More Myofascial

More than five years after I felt my first symptoms, two years after I received my diagnosis of myofascial pain syndrome, and a year after I finally resolved my remaining pelvic pain, The Washington Post published my article on myofascial pain in the Health and Science section on June 18, 2013.  Myofascial pain and the strange bladder symptoms it triggered had dominated my life for years, limiting my diet, my exercise, my work, my travel and my social life as I searched for answers about what was happening to my body.   I wrote the article so that others don’t have to experience the confusion and frustration that I did.  At only 1,500 words, it can’t describe every symptom that someone with myofascial pain – and in particular pelvic pain – experiences, or outline all the treatment options available.  But I hope my article prompts perplexed patients and their practitioners to seek out more information and find answers quickly.  As a starting point, I include some references below.

In particular, patients experiencing symptoms such as bladder pain and urinary frequency and urgency might be interested in Dr. David Wise’s book A Headache in the Pelvis, and his protocol for treatment described at  http://www.pelvicpainhelp.com/.  I attended Dr. Wise’s clinic in February 2012.  By then, Dr. Timothy Taylor of Richmond VA had successfully treated the trigger points in my hips, thighs and backside with dry needling, taught me how to compress trigger points and stretch my muscles between treatments, and prescribed thyroid medication and vitamin D.   With this treatment, most of my symptoms had disappeared or diminished, but the bladder irritation persisted.  Dr. Wise’s protocol filled in the remaining gap.  It focuses specifically on resolving trigger points in the pelvic floor that cause referred symptoms to the bladder, and includes a relaxation technique to help eliminate the clenching tendency that leads to chronic trigger points.    

In the course of researching this article, I reviewed dozens of scientific papers on myofascial pain syndrome and pelvic pain and spoke with many experts.  I’ve listed some of the scientific papers here for those interested in current understanding of the pathophysiology, diagnosis and treatment of myofascial pain.  I hope to publish a longer magazine piece in coming months that tells more of the myofascial story, and why it’s so challenging to diagnose and treat this condition. In the meantime, my best wishes for successful healing to everyone who may be struggling with myofascial and pelvic pain.    

References

American Physical Therapy Association.  Description of Dry Needling.in Clinical Practice:  An Educational Resource Paper. Produced by the APTA Public Policy, Practice and Professional Affairs Unit. February 2013.

Physical Therapists and the Performance of Dry Needling:  An Educational Resource Paper.  Produced by APTA Department of Practice and APTA State Government Affairs.  January 2012.

Doggweiler, Ragi.  Urologic myofascial pain syndromes. Current Pain and Headache Reports.  Vol. 8:445-451. 2004.

Dommerholdt, Jan and Peter Huijbregts (eds). Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.

Dommerholdt, Jan, Carel Bron, and Jo Frannsen. “Myofascial trigger points: an evidence informed review” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC,  Sudbury Massachusetts. 2011.

Fernandez-de-las-Peῇas, César, Lars Arendt-Nielson and David G. Simons. “Contributions of myofascial trigger points to chronic tension-type headache” in Myofascial  Trigger Points: Pathophysiology and Evidence Informed Diagnosis  and Management.  Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.

Gerwin, Robert D. “A review of myofascial pain and fibromyalgia – factors that promote their persistence.” Acupuncture in Medicine Vol. 23(3):121-134.2005.   

Gerwin, Robert D. “Classification, epidemiology, and natural history of myofascial pain syndrome.” Current Pain and Headache Reports. Vol. 5:412-420.2001.    

Gerwin, Robert D. “Myofascial pain syndrome: unresolved issues and future directions” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds).   Jones and Bartlett Publishers LLC, Sudbury Massachusetts.  2011.                                                                                                                                                                 

Gerwin, Robert D. “Myofascial and visceral pain syndromes: visceral-somatic pain representations.” Journal of Musculoskeletal Pain [The Haworth Medical Press, an imprint of The Haworth Press, Inc.] Vol. 10 (1/2):165-175. 2002.

Gerwin, Robert D., Jan Dommerholt, and Jay P. Shah. An expansion of Simons’ integrated hypothesis of trigger point formation.” Current Pain and Headache Reports. 8:468–475. 2004.

Gerwin, Robert D., Steven Shannon, Chang-Zern Hong, David Hubbard, Richard Gevirtz. “Interrater reliability in myofascial trigger point examination.” Pain. Vol. 69:65–73. 1997.             

Harden, R. Norman, Stephen P. Bruehl, Suzanne Gass, Claudia Miemiec, Brian Barbick. “Signs and symptoms of the myofascial pain syndrome:  a national survey of pain management providers.” Clinical Journal of Pain. Vol. 16: 64-72. 2000.

