Myofascial Pain Treatment - Brisbane MSK Clinic

What is Myofascial Pain Syndrome?

Myofascial Pain Syndrome involves localised musculoskeletal pain and fascial trigger point tenderness, which a myofascial release therapist aims to treat. Research has consistently shown links or the presence of myofascial trigger point involvement in myofascial pain conditions, such as Myofascial Pain Syndrome. It is widely agreed in the research community that the primary causes of trigger point formation are likely injury and overuse, which are both forms of trauma. However, there may be other possible causes, such as lack of use or misusing tissues (effectively another type of trauma). Changes to soft tissue structures within the fascial network caused by the trauma and corresponding necessary soft tissue adaptations, can then restrict mobility and result in myofascial pain.

What is fascia and why is it relevant?

Fascia can be found throughout the human body and does not look too dissimilar to cotton wool or spider silk under magnification. It is a densely woven collagen fibre matrix that is understood to penetrate every tissue within the body and cover muscles and organs _[1,2]. Fascia is a form of connective tissue and, as per the name, connects structures throughout the body. There are also specific deep and superficial layers of fascia, which aid with functional movement, support structures within the body and provide stability _[3]. Without fascia, our muscles would lack their distinctive shapes. In normal circumstances, the properties of fascia mean it is a smooth, translucent, slippery, well-hydrated and durable material. However, such properties can change, which has consequences for musculoskeletal mobility and pain. The anatomist Tom Myers has been conducting work on fascia and the fascial network for over 20 years. During his research, Myers identified multiple specific facial lines that support our functional movement: the superficial front and back lines, lateral lines, spiral lines, arm lines, functional lines and deep front lines. There are at least four distinctive "solid" fascia types, each providing a different function, including the inter-structural, spinal, structural and visceral, often classed as solid fascia. However, a more recent concept is liquid fascia which includes blood and lymph _[4].

It is relatively easy to see fascia within a piece of raw chicken breast or other meat. A chicken breast typically has a thin translucent fascia portion between the breast meat and the tenderloin. Research also indicates that fascia thickness, density and stiffness vary throughout the body and tend to be thicker in areas likely to experience increased load _[5]. In many respects, it would appear that fascia can remodel, much like bone (Wolff's Law) and other soft tissues (Davis's Law), see the article on Soft Tissue Adaption for further details. Equally, there is evidence of fibroblast cells within the fascia, which are involved in injury repair _[6]. There is also a good deal of research supporting the notation that fascia operates as a global bodily communication system, which has relevance to Myofascial Pain Syndrome and the treatment of many other conditions. Research shows that fascial tissues contain a high density of nerves (neurons) and tiny tubes or a primo vascular system _{[7, 8]}. Hence, possible communication paths may include tensional, neurological and biochemical (including hormones). The global combination of potential communication methods has implications for the possible causes of myofascial trigger point formation, pain and treatment. Hence, the importance of taking a holistic approach to assessment and treatment cannot be understated.

As with various tissues and structures within the body, things can stop working normally. The fascial network supports, facilitates and even makes functional movement more efficient with elastic recoil. Elastic recoil enables a variety of soft tissues, including fascia, ligaments, tendons and muscles, to store energy for later use, much like an energy recovery system in a car. Without elastic recoil, muscles would consume more energy for the same level of effort and fatigue far more quickly, impacting our endurance capabilities. A kangaroo is an excellent example of an animal using the principles of elastic recoil to bounce along at high speed, for long durations, in hot climates and over varied terrain, seemingly effortlessly. The ability of soft tissues to store energy also has implications for the treatment of soft tissue injuries, rehabilitation and training in general. Elastic recoil is easily seen by pulling the skin and then letting it go again, much like an elastic band. However, some conditions can negatively impact the elastic recoil properties of tissues. Primary human movement requires multiple muscles and layers to either contract, relax or stabilise for any given movement. Also, muscles have different origins, insertions, or attachment points, e.g. from "a to b" in the simplest muscles. The section about Soft Tissue Release (STR) explains muscle origins and insertions more.

