about trigger points

8/13/2019 About Trigger Points

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About Trigger Points

WHAT IS A TRIGGER POINT? A trigger point is a highly sensitive nodule in an unusually tautband of skeletal muscle. It normally occurs near the middle of the fiber at the motor end plate

junction (where the motor nerve contacts the muscle). This nodule is a knot of contractedsarcomeres,that is, an area where many sarcomeres bunch closely together, leaving thesarcomeres in the rest of the fiber stretched out, which causes the tension. Although triggerpoint may not initially strike the reader as a term of science, the condition is now well!characteri"ed and the term is accepted in medical te#ts.

TRIGGER POINT FEATURES.

$AI%&' A% *+*$TI*, -'T *ATI*/ *A0/ T1 T*AT. This special condition ofmuscle tissue causes a great number of people a great deal of pain. 'nfortunately trigger points

remain unnoticed unless the e#aminer is aware and specifically looking for them. They deceive inpart because they are hidden from easy observation. (2achines in a typical doctor3s office can3tdetect them.) They also deceive because the pain they cause is most often felt at anotherlocation. $ain perceived at a distance from its actual source is known as referred pain. -utonce trigger points are located (usually through range of motion testing and palpation) they areamenable to treatment through relatively simple procedures, such as manual pressure,speciali"ed stretch techni4ues, acupuncture!style needling, and injection.

$AI% *&*A. 567 of trigger points refer pain to another location in the body. *ach triggerpoint produces a characteristic pattern of referred pain, that is, a pattern generally unlike oneproduced by trigger points in other muscles, or even trigger points in other fibers in the samemuscle. Accordingly, knowledge of muscles3 typical pain referral patterns helps greatly indetermining which muscle, and sometimes even which part of a muscle, is involved.

*0TI+TI1% 1& 21TI1% A% $10T'*. -eside creating referred pain, the other key actionof trigger points is to restrict the length to which the affected muscle can e#tend. This means thatthe motion of that part of the body becomes restricted or stiff. Thus a trigger point in the leftlevator scapula muscle can prevent the neck from turning very far to the right. In severe casesthe neck becomes immobili"ed. Trigger points in certain fibers of the gluteus ma#imus musclecan prevent the individual from bending over very far at the hip, and, in addition to causing hippain, may cause a distortion of posture in which the hip becomes rotated backward. Any part ofthe body can stiffen and lose its mobilitybecause of trigger points.

1T8* 0/2$T120. 0ometimes trigger points causes paresthesia (numbness, tingling or aburning sensation). +ertain trigger points can cause di""iness and unsteadiness rather thanpain, which is especially detrimental to the elderly.

+1%&I2I%9 0I9%0. irect pressure on a trigger point often recreates pain that the subjectidentifies as 3their pain3. This reaction confirms the relevance of that point. 2anual plucking ofthe taut band of muscle in which the trigger point lies often produces a local twitch response,which provides another useful confirmation.

:*/ A% 0AT*IT* TI99* $1I%T0. Trigger points can influence each other and havedependency relationships. In other words they are sometimes arranged in hierarchies in whichsome, which are called key trigger points, cause or perpetuate others, which are called
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satellite trigger points. In this situation the clinical picture is more comple#. 0ometimes, fore#ample, disabling a key trigger point will simultaneously disable dependent satellite triggerpoints that have been causing additional pain according to their own referral patterns. 1n theother hand, treating only a satellite trigger point may bring no lasting relief as long as anundiscovered key trigger point in some other muscle keeps reactivating it.

TRIGGER POINTS ARE NOT IMAGINARY. The reality of trigger points is evident to anyonewho has had pain 4uickly relieved by a simple trigger point treatment. &or skeptics !! whichmeans most people who3ve never had such treatment !! the reality of trigger points has beendemonstrated by sensitive instruments that can photograph the abnormal structure of the muscleat the trigger point, and instruments capable of measuring their unusual biochemical and micro!electrical signatures. &or e#ample, Travell and 0imons (;


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Trigger points can be latent or active. An active trigger point causes pain and restricts motion.This pain may be merely annoying, or it may be severe, e#cruciating, debilitating, or evenparaly"ing. A latent trigger point restricts the range of motion of the affected muscle but does notcause pain within this restricted range. This restricted motion is usually e#perienced as stiffness.

atent trigger points are painful when directly pressed.

T8* -A %*D0 about latent trigger points is that, over time, they create uncomfortablepostural distortions !! such as rounded, hunched or uneven shoulders, protruding head, abnormalcurvature of the spine, twisted hips, rotated sacrum, functional lower leg length ine4uality,e#cessive pronation of the feet, etc. These effects result from the individual unconsciously tryingto avoid pain= over time he or she builds postural and movement habits that avoid bringing themuscle beyond it3s restricted range, which is painful. In this way latent trigger points become thesource of dysfunctional posture that seems impossible to change. They are the source of muchof the decrepitude and discomfort of old age, for we tend to accumulate latent trigger points as weget older. 0imilarly, athletes and dancers who try to stretch out stubborn restrictions in movementare usually unknowingly wrestling with latent trigger points.

T8* 911 %*D0 is that latent trigger points can be cleared up just like active trigger points.Dith careful and accurate therapy posture improves and ease of movement returns !! withoutforcing stretches that may be too painful to bear. This aspect of trigger point therapy is obviouslyimportant for older people who may think they are doomed to shuffling around, or for anyone withsigns of incipient decrepitude. It is also useful for younger people, especially dancers andatheletes, 4uite apart from any pain condition, because movement becomes more fluid.

