Headache is the most common single complaint reported by patients seeking medical care. The next most common complaints, in sequential order, are neck and back pain. It has been estimated that close to ten percent of the population of the United States suffers from chronic headache pain. An even larger group suffers from combinations of head, neck, and back pain. Everyone is familiar with the seemingly endless TV and magazine advertisements for over the counter pain medications. They sell hundreds of tons of that stuff every year for a very good reason reason. Pain is big business, and big business has no interest in changing that fact.
Chronic headache sufferers have usually consulted their family doctor and other medical specialists about their problem many times. They undergo medical test after medical test without any definitive result. Many patients have been told by at least one physician that there is nothing wrong with them, or that it is "all in your head"; which can be quite demoralizing. Sometimes they get some relief from prescribed medications, but medications that can handle chronic headache pain commonly have side effects that make them undesireable for long-term use. More often, they get little, or no relief, in spite of taking numerous drugs. Many victims just give up and stoically adapt to a position of tolerating their pain rather than continuing to take medications that interfere with their daily routines.
Many chronic headaches, and the neck and shoulder discomfort that often accompanies them, are related to an improper jaw relationship, and occasionally, to a damaged jaw joint. When the lower jaw is not functioning correctly in it's relation to the upper jaw numerous muscles that control jaw motion can develop painful muscle spasms. In addition, the same muscles that allow you to use your jaw in chewing, speaking, and swallowing have important additional functions to perform in balancing your head on your neck. When you have headaches, it is common to also have neck discomfort at the same time. When the neck is sore, it doesn't take much more insult to begin having problems with your shoulders.
A significant portion of chronic headache pain and neck pain may actually represent REFERRED PAIN from another area. A surprising percentage of head pain is just that, referred pain. Referred pain means that where you feel the pain may not actually be the area where the problem is located. For example, pain from a TRIGGER POINT area in the shoulder muscles can be interpreted, and really felt, as a headache as far away as the forehead.
Chronic head and neck pain is very difficult, maybe even impossible, to treat if the only focus of therapy is on the symptom. Medications directed at relieving pain cannot correct misalignment of the jaw, reverse the damage within the jaw joints, or silence active trigger points. Medications have their place, but the major focus of treatment should be on properly evaluating the problem as a first step, planning what treatment modalities would best neutralize the painful effects, correcting the misalignment problem, and eliminating any active trigger points in the muscles that may be involved in the pain pattern. Applying treatment in the proper order, it is often possible to significantly change the degree of pain severity and pain duration that a patient may experience throughout the head and neck area.
Chronic pain has other physiologic effects that must be discussed, especially when it has been present for a long time, maybe even years. Chronic pain sometimes becomes part of you in a way that almost defies explanation. You probably have heard of something called "phantom limb pain" in someone who had a leg, or arm amputated. These individuals experience real pain sensation in the missing limb and even feel they can move the missing part. Chronic head and neck pain sometimes produces a similar effect, even though the true cause of the problem has been corrected. This doesn't mean you cannot be helped to some degree if you have a chronic problem, but it does means that you may never reach a point of being totally pain free. Most of the time a 2/3 reduction in severity of pain symptoms is a reasonable expectation with proper therapy.
Every patient with headache pain presents a unique problem and an equally unique set of physical findings. A detailed Patient History is the first step. The more you can tell me about your pain and how it affects you, the better I can understand what may be going on. Next, your painful symptoms must be evaluated carefully before any treatment suggestions can be made and this will require a careful physical examination of your head, neck, and mouth. Dental impressions will be taken to help evaluate your bite and jaw relationship. X-rays of your head, jaws, and jaw joints may be required to help in arriving at a proper diagnosis.
Finally, you may find yourself wondering what a dentist, and especially an orthodontist, is doing treating headaches? Lets just say that in cases where your headache is coming from a misalignment of your jaws and teeth, dentists are the only practitioners who can legally provide the type of treatment you may need, and orthodontists are specifically trained in evaluating your bite and providing treatment of these problems.
Read through the following list. Chances are that you will have some of the symptoms listed. If you have two or more of these symptoms, then you probably have some degree of temporomandibular joint dysfunction and you may even have active trigger points and referred pain. Whether you need treatment is a decision that will not be made until you have had a thorough evaluation of all of the anatomic structures that are associated with the problem.
1. HEADACHES - in the temples, front of head, back of head, between your eyes.
2. PAIN IN NECK, SHOULDERS, OR BACK. STIFFNESS. NUMBNESS IN FINGERS
3. PAIN IN FRONT OF YOUR EAR
4. CLICKING, POPPING, OR GRATING SOUNDS IN JAW JOINTS
5. LIMITATION OF JAW OPENING OR RANGE OF MOTION
6. GRINDING AND CLENCHING OF TEETH, VISIBLE TOOTH WEAR
7. MUSCLE FATIGUE FROM CHEWING
8. PAIN FROM CHEWING-- DURING, OR AFTERWARDS
9. STUFFINESS IN EARS, or even RINGING IN THE EARS
10. DIZZINESS
11. BONE LOSS AROUND TEETH, GUM RECESSION
12. CHRONIC SORE THROAT, OR UNUSUAL PRESSURE SENSATIONS
13. PAINFUL SWALLOWING, or LUMP IN THROAT WHEN SWALLOWING
14. PSYCHOLOGICAL DEPRESSION mainly coming from an inability to shake off a pain problem
Anything else you may feel is associated with your problem can be added to the list here, or on your PATIENT HISTORY Form.