For tissues, including individual muscles, to move normally and not interfere with the function of other muscles or structures, surfaces need to glide without restriction. When fascia works normally, it is similar to a well-oiled and slippery surface, reducing friction and enabling unhindered movement. The cosmetic industry is constantly advertising products with hyaluronic acid, effectively the "oil" enabling fascial surfaces to glide over one another _[9]. Fascia conveniently separates muscles into separate bags or compartments, allowing each muscle to glide over the next without problems. However, fascia can become dysfunctional, impacting how muscles glide over each other. Parts of the fascia can become sticky, increasing friction between structures. The stickiness of fascia then affects other tissues and mobility and often leads to myofascial pain, including Chronic Pain (see the related article about Chronic Pain treatment). Myofascial trigger points can also form within skeletal muscles and result from small sections of muscle fibres becoming stuck (see later). Myofascial release techniques work in different ways and aim to free such "stuck" areas of tissue to provide pain relief and increase mobility.

There are various theories as to why fascia can become dysfunctional, including overuse (including postural fatigue), lack of use (activity levels), lack of hydration, specific medical conditions, trauma, diet, hormones and age. In many respects, much like anything with moving parts, things tend to deteriorate more without use and maintenance. Equally, a wealth of research demonstrates the benefits of an active lifestyle in preventing a range of developed world health problems. Hence, it is no surprise that movement or lack of movement may have possible consequences for the fascial system, solid and liquid.

The Kinetic Chain and Fascia

Kinetic Chain theory is a concept from engineering and is sometimes called the kinematic chain dating back to the early 1800s. The theory examines human movement as rigid lever structures (bones) and how these work with joints and muscles to create an overall movement chain. Hence, mobility in one area of the chain can impact the rest of the chain. These segments or sections form a kinetic chain when one moves. The theory is that if all parts of the chain operate correctly or normally, one tends not to experience pain, discomfort or restricted mobility. If tissues, joints or other structures are not functioning correctly, this can affect how a specific segment moves and general mobility. Logically, if one section is not working correctly (as in a spinal fusion), it would soon lead to other areas in the kinetic chain also encountering problems. However, sometimes such surgeries are the only option to stabilise structures after trauma. The image shows the basic idea of the kinetic chain sections or joint structures, yet human movement is far more complicated:-

• Cervical Spine (Neck)
• Thoracic Spine (Upper Back)
• Lumbar Spine (Lower Back)
• Hips
• Knees
• Ankles

The body is extremely good at adapting to avoid pain, so it may take a while to notice changes to the kinetic chain. Mechanically, the kinetic chain concept makes a great deal of sense and dysfunction in one area of the kinetic chain can affect both sides of the body and not just (higher) or (lower) than the affected segment or side. Research into the roles of fascia in general movement and the identification of specific supportive fascial lines have implications for the simplicity of the "kinetic chain". Tom Myers (the anatomist) has noted that the fascial lines/meridians he has identified perform different supportive functions and that dysfunction in one area can impact other areas. The theory of these myofascial meridians builds on aspects of the Kinetic Chain theory. Research suggests that most skeletal muscles within the human body are connected via connective tissues, forming a myofascial chain _[10]. Myofascial meridians/chains appear able to transmit forces along their length, yet there is little research covering these lines' actual relevance or role. Equally, research has identified myofascial meridians connecting the neck, shoulders and forearms, though there is little research on the mechanical relevance _[11]. However, there is a great deal of logic to how these meridians have relevance for movement, injuries, treatment and rehabilitation.

