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Tennis ball massage to alleviate trigger point pain.

Every singer has experienced muscle aches and tension, yet few know of simple, low cost methods that will help alleviate these conditions. Muscle pain is far from trivial; it is most frequently related to tension, overuse, misuse, or muscle injury, yet can be a symptom of an addressable condition that is treatable if properly diagnosed. In these situations, the pain tends to involve specific muscles and can either be chronic or acute. One very common cause for this pain is a trigger point laden in the tissue. The daily clinical experience of thousands of massage therapists, physical therapists, and physicians strongly indicates that the most common body aches and pains are actually caused by trigger points. (1) The bad news is that one or more predisposing conditions most likely cause the trigger points, but the good news is that something can be done about it. Self-massage by using a tennis ball is an easy, low cost way to tackle trigger points and keep muscles healthy.

TRIGGER POINTS 101

Simply defined, a trigger point is a knot in the muscle tissue. These knots can be as small as a pea or as big as a half dollar and are a result of muscle fibers unable to release their contraction. This in turn can affect the thin layer of connective tissue wrapping around each muscle. Though trigger points are more commonly found in muscle tissue, they can also occur in more fibrous tissues such as ligaments, tendons, and scar tissue. Trigger points tend to behave in a particular and identifiable manner; they can either be tender to the touch or radiate pain even without palpation and can refer pain or stimulus to another area of the body. For example, a trigger point in a neck muscle such as the sternocleidomastoid can refer to the temporalis muscle, located on the side of the skull, and cause a tension headache. The referred pain of a trigger point can be described as "dull and aching, often deep, with intensity varying from low-grade discomfort to severe and incapacitating torture. It may occur at rest or only in motion." (2) Referred sites can be either close to the primary trigger point or a substantial distance away. Other characteristics of trigger points can include weakness of the involved muscle(s) and a restricted range of motion, with musculature in the immediate area often feeling taut and ropelike. Trigger points should not be confused with other causes of muscle soreness, such as bruising, muscle strain, or muscle tearing, all of which involve actual physical damage to the muscle fibers.

Trigger points can result from a variety of factors, such as:

* muscle fatigue (repetitive movement or excessive contraction beyond a certain point without proper recovery);

* muscle weakness (too much is being asked of a muscle over a prolonged period);

* joint instability (when a joint is compromised due to injury, the muscles supporting that joint are required to overwork to protect the joint from damage);

* muscle tightness (tightness in specific muscles that are required to be flexible);

* poor alignment (putting undue stress on muscles because of poor body mechanics);

* muscle trauma (a partial or full tear of muscle tissue);

* nutritional and health factors (poor nutritional and health conditions can hinder the regenerative ability of muscle tissue);

* psychological factors (impaired sleep, excessive stress, and emotional issues can have an effect on muscle).

Trigger points in vocalists are excessively common. The use of the body during singing is a taxing effort and any number of the above predisposing factors can cause imbalance and physical distress resulting in trigger points. Indicators such as diminished breath capacity, throat tightness, headaches, jaw pain, diminished vocal range, and neck pain could all be symptoms of trigger points.

THE BENEFITS OF MASSAGE

From rubbing a sore shoulder to rubbing someone else's back when he or she is upset, the action of massage is natural and instinctive. Massage is defined as the systematic manipulation of the soft tissues of the body to enhance health and healing. Massage releases tension, breaks up adhesions, and enhances blood flow to the soft tissues of the body. Massage can be performed with just the hands or with tools that can make the protocol easier and more effective. There are quite a few massage tools available for purchase, but a tennis ball is far cheaper and is just as effective.

Trigger point therapeutic massage can help increase circulation, range of motion, and muscle tone. In turn, the relaxation of muscles can help reduce chronic pain and the effects of stress. Trigger point massage can prevent and treat a wide variety of conditions involving connective tissue such as sports injuries, repetitive strain injuries, migraines, arthritis, chronic pain, and fibromyalgia.

