Curr Urol Rep (2013) 14:409-417
MTrP: Knots in taut muscle bands that produce pain,
local or referred. Twitch response when palpated; active or Latent,
Trigger points of the pelvic floor are almost always accompanied by “high tone” pelvic
floor muscular dysfunction (HTPDF)
Pain with MTrP attributed to high local concentrations of inflammatory
mediators, neuropeptides and neurotransmitters.
Stimulation of local nocioceptors elicits pain- local and referred.
Shah study: n=12, 3 groups- no pain, no TrP (normal)
no
pain, TrP present (latent)
pain,
TrP present (active)
Needle inserted to UT, advanced to elicit Local Twitch response (LTR)
in active and latent groups. LTR confirmed
by EMG. Active group showed higher bradykinin, CGRP, substance P,
TNF-Alpha, IL-Beta, serotonin and norepinephrine than nl group. pH lower in
active group.
2008 repeat study on gastrocs. Same results and increased IL-6 and IL-8 AND opposite
uninvolved gastroc had same result of elevated chemicals in active group versus
latent and normal groups. Inflammatory
response goes beyond focal process. (Central Sensitization? Fibro?)
MTrP also local nocioceptor sensitization, local ischemia and
sustained release of acetylcholine. Results in local twitch response ,
contracture of sarcomeres and knots.
IC/BPS, CP/CPPS, Vulvodynia and MTrP
IC/BPS : c’stics:
urgency, frequency, PP, discomfort. May not be bladder based, but HTPFD and
MTrP. Same for CP/CPPS and vulvodynia.
Many failed treatments or suboptimal results with organ based
therapies.
85% of IC/BPS have MTrP and
HTPFD can account for irritative and obstructive void symptoms.
AUA guidelines for IC/BPS recommend PT for HTPFD.
Berger study found that men with CP/CPPS have both int. and ext. MTrP
assoc with increase pain in non-prostatic locations.
Involves entire pelvis.
Label of Prostatitis can
misguide the plan.
Women with vulvodynia- Pain cycle of HTPFS lead to decreased strength
and TrP from clenching. (Defense reaction).
HTPFD has been postulated to activate vulvar mucosal sensitivities.
Leads to viscous cycle. IC may resolve when bladder treatment fail and therapy
is directed to MTrP. So, good history taking and exam needed to properly ID
MTrP.
Treatment of MTrP
Must treat underlying cause and active TrP.
Treat via Behavior Modification : modalities, biofeedback, avoid Kegel
and Valsalva, paradoxical relaxation.
Control Constipation: Often
found with chronic PP due to Hypertonic PF
Heat, Ms. Relaxants,
Physical Therapy: stretching, MFR. Studies show Myofascial treatment
had best results.
Trigger Point injections
Dry Needling:
Literature indicated that needle effect is more important than
substance injected. Ay et al study showed substance injected isn’t as important as injection itself.
Tsai study showed beneficial effects distant to
site of injection. Pts with unilateral shoulder pain from MTrP at UT received
sham needling to ECR , control: Dry needling to ECR. Statistically improved pain, Cervical spine
ROM as compared to control group. ( No mention of results at shoulder)
Good for CPP pts too sensitive to receive needle to primary area of pain.
Good for CPP pts too sensitive to receive needle to primary area of pain.
How does it work?
1. Mechanical disruption of ms. Fibers and nerve
endings depolarize nerve endings
2. Interruption of pos. feedback loop that
perpetuates pain
3. Dilution of nociceptive substances by anesthetic
4. Vasodilation from anesthetic to remove excess
metabolites
5. Endorphin release
6. Release of nocioceptive /inflammatory
biochemical
Injections
versus dry needling can be beneficial to decrease post injection soreness.
Injection
Technique
25 or
27 gauge needle 1.5 in – 8 in. Guided to vaginal, sub gluteal and
perineal region. Stretching of Theile’s massage
afterwards. Up to 3 treatments for relief.
Discussion
1. Clinical Applications:
2. Experiences with Dry Needling or pts who have
had injections
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