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Trigger Points
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Trigger Points - January 24, 2005 1:40:00 PM
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cneup
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Hello all -
Just wanted to get some thoughts on the most effective ways to resolve trigger points - especially those stubborn ones in the levator, scalenes, and upper traps. My current methods seem to take too long.
Thanks
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Re: Trigger Points - January 24, 2005 2:08:00 PM
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FLOrthoPT
Posts: 85
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From: wellington, fl, usa
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make sure no underlying joint dysfunction or neural facilitation, get rid of the cause...postural stress, weakness?, etc...they'll work them selves out, if not a good strain counterstrain or stripping of the muscle sometimes wokr...I am just not a big believer in a random trigger point...
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Re: Trigger Points - January 26, 2005 1:05:00 PM
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cneup
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I agree --
I work A LOT on postural correction - probably don't assess segmental alignment as much as I should. It just seems like it takes FOREVER for postural correction to finally work (obviously it takes time to improve flexibility and strength) - but I'm wondering if there is a quicker way to "fix" overfacilitated musculature which is inhibiting correct mechanics etc in order to get faster results with postural correction (and whatever joint corrections one is working on). Sorry 'bout that run-on - LOL
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Re: Trigger Points - January 26, 2005 2:04:00 PM
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chiroortho
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Wow, some good points here (no pun intended).
An anecdote: I have TPs in my left glut medius which I attribute to being bent over from the left side of a treatment table for significant periods of time qd. Get in there with some ischemic compression and I can feel it in my leg.
Scrub it with a G5 unit and I'm good to go for weeks to months at a time.
If I didn't have the work posture that I have, I don't think I'd have the same TPs.
Good train of thought here folks. Wish more people would pipe in. I can't believe that you guys don't see boatloads of active myofascial tp's in the infraspinatus, glutes, etc.
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Greg Priest, DC, DABCO
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Re: Trigger Points - January 26, 2005 3:01:00 PM
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Jon Newman
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From: Amherst, WI
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My personal experience with my own and my wife's "trigger points" (we don't seem to get these too often though) is that they go away well within a week. I don't know why I get them and I don't know why they go away. I've tried the deep massage stuff and sometimes it feels good (for a while) and sometimes it makes it worse (for a while). Mostly I just ignore them and they go away. I have found ibuprofen typically shortens the course. I have never had a trigger point just stick around for any prolonged period. Perhaps I'm lucky. Have others had trigger points that don't go away? Maybe my criteria for a trigger point is too stringent but if I have to make an effort to find them I have to wonder, what's the point?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Trigger Points - January 26, 2005 3:04:00 PM
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nari
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From: Australia
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As in Oz we do not seem to have these strange trigger points - or not that we treat in any local fashion anyway - can anyone enlighten me as to where and what these points are, and what are they triggering??
Just curious
Nari
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Re: Trigger Points - January 26, 2005 3:17:00 PM
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chiroortho
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Nari, I realize that the elusive 'trigger point' or, as I refer to them in my notes, 'myofascial trigger areas' are a bit nebulous. I'm with you on the 'show me the evidence' part. But I have seen WAY too many patients with characteristic referral patterns on deep digital compression to be able to discard the phenomenon out of hand.
I'll willingly open myself up to your criticism and that of your colleagues by saying that I can push on certain 'tender areas' and predictably elicit certain dysesthesias in my patients. In fact, I can do so on a large percentage of the patients that I see, and 90% of such 'trigger areas' are in two areas: the infraspinatus area and the gluteal area.
It's okay with me that we say that we don't fully understand the mechanism of TPs, but I can tell you this Nari, patients seek me out because I'm willing to do this kind of work. There may be a fancier name for it in Physical Therapy, but we DCs call it ischemic compression.
This post is already too long or I'd get into the theoretic mechanism. If you'd like, I'll go further out on a limb and tell you what I tell my patients as to what causes it and why ischemic compression seems to work so well in alleviating tp's.
_____________________________
Greg Priest, DC, DABCO
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Re: Trigger Points - January 26, 2005 6:16:00 PM
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nari
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From: Australia
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Greg, I am interested in your views, certainly..
But if I poke the approximate centre of SS, or deltoid, or the insertions of SCM, to name a few, it is tender. I have no pain experience at all, as long as no-one pokes a finger at these points.
If someone came in to you and said they had neck and back and arm and head pain- their 'points' would be painful to firm touch, wouldn't they?
So I wonder really what significance these points do have in the scheme of things?
Just curious
Nari
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Re: Trigger Points - January 26, 2005 6:19:00 PM
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Synergy
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Interesting topic of discussion. Greg, please 'go further out on a limb' and provide your theories as I know most people here would find it interesting. :)
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Chris Adams, PT, MPT
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Re: Trigger Points - January 26, 2005 8:40:00 PM
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Alex Brenner PT MPT OCS
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Would you classify the small muscle spasms that you typically see in the upper in middle thoracic areas as trigger points? I sometimes refer to them as "tootsie roll" signs, basically small tootsie roll size nodules that you can physically palpate and reproduce pain. With these types of "trigger points" I have had success with thoracic manipulation to relieve them, however, lets not let this thread go into a manipulation debate. I can say though that I routinely see these small spasms, I manipulate, then they are no longer there. This approach seems to work for me better than trying to massage them out or by just applying pressure to them.