LOCATING TRIGGER POINTS

Anyone who has rubbed his shoulder and found an "ouch" there has most likely stumbled on a trigger point. It is a good idea to take inventory of the body for potential trigger points before starting a self-treatment regimen, checking to be sure the involved muscle area in question is relaxed rather than stretched or contracted. Two suggested exploratory techniques are:

* Flat Palpation. Move the fingers across the muscle fibers with some pressure until a taut or sensitive area is located. Having found this section of the muscle, explore the area to ascertain if there is a spot of maximum tenderness.

* Pincer Palpation. Some muscles such as the shoulder area or the calf muscle can be lifted from surrounding tissue. Lift the muscle between the thumb and forefinger to locate trigger points.

Once a sore area has been located, pain is assessed by asking the following questions:

* Was it sore before I palpated the area or was I unaware of it until I made contact with the area?

* How large is the trigger point site? Can I compare it to an object such as a pea or an eraser? A quarter? An olive?

* Does the pain stay localized, or does it refer to another site? Is the referral site close or distant from the primary trigger point?

* Am I holding my breath?

* On a scale of 1 to 10, how would I rate this pain?

TREATMENT OF TRIGGER POINTS

Among a number of ways to address trigger points, one easy and cost effective treatment is self-massage using a tennis ball. The benefits are numerous--the treatment is convenient, free, and personalized. Other benefits can include healthier and more responsive tissues, a heightened sense of body awareness and a proactive step toward identifying and lessening predisposing factors that can cause trigger points in the first place. The protocol is noninvasive and can be done anywhere.

When using a tennis ball on trigger points, wincing or a build-up of tension is a sign that too much pressure is being used. Some people may be somewhat "desensitized" from their bodies, especially if they are not used to therapeutic touch. When beginning a massage protocol, it may be difficult to readily interpret what the body is feeling. A common response is to press harder and deeper, which is counterproductive. There are three principles in palpation: 1) move slowly--haste only interferes with sensation; 2) avoid excessive pressure--less is truly more; 3) concentrate and focus awareness on what the body is feeling--in other words, be present. (3) Although there is no set time limit for tennis ball massage, it would be wise to plan a generous window of time to start; as the protocol becomes more familiar, it will be easier to assess the amount of time needed to work on an area.

Since a trigger point is essentially a locked contraction of specific muscle fibers into a shortened position, treatment involves releasing that contraction. Tennis ball massage subscribes to the Trigger Point Pressure Release protocol created by David Simons and Janet Travell and involves applying pressure with the ball to the trigger point and increasing the pressure as the trigger point "releases" and softens. Once trigger points are released, the muscle area must be moved throughout its full range of motion. Range of motion exercises that address the range of flexion and extension across a joint are an important final component of the protocol in order to retrain the fibers of the muscle.

Body areas will be addressed beginning with the head and ending with the feet, though the practitioner should feel free to adjust the order as necessary while considering the following guidelines:

* The use of a tennis ball is highly recommended, though there are other tools available, such as foam rollers.

* The rhythm of tennis ball rolling should be smooth and even, firmly moving along the muscle area.

* Movement of the ball can either be with the grain of the muscle fibers or across them.

* Static pressure should only be used only on trigger points, holding the ball on the knot between 30-90 seconds.

* If the trigger point has not "melted" after 90 seconds, move on from the area and give it a chance to recover; try again after a few minutes, or choose to leave it alone for another treatment day.

* If the trigger point is referring stimulus to another area, notice whether the pain in the referred area diminishes as the trigger point fades. If it does not, then the referred pain might belong to a different trigger point.

* Assess the pain level of each trigger point and keep track as to whether the pain level for that trigger point changes from treatment to treatment.

* Breathing should be deep, inhaling through the nose and slowly exhaling through the mouth.

* Remember that the majority of muscles come in pairs, so be sure to treat both sides.

* Always stay hydrated after massage--drink plenty of water.

UPPER BODY

For vocalists, much physical consciousness is focused on the upper body. The head, face, and neck are where the instrument is housed, where feelings are conveyed through facial expressions, and form the center for processing information. The action of breath is generated in the chest cavity and affects the entire body, and the gestures of the arms are produced from their attachments to the axial skeleton. Proper alignment of the head and spine is dependent on the healthy integrity of the upper body musculature.

