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Re: Trigger Points
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Re: Trigger Points - January 29, 2005 10:49:00 AM
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bonmar
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From: Boston, MA
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Has anyone every read The Trigger Point Manual (two volumes: upper and lower extremeties) by Travell and Simon? They are excellent references for each muscle and what the causes, s/s, and treatment are when there are trigger points present in that particular muscle. I have them in the clinic and am always referring to them.
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Re: Trigger Points - January 29, 2005 5:47:00 PM
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Lukey
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Hi all,
Trigger points are defined as hyperirritable areas within taut bands of skeletal muscle or fascia. These points are painful on compression and can give rise to characteristic patterns of referred pain, tenderness, autonomic nervous system symptoms, and restricted range of motion.
Travell and Simons (1983) describe the clinical features of trigger points to include:
1. a taut, fibrous muscle band containing a discrete nodule;
2. a history of focal tenderness;
3. a local twitch response cause by ‘snapping’ palpation;
4. a spontaneous exclamation of pain by the patient (‘jump sign’) as a result of mechanical pressure;
5. and a consistent and reproducible pattern of referred pain
Trigger points are classified as ‘active’ or ‘latent’ in nature, depending on the presence of a characteristic pattern of pain referral. Active trigger points refer pain at rest, with muscular activity, and upon direct palpation. In comparison, latent trigger points remain non-painful and only refer pain when steady direct pressure is applied (Travell & Simons, 1983).
Trigger points can arise in virtually any muscle group. However, the most common sites for trigger points are the muscles involved in maintaining posture: levator scapulae, upper trapezius, sternocleidomastoid, scalene, and quadratus lumborum muscles. Patients who have active trigger points usually report regional, persistent pain that often results in a decreased range of motion. Associated signs, such as joint swelling and neurologic deficits are usually absent on physical examination, and the pain does not follow a dermatomal or nerve root distribution (Simons et al, 1999).
The underlying etiology of myofascial pain and trigger point pathogenesis appears to be multifactorial, with postural stresses, inefficient biomechanics, and repetitive overuse the most frequently described causes (Nadler et al, 2001). However, no substantiated scientific theory exists that explains the precise physiological nature of these clinical entities. The most recent hypotheses include - dysfunctional motor endplates, AIGS in the vicinity of the neuromuscular junction, and integration in the spinal cord (formation of TrP circuits) in response to the disturbance of nerve endings at multiple dysfunctional endplates (Hong, 2002).
Even a brief look at the literature reveals several dozen proposed treatments for trigger point pain - and none showing convincing evidence. Cummings et al (2001) conducted a review of invasive treatments (needling) for trigger point pain. The result was that any type of needling appears to be effective for myofascial trigger point pain, as marked improvements were recorded in all groups that received this intervention. The effect was shown to be due to the needle itself, or to placebo, rather than the injection of saline or drugs. The study concluded that further controlled trials are needed to investigate whether needling has an effect beyond placebo.
I am currently reviewing non-invasive treatments and I'll let you know what I find.
Personally, I have found deep (ischemic) compression useful only in mild latent trigger points, and only in certain muscles. In active TrP cases and many areas in the body it is simply too painful and labourious, especialy where multiple foci exist.
Duffy, I have seen many people (including my wife) who fantasize about sticking needles into these points and this has been the most effective method in my experience.
If one is able to illicit a local muscle twitch response by pecking at the muscle gently with the tip of an acupuncture needle then the relief can be instant. I have heard people describe this sensation as a kind of orgasm. If the twitch response is not illicited results can take a little longer but are still mostly statisfactory.
Luke
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Re: Trigger Points - January 30, 2005 4:35:00 AM
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cneup
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Luke -
Thanks for that great informative post. Keep us posted on what you find in the literature!
I agree with your comments regarding ischemic compression. I have found ischemic pressure to work very well for suboccipitals and the QL - Rarely in the UT /levator and only if it is relatively acute at that.
[QUOTE] If one is able to illicit a local muscle twitch response by pecking at the muscle gently with the tip of an acupuncture needle then the relief can be instant. [/QUOTE]Could this not also be done with estim (small electrode or probe) rather than a needle??
