trigger points

[12R34Y]

I only learned one way to treat trigger points in school (allopathic) and that was to inject them with steroids/anesthetic mix.

Is there any other thing you can do for trigger points for example the kind between your shoulder blades that when you push on them they send pain down your arm, up your neck or whatever. is there something other than the obvious.........stop sitting and studying with bad posture all day long that osteopaths may try on trigger points?

thanks

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[rescuetomm]

12R34Y

One of the major causes of upper thoracic paraspinal trigger points are weak over stretched traps/rhomboids and contracted shortened pect muscles. First you need to begin stretching the pects and strengthening the scapula retractors(Traps/Rhomboids). Strengthening the serratus anterior will also help to keep the scaps in the proper posture.

Myofascial release of these trigger points is very effective but will usually only give temporary relief unless you do the previous listed exercises. You need to find someone trained and willing to work on them. Manipulation will give relief but is not a permanent solution. Ideally using all three methods together will give you the best relief in the shortest period of time. Injections when needed,seem to work the best if coupled with myofascial release. I have had a great deal of experience working with myofascial pain and these modalities have been the most successful.

 

[Kalel]

I'm not sure if this is using the same terminology, but we had an MD give us a lecture about using accupuncture in trigger points or to relieve trigger point pain. It seemed very hocus pocus to me, but she assured us that it was all evidence based medicine. They even use it to augment the treatment of heroin addiction at my school.

 

[12R34Y]

could you explain to me a little bit about what myofascial release actually is?

I've heard (take with grain of salt) that if you push on the "knot" or "trigger point" and hold it for a while it will eventually "release"?

is this what you are talking about?

thanks

 

[coreyw]

Certainly, the only treatment I've ever received or given for trigger point pain has been manual and it usually produces quick and often lasting relief - depending on the root cause of the problem, and the overall state of the person, their postural habits, etc.

Treatment by injection of steroids strikes me as a little primitive and quite radical.

When might a physician choose to use this invasive technique over more conservative methods?

 

[coreyw]

Drugs. 2004;64(1):45-62.


Myofascial pain disorders: theory to therapy.

Wheeler AH.

Pain and Orthopedic Neurology, Charlotte Spine Center, Charlotte, North Carolina 28207, USA. [email protected]

Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and actuates movement against inertia. Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading. Muscular pain is often attributed to a myofascial pain disorder, a condition originally described by Drs Janet Travell and David Simons. Among patients seeking treatment from a variety of medical specialists, myofascial pain has been reported to vary from 30% to 93% depending on the subspecialty practice and setting. Forty-four million Americans are estimated to have myofascial pain; however, controversy exists between medical specialists regarding the diagnostic criteria for myofascial pain disorders and their existence as a pathological entity. Muscles with activity or injury-related pain are usually abnormally shortened with increased tone and tension. In addition, myofascial pain disorders are characterised by the presence of tender, firm nodules called trigger points. Within each trigger point is a hyperirritable spot, the 'taut-band', which is composed of hypercontracted extrafusal muscle fibres. Palpation of this spot within the trigger point provokes radiating, aching-type pain into localised reference zones. Research suggests that myofascial pain and dysfunction with characteristic trigger points and taut-bands are a spinal reflex disorder caused by a reverberating circuit of sustained neural activity in a specific spinal cord segment. The treatment of myofascial pain disorders requires that symptomatic trigger points and muscles are identified as primary or ancillary pain generators. Mechanical, thermal and chemical treatments, which neurophysiologically or physically denervate the neural loop of the trigger point, can result in reduced pain and temporary resolution of muscular overcontraction. Most experts believe that appropriate treatment should be directed at the trigger point to restore normal muscle length and proper biomechanical orientation of myofascial elements, followed by treatment that includes strengthening and stretching of the affected muscle. Chronic myofascial pain is usually a product of both physical and psychosocial influences that complicate convalescence.

 

[12R34Y]

My preceptor is a FP (MD) and in school we were taught to inject trigger points.

My FP guy does them a TON!

I assumed that was the standard of care and that manual therapy was only minorly considered.

interesting.

later

 

[12R34Y]

My FP preceptor inject trigger points CONSTANTLY. That's what I was taught in my clinical medicine course as well.

