Robert Byrnes has been providing massage therapy in a professional setting since 1994, and integrates several modalities for a unique treatment that is individualized to each client's needs. He provides therapeutic treatments by appointment in his Phoenix, Arizona office: 602-334-1919.

Myofascial Trigger Points

Myofascial trigger points (TPs) are extremely common and become a distressing part of nearly everyone's life at one time or another. Latent TPs, which may cause some stiffness and restricted range of motion, are far more common than active TPs. A myofascial TP is a hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia. The spot is painful on compression and can evoke characteristic referred pain and autonomic phenomena. A myofascial TP is to be distinguished from a TP in other tissues, such as skin, ligament, and periosteum.

You will wear clothes for this treatment.

We do not think of the published TP sites as immutable locations, but as a guide for where to start looking. Every muscle can develop TPs; many muscles have multiple TP locations. Only the most common TP locations are shown in the published illustrations; individual muscles may have TPs in other locations. The TP sites in a given muscle vary from person to person; no two people are exactly alike.

The likelihood of developing pain-producing active TPs increases with age into the most active, middle years. As activity becomes less strenuous in later years, individuals tend to exhibit chiefly the stiffness and restricted motion of latent TPs. Researchers found that laborers, who exercise their muscles heavily every day, are less likely to develop active TPs than are sedentary workers who tend to indulge in occasional orgies of vigorous physical activity.

Active TPs are most likely in postural muscles of the neck, shoulder and pelvic girdles, and the masticatory muscles. The upper trapezius, scalene, sternocelidomastoid, levator scapulae and quadratus lumborum muscles are very commonly involved.

Cross-fiber palpation reveals a taut band that includes the TP, whereas, deep palpation along the length of the same muscle fibers gives the impression of a nodule at the TP.

The mere passage of time often fails to bring about recovery from a myofascial pain syndrome.

When injured, most tissues heal, but muscles "learn"; they "learn" to avoid pain. Active TPs develop habits of guarding that limit movement of that muscle. Chronic muscular pain, stiffness, and dysfunction result. With adequate rest, and in the absence of perpetuating factors, an active TP may revert spontaneously to a latent state. Pain symptoms disappear, but occasional reactivation of the TP accounts for the typical history of recurrent episodes of the same pain over a period of years.

Relief is more likely to be lasting when the client moves all of the treated muscles through several cycles of their full range of motion at the end of a therapy session. This teaches the muscles that their full range of motion is again available and encourages the client to use this full range in the course of daily activities. If the client continues to guard and restrict movement of the muscle following treatment, the TP activity and pain are likely to recur.

When clients mistakenly believe that they must "live with" TP pain because they think it is due to arthritis or a pinched nerve that is inoperable, they restrict activity in order to avoid pain. Such clients must learn that the pain comes from muscles, not from nerve damage, and not from permanent arthritic changes in the bones. Most important, they must know it is responsive to treatment. This gives the pain a new meaning. When these clients realize the twin facts that their pain is myofascial and is treatable, their lives take on new meaning and they are started on the road to recovery of function.

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What Causes Trigger Points?

Activating and Perpetuating Factors:
1. Strenuous use of the muscle, especially in the shortened position. Defining precisely the movement that increases the pain provides a major clue to the muscle that harbors the responsible TPs.

2. By sustained or repeated contraction of the involved muscle.

3. By placing the involved muscle in a shortened position for a prolonged period of time. Lack of movement, especially when a muscle is in the shortened position, tends to aggravate and perpetuate myofascial TPs. Pain and stiffness are often at their worst when the client gets out of bed in the morning, or when getting up from a chair after sitting immobile for a while.

4. During pressure on the TP, or prolonged constricting pressure on a muscle.

5. Nutritional Inadequacies; nutrients of special concern in clients with myofascial pain syndromes are the water-soluble vitamins B1, B6, B12, folic acid, vitamin C; and certain elements, calcium, iron and potassium.

6. Structural inadequacies; body asymmetry.

7. By passively stretching the muscle. However, active stretch by voluntary contraction of the antagonist does not ordinarily cause pain; the muscles quickly learn to limit this movement. The client is aware of restricted range of motion and "weakness", but rarely thinks of the affected muscle as painful.

8. During cold, damp weather, viral infections and periods of marked nervous tension.

9. By exposure to a cold draft, especially when the muscle is fatigued.

10. By cold packs continuously applied on the TP area. However, cold packs may afford some relief when applied to the pain reference zone. Also, relief by cold may indicate that the pain is of neuritic rather then of myofascial origin. Clients with nerve entrapment prefer cold packs on the painful region; clients with myofascial pain usually find their symptoms aggravated by continuous cold, and relieved by heat on the TPs.

