This chapter is the review of the available literature concerning the theoretic content that is necessary to understand the trapezius muscle and its role in the symptoms associated with upper back pain. Particularly the issues about the types of trigger points, including a discussion of myofascial trigger point therapy and acupuncture trigger point therapy. More importantly the awareness and understanding on how to improve the quality of life by learning about the alternative options, making changes and applying self-help strategies on myofascial trigger points.
Given this points, a brief description of the topics are noted: It is painful to say that about 23 million persons, or 10 percent of the U. S. population, have one or more chronic disorders of the musculoskeletal system (Imamura, Fischer, Imamura, Teixeira, Tchia & Kaziyama, (1997). The most common reason for the breakthrough of pain and rigidity in the head, neck and shoulder is the development of myofascial trigger points (MTrPs) activity in those areas.
Factors responsible to set in motion trigger point in the muscles of the neck and shoulder region include postural disorders, drooping of the shoulder girdle, direct and indirect overloading of the neck muscles, acute trauma to the neck and anxiety (Baldry, 2002). For instance, the muscle most often affected by MTrPs is the trapezius muscle. Any position or task that requires the shoulders to carry out the weight of the upper extremities repeatedly or for prolonged periods of time overloads the upper trapezius muscle, and strongly boosts the development of MTrPs (Mense, 2001).
Incidentally, MTrPs extremely common and became a painful part of nearly everyone’s life at one time or another. ), the upper trapezius active MTrPs are common in patients presenting neck pain (Simons &Travell 1999). Surprising statistics suggested that neck pain has a lifetime incidence of 45%-54% in the general population (Fernandez-de-las-Penas, Alonso-Blanco & Mangolarra, 2007). Trigger points are tender to direct pressure or squeezing, they are painful and they are palpable as hard nodules. Rachlin, 2005). In fact, Simons &Travell (1999) has described pain due to TrPs is a cause of pain in all parts of the body and it has been reported as a source of pain in numerous medical conditions. Patients presenting mainly with upper body pain or headaches are more likely to MTrPs pain than patients presenting with pain located elsewhere (Rachlin, 2005). Indeed, therapy for MTrPs has been used by Bilkstad and Gemmell, (2008) with anecdotal success in patients with non-specific neck pain.
Gemmell and Allen’s (2008) study also proved that a session of trigger point therapy, has a clinical meaningful effects in the treatment of acute trigger points of the upper trapezius muscle. Certainly acupuncture for MTrPs is an effective and efficient technique for the treatment of myofascial pain and dysfunction. That is, an acupuncture needle is inserted through the skin and moved gently up and down through the MTrPs. The effect is to de-activate the trigger point and relax the muscle according to Travell and Simons (1999).
Furthermore, studies of neck pain have proposed that manipulation is an effective therapy, especially when combined with exercise (Rubinstein, Leboeuf-Yde, Knol, de Koekkoek, Pfeifle & van Tulder, 2008). Gatterman (2005) stated that chiropractic treatment of the spine has a relaxing effect on the spinal muscle and a loosening effect on spinal articulations, hence making a difference in a number of ailments drawn by cervical structure.
Historical Background Review Back to 1816, British physician Balfour, as cited by Stockman, described “nodular tumors and thickenings which were painful to the touch, and from which pains shot to neighboring parts” (Stockman, 1904 p. 107-116). In 1841, trigger points have been documented in western medicine research. In the European literature, regional musculoskeletal pain conditions have been documented since the 18th century (Reynolds, 1983). Dr. Janet Travell (1901-1997) is generally credited for bringing MTrPs to the attention of healthcare providers.
MTrPs have been described and rediscovered for several centuries by various clinicians and researchers as far back as the 16th century, de Baillou (1538-1616), Ruhmann (1940) described what is now known as myofascial pain syndrome (MPS). Bron & Dommerholt, ( 2012, p. 1) acknowledges, myofascial pain syndrome is defined as the “sensory, motor, and autonomic symptoms caused by Mypfascial Trigger Points”, and has become a recognized medical diagnosis among pain specialists.