W"!t #!uses Trigger Points?

THERE ARE SE$ERA #AUSESof trigger points. These include direct trauma (an accident orinjury), unusual e#ertion and repetitive strain. irect trauma involves impact, as from a fall, or anautomobile or skiing accident. 'nusual e#ertion results from sudden effort, such as picking up aheavy bo#, or pulling hard on something that is stuck. epetitive strain trigger points, on theother hand, come from less intense use (or misuse) of a muscle that adds up over time.*#amples include habitually reading in a position that stresses the neck muscles, holding amusical instrument imperfectly, habitually slumping over a computer, or bending over to cut hairall day. The repetitive strain category also includes abnormalities in the skeleton that activate

certain muscles inappropriately, such leg length ine4uality or 2orton3s &oot.

#OM%INATIONS OF #AUSES. Trigger points fre4uently arise from a combination of thesecauses. A person may have a whiplash injury from a car accident (trauma) and then, months oryears later, develop terrible headaches following e#cessive work at the computer (repetitive


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strain). An initial injury, in other words, can set the stage, making the person more prone todevelop trigger points from later stresses.

SYSTEMI# #ONTRI%UTING FA#TORS. 9reat emotional stress, inade4uate nutrition, infectionsand endocrine system imbalances are other factors known to encourage development of triggerpoints, and to perpetuate them once they are established (Travell and 0imons ;


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o people not in doctor3s offices have trigger points tooG

(E) In one study cited by Travell and 0imons, >< student nurses were e#amined for the presenceof trigger points in various jaw and neck muscles. In the four different jaw muscles tested triggerpoints were found in 6E7, E67, EC7 and EB7 of the individuals. In the three neck musclese#amined trigger points were found in C67, CC7 and E7 of them. (This study did not

distinguish latent from active trigger points, but Travell and 0imons note that some were probablyactive because some individuals had pain in the referral areas.)

(6) In another study of five lower back and hip muscles in ;BB asymptomatic individuals, latenttrigger points were found in a high percentage= 4uadratus lumborum E67, gluteus medius E;7,iliopsoas E7, gluteus minimus ;;7, piriformis 67.

(>) /et another study considered the age of patients with fibrositis syndromeH. Travell and0imons note that

The greatest number were between C; and 6B years of age. These data agree wtih ourclinical impression that individuals in their mature years of ma#imum activity are mostlikely to suffer from the pain syndromes of active myofascial Tr$s. Dith the reducedactivity of more advanced age, the stiffness and restricted range of motion of latent Tr$s

tend to become more prominent than the pain of active Tr$s. (ol.;=;E).

/ounger people also have trigger points that can cause debilitating pain. These cases are morelikely to be caused by a specific traumatic incident, such as a car accident or twisting the neck thewrong way while making some muscular effort. As people age they tend to accumulate latenttrigger points left over from the various insults that an active life visits on the body. Then whennew trauma occurs, or repetitive strain builds up, they are much more suspectible to a triggerpoint that can cause serious and perhaps long!lasting pain.

H &I-10ITI0= Travell and 0imons consider the term fibrositis

An outmoded term with multiple meanings. 2any authors in the past used it to identifywhat were myofascial trigger points. 1ther authors have used the term very differently....De avoid using the term because of its ambiguity.

1ne of the problems that historically kept medical science from systemati"ing knowledge abouttrigger point pain was theproliferation of terms for the condition.Top of $age812*

Wi)) Trigger Point T"er!*+ He)* 'it"

+our P!in?

A #OMMON SOUR#E OF PAIN. 2odern medicine has many important results to its credit and Iam an admirer. -ut many people have had pain that couldnt be resolved by their doctor orchiropractor. Dhile pain from inflamation is often treated successfully with ibuprofen and relateddrugs, many common pains are not inflammations. ather their source is a condition in muscle
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tissue known as a trigger point. Trigger points can be treated by manual therapies that don3tre4uire drugs, surgery, or injections. ($hysicians can resolve trigger points by injection if theyknow how to locate them.)

TYPES OF PAIN. Trigger point therapy is effective for a great variety of pains, but not all. 8ereare some markers that help distinguish trigger point pain=

!! If pain is from a specific incident or has built up over time (and is not in the gut), triggerpoint therapy will probably help.!! Trigger point pain is usually of the dull aching variety rather than stabbing or throbbing.0ome trigger point pain, however, is stabbing, as lower back pain from trigger points inthe 4uadratus lumborum can be, or neck pain from twisting the head when there aretrigger points in the levator scapulae. In the event of throbbing pain one should see aphysician.!! Trigger point pain entails less freedom of movement in the part of the body which is

affected.!! $ain from trigger points generally increases when you strain the involved muscle. Thusit often gets worse as the day goes on. -ut note that sleeping in certain positions alsoputs stress on important muscles. Therefore trigger points can cause you to wake up tooearly, or wake up with a backache, pain in your neck, etc.!! If the pain is accompanied by swelling or redness you should consult a physician, not atrigger point therapist.!! If the pain is accompanied by tingling sensations it would be logical to think of aneurologist, but trigger point therapy can often help in these cases too. &or e#ample,unusually taut muscles caused by trigger points can pinch nerves. And, as noted in the1ther 0ymptoms sectionin the About Trigger $oints page, trigger points in somemuscles do cause numbness, tingling and even burning sensations.

