Active Myofascial Trigger Point Therapy

[jillybutt]

Hi, I am a 3rd year physiotherapy student and just about to start my dissertation, for which i have chosen to research the 'effectiveness of ischaemic compression therapy for active trigger points'. I believe that it is important to retain manual skills in light of recent 'medicalised' approaches to many conditions (i.e. injections). But of course I need to be able to provide evidence on their effectiveness. Although there is information out there for this well used technique, there is little research either clinical or evidentially based from which i can justify this method of treatment. Just hoping that someone out there could help - with views, research or clinical details.
Thank you in anticipation.

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[Physiobase]

Try to ask fellow physios in this instance for single case design data, i.e. one patient who benefited from this technique when applied in a way to justify that it was the treatment causing the change. Or if no one can supply data but uses the technique - perhaps be even more radical by outlining a single case design and ask those using the technique to follow your single case guideline and report back to you!

Numerous single case techniques are perhaps more powerful than any RCT

[Cris K]

Hi Jilly,
I trained in the u.s. in neuromuscular therapy - a well defined method for treating trigger points that utilises ischaemic compression as one of the soft-tissue techniques. It works very well, but like much of physio, is poorly researched.
You may want to use 'neuromuscular therapy' or 'nmt' as search terms on google.
Authors on the subject include the classic works by Travell & Simons, and newer texts by Leon Chaitow & Judith Walker DeLany.
Look for papers by David Simons, e.g. in the J. of Bodywork & Movement Therapies.
Finally, take a look at the papers by Chan Gunn on trigger points and myofascial pain. I now use his techniwue of dry-needling (Intramuscular Stimulation) to treat TP's.
Hope this helps.
Cris[/i]

[jillybutt]

Thanks Chris

[Bravocosta]

Hello Jillybutt,

For the treatment of the "so called" trigger points, in my experience the problem is not in the muscle per se , but is being caused by another problem ie- neural , postural , or joint. Your job is to find out what the source of the problem is and that will resolve it the most effectively. Have long ago stopped trying to "massage out" or use ischemic pressure as these in my experience usually provide only transiet relief of the so called "trigger point". Muscle biopsies have not shown any abnormality in the muscle itself, so just treating the muscle is unlikely to help in the long term.

Good luck on your new career......Thomas

[mageshanand]

hi jilly nice idea, but have you done your search adequately, cos there are few articles that might be quite interesting to you, one is hong CZ et al published in arch phy ned rehab, and other in the journal physical therapy, both the studies have dealt with ischemic compression to a major extent,amd i have done quite a bit of study on this myself, you can contact ,me on my mail id, [email protected] if you want any further suggestions, as it may not be much importance to the readers, in this forum.

[fisiosimo]

Hello. I've searched for fluorimethane (or alternative vapocoolants) on the internet, without success. Can you help me ?

[Baby_Physio_Kieran]

I have to agree with Bravocosta. In my (admittedly limited) experience I've found that most "trigger points" and "knotted muscles" seem to be caused by a more proximal problems. And (I'm sorry to generalize as this is generally considered the cardinal sin) tend to respond well to mobs of the appropriate spinal level. I have experienced many patients claiming that certain mobs at the corresponding spinal level causes the pain to "switch on and off". Gentle rhythmic mobs relieved the more distal muscular pain/knot/trigger point and combined with regular stretches to firmly break the pain-spasm cycle. I would appreciate opinions on the possible mechanism of this re. ?merely pain-gate at nerve root or ?"freeing up" nerve root.

[physiobob]

Hello. I've searched for fluorimethane (or alternative vapocoolants) on the internet, without success. Can you help me ?

I think you mean Fluorimethane.

I found this info on the site: http://www.bayareapainmedical.com/wtrgrpnts.html

MYOFASCIAL TRIGGER POINTS

Myofascial trigger points are small areas of muscle spasm in larger muscles. These small areas can be exquisitely painful. There is often an area of inflammation in the surrounding fascia. Trigger points can be palpated using the finger tips and this type of palpation not only induces pain, but also reveals the actual area of spasm of the muscle being evaluated. The fascia around the trigger point is pulled taught and can lead to inflammation of that area. The pain caused by chronic trigger points can be severe, breaking through high doses of opioid medications and combinations of medications. Pain can be referred and may imitate neuropathic pain. It can be aching, stinging, burning or throbbing in nature. Referred patterns of headache are quite common from the shoulder and intrascapular areas of the trapezius muscle.