Lucas, Nicholas, Petra Macaskil, Les Irwig, Robert Moran, Nikolai Bogduk. “Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clinical Journal of Pain. 2009. 25(1):80-89.

McEvoy, Johnson and Peter Huijbregts. “Reliability of myofascial trigger point palpation: a systematic review” in Myofascial  Trigger Points: Pathophysiology and Evidence Informed Diagnosis  and Management.  Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC, Sudbury Massachusetts. 2011.

McPartland, John M. and David G. Simons. “Myofascial trigger points: translating molecular theory into manual rherapy” in Myofascial Trigger Points: Pathophysiology and Evidence Informed Diagnosis and Management. Dommerholdt, Jan and Peter Huijbregts (eds). Jones and Bartlett Publishers LLC.  Sudbury Massachusetts. 2011.

Shah, Jay P. and Elizabeth A. Gilliams.  Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis:  An application of muscle pain concepts to myofascial pain syndrome.  Journal of Body Work and Movement Therapies. Vol. 12: 371-384. 2008.

Shah, Jay P., Terry M. Phillips, Jerome V. Danoff and Lynn H. Gerber. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 99: 1977–1984. 2005.

Sikdar, Siddartha, Jay. P. Shah, Tadesse Gebreah, Ru-Huey Yen, Elizabeth Gilliams, Jerome Danoff, Lynn H. Gerber.  Novel Applications of Ultrasound to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue. Arch Phys Med Rehabil Vol 90:  1829 -1838.  2009.

Skootsky SA, Jaeger B, Oye RK.  Prevalence of myofascial pain in general internal medicine practice.” Western Journal of Medicine. Vol. 151:157–160. 1989.                                                                          

Tough, E.A, A.R. White,  T.M. Cummings, S.H. Richards, J.L. Campbell.Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. European Journal of Pain.  Jan;13(1):3-10. 2009. 

Wise, David and Rodney Anderson.  A Headache in the Pelvis: A new understanding and treatment for chronic pelvic pain syndromes.  Sixth Edition.  National Center for Pelvic Pain Research.  Occidental CA. 2011. 

 

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15 Responses to More Myofascial

  1. Pam Ellison says:

    Amy — I believe your article has led me to a possible explanation of an experience I have had periodically. I have had UTIs fairly regularly since I was 18 (I’m now 71), and have come to understand that my bladder is lacking a mechanism which prevents bacteria from attaching to its walls and causing infection. I have managed it in various ways, with the help of my physicians and urologists — mostly by taking a low dose of antibiotics with intercourse, washing before and after intercourse, drinking lots of water etc. But sometimes I develop referred pain in the pelvic area and in my lower back which does not immediately resolve even when a culture shows no infection. It eventually goes away, but it is very troublesome. You mention several physicians in your article — to which one would you suggest that I go? I live in DC.
    Thanks, Pam

    • admin says:

      Hi Pam, I also had the UT symptoms on and off for years with this (although I was never treated with antibiotics because there was no sign of infection). The treatment that finally made the difference for me was reading A Headache in the Pelvis and attending Dr. Wise’s clinic in Santa Rosa CA where they show you how to use an internal wand to release trigger points on the pelvic floor that can cause (at least in my case) the urgency and frequency feelings.

      In the DC area, I also got a lot of help with pelvic floor tightness and pain from Ann Udofia, a very gentle PT who does internal pelvic floor release (at least she did at the time). She has now opened her own practice. I don’t know if she is still doing the internal pelvic floor work, but you can check out her website at: http://www.wellness.com/dir/2615781/physical-therapist/va/arlington/ann-udofia-body-connect-physical-therapy-dpt

      best of luck, Amy

  2. Louise Kelley, PT says:

    I read your article in today’s Washington Post. Through your accurate description of the etiology of trigger-point referred pain, and the frustrations associated with getting a proper diagnosis, you have provided much-needed direction and hope for others afflicted with this syndrome. Thank you for a well-written and enlightening article.

  3. Leslie Sarapu says:

    Hi,
    I found your article in the Post really interesting. I just wanted to share a potentially related issue – pelvic organ prolapse. I am 35 and experienced this after my first child was born (most women experience prolapse after menopause). I did a lot of research and the most effective and least invasive way to manage my symptoms has been changing posture. I thought you might find this website interesting — I owe a lot to this woman! http://wholewoman.com/
    Best,
    Leslie

  4. L says:

    I have read Headache in the Pelvis books, studied/tried myofascial release, trigger point therapy, massage, dry needling, ART, Graston, stretching, spent 5 years with 10 different pelvic floor therapists, multiple surgeries and STILL I have tight pelvic floor muscles and severe pain. Most people cannot travel to CA, especially from the east coast with IC/pudendal nerve pain, not being able to sit or able to afford the 4-5 thousand dollars, Dr. Wise’s facility charges for his treatment or the home care work that involves having a partner to participate in doing the internal work.