8eadaches, even ones you3ve had for ;B or B years, can usually be treated effectively with

trigger point techni4ues. 8eadache treatments alone would be enough to make all the work andresearch that has gone into developing trigger point therapy worthwhile. -ut on the other hand,trigger point treatments for low back pain, hip pain, shoulder or neck pain would also make all thisresearch more than worthwhile. The list is long.

EFFE#TI$E THERAPY FOR SE$ERE PAIN. Trigger point pain, whetherreferred elsewhereornot, can be severe J so severe that a person bends over and cant straighten up, so severe thathe or she cant walk or type. In e#treme cases trigger point pain has led people to considersuicide. -ut despite the occasional severity of trigger point pain, despite that fact that manypeople may have endured it for years, it is usually not difficult to treat by a skilled practitioner

using one or more manual techni4ues.

TRIGGER POINT THERAPY USUAY WOR(S ,%UT NOT AWAYS-. $eople can suffer agreat deal of pain following candida and other infections, cancers, organ dysfunctions, allergies,metabolic disorders, and other systemic conditions. Dhen such conditions are present
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myofascial trigger point therapy can often help (because myofascial pain is part of the overallpicture), but does not offer to cure the underlying condition. A good trigger point therapist canusually !! though not always !! make the patient more comfortable (but sometimes not even that.)

These caveats being stated, it3s fair to say that trigger point therapists substantially help mostpeople who come to them. Although non!physician trigger point therapists cannot resolve serious

medical problems, what they can do, and what they are especially good at, is relieving pain thatseems to have no identifiable medical cause. 1ften they succeed in getting rid of pain enduredfor years that has not yielded to a variety of medical specialities. &or the treatment to take fulleffect patients often need to take action themselves, for e#ample, doing recommended stretchesor improving posture during certain activities. All trigger point therapists I have talked to reportoccasionally achieving total relief for seemingly difficult pain !! pain perhaps endured for months!! in just one treatment. I3ve certainly seen this happen in my practice. -ut in most cases severaltreatments are re4uired.

FAST SAFE AN& &IAGNOSTI#. Trigger point therapy usually gives at least partial relief4uickly, surprising most patients. This means that both therapist and patient understand early onwhether further trigger point work is appropriate. This knowledge can save time, money andworry. In addition to its 4uick action, trigger point therapy won3t harm you (when done by aproperly trained practitioner). This outstanding safety profile is an important feature of triggerpoint therapy.

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Ho' &oes Trigger Point T"er!*+Wor/?

#OMPONENTS OF TRIGGER POINT THERAPY.

Trigger point therapy, as practiced by +ertified 2yofascial Trigger $oint Therapists, has threebasic tasks. *ach component can be simple or comple#=

;. ocatethe trigger points causing the patient3s pain andKor other symptom.. *liminatethese trigger points.C. 8elp eliminate perpetuating factors. This means determining if the patient has habitsthat are perpetuating his trigger points and counseling him or her how to change orimprove them.

0. O#ATING TRIGGER POINTS.
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&12 T8* $AI% *&*A $ATT*%. *#pensive scanning and testing e4uipment is of littleuse in locating the trigger points causing the pain problem. The necessary detective work isaccomplished with direct observation and testing. The most important indicator is the painpattern itself. As noted in the section on trigger point characteristics, each muscle trigger pointlocation has acharacteristic pain referral pattern.

&1 *LA2$*, if the patient has a severe headache behind the eyes it is probablycaused by a trigger point in the sternal division of the sternocleidomastoid muscle. esscommonly, it could be caused by a trigger point in the temporalis muscle, one in theupper portion of the splenius cervicis muscle, or even from one in the masseter, thesuboccipitals or a couple other muscles. 'nless you are an orthopedist or physicaltherapist this list of muscles that can refer pain behind the eye may sound overlytechnical and boring. That3s because good trigger point work, though not boring, istechnical. ocating trigger points re4uires precise knowledge of anatomy and the painreferral patterns.

&12 A%9* 1& 21TI1%. The second method used to track down the source of pain is rangeof motion testing. As noted in the section on trigger point characteristics, a trigger point prevents

the full e#tensionof the affected muscle. Arranging the patient3s body in specific postures, thetherapist tests the range of motion of the various muscles that are likely to be involved and noteswhich which ones restrict movement the most.

A% *LA2$*. +onsider a patient with pain in the front of the upper right thigh one thirdof the way to the knee. &rom the pain pattern the muscles most likely harboring triggerpoints are the psoas and the vastus intermedius . (%ote that although the pain reported ison top of the rectus femoris rather than on the psoas or vastus intermedius, the rectusfemoris is not a likely candidate because it typically refers pain to the knee). ange ofmotion testing usually gives a good indication whether the psoas or the vastusintermedius is the more likely source of pain. Thus if the patient cannot lunge wellforward on his left leg while keeping the torso erect there is probably a restriction in theright psoas. If, while lying on the back with a bent right knee the right heel cannot be

brought back to the buttock the vastus intermedius may harbor trigger points. 1f coursethe tests could show restricted motion in both muscles. This simplified e#ampleillustrates how muscle testing usually gives crucial clues as to trigger point location. Inactual practice the testing would probably begin with an assessment of the patient3s hipalignment and would test psoas range of motion using a more!difficult!to!describeposition. -ut the e#ample illustrates how a trigger point therapist uses knowledge ofbody mechanics and normal ranges of motion in his detective work.