11. Postural stresses; due to misfitting furniture, poor posture, immobility, and abuse of muscles: poor body mechanics that render movements needlessly stressful; by sustained isometric contraction or immobility of the muscles; with too many repetitions of the same movement; and by excessively quick and jerky movements.

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Trigger Point Therapy

Clients who have suffered myofascial pain for months or years are likely also to have developed secondary depression and sleep disturbances, and to have restricted their activity and exercise. The ensuing restriction of body movement and the increased psychic tension aggravate their TPs, causing a vicious cycle. All contributory factors should be identified and managed medically.

Typical symptoms of myofascial TPs:
Pain
Limited range of motion
Weakness
Other non-pain symptoms such as lacrimation, nasal secretion, changes in sweat patterns.
Depression
Sleep disturbances

Myofascial TP pain is decreased:
1. By a short period of rest.

2. By slow, steady passive stretching of the involved muscles, particularly when the client is seated under a hot shower or in a hot bath.

3. When moist heat is applied over the TP. The pain is decreased much less when the heat is applied over the reference zone.

4. By short periods of light activity with movement (not by isometric contraction).

5. By specific myofascial therapy.

Treatment Protocol:
When a band is identified, it is explored along its length to locate the spot of maximum tenderness in response to minimum pressure; that is the TP. Palpation technique can be snapping, flat, or pincer.

1. Ischemic compression is the application of sustained digital pressure to a trigger point for a period of about 20 seconds to a minute. Pressure is gradually increased as the sensitivity of the TP wanes and the tension in its taut band fades. Pressure is released when the practitioner feels the TP tension subside or when the TP is no longer tender to pressure. Sustained pressure should not be applied to blood vessels or a nerve; it may induce numbness and tingling. Ischemic compression should be followed by lengthening of the muscle, except when stretching is contraindicated, as in hypermobility.

Make sure the client is not holding their breath! Have the client breathe with your increasing pressure, taking long, slow, deep breaths. This focus on the breathing facilitates the release.

To apply ischemic compression, the relaxed muscle is stretched to the verge of discomfort. Initially, a thumb (or strong finger) is pressed directly on the TP to create tolerably painful, sustained pressure. Treatment is useless if the client tenses the muscles and so protects the TP from the pressure. As the discomfort tends to abate, pressure is gradually increased by adding a thumb or finger from the other hand, as necessary, for reinforcement. This process is continued up to 1 minute with as much as 20 or 30 pounds of pressure. If TP tenderness persists, the procedure can be repeated, preferably after a hot pack and active range of motion.

Ischemic compression may fail to afford relief: (a) because the TP is too irritable and requires many applications of pressure; (b) because the operator may have released pressure, rather than gradually increasing it; (c) when the operator may have pressed too hard at first, causing excessive pain and autonomic responses with involuntary tensing by the client; and (d) when the client has perpetuating factors that continue to make the TPs hyperirritable.

2. Stripping massage, or deep-stroking massage, produces the effect of "milking" the muscle. Stripping massage is performed by lubricating the skin and/or hands and applying firm pressure, slowly and deeply, progressively along the length of the taut band, through the region of the TP. Treatment starts with light stroking massage that barely involves the underlying muscular tissue. Then more pressure is gradually added. Vigorous massage of hyperirritable TPs can cause an adverse reaction with marked increase in pain.

The client must be positioned comfortably so that the muscles to be treated are completely relaxed under moderate stretch. The skin is lubricated, and the thumbs or fingers of both hands are placed at the distal end of the muscle and then slowly slid along the length of the muscle toward the TP, so that the muscle is milked of its fluid content. Pressure is light on the first pass. As the pressure increases on successive passes, a sense of nodular obstruction is encountered at the TP. It feels like a lump, which could be due to damming of blood and other tissue fluids by obstructed blood flow in the region of the TP. The sliding movement continues smoothly over the TP and through the clear area beyond. Repeated strokes with increasing pressure gradually reduce the bumpiness at the TP. By then, the procedure has inactivated the TP, which has become non-tender and no longer refers pain. This technique probably produces ischemia followed by reactive hyperemia behind the massaging fingers.

3. Stretching
The muscle must be completely relaxed and then firmly, slowly stretched to the point of moderate pain, gradually restoring its full normal length.

CRAC (Contract - Relax - Antagonist Contract) method of facilitated stretching:

1. Contract:
Have the client extend the target muscle so it is comfortably lengthened. Provide resistance for an isometric contraction for 6 to 10 seconds at 50 to 95% effort. Make sure that the client is not holding their breath during this effort.