    Can you please describe the relaxation technique that Dr. Wise prescribes. Why is this such a deep secret? Do they make you sign an agreement not to disclose this piece of information?

  5. admin says:

    Hi L,
    The thing I actually found most useful about the Wise clinic was the internal wand. David Wise has designed a smoothly curved tool that anyone can use themselves to apply pressure on trigger points on their pelvic floor and release them. You can do it yourself at home as needed. It received FDA approval last fall. You don’t need a partner to do this.

    They don’t make you sign an agreement not to talk about the relaxation technique, but it is a challenging practice and I think he wants to make sure that people do it correctly so that they don’t get frustrated and give up on it. In my experience, it takes a lot of practice (much like meditation) to shut down the thoughts and pathways that cause me to (pretty much reflexively) clench my pelvic floor muscles (often in response to stress, which is pretty much all the time for many of us in modern life). I’m still working on this.

    The cost is definitely a challenge. You might try calling Dr. Wise and talking with him about your situation and see what he says. I did that when I was considering going and he called me right back and we spoke for a half hour or so.

  6. The most important part of Myofascial Trigger Point Therapy is identifying the Perpetuating Factors (what’s actually causing the pain) If your postures…hip height..Morton’s toe..diet are not looked at, it will most likely be a temporary fix. I had migraines and back pain for over 20 yrs. I’ve been pain free now for the last 12 yrs of my life. I am now a Trigger Point Therpaist who closely follows Dr.Janet Travell’s protocol. Too many people try to go right to the trigger point right away. I do not work on my patient on the first visit. I find the “why” of their pain and have them make the changes that are necessary to relax the tight shortened muscles. After they have corrected the perpetuating factors I can then release the trigger points and they have a much greater chance of staying pain free. I try to see my patients typically 2 to 6 times depending on how long they’ve had their pain. If you get a minute…Google “the chronic pain center, springfield, va” That’s the name of my business and I enjoy helping others get pain free. I’ve been there myself with the pain. I was on 80 pain pills a week 12 yrs ago……no more….Thank God. I’m here if anyone has any questions.

    • admin says:

      I agree completely about perpetuating factors – that has been my experience. In my case, poor posture and constant clenching of abdominal, pelvic floor, and hip seem to be the cause of my pain. And so I am now constantly aware of how I’m holding my body, so I can minimize recurrence. Trigger points do recur if I’m not careful (which often happens during times of stress). But I now know what’s causing the trigger points, and I know how to treat the trigger points once they form, and so I can manage my MPS without major disruption in my life.

      “Metabolic” factors can also be an issue. Dr. Taylor ran extensive blood tests when I first consulted him, because some deficiencies are believed to contribute to myofascial pain. My thyroid and vitamin D levels were low, and so we treated those as part of my treatment.

  7. PJ says:

    I enjoyed your article in the Post and it has so much more relevance than just what happens in the pelvic region. Some of the techniques you mention to deal with the trigger points are really some sort of deep tissue massage and I was curious why you didn’t mention massage as a treatment for these muscle knots? As a competitive racquetball and street hockey player, I did extensive research when I experienced debilitating pain in my calf that kept me from playing my sports. The doctors sent me a vein doctor to ensure I didn’t have a blood clot, but then couldn’t figure out what was wrong. During the course of my own research, I came across the web site of Julie Donnelly – http://www.julstro.com. She does a fantastic job of describing what happens in the muscles, what trigger points are, and why simple stretching is NOT the answer when you’re dealing with muscle knots. She lays out a wonderful way for you to treat yourself when you experience muscle pain. I’ve even visited her twice to get treatment for various muscle-related issues. I now make it a point to get deep tissue massage locally once a month to ensure I get to keep playing my sports.

    You did some wonderful research and provided some very helpful advice for dealing with trigger point issues. I just wanted to add that deep tissue massage could be another tool to help deal with the issue.

    • admin says:

      I was helped tremendously during all of this by a manual therapist who did deep tissue work on me weekly for more than a year (externally) and a PT who used the Barnes method of release on me internally. The problem was that the trigger points kept coming back. Dr. Taylor was the first one to run blood tests for metabolic conditions that were likely contributing to that (low vitamin D and hypothyroidism), adjust my posture to reduce recurrence, do extensive dry needling repeatedly on each muscle to remove the worst of the trigger points, and direct me to David Wise’s protocol, which includes deep relaxation to reduce recurrence and an internal wand to self treat my internal points. For me, it took multiple therapies over a period of months to get significant, meaningful relief. I still get trigger points, but I can keep it manageable and treat it myself now.