You can feel the jaw joint slightly in front of your ear. When you open and close your mouth, or waggle your jaw from side to side, you can feel the condyle of the mandible move within the joint capsule. The jaw joints are very mobile.
The jaw joint, TMJ, or temporomandibular joint, is made up of three bones. The mandible is one, and the temporal bones of your skull on the right and left side make up the other two. These joints are unique in that they are the only ones that function on both sides of the body at once, and they are the only ones that are located on the opposite ends of one bone.
If your TMJs are working properly, you can feel another unique thing about them. As you open your mouth, the condyles slide downward and forward in the sockets. That motion is called TRANSLATION, and it is an important part of jaw function because it lets you move your jaw (and teeth) from side to side during normal chewing. The unusual aspect of these joints is that they allow rotation, or hinge-type movement, sliding movements forward and backward, and side to side movement. A schematic view of a typical TMJ is shown below.
The FIBROCARTILAGE DISC is supposed to stay between the condyle and the socket, or FOSSA, during all of the possible motions the joint can make. When things are working correctly, the disc is almost impossible to dislodge from the normal location. However, that is not the situation in a large percentage of people for some reason.
It has been estimated that about 50% of people have one, or both, articular discs displaced forward, or ANTERIORLY, in the joint. Actually, the displacement is really more inward than forward. This results from the direction of pull from the muscles attached to the joint structures This displacement can be the result of numerous factors, one of which can be a poor bite relation. It is also my personal feeling that a large proportion of these dislocations are related to injuries sustained in childhood. Little kids fall down a lot. In the process, a lot of them end up hitting their chins. They get up, cry for awhile, then go back about the business of being a little kid. Unfortunately, they may have also done enough damage in the area of the joint to guarantee developing some problems later in life. Another large percentage of disc dislocations are related to trauma sustained in sports, fights, and vehicular accidents, but that is another area where a lot depends on a patient's ability to associate an incident in the past with an effect in the present. Most of the time the cause remains a mystery.
About half-way up the dome shaped condyle is an important growth center for the whole lower jaw. In youngsters, the whole surface of the condyle is covered with thin layer of cartilage covering a fairly weak dome shaped layer of bone. This area of the mandible is made up of bone that is less dense than the rest of the jaw and resembles something like a sponge covered by an eggshell. Relatively insignificant blows to the chin can crush that thin bony layer and disrupt the smooth contour of the cartilage layer. This creates a rough area on the condyle that may be involved in gradually displacing the disc by decreasing its normal motion and stretching its attaching ligaments. The condylar bone heals well enough because it has a good blood supply, but the cartilage layer is a different matter. Significant damage doesn't have to hurt more than a few days, but the damage is done. Bumps on the chin that produce a bruise, or small lacerations needing a stitch or two, are common. In actuality, there isn't much more you can do about it at the time, so it is often forgotten by all concerned. However, remember that Murphy"s Law does state that if anything can go wrong, it will.
Getting back to our anatomy lesson, there is one other thing about the TMJs and mandible that really makes it unique. The mandible is the only bone that has the same joint on both ends, but it is also has additional complexities. Taking up a good portion of the total structure are those things we call TEETH. The teeth in the mandible are designed to function against teeth in the upper jaw, or maxilla. The primary function of the jaws is chewing. A lot of us are able to do that even though our teeth may not exactly fit where nature intended them to fit. The teeth and jaws, and the muscles that are responsible for running the mechanism properly only perform correctly when they are working very closely within the design specifications Mother Nature.
Very few animal species can compete and survive in the wild if they have any problems with their teeth and jaws. There really aren't any examples of lions and tigers with malocclusions to show. That problem, although it could exist from a strictly genetic point of view, is quickly eliminated by Mother Nature. Imagine the problems a turtle with a bite problem would have. Human beings are not quite the same. We have been able to survive in spite of having what we term MALOCCLUSIONS. Instead of everyone looking like a movie star, we have great INDIVIDUAL VARIATION between people - even children in the same family. That individual variation is also responsible for the errors in one person's bite compared to another's. After due consideration, it is really remarkable that we get along as well as we do, but it also helps to explain why we have problems with a joint mechanism that seems to work quite well in other animal species. It is another price we pay for what we are.
