LECTURE NOTES

Trigger points massage therapyTeacher: Taina AvramescuTABLE OF CONTENTS

3Introduction

41. History..................................................................

42. Definition..

3.Clasification .54.Pathogenesis75. Microscopic view.96. Clinical presentation107.Trigger points therapy.128. Trigger points maps 16Bibliography 20

Introduction

The present notes are coming into helping the student by offering the most reliable information related to the topic in a condensed and didactic manner, as a review of the most current available literature and interactive WEB sites. The author collected the informations using the published researches mentioned in the bibliography. Because this is just an educational course more informations can be reached by following the external links.Course objectives

To provide basic informations regarding the trigger points To provide informations about the examination technique used for trigger points identification To provide informations concerning indications and most reliable therapeutical massage techniques Prior to follow this course the student need to accomplish the following:

basic knowledge of human anatomy basic knowledge of general massage techniques.After completion of this task the student should be able to:

Demonstrate and identificate the myofascial trigger points

Perform trigger points massage therapy

Obs. This lecture notes will be visualised together with the PPT presentation and will be completed by a multimedia lesson and virtual classes in real time for practical aspects and case studies.

2. HISTORYFor many years the researchers described the existence of tender areas and zones of induration in muscles; several terms were used, such as muscular rheumatism or fibrositis in English; and myogelose and myalgie in German. For more informations regarding the history of trigger pointa please consult

http://www.scienceofmassage.com/dnn/som/journal/0903/medical.aspx3. DEFINITIONThe term "trigger point" was used for the firts time in 1942 by Dr. Janet Travell to describe a clinical finding with the following characteristics:

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.

The painful point can be felt as a nodule or band in the muscle (point tenderness on a taut muscle band), and a twitch response can be elicited on stimulation of the trigger point Palpation of the trigger point reproduces the patient's complaint of pain (reproduction of patient usual pain), and the pain radiates in a distribution typical of the specific muscle harboring the trigger point (reffered pain). The pain cannot be explained by findings on neurological examination. Weakness without atrophy

Autonomic symptoms

In this way trigger points can be defined as discrete, focal, hyperirritable spots in taut bands located in a of skeletal muscle. It represents a thickened, palpable nodule, even when the muscle is at rest and should be soft and pliable.They produce pain locally and in a referred pattern, referred tenderness, motor dysfunction, and autonomic phenomena and often accompany chronic musculoskeletal disorders. Trigger Points can cause a variety of pains, sometimes very intense and many times well away from their own location (reffered pain). They are not only painful; there is also a tendency for strains, tears or other injuries to occur at these points. Trigger points are present in all patients with chronic musculoskeletal pain.These points can be developed in any of the 200 pairs of muscles in the body, which allows a large area that can create strains (Travel, Simons, 1999).Travell and Simons's research suggests that trigger points are a component of up to 93% of pain and are the only source of pain in 83% of cases.

Trigger Points are typically associated with various forms of myofascial dysfunction, including chronic pain, weakness, limited range of motion and autonomic phenomena. Individuals with trigger points in numerous areas and who are experiencing various perpetuating factors may also be suffering from Widespread Myofascial Pain Syndrome or Fibromyaglia.

When firm pressure is applied over the trigger point in a snapping fashion perpendicular to the muscle, a local twitch response is often elicited. A local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle and skin as the tense muscle fibers (taut band) of the trigger point contract when pressure is applied. This response is elicited by a sudden change of pressure on the trigger point by needle penetration into the trigger point or by transverse snapping palpation of the trigger point across the direction of the taut band of muscle fibers. Thus, a classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response. Trigger points help define myofascial pain syndromes.

Myofascial pain syndromes is a concept introduced by Travell (myofascial referring to the combination of muscle and fascia). This is described as a focal hyperirritability in muscle that can strongly modulate central nervous system functions. Travell and followers distinguish this from fibromyalgia, which is characterized by widespread pain and tenderness and is described as a central augmentation of nociception giving rise to deep tissue tenderness that includes muscles. Studies estimate that in 7595 % of cases, myofascial pain is a primary cause of regional pain. Myofascial pain is associated with muscle tenderness that arises from trigger points, focal points of tenderness, a few millimeters in diameter, found at multiple sites in a muscle and the fascia of muscle tissue. Biopsy tests found that trigger points were hyperirritable and electrically active muscle spindles in general muscle tissue. This topic is hotly debated amongst experts. Leading theories state that the painful trigger points develop in susceptible muscle tissues that are overworked for long periods of time. These muscles develop focal regions, or knots of increased contraction. These focal areas are not able to get their proper blood flow because the contracted fibers are closing down nearby capillaries that supply individual fibers with essential nutrients and oxygen. Furthermore, because the blood flow is insufficient, the muscle fibers are unable to get rid of toxic waste products (e.g. lactic acid) that build up during normal resting metabolic states. What ensues is a chronic cycle of pain in the affected tissues that is difficult to break out.