The first trigger point manual was published in 1931 in Germany nearly a decade before Dr. Janet Travell became interested in MTrPs These early descriptions and other historic papers did illustrate the basic features of MTrPs quite accurately (Simons, 1975). In 1966, Dr. Travell founded the North American Academy of Manipulative Medicine, together with Dr. John Mennell, who also published several articles about MTrPs (Mennell, 1976-1989). In the early 1960s, Dr. David Simons was introduced to Dr. Travell and her work, which became the start of a fruitful collaboration eventually resulting in several publications, including the Trigger Point Manuals (Simons &Travell 1999).
The Trigger Point Manuals are the most comprehensive review of nearly 150 muscle referred-pain patterns based on Dr. Travell’s clinical observations, and they include an extensive review of the scientific basis of MTrPs. Both volumes have been translated into several foreign languages. These books are considered the definitive reference on myofascial pain and locating trigger points. Trapezius Muscle This diamond shape muscle is situated in the neck and upper part of the back and lies most superficially (Moore & Dalley, 2006).
It was given its name because the muscles of the two sides form a trapezium. The main action of the trapezius is to aid in head, neck and the clavicle movement. The trapezius commonly contains trigger points, and referred pain from these trigger points bring patients to the office more often than for any other problem. Figure 2. 1 shows the trapezius- a large kite-shaped muscle, covering much of the back and posterior neck. There are three main parts to the muscle: the Upper, middle, and lower part. Each part has its own actions and often different functions. Figure 2. 1 Trapezius Muscle
Namely the upper portion of the trapezius muscle laterally flexes the head and the neck towards the same side, and assists in extreme rotation of the head so that the face turns to the opposite side. It can draw the clavicle backwards and raise it by rotating the clavicle. It usually helps to carry the weight of the upper limb during standing, or support a weight in the hand with the arm hanging. Acting bilaterally, the upper fibers extend the head and the neck . The upper trapezius can reflect headaches on the temples, dizziness, severe neck pain, intolerance to weight on your shoulders.
While the middle trapezius reflects pain on the mid-back, headaches at the base of your skull and superficial burning pain close to the spine. On the other hand lower trapezius on the mid-back refers pain to the neck, and/or upper shoulder region (Simons & Travell, 1999). Figure 2. 2 Trapezius Trigger Points Myofascial Trigger Points The word myofascial means muscle tissue (myo) and the connective tissue in and around it (fascia). According to the most commonly accepted theory, a myofascial trigger point ( Figure 2. ) is an area of hypersensitivity in a taut band, or contraction knot of skeletal muscle with respect to pain (Simons, et al. , 1999), as opposed to healthy muscle, which does not contain taut bands or trigger point (Shah, et al. 2005). The trigger point feels like a pea embedded within the muscle to the touch. A trigger point is always tender and becomes painful, like contracted knots that refers pain and tightness upon direct compression and is mediated by a local twitch response (Hong, 2006; Simons et al. , 1999; Simons, 2004).
Auleciems (1995) furthermore researched the incidence of MPS, reported to be as high as 85% at certain American pain clinics. Figure 2. 3 Myofascia Trigger Point Taut Band Myofascial Trigger Point Development There are existing studies to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Many researchers concur that an acute injury or repetitive small injuries may lead to the development of a trigger point which creates some degree of tissue damage (Rachlin, 2005). The damage to muscle and connective tissue can befall several ways.
From lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems (Simons &Travell, 1999). Examples of predisposing activities such as typing/moussing, handheld electronics, gardening, home improvement projects, work environments, holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all (Simpson &McCarthy, 2001); sustained loading as with heavy lifting, carrying babies, briefcases, boxes, wearing body armor or lifting bedridden patients.
Injury from falling down stairs or whiplash injury in a motor vehicle accident (Lavelle, Lavelle, & Susti, 2007). Myofascial Trigger Point Classification Trigger points are classified as being active or latent. The active, painful phase of the trigger point is the one which motivates people to seek relief. The active trigger point hurts when pressed with a finger and causes pain around it and in other areas. (Hong, 2006; Simons, 2004). The active trigger point referral symptom may feel like a dull ache, deep, pressing pain, burning, or a sensation of numbness and fatigue.
