Myofascial trigger points: fact or fiction?

MrRippedZilla

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Most of you readers are aware of myofascial trigger points but for those who are not, it basically refers to a sensitive area of the muscle that is claimed to result in local and/or peripheral pain. This model has been accepted by many as fact when it comes to explaining why people experience pain in these areas but, by the end of this article, it will become clear that this simply isn't the case.


No accurate diagnosis = no confirmation of cause

First of all, I'm not dismissing the actual clinical symptoms. We all know that something is going and that the pain people feel is very real. I am questioning the mechanism of action (MOA) that practitioners seem to believe explains these symptoms. Hell I've seen some guys claim that if you have trigger points then you can't make gains and if you don't seek treatment then it might become a permanent, structural condition. You better have some solid data to make such claims.

So, for trigger points to be the real cause they need to be identifiable. In other words, if pain is a symptom then a diagnosis should identify trigger points as the cause.
https://www.researchgate.net/public...on_for_Diagnosis_of_Myofascial_Trigger_Points
- This is a systematic review paper stating that NO data exists to validate the reliability of trigger point diagnosis.
- "On the basis of limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points.”

https://www.ncbi.nlm.nih.gov/pubmed/18503816
- Another systematic review paper with a similar conclusion.
“The methodologic quality of the studies for the purpose of establishing trigger point reproducibility is generally poor. More high-quality studies are needed to comment on this procedure.”

Yes, the data does have limitations as addressed in both reviews, but the fact still remains that science hasn't provided us with anything to accurately diagnose trigger points as the cause of pain. If something cannot be accurately diagnosed then it is impossible to accurately suggest what it is and how to treat it. Impossible.


Misunderstanding the true cause of pain

The trigger point model suggests that the cause of pain is related to a structural issue (related to the muscle itself) when in fact the data is pretty clear that pain in general can be explained through the biopsychosocial model.
This model explains that pain has little if anything to do with structure and is related more to biological (genes, biochem interactions, etc) and mental (psychological/social) factors. The evidence behind this model is extremely strong and here is just a couple of papers diving into the topic (warning: not for the non-pro researcher):
http://enniscentre.com/Presentations/Gatchel-Biopsychosocial Approach to Chronic Pain.pdf
https://www.researchgate.net/public...to_platform_a_new_concept_for_pain_management

"Well, if pain is not related to structure then how come certain movements help people alleviate it?" I hear you ask.
Rehab through movement is possible due to its impact on the brain (fitting into the biopsychosocial model). It allows us to target certain portions of the brain (cortical representations) that influence our proprioception, sensory output and threat level - all things that play a part in causing pain to begin with. The impact of the brain on pain perception is discussed in more detail here:
https://www.bodyinmind.org/wp-conte...l-Rep-targeting-the-brain-in-rehab-review.pdf


So trigger points causing myofascial pain is bullshit?

That certainly appears to be the case:
https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/keu471
- This awesome paper diving into the topic at hand concluded that both myofascial pain syndrome and trigger points lack a scientific basis despite evidence looking into the topic. In other words, the pathology at hand is based on nothing but presumption. It's bullshit.
- They also suggest their own theoretical model to explain the clinical symptoms that revolves combining the established MOA of pain, interesting findings regarding nerve allodynia (unexpected pain from touch) and experimental data on nerve inflammation. Good read for any physio nerds out there.


Summary

At best, we don't have enough quality data to suggest that trigger points are the cause of pain. It's an unclear topic that needs more research.
At worst, the trigger point model is complete nonsense and shouldn't be used to explain the symptoms of trainees.

Not a lot of real world, applicable, information here but it does lay some groundwork for when I do get around to writing rehab/mobility/whatever type stuff :)
 
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Milo

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But does this not mean that trigger points COULD be an issue, its just not definitive yet? This is hardly scientific evidence but I know that when Im having bicep pain, rolling out my shoulders and biceps with a barbell seems yield a good deal of relief.
 

MrRippedZilla

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But does this not mean that trigger points COULD be an issue, its just not definitive yet? This is hardly scientific evidence but I know that when Im having bicep pain, rolling out my shoulders and biceps with a barbell seems yield a good deal of relief.

Sure, it COULD be an issue, if you believe that the reason the data taken as a whole doesn't support the model has to do with methodological flaws. That is a valid position to adopt if your conclusion is "we need better research" but not if your conclusion is "it exists".

Claiming that something that cannot be diagnosed can cause any condition is stupid and yet plenty of "gurus" are doing just that.
Imagine if your doctor told you that you had a condition because of X. He can't actually diagnose X, he can't show you that X caused your condition and he can't show you how X would cause your condition. Are you going to trust his gut instinct on this or remain skeptical until he shows you some solid evidence?

A couple of quotes from the final paper I referenced to show you where we stand on this topic (mps = myofascial pain syndrome, trps = trigger points):
"Physical examination cannot be relied upon to diagnose a condition that is supposed to be defined by that physical examination."
Translated: the definition of X is based on Y but Y doesn't actually show you X...