Human beings can have malocclusions where the upper jaw is too far forward. We can have malocclusions where the lower jaw is too far forward. We can have malocclusions where the upper jaw is too narrow. We can have malocclusions where the lower jaw is not forward far enough. This doesn't even scratch the surface when you start to add in little things like crowded teeth. Suffice it to say that the possibilities are endless when it comes to things that can play havoc with the "normal" operation of the temporomandibular joints. Very few people have ideally functioning occlusions, but most of us are able to get along without much bother. Headache is just one of the problems that come from having that INDIVIDUAL VARIATION. However, a lot of the time it is possible to improve the way things function and compensate Mother Nature's errors to some degree.
Now that you have some reasons explaining why you might have headaches from a anatomic and developmental point of view, you still have to get some information on WHY they happen.
An alligator has a simple bite mechanism. He is limited to just an opening and closing movement because his jaw structure doesn't allow anything else. His teeth are aligned in such a manner that the upper and lower teeth form something very much akin to a shear. The edges of his teeth meet in a manner very much like the triangular cutter bars on a farmer's harvester, or brush cutting machinery. Anything caught in the mechanism is just cut off neatly by the scissors and swallowed whole. The same type of jaw and tooth mechanism exists in most of the carnivorous animals. A simple cut and swallow mechanism that is very efficient.
Things get a bit more complicated in animals that eat vegetable matter, or what are termed herbivores. This type of diet requires as lot of chewing to crush and grind up the tough materials they use for food. Human beings are a combination of carnivorous, and herbivorous, and this is called omnivorous. It means that we can both use our teeth to cut and shear things using our cuspids and incisors, and it also lets us grind up the tougher food items with our molars. This mechanism requires a joint that can shift from side to side as well as allowing opening and closing. The design is really rather clever.
The pattern of chewing that we have developed as a result of our heredity is mostly a grinding action that relies on the molar teeth in the back part of our mouths. One very important feature of this grinding action in the ideal occlusion is that food is actually mashed between the molars without direct molar to molar contact except in a straight line closure. This grinding action, without actual physical contact of the molars, is supposed to be the result of the way our cuspid teeth contact during the chewing cycle. Ideal functional occlusions disconnect the molar areas almost immediately once the lower jaw starts to shift to one side or another.
Molars are designed to take a lot of pressure in a direction going directly down the roots. Pressures applied from side to side can have a damaging effect on the teeth over time, and we have a lot of other mechanisms attached to the chewing apparatus that are designed to prevent this potential overload. One of the most important of these is the neurologic feedback mechanism that causes some of the smaller muscles attached to the lower jaw to pull things this way and that to avoid any unwanted molar contacts. These small muscles, known as the PTERYGOID GROUP, allow small adjustments in position of the lower jaw, and teeth, during chewing so that potentially harmful tooth contacts are avoided. These muscles are the same ones that let you swing your jaw from side to side and go forward to bite on the edges of your front teeth. Generally, similar, but much smaller motions occur constantly when you are chewing something, but you hardly even notice these changes. You have really learned these motions so well that they have become automatic and almost reflexive.
Most of the time that protective mechanism works fairly well. Sometimes, it is called on so constantly during the chewing process that it actually overworks these positional adjusters to the point that they become hyperactive and sore. This is the beginning of work overload and these muscles can CRAMP and go into SPASMS as a result. Unfortunately, again, these same muscles are intimately involved with proper operation of the temporomandibular joints. They attach directly to the condyles and the discs within the joints. Hyperactivity and muscle spasm of the pterygoid group is one of the prime causes of TMJ DISC DISLOCATION. The muscles, by never relaxing an abnormal pull on the discs, begin to gradually draw the disc ever more forward in the joint. The ligamentous connection of the discs at the back of the joint gets stretched more and more, and the discs can gradually assume a position forward of their normal position. Of course, this can go on for a long time without anyone ever being aware of what is happening. Most often this happens in childhood and no one, including the patient, is any the wiser until a problem shows up years later.
Once the pterygoid muscle group gets trapped in a vicious cycle of muscle spasm the larger muscles that are involved in total jaw function are gradually enrolled in the problem. One common reaction of the whole group of muscles controlling the jaw is something we refer to as MUSCLE BRACING. This really isn't seen as a hard uncontrolled clenching action when it occurs, rather it is more like a normal protective mechanism that is being overdone for some reason. A little bit of muscle bracing might be a good thing at times, but there does not seem to be any fine control of the process within the whole group to engage a beneficial 10 percent bracing instead of a possibly detrimental 60 percent. Bracing can occur unilaterally in a single muscle, or involve a whole group. The presence of constant increased activity within any muscle can lead to development of muscle soreness. The greater the degree of bracing activity, the greater the degree of pain and soreness. Treatment of these problems should be specifically aimed at reducing the degree of bracing within the muscles, either through chemotherapy, or mechanical means. Classically speaking, this treatment process usually involves the fabrication of an appliance known as a bite splint, and the use of analgesic, anti-inflammatory, and muscle relaxant drugs to back up the mechanical part.
It would be great if everyone followed a set pattern in developing a problem with headache pain. Again, the usual thing is that everyone follows their own individual pattern. There are a few things that are commonly involved in the development of a majority of headache problems that relate to jaw function. One is JOINT SOUNDS. The only indication that something is not perfectly OK within the TMJs is usually the onset of a CLICKING sound during chewing. If you ever heard CLICKING or SNAPPING sounds within your joints, you probably have a dislocation of the discs. Sometimes this dislocation happens without ever hearing any noises at all.
