Myofascial Pain and Trigger Point Creation

Fibrosis in the Elderly

The evolution of trigger points in the Elderly

Latent Trigger Points in the Elderly

Many people keep some—maybe even most—of their body parts practically immobile. That is, they use certain parts of their bodies in a guarded, tightly restricted range of motion. This is especially true of elderly patients. Many of these people have trigger points in these relatively immobile tissues, although most of the trigger points are "latent." This means, of course, that the trigger points aren’t actively referring pain.

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Travell and Simons (the authors of the famous Trigger Point Manuals) have pointed out that many elderly people have latent trigger points. They say these people seem to automatically restrict their range of motion to avoid activating and suffering from their trigger points. Based on this principle, these elderly people’s myofascial tissues are more likely to be fibrotic. This is likely because their reduced mobility permits type I collagen fibers to cross-link extensively throughout their bodies.

The cross-linked collagen will exhibit physiological movement —that is, a steady pulling in on itself. The creep will cause the pressure within the tissues to increase to a critical point. Blood flow will diminish, perhaps to the level of ischemia, and pain mechanoreceptors will be activated. At this time, the people will begin experiencing pain although they restricted their motion to avoid it. This is consistent with the view that the amount of collagen in connective tissues increases with age, making old animal meat tough. While the amount of collagen increases, the collagen fibers also develop extensive type I cross-linking.

As the years pass, many people restrict their body movements more and more. Eventually, their capacity for mobility becomes markedly reduced and they generally perceive stiffness. Mobility is important to tissue fluid exchange, and so their limited mobility seriously reduces blood flow. Blood flow in some circumscribed areas becomes so sluggish that the tissues become distinctly ischemic.

This makes a strong case for stretching activities of yoga and the field of flexibility training

At that stage, real trouble begins. First, energy-deficiency contractures can form and create trigger points. Far worse, though, the ischemia can cause muscle fibers to deteriorate. At the same time, fibroblasts become active and increase their output of collagen, bringing about some degree of myofascial fibrosis. The collagen fibers of this fibrotic area are likely to form cross-bonds that will tighten the tissue even more.

If the receptors of nerves are trapped in this squeezing fibrotic tissue, you are likely to experience local tenderness and referred pain. These nerve responses are also likely to increase neural firing in the segments of the spinal cord they enter. This will stimulate motor fibers at the same level and cause hypertonicity of the associated para-spinal muscles. The nerve signals will also ascend to the brain stem and stimulate their reticular activating formations. The signals will also reach the thalamus. From there, relayed signals will stimulate cortical centers, disturbing thought and perception. The signals will also reach the basal (limbic) areas of the brain beneath the thalamus, which can produce disturbed emotions and interfere with the body's general homeostasis.

When relatively immobile myofascia lead to pain, freeing the patient from it may be difficult. Patients with fibrotic tissue aren't as responsive to therapy as patients whose source of pain is muscle contractures. There are at least two reasons for this.

First, fibrotic tissue can only be softened or stretched, and its cross-binds broken. In between therapy sessions, the tissue can shorten again unless the patient works diligently to keep it elastic. Client complinance is always an issue in trigger point treatments and training and recommendations for home care are indicated.

Second, many people who’ve minimized their movements to avoid myofascial pain have lost mobility and become generally stiff. They may lack the flexibility to cooperate in stretching muscles that house painful contractures and trigger points. For some of these people, relief can come only from therapies such as ultrasound and cross-friction massage that soften fibrotic tissues. Stretching the involved tissues, however, is fundamental to long-term improvement. If the patient isn’t able to effectively stretch because of severe inflexibility, training in this area is required.

Dr. John C. Lowe