A scientific research review published in the journal Current Brain and Headache Reports investigated the link between trigger points and fibromyalgia. They found that trigger points were an important cause. Over a period of time chronic pain impulses from trigger points cause a sensitisation of the nervous system. This results in normal stimuli becoming painful plus a host of other symptoms. A clinical trial showed that treating trigger points to eliminate these impulses not only diminished localised pain, but also substantially improved overall fibromyalgia symptoms. The authors not only state that treating trigger points substantially improves fibromyalgia symptoms, they concluded that this approach should be used before any other therapy was initiated.
The evidence produced by the review
Trial One: high prevalence of trigger points, and trigger points reproduced fibromyalgia symptoms
In a trial with 44 patients with fibromyalgia and 50 controls the fibromyalgia patients were found to have on average 10 active (pain producing) and one latent (non pain producing) trigger points. On the other hand the control group had an average of only just 2 latent trigger points. Furthermore, for the fibromyalgia patients pressing on their trigger points tended to reproduce their fibromyalgia symptoms.
Trial two: the tender spots used to diagnose fibromyalgia were trigger points
For the diagnosis of fibromyalgia there are 18 (9 symmetrical pairs) of points that are tested for tenderness. In 30 patients diagnosed with fibromyalgia these tender points were examined both manually and with using surface electrodes for trigger point characteristics. Most were found to be trigger points, and pain from these points reproduced the fibromyalgia symptoms.
Trial three: abnormal sensitivity remedied by injecting trigger points with anaesthetic
In a trial of 28 fibromyalgia sufferers subjects were found to have abnormal pain sensitivity to heat on the forearm. Injections of anaesthetic in trigger points in the muscles above the shoulders resulted in a reduction in sensitivity to heat. This demonstrates the core mechanism upon which the sensitisation theory is based.
Trial four: the injection of trigger points with anaesthetic significantly improved fibromyalgia
In a double blind trial of 68 fibromyalgia sufferers an injection of anaesthetic into trigger points not only caused a reduction in local and referred pain, but also an improvement in fibromyalgia symptoms overall. This is a demonstration of the so called “extinguishment of peripheral pain generators treatment”, where simply the cause of the sensitisation is removed.
Trial five: massage treatment of trigger points produced lasting improvement in fibromyalgia
In a controlled trial of 74 fibromyalgia sufferers subjects had trigger points treated with massage and other physical therapy. They exhibited a reduction in pain and anxiety, and an improvement in sleep. Improvements were still evident after 6 months.
The conclusion of the reviewers:
“On the whole, the results of the reported studies indicate that nociceptive muscle input in fibromyalgia, most often originate from trigger points, exacerbates fibromyalgia symptoms, and a reduction/extinction of this input substantially contributes to improving the fibromyalgia condition. … Thus, a systematic search for trigger points in fibromyalgia and their extinction is an approach that should systematically be adopted before any other therapy is initiated when faced with a patient with fibromyalgia.”
Giamberardino MA, Affaitati G, Fabrizio A, Costantini R Effects of treatment of myofascial trigger points on the pain of fibromyalgia. Curr Pain Headache Rep. 2011 Oct;15(5):393-9
Some clinical guidelines
Overview of the issues
Typically fibromyalgia has been thought of thought of as a condition with no known cause. Because of this the typical management of these conditions has been via the use of drugs and therapies that address the symptoms. However, as long as the source of neurological bombardment remains the condition will remain. The best way to deal with fibromyalgia is to treat trigger points and other conditions appropriately so they don't bombard and sensitise the nervous system in the first place. Once fibromyalgia develops there are actually two problems. There is the underlying condition that is bombarding the nervous system with pain impulses, and the sensitisation of the the nervous system itself. After a period of time being in pain, being told that that there is no known cause for their problem, and being treated inappropriately patients tend to also develop psychological stress related issues and a scepticism towards care.
As the researchers who relieved the symptoms of fibromyalgia by injecting trigger points with anaesthetic state the appropriate way to deal with these conditions is to remove the source of the sensitising impulses. There are two main issues affecting the ability to achieve this.
- By the time fibromyalgia (or migraines) develops any underlying condition is likely to have become very extensive and chronic.
- Because of the sensitisation treatment of the underlying cause may not be well tolerated.
As an illustration of this trials of the use of massage as a treatment for fibromyalgia have tend to be positive, but have shown some mixed results. On one hand massage would be an excellent therapy for the underlying musculoskeletal issues, but on the other hand due to the sensitivity massage itself may cause pain. It is clear that in order to deal with the underlying issues some form of therapy will needed. Given the chronicity this will need to be repeated many times.
The strategy to deal with these conflicting objectives would need to be determined and closely monitored by a qualified professional. The following ideas may be useful.
Therapy may be better tolerated if more treatments of a more conservative nature were used. For example, an hour of manual massage may not be well tolerated whereas several shorter sessions may. This is where self massage using a vibration massager may benefit, as it can more conveniently and economically deliver this sort of care. The only caveat is that most chronic trigger points do need 60 seconds of vibration to disrupt the reflex and relax the muscle. However, if doing it at home under instruction a patient can do one trigger point at a time if this is all that can be tolerated.
The researchers were able to temporarily cease the painful neurological bombardment from the trigger points by injecting them with anaesthetic. It may be a strategy to use such injections before applying therapy.