Sushumna Complementary Therapies
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.
Skeletal muscle accounts for 40% of body weight, and about 85% of human pain complaints. The commonest muscles affected are those in the neck, shoulder girdle, low back and hip girdle. Muscles are sprained when they are placed under an excessive physical load. The sprain does not normally affect the whole muscle, but is usually confined to one or two small muscles fibres within the main body of the muscle.
The sprain causes a rupture of a few muscle cells, producing initial pain and inflammation, and which usually settles within 1 -2 weeks. During this healing period it is possible to feel a painful taut band within the affected muscle where it has been sprained. This taut band is often referred to as an active Trigger Point (TrP). If the sprain is bad enough, sensitisation at the appropriate level in the spinal cord occurs leading to a increase in resting tone within the whole muscle i.e. it appears that the whole muscle has gone into spasm. When the resting tone of the whole muscle increases, it is much less willing to relax increasing the likelihood of further injury and cramps.
In most people the sprain heals naturally, leading to resolution of the muscle tenderness and the trigger point. In some people the pain resolves but the taut band remains, producing a latent trigger point (TrP). A latent TrP does not normally cause pain unless it is prodded, rolled around, or stretched. It may leave the muscle vulnerable to further injury in the future as the latent trigger point may make the muscle less willing to lengthen or relax.
In a small proportion of people the TrP remains active long after the original injury. The reason for this is not fully understood, but it appears that a self-perpetuating loop operates making it possible for trigger points to remain active for decades. There is often also a complex interactive between fear of the pain, excessive guarding of the part, and abnormal beliefs about the cause of the pain. Many patients are told that the cause of the pain is due to arthritis, especially when it has gone on for many months after the original injury.
Active Trigger Points usually have the following characteristics:
″ A history of sudden onset after an acute muscle overload, or a gradual onset with chronic overload.
″ A pattern of referred pain characteristic for the individual muscle.
″ Weakness and restricted range of movement appropriate for the muscle involved.
″ A taut palpable band within the muscle.
″ Focal tenderness on digital pressure.
″ A twitch response in the muscle on snapping the trigger point with the finger.
″ Resolution of the pain with specific treatment for the trigger point.
Trigger points have a number of qualities. They may be classified as active/latent and also as key/satellites and primary/secondary.
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). 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 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 often will resolve the satellite and return it from being active to latent, or completely treating it too.
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. 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, radiculopathy, infections and health choices such as smoking.
Trigger points can appear in many myofascial structures including muscles, tendons, ligaments, skin, joint capsule, periosteal, and scar tissue. When 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.
Diagnosis of trigger points
Trigger points are diagnosed by examining signs, symptoms, pain patterns and manual palpation. Usually there is a taut band in muscles containing trigger points, and a hard nodule can be felt. Often a twitch response can be felt in the muscle by running your finger perpendicular to the muscle's direction; this twitch response often activates the "all or nothing" response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the gluteus group (gluteus maximus, gluteus medius, and gluteus minimus). Often there is a heat differential in the local area of a trigger point, and many practitioners can sense that.
Misdiagnosis of pain
The misdiagnosis of pain is an important issue. 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.
Trigger Point Treatments
The principles of treating trigger points are as follows:-
″ Reduce the pain generated by the TrP by using local methods.
″ Improve the suppleness of the muscle by using stretching techniques shortly after the treatment.
″ Strengthening the muscle afterwards to prevent vulnerability to further injury.
″ Using one without the other often results in failure. It is extremely important for patients to fully understand and accept the cause of the pain, the patterns of referred pain, and to accept responsibility for their own recovery by complying with the necessary stretch routines.
Spray and Stretch Treatment
A cool spray or Gel is applied to the skin overlying the affected muscle, whilst the muscle itself is gently placed into it's maximum stretched position. The coolant helps to inhibit the nerve mechanisms responsible for keeping the muscle in a contracted state, allowing the TrP to be deactivated by the stretching techniques.
TrPs are deactivated by positioning the patient in such a way that the affected muscle is shortened as much as possible. This minimised position is then held and supported by the therapist (with the patient in a completely relaxed state) for at least 90 seconds, before being slowly