&12 $A$ATI1%. $alpation is one of the more difficult skills to master. It3s one thing to pointto a muscle in a diagram and 4uite another to locate it in a living body with your fingers !!especially if it is not right on the surface, or is surrounded by many others. Then there is thefurther task of identifying the taut band and the trigger point. 1nce located, pressure directly on a

trigger point gives a final clue by producing an intense local sensation. This stimulation may alsocause a 4uick muscle twitch, and may reproduce the patient3s pain or other symptom. Thesesigns tell the therapist that he or she is at the source, or one of the sources, of the problem.

&12 T8* $ATI*%T 8I0T1/. 2ost therapists take the patient3s history at the outset. Dhilethe pain pattern and range of motion restrictions reliably indicate trigger point location, moreinformation may be needed. 0ometimes the most important trigger point remains elusive. &or
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e#ample, the patient may complain of pain in the back and arm, but his history shows that theaccident probably caused a side!bending neck injury, indicating that treatment might be betterbegun with scalene or other neck muscles. The therapist thus could combine the history of neckinjury with knowledge that trigger points in scalene muscles can entrap the brachial nerve ple#usby compressing it directly, or by elevating the first rib, thereby compressing it indirectly. *itherway the scalenes are a possible cause of the shoulder and arm pain, and the detective work hasbeen greatly assisted by knowing the patient3s history.

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1. EIMINATING TRIGGER POINTS.

Trigger points can be eliminated by a variety of techni4ues, including certain kinds of manualpressure, speciali"ed stretching techni4ues sometimes including the use of cold spray, injection,dry needling and others. avid 0imons 2, ?anet Travell3s co!author, provides an up!to!datereview of the most effective manual methods, including important variations on the pressurerelease and stretching themes (BB).

*M'I*0 A++'A+/. :nowledgeable physicians can treat trigger points by injection.Injections in e#pert hands can provide lasting relief, but not all physicians who inject formyofascial pain know where the trigger points are, a fact I have ascertained many times talkingto my patients. +ertain trigger points are too dangerous to inject, e.g., those over the lung area.2anual techni4ues have the added advantage that many trigger points in different muscles canbe treated in one session.

I0 A-1!I%T*%0I*. Trigger point therapy takes time and in this sense is labor intensive. Thefront!line health care system often cannot allocate enough time to any one patient to treatmyofascial pain successfully, a gap which can be filled by non!physician therapists who canallocate more time to the individual. In chronic pain syndromes in particular, time must be takento ferret out the underlying key trigger points, and further time must be spent reviewing stretching

routines and figuring out life!style changes that may be necessary to finally end the pain.

2. PERPETUATING FA#TORS.

I& IT 1*0%3T D1: T8** 2'0T -* A *A01%. After r. Travell3s research and clinicalwork had convinced her how widespread trigger point pain was, and how effective the treatmentswere, she began to teach others. 0he would speak before groups and do demonstrations on painpatients she had never seen before, apparently with skilled showmanship. r. avid 0imonsreported that on one occasion, when asked afterward how the demonstration went, she repliedwith a sense of spiritual reverence 3the magic never fails3 (0imons BBC). A corollary to her

conviction about the effectiveness of trigger point work is that if the treatment was not effectivethen there must be a reason. This reason was usually a perpetuating factor. 0imons goes on toreport that in her practice,

0he looked under every physical and medical stone imaginable until she found why thatpatient had failed to respond to treatment as e#pected. The answers ranged fromrelatively short upper arms or leg!length discrepancies to inade4uate vitamin intake.
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012* *LA2$*0 can illustrate factors that perpetuate myofascial pain. The history of a patientwith long!standing pain may reveal that the person never eats vegetables or takes vitamins. Thetherapist would suspect that folate deficiency is helping perpetuate the pain (Travell and 0imons;


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NEW FO#US. 8istorically speaking, myofascial pain syndrome was difficult to understandbecause trigger points usually refer pain elsewhere in the body, and because pain they cause canmas4uerade as pain from other tissues (including viscera). The fact that clinicians gave differentnames to the entity they were trying to describe may have kept them from reali"ing they were

studying the same syndrome that others in different specialities had worked on. 0o an importantpart of Travell and 0imons3 achievement is simply that the medical community now agrees to callthis condition moyfascial trigger point pain. Dith this focus, effective, coordinated research canproceed. $erhaps a new medical speciality will evolve with muscle tissue as its subject.2uscles, after all, make up 6B7 of the body, cause much pain, and deserve attention.

THE TERM 5MYOFAS#IA5. 2yo refers to muscle and fascial refers to fascia. &ascia is theconnective tissue that surrounds all structures of the body, including muscles, organs, bones,nerves, etc. 2uscles attach to bones and other structures by tendons located at the ends ofmuscles where the fascia surrounding and permeating the muscle becomes thick and strong andconnects with the fascia surrounding the bone in 4uestion. Tendons can become tense and

develop their own tender points in response to trigger points in the muscle. +onversely, triggerpoint pain may in some cases be aggravated and perhaps caused by unhealthy fascia. &ascia isunhealthy when it has become immobile, too fibrotic andKor adhered to other structures. In thisstate it ties down the related muscles and otherwise limits their mobility. $roblems in the fasciacan normally be relieved by accurate bodywork that stretches fascia and helps bring moisture andfle#ibility back.