Besides Myofascial Meridians, there are at least two other theoretical fascia models, Fascintegrity and Biotensegrity _[12]. Fascintegrity considers the relevance of solid and liquid fascia. In contrast, Biotensegrity takes a more mechanical view of fascia, and myofascial meridians are more concerned with force transmission and movement, as already discussed. The article on Biotensegrity takes a much more detailed look at how changes in one body area affect another. Equally, although some view Biotensegrity as only relating to solid fascia, logically, any shape changes could impact liquid fascia, creating restrictions, increasing pressure etc. The changes during pregnancy are a great example of Biotensegrity and tissue adaptation in action (see Biotensegrity in Pregnancy diagram). Sections of the "kinetic chain" above and below the pelvis adapt to changes in weight distribution. Such global bodily changes would not make sense by purely taking a kinetic chain theory approach. Equally, myofascial trigger points within tissues can impact multiple body areas due to the resulting changes in the fascial network.

Often a symptom of an injury or problem is not the reason for symptoms, as might be the case with Achilles tendon pain. Typically, one might self-treat the area of pain and the Achilles Tendon, which seems to make things feel better or worse. Failing to treat the reason for symptoms often leads to further injuries at a later date or seemingly unrelated injuries later. We have all met or know somebody who seems plagued by injuries and continues to try and resolve everything on their own. Equally, just because one specific self-treatment technique worked for one person does not mean it will work for another. No two injuries are the same due to many individual factors, so no two people should be treated with the same standard treatment, and personal factors need consideration. As good as the evidence is, research has limitations, so strictly working in an evidence-based way rather than being evidenced informed can lead to mixed patient outcomes.

Is myofascial pain a nerve pain?

Research now suggests that fascia is a sensory organ full of nerve endings, and fascia plays an important role in myofascial pain. Although sensory pain information is often transmitted via nerves to the brain for interpretation, there are other ways the body can communicate. Myofascial pain is not the same as general nerve pain and feels different and more of a deep muscular aching type of pain. Nerve pain is typically sharp, shooting, stabbing, tingling, burning, electrical or a dull aching feeling. For example, sciatic pain might shoot from the lower back, down the leg, to the foot or toes.

Can MRI detect myofascial pain?

Modern MRI cannot detect myofascial pain as such, as pain interpretation occurs in the brain. Hence, although it may be possible to see areas associated with pain perception light up in the brain on MRI, this provides little detail on why or where the pain is. However, a vast amount of research shows evidence of myofascial trigger points within the skeletal muscle tissues of people experiencing myofascial pain. Although historically, trigger points were not visible on MRI, it was always possible to feel the telltale signs within skeletal muscles. With advances in MRI and other imaging techniques, it is now possible to see myofascial trigger points. Evidence also shows that effective treatment of such trigger points reduces pain and symptoms. It is debatable whether myofascial pain is the same as a trigger point, but they are intrinsically linked.

What are Myofascial Trigger Points (MTrPs or TrPs)?

The generally accepted definition of Myofascial Trigger Point includes terms such as a palpable taut band of hyperirritable skeletal muscle _[13]. Trigger Points are small sections of taut fibres (sarcomeres) within the muscle tissues and the fascial network. These taut bands become stuck in a contracted state, affecting the overall muscle function and typically resulting in referred pain or discomfort. The exact cause or etiology of trigger point formation is not fully understood, though there is some consensus that direct trauma and muscle overuse may play a part. Several studies have also shown Neuromuscular junction involvement with the motor neuron axon and the connection to the muscle fibre. Such studies have noted an association between excessive acetylcholine levels, causing "end plate" noise and myofascial trigger points _{[14, 15]}.

The following diagram represents a typical skeletal muscle and a magnified section of muscle fibres. Trigger points are not visible to the human eye, and the shaded muscle area illustrates the concept. However, one might feel a knotted sensation, with or without pain. The thin and thick muscle fibres are visible in the diagram. One can also see evenly spaced sections (sarcomeres) in the unaffected fibres. Affected fibres have small blob-like or bulging areas and uneven sarcomere spacing. In many respects, it is as if the sections in the affected fibres have become glued together. These bulges will change tensional forces within the affected muscle fibres and alter the pressure on surrounding structures. These microscopic changes result in a larger affected area or a trigger point (TrP). The tiny changes within the muscle fibres and the trigger points impact overall biotensegrity (see related articles later). Research has shown a relationship between trigger points and many types of headaches, and migraines (see the article on headache pain treatment). Equally, there is evidence for treating headaches and migraines with specific myofascial release techniques.

