prudden made the serendipitous discovery that manual compression of offending trigger points for a period from 5 to 7 seconds was equally effective in bringing about muscle relaxation. This approach had the advantage of being non-invasive, and multiple trigger points could be “erased” at the same sitting. Prudden then complemented the technique by including her own corrective exercise program: First, shortened and weakened muscles are reeducated to revert to their normal resting length, then progressive strength training helps lead to gradual return of normal function. Compression of trigger points is slightly painful, but as soon as the pressure is released the pain subsides. After a group of related trigger points has been inactivated, the muscle is gently stretched. The sequence of trigger point compression and passive muscle stretching continues throughout the treatment.
At the end of the treatment, active range of motion exercises are begun. Furthermore, because of the simplicity of the technique, a patient’s spouse or friend can easily be taught to administer Myotherapy to key trigger points at home in between scheduled sessions. Hence, Myotherapy combined with the corrective exercise program effectively interrupts the pain, spasm, pain cycle at both the sensory and the motor levels.
The Corrective Exercise Program: Key to Permanent Pain Relief
The corrective exercise program component seems to be the key to long term pain relief achieved over a short period of time. Exercise has indeed long been used for pain control. It is a known mood elevator and allows patients to become actively involved in their recovery. But it is also true that for many patients with pain due to active trigger points, exercise is initially not a viable option. However, once the pain factor is removed, most people will find exercise enjoyable.
The homework exercise program is tailored to the individual needs of each patient and includes progressive range of motion exercise (warm ups), muscle strengthening and flexibility routines. These Bonnie Prudden exercises are easy to perform, should not elicit any pain, and are to be done frequently throughout the day, preferably to music. The exercises are reviewed during each session. Towards the end of the treatment program, patients are coached to engage in a regular physical fitness activity such as walking, swimming, water exercises, etc., appropriate to their lifestyles. The exercise program is thus the key feature distinguishing Myotherapy from other pain relief methods, such as trigger point injection, application of the TENS unit, and acupuncture, which focus mainly on modulating sensory inputs.
Myotherapy: A Successful Approach to the Challenge of Pain
The simplicity of Myotherapy which involves neither drugs nor surgery is especially remarkable when the severity and disabling nature of many of the myofascial pain syndromes is considered. Persistent intractable pain will increasingly dominate a person’s life, leading to depressive behavior, economic deprivation and disruption of family dynamics. Therapeutic drugs often have undesirable side effects, and surgery is usually unsatisfactory for long term control of myofascial pain syndromes. In the continued search for treatment and relief of chronic pain, the patient encounters alternating cycles of hope and despair and eventually halts all expectation of ever being able to lead a normal life again. Thus, by the time Myotherapy has become a treatment option, (Myotherapists accept patients by physician referral), considerable emotional support may be needed to rekindle the motivation to get well. Yet, some 85% of our patients, regardless of their presenting problems, experience substantial pain relief over a short period of time and are able to resume productive lives. In our patient population, the median number of treatments is five. Most patients fall into a range of between three to ten sessions, with a few located at either end of the spectrum.
It appears that the required length of treatment depends as much on a person’s previous state of physical fitness and motivation to perform the prescribed exercises as on the severity and duration of the presenting problem. We also have found that certain medications, notably antidepressants, tranquilizers, muscle relaxants, and narcotics interfere with Myotherapy. Side effects of Myotherapy seems to be limited to occasional bruising and residual soreness. At this stage, Myotherapy is largely an empirical treatment modality, but given the similarities to other sensory methods of pain control, such as use of the TENS unit, acupuncture and trigger point injection, similar underlying neural mechanisms may explain their pain relieving effects. The uniqueness of the Myotherapy approach lies in the exercise component. Since the technique is not only comprehensive but also simple and relatively free of side effects, it is to be hoped that Myotherapy will find its place as a first line method for control of chronic pain syndromes.