Another important consideration that has to be addressed is the fact that you can develop temporomandibular joint related head and neck pain WITHOUT any outward sign of a problem within the joints themselves. The key to interpreting this type of pain is a thorough analysis of the pattern of pain. The culprits here can be minor changes in the bite relation, especially the changes that can take place as a result of tooth loss, and uneven bite caused by fillings or new crowns. Sometimes, the damage doesn't even show at the joints, it shows up as damage to the bone supporting the teeth.
So now you know that the NORMAL FUNCTION of the jaws can be messed up by a lot of little factors. TMD, or Temporomandibular Joint Dysfunction, as I prefer to call it, can express itself as a problem within the joint, in the musculature around the joint, or even in the bone supporting the teeth. You know that various malocclusions have a great influence on the development of muscle spasms, and you also know that a relatively minor deviation from the ideal situation can cause a lot of difficulty. Some people can exist very comfortably with gross abnormalities. Most people can tolerate a little bit of abnormal jaw and tooth function. As long as they stay within a relatively narrow range of misalignment, they can put up with the discrepancies. What happens to most adults that tips them over the edge and to the point that their tolerance level goes down to zero is adding a couple of other factors like the changes brought on by AGE, WEAR, TOOTH LOSS, occasionally TRAUMA, and the real killer, STRESS.
Nature assigns a lot of importance to the general area occupied by the mouth and jaws. The teeth, jaws, muscles, joint structures, and overlying tissues have a huge blood supply and are serviced by a staggering amount of nervous connections when compared to another area like a knee. Think about this for a minute. Could you feel the thickness of sandwich bag plastic under one foot and not the other? Of course you can't. However, you can easily discriminate something as thin as that with your teeth from one side to another. In fact, you can discriminate tooth contacts that are as small as the thickness of a red blood cell, or about 10 microns. That much sensitivity in a system we take so much for granted coupled with a high degree of sophistication in the neurologic monitoring network that runs it implies that it has some importance to Mother Nature. That sophistication is only the sensory side of the neurologic picture. The motor network is just as intricate.
Temporomandibular joint related headache pain really represents a series of cumulative and complicated causes and effects that can involve the bite relationship of the teeth, changes within the joint mechanism itself that come from age and possible trauma, the muscular system that is charged with making the jaw system function properly, the neurologic connections that monitor and control the system, and the individual's own level of tolerance for errors. Once the limits of individual tolerance has been exceeded, whatever the cause, the most common result is a vicious cycle of altered function, recurring and nagging pain, and discouragement. This pain is real and often quite debilitating.
As members of the human race, you and I share a lot of things in common. We can both have blue eyes and brown hair. However, when it comes to sharing, or even describing the feeling we call PAIN, all similarity ceases. Telling me that "it hurts real bad" does not assign any particular numeric value to your discomfort. The best thing I have been able to use to interpret your degree of suffering is the following line on the paper.
No Pain at All Worst Pain Imaginable!
0________________________________10
After some initial questions to let you describe why you are sitting in my examination room, we usually get down to an examination of your face, mouth, head, and neck.
A general appraisal of your facial features gives me a lot of information about how you are put together skeletally.
I examine the soft tissues of your face, lips, tongue, cheeks, and throat for any signs of problems in these areas.
I examine the teeth for a general assessment of their condition and the health of your gums and supporting bone. I count them and note what teeth are missing, if any. I look at how your teeth come together in your bite and if there are any possible problems in the way they fit. I look at how your teeth work together as you shift your jaw from side to side. I look at the wear patterns on your teeth and see if these match up with the way you are functioning at that time.
I examine how well and how rapidly your lower jaw moves during side shifts and into a protrusive bite.
I measure how far you can open your lower jaw, how far you can shift from side to side, and how far you can protrude.
I might have you bite on a soft object to see if bite pressure generates any painful sensations anywhere.
Next, I examine the muscles that attach to your lower jaw to see if they have any painful areas. This includes the muscles in your temples, cheeks, under you jaw, and deep in your mouth.
Next I check for trigger points in the facial skeleton and in the muscles of your neck and shoulder area.
TRIGGER POINTS - are defined as a small area of hyperirritability in a tissue, such as a muscle, that, when compressed is locally tender, and if sufficiently hypersensitive, can give rise to referred pain at a site that can be distant from the area being tested. Trigger Points can be MYOFASCIAL, CUTANEOUS, FASCIAL, LIGAMENTOUS, or PERIOSTEAL. This means they can be found in muscles, connective tissues, the skin, in ligaments, or on the covering layers of bones. Trigger points are responsible for painful symptoms that can range from very mild dicomfort, to pain that is on the same level as heart attack and broken bones.