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Re: Trigger Points - January 30, 2005 8:31:00 AM
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chiroortho
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[QUOTE]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.[/QUOTE]In the interest of being completely honest here, I would have to answer 'yes'. Typically, these patients have other muscular issues, and will go through a series of therapeutic massage sessions. [QUOTE]Also, many people neglect/forget about a very active point that occurs in the lateral infraspinatus muscle belly[/QUOTE]Duffy, absolutely right. This is the single most common tp that I find. [QUOTE]Has anyone every read The Trigger Point Manual (two volumes: upper and lower extremeties) by Travell and Simon? They are excellent references for each muscle and what the causes, s/s, and treatment are when there are trigger points present in that particular muscle. I have them in the clinic and am always referring to them.[/QUOTE]Bonmar, they also have a fantastic flip-chart to which you can refer. We often use it to help patients understand why we can so easily reproduce their arm/leg dysesthesias although they have a completely normal MR scan. [QUOTE]The effect was shown to be due to the needle itself, or to placebo, rather than the injection of saline or drugs.[/QUOTE]Yes, Luke, I read this years ago, and this is one of the primary reasons that I think there is something to the counterirritant effect on tp's. I have used fluorimethane spray and stretch with frankly unsatisfactory results. I have also used strong probe stim (very perceptive question, Cneup) but found that although the patient did experience the characteristic referral pattern of dysesthesia, it didn't seem to have any lasting effect for reasons beyond my understanding. My best guess is that ischemic compression for 15 seconds or more, followed by release and some quick effleurage with the thumb or tips of the fingers, results in a sort of 'flushing out' of the muscle belly and dissipation of the lactic acid and other metabolic products. The needling probably serves the same purpose.
Thanks to all of you for outstanding insights. I hope we will see more here. I realize that my hypotheses might be totally wrong and I could be completely full of it, but this in my view is what these forums are for. Put your ideas out there and let your colleagues pick them apart. It's a great way to learn, so don't be shy, you're among friends.
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Greg Priest, DC, DABCO
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Re: Trigger Points - January 30, 2005 1:37:00 PM
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Randy Dixon
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TrP seem to be pretty well covered here but two issuses that I think are important about them are: 1. since they are at least somewhat predictable in their presence and in their relationships to dysfunctions that their primary significance in the clinic is in diagnosing and as a monitor for correcting dysfunctions. I think that this is related to people saying that if they clear up the underlying problem the TrP's go away. 2. They seem to act like a "smoke alarm" for some dysfunctions, I'm not sure it is always the best idea to relieve them. Just like it is ok to take the batteries out of the smoke alarm when you know you just burned dinner, but if you don't know why they are going off maybe it is better to let them buzz, irritating as they are.
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Re: Trigger Points - January 30, 2005 2:00:00 PM
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Jon Newman
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From: Amherst, WI
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Cneup asked: "Any more thoughts on the physiologic mechanism that produces these nodules/"tootsie rolls"???? "
Here are some links.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8008795]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11560808]link 2[/URL]
Randy's suggestion that trigger points are symptoms of something that needs to be fixed versus something that needs to be fixed itself is interesting. Another way of looking at his smoke alarm analogy is that if it keeps going off when someone burns food, perhaps it would be best to learn not to burn food (versus taking the batteries out). Although taking the batteries out is faster.
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 30, 2005 4:08:00 PM
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PTupdate.com
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I have had cases where the original problem in the cervical spine is resolved, and the trigger point is a left over, or after image. If someone has that kind of tissue/muscle response for 6 months, we have to assume that there is some type of physiologic change to that muscle due to the constant contraction and tone.