If unaddressed or ineffectively treated, eventually other muscles around the dysfunctional one become stressed and develop secondary trigger points. It is not unusual for chronic pain patients to have multiple, overlapping referred pain patterns, making diagnosis and treatment more complex. Trigger points can also lie quietly in muscles, sometimes for years. This type of trigger point is called latent. Latent trigger points are very common. Probably one won’t know they are there for the fact that they cause pain unless it is compressed.
Latent trigger points cause restricted movement, distorted muscle movement patterns; stiffness and weakness of the affected muscle (Fricton, Kroening, Haley & Siegert, 1985). When firm pressure is applied over the trigger point in a snapping often causes the muscle to “jump” or briskly contract a “local twitch response” (Simons & et al. , 1999). The reaction of a twitch response during palpation of a trigger point, or during a trigger point release procedure, is a reliable confirmation that the trigger point has been accurately located.
When a trigger point in one muscle can create pain in another area it is known as referred pain. This referred pain is felt not at the site of the trigger-point origin, but remote from it (Mense &Schmit, 1977). For example (Figure. 2. 4), a primary trigger point in the upper trapezius muscle refers pain to the temple region of the head. All muscle tissue is potentially prone to developing trigger points. Fig. 2. 4 Referred Pain from Trapezius Trigger Points Treatment of Myofascial Trigger Points As a matter of fact treating each trigger point is relatively simple.
Treating the whole myofascial pain syndrome so that pain fully goes away is a more complicated process. Pharmacologic treatment of patients with chronic muscle pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, anti-inflammatory drugs are often prescribed (Imamura et al. , 1997). The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available. No laboratory test or imaging technique has been established for diagnosing trigger points (Fricton et al. , 1985).
However, the use of ultrasonography, electromyography, thermography, and muscle biopsy has been studied. A variety of hands-on skills, such as stretching, massage, manipulation, mobilization and strengthening (Simons, 2002), and a wide variety of modalities namely, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid heat, ice, ultrasound, electrical stimulation, mechanical pressure and light energy, are available to physicians and therapists for the treatment of trigger points (Edward &Knowles, 2003).
For instance trigger point therapies can help specifically a number of health issues such as: 1) Relieve migraine and headache 2) Alleviate low-back pain and improve range of motion Ease dependence over the counter or prescription medication 3) Release endorphins that work as the body’s natural painkiller 4) Enhance immunity by stimulating the body’s natural defense system. 5) Increase blood flow to bring oxygen (Dommerholt & Huijbregts (2011, p. 18 ).
The proposed principle of treatment of MPS is to inactivate the active MTrPs through the use of various therapeutic modalities (Hong, C. 2000). However, the various treatments are beyond the scope of this study, the main focus here is to determine the efficacy of acupuncture and myofascial trigger point therapy for upper back pain. Acupuncture Trigger point pain may result from old or new injuries, excessive work out, incorrect body mechanics and poor body posture.
In this light, acupuncture treatments can help return the balance to muscles. It is one of the safest ways to address physical problems. Using FDA-approved grade of acupuncture needles, it stimulates the muscle fibers, generating involuntary twitching of muscles located on the suspect trigger point (Figure 2. 5). Usually leads to an immediate reduction of the tightness as well as a reduction or elimination of the related problems (Scholar & Hong, 2000. Aside from relieving muscles from stress, acupuncture treatment releases endorphins, boosts the nervous system, enhances the immune system, and causes a number of other biochemical and hormonal changes (Napadow, Webb, Pearson, et al. , 2006). Acupuncture is a time proven and safe method to optimize health. In restoring balance to brain and nervous system functions, it helps regulate blood pressure, blood flow and body temperature, which is indirectly beneficial to managing and relieving body stressor (Birch, Hesselink, Jonkman, et al. , (2004).