Several approaches to treating these pinpoint areas of muscle spasm have been tried. Message therapy can be helpful, but should probably be combined with the use of Fluorimethane and trigger point injections. Using cold in the form of Fluorimethane spray and stretching after this treatment can be quite effective. Injecting the trigger points with a small gauge needle and local anesthetic can also be helpful. The injections should be aimed at multiple puncture of the part of the muscle in spasm, using 1 to 2% Lidocaine for local anesthesia and some local anti-inflammatory effects. The key here is not the pain relief from the infiltration with the Lidocaine, but is more for the needle penetration, breaking up the muscle spasm. Some people inject steroids with the anesthetic, but the IM nature of the steroid injections can lead to cumulative steroid toxicity, if the injections need repeating every three to four weeks.

In instances of chronic trigger point recurrence the use of botulinum toxin can give longer term relief. This treatment is somewhat controversial, but patient's can gain excellent long term results, when other methods have failed.

A less invasive approach can be to put a Lidoderm® patch over the area of trigger points or to use transdermal Ketamine in PLO. Muscle relaxers, such as cyclobenzaprine may also be helpful. Again this treatment tends to stretch the length of time between trigger point injections and can be very helpful with referred pain.

[ginger]

Agree with Bravacosta and Kieren, dealing with "trigger points " will provide only short term relief from altered patterns of recruitment of muscle , and elements of referred pain associated with hypertonicity. Long term solutions will be provided by appropriate mobilisation to the relevant spinal facet joints. By freeing these joints from protective responses leading to inflammatory events of joint and nerve . There are lots of compelling ways to waste time, trigger point therapies are just another. I'd put it right up there with cupping.

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[Dhul-Qarnayn]

There are lots of compelling ways to waste time, trigger point therapies are just another. I'd put it right up there with cupping.

Wow, just wow. You are binning the works of some of the top therapists on the planet with that comment. Around 600 of my clients say quite the opposite. I have completely mended people with Myofascial techniques alone, and they have gone onto to enjoy a life free of pain (long term)

[Lorcan]

Hi Jill! Just wondering did you manage to get your dissertation finished on the "trigger points" as would be extremely interested in getting a copy of it?

[hariharan]

dear physio, its the best technique i have practised in tr. points. you try TRAVELL and SIMONS book. if you have doubts contact me at [email protected].
did the best , do the best

[rosinbag]

do whichever myofascial/trigger point treatment works and then look for the imbalance or other structural issue might be causing the pain.

[mulberry]

sa wa dee krab (hello in thai)

trigger points are very interesting indeed. you push one which is active or latent you get anything from pain to nausea. interesting how one trigger point referres pain to the opposite side of the body; annecdotally, definitely spinal cord related for this to occur otherwise referral would only be ipsilateral. any one else please

[quorthon]

i would agree with a colleague that has posted about the waste of time on so calles "trigger point" therapy...I would add that it may be harmfull sometimes, not just waste of time....As primary clinicians (which means we are interfering in diagnostic processes,not just treat) we should ask ourselves where the trigger points are coming from....There is a huge literature which supports that the mechanisms of REFERRED PAIN from a variety of tissues (somatic,neural, even visceral!) can generate trigger points in a quite bizzare fashion. If a therapist starts treating a area of hypertonicity (aka trigger point) he doesnt know if the pain is local or referred.....For example, cardiac (visceral) pain generates trigger points in pectoralis major or left shoulder, discogenic pain generates trigger points in quadratum lumborum or erector spinae or even more serious an underlying systemic disease can generate "innocent" trigger points manifesting as a PRIMARY musculoskeletal condition..It becoming clear that in the above situations (and many more examples ) we will treat just a CLINICAL SIGN (not even symptom!) of a primary condition...We cannot identify the true SOURCE of the problem....
Forgot to mention that even those who thinks that trigger points are effective treatment modality maybe should start reviewing their patients more in the LONG-TERM for potential benefits, which i really doubt...Any SHORT-TERM benefits may induced just by the benign NATURAL COURSE of many musculoskeletal dysfunctions...Only through exercises and self-mobilisations we can achieve guaranteed results!