There are also different types of Trigger Points , latent and active. People tend to be aware of active trigger points, as one can feel muscular pain in an area, which may refer elsewhere in the body when pressed. One can also often feel the taut bands of tissue or what some might call "knots". Latent trigger points are also taut bands, though they tend not to cause pain or symptoms when pressed. Hence one may be oblivious to their presence. However, taut bands within tissue structures will subtly affect mobility in some shape or form. Trigger Points can occur for many reasons, including trauma, habits and more. The articles on Tissue Healing/Soft tissue repair, Adaptation, and Biotensegrity are hugely relevant.

Controversial history of Myofascial Trigger Points

The concept or existence of trigger points has a somewhat controversial history. Part of the issue is that TrPs are not visible to the human eye and historically could not be seen on imaging (x-rays, CT, MRI and Ultrasound). Hence, General Medicine held the view that TrPs do not exist. However, it is possible to feel the telltale signs of TrPs within soft tissues. Soft tissue therapists and bodyworkers have always known about TrPs, though under different names throughout the history of manual therapy. Many soft tissue structures and related issues do not show up on imaging. The presence or absence of pathology on an image may or may not indicate the root cause of a problem. Many people seeking routine imaging for unrelated conditions have disc or back-related pathologies and no symptoms. Equally, imaging for somebody with back pain may prove inconclusive as to the reason for symptoms (see article on Lower Back Pain). In other cases, imaging can highlight an obvious root cause. Diagnostic ultrasound and MRI imaging have improved dramatically over the years and can now show more soft tissue structures. Research has even demonstrated the presence of trigger points in the upper trapezius muscle of migraine sufferers, using T2-weighted MRI _[16]. Magnetic resonance elastography (MRE) imaging has shown that trigger points are visible as areas of increased muscle stiffness _[17]. It has also been possible to indicate the presence of trigger points within muscle tissues using Diagnostic ultrasound _[18]. Magnetic resonance elastography (MRE) imaging has shown that trigger points are visible as areas of increased muscle stiffness. It has also been possible to indicate the presence of trigger points within muscle tissues using Diagnostic ultrasound. Besides changes in muscle stiffness, other ultrasound-based research has shown differences in vascular supply with trigger points _[19], which is logical given that the muscle fibres are contracted and compressing areas of tissue. Other research using ultrasound and thermography has noted differences in the temperature of trigger points (warmer) and the immediate surrounding area (colder), again suggestive of vascular changes _[20]. Biochemical analysis of active trigger points indicates a difference in biochemical makeup compared to normal tissues _[21]. Hence, although trigger points have a controversial history, it is now hard to refute the overwhelming evidence for their existence.

Is massage good for myofascial pain?

Massage is a generic term covering a massive range of soft tissue therapy techniques. There are also huge variations in the levels of training, education and experience that therapists working in the massage industry may have. Some massage therapy techniques may worsen symptoms, while others can be beneficial. Anybody can call themselves a massage therapist with little to no training. Equally, many unique individual patient-specific factors can play a part in myofascial pain symptoms. Such factors are also likely to affect which types of myofascial release techniques are most suited to the patient's unique circumstances. Two people may have the same diagnosed condition but respond differently to a specific treatment method.

Does stretching make myofascial pain worse?

Stretching can worsen myofascial pain due to the presence and relevance of myofascial trigger points. Although myofascial trigger points are not the same as muscle spasms, there are some similarities. Both involve sections of muscle fibres effectively becoming stuck in a shortened state to varying degrees. Stretching or pulling on these tight areas can result in additional trauma and pain at the time or often later as the inflammatory response kicks in. Generally, it is best to avoid stretching and even some soft tissue therapy techniques.