Generally, trigger points in muscles exist as palpable nodules, or even bands of harder muscle tissue that can be felt with the fingers. There has been some confusion in terminology related to myofascial disorders because of tendencies to relate them to specific muscles. They are, however, basically the same thing and are probably best known as FIBROCITIS. You have probably heard of "tennis elbow". This is myofascial pain just as surely as it is" interstitial myofibrositis" and "myofasciitis", or "fibrocitis" depending on how doctors use the terms.
Your body contains about 400 pairs of muscles, any of which can develop myofascial trigger points that can refer pain and other disturbing sensations to other areas. Muscle tissue does the vast majority of work that the body performs, but it is probably lowest on the list of tissues that receive the attention of most doctors.
Active myofascial trigger points are responsible for a great deal of pain and suffering. ACTIVE means just that. Pain referred from these triggers is the symptom most patients report to their medical practitioners, and tons of analgesic drugs are prescribed for them every year with little result. Trigger points can also be LATENT. Latent means they are not actively referring pain to other areas at that particular time, but they are also not out of the picture, or absent. Latent trigger points are responsible for symptoms like STIFFNESS, and RESTRICTED RANGE OF MOTION, and they are much more common than one might believe. Latent trigger points are most common in the age range of 30 - 50, and that also happens to be the period when most myofascial problems also occur. Put two and two together.
ACTIVE Trigger Points, while not life threatening, cause pain of a level that does not respond to pain relievers even though these drugs are often the first thing prescribed. Active trigger points are also responsible for another underappreciated side effect, disturbed sleep. Failing to get any relief for these problems over a long period of time, many patients get discouraged (depressed) and often they simply stop taking medications and endure their suffering in silence.
1.) area wide aching of more than 3 months duration,
2.) localized tenderness at more than 12-14 area sites,
3.) skin roll tenderness over the upper back and scapular region, and
4.) a pattern of disturbed sleep with morning fatigue and stiffness.
TMD patients easily come up with 2 - 3 of these criteria, or symptoms. The clinician who overlooks some of these "other" factors in his zeal to slap in a bite splint, or begin correction of a malocclusion may really believe he is doing his patient a favor, but a careful analysis of the treatment OUTCOME may reveal a less than perfect result. One hundred percent cures are really unusual.
Most of the time I will take some x-rays of your jaw joints. These are taken when you are biting down with some force, and when you have your mouth partly opened.
The films are examined to see if your jaw joints are showing any signs of being out of the proper position, and if there is any bone damage present. I may also want some other x-rays, usually, a PANOREX film, which shows the teeth in both jaws at once, and even a special x-ray called a CEPHALOMETRIC FILM, which shows an accurate picture of how your head and jaws are aligned. This film can be used to show what is not correct in your general facial skeleton, and what might be done to change that situation.
I will take impressions of your teeth, both upper and lower jaws, in order to make a set of dental study models. These models can be mounted on a special dental device called an ARTICULATOR which can duplicate how your jaw and joints work for further study. I can get a picture of how your teeth function from a viewpoint that can't even be seen looking directly in your mouth. In some cases I even use another device called a FACE BOW, which lets me duplicate all the proper distances from teeth to joints for the articulator mounting.
The impressions also allow me to make accurate models of your teeth that can be used to make any treatment appliances I may need to treat your problem.
These models can also be used to demonstrate changes that may be needed in your bite so that you can see how things might look before any permanent changes are started.
Most of the time it is possible to get enough information assembled during the examination to make a diagnosis of your problem and begin a discussion about how WE are going to go about treatment. I say WE, because I have one part to play in the situation, and YOU have the other part to play.
Medical treatment of any kind is a cooperative venture between the doctor and the patient. My job is to find out what is wrong, and what kind of treatment should be suggested to the patient. Your job is to listen to what I have to say, and then make a decision as to whether or not you are going to go along with my suggestions. You have to wear any appliances I make, and most of the time this is going to cause a bit of inconvenience to say the least. Appliances may cause some temporary problems with your speech. They can feel bulky, they can make your teeth a bit tender for a few days, and you can find any number of reasons to gripe about them if you really want to gripe. Every effort is made to keep them as small as possible and every effort is made to make them comfortable. Expect some inconvenience.
Occasionally, I may ask that you consider getting some additional tests or x-rays done that I cannot do in the office. Sometimes this means going to one of the area hospitals for a CT-Scan, or MRI-Scan of the jaw joints. On some occasions, this could even mean having a radiologist do some special studies with injection of dye into the joints. That isn't done very often, but might come up. During the consultation I will explain the why and wherefore about these extra diagnostic studies.
The consultation is also a chance to discuss a lot of things about your problem and what might have to be done to help you. It is not a one way street. I like my patients to have a good understanding of their problems and what can be done for them. Essentially, you guys really do all the hard work, so I want you to understand the situation as it is, and what you have to do to change things for the better. Please do not be afraid to ask any question you might have. As your doctor, I am trying to provide a service that will be to your benefit. I need your understanding and cooperation as much as you need it from me.