[violablue]

i would agree with a colleague that has posted about the waste of time on so calles "trigger point" therapy...I would add that it may be harmfull sometimes, not just waste of time....As primary clinicians (which means we are interfering in diagnostic processes,not just treat) we should ask ourselves where the trigger points are coming from....There is a huge literature which supports that the mechanisms of REFERRED PAIN from a variety of tissues (somatic,neural, even visceral!) can generate trigger points in a quite bizzare fashion. If a therapist starts treating a area of hypertonicity (aka trigger point) he doesnt know if the pain is local or referred.....For example, cardiac (visceral) pain generates trigger points in pectoralis major or left shoulder, discogenic pain generates trigger points in quadratum lumborum or erector spinae or even more serious an underlying systemic disease can generate "innocent" trigger points manifesting as a PRIMARY musculoskeletal condition..It becoming clear that in the above situations (and many more examples ) we will treat just a CLINICAL SIGN (not even symptom!) of a primary condition...We cannot identify the true SOURCE of the problem....
Forgot to mention that even those who thinks that trigger points are effective treatment modality maybe should start reviewing their patients more in the LONG-TERM for potential benefits, which i really doubt...Any SHORT-TERM benefits may induced just by the benign NATURAL COURSE of many musculoskeletal dysfunctions...Only through exercises and self-mobilisations we can achieve guaranteed results!

Mmm...waste of time? Can't find true source? We're taught to assess, evaluate, and diagnose. Set up a prognosis and plan. Then treat. Always reassessing and revising as needed. The trigger point information is so rich and helpful, why just write it off with a swish of the arm? Why can't it work in conjunction with mobilizations and exercises?

After all, if you are stretching a muscle are you not working at bringing it to a non-restricted length? Trigger point release does the same thing for a muscle. So why paint the whole therapeutic method over with such a negative brush stroke?

I think we are taught enough about referral patterns to be able to have some idea of things without feeling we are pellmell bent on destruction-by-trigger-point of say a heart patient.

[f1progeny]

Hi everyone,

Have to say I agree with viola above. TrP cannot be seen as a stand-alone method of treating patients however i use them regularly in my treatment of a variety of conditions- to excellent effect. Attending courses in manual release of MTrP's and Dry-needling it was stressed that to try to treat the TrP's alone is not sufficient and in fact is just poor-practice.
In undergrad we did very little soft-tissue release but had large emphasis on manual mobs etc and i feel this did not prepare me for optimising patient treatment. For optimal out-comes in any case all elements of the joint, myofascial and neural restrictions need to be treated along with correction of postural/biomechanical issues and correct re-training of neuro-muscular control(among other things).

I think any clinician woth their salt should always be wary of referred pain especially visceral pain masquerading as a musculoskeletal condition but a detailed history and examination looking out for yellow/red flags should help confirm the diagnosis/need for onward referral.
The key is the diagnosis, I just find that for musculoskeletal conditions release of TrP's is a quick and effective way for restoring soft-tissue to normal length/function in preparation for rehabilitation.

I'm not even going to go into the treatment of myofascial pain using dry-needling/manual release of TrP's which in my experience is extremely effective - however again the clinician and patient need to be aware that unless causative factors are addressed the TrP's will continue to develop.

As for research chris-k mentioned people above but i feel there will be a growing body of evidence in support of treating TrP's over the next few years. Search Jan Dommerholt for a very interesting chapter on craniomandibular pain.

Hope this helps, it's certainly an area that needs more research but a promising one.

[enggrajshukla]

Hi every,

I am agree with all, Dealing with "trigger points " will provide only short term relief from altered patterns of recruitment of muscle , and elements of referred pain associated with hypertonicity. Tell me why it does not work with the exercise.

[quorthon]

Hi everyone,.

As for research chris-k mentioned people above but i feel there will be a growing body of evidence in support of treating TrP's over the next few years. Search Jan Dommerholt for a very interesting chapter on craniomandibular pain.

Hope this helps, it's certainly an area that needs more research but a promising one.

You should also check more critisizing references if you want to have a more objective opinion about Trps...Quintner for example has published many articles on the subject based on clinical cases which show that Trigger points is nothing but a MANIFESTATION of other dysfunctions....In my own little experience (if i was 60 years old i would only say HUGE) when u treating succesfully a patient, u often observe that Trps dont longer exist...For example on a discogenic situation on lumbar spine, when Trps are in erector spinae or gluteus muscles, and after treatment there is no "tenderness" over this area...

