What are the treatment options for trigger points?

Treatment Options for Trigger Points

Manual trigger point therapy is strongly recommended as a first-line treatment for trigger points, providing significant pain reduction with minimal risk of adverse effects. 1

Definition and Characteristics

Trigger points are discrete, focal, hyperirritable spots located in taut bands of skeletal muscle that produce both localized and referred pain patterns 2. They are characterized by:

• Hypersensitive nodules or bundles of muscle fiber with harder-than-normal consistency
• Pain on direct compression
• Referred pain to characteristic zones
• Local twitch response when stimulated
• Decreased range of motion in affected muscles 2

First-Line Treatment Options

1. Manual Trigger Point Therapy

Manual trigger point therapy involves direct pressure and manipulation of trigger points by a trained therapist. This approach:

• Provides significant pain relief, approximating twice the minimally important difference in pain reduction 1
• Has strong evidence supporting its effectiveness for chronic pain conditions, particularly temporomandibular disorders 1
• Carries minimal risk of adverse effects 1
• Can be combined with other conservative approaches for enhanced effectiveness 1

2. Supervised Exercise Programs

• Supervised jaw exercise and stretching with manual trigger point therapy: Strong recommendation based on moderate to high certainty evidence 1
• Supervised postural exercise: Improves pain and function with minimal risk 1
• Home exercise programs: Can be taught as part of usual care for ongoing management 1

3. Heat Therapy

• Local application of heat to trigger points has been shown to significantly reduce pain in neck and plantar fascia trigger points 3
• Heat therapy provides greater pain relief than sham treatments 3
• Can be used as a home-based alternative to more invasive treatments 3

Second-Line Treatment Options

1. Spray and Stretch Technique

• Involves spraying a vapocoolant over the affected muscle followed by passive stretching 4
• Non-invasive approach that can provide immediate relief 5
• Best used as adjunctive therapy rather than standalone treatment 5

2. Trigger Point Injections

• Effective for prompt relief when conservative measures fail 2
• Options include:
  • Local anesthetic injections
  • Dry needling (insertion of a needle without medication)
  • Corticosteroid injections
  • Botulinum toxin injections 4

Caution: Trigger point injections carry a conditional recommendation against their use in the BMJ clinical practice guideline due to potential moderate harm (such as local infection) with uncertain benefits 1

3. Other Physical Modalities

• Transcutaneous electrical nerve stimulation (TENS): Conditional recommendation against use due to uncertain benefits 1
• Low-level laser therapy: Conditional recommendation against use due to uncertain benefits 1
• Ultrasound: Limited evidence for effectiveness 4

Comprehensive Management Approach

1. Start with manual trigger point therapy as the primary intervention 1
2. Add supervised exercise programs including postural correction and specific stretching 1
3. Incorporate heat therapy for home management 3
4. Consider cognitive behavioral therapy if pain persists, as it provides significant pain reduction 1
5. Reserve trigger point injections for cases that don't respond to conservative measures 2

Common Pitfalls and Caveats

• Failure to identify perpetuating factors: Posture, body mechanics, psychological stress, poor sleep, and nutritional deficiencies can perpetuate trigger points and must be addressed 5
• Overreliance on passive treatments: Active patient participation through exercise and self-management is essential for long-term success 1
• Focusing only on local pain: Trigger points often cause referred pain patterns that may be the primary complaint rather than the local tenderness 6
• Inadequate palpation technique: Proper diagnosis requires accurate palpation with 2-4 kg/cm² of pressure for 10-20 seconds to elicit the referred pain pattern 5
• Using invasive procedures too early: Invasive treatments like trigger point injections should be reserved for cases that don't respond to conservative approaches 1

Manual trigger point therapy, supervised exercise, and heat application represent the safest and most effective first-line approaches for managing trigger points, with the strongest evidence supporting their use for reducing pain and improving function.