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Myofascial trigger points revisited.

Our understanding of the pathogenesis of trigger points is evolving. One current hypothesis suggests that trigger points are formed when a sensitive locus (nociceptor) and an active locus (abnormal motor endplate) coincide. Pain is thought to be initiated when the trigger point area is stimulated by stressors like cold, postural distortions and emotional stress which set up a self-perpetuating pain cycle that long outlasts the initiating stimulus. Referred pain patterns, local twitch responses and autonomic phenomena are thought to be related to interneuronal integration in the spinal cord. (1) There is also much interest in the relationship between acupuncture points and trigger points, a number of studies reporting considerable overlap. (2,3) According to Peng (3) 95% of trigger points (235 out of 255) correspond to acupuncture points in anatomical location and clinical indications.

It has been observed that trigger points tend to develop more readily in postural muscles (e.g. upper trapezius, levator scapulae, quadratus lumborum, iliopsoas, piriformis and tensor fasciae latae) than in phasic muscles, (4) and in high demand muscles more than in low demand muscles. Trigger points in skelet al muscles usually develop at the origins, insertions (attachment trigger points) and bellies of muscles, particularly at the neuromuscular junction (central trigger points). According to Fritz5 trigger points tend to be found near origins and insertions in long eccentrically contracted muscles, and in muscle bellies in short concentrically contracted muscles. Areas of muscles that are prone to mechanical strain, impaired circulation and muscular or fascial adhesions are also common sites.

Key trigger points have also been identified. It appears that by treating key trigger points satellite trigger points can also be reduced or eliminated. (6,7) Key trigger points include: (8)
Key trigger point Associated satellite trigger point

sternocleidomastoid temporalis, masseter

upper trapezius temporalis, masseter

scalene deltoid, extensor carpi radialis,
 extensor digitorum communis

splenius capitis temporalis

supraspinatus deltoid, extensor carpi radialis

infraspinatus biceps brachii

pectoralis minor flexor carpi radialis, flexor carpi
 ulnaris

latissimus dorsi triceps brachii, flexor carpi
 ulnaris

serratus posterior superior triceps brachii, extensor
 digitorum communis, extensor
 carpi ulnaris

quadratus lumborum gluteus maximus, piriformis
piriformis hamstrings

hamstrings gastrocnemius, soleus


MANUAL TREATMENT TECHNIQUES

Since the identification of central and attachment trigger points (9) it has become apparent that each requires a different treatment approach. The traditional manual techniques (e.g. digital ischaemic pressure) that have been used to treat all trigger points are now recommended for central trigger points only. Such deep techniques may inflame or irritate tissues near attachment trigger points and cold applications are now recommended for direct application to attachment trigger points.

PROTOCOL FOR MANUAL TREATMENT OF TRIGGER POINTS

1. Warm the area to be treated with Swedish massage.

2. Treat key trigger points first. They are usually closest to the head and the midline. Treat two or three of the most painful trigger points.

3. Treat central trigger points before attachment trigger points. Treatments include:

* digital ischaemc pressure

Steady pressure is applied using the thumb, fingers, elbow or knuckle to the trigger point within the client's pain tolerance (between 4 and 7 on a pain scale of 1 to 10) for up to 60 seconds. Chaitow (10) recommends gradually increasing the pressure until the client reports a 7 or 8 out of 10 on the pain scale, maintaining pressure until the client reports a reduction to 3 or 4 and then increasing the pressure again up to 7 or 8. This process is repeated up to three times or until the therapist feels a tissue change in the trigger point area. Using variable pressure prevents further irritation to the trigger point.

* gliding from the muscle belly out towards the muscle attachments

* mild stretching

* thermotherapy

* deep stroking or stripping massage over the trigger point area (9)

4. Treat attachment trigger points using short applications (20-30 seconds) of cold (e.g. Ice massage)

5. After trigger points in a muscle group have been treated the muscles are gradually stretched to their full length.4 (Most sources describe passive stretching following the hyperstimulation phase of treatment.)

6. Correct or reduce mechanical factors predisposing to trigger points (e.g. postural distortion, muscle imbalance, joint dysfunction).

SAVE YOUR BODY

A lot of strain can be placed on therapists' joints and muscles during sustained ischaemic compression. McMahon et al. (11) found that 65% of physiotherapists who responded to a survey had experienced thumb problems at some stage during their working lives. Trigger point therapy was reported as one of the factors that were significantly associated with thumb problems. Vary the contact (use your thumbs sometimes, knuckles and elbows at other times) and avoid flexion and extension, especially of metacarpophalangeal joints or interphalangeal joints when applying pressure (see 6.2). Some therapists use a T-bar made of wood, plastic or met al, and often rubber capped, to save their hands. Another study compared muscle load to the shoulder using three different trigger point therapy techniques: digital ischaemic pressure using a single hand contact, a double hand contact and a treatment tool. The authors found that using the treatment tool decreased the muscle load to the shoulder of the contact arm although they were unable to comment on where the load was redistributed. (12)

REFERENCES

(1.) Hong CZ. Myofascial trigger points: Pathophysiology and correlation with acupunture points. Acupuncture in Medicine. 2000;18(1):41-7.

(2.) Dorsher PT, Dorsher PT. Myofascial referred-pain data provide physiologic evidence of acupuncture meridians. J Pain. 2009;10(7):723-31.

(3.) Peng ZF. Comparison between western trigger point of acupuncture and traditional acupoints. Zhongguo zhenjiu. 2008;28(5):349-52.

(4.) Chaitow L, Fritz S. A massage therapist's guide to understanding, locating and treating myofascial trigger points. Edinburgh: Churchill Livingstone; 2006.

(5.) Fritz S, Chaitow L, Hymel GM. Clinical massage in the healthcare setting. St Louis, Ml, Mosby Elsevier; 2008.

(6.) Tsai C, Hsieh L, Kuan T, Kao M, Chou L, Hong C. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. American Journal of Physical Medicine and Rehabilitation 2010 Feb;89(2):133-40.

(7.) Hsieh Y, Kao M, Kuan T, Chen S, Chen J, Hong C. Dry Needling to a Key Myofascial Trigger Point May Reduce the Irritability of Satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007 May;86(5):397-403.

(8.) Hong C, Simons D. Remote inactivation of myofascial trigger points by injection of trigger points in another muscle. Scand J Rheumatol. 1992;21(s94):25.

(9.) Simons D, Travell J, Simons L. Myofascial pain and dysfunction: The trigger point manual. Volume 1 Upper half of body. 2nd ed. Philadelphia: Williams & Wilkins; 1999.

(10.) Chaitow L. Osteopathic self-treatment. London: Thorsons; 1990.

(11.) McMahon M, Stiller K, Trott P, McMahon M, Stiller K, Trott P. The prevalence of thumb problems in Australian physiotherapists is high: an observational study. Australian Journal of Physiotherapy. 2006;52(4):28792.

(12.) Smith EK, Magarey M, Argue S, Jaberzadeh S, Smith EK, Magarey M, et al. Muscular load to the therapist's shoulder during three alternative techniques for trigger point therapy. J Bodywork Mov Ther. [Clinical Trial]. 2009 Apr;13(2):171-81.

Sandra Grace PhD

Senior Lecturer in Osteopathic Medicine, Southern Cross University
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Author:Grace, Sandra
Publication:Journal of the Australian Traditional-Medicine Society
Date:Mar 1, 2011
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