COVID-19 has presented a new reality in which we as healthcare providers find ourselves in the unique position of simultaneously managing the effects of the virus, while still learning about it. Amidst the new information that continues to be revealed is an increasingly common connection between COVID-19 and lingering after-effects that have been reported by post-COVID patients.
Imagine the frustration of recovering from the initial symptoms of COVID-19 only to be stuck with long-term effects that make life more difficult than it was before. As rehabilitation therapists, we may wonder: Is there an opportunity for us to provide relief to those suffering the clinical after-effects of COVID-19?
Clinical Presentations of Post-COVID Symptoms
To explore this question further, let’s look at the example of a patient named “Mary” who presents a challenging case:
Mary walks into your clinic with various complaints including tinnitus, positional vertigo, jaw pain, migraine-like headaches, and a toothache that won’t go away despite clearance from her dentist. She reports that her current symptoms began just one week after a COVID-19 diagnosis. Your examination findings do not support clinical migraine, temporomandibular dysfunction, or vertigo originating from inner ear impairment.
Upon further examination, it becomes clear that Mary’s complaints can be manipulated during the examination through active movement, muscle contraction, and palpation. With these clinical findings, it becomes clear that while Mary’s conditions seem to have been brought on by COVID-19, she will still benefit from the therapy treatments you can offer.
What becomes important now is getting to the root of Mary’s symptoms so that you can begin treating her appropriately and, hopefully, restore her quality of life. Further assessment is necessary, and a good place to start is Mary’s myofascial trigger points.
What Are Myofascial Trigger Points?
Skeletal muscles can form tight bands or nodules in their fascia known as myofascial trigger points. Behaviors and conditions that can lead to trigger point formation include poor posture, muscle imbalance/overuse, labored breathing, excessive coughing or vomiting, and stress. There are two kinds of myofascial trigger points in the body—active trigger points and latent trigger points:
- Latent trigger points are diagnosed as such if firm palpation to the myofascial nodule does not reproduce the patient’s symptoms or pain complaints.
- Active trigger points are diagnosed as such when firm palpation to the myofascial nodule does reproduce the patient’s symptoms. Active trigger points often demonstrate sensitivity, local twitching, and referred pain/symptoms.1
Myofascial trigger points can create unique symptoms such as referred pain patterns, often making it difficult to accurately diagnose and treat the patient’s root cause of complaints.2 A referral pain pattern is when the brain perceives symptoms in one area of the body when the painful stimulus is actually in an alternative location. Referred pain patterns from a trigger point are distinct but do not coincide with true dermatome or myotome findings.3, 4, 5, 6
Assessing Muscles for Active Myofascial Trigger Points
Each skeletal muscle has specific referral pain patterns and associated symptoms. It is important to note that there is often overlap between pain patterns, making a careful history and examination crucial. Equally as important is the understanding that following a bout of serious illness, patients may have trigger points in other skeletal muscles. A thorough examination should be conducted to ensure the best patient care and treatment. The muscles discussed in the scenario of “Mary” include temporalis, masseter, sternocleidomastoid, and scalenes (anterior, middle, and posterior). Here, we will explore the primary action that causes Mary pain, and the common referral pain pattern that presents when that action is taken.
- Primary action: Closing the jaw, ipsilateral mandible deviation
- Referral pain pattern/symptom complaints listed, but not limited to: ipsilateral temporal region pain, ipsilateral forehead pain, pain superior to the ear, nuchaline of the occiput, headaches, pain in upper and lower teeth and gums, hypersensitivity of the teeth, ipsilateral eyebrow pain, pain behind the eyes, temporomandibular dysfunction, tingling sensation in the cheek 7
- Primary action: Closure of the jaw through elevation of the lower mandible 8
- Referral pain pattern/symptom complaints listed, but not limited to: Vertigo, headaches, sinusitis, headaches, temporomandibular dysfunction 9
- Primary action: Cervical flexion and rotation to the opposite side
- Referral pain pattern/symptom complaints listed, but not limited to: Eye pain, throat soreness, earaches, popping in the ear, fullness in the ear, sinusitis, neck pain, shoulder pain, postural vertigo, tinnitus, nausea, headaches, and impaired balance 10
- Primary action: Assist with inspiration, cervical forward flexion, and ipsilateral side bending; anterior and middle scalenes elevate the first rib, posterior scalene elevates the second rib
- Referral pain pattern/symptom complaints listed, but not limited to: Chest pain, shoulder pain, upper back pain, nerve-like pain radiating into the ipsilateral arm, thoracic outlet syndrome symptoms, carpal tunnel symptoms, ipsilateral hand/wrist pain, difficulty breathing, headaches, voice changes, difficulty swallowing, a sensation of something being stuck in the throat, sinusitis, pain in the teeth, fullness in the ears 11, 12
Treating Active Myofascial Trigger Points
When treating active myofascial trigger points, there is no one-step approach. Some options for trigger point treatment could include manual trigger point therapy release, dry needling, and pro-lo therapy. Patients need to receive further training from their rehabilitation therapist regarding muscle postural retraining, specific functional muscle training/strengthening, neuromuscular retraining, along with different methods of stretching, such as contract-relax-contract, contract-relax, and reciprocal inhibition.13, 14
When working with active trigger points, it is crucial to monitor the patient’s symptoms and watch for a possible sympathetic nervous response. Treatment for active trigger points is often determined by the patient’s tolerance, and should always be given using caution and care to reduce symptoms and restore function.