4. CLASIFICATION According to the world wide accepted classification (Travel and Simmons, 1983) the trigger points in the skeletal muscles separated on:

1. Active trigger point (ATP)

2. Latent or "sleeping" trigger point (LTP)

3. Satellite or referred trigger point (STP)

4. Secondary trigger points (SCTP)

5. Motor trigger point (MTP)

6. Tender points (TP)An active trigger point is one that actively refers pain either locally or to another location (most trigger points refer pain elsewhere in the body along nerve pathways). Also an active trigger point causes pain at rest. If stimulated cause a reflex reaction to the muscle that is characterized by visible and palpable contraction, the activity is registered and EMG route. It is tender to palpation with a referred pain pattern that is similar to the patient's pain complaint. This referred pain is felt not at the site of the trigger-point origin, but remote from it. The pain is often described as spreading or radiating. Referred pain is an important characteristic of a trigger point. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only (Table 1). TABLE 1 Trigger Points vs. Tender Points (Am Fam Physician. 2002)Trigger pointsTender points

Local tenderness, taut band, local twitch response, jump sign Local tenderness

Singular or multipleMultiple

May occur in any skeletal muscleOccur in specific locations that aresymmetrically located

May cause a specific referred pain patternDo not cause referred pain, but often cause a total body increase in pain sensitivity

A latent trigger point does not cause spontaneous pain, but may restrict movement or cause muscle weakness. The patient presenting with muscle restrictions or weakness may become aware of pain originating from a latent trigger point only when pressure is applied directly over the point. In this way we can say that a latent trigger point is one that exists, but does not yet refer pain actively, but may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point. Latent trigger points can influence muscle activation patterns, which can result in poorer muscle coordination and balance.

A latent trigger point shows local tenderness but no pain localized reflex response. May be associated with a feeling of local pulping or weakness. Travell and Simions think long-term effects of latent trigger points called hotspots by the American Association of Rheumatology, may be even more worrying than the pain of those assets. They argue that latent tend to accumulate points throughout life, becoming the main cause of stiff joints and limited range of motion in people with age. In addition, muscle tension required by paragraphs sensitive tendons tend to ask even in young people, which can cause arthritis. Sensitivities can be activated without effort or strain of musclesA key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway, or creates it. A satellite trigger point is one which is activated by a key trigger point. Successfully treating the key trigger point will often resolve the satellite, either converting it from being active to latent or completely treating it.

In contrast, a primary trigger point in many cases will biomechanically activate a secondary trigger point in another structure. Treating the primary trigger point does not treat the secondary trigger point.

Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly. Patients with fibromyalgia have tender points by definition. Concomitantly, patients may also have trigger points with myofascial pain syndrome. Thus, these two pain syndromes may overlap in symptoms and be difficult to differentiate without a thorough examination by a skilled physician.For more informations regarding trigger points types and evaluation, please consult http://www.scienceofmassage.com/dnn/som/journal/0905/medical.aspx

For trigger point characteristics summarised and different types of trigger points, please consulthttp://www.sld.cu/galerias/pdf/sitios/rehabilitacion/scs_for_muscle_pain.pdf5. PATHOGENESISTrigger points form only in muscles. They form as a local contraction in a small number of muscle fibers in a larger muscle or muscle bundle. These in turn can pull on tendons and ligaments associated with the muscle and can cause pain deep within a joint where there are no muscles. The integrated hypothesis theory states that trigger points form from excessive release of acetylcholine which produces sustained depolarization of muscle fibers. These sustained contractions of muscle sarcomeres compresses local blood supply restricting the energy needs of the local region. This crisis of energy produces sensitizing substances that interact with some nociceptive (pain) nerves traversing in the local region which in turn can produce localized pain within the muscle at the neuromuscular junction (Travell and Simons 1999). When trigger points are present in muscles there is often pain and weakness in the associated structures. These pain patterns in muscles follow specific nerve pathways and have been readily mapped to allow for identification of the causative pain factor. Many trigger points have pain patterns that overlap, and some create reciprocal cyclic relationships that need to be treated extensively to remove them.

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, accident trauma (such as a car accident which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points.This must be differentiated from fibromyalgia syndrome, which involves multiple tender spots or tender points. These pain syndromes are often concomitant and may interact with one another.