[f1progeny]

Hi quorthon, would you have those references for Quintner specific to TrP's? Limited journal access and keep getting the 1994 article and responses to same.

Another problem with the effectiveness of TrP therapy i feel can be the inability of some practitioners to identify TrP's correctly, and not just push the "tender" spot and expect something to happen. I do agree that referred pain from neural structures can activate TrP's in the referral area however "in my own little experience" i certainly do not think this is the only way they are activated. Also i've noted quicker responses to mobilisation of joints after releasing TrP's with ischaemic pressure or dry needling.

[mudrubble]

Hi Guys,

I don't know if this is a site for laymen or not, but please let me know if I'm posting in the wrong place. Here's my issue in a nutshell:

I seem to have massaged a trigger point in my right vastus medialis that has loosened up and released its hold on my kneecap, which now buckles and tricks out on me when I walk. I have never had a buckling knee in my 35 year old life until two days ago, after intense massage to my leg trps.


Details:

I bought the Trigger Point Workbook by Clair Davies, and eradicated my persistent, 3 month old lower back pains overnight. They haven't returned in a week, and I only do light upkeep on those muscles. Spurred on by that success, I moved onto other trps.

So I started working on my calves, which were INCREDIBLY tight and painful. That led to up behind the knee, to what I assume are the popliteus and plantaris muscles. Then I started moving up the inside of the thigh to what I'm thinking must be the semitendinosus and semimembranosus, and further around the inside of the lower thigh and knee to the vastus medialis, which I worked on for a good amount of time. It felt great after, less tight, freer.

The next morning I awoke fine, leg felt longer and freer. After some basic walking, my knee gave out and I almost fell. It was more shocking than painful, but it was also lightly painful. Then it happened again and again, and honestly, I don't know how I went through the whole day without falling. I almost fell a hundred times. Started walking like a cripple. It doesn't hurt at all, for the record. My knee feels fine. It feels a little "empty" behind it and it feels like if I contract my quads too much, I might permanently move my kneecap up (I understand this is not possible, I'm only describing sensations now). When I walk up stairs, It feels like the kneecap is not securely held in place.

So it doesn't hurt, but it's uncomfortable. To be honest, there might be a very light pain where the tendon from my bicep femoris attaches to the top of the fibula. Just noticed this now. As in this second. Can't say I've known this till this moment. I guess writing helps.

So anyway, doesn't hurt (much anyway) but tricks out constantly and I'm a little afraid I'm going to tear something before it settles back down.

So my questions are:

1 - Should I wear a knee brace until this settles down or is that more likely to aggrivate the problem?

2 - Do you guys have any idea which muscles I should investigate first? My peronius and gastrocnemius muslces feel like they might be tight. So does my vastus lateralis, my biceps femoris, all my inner thigh muscles hurt, my gracilis hurts fairly intensely to touch along its length, my semitendinosus and semimembranosus both feel tight and hurt. So obviously all my leg muslces need work. Question is, where should I start to get my knee settled back in to where it's been for the last 35 years??

3 - Is it possible that massage to the vastus medialis is really responsible for MAKING my knee trick out? Clair Davies suggests it CURES that condition, but in my case, working on it SEEMS to have brought the condition on..... or am I just crazy?

Finally, it might also help to know that I also used to walk on the inside of my feet until two days ago, especially with this right foot. Not sure if I have morton's foot, as the metatarsal bones are damned near even, but I've always had problems walking on the outside of my feet, even when I've tried consciously. Strangely enough, since the kneecap slipped, the only way I can prevent it from tricking is to stay on the outside of my feet, which feels a lot easier. It doesn't stop it from buckling entirely, but cuts down greatly on the buckling. Don't know if that info helps or not.....

Anyway, if any of you gurus could help me, I'd appreciate it. Sorry this was so long, but I felt with this many connecting muslces it might help to give that info up front. Thanks again,
--

[gangaa]

well, according to my knowledge, myofascial trigger release never induce problems as you said. if u feel your muscles are tight, why don't you try stretching. First of all, this technique can be practiced in a proper way by a Physiotherapist only. Don't try yourself with theoritical knowledge. It needs lots of experience to releive pain and spasm.
1. Try hot pack, massage and stretching
2. Do regular relaxation and strengthening exercises
3. Improve your day to day physical activities
4. Don't try anything without consulting a physiotherapist or your physician
Proper myofascial trigger release technique never cause problems... consult a physiotherapist and get well soon..