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Alex Brenner, PT, MPT, OCS
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Re: Trigger Points - January 27, 2005 1:52:00 AM
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FLOrthoPT
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From: wellington, fl, usa
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I agree, I also find that the spasm or point is directly over lets say a more prominant TP which may have influence on the tone of the area or really even the proximity and density of the tissue with respect tot he other side. The deep tenderness can be underlying at the prominant TP. Especially in the t-spine, I'd agree with Army, joint work seems to resolve these immediately, postural stress from either weak abductors ot forward head etc will place uneeded stress on the muscle that is eccentrically working all day. Wouldn't that muscle be sore just from use, or overuses? In ideal spinal positions the spine and it's lig. nature take most of the gravity forces, but with center of gravity displaced forward or lateral, etc, abnormal forces are put on to the eccentrically stabilizing muscles...so they get sore, and if you poke hard enough they hurt...just not a firm believer that going for the noxious stimuli approach (pushing real hard into it, or what was it ischemic push?) is doing anything much different than as if you put noxious stim on the area...same results no bruising, no work really...I still say treat whatever is underlying if you want real results...my 19 cents..
Ben
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Re: Trigger Points - January 27, 2005 2:39:00 AM
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Shill
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From: Madison WI USA
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I agree with Army, Nari, and Flaortho, these things are not local pathologies of any kind, but rather referred from somewhere else, likely the spine. I also question the clinical significance of tenderness to palpation in these cases. My point is this, if it hurts to press on it, and only when it is pressed on, and can only be brought to the patient's attention when pressed on, LEAVE IT ALONE! Why crank up their awareness of a painful area, when it is typically not noticed? I typically will tell these patients that unless you have someone following you around all day, pressing on your sore spots, these are of no concern. They will decrease as you decrease the underlying reason for the tissue strain that refers this pain to this region, if in fact that is what it is.
People can and do make a living off of treating trigger points, but have you ever seen these tender areas go away, and stay away, when they are being treated directly? I havent. Sure, they get some temporary neuropraxia, feel good for a few hours, but then the tenderness returns, just as it was before.
If they like the deep pressure stuff, I say get them a theracane or backknobber, or one of these self imposed pressure devices. I, for one, dont think it requires a whole lot of skill to mash the bejeezus out of a muscle.
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Steve Hill PT
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Re: Trigger Points - January 27, 2005 3:24:00 AM
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chiroortho
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Many excellent comments, I'm glad to see interest picking up a bit. I'll try to address your comments without being verbose. [QUOTE]But if I poke the approximate centre of SS, or deltoid, or the insertions of SCM, to name a few, it is tender. I have no pain experience at all, as long as no-one pokes a finger at these points. If someone came in to you and said they had neck and back and arm and head pain-their 'points' would be painful to firm touch, wouldn't they? So I wonder really what significance these points do have in the scheme of things?[/QUOTE]Yes, in fact I tell patients that 'if I push hard enough anything will hurt', and that I'm looking for a VERY tender spot. More often than not, before I get a chance to explain what I'm doing, the patient will actually flinch slightly with only very minimal pressure. I'm not talking about Waddell's flinching, I'm talking about almost a reflex. As to significance, I surmise that these points reflect a constant contraction of the muscle. This DOES point to another process causing the contraction, you're exactly right. As Army and others point out, I don't stop looking when I find a TP, but by the same token I don't ignore it either.
Why do TPs form? I think the muscle may be producing waste products more quickly than it can get rid of them, leading to a concentration of such in the belly of the muscle, or in certain characteristic areas, which in turn irritate the muscle further, leading to more contraction. The mechanism(s) by which I postulate that deep compression can provide relief include the Gate theory; possibly spreading out the concentrated products of metabolism so that they aren't so concentrated in one area; even placebo. I don't know for sure. Clearly there is a neural component to TPs. I can't tell you how many times as I am applying pressure to a TP in the left infraspinatus that I've seen patients opening and closing their left hand. They feel tingling down to the hand. More frequently they feel it in the posterior brachium. But nearly all of them with what I determine to have tp's do feel it.
What's the difference between a TP and just mashing the crud out of a muscle and making it sore? Those of you that have palpated tp's will understand that when you hit a tp you feel a knot of some sort, and you DON'T have to push hard at all before your patient says 'THAT'S IT!' The phenomenon of 'good pain' is remarkable in these people. 'OUCH, YOU'RE KILLING ME! PUSH HARDER!!'