Lack of exercise, prolonged poor posture, vitamin deficiencies, joint problems may all predispose to the development of micro-trauma. Occupational or recreational activities that produce repetitive stress on a specific muscle or muscle group commonly cause chronic stress in muscle fibers, leading to trigger points. Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics. Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points. So basically, any muscle can develop a trigger point for any number of reasonsThere are several theories about the emergence and subsequent development of trigger point pain, but research is still incomplete. Both acute trauma and microtrauma may be involved, other factors include sleep disorders and anxiety.Mens and Simmons proposed a theory that sensibilisation of nociceptors leads to local edema, venous congestion and ischemia. Ischemia interfere with energy production (ATP), leading to disorders of calcium pump activity and preventing actin-myosin decoupling.

Clinical Applications of Neuromuscular Techniques by Leon Chaitow and Judith Walker-Delaney (Vol 2, pg. 20) identifies the following factors:

A. Primary activating factors:

Persistent muscular contraction, strain or overuse (emotional or physical cause)

Trauma (local inflammatory reaction)

Adverse environmental conditions (cold, heat, damp, draughts, etc)

Prolonged immobility

Febrile illness

Systemic biochemical imbalance (e.g. hormonal, nutritional)

B. Secondary activating factors:

Compensating synergist and antagonist muscles to those housing triggers may also develop triggers

Satellite triggers evolve in referral zone (from key triggers or visceral disease referral, e.g., myocardial infarct)

Infections

Allergies (food and other)

Nutritional deficiency (especially C, B-complex and iron)

Hormonal imbalance (thyroid, in particular)

Low oxygenation of tissues

There are numerous studies that tried to demonstrate the predictive factors that can cause tension in the soft tissue leading to the development of trigger points: the abnormal posture during dynamic or static activity. Sports activities not protect against soft tissue damage, or against the occurrence or sensitive trigger points.

Rotation or non-physiological movement of the neck, spine or hips can also be a result of the activity or sensitivity of myofascial trigger point. Thus begins a vicious circle that maintains and accelerating the transformation of the inquiry profound muscle tissue. At this point, the circumstances are difficult to stop. Very often, congenital irregularities of bone structure, posture, work habits, repetitive contractions and lack of exercise can contribute to hinder removal of trigger points.

In the two groups analyzed by us can see an imbalance between the two sides of the body, even if it is not classified as physical dysfunction.

All muscle balance will be affected even if the body will try to compensate. Some muscles are too involved in movement or posture maintenance, while others do not. Some muscles are in constant tension and contraction, thus developing a voltage that indicates a noticeable imbalance in posture.Binding or non-physiological positions can perpetuate trigger points or tender. Apparent comfort and familiarity of a long term habit can cause the individual to be less responsive to the effects of such a custom has on the muscle.

People who do not practice sports have more sensitive points (tender) with different particular location and sensitivity.

For more informations regarding the formation of trigger pointa please consult

http://www.scienceofmassage.com/dnn/som/journal/0903/medical.aspxFor oher informations about what causes the trigger point to develop and the pathophysiology of fibromyalgia/fibrositis/ myodysneuria and what is happening in the FMS patients muscles, please consulthttp://www.sld.cu/galerias/pdf/sitios/rehabilitacion/scs_for_muscle_pain.pdfFibromyalgia Trigger Point

The American College of Rheumatology bases the diagnosis of FM upon two major criteria: 1) widespread, diffuse pain lasting at least three months and 2) a minimum of 11 (out of 18 possible) specified tender points throughout the body. This is the strict definition for being included in a clinical study of fibromyalgia, but tender points may change from time to time, and may worsen or get better in the cyclical way that this syndrome seems to work.

These tender points will hurt when pressed, but the pressure will not cause pain in any other part of the body. The physician applies a standardized amount of pressure, about 4 kg (enough to turn the thumbnail white). Remember, a tender point has to be painful at palpation, not just "tender." When pressed, these areas tend to feel like bruises in various stages of healing.

Also, a tender point is different from what you may know as a trigger point. Tender points hurt, trigger points hurt and refer pain to other body parts. Trigger points cause myofascial pain syndrome, which often coexists with fibromyalgia, but can be treated with massage, physical therapy, or gentle stretching. When muscles feel hard and pressing on them causes a response elsewhere in the body, or even nausea, trigger points are responsible. Tender points are caused by an unknown mechanism, and their severity is often cyclic. Tender points do not generally respond to physical therapy, often becoming more painful with pressure.

Widespread pain is defined as having pain in both sides of the body and pain above and below the waist. In addition, pain must also be present in the cervical spine, anterior chest, thoracic spine or lower back.