I assumed that was the standard of care since it is so commonly performed.

interesting

 

[rescuetomm]

Myofascial release is a manual therapy used to break adhesions that develop between the muscle belly and the overlying fascia. These adhesions are innervated with nociceptive receptors and can cause significant pain. Muscles may also develop adhesions between the fibers themselves essentially causing the "knot" feeling to you and the patient. Some will call myofascial release muscle stripping because that is basically what is done. There are several techniques that can be used. First you will use your fingers or a commercially made tool, working parallel with the fibers through the tp. If you are doing it right it is going to be uncomfortable if not downright painful. That is why I said the injections are helpful for the persistant longstanding tps. For a new tp or minor one, injections are usually not needed. Usually it will take several treatments. Another effective treatment especially for the upper traps or levator scap(or any muscle that is easy to stretch) is to start with slack in the muscle(ie. laterally flex the head to the affected side) and your thumb on the affected muscle proximal to the tp, as you stretch the muscle (laterally flex the head to the opposite side) your thumb will run parallel with the fibers through the tp to the distal end of the muscle. I usually will do this 5-10 times depending on patient tolerance and where we are in the treatment plan. It is definitely an art. You can't be a bull and "muscle" them out. This is kind of tough to describe in a forum. It would be easy to show to you . Maybe try to find a PT that would show you what to do or a DO or DC that is trained in it.

 

[12R34Y]

Thanks for the info!

Unfortunately, I'm probably not going to have much time (due to the whole boards thing coming up) to be hunting down a PT or DO.

anyone got any good websites for demonstration of these techniques?

later

 

[Dr JPH]

Originally posted by rescuetomm
Myofascial release is a manual therapy used to break adhesions that develop between the muscle belly and the overlying fascia. These adhesions are innervated with nociceptive receptors and can cause significant pain. Muscles may also develop adhesions between the fibers themselves essentially causing the "knot" feeling to you and the patient. Some will call myofascial release muscle stripping because that is basically what is done. There are several techniques that can be used. First you will use your fingers or a commercially made tool, working parallel with the fibers through the tp. If you are doing it right it is going to be uncomfortable if not downright painful. That is why I said the injections are helpful for the persistant longstanding tps. For a new tp or minor one, injections are usually not needed. Usually it will take several treatments. Another effective treatment especially for the upper traps or levator scap(or any muscle that is easy to stretch) is to start with slack in the muscle(ie. laterally flex the head to the affected side) and your thumb on the affected muscle proximal to the tp, as you stretch the muscle (laterally flex the head to the opposite side) your thumb will run parallel with the fibers through the tp to the distal end of the muscle. I usually will do this 5-10 times depending on patient tolerance and where we are in the treatment plan. It is definitely an art. You can't be a bull and "muscle" them out. This is kind of tough to describe in a forum. It would be easy to show to you . Maybe try to find a PT that would show you what to do or a DO or DC that is trained in it.

Just curious where you are in your osteopathic training.

I have an entire different approach to trigger points. Myofascial release MAY be in there, but there are far more effective treatments which DO last...particularly in the rhomboid/scapular area.

 

[12R34Y]

care to elaborate JPhazelton?

thanks

 

[Dr JPH]

This is a very common trigger point. One of those that cannot be easily treated using a simple "push and hold" philosophy as some trigger points will respond to.

I usually do some soft tissue initially to maximize blood flow. There are also ROM techniques using a modified resitance technique that was taught to me by a personal trainer...again, increasing blood flow to the area.

Once the tissue is softened (usually about 2 minutes tops) I use facilitated positional release (FPR). Basically finding the balance point of the muscle tissue...also doing some balancing of the muscle band will help.

If nothing else works, counterstrain can sometimes loosen the tissue enough that the pain is dramatically decreased.

Often because this trigger point is functional or postural, it does return. But once you find the best way to treat a patient using the manual techniques, its easy to go through the motions and get rid of it easily the next time.

You can also educate the patient about posture during reading, studying, and writing. Sidebending the neck to hold the telephone should also be avoided. But then again, proper posture in the previous mentioned activities not only prevents this particular dysfunction, but it better for your neck, back and maybe even migraines.

If you have more questions I can direct you to some osteopathic texts which will explain the techniques in a stepwise fashion. Counterstrain and soft tissue can be done by anyone. FPR and balancing tissues takes a "feel", but can be learned with practice.

 

[Dr JPH]

Almost forgot:

Don't forget to treat the splenius cap. and traps.

Also, an unbalanced pelvis, scoliosis or out-of-place rib cannot only mimick this trigger point, but cause it.

