Posted by MERM on 6/15/2008, 12:45 pm, in reply to "Fibromyalgia and Chronic Myofascial Pain"
Deep fascia is tougher and denser, and is used to separate large sections of the body. It covers some areas like huge sheets, protecting them and giving them shape, and separates muscles and organs. The pericardium, the pleura and the perineum are all made up of specialized deep fascia. The dural tube is also fascial, and this fascia is connected to the membranes surrounding the brain. Together, they hold and protect the craniosacral system, and changes in the craniosacral fascia can affect what it contains. Sheets of fibrous myofascial adhesion can form anywhere along nerves and block normal healthy function.
The subserous fascia is loose tissue covering the internal organs and holding the network of blood and lymph vessels that keep them moist. Myofascia is fascia related to muscle tissue. Healthy myofascia allows for compression and tension, as well as relaxation. It is the fascia that forms adhesions and scar tissue. Healthy ground substance making up part of the myofascia has a gelatinous consistency so that it can better absorb the forces that are created during movement. Ground substance maintains the distance between connective tissue fibers. This prevents microadhesions from forming and keeps tissues supple and elastic. When the critical distance is not maintained, the fibers become cross-linked by newly synthesized collagen fibers, which are also part of the fascia. Collagen crosslinks are arranged haphazardly, unlike healthy linkages, and are harder and more painful to break up. If this pain is further amplified by FMS, extra care by the bodyworker and extra medication during and after treatment may be needed to prevent further central sensitization. It is insufficient therapy to break up the cross-linkages. The ground substance must be returned to its healthy, more fluid state. The transfer of nutrients from where they are metabolized into usable materials to where they will be used, as well as the removal of waste products from these areas of use, takes place in the ground substance. The state of the ground substance can profoundly affect the state of health.
Muscles and tendons join bones and ligaments and come together at attachment areas. The cellular membranes in these areas can become extremely convoluted, which increases the surface area and changes the angle of force. This increases the potential for tissues to stick together and causes tissues near attachment areas to become more easily torn (Simons, Travell and Simons, 1999). Attachment TrPs can become fibrotic or calcified with time. The sooner they are appropriately treated, the easier it will be to return the myofascia to a healthy state. Chronicity can often be prevented by prompt and through acute care.
Myofascial Trigger Points
Trigger Points (TrPs) are extremely sore points occurring in ropy bands throughout the body. To more easily palpate TrPs in the arm or leg muscles, stretch the involved muscle about 2/3 of the way out. If there is pain at the end of a restricted range of motion, there is probably a TrP involved. TrPs cause muscle weakness and other dysfunction before they cause pain. Much of the restricted range of motion and dysfunction often attributed to old age may be due to myofascial TrPs and thus can be successfully treated. Travell and Simons have carefully documented and detailed the maps and common associated proprioceptive and autonomic concomitants.
A latent TrP doesn't hurt unless you press it. Your patient might not even know it's there, but his or her body does. It weakens the affected muscle, restricting movement and preventing its full lengthening. If you press on the TrP it refers pain in its characteristic pattern. Latent TrPs may be activated by overstretching, overuse, or chilling the muscle. People who get little exercise have a greater chance of developing latent TrPs. Some people believe that by restricting their range of motion they are getting rid of their TrPs. Nothing can be farther from the truth. When someone with multiple latent TrPs falls, develops an infection, or is affected by any other stressor, all of the latent TrPs can activate simultaneously. Physical stress isn't the only thing that can cause TrPs. Tension TrPs can occur. These are not the psychological result of tension, but they are physiological biological effects of long-term emotional abuse, mental trauma or other stressor. Constantly holding muscles tight in a "fight-or-flight" stress response changes biomechanics. It will take both patient and care provider effort, time and persistence to change them back.
Bodywork and exercise can activate TrPs, and so can a TrP examination. Ask your patients for feedback about after-affects of your examination. You may need to modify your technique. Please don’t strum across the taut bands. If your patient has both FMS and myofascial TrPs, s/he may need medication to allow for complete testing without further sensitizing the central nervous system. You may need to restrict examination to one muscle function group and treat the TrPs in that group immediately after you test. Full range of motion stretches and a hot bath with Epsom salts and ground ginger may help relieve post-exam and post-therapy soreness.
An active TrP not only hurts when it is pressed, like an FMS tender point, but it "triggers" a referred pain pattern somewhere else in the body. This pain pattern is similar from patient to patient and may include spillover pain areas. These TrPs often produce symptoms other than pain. Active TrPs hurt when the muscle is in use. When the TrP becomes very active, pain and other symptoms occur even when the muscle is resting. The fact that these pain patterns are very much similar from patient to patient helps if the diagnostician is familiar with the patterns so well described by Travell and Simons. A comprehensive history will tell you where to look for TrPs and may help prevent needless pain. If your patient has a stiff neck, for example, you can check for TrPs in the levator scapulae, and if there is a problem with incontinence, there are TrPs that can affect that too. Some other TrP associated symptoms include localized sweating, tearing, poor balance, nausea, tinnitus, goosebumps, runny nose, buckling knees, weak ankles, illegible handwriting, headaches, and muscle cramps.
It is of critical importance to become familiar with the referral pain patterns of the individual myofascial TrPs and their TrP locations. TrPs are sometimes within their pain referral pattern, but they also can be at some distance from it. The specifics of the TrP referral pattern give you clues to the location of the TrP. With multiple TrPs, there can be complex overlying pain patterns. Knowing the specifics is the key to unraveling the puzzle. TrPs may form as a result of other medical conditions.
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