These tender points are located at:

Occiput (2) - at the suboccipital muscle insertions (near the base of the skull)

Low cervical (2) - at the anterior aspects of the intertransverse spaces at C5-C7 (the lower vertebra of the neck)

Trapezius (2) - at the midpoint of the upper border (the neck, mid back and upper back muscles between the shoulder blades)

Supraspinatus (2) - at origins, above the scapula spine near the medial border

Second rib (2) - upper lateral to the second costochondral junction (the insertion of the second rib)

Lateral epicondyle (2) - 2 cm distal to the epicondyles (the side of the elbow)

Gluteal (2) - in upper outer quadrants of buttocks in anterior fold of muscle (the upper and outer muscles of the buttocks)

Greater trochanter (2) - posterior to the trochanteric prominence (the upper part of the thigh)

Knee (2) - at the medial fat pad proximal to the joint line (the middle of the knee joint)

5. MICROSCOPIC VIEWA trigger point exists when over stimulated sarcomeres are chemically prevented from releasing from their interlocked state.

.

Fig. 1. Microscopic view of a trigger point.

( http://www.triggerpointbook.com/triggerp.htm)A is a muscle fiber in a normal resting state, neither stretched nor contracted. The distance between the short crossways lines (Z bands) within the fiber defines the length of the individual sarcomeres. The sarcomeres run lengthwise in the fiber, perpendicular to the Z bands.

B is a knot in a muscle fiber consisting of a mass of sarcomeres in the state of maximum continuous contraction that characterizes a trigger point. The bulbous appearance of the contraction knot indicates how that segment of the muscle fiber has drawn up and become shorter and wider. The Z bands have been drawn much closer together.

C is the part of the muscle fiber that extends from the contraction knot to the muscles attachment (to the breastbone in this case). Note the greater distance between the Z bands, which displays how the muscle fiber is being stretched by tension within the contraction knot. These overstretched segments of muscle fiber are what cause shortness and tightness in a muscle.

Normally, when a muscle is working, its sarcomeres act like tiny pumps, contracting and relaxing to circulate blood through the capillaries that supply their metabolic needs. When sarcomeres in a trigger point hold their contraction, blood flow essentially stops in the immediate area.

The resulting oxygen starvation and accumulation of the waste products of metabolism irritates the trigger point. The trigger point responds to this emergency by sending out pain signals.

6. CLINICAL PRESENTATIONPatients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question. Often, the muscles used to maintain body posture are affected, namely the muscles in the neck, shoulders, and pelvic girdle, including the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum. Although the pain is usually related to muscle activity, it may be constant. It is reproducible and does not follow a dermatomal or nerve root distribution. Patients report few systemic symptoms, and associated signs such as joint swelling and neurologic deficits are generally absent on physical examination. Trigger points cause headaches, neck and jaw pain, low back pain, tennis elbow, and carpal tunnel syndrome. They are the source of the pain in such joints as the shoulder, wrist, hip, knee, and ankle that is so often mistaken for arthritis, tendinitis, bursitis, or ligament injury.

Trigger points also cause symptoms as diverse as dizziness, earaches, sinusitis, nausea, heartburn, false heart pain, heart arrhythmia, genital pain, and numbness in the hands and feet. Even fibromyalgia may have its beginnings with myofascial trigger points.

Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. In the head and neck region, myofascial pain syndrome with trigger points can manifest as tension headache, tinnitus, temporomandibular joint pain, eye symptoms, and torticollis. Upper limb pain is often referred and pain in the shoulders may resemble visceral pain or mimic tendonitis and bursitis. In the lower extremities, trigger points may involve pain in the quadriceps and calf muscles and may lead to a limited range of motion in the knee and ankle. Trigger-point hypersensitivity in the gluteus maximus and gluteus medius often produces intense pain in the low back region.Examples of trigger-point locations are illustrated in Figure 2.

Fig. 2. Most frequent locations of myofascial trigger points (Am Fam Physician. 2002)Pain in patients with active trigger points may increase at night, is frequently associated with muscle shortening and decreased mobility. There is a significant relationship between the presence of sensitive points and problems related to posture, there is a relevant correlation between the presence of trigger points, pain and decreased functional level of daily activities (sports or not).

Misdiagnosis of painThe misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies, but physicians, in weighing all the possible causes for a given condition, rarely consider a myofascial source. The study of trigger points has not historically been part of medical education. Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain.

No laboratory test or imaging technique has been established for diagnosing trigger points.9 However, the use of ultrasonography, electromyography, thermography, and muscle biopsy has been studied.

Evaluation

Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response.