So I guess what I am saying is "make sure everything else is ok and this is jsut a trigger point." Or you can treat it all you want and it will come back in days.

 

[12R34Y]

I'd love some recommendations..............wish they taught us some of this stuff in MD school. sounds very useful.

later

 

[Dr JPH]

This is just some of what we learn in DO school. I am a big proponent of OMM.

Here are two books that you should find helpful:

Osteopathic Approach to Diagnosis and Treatment; DiGiovanna
a bit tought o read for those who aren't familair with OMM

A book that may be a better start:

Easy OMT: A Photo Reference Guide for Manual Medical Care
; W.H. Howard. About $20 or so. pictures and how-to steps

Hope they help.

 

[Cowboy DO]

Originally posted by JPHazelton
Once the tissue is softened (usually about 2 minutes tops) I use facilitated positional release (FPR). Basically finding the balance point of the muscle tissue...also doing some balancing of the muscle band will help.

If nothing else works, counterstrain can sometimes loosen the tissue enough that the pain is dramatically decreased.

JP, I just have a quick question maybe you can clear up. If FPR doesnt work why would counterstrain? Aren't they essentially the same technique, and what about exercise? would that help?

 

[coreyw]

Originally posted by 12R34Y
I'd love some recommendations..............wish they taught us some of this stuff in MD school. sounds very useful.

later

I understand some osteopathic medical schools offer manipulative medicine courses for MDs if you're interested. (JPH - do you know which ones?) Although, apprenticing yourself to a willing OMM practitioner might be cheaper and easier!

 

[Dr JPH]

Originally posted by Cowboy DO
JP, I just have a quick question maybe you can clear up. If FPR doesnt work why would counterstrain? Aren't they essentially the same technique, and what about exercise? would that help?

Counterstrain, as it is taught in most DO schools (especially in first year) is a static technique. "Fold and hold" if you will, for 90-120 seconds depending on the body region or muscle group being treated. This technique basically involves finding a tender point (technically different than a TRIGGER point, but you can use counterstrain for many things), placing the patient in a position of greatest ease (there are many documented "classical positions") then holding for 90 seconds at which point the practitioner will feel a release of the tissues beneath his finger. Bringing the patient slowly from the position back to neutral will prevent a "recoil" of the original tender point. The basic mechanism behind counterstrain is a resetting of the gamma neuron fibers so the muscle basically says "ok, THATS how its supposed to be...got it...ok, I'm there".

FPR is sometimes referred to as "counterstrain with an attitude" as it involves a compression along with finding a point of greatest comfort for the patient. The major difference for the practitioner is that you need to be able to feel what is takign place beneath your fingers and modify the tissues accordingly, almost incorporatin BLT at the same time...at least thats how I find it to work the best. With FPR you take the pt to the position of ease and compress THROUGH the tender point, using it almost as a vertex for your pressure. This is a more dynamic technique as you need to adjust the position of the pts head, shoulder, leg, etc as the tissues move beneath your fingers...this is why it takes more practice to learn and become good at.

Interestingly enough, when Dr. Jones originally developed counterstrain he did not mean it to be a totally static technique. In fact, he did make micro-adjustments as he felt the tissues changing during treatment. It is taught as a static technique for a few reasons...
1. It's easier
2. You don't need to be able to feel anything
3. If you move things the wrong way during treatment, you may increase the pain, make your pt jump and effectively have to start over

I hardly use straight counterstrain anymore. I do FPR along with my counterstrain. I use Still technique as well, which is a whole other ballgame. The better you get at palpating and feeling tissues change and move beneath your hands, the quicker and more effectively you will be able to treat patients, particularly the pain in the ass points.

And yes, exercise can certainly help because it does a few things:
1. Delivers blood to the tissue
2. Delivers oxygen
3. Stretches muscle
4. Improves lymphatic drainage
5. Improves venous drainage


Hope that helped a bit.

 

[Dr JPH]

Originally posted by coreyw
I understand some osteopathic medical schools offer manipulative medicine courses for MDs if you're interested. (JPH - do you know which ones?) Although, apprenticing yourself to a willing OMM practitioner might be cheaper and easier!

I am not sure which schools offer programs. I know there are MDs who have done some things through PCOM. Whether it is official courses or just shadowing, I'm not sure.

Your best bet would be to start here:

http://www.academyofosteopathy.org/continuinged.cfm

Hope this helps.

 

[Cowboy DO]

jp,

yes, thank you.