2. Relax and take in a deep breath.

3. Antagonist Contract:
This is the stretch via reciprocal inhibition. Have the client contract the antagonist muscle for 15 to 20 seconds. Make sure that the client is not holding their breath during this effort.

Repeat 2 to 3 times going deeper with each stage. Move slowly and do not bounce the muscles. The client does all the work, the practitioner is only assisting with the different positions.

Contraindications to Trigger Point Therapy:
Areas of inflammation
Fever or systemic infections (cold or flu symptoms)
Over lymph nodes, major arteries, veins, and nerves - especially avoid varicose veins
Open wounds, sores, burns, bruises, rashes, undiagnosed lumps, etc.
Acute injuries
Intoxication or heavy pain medication
Caution with diabetics and pregnancy

Acupuncture and Trigger Points:
The relationship between TPs and acupuncture points is frequently questioned. Superficially, they seem to have much in common. One researcher compared the congruence of the TP locations reported by three authors with the location of acupuncture points related to pain, as published by an acupuncturist. By allowing a difference of 3 cm, they found an overall correspondence of 71%.

One experimentally well demonstrated mechanism for pain relief by acupuncture is the modulation of endorphin levels. Myofascial pain is relieved primarily by inactivating the source of pain, the TP. Acupuncture apparently alleviated the awareness of pain; inactivation the TP eliminates the cause of the pain.

Acupuncturists claim effects other than pain relief by treatment of many acupuncture points; we observe no corresponding effects by inactivating myofascial TPs, only relief of pain and of the specific non-pain referred phenomena characteristic of myofascial TPs. We see no relation between non-pain acupuncture points and myofascial TPs. Acupuncture points and trigger points are derived from vastly different concepts. The fact that a number of pain points overlap does not change that basic difference.

Learn more about acupuncture and Oriental medicine.

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Some Definitions

Trigger Point: A focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness, and sometimes to referred autonomic phenomena and distortion of proprioception. (The ability to sense the position, location, orientation, and movement of the body and its parts.) Types include myofascial, cutaneous, fascial, ligamentous, and periosteal trigger points.

Myofascial Trigger Point: A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle's fascia. The spot is painful on compression and can give rise to characteristic referred pain, tenderness, and autonomic phenomena. A myofascial trigger point is to be distinguished from cutaneous, ligamentous, periosteal, and nonmuscular fascial trigger points.
Phenomena other than pain are often caused by myofascial trigger points. Autonomic concomitants in the pain referral zone caused by TP activity include localized vasoconstriction, sweating, lacrimation, coryza (nasal discharge), salivation, and pilomotor (gooseflesh) activity.

Primary Myofascial Trigger Point: A hyperirritable focus within a taut band of skeletal muscle. The hyperirritability was activated by acute or chronic overload (mechanical strain) of the muscle in which it occurs, and was not activated as the result of trigger-point activity in another muscle of the body.

Secondary Myofascial Trigger Point: A hyperirritable spot in a muscle of its fascia that became active because its muscle was overloaded as a synergist substituting for, or as an antagonist countering the forces of, the muscle that contained the primary trigger point.

Active Myofascial Trigger Point: A focus of hyperirritability in a muscle or its fascia that is symptomatic with respect to pain; it causes a pattern of referred pain at rest and/or on motion that is specific for that muscle. An active trigger point is tender, prevents full lengthening of the muscle, weakens the muscle, usually refers pain on direct compression, mediates a local twitch response of its taut muscle fibers when adequately stimulated, causes tenderness in the pain referral zone, and often produces specific referred autonomic phenomena, generally in its pain reference zone.

Latent Myofascial Trigger Point: A focus of hyperirritability in muscle of its fascia that is clinically quiescent with respect to spontaneous pain: it is painful only when palpated. A latent trigger point may have all the other clinical characteristics of an active trigger point, from which it is to be distinguished. A latent TP is clinically silent with respect to pain, but may cause restriction of movement and weakness of the affected muscle.
A latent TP may persist for years after apparent recovery from injury; it predisposes to acute attacks of pain, since minor over-stretching, overuse, or chilling of the muscle may suffice to reactivate it. Both latent and active TPs cause dysfunction; only active TPs cause pain.

Satellite Myofascial Trigger Point: A focus of hyperirritability in a muscle or its fascia that became active because the muscle was located within the zone of reference of another active trigger point.