Localization of a trigger point is based on the physician's sense of feel, assisted by patient expressions of pain and by visual and palpable observations of local twitch response. This palpation will elicit pain over the palpated muscle and/or cause radiation of pain toward the zone of reference in addition to a twitch response. The commonly encountered locations of trigger points and their pain reference zones are consistent. Many of these sites and zones of referred pain have been illustrated in Figure 3.

Fig 3. Examples of the three directions in which trigger points (Xs) may refer pain (red). (A) Peripheral projection of pain from suboccipital and infraspinatus trigger points. (B) Mostly central projection of pain from biceps brachii trigger points with some pain in the region of the distal tendinous attachment of the muscle. (C) Local pain from a trigger point in the the serratus posterior inferior muscle (Am Fam Physician. 2002)

For more informations regarding muscle pain, , the evolution of muscle dysfunction and progressive adaptation please consult

http://www.sld.cu/galerias/pdf/sitios/rehabilitacion/scs_for_muscle_pain.pdf7. TRIGGER POINT THERAPYEliminate myofascial trigger points is an important component in the management of chronic pain. Trigger Point Therapy is the study and practice of identifying Trigger Points on the patient body and proceeding with a treatment plan that will alleviate muscle pain and treat the myofascial dysfunction in muscles, fascia, ligaments, and tendons due to the presence of Trigger Points, through applied pressure to trigger points of referred pain. Trigger Point Therapy can also assist with the redevelopment of muscles and/or restore motion to joints.

There are various modalities used to inactivate trigger points.

Pharmacologic treatment of patients with chronic musculoskeletal pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for these patients.

Nonpharmacologic treatment modalities include stretching techniques associated with cryotherapy (Travell and Simons), various physical therapy applications, soft tissue techniques to the pressure type massage and myofascial ischemic local anesthetic injections or corticosteroids. Other described techniques include acupuncture, manipulative therapy, osteopathic manual medicine techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid.The Spray and Stretch technique involves passively stretching the target muscle while simultaneously applying dichlorodifluoromethane-trichloromonofluoromethane (Fluori-Methane) or ethyl chloride spray topically. The sudden drop in skin temperature is thought to produce temporary anesthesia by blocking the spinal stretch reflex and the sensation of pain at a higher center. The decreased pain sensation allows the muscle to be passively stretched toward normal length, which then helps to inactivate trigger points, relieve muscle spasm, and reduce referred pain. Stretching techniques invoke reciprocal inhibition within the musculoskeletal system.Physical therapies refer to pulsed ultrasound, electrostimulation, ischemic compression, Low Level Laser Therapy. More recently, we have pioneered the use in the US of advanced medical devices such as the WellWave, which delivers extracorporeal shockwave therapy. This device uses pulses of sound waves to provide "acoustic compression" as an alternative to manual compression techniques. it is an extremely effective leading edge technology for the reduction of pain from myofascial dysfunction and trigger points.The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available.MTP therapists may use myotherapy (deep pressure as in Bonnie Prudden's approach, massage or tapotement as in Dr. Griner's approach), mechanical vibration, One of the most popular techniques for treating Trigger Points is the use of manual compression techniques. This might appear to be similar to deep tissue massage - however a Trigger Point therapist is trained to assess the overall muscular health of their patient, identify myofascial pain and dysfunction, and precisely locate and treat the associated Trigger Points. Practitioners use elbows, feet or various tools to direct pressure directly upon the trigger point, to save their hands.There are three local therapeutic outcomes of trigger point therapy by massage: stimulation of local metabolism, release of the vasoactive substances, and reflex vasolidation after termination of ischemic compression.Massage of the trigger points is one of the most effective methods used by therapists to ease the pain, and is based almost entirely on observations of Dr. Travell, as well as innovative clinical techniques used to treat myofascial pain. After this start, Dr. Simons David gives a new value for the myofascial pain by its long experience as a researcher. The two researchers have developed Trigger Point Manual. For more informations please consult TRIGGER POINT Manual THERAPY

http://www.pressurepointer.com/PressurePointerManual.pdfA successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

Ussually trigger points are identified by objective and subjective findings. Objective signs include a palpably firm, tense band in the muscle, production of a local twitch response, restricted stretch range-of-motion, weakness without atrophy, and no neurologic deficit. Subjectively, the patient reports stiffness and easy fatigability, spontaneous pain in a distribution predictable for that TP, an exquisite deep tenderness specifically at the TP. Sustained pressure on the TP induces referred pain in the predicted pattern. Some muscles are likely to produce additional objective and subjective autonomic concomitants. The clinical findings considered as the minimum criteria for identifying trigger points are: spot tenderness, pain recognition, and the presence of a taut band.