Thomas...you mention it is a transient treatment and could lead to patient dependence. Who cares? Someone with a cervical herniation that gets a nights rest due to trigger point therapy could care less about that kind of thinking.....all they want is a nights rest. How many times have we had patients come in on that first visit having learned themselves the value of ischemic compression/accupressure? (If I sit on a tennis ball, it hurts like a mother, but my sciatica is relieved for hours....if I dig my shoulder blade against the doorjamb, it relieves the pain for a period of time)
It can always be easy to say "well, just fix the problem/root, not an effect. What about those with a severe herniation that may not be able to avoid the knife, or those just in that acute period?
Duffy
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Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Trigger Points - January 31, 2005 12:18:00 AM
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Lukey
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Duffy,
I agree with you. Of course it is important to resolve underlying dysfunction but often symptomatic treatment is part of that process. If the theory that severe or multiple trigger point foci can result in sensitization at the spinal cord has any validity, then desensitizing trigger points asap would seem like a sensible approach. Decreasing symptomatic pain can also allow one to procede more easily with other forms of treatment.
Luke
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Re: Trigger Points - January 31, 2005 5:55:00 AM
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Yogi
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From: San Antonio, Tx., USA
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Bonmar, so what treatment do you find effective, if you're always referring to the Trigger Point Manuals? Greg, thanks for verfifying my opinion of the spray and stretch effectiveness. I've tried acupressure a few times, with no success, but that was years ago and perhaps the fault was mine, not the technique. I do suspect as folks have mentioned, that TrPs occur from alignment problems resulting in neural tension, and that may be why manipulation alleviates the axial TrPs. Duffy, as always, thanks for the insights, esp. the tip on IF stim., Luke, thanks for the sharing of your experience, esp. on the needling, but who do you refer to for that, that's the problem I have, my feeling is that that is the most effective treatment. However, if I have the opportunity, I will certainly try again with the deep pressure as reported by Greg and John.
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Re: Trigger Points - January 31, 2005 6:15:00 AM
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bravocosta
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Dear Duffy,
You are quite correct in your comments above. All the patient is primarily concerned with is getting some relief from their pain, and so by all means use what is helpful. Was thinking about some patients that come to our clinic for MANY visits and always receive TP accupressure/massage with no appreciable change in their pain symptoms, because the underlying cause was not being addressed. Those heading to Dr. Knife, well that is a different animal. If no treatment provides lasting relief then you will help them any way you can.
Anyone have any good ideas on TP's in infraspinatus/axillary area. Been thinking resolving these would accelerate shoulder treatment. Haven't much too much (any)luck with this area lately.
Cheers......Thomas
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Re: Trigger Points - January 31, 2005 9:32:00 PM
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Lukey
Posts: 180
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From: Australia
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Yogi, I am registered as an acupuncturist in Aus so I do it myself. If you are interested check out Dr Chan Gunn's course in Vancouver - http://www.istop.org
When using ischemic compression patient feed-back is very important. Most patients will describe a range of 'good pain' before you get to the 'bad pain' depth. Increasing the pressure very slowly results in far less anxiety and muscle contraction in other areas. Try to stay at a pressure level just before the 'bad pain' for 10-15 secs. This can be repeated a few times (but I like to leave it for a few minutes while I start on the next one). In some people, (usually those with a higher pain threshhold) placing the muscles on stretch while you do this gives better results. In others, you will need to shorten it just to put your fingers in. Where convenient, stretching the muscle while the pressure is maintained can be very useful, but don't overstretch. Ask your patient to breathe deeply and rythmically during the procedure. A bit of vigorous friction (within the 'good pain' range) after the pressure helps break up any fibrous tissue that has formed.
Cneup, it is very common to attach electrodes to the end of the needle to increase the stimulation. Some people say this is even more effective, others say if you needle exactly the right spot in the TrP then electrical stimulation is not needed. I guess all this choice comes down to lack of understanding regarding the exact mechanisms of pathogenesis and treatment. I don't use electricity much but I think that is probably more due an emotional reaction (I feel like Dr Frankenstein). Check out the work of Ulett and Han for more on transcutaneous electrical stimulation style acupuncture.
Luke
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Re: Trigger Points - February 1, 2005 2:55:00 AM
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Yogi
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Thanks, Luke, those detailed tips should be very helpful.