At the 1ctober BBF &irst International &ascia esearch +ongress in -oston several papersreported research showing that fascia fre4uently has contractile properties of its own ( 0chleipet.al.BBFN &ournie BBF) . 0ome researchers suggested that fascia may assist with movementbecause of its springy 4uality (Oorn et.al. BBF). The propriosensoryrole of 9olgi tendon organs

has been understood for a long time. (9olgi are tiny sensory cells in tendons that providefeedback when the tendon is stretched too tightly, feedback that can cause the nervous system toinhibit the muscle3s action.) &ascia is no longer viewed as something that just links or protectsother tissues, but as an active system whose role needs much more research.

IST NOT E6HAUSTI$E7 In an instructive e#ample, a physician named Adler wrote in ;


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SAR#OMERES7 1n microscopic e#amination muscle fibers have a striated appearance, withtiny lines perpendicular to the fiber all along its length. The muscle tissue between two of thesetiny lines is a sarcomere. The sarcomere is the basic contractile unit of muscle tissue.

PROPRIOSENSORY7 The ability of the body to sense various conditions within itself.

T"e E8o)ution of Trigger PointT"er!*+

D8I+8 2*I+A 0$*+IAT/ T*AT0 TI99* $1I%T $AI%G 2any people I see havealready been to a number of medical specialists, often including a pain specialist. 1ne of thesewould likely have resolved the person3s pain problem if it fell clearly within his or her area ofe#pertise. $art of the reason physicians did not successfully treat these pain problems may bethe way medicine is currently organi"ed= in spite of the fact that 6B7 of the body is muscle, nomedical specialty claims muscle tissue as it3s subject matter.

'ntil the first edition of Travell and 0imons3 groundbreaking work came out in ;


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fibers without causing the patient considerable discomfort. 0ometimes he or she has to pokearound to find the spot causing the pain. In addition there are important muscles so near thelungs or other vital organs that it can be dangerous to inject them. A manual therapist also hasthe advantage of not having to stop after treating just a few trigger points. 8e or she can treatmany in one session when this is appropriate. Injections in skilled hands can be 4uite effective,but this form of trigger point therapy has limitations and need not be relied on e#clusively whenless invasive options are available.

To* of P!geHOME

Trigger PointS9reening %efore

Surger+

2yofascial pain caused by trigger points is very commonand often mimics more serious conditions. -ecausetrigger points arerelatively easy to diagnose and treat,screening for myofascial pain should be performed beforemusculo!skeletal surgeries are undertaken. If theunderlying pain is caused by trigger points in muscletissue, surgery will not eliminate it. 'nfortunately thisscreening is almost never done. Travell and 0imons make

this point using thoracic outlet syndrome (T10) as ane#ample=

... surgeons are frustrated because only about halfof operative interventions for T10 are successful.0ome are dramatically succcessful and some aredisastrously unsuccessful. ...Apparently a piece ofthe pu""le is missing. The fact that a majorcontributing cause for the pain and entrapments !myofascial trigger points!! is commonly overlookedcontributes to the confusion and frustration (Travelland 0imons ;


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physicians in the last few decades. Its primarypurpose is to eliminate myofascial pain, but it alsoimproves movement and posture.

I offer myofascial treatment and pain managementservices for the ackettstown, opatcong, Mount%reedom and (ashington area of northern "#,though I am not immediately nearby. If you live ina town such as !reen &illage, Mine ill, $andolphor "ew &ernon "# I would still be the closestcertified therapist. Mill Brook, Tabor and &ictory!ardens "# also fall into this category, and muchof the rest of "ew #ersey. )omewhat distant townsare mentioned because I have seen many timesthat people are glad to travel even several hoursto get rid of pain. If you live elsewhere you may beable tofind a practitioner nearby.

+opyright BBF ?oseph 8oane

HOME Site M!*

Travell and 0imons3 two!volume trigger point manual

Pain Categories - Other Types of Pain

Other Types of PainWind-up Pain

Nerve fibers that transmit painful impulses to the brain become "trained" to deliver painsignals after receptors in the back part of the spinal cord are bombarded with pain for an

extended period of time These receptors can cause a marked increase in the amount of paintransmitted to the brain Changes in these receptors can also inhibit the efficacy of opioids

Mixed Pain

!oth nociceptive and neuropathic mechanisms are thought to operate in chronic sciatica incedifferent pain-generating mechanisms possibly underlie sciatic pain# the term $ixed Pain

yndrome was established

Breakthrough Pain

!reakthrough pain# also known as episodic pain# is pain that %breaks through& a regular painmedicine schedule !reakthrough pain generally falls within three classifications' incident# end-

of-dose failure# and spontaneous Temporal features# including the onset# duration and
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fre(uency of each episode# characteri)e breakthrough pain *esearchers estimate that up to+, of chronic pain suffers on long-acting medication experience breakthrough pain ./Pain

can occur even through a patient is adhering to the medication schedule and is taking thecorrect dose of pain medication 0pisodes of breakthrough pain may be spontaneous#

occurring without a precipitated event# or initiated by a volitional or nonvolitional event .12hile the fre(uency of breakthrough pain reported in the literature is somewhat variable# it isgenerally accepted that patients will experience one to four episodes per day .3#.4#.,#..#

.+5n one key study# the median number of breakthrough pain incidents over a /3-hour periodwas four# with 6/ patients experiencing seven or more breakthrough pain episodes during thatperiod .78orty-three percent of the pain episodes had an onset within three minutes# and the

median duration of the pains was 19 minutes :range 6-/39 minutes; +9

!reakthrough pain is more common in the cancer patient population isceral pain is defined as pain that originates from deep visceral structures and can beidentified by location :eg# abdomen; +1and by pain features :eg# dull# cramping;+3#+4

*elatively minor lesions in viscera such as the stomach# the bladder or the ureters canproduce excruciating pain $any diseases of the liver# the lungs or the kidneys are completely

painless and the only symptoms felt by the patient are those derived from the abnormalfunctioning of these organs +,#+.