Zone of Reference: The specific region of the body at a distance from a trigger point, where the referred phenomena (sensory, motor, autonomic) that it causes are observed. Also known as the pain referral zone or the pain reference zone.

Jump Sign: A general involuntary pain response of the client, who winces, may cry out, and may withdraw in response to pressure applied on a trigger point.

Local Twitch Response: Transient contraction of the group of muscle fibers (usually a palpable band) that contains a trigger point. The contraction of the fibers is in response to stimulation (usually by snapping palpation or needling) of the trigger point, or sometimes of a nearby trigger point.

Ischemic Compression: Application of progressively stronger, painful pressure on a trigger point for the purpose of eliminating the trigger point's tenderness and hyperirritability. This action blanches the compressed tissues, which usually become hyperemic (flushed) on release of the pressure. Other modalities that also utilize ischemic compression are Myotherapy, Acupressure, and Shiatsu.

References:
Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1: The Upper Half of Body
by David G. Simons, Lois S. Simons, Janet G. Travell
ISBN: 0683083635

Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 2: The Lower Extremities
by David G. Simons, Barbara D. Cummings (Illustrator), Janet G. Travell
ISBN: 0683083678

Facilitated Stretching by Robert E. McAtee, Jeff Charland 1999
ISBN: 0-7360-0066-6

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Preparation for Treatment

Food:
Eating a lot of freshly-prepared protein (fish, meat, eggs, raw nuts) before your session is critical for you to get the best result from your treatment. Have plenty of protein in the 24-hour period before an appointment. On the day of your appointment, eat a large breakfast including plenty of protein. However, do not eat within two hours of your appointment. Individuals with low blood pressure and/or low blood sugar should pay special attention to eating well throughout the day of an appointment.
Water:
Please drink plenty of water the day before and the day of an appointment. The definition of plenty varies; one physician recommends that you take your body weight in pounds, divide by two, and consume that many ounces of water in a day. According to this formula, a 120-pound person would drink 60 ounces of water, or 7.5 cups, daily. Alcohol and caffeine are diuretics (they will work to eliminate water from your body) so if you consume alcohol or caffeine in the two days before an appointment, please drink extra water. Please continue to drink a lot of water after an appointment also.
Vitamins:
If you normally take vitamins, please remember to take vitamins on the day of an appointment. Bernard Filner, M.D., a Maryland physiatrist who studied with Janet Travell, M.D. and treats trigger points using her methods, requires his patients to take 2 grams (2000 milligrams) of timed release vitamin C per day for at least three days before their first visit (unless the patients have kidney stones). The timed release is important: Dr. Filner holds the opinion that 2 grams of timed release vitamin C is more useful to the body than 18 grams of regular vitamin C. In addition, he requires all his patients to start taking B-complex (50 milligram) vitamins, one pill daily, for six weeks, starting at least two weeks before the first appointment. In the B-complex vitamins, he requires the niacin to be in the form of niacinamide. Carol McMakin, D.C., an Oregon chiropractor who treats trigger points with microcurrent therapy (she presented this treatment strategy at the National Institutes of Health in April 2000), recommends that her patients to take complex low-dose anti-oxidant vitamins two hours before and immediately after a patient visit. For patients who do not have access to such vitamins, Dr. McMakin suggests an ordinary multi-vitamin two hours before and immediately after the patient visit.
Medication:
Do not stop any prescribed medication for an appointment. However, if you are choosing to take an over-the-counter anti-inflammatory drug such as aspirin, naproxen, acetaminophen, or ibuprofen, please avoid the use of such medication on the day of an appointment. Also, if you can, please do not take muscle relaxants 36 hours before your treatment.
Anti-inflammatory diet:
Recent research at the National Institutes of Health has linked localized myofascial pain syndrome with systemic inflammation. Andrew Weil, in his book, Eating Well For Optimum Health, recommends the following dietary changes to reduce inflammation naturally, without medication:
"Eliminate polyunsaturated vegetable oils, margarine, vegetable shortening, all partially hydrogenated oils, all foods (such as deep-fried foods) that might contain trans-fatty acids.
Use extra-virgin olive oil as your main fat.
Increase intake of omega-3 fatty acids.
Eat more fruits and vegetables.
Eat ginger and turmeric regularly."

David Seaman, author of Clinical Nutrition for Pain, Inflammation and Tissue Healing, has similar recommendations, noting also the value of fish oil (not for individuals taking blood-thinning medications), Vitamin D, magnesium, and probiotics.
Sleep:
Get plenty of sleep the night before an appointment.
Exercise:
Please do not engage in vigorous exercise on the day of an appointment.

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