Army and others bring up the thoracic tp's and how they seem to resolve with manip or other joint work. I agree 100%. What I have found is that axial tp's seem to respond much more to manip, whereas the infraspinatus tp's seem to require manip of c-spine IN ADDITION TO ischemic compression. [QUOTE]If they like the deep pressure stuff, I say get them a theracane or backknobber, or one of these self imposed pressure devices. I, for one, dont think it requires a whole lot of skill to mash the bejeezus out of a muscle.[/QUOTE]Shill, I agree with the skill part. I'm not here beating my chest, I'm just trying to share something that's been helpful to my patients. If you find that theracanes do the job, great. I'll pass on the 'making a living out of tp's' comment.
Lastly, I agree completely that postural factors have to be evaluated. Guys, one of the things that I appreciate most about PTs is that you tend to look at things in terms of 'chains' or 'processes'. This is an area that DCs could learn a great deal from you.
_____________________________
Greg Priest, DC, DABCO
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Re: Trigger Points - January 27, 2005 4:10:00 AM
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bravocosta
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Great post. Would agree with all who advocate finding the underlying causes of the "trigger point" so nothing to add there.
In my opinion, some "trigger points" in the uppertraps and upperquarter are exacerbated by chest (more shallow ) breathing patterns especially when clients are under work stress. Chest breathing also involves more accessory muscles of respiration and in my opinion increased sympathetic tone. Have never had a trigger point per se. Teaching clients diaphragmatic breathing is an excellent way to help to soften the chronically held tension in the upperquarter. Also teaching them "perch posture" improves their alignment with all their sitting activities and further decreases thoracic and upper quarter tone. I suspect that some of the trigger areas in the T-spine correlates with kyphotic sitting postures.
cheers... Thomas
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Re: Trigger Points - January 27, 2005 4:38:00 PM
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PTupdate.com
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From a guy with C5-6-7 DDD/DJD and bulging, I can say I am quite familiar personally with trigger points in the levator, upper trapezius and interscapular musculature.
My wife, who is a massage therapist, says it's the most F...ked up back she's ever felt!
Besides addressing the cervical issues that caused this to being with, I have luck with VERY strong IF stim, deep accupressure...often using the elbow, ice, and believe it or not, heavy weightlifting using those muscle groups.
Best,
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Trigger Points - January 27, 2005 5:19:00 PM
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Bournephysio
Posts: 585
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From: Calgary
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Needles
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Re: Trigger Points - January 28, 2005 6:38:00 AM
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chiroortho
Posts: 655
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[QUOTE]From a guy with C5-6-7 DDD/DJD and bulging, I can say I am quite familiar personally with trigger points in the levator, upper trapezius and interscapular musculature.[/QUOTE]John, we agree completely with the nuclear IF, deep digital compression, heat followed by ice.
Our fantastic massage therapists do this daily, and I stand in awe of their results.
The weightlifting part I had not contemplated, but it makes sense to me. Use the muscles, wear them OUT. Get that metabolic junk OUT of there.
As to needling, I've heard of the technique, but I think the intramuscular bleeding that it causes is more than is necessary to resolve TPs.
Greg
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Greg Priest, DC, DABCO
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Re: Trigger Points - January 29, 2005 6:59:00 AM
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cneup
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Great discussion everyone!
Just thought I'd add some personal experience to this ....
During PT school when we were carrying heavy backpacks and laptops around (in addition to sitting hunched over a desk and studying 8 hours per day) I can say I definitely had some TPs in the upper traps etc. These produced dull aching in the local region in addition to some radiating pain in the neck and deltoid region. These persisted for 2-3 years until I finally started working out using a lot of rowing, pull-ups and overall strengthening. The interesting thing now is that the constant pain is gone (if I continue to work out), but the tender nodules or "tootsie rolls" to quote Army are still present and produce radiating pain with deep pressure.
Also have had a few patients who presented exactly the same way - they felt great as long as they were working out, but if they fell back into their bad postural habits the pain would come back.
Any more thoughts on the physiologic mechanism that produces these nodules/"tootsie rolls"????
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Re: Trigger Points - January 29, 2005 8:15:00 AM
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bravocosta
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Dear Chiro-ortho,
Per your quote "our fantastic massage therapists do this daily and I stand in awe of their results", are they doing the same patients over and over ? In my experience this is a very transient way to treat (regardless of the term neuromuscular massage or whatever coined by Chaitow?) and encourages patient dependence.I still have not seen any evidence that the problem lies in the muscle itself per se.
Cheer.........Thomas
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Re: Trigger Points - January 29, 2005 9:54:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Needling? You cannot imagine how many times I laid there at night with those trigger points throbbing, basically fantasizing about someone sticking needles into those points.
One night I grabbed the ortho spine surgeon and asked if he would inject it...not a corticosteroid, but only an anesthetic from the 'caine family. I knew the pain was referred, as I could reproduce with pure cervical motion, but still could not wonder why local treatment such as those listed above resolved something that was referred.
We basically pumped in enough anesthetic to make the entire upper back quite numb, and digital pressure no longer reproduced the pain. However, cervical motion still reproduced the exact same thing.
Curious phenomenon. Also, many people neglect/forget about a very active point that occurs in the lateral infraspinatus muscle belly, and T4 syndrome also creates it's own unique points.
Best,
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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