Referred Pain

*eferred Pain is felt at a site other than where the cause is situated


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"europathic Pain O#er#ie$% &nimation

Causes and effects of neuropathic pain

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Pathophysiology of "europathic Pain% &nimation

Principle types of pathophysiologies related to neuropathic pain

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Neuropathic pain involves in=ury or alteration of thenormal sensory and modulatory nervous systems

Painful neuropathies can result from a broad range ofetiologies# including'4.$etabolic and endocrinologic

disorders such as diabetes and liver disease# infection#demyelinating disorders# stroke and spinal cord

in=uries# malignancies# and other causes

These changes can produce a set of neuropathicsymptoms that are often difficult to treat 4+$ultiple

changes may occur in the in=ured neural structures uch changes may include' abnormalnerve regeneration# disinhibition of modulatory processes# and decreased expression of mu-

opioid receptors

Changes may also occur in areas not directly in=ured A often distant from the originalinsult47#,9The resulting pain complaints include spontaneous %burning& sensations# with

intermittent sharp# lightening-like stabbing and shooting pain,6$arked sensitivity and painmay be elicited by minimal stimulation such as a light touch# a slight bree)e# or a temperature
http://www.painbalance.org/videos/sl_iis_1.htmlhttp://www.painbalance.org/videos/sl_wmv_1.htmlhttp://www.painbalance.org/videos/mp_wmv_1.htmlhttp://www.painbalance.org/videos/mp_wmv_1.htmlhttp://www.painbalance.org/videos/sl_iis_3.htmlhttp://www.painbalance.org/videos/sl_wmv_3.htmlhttp://www.painbalance.org/videos/mp_wmv_3.htmlhttp://www.painbalance.org/videos/mp_wmv_3.htmlhttp://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#57http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#58http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#59http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#60http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#60http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#61http://www.painbalance.org/videos/sl_iis_1.htmlhttp://www.painbalance.org/videos/sl_wmv_1.htmlhttp://www.painbalance.org/videos/mp_wmv_1.htmlhttp://www.painbalance.org/videos/mp_wmv_1.htmlhttp://www.painbalance.org/videos/sl_iis_3.htmlhttp://www.painbalance.org/videos/sl_wmv_3.htmlhttp://www.painbalance.org/videos/mp_wmv_3.htmlhttp://www.painbalance.org/videos/mp_wmv_3.htmlhttp://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#57http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#58http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#59http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#60http://www.painbalance.org/pages/getpage.aspx?id=87FEBEDD-EA7A-40DF-B1FD-46DA23811BA9#61


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change,/

Treatment of neuropathic pain can be a challenge ymptoms vary among patients and maybe resistant to common analgesics ?owever# most patients will experience satisfactory pain

relief and improved (uality of life after appropriate therapy,1

Pathophysiologies

$ultiple processes are capable of producing sufficient neural alteration to produce neuropathicpain,3These processes include'

Biabetesiver disease

*enal dysfunction and hemodialysis?ypothyroidism


19/28

(nfection

?5>>arcella )oster virus

?epatitis ! and C?uman T-cell lymphotrophic virus :?T>-6;

yme diseaseeprosy

emyelinating isorders

Duillain-!arreE syndrome$ultiple clerosis

Chronic inflammatory demyelinating polyneuropathy

Stroke and Spinal !ord (n*uries

Malignancies

)ntrapment

&utoimmune and +ranulomatous isorders

=ogrenEs syndromeystemic lupus erythmatosus

*heumatoid arthritisarcoidosis

Polyarteritis nodosaChurg-trauss vasculitis

2egenerEs granulomatosisDiant cell or temporal arteritis

(mmunoglo'ulinemias

$onoclonan :$; proteins


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?eavy metalsChemotherapy

,ereditary "europathies

Charcot-$arie-Tooth8abryEs disease

8amilial amyloid polyneuropathyPorphyria

!ryptogenic "europathies

5diopathicComplex regional pain syndromes

0ssential trigeminal and glossopharyngeal neuralgias

"ocicepti#e Reception and

Transmission"ocicepti#e Pain O#er#ie$

% &nimation

The physiology of nociceptive pain transduction# conduction# transmission# perception andmodulation

elect format' :ilverlight smooth streaming; :ilverlight - 2$>; :2indow $edia Player @2$>;

Nociceptive pain occurs as a result of the activation ofthe nociceptive system by noxious stimuli#

inflammation or disease 39#36

The neurophysiologic underpinnings of pain can bedivided into four stages' transduction# transmission#pain modulation# and perception 3/


21/28


22/28

Home> Library> Literature & Language>Dictionary

(r-frd')n.