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Re: Trigger Points - February 2, 2005 6:04:00 AM
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JLS_PT_OCS
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The infamous trigger point...
I would agree with Greg about the frequency of this phenomenon and also with it's treatment.
I find manipulation does wonders, but some stubborn ones really do well with the pressure and massage technique Greg mentioned.
For long term management, I have had great success with strengthening exercises. I have found few patients with chronic periscapular and posterior neck trigger points that did not do very well with thoracic and scapular strengthening and postural control/stabilization exercises for long term management. Weakness of back and UEs is an issue frequently. Have had some resolution with several chronic cases, for what that's worth.
Not sure what is going on there, but the metabolic byproducts thing seems to make sense. I think of it like a sponge you use to wash dishes. If you want to get the cold water at the center of the sponge out and new hot water in, you really have to squeeze that sponge. And strengthening exercises seem to me anecdotally the best way to keep my patients "squeezing their sponges".
Duffy, never thought of these in the smoke alarm type of way. Good point. Food for thought...
Jason
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Trigger Points - February 2, 2005 11:15:00 AM
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cjain
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I second the recommendation of Travell & Simons' books: _Myofascial Pain and Dysfunction: The Trigger Point Manual_
To respond to Shill's comments, a latent (not painful unless pressed on) trigger point can overtension the whole muscle, limiting the range of motion of the affected joint. This can affect the patient's gait and cause other problems seemingly unrelated to the trigger point. I agree that its important to find the underlying reason for the trigger point, but until that is identified and taken care of, releasing the trigger point is a good stopgap measure in my opinion.
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Re: Trigger Points - February 2, 2005 9:39:00 PM
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Randy Dixon
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For those using "The trigger point manual" by Travell and Simons, the second edition, 1998 is quite a bit different than the original. The different types of TrP's are explained, since they develop and are treated differently. The mechanism for the Central TrP's (CTrP) is now considered to be what the article Jon posted suggests. I think it is sometimes referred to as the "open gate" hypothesis. The easiest analogy for me to think of is that it is like a "chemical short" in the muscle.
There is an endplate dysfunction or muscle lesion which releases calcium, this excess calcium causes a muscular contraction at the cellular level and this causes ischemia. The normal contract-relax process never happens because the excess calcium keeps the "gate open", like a charging battery that is being shorted by a wire, it builds up a charge but when the charge reaches a firing point it discharges before it has enough power to do what it's supposed to. Well, that's the way I understand it.
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Re: Trigger Points - February 2, 2005 9:40:00 PM
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Randy Dixon
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For those using "The trigger point manual" by Travell and Simons, the second edition, 1998 is quite a bit different than the original. The different types of TrP's are explained, since they develop and are treated differently. The mechanism for the Central TrP's (CTrP) is now considered to be what the article Jon posted suggests. I think it is sometimes referred to as the "open gate" hypothesis. The easiest analogy for me to think of is that it is like a "chemical short" in the muscle.
There is an endplate dysfunction or muscle lesion which releases calcium, this excess calcium causes a muscular contraction at the cellular level and this causes ischemia. The normal contract-relax process never happens because the excess calcium keeps the "gate open", like a charging battery that is being shorted by a wire, it builds up a charge but when the charge reaches a firing point it discharges before it has enough power to do what it's supposed to. Well, that's the way I understand it.
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Re: Trigger Points - February 3, 2005 4:45:00 AM
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cneup
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So ....
Besides injection, any theories on how to treat endplate dysfunction??
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Re: Trigger Points - February 4, 2005 6:47:00 AM
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JLS_PT_OCS
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Don't worry about the endplate dysfunction.
Use EBM for the area (back, neck, etc), and if that fails, use an impairment based approach to manage the condition.
Let's not fall into the same trap with TP's we all did with nonspecific back pain -- thinking we knew what it was and treating the theory without outcome measures...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Trigger Points - February 4, 2005 2:21:00 PM
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cjain
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Thanks for the link, Jon. I clicked through to the full article (which is available for free.
Marijuana an effective treatment for myofascial pain? Who'd have thunk it!
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