Normal muscles do not have trigger points and are not sensitive to firm palpation. You basically can put firm pressure anywhere on a normal muscle without feeling any pain or soreness within the muscle, or anywhere else. Normal muscles do not refer pain to other areas. Normal muscles do not have twitches, or unwilled jerkiness. Abnormal muscles do develop trigger points, can twitch, and can refer pain to other areas.
Myofascial trigger points are defined as a hyper-irritable spot within a tightened band of skeletal muscle and its loose connective tissues. The spot where the trigger area exists is unusually quite painful when compressed and may possibly generate separate and distinct referred pain at another area. There may also be associated autonomic responses such as localized vasoconstriction, gooseflesh, sweating, tearing, salivation, and runny nose. Finally, trigger areas can cause disturbances in the normal proprioceptive mechanisms resulting in muscle stiffness and weakness, dizziness, imbalance, tinnitus (ringing in ears) and loss of fine descrimination of position of the jaw, or even arms and legs. Trigger points are highly involved in sleep disturbances. The mechanism is simple, e,g, the weight of the reclining body on muscles containing trigger areas causes referred pain at other areas, and the perception of this pain causes constant changing of position. The net result is lack of restful sleep.
Trigger points in muscles do not seem to be exactly associated with nerve endings, nor other neurologically related structures such as muscle spindles. What they basically seem to represent is a small area of muscle tissue that is running at a high metabolic rate, but with decreased circulation in the immmediate area because of the constant state of contraction. This constitutes a vicious cycle under most definitions. They also seem to be areas of muscle contraction without any corresponding electrical activity.
Trigger points are classified as either ACTIVE, or LATENT. An active trigger point causes pain. A latent trigger point is more often associated with stiffness and limited motion. Both can persist for years. Latent triggers can easily be reactivated by activities like overuse, sudden stretching (trauma), or chilling associated with changes in the weather.
Both sexes can develop trigger points, but the middle aged female seems exceptionally vulnerable. Numerous studies have found active trigger points in all age groups, and both sexes seemed equally affected. Women, in general, are more likely to seek medical help for pain of any origin and are probably treated more often. Trigger points seem to become more frequent with increasing age and decreasing physical activity. People who engage in heavier physical labor are less likely to develop trigger areas than people in sedentary occupations. The areas of the body where trigger points are most likely to develop are in the muscles of the neck, shoulder area, and pelvic, or low back area.
Patients are rarely aware of active trigger points within muscles causing their referred pain, but are well aware of the referred pain.
1. Pain from a trigger point is unlikely to develop in close proximity to the actual trigger spot. Generally the pain is superior, or more dorsally sited.
2. The pain from an active myofascial trigger point is usually described as a dull, aching pain often felt deep in the area affected. The pain may be felt while at rest, or only during motion. The intensity of this pain can vary from barely perceptable, to severe and agonizing.
3. Referred pain from a trigger area can usually be generated, even increased in severity, by direct digital pressure on the active trigger area.
4. Generally, the more hypersensitive the trigger area is in itself, the more the referred pain increases in intensity and area affected.
5. The size of the muscle where the trigger point exists has no relation to the level of pain found in the referred pain area.
6. Pain referred from active triggers does not always follow strict rules. It does not follow normal neurolgical, nor segmental patterns.
7. Trigger points can be activated by muscle strain, sudden muscular overload, overwork fatigue, trauma, and envioromental chilling.
8. The initiating factor can occur months, even years before onset of painful symptoms.
9. Secondary, or satellite trigger points can be activated within the referred pain area of a primary trigger point. Usually this occurs in synergistic muscles, or muscles that assist the action of another muscle.
10. Trigger points can be activated by other disease processes.
11. Trigger points can be activated by emotional distress.
12. Active trigger points can vary in irritability on a day-to-day, and hour-to-hour basis.
13. The signs and symptoms of active trigger point hyperirritability can persist long after the trigger point itself turns latent.
14. Phenomena other than pain are caused by active trigger points. Muscles within the referred pain zone have reduced excitability and weakness. Motor coordination can be reduced.
1. In the presence of an active trigger point, stretching the affected muscle increases pain and when the muscle reaches the point where pain begins, the muscle begins to actively resist the stretching.
2. Range of Motion in stretching is restricted.
3. Contracting the muscle against fixed resistance increases the pain.
4. Muscle strength may be decreased compared to opposite side.
5. Dysesthesia, or painful sensation with very light stimulus, may be elicited in the referred pain area.
6. Autonomic reactions, such as vasoconstriction in area (pallor), lacrimation, and nasal secretion may be seen.
7. Generally, muscles adjacent to the trigger point will also be somewhat tender.
8. The trigger point, itself, can be identified by the presence of a tightened band of muscle, or an exquisitely sensitive focal spot within the muscle mass.
9. The patient will usually let you know in no uncertain terms that it hurts where you are poking. They squirm, even move away from your fingers. This is also known as the "jump sign".
10. Snapping the area with your finger will sometimes elicit a reflexive muscle twitch, or shuddering. Of course, this is not as evident on deep muscles.