ain t!at i" felt in a part of t!e body at a di"tance from t!e area of pat!ology# a" pain in

t!e rig!t "!oulder deri$ed from t!e pre"ence of a gall"tone in t!e bladder%

Home> Library> Healt!>port" cience and edicine

"ynalgia

ain felt in an undamaged part of t!e body aay from t!e actual point of inury or

di"ea"e% *t may be a $i"ceral (abdominal organ) pain# !ic! i" percei$ed a" originating in

t!e body all due to ner$e impul"e" from $i"ceral pain receptor" tra$elling along t!e"ame pat!ay a" "omatic pain impul"e"# or t!e pain may ari"e in body all "tructure" and

be referred di"tally% Degenerati$e c!ange" in cer$ical $ertebrae# for e+ample# can cau"e

tendiniti"-li,e pain in t!e elbo# and degeneration of lumbar facet" can cau"e calf pain%

ee al"o radicular pain# "omatic pain%

null

i,ipedia:

Referred pain

.opHome> Library> i"cellaneou"> i,ipedia

Referred pain("ometime" referred to a" reflective pain/01) i" a term u"ed to de"cribe t!e

p!enomenon ofpainpercei$ed at a "ite adacent to or at a di"tance from t!e "ite of an

inury'" origin%

/21

3ne of t!e be"t e+ample" of t!i" i" during i"c!emiabroug!t on by amyocardial infarction(!eart attac,) !ere pain i" often felt in t!e nec,# "!oulder"# and

bac, rat!er t!an in t!e c!e"t# t!e "ite of t!e inury% .!e *nternational 4""ociation for t!e

tudy of ain# a" of 2550# !a" not officially defined t!e term6 !ence "e$eral aut!or" !a$edefined t!e term differently%

!y"ician"and "cienti"t" !a$e ,non about referred pain "ince t!e late 0775"% De"pite an

increa"ing amount of literature on t!e "ubect# t!e mec!ani"mof referred pain i"

un,non# alt!oug! t!ere are "e$eral t!eorie"%

8ontent" /!ide1

0 8!aracteri"tic" 2 ec!ani"m

o 2%0 8on$ergent-proection

o 2%2 8on$ergence-facilitation

o 2%9 4+on-refle+

o 2% Hypere+citability

o 2%; .!alamic-con$ergence

9


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Laboratory te"ting met!od"

o %0 4lgogenic "ub"tance"

o %2 ="ing electrical "timulation

; ="e in 8linical Diagno"i" and .reatment"

o ;%0 3rt!opedic Diagno"i"

o ;%2 eneral Diagno"i"

? @eference"

Characteristics

.!e "iAe of referred pain i" related to t!e inten"ity and duration of ongoingBe$o,ed

pain%/01

.emporal "ummation i" a potent mec!ani"m for generation of referred mu"cle

pain%/01 8entral !ypere+citability i" important for t!e e+tent of referred pain%/01

atient" it! c!ronic mu"culo",eletal pain" !a$e enlarged referred pain area" toe+perimental "timuli%/vague1.!epro+imal"pread of referred mu"cle pain i" "een inpatient" it! c!ronic mu"culo",eletal pain and $ery "eldom i" it "een in !ealt!y

indi$idual"%/01

odality-"pecific "omato"en"ory c!ange" occur in referred area"# !ic!

emp!a"iAe t!e importance of u"ing a multimodal "en"ory te"t regime for

a""e""ment%/01

Mechanism

.!ere are "e$eral propo"ed mec!ani"m" for referred pain% 8urrently t!ere i" no definiti$e

con"en"u" regarding !ic! t!eory may be correct% .!e cardiac general $i"ceral "en"orypain fiber" follo t!e "ympat!etic" bac, to t!e "pinal cord and !a$e t!eir cell bodie"

located in t!oracic dor"al root ganglia 0-(;)% 4" a general rule# in t!e t!ora+ and

abdomen# C4 pain fiber" follo "ympat!etic fiber" bac, to t!e "ame "pinal cord"egment" t!at ga$e ri"e to t!e preganglionic"ympat!etic fiber"% .!e central ner$ou"

"y"tem (8) percei$e" pain from t!e !eart a" coming from t!e "omatic portion of t!e

body "upplied by t!e t!oracic "pinal cord "egment" 0-(;)% 4l"o# t!e dermatome" of t!i"

region of t!e body all and upper limb !a$e t!eir neuronal cell bodie" in t!e "ame dor"alroot ganglia (.0-;) and "ynap"e in t!e "ame "econd order neuron" in t!e "pinal cord

"egment" (.0-;) a" t!e general $i"ceral "en"ory fiber" from t!e !eart% .!e 8 doe" not

clearly di"cern !et!er t!e pain i" coming from t!e body all or from t!e $i"cera# but it

percei$e" t!e pain a" coming from "ome!ere on t!e body all# i%e% "ub"ternal pain# leftarmB!and pain# a pain%

Convergent-projection

.!i" repre"ent" one of t!e earlie"t t!eorie" on t!e "ubect of referred pain% *t i" ba"ed on

t!e or, of %4% turge and E% @o"" from 0777 and later .8 @uc! in 0F?0% .!i" t!eorypropo"e" t!at afferent ner$e fiber" from ti""ue" con$erge onto t!e "ame "pinal neuron%
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.!i" t!eory e+plain" !y referred pain i" belie$ed to be "egmented in muc! t!e "ame

ay a" t!e "pinal cord% 4dditionally# e+perimental e$idence "!o" t!at !en local pain

(pain at t!e "ite of "timulation) i" inten"ified t!e referred pain i" inten"ified a" ell%