More, identification by palpation requires good developed skill in the physical examination of muscle.

Although clinical examinations and full patient history remain a standard for evaluating MTPs, the reliability of these examinations are questionable. The evaluation of electrodermal properties in the identification of myofascial trigger points is moreand moretaken into consideration. Skin resistance was shown to be an optional method for objectively identifying the location of MTPs compared with the surrounding tissue. The findings support claims that MTPs can be located using electrodermal tools.For more informations regarding Finding Trigger points please consult http://lifeafterpain.com/vault/treat-your-triggers/finding-triggers/

Once the therapist have found and confirmed the trigger point, he needs to set up a barrier, which breaks apart the actin and myosin (the contractile proteins within the sarcomere). Actin and myosin are bound together due to the chronic contraction in the specific band of the muscle.This barrier can be created with your fingers (as fig.4) or with any one of the self-care tools available today (e.g. foam roll, the stick, thera-cane, trigger point ball, tennis ball). Many people like to take the foam roller and roll back and forth on it. This is okay because it helps to address the fascia, improves circulation to the tissue, and breaks up adhesions. However, if you want to deactivate the trigger point, you need to stop on the tender area that is referring pain and hold your pressure until it begins to release and the pain starts to dissipate.

The amount of time that you hold the trigger point has been debated over the years, but approximately 812 seconds is the accepted amount of time. Its important to note that if youre pushing and it isnt releasing, you may be giving it to much pressure and just blasting through superficial tissue and/or more superficial trigger points. Also, if the trigger point doesnt release after a short period of time, you may want to mark the area (with a pen or something that will wash off), work other areas of the muscle, and come back to it, as trigger point therapy can get very intense. This intensity may not allow the trigger point to release right away. The real key is to give the trigger point just enough pressure that you start to feel it release (and confirm that with a slight dissipation of the referral symptoms) and go deeper and work through the next barrier.

Fig.4. Setting up a barrier in a trigger point

How much pressure is enough? A little bit goes a long way with this. In the past, it was suggested that you hold pressure on the trigger point at the individuals pain tolerance of 78/10 (10 being excruciating pain). It is now accepted that even a 78/10 may be too high to get a proper release, so authors and researchers suggest holding the trigger point at a level of 5/10 until the individual experiences a decrease in symptoms. At this point, you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points (the trigger point clusters that I referred to above).

It is important to know that this sustained compression is what will help to alleviate the trigger point. If you only hold for a short period of time and dont continue with the treatment, the shortened nodule within the muscle will return to its previous state and very little therapeutic benefit will be gained.

So to review:

Find the trigger point.

Hold pressure at 5/10.

Wait for the tissue to release (you can feel it soften under your skin or youll begin to feel a decrease in the pain referral pattern).

Once the tissue releases and the referral starts to dissipate, either go deeper into the tissue or move on and look for other trigger points in the cluster.

Once the trigger points have been deactivated and order has been restored to the muscle, you can go ahead and roll the muscle out to promote some blood flow to the area, stretch the tissue (if its a muscle that needs stretching), and strengthen the tissue.

Things to considerRemember, not all tender areas are trigger points. They may be tender points where tissue is ischemic, scarred up, or fibrotic. This may require other forms of soft tissue therapy. Trigger points are not (usually not) the only problem. They are usually part of a bigger problem that has to do with other soft tissue dysfunctions and should determine what the underlying problems are.

Self care is important. Talk with the patient and make sure his training program is developed properly to limit tissue stress and overuse. Be aware of his/her activities of daily living and posture. So much of our pain and dysfunction comes back to how we operate on a daily basis. Altering activities of daily living, while difficult, is crucial in making lasting changes for the soft tissue.

Soft tissue work, foam rolling, and proper strength exercises are essential.

Trigger Point therapy can reduce pain, increase movement, and allows the muscles to lengthen and become stronger again. To treat Trigger Points, heavy pressure must be applied to the Trigger Point. Light pressure is not effective for treating Trigger

Points, and in fact may increase spasms as the muscle tries to protect itself, leading to increased and more constant pain. In contrast, moderate to heavy pressure applied to a Trigger Point causes the pain to initially increase, but then as the muscle relaxes the pain will fade.

Pressure should be applied slowly and released slowly for best results. The pressure should be maintained until there is a change in pain. If there is no decrease in pain after one minute, stop the pressurethis is probably not a Trigger Point! After applying pressure to Trigger Points, the relaxed muscle should be stretched. If the muscles are not returned to normal length, there is a greater likelihood the Trigger

Points will reoccur. Stretching is safer and less painful after the Trigger Points have been treated.