Head. Gently roll the ball along the surface area of the skull, paying special attention to the posterior ridge (Figure 1), the sides, and the top (Figure 2).

Face. Gently move the ball along the forehead and back around the eye brow (Figure 3). Move along the edge of the cheekbone and down the back edge of the mandible. Pay close attention to the lower edge of the jaw (Figure 4).

Neck. Roll the ball along the sides and back of the neck, avoiding the vertebrae. Move the ball along the sternocleidomastoid muscle from behind and below the ear all the way down to the clavicle (Figure 5).

Upper chest. Roll the ball along the lower edge of the clavicle from sternum to the shoulder (Figure 6). In this action you will be massaging some neck muscle attachments as well as pectoralis major. Roll down the chest a few inches from the clavicle and back to the sternum.

Upper back. The largest muscle in the upper back is the trapezius muscle, a large sheet of muscle whose upper fibers come from the cervical vertebrae out to the edges of the clavicle and shoulder blade. Using the opposite hand, roll the ball along the top edge of the shoulder (Figure 7). This is an infamous area for trigger points and it is not surprising to find large knots here.

Middle back and rhomboids. Place the tennis ball between the back and the wall. Being careful to avoid the vertebrae, roll the ball up and down the erector spinae muscles that run along the sides of the spine while pressing into the wall at the same time. Continue rolling the ball over to the shoulder blade and maneuver the ball around all the edges and over the surface. Between the shoulder blades and the spine are the rhomboid muscles (Figure 8). The rhomboids have a tendency to house numerous trigger points and can be surprisingly sensitive. Roll along them with the muscle fibers (left and right) as well as across the muscle fibers (up and down), being careful to avoid the spine.

LOWER BODY

The lower body of a vocalist is easy to overlook--the integrity of the lower spine, the pelvis, and even the legs and feet can take a back seat to proximal areas of the voice such as the neck, head, and chest. However, hip, sacral, and pelvic alignment is primary in healthy posture and upper body alignment is dependent on the integrity of the lower body.

Lower back. In the same manner as the middle back, place the tennis ball between the back and the wall. Being careful to avoid the vertebrae, roll up and down the muscles that run along the sides of the spine while pressing into the wall at the same time. Quadratus lumborum is the larger muscle of note in this area, connecting the lower ribs to the top of the pelvis. This muscle often suffers from shortening due to poor posture.

Hip/gluteal area. Place the ball between the gluteal area and the wall (Figure 9). Deep within the hip socket are the lateral hip rotators. This area can be unexpectedly tender, so proceed gingerly and honor the body's response.

Upper/lower leg. In a small circular motion, roll the ball along the muscles of the front of the upper, sides, and back of the thigh, staying well above the knee (Figure 10). On the lower leg, roll the ball along the back and sides of the calf (Figure 11).

Foot. The bottom of the foot can be a very sensitive area and is home to several layers of muscle. In addition to the muscles that flex the toes, there is a thick tissue that forms the plantar surface of the foot. Place the ball between the foot and the floor and roll the ball along the underside of the toes and along the arch of the foot while pushing down gently (Figure 12).

RESULTS OF TRIGGER POINT MASSAGE

A muscle that has been released from a trigger point will feel softer, more malleable, and looser to the touch, with a greater range of motion. According to Associated Bodywork & Massage Professionals (ABMP), numerous benefits validate massage therapy as an important component of a wellness program, such as:

* alleviates low back pain and improves range of motion;

* eases medication dependence;

* enhances immunity by stimulating lymph flow;

* exercises and stretches weak, tight, or atrophied muscles;

* helps athletes of any level prepare for, and recover from, strenuous workouts;

* improves the condition of the body's largest organ, the skin;

* increases joint flexibility;

* lessens depression and anxiety;

* promotes tissue regeneration, reducing scar tissue and stretch marks;

* pumps oxygen and nutrients into tissues and vital organs, improving circulation;

* reduces spasms and cramping;

* relaxes and softens injured, tired, and overused muscles;

* releases endorphins;

* relieves migraine pain.

