Identifying Myofascial Trigger Points

To the Editor,

The paper from Turkey on trigger points [TrPs] ([1]) was basically well designed and executed, but the results were almost uninterpretable because of two fundamental glaring omissions. As the editor of the Journal of Musculoskeletal Pain [JMP], I hope you would pay some attention to what you are publishing and would not, like some other editors, turn the review process over exclusively to their reviewers. It would do us all a great service if you reject papers like this or get the authors to complete their job.

The authors said that they divided subjects into test and control groups on the basis of whether or not they had myofascial pain syndrome [MPS]. I found nothing as to what criteria they used for making this decision.

The authors said that “all subjects were examined for TrPs in the lying position.” They then listed the muscles that were examined by them, which is laudable. But the criteria, if any, they used to identify a TrP when they suspected the presence of one, could not be found anywhere in the article.

My confusion concerning these two issues is brought into focus by their results, which claim that 25 or 26 male subjects without MPS had TrPs, but the last entry given in Table 5 is contradictory. Some of those subjects had as many as four or five TrPs out of five muscles examined. Among control group of females it was 30 of 30 subjects with TrPs. In both TrP and MPS groups all of the subjects were reported as having TrPs. Recent well-done studies ([2], [3], [4], [5]) show that only about half of the muscles of a group of healthy normal controls have latent TrPs. The rest of their muscles have none. Nearly all of the muscles in fibromyalgia syndrome [FMS] subjects have either active or latent TrPs ([6]). To present this as a credible TrP research is nothing but a great disservice to the field.

In fact, a very important clinical distinction is active versus latent TrPs ([7]) that may help to account for many of the TrPs in subjects without MPS. The authors of the JMP paper ([1]) apparently never heard of this distinction. Latent TrPs, by definition, cause no clinical pain problem, but otherwise may have TrP characteristics ([8]). If the authors of the JMP paper ([1]) had presented their data on this basis, it would have helped to advance the field significantly and emphasize also the importance of that clinical distinction.

I would be enormously grateful if you consider these issues in papers you select for your journal. It will help if JMP contributes toward clarifying and not confusing the TrP issue. Jan Dommerholt and I put a lot of time and effort on doing reviews toward that end.

When you read through some of our reviews, we hit these points again and again. Some of our comments should be of interest.

To the Editor,

I would like to thank Dr. David G. Simons for his significant review of our article ([1]). All subjects were gathered from the student body of Dumlupinar University. Subjects had pain for longer than three months and applied for treatment to our physical therapy clinic, or to the general hospital in Kütahya, Turkey.

All subjects were examined for TrPs in lying positions [supine, side lying, and prone, depending on the examined muscle]. These positions are selected for optimal muscle palpation and relaxing.

First we analyzed postural abnormalities, and then muscle palpations were performed. We tried to find TrPs as a simple small contraction knot in the muscles. It feels like pea-sized nodules buried deep in the muscle. Sometimes these muscles are tight and often painful. We applied firm pressure to elicit pain. In addition, we noted whether or not the TrPs referred pain.

Myofascial pain syndrome and FMS are characterized by hypersensitive spots in various parts of the body. With FMS, these spots are called “tender points” rather than “trigger points.” There are many differences between MPS and FMS. Muscles with TrPs feel firm; muscles in the FMS sufferers are soft and doughy. Muscles with TrPs stiffen the joints and inhibit the range of motion. In FMS, the joints are loose, or even hypermobile, although the person may have an overall subjective sense of stiffness and may be hesitant to move because of ongoing pain ([2]).

The number of male subjects without MPS in Table 3 was 24; it should have been 30. This is either a mistake in publishing or writing. We apologize to the readers.

Trigger points were found in the latent state, in which they were not actively referring pain. Travell and Simons ([3]) believe that the long-term effects of latent TrPs may be of even greater concern than the pain caused by active ones. They assert that latent TrPs tend to accumulate over a lifetime and appear to be the main cause for stiff joints and restrictive range of motion in old age. Our results are concordance with that of Simons et al. ([3]) and Shah et al. ([4]); TrPs that developed during school days can persist for years and then become a serious problem in the declining ages ([1]).

Ali Cimbiz, PT, PhD Associate Professor