8ritici"m of t!i" model ari"e" from it" inability to e+plain !y t!ere i" a delay beteen

t!e on"et of referred pain after local pain "timulation%


25/28

e$eral c!aracteri"tic" are in line it! t!i" t!eory of referred pain "uc! a" dependency on

"timulu" and t!e time delay in t!e appearance of referred pain a" compared to local pain%

Hoe$er# t!e appearance of ne recepti$e field"# !ic! i" interpreted to be referred pain#conflict" it! t!e maority of e+perimental e$idence from "tudie" including "tudie" of

!ealt!y indi$idual"% Gurt!ermore# referred pain generally appear" it!in "econd" in

!uman" a" oppo"ed to minute" in animal model"% ome "cienti"t" attribute t!i" to amec!ani"m or influence don"tream in t!e "upra"pinal pat!ay"% euroimaging

tec!niJue" "uc! a"


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*n recent year" "e$eral different c!emical" !a$e been u"ed to induce referred pain

including brady,inen# "ub"tance #cap"aicin#/1and "erotonin% Hoe$er before any of

t!e"e "ub"tance" became ide"pread in t!eir u"e a "olution of !ypertonic "alinea" u"edin"tead% .!roug! $ariou" e+periment" it a" determined t!at t!ere ere multiple factor"

t!at correlated it! "aline admini"tration "uc! a" infu"ion rate# "aline concentration#

pre""ure# and amount of "aline u"ed% .!e mec!ani"m by !ic! t!e "aline induce" a localand referred pain pair i" un,non% ome re"earc!er" !a$e commented t!at it could be

due to o"motic difference"# !oe$er t!at i" not $erified%/01

"sing electrical stim!lation

*ntramu"cularelectrical "timulation (*


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an e+amination% tudie" !a$e reported t!at t!e maority of patient" t!at centraliAed ere

able to a$oid "pinal "urgery due to i"olation of t!e area of local pain% Hoe$er# t!e

patient" t!at did not centraliAe !ad to undergo "urgery in order diagno"e and correctproblem"% 4" a re"ult of t!i" "tudy t!ere !a" been a lot of re"earc! into t!e elimination of

referred pain t!roug! certain body mo$ement"% 3ne e+ample of t!i" i" referred pain in t!e

calf% cenAie "!oed t!at t!e referred pain ould mo$e clo"er to t!e "pine !en t!epatient bent bac,ard" in full e+ten"ion a fe time"% ore importantly# t!e referred pain

ould di""ipate e$en after t!e mo$ement" ere "topped% /?1

$eneral iagnosis

4" it! myocardial i"c!aemiareferred pain in a certain portion of t!e body can lead to a

diagno"i" of t!e correct local center% omatic mapping of referred pain and t!ecorre"ponding local center" !a" led to $ariou" topograp!ic map" being produced in order

to aid in pinpointing t!e location of pain ba"ed on t!e referred area"% Gor e+ample local

pain "timulated in t!e e"op!agu" i" capable of producing referred pain in t!e upper

abdomen# t!e obliJue mu"cle"# and t!e t!roat% Local pain in t!e pro"tate can radiatereferred pain to t!e abdomen# loer bac,# and calf mu"cle"% idney "tone" can cau"e

$i"ceral pain in t!e ureter a" t!e "tone i" "loly pa""ed into t!e e+cretory "y"tem% .!i"

can cau"e immen"e referred pain in t!e loer abdominal all%/O1*n addition to t!i"# recentre"earc! !a" found t!at ,etamine# a "edati$e# i" capable of bloc,ing referred pain% .!e

"tudy a" conducted on patient" "uffering from fibromyalgia# a di"ea"e c!aracteriAed by

oint and mu"cle pain and fatigue% .!e"e patient" ere loo,ed at "pecifically due to t!eirincrea"ed "en"iti$ity to nocicepti$e "timuli% Gurt!ermore# referred pain appear" in a

different pattern in fibromyalgic patient" t!an it doe" in normal people% 3ften t!i"

difference manife"t" a" a difference in term" of t!e area t!at t!e referred pain i" found(di"tal $"% pro+imal) a" compared to t!e local pain% .!e area i" al"o muc! more

e+aggerated oing to t!e increa"ed "en"iti$ity%/71

References

0% P abcdefghijklm4rendt-iel"en L# $en""on (2550)% I@eferred mu"cle pain:

ba"ic and clinical finding"I% Clin J Pain%&(0): 00QF%doi:05%05FOB55552;57-255059555-55559% *D0027F579%

2% ' referred painat Dorland'" edical Dictionary

9% P abc(255O)% ain and nociception% @etrie$ed o$ember 27# 255O# from ain andnociception - i,ipedia# t!e free encyclopedia eb "ite:

!ttp:BBen%i,ipedia%orgBi,iBainRandRnociception

% ' itting # $en""on # ottrup H# 4rendt-iel"en L# Een"en . (2555)%

I*ntramu"cular and intradermal inection of cap"aicin: a compari"on of local andreferred painI%Pain()(2-9): 5OQ02%doi:05%050?B595-9F;F(FF)55290-?%

*D05???;O%

;% ' o"e,


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?% ' Da$i"# Klac,ood# 8 (255)% .!e centraliAation p!enomenon: *t" role in t!e

a""e""ment and management of lo bac, pain% K8 edical Eournal% ?# 97-9;2%

O% ' ur$e"# D et al% (255)% euro"cience 9rd

about trigger points

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