      Thanks for sharing your experience.

  8. Pat Dean says:

    WOW! Your description of your symptoms matched my problems very closely. I had just about given up hope of ever finding out what was wrong with me. I was dx with interstitial cystitis over a year ago and have stopped eating many foods and hardly ever leave the house because I am always hurting and riding in a car just makes it that much worse. Even though, I am taking elmiron for IC, I still hurt all over. It seems as though my pain is spreading more and more. I also have been to many doctors. Your article made me realize that what I am feeling is real.

    I tried to make an appointment with Timothy Taylor of Pain Relief Home, Richmond, VA, but the phone number listed online for him is no longer in use. 804-320-1128 at 1702 Homestead Ct. Richmond, VA 23235. Do you know of another phone number for him? Thanks again for your very supportive article!

    • admin says:

      Hi Pat,

      I had the same food situation – I went on the IC diet when I was misdiagnosed and found that following it strictly reduced my bladder symptoms substantially. And so I stuck with it even though it made a social life impossible (it’s amazing how much of our interaction with other people is over food and drink – and I couldn’t eat most foods or drink anything other than plain water or chamomile tea) and I missed food with flavor desperately. The other symptoms emerged in the months after that. I assumed they were a totally separate problem, and that somehow I was having a terrible string of bad (health) luck. It took a long time before I realized they were connected. But trigger points in the pelvic floor can cause the bladder pain and urgency and frequency symptoms. Treating those trigger points has made a huge huge difference in my life.

      Dr. Taylor is no longer practicing. However, Dr. Robert Gerwin in Bethesda treated Dr. Taylor for his myofascial pain, and he and his partner Jan Dommerholt trained Dr. Taylor to treat others. Dr. Gerwin’s practice is called Pain and Rehabilitation Medicine. Their website is: http://www.painpoints.com/. I also strongly encourage you to check out Dr. David Wise’s website and book, which I mention in my blog post above. Ultimately the only way I got real relief from the bladder symptoms was treating the trigger points internally using Dr. Wise’s techniques. If you think these techniques will help you, call him and talk about your symptoms. I called him after I read his book and spoke with him about my symptoms. I decided to attend his clinic after speaking with him. It is expensive, but it has helped me get my life back.

      Good luck and be persistent. This takes time.

      best wishes, Amy

  9. Pat says:

    Hi Amy

    I am also down to drinking only water or chamomile tea. I like chamomile tea, but I am so tire all the time that I don’t drink it very often. I can’t even watch one hour long TV show without falling asleep. I also felt that my other symptoms were not related to my IC. I even make my own bread to keep chemicals out of my diet.

    Thanks for getting back to me so quickly. I went to the Pains Points web site. There was so much information that I printed out the articles so that I can sit down and read them that way I can highlight points of interest. I also have a copy of Doctor Wise ‘s book which I will read again. I will also call Doctor Robert Gerwin about scheduling an appointment. I finally have some hope after months of no hope. How did we get so lucky to get this problem? Take care Pat

  10. Stan says:

    Hi Amy–

    I have been meaning to write you for some time regarding your excellent Post article on myofascial pain. I am a patient of Dr. Gerwin, and have found his therapies most helpful but temporary. What I have found most effective are the recommendations of Dr. John Sarno, particularly in his books “Healing Back Pain” and “The Mind-Body Prescription.” My daughter gave me his first book and I knew upon reading it that this was the answer for me.
    While most physicians regard his views as focusing on “psychosomatic” disorders, I believe they have real relevance, particularly his view that most muscle pain is caused by stress, tension, and repressed anger. Following his advice has given me the only sustained relief in more than seven years of neck and back pain.
    You may want to explore his ideas, which I believe are largely ignored by mainstream medicine.

    Many thanks again for your article.

    • admin says:

      Stan, thank you for writing. I agree that for some of us, the pain starts with our thinking. In my case, I found Dr. David Wise’s book and clinic (mentioned in the blog post) really hit the nail on the head for me as the ultimate source of my pain. Dr. Wise has found that many people with pelvic pain chronically clench their pelvic floor muscles and abdomen in response to stress and as a protective mechanism. This chronic response to stress fatigues the muscles and leads to trigger points. His therapy includes something he calls paradoxical relaxation, to help people recognize and release this tendency. I’m still trying to master paradoxical relaxation, but I can see now how my tendency to respond to stress this way creates new trigger points. I agree, to resolve these problems, many of us need to address the thought patterns that lead to muscle tension and pain need to be addressed.

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