"The construct of MPS caused by TrPs remains conjecture. All working hypotheses derived from this conjecture have been refuted and therefore the theory can be discarded."
Translated: The idea that myofascial pain is caused by trigger points is bullshit. This idea has been proven to be bullshit by the data and therefore we need to move the **** on to better models.

Note that I'm not disuputing the symptoms or the methods we use to relieve those symptoms. Just the idea that it's all based on trigger points/muscle knots/whatever.
 

Milo

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Oh I fully agree. My position is that even though you cannot indisputably(?) dignose X, but symptoms seem to be kept at bay with Y, I think there's no reason to not prescibe Y. But saying that the diagnosis or treatment here is an absolute would be BS at best.
 

MrRippedZilla

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A couple of commentary articles discussing the final, strong worded, paper I referenced in the OP. Both are only 1-2 pages long and easy reads for those not inclined to go through some of the essays I originally referenced:
https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kev028

https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/kev095

The first suggests that we don't have strong enough data to completely refute the trigger point model; a perfectly acceptable position to adopt as I mentioned to Milo.
The second is the authors response that says that we've been looking into this model for 50 years. If in that time frame we haven't been able to identify it as the true cause of pain, then its time to accept that its a failed hypothesis and move on to better theories. As my OP makes plainly obvious, I'm siding with these guys on this one.
 
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ToolSteel

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What's what thing they say about not being able to prove a negative...
 

DieYoungStrong

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Donnie Thompson, Chris Duffin, Kelly Starrett and pretty much the entire Sports S/C community disagree. I'll take the word of guys using these techniques to keep athletes on field/platfrom/wherever over a study. Maybe there are better/different techniques? I don't know, but until I see them being used with real world success, I'll keep using the methods that are currently working in the real world.
 

MrRippedZilla

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What's what thing they say about not being able to prove a negative...

This isn't about proving a negative. It's about having evidence to support a positive - in other words, does the data support the trigger point model hypothesis? As we stand today, the answer is no :)

Then you can either decide a) that this is due to the quality of the data and that we need to address methodological issues in the future or b) the inability of the data we have to support the hypothesis is in and of itself refuting it.

Donnie Thompson, Chris Duffin, Kelly Starrett and pretty much the entire Sports S/C community disagree. I'll take the word of guys using these techniques to keep athletes on field/platfrom/wherever over a study. Maybe there are better/different techniques? I don't know, but until I see them being used with real world success, I'll keep using the methods that are currently working in the real world.

Again, this isn't about the methods that work - it's about the MOA that allows those methods to work.

People seem to forget that myofascial release isn't just about "trigger points":
- It leads to an increase in oxytocin, which is an analgesic (pain relieving) hormone.
- It leads to an inhibition of pain feedback via stimulation of certain nerve fibers. This is similar to the way a massage works and seems to be most supported MOA as far as the research is concerned (basically suggesting a huge neural involvement in all of this).
- Not related to pain, but it also improves ROM through a NEURAL, not mechanical, mechanism as the evidenced by the cross-over impact: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970845/
 
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ToolSteel

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I gotta be honest here it really just sounds like you're finding a nit-picky detail to bitch about. If there's a genuine purpose it's definitely not apparent.
 

MrRippedZilla

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I gotta be honest here it really just sounds like you're finding a nit-picky detail to bitch about. If there's a genuine purpose it's definitely not apparent.

The purpose was to question an MOA commonly accepted as fact.
I don't consider that to be a "nit-picky detail" to understand, and made it pretty ****ing clear in the article summary, that the real life relevance of this information is minimal.

If this stuff is of no interest to the readers here, as it appears to be the case, that's fine. I'll ensure to save such chatter for other places.
 
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ToolSteel

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The purpose was to question an MOA commonly accepted as fact.
Ok, what is the point of that; what is the goal?
I don't consider that to be a "nit-picky detail" but do understand, and made it pretty ****ing clear in the article summary, that the real life relevance of this information is minimal.
And I'm just telling you that it wasn't very clear. I have no doubt that it was/is to you.
If this stuff is of no interest to the readers here, as it appears to be the case, that's fine. I'll ensure to save such chatter for other places.
It's not that it's chatter, it's that I don't really see the benefit.

As far as I can see, you've said:

A causes B and C takes care of B. But since there isn't undiable proof of A, I'm calling the whole thing bullshit.
 

MrRippedZilla

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As far as I can see, you've said:
A causes B and C takes care of B. But since there isn't undiable proof of A, I'm calling the whole thing bullshit.

By understanding what A actually is, you will inevitably improve C. More accurate diagnosis = better treatment.

And at no point did I say A causes B. In fact the whole article was based on...you know what...**** it. I'm taking Jols advice on this.
 

ToolSteel

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Ok, ok, A "allegedly" causes B.


Buddy just just take a breath and understand that this is just like the protein thread. I'm just telling you how things are coming across.
 

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