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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.
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.
Activating and Perpetuating Factors:
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:
Myofascial TP pain is decreased:
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:
Trigger Points and Acupuncture
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.
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.
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
Myofascial Pain and Dysfunction:
The Trigger Point Manual, Vol. 2: The Lower Extremities
by David G. Simons, Barbara D. Cummings (Illustrator), Janet G. Travell
by Robert E. McAtee, Jeff Charland 1999
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