Fig. 5. Trigger point massage techniqueTrigger Point Therapy also involves the use of various other techniques including active contract/relax and postisometric relaxtion. Predisposing and perpetuating factors in chronic overuse or stress injury on muscles must be eliminated, if possible. The decision to treat trigger points by manual methods or by injection depends strongly on the training and skill of the physician as well as the nature of the trigger point itself. For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy. Furthermore, manual methods are indicated for patients who have an extreme fear of needles or when the trigger point is in the middle of a muscle belly not easily accessible by injection (i.e., psoas and iliacus muscles). The goal of manual therapy is to train the patient to effectively self-manage the pain and dysfunction. However, manual methods are more likely to require several treatments and the benefits may not be as fully apparent for a day or two when compared with injection. The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 13 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.If you want to know more please consult

http://www.scienceofmassage.com/dnn/som/journal/0907/medical.aspx

You can find more details by following the TRIGGER POINT THERAPY PROTOCOL

http://www.scienceofmassage.com/dnn/som/journal/0909/medical.aspxFor other details regarding General treatment methods and Choice of trigger point treatment you can consulthttp://www.sld.cu/galerias/pdf/sitios/rehabilitacion/scs_for_muscle_pain.pdf8. TRIGGER POINT MAP

Muscles both produce and accumulate waste products. The more a muscle is used, the more waste material it produces. As mentioned previously, repetitive use of certain muscles will ultimately cause an accumulation of waste products -- this creates trigger points. Trigger points cause tenderness, restrict normal range of motion, limit muscle flexibility, weaken the muscle, and may refer pain to other parts of the body.

The referral of pain can lead to symptoms in areas far away from the trigger point. The referral of pain does not follow nerve pathways, and may sometimes be in a muscle far away from the trigger point.

A good understanding of trigger points and where they refer pain may shed light on pain conditions that appear to be unexplainable.

There are a few more than 620 potential trigger points possible in human muscles. These trigger points, when they become active or latent, show up in the same places in muscles in every person. For that reason trigger point maps can be made and they are accurate for everyone.

Researches that took place over 10 years, including the participation of 100 (70 women and 30 men) indicates that, without exception, all these people have at least 8 points sensitive, which can cause different symptoms and forms of pain, especially headaches, neck and shoulders, mostly located in the following areas: sternocleidomastoid, trapezius, muscles suboccipitali, splenius head semispinalis capitis, masseter, zygomaticus, orbicularis oculi, temporalis, scalene, rhomboid, infraspinatus, deltoid, latissimus dorsi, teres major, triceps, indicis extensor, flexor carpi radialis, flexor policis longus, adductor policis, illiocostalis, Longissimus, serratus posterior inferior, Quadratus lumborum, gluteus maximus, medius and minimus, tensor fasciae lata, vastus intermedius, lateralis and medialis, hamstring, popliteus, tibialis anterior, peroneus longus. The number and location of trigger points was different in men and women.

Trigger point charts or maps show specific areas that have been identified as trigger points and typical trigger point referral patterns. By strengthening, toning, and massaging these areas, flexibility and strength that has been lost can potentially be regained. The trigger point model states that unexplained pain frequently radiates from these points of local tenderness to broader areas, sometimes distant from the trigger point itself. Practitioners claim to have identified reliable referred pain patterns, allowing practitioners to associate pain in one location with trigger points elsewhere. Many chiropractors and massage therapists find the model useful in practice, but the medical community at large has not embraced trigger point therapy. Although trigger points do appear to be an observable phenomenon with defined properties, there is a lack of a consistent methodology for diagnosing trigger points and a dearth of theory explaining how trigger points arise and why they produce specific referred pain patterns.

Fig.6. Common trigger pointsBelow are several maps of trigger points for the upper back. Keep in mind that trigger points can form in any muscle in the body -- they are not limitted to the upper back.

Understanding the maps: The 'x' represents the location of the trigger point.

The darker the color on the map represent the primary location of pain referral.

The lighter areas on the map represent "spillover" areas of pain, which may or may not be present.