11. Moderate and sustained pressure on the spot will usually initiate, or even increase the pain at the referred site.
12. Some trigger areas can even show visible welts in the overlying skin.
The pattern of referred pain from a trigger point in a specific muscle is somewhat predictable. For that reason, it is highly recommended that the patient's individual pain pattern be mapped on a schematic diagram. Have the patient outline the area of pain on their body, draw it on your schematic, and then have them verify the location and area on your diagram.
Delineate the areas of pain and other altered sensation. Mark areas as most severe, moderate, less severe, etc., and also note areas of tingling or numbness.
In general, referred myofascial pain from a muscle is most often projected distally in the limbs and often to the distal joint the muscle moves. Some muscles, like the deltoids, only refer pain locally. Comparatively, the scalene group refer pain extensively.
Muscle function is often disturbed in the presence of active trigger points. A specific muscle may have it's functional anatomic origin and insertion reversed, and the muscle is essentially working backward. That may sound strange, but think of how that activity would affect the expected action. Muscles are dynamic and don't behave like anatomic diagrams often would lead you to believe.
When examining one muscle, keep in mind that this muscle may have both synergistic assistors and antagonist resistors all lumped into a functional myotactic unit. Triggers may have developed in all associated muscles.
Trigger points can also be found in joint capsules and in ligaments as well as within the periosteal layer covering bones. These are a significant source of pain, and refer pain in a manner similar to trigger points found in muscle and fascial structures.
Several methods of treatment have evolved over time and are roughly equal in efficacy. The most common methods are STRETCH AND SPRAY, ISCHEMIC COMPRESSION, PUNCTURE, ULTRASOUND, and POSITIONAL MANIPULATIONS.
Stretch and spray is commonly used on long muscle involvements where limitation of range of motion and stiffness are seen.
Ischemic compression involves firm digital pressure applied to the trigger point along with deep massage, stripping, and vibratory massage. It can be thought of as almost "crushing" the trigger point itself.
Puncture involves placing a needle directly into the center of a trigger point. What is termed "dry needling" is puncture alone. Adding injections of local anesthetics and steroid agents seems to be most effective while not requiring absolute accuracy in penetrating the trigger point precisely. Never use local anesthetic agents containing epinephrine as this can cause muscle necrosis at the site of the injection in the muscle. Also, local anesthetic concentrations should be restricted to 0.5% solutions. Lidocaine 2%, or Carbocaine 3% will cause muscle necrosis where injected. Mepivicaine 0.5% does not appear to cause this problem. Dilute more concentrated agents with normal saline. Injection of sterile distilled water has also been reported as being effective in trigger point therapy (Lancet 1993) but I have not tried it, yet.
For most applications a 3/4 inch 30 gauge needle on a 2 cc plastic syringe is more than adequate. The 1-1/2 inch 22 gauge needles on the 2 cc syringes is used to fill the syringe, then the 3/4 inch 30 gauge is attached for actual use. The aspirating dental syringe with longer 28 gauge needles works well, too, but I prefer not to use preloaded carpules (for the reason noted above) which means you end up squirting 3/4ths of the solution away and reloading it sterile saline from another bottle. Marcaine 0.5% is available in 50 ML multiple dose bottles.
Ultrasound essentially amounts to a high-tech method of massage that uses intense high freguency sound waves to vibrate the tissues down to the cellular level. It stimulates a rather large area and is of benefit by increasing blood flow and movement of intercellular fluids.
Positional manipulation is a method where trigger points and other myofascial dysfunctions are treated by actually shortening the involved muscle while monitoring the trigger site for decreased sensitivity and then holding, or maintaining that position for a period of time sufficient to allow normal physiologic mechanisms a chance to (so to speak) re-set spastic muscle and tendon spindles. It is primarily a gentle method that does not involve high pressures and sudden snaps as seen in some chiropractic manipulation, but it may be enhanced by other therapeutic actions, like injections, to assist in gaining maximum relief. Also known as "Counterstrain Therapy", you can look into the Osteopathic literature, or see Jones, L. H., Strain and Counterstrain. American Academy of Osteopathy, 2630 Airport Rd., Colorado Springs, CO, 1981, for more information. Properly applied, counterstrain is quite effective, but it's use demands a committment to spend a good deal of time with the patient on the part of the clinician. If you can refer a patient to an osteopathic physician who takes the time to do this type of therapy you can count on it to help with a lot of myofascial problems.
There are quite a number of possible trigger point areas in the head and neck region of the body. Compared to the rest of the body, the head and neck are complex structures with a higher concentration of both large and small muscles, blood vessels, and nerves than exist anywhere else. The next comparable area for complexity in order would have to be the area between the shoulders and lower spine. The majority of patient pain complaints involve headache and neck pain followed closely by shoulder and back pain, especially low back pain. For the purposes of this introduction, the discussion will be limited to pain in the head and neck.
Managing trigger point pain in the shoulder to low back is possible using the same basic techniques and therapeutics, but really are outside of the limits of dental practice. If needed, referral to a physician who can treat these areas is the best course.
