As therapists are increasingly immersed in understanding of mechanisms of chronic pain and central nervous system phenomena, a question persists: what should we do with the peripheral tissues? As is usual in discussions that can take an either/or approach, the answer may lie somewhere in the middle. A recent article discussing myofascial trigger points (TrP) discusses the hypotheses surrounding this phenomena as a peripheral versus central mechanism. In a very well-cited summary of the issue, the authors come to some very helpful conclusions that you may find useful in your clinical practice.
If a trigger point, by definition, is a hyperirritable spot in a taut band of skeletal muscle that may or not have referred pain, what then, is driving the soft tissue dysfunction? Some authors argue that the peripheral nervous system is at fault, while others point to the central nervous system as the driver. Peripherally, nociceptive input may sensitize dorsal horn neurons. Centrally, patients who have chronic pain will have larger areas of pain, described as being a result of higher central neural plasticity. This is a controversial topic, and the authors are quick to point out that experimental evidence is "sparse." While there is support in the literature for peripheral trigger points creating central sensitization, the article states that "…preliminary evidence suggests that central sensitization can also promote TrP activity."
While this study does an excellent job describing various clinical and experimental research, hypotheses, and strength of evidence to support the hypotheses, the summary points are that trigger points may be both a central and peripheral phenomena, and that chronicity of the condition may drive the focus of rehabilitation efforts. Specifically, the authors state that when a patient presents with peripheral sensitization, treatment should be directed towards inactivation of the trigger point, mobilizing joints and nerves, and functional activity. Patients who present with persistent pain may require more attention directed to the central system utilizing a multidisciplinary approach such as medications, medical and physical therapy management, and psychological therapy. Fear, anxiety, and the neuroscience approach to pain should be addressed.
These issues are discussed throughout many the Institute's courses, but if you hope to get an earful about connective tissue and chronic pain research AND add tools to your toolbox, Institute faculty member Ramona Horton offers Myofascial Release for Pelvic Dysfunction. Join Ramona in June in Ohio, the last chance to take the course in 2014!