Fig. 7. Upper back trigger points.

http://www.aaachingback.com/Trigger_Point_pain_referral.htmlFor more informations please consult Free Myofascial Trigger Point Charts http://www.youtube.com/watch?v=7_j9RJYII1khttp://www.triggerpointmaps.com/tp_finder.htmlReferences

1. Travell, Janet; Simons David; Simons Lois (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual (2 vol. set, 2nd Ed.). USA: Lippincott Williams & Williams. ISBN0-683-08363-5.2. DAVID J. ALVAREZ, PAMELA G. ROCKWELL Trigger Points: Diagnosis and Management, Am Fam Physician. 2002 Feb 15;65(4):653-661. 3. Leon Chaitow and Judith Walker-Delaney - Clinical Applications of Neuromuscular Techniques Elsevier, 2002, Vol 2http://books.google.ro/books?id=utJagjr-HuIC&printsec=frontcover&hl=ro&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

External links

1. Ross Turchaninov, MD and Boris Prilutsky- SCIENCE OF TRIGGER POINT THERAPY. PART Ihttp://www.scienceofmassage.com/dnn/som/journal/0903/medical.aspx PART II TYPES and Evaluation OF TRIGGER POINTS

http://www.scienceofmassage.com/dnn/som/journal/0905/medical.aspx Part III THERAPEUTIC OUTCOMES OF TPT

http://www.scienceofmassage.com/dnn/som/journal/0907/medical.aspx Part IV TRIGGER POINT THERAPY PROTOCOL

http://www.scienceofmassage.com/dnn/som/journal/0909/medical.aspx

2. SCS for muscle pain (plus INIT and self-treatment

http://www.sld.cu/galerias/pdf/sitios/rehabilitacion/scs_for_muscle_pain.pdf3. wikipedia- http://en.wikipedia.org/wiki/Trigger_point

4. Trigger Point Pain Guide - http://triggerpoints.net/5. Referred Pain Symptom Guide - http://myofascialtherapy.org/symptom-checker/6. Myofascial Trigger Point Charts http://www.youtube.com/watch?v=7_j9RJYII1k http://www.triggerpointcharts.com/http://www.triggerpointmaps.com/tp_finder.html7. Trigger Point Maphttp://www.aaachingback.com/Trigger_Point_pain_referral.html8. Finding Triggers

http://lifeafterpain.com/vault/treat-your-triggers/finding-triggers/9. TRIGGER POINT Manual THERAPY

http://www.pressurepointer.com/PressurePointerManual.pdf10. The Trigger Point & Referred Pain Guidehttp://www.triggerpoints.net/11. CHIROPRACTIC PERSPECTIVES ON MYOFASCIAL THERAPYhttp://www.chiro.org/ACAPress/Myofascial_Therapy.html12. Introduction to Clinical Trigger Point Therapy

https://itunes.apple.com/us/book/introduction-to-clinical-trigger/id591601476?mt=11Videos

1.Myofascial Trigger Points: Causes and Treatment http://www.youtube.com/watch?v=9Aakc59YFJE1. What Is a Trigger Point and What Causes Them

http://www.youtube.com/watch?v=P-ljVkkBWQE3.Trigger Points and How They Work http://www.youtube.com/watch?v=f2R_d0eqDjY

4. Free Trigger Point Therapy Course-Part 1 of 7: Introduction http://www.youtube.com/watch?v=aiKKCNIWXgs5. Free Trigger Point Therapy Course-Part 2 of 7: What is a Trigger Point? http://www.youtube.com/watch?v=yCkYs8ISxyw6. Free Trigger Point Therapy Course-Part 3 of 7: Trigger Point Physiology and Effectshttp://www.youtube.com/watch?v=rghCYqMvLpc7. Free Trigger Point Therapy Course-Part 4 of 7: Referred Pain and Symptoms http://www.youtube.com/watch?v=QuTtGG61SUk8. Free Trigger Point Therapy Course-Part 5 of 7: Trigger Point Treatment http://www.youtube.com/watch?v=ZiXUritQxAk9. Free Trigger Point Therapy Course-Part 6 of 7: Clinical Procedures http://www.youtube.com/watch?v=RY-cHjIgxIg10. Free Trigger Point Therapy Course-Part 7 of 7: Protocols http://www.youtube.com/watch?v=biRgQh-Khgk11. Trigger Point Massagehttp://massage-tutorials.wonderhowto.com/how-to/do-trigger-point-massage-5261/

12. The Gluteus Medius Trigger Points and Low Back Pain http://www.youtube.com/watch?v=4W_RtAong-U13. Trigger points massage techniques

http://www.youtube.com/results?search_query=trigger+point+massage+techniques&page=214. Massage Techniques : Basics of Deep Tissue Massage http://www.youtube.com/watch?v=pihxy4iUkcE15. Upper Traps Trigger Point - Massage Therapy Lesson http://www.youtube.com/watch?v=i7yR4hn08yIOptional Bibliography1. Tough EA, White AR, Richards S, Campbell J (MarchApril 2007). "Variability of criteria used to diagnose myofascial trigger point pain syndromeevidence from a review of the literature". Clin J Pain 23 (3): 27886. doi:10.1097/AJP.0b013e31802fda7c. PMID17314589.

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