It is important to note that self-massage should be considered as a component of a wellness and maintenance protocol; one treatment will offer some relief in the short term, but over time the issue will return unless therapy is continued and the cause behind the predisposing factor(s) is altered. Through attention, patience, and commitment, tennis ball massage can help alleviate trigger points with the outcome resulting in healthier muscles and a healthier voice.

REFERENCES

American Massage Therapy Association. "Massage Therapy can be a Valuable Component of a Wellness Program." Approved September 2008. http://www.amtamassage.org/statement3.html.

Associated Bodywork & Massage Professionals. "The Benefits of Massage." http://www.massagetherapy.com/learnmore/ benefits.php.

Biel, Andrew. Trail Guide to the Body, 4th revised ed. Boulder, CO: Books of Discovery, 2010.

Davies, Clair. The Trigger Point Therapy Workbook. Oakland, CA: New Harbinger Publications, 2004.

Finando, Donna, and Steven Finando. Trigger Point Therapy for Myofacial Pain: The Practice of Informed Touch. Rochester, VT: Healing Arts Press, 2005.

National Association of Myofacial Trigger Point Therapists. "Myfacial Trigger Point Therapy--What Is It?" http://www. myofascialtherapy.org/myofascial-therapy/index.html.

Salvo, Susan G. Massage Therapy Principles and Practice, 3rd ed. St. Louis: Saunders Elsevier, 2007.

Tappan, Frances M., and Patricia J. Benjamin. Tappan's Handbook of Healing Massage Techniques, 3rd ed. Stamford: Appleton & Lange, 1998.

Thibodeau, Gary, and Kevin Patton. Structure & Function of the Body, 12th ed. St Louis: Mosby, 2004.

Travell, Janet, and David G. Simons. Myofacial Pain & Dysfunction: The Trigger Point Manual, 2nd ed. Baltimore: Williams & Wilkins,1999.

Perle, Stephen M. "Clinicians Corner: Myofascial Trigger Points." Chiropractic Sports Medicine 9, no. 3 (1995): 106-108.

NOTES

(1.) Clair Davies, The Trigger Point Therapy Workbook (Oakland, CA: New Harbinger Publications, 2004), 2.

(2.) Janet Travell and David G. Simons, MyofacialPain & Dysfunction: The Trigger Point Manual, 2nd ed. (Baltimore: Williams & Wilkins, 1999), 94-95.

(3.) Andrew Biel, Trail Guide to the Body (Seattle: Consolidated Press, 1987), 6.

Alissa Deeter is a nationally recognized performer with firm footing in both classical and music theater circles and is currently serving as treasurer for the Mid-Atlantic region of the National Association of Teachers of Singing. Dr. Deeter is an Associate Professor of Applied Voice and Vocal Pedagogy at the University of North Carolina Charlotte, and is the coordinator for the Graduate Certificate in Voice Pedagogy. She received her undergraduate degree in Vocal Performance with a minor in Theatre from Central Michigan University, and both a Masters of Music in Opera Performance and a Doctor of Music in Vocal Performance from Florida State University. Understanding human physiology and anatomy has always been a cornerstone of knowledge for Dr. Deeter, and during her doctoral work at Florida State she also attended the Core Institute of Massage Therapy in Tallahassee to better integrate those studies with her singing and teaching methodologies. She has become a leader in optimizing a "form follows function" approach to singing, has been published in the Journal of Singing, and is a regular presenter at conferences and academic institutions nationwide. Dr. Deeter wrote the liner notes for the recently released CD, From The Heartland (Albany Records-TR1349), as well as appearing on the duet "It Was a Lover and Her Lad." Her new book, The Melodies of Francis Poulenc: A Study Guide, is scheduled to be released in fall 2013 by Scarecrow Press.
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Author:Deeter, Alissa
Publication:Journal of Singing
Date:Nov 1, 2013
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