- Travell, J. G., Simons, D. G., & Simons, L. S. (1999). Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins
- Niel-Asher, S. (2014). The Concise Book of Trigger Points: A Professional and Self-Help Manual. Lotus Publishing.
- Travell, J. G., Simons, D. G., & Simons, L. S. (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual: Vol. 1: Upper Half of Body. Williams & Wilkins.
- Alvarez, D. J., & Rockwell, P. G. (2002). Trigger points: diagnosis and management. American Family Physician, 65(4), 653–660.
- Davidoff R. A. (1998). Trigger points and myofascial pain: toward understanding how they affect headaches. Cephalalgia : An International Journal of Headache, 18(7), 436–448.
- Vázquez-Delgado, E., Cascos-Romero, J., & Gay-Escoda, C. (2009). Myofascial pain syndrome associated with trigger points: a literature review. (I): Epidemiology, clinical treatment and etiopathogeny. Medicina Oral, Patologia Oral y Cirugia Bucal, 14(10), e494–e498. https://doi.org/10.4317/medoral.14.e494
- Fernández-de-Las-Peñas, C., Ge, H. Y., Arendt-Nielsen, L., Cuadrado, M. L., & Pareja, J. A. (2007). The local and referred pain from myofascial trigger points in the temporalis muscle contributes to pain profile in chronic tension-type headache. The Clinical Journal of Pain, 23(9), 786–792. https://doi.org/10.1097/AJP.0b013e318153496a
- McComas A. J. (1998). Oro-facial muscles: internal structure, function and ageing. Gerodontology, 15(1), 3–14. https://doi.org/10.1111/j.1741-2358.1998.00003.x
- Ciancaglini, R., Testa, M., & Radaelli, G. (1999). Association of neck pain with symptoms of temporomandibular dysfunction in the general adult population. Scandinavian Journal of Rehabilitation Medicine, 31(1), 17–22. https://doi.org/10.1080/003655099444687
- Weeks, V. D., & Travell, J. (1955). Postural vertigo due to trigger areas in the sternocleidomastoid muscle. The Journal of Pediatrics, 47(3), 315–327. https://doi.org/10.1016/s0022-3476(55)80006-6
- Ingraham, P. (2018, June 13). Massage for neck, chest, and shoulder pain (scalenes). www.PainScience.com. Retrieved October 12, 2021, from https://www.painscience.com/articles/spot-04-scalenes.php.
- Machleder, H. I., Moll, F., & Verity, M. A. (1986). The anterior scalene muscle in thoracic outlet compression syndrome. Histochemical and morphometric studies. Archives of Surgery (Chicago, Ill. : 1960), 121(10), 1141–1144. https://doi.org/10.1001/archsurg.1986.01400100047009
- De las Peñas, C. F., Sohrbeck Campo, M., Fernández Carnero, J., & Miangolarra Page, J. C. (2005). Manual therapies in myofascial trigger point treatment: A systematic review. Journal of Bodywork and Movement Therapies, 9(1), 27–34. https://doi.org/10.1016/j.jbmt.2003.11.001
- Cummings, T. M., & White, A. R. (2001). Needling therapies in the management of myofascial trigger point pain: a systematic review. Archives of Physical Medicine and Rehabilitation, 82(7), 986–992. https://doi.org/10.1053/apmr.2001.24023