Do muscle relaxers work for myofascial pain?

The general medicine approach to myofascial pain may involve a combination of medications, including muscle relaxants, analgesics, anti-psychotics or anticonvulsants. Although such drugs may help manage pain levels and muscle spasms where relevant, they have a limited impact on the cause. However, such drugs may improve sleep quality for people who experience myofascial pain syndrome or similar conditions such as fibromyalgia. Myofascial pain can also greatly impact our quality of sleep, and research has shown direct links between sleep duration, quality and our perception of pain. Effectively, less sleep, and we perceive higher levels of pain, and often there is a cumulative effect in chronic cases.

How do I fix Myofascial Pain?

The best option is to see a professional in the first instance. There are many possible causes of myofascial pain, and taking the wrong approach can make things instantly feel worse or better and then worse later. There are still some self-help treatment options, but it is all guesswork if you don't understand what you are treating or the limitations of various techniques. Although the internet may provide details of possible symptoms, it cannot replicate a professional's detailed consultation and assessment process, the relevant testing and history taking needed to gain complete insight into the root cause of the problem. Occasionally, using a specific technique is unwise or even dangerous (contraindicated).

All the evidence suggests that myofascial trigger points and associated myofascial pain result from trauma or overuse. Excessive tissue loading or overuse can also occur from stress, poor work setup, even sleeping position and a lack of adequate support. Countless studies have shown how movement and general activity have wide-ranging physical and mental health benefits. Although the human body can hold set positions for periods, doing so requires sustained isometric muscle contractions, which are unnatural and clearly have consequences. Movement is relevant for moving various fluids around the body, which is relevant for normal bodily maintenance functions. However, modern-day life often involves people sitting or performing tasks which involve maintaining a set position for extended periods, resulting in muscle overuse. Hence, the best way to fix myofascial pain is through a combination of prevention strategies and seeking treatment early when required. Once symptoms appear, preventative strategies have limited effect, and some such strategies can worsen things. Some common strategies might include:-

• Taking breaks
• Moving more
• Strengthening muscles (Resilience to demands)
• Self-stretches
• Self-treatment (SMFR) where applicable
• Creating an ergonomic work setup
• Adopting a good supportive sleeping position
• Managing stress

The following articles have relevance to preventative strategies relevant to stress, ergonomic computer setup and adopting a good and supportive sleeping position.

• Ergonomic Computer Setup back and neck pain prevention
• Sleeping position and pillow height
• Stress, the Individual, Wellbeing, Performance and the human stress response (Part One)
• Stress, the Individual, Wellbeing, Performance, the effects of stress on bodily systems (Part Two)
• Stress, the Individual, Wellbeing, Performance and stress, coping strategies (Part Three)

Spasms and myofascial trigger points tend not to respond well to being stretched, even if it may seem good or bad while performing the stretch. Self myofascial release (SMFR) techniques can prove helpful when used in the correct circumstances. It is essential to understand the restrictions of any technique and avoid going beyond them. Applying techniques in a self-treatment context creates additional limitations that affect technique application, tissue accessibility and a range of other challenges. It is usually best to avoid SMFR in the acute stages of myofascial pain, as it might be another condition or, in chronic cases, where symptoms are easily irritated. Sometimes heat, such as a warm wheat bag or similar, can help relieve muscle spasms and myofascial pain to some extent. SMFR can work exceptionally well as part of a self-maintenance strategy.

• Foam Roller Myofascial Release
• Self Myofascial Trigger Point Therapy using a Massage Ball
• Self Myofascial Release (SMFR) Legs - Spiky Massage Ball

Myofascial Pain Relief - Treatment and Techniques

• Dry Needling - DN
• Soft Tissue Release - STR
• IASTM - Instrument Assisted Soft Tissue Mobilisation
• Gua Sha treatment
• Muscle Energy Technique - MET
• Neuromuscular Therapy - NMT
• Positional Release Technique - PRT