There are several trigger point areas in the head and neck region that are often involved in referring painful sensations to the head, facial area, and neck. The presence of active trigger areas that produce pain in this region can complicate treatment to a great degree unless the clinician is aware of their existence. The physical examination of the patient has to include these areas in order to properly diagnose the presenting pain pattern and establish an effective treatment plan.
Travell found the trapezius muscle to be the most overlooked source of referred myofascial pain to the head and neck region. Seven trigger point areas have been identified in the trapezius, six referring pain, and the seventh, autonomic responses in the area of the arm near the elbow.
TP1 is found at the anterior margin of the trapezius muscle just above the clavical. It can be identified by rolling the margin of the muscle gently between thumb and fingers, and can feel like a corrugation in the muscle tissue. The trigger area may be quite sensitive.
TP1 refers
pain upward in the neck and to the mastoid area, occipital area and forward
along the whole temporal area up to, and including, the orbital rim of
the frontal bone. On occasion the angle of the mandible is also included
in the pain referral pattern. Additional effects, like vertigo and dizziness
are also associated with active triggers in this mucle.
Trigger points in the trapezius can also have satellite triggers in the underlying supraspinatus, infraspinatus, and levator scapuli muscles.
When neck and shoulder pain are severe, the actual trigger areas may be in these deeper muscles instead of the overlying trapezius.
TP2 is located somewhat inferiorly to TP1 and posteriorly and dorsally. It generally refers pain superior to its location up into the occipital region of the head.
TP3 is located medial to the inferior border of the scapula. It refers pain superior and deep to itself up into the mastoid area, and laterally to the acromion. The pain can be severe, but usually is seen as a deep aching and a tenderness, or soreness over the suprascapular area. This generalized soreness can be mistaken as the actual trigger area because of a tendency for an active trigger at TP3 to develop satellite tenderness at TP1, or TP2. Stay in the region diagrammed. All 3 can exist together.
TP4 is located more superior to TP3 and slightly more laterally at the base of the acromial process of the scapula. It usually is found to refer a steady burning pain along the vertebral border of the scapula and medially toward the vertebral column. Some patients report this as a sore feeling instead of burning.
TP5 is found in the same general area, somewhat superior to TP4 but more medial and between the vertebral border of the scapula and the vertebral column. TP5 refers pain about its location and superiorly to the area of C4-5.
Locations shown on the diagrams are usually accurate enough to allow identification of the trigger points. The TPs shown can be quite tender to pressure and usually will demonstrate intensified pain in their referral area when stimulated.
TP6 is found near the acromial process of the shoulder. It refers pain about the same area and into the shoulder joint area on a fairly local basis.
TP7 can be found in a general area about 1/3 of the distance between the spine and shoulder area. TP7 is considered a "superficial trigger", that is it seems to be in the skin itself, over that area.
TP7 does not refer painful sensation, but often can generate autonomic responses, such as goose flesh in the arm on the same side down to the region of the elbow.
Any of the trigger points dicussed above can be activated by overwork, chilling, etc., but they are also commonly found in automotive trauma when the head is suddenly wrenched forward, or to either side. Whiplash injuries are a major activating factor in TP1 - TP7.
Retrospectively, TP1 usually generates moderate to severe posterolateral neck pain along with temporal headache and jaw pain on the same side. TP2 also generates neck pain, but usually without headache. TP3 and TP4 are usually associated with severe pain when the neck is rotated opposite the trigger area. A complaint of "stiff neck" usually means TP1 - TP4.
TP 5 causes burning interscapular pain, while TP6 refers pain over the shoulder joint area. Any pressure or weight on the shoulder itself is uncomfortable. TP7 does not generate pain, but often the complaint is an unusual sensation of gooseflesh on the lateral surface of the arm, or a feeling like shivering in the same area.
Trauma, of some form or another, is high on the list of causes for activation of trigger points, but, occupational and habit factors can also be responsible for trigger points in the trapezius. The trapezius normally functions to keep the head and neck vertical and the eyes level. When it is forced to take over other functions by poor organization, poor posture, or poor habits, expect problems. What you have to look for is any activity that results in the trapezius muscle having to support the weight of the arm in an unusual manner, and postural habits where the trapezius is used to maintain unusual neck positions. Desk heights where the arms cannot be supported properly, and working with the arms extended for long periods may cause problems. Heavy purses, back packs, etc., are other factors. Worst of all are habits where the neck is held rotated to one side during work, when supposedly relaxing, or even during sleep when improper pillows are used.
TP1 and TP2 can be treated with injection with the patient lying on his back. But the most effective approach to any of the others, e.g., TP3 - TP7 is with the patient lying on their side with the area you plan to treat upward. This allows better relaxation of the trapezius and underlying muscles and allows you to assist in passive stretching after injections.
Immediately after injecting the trigger area, the muscle should be passively stretched several times. Instructions should be given to apply local moist heat packs along with further passive stretching and massage when the patient goes home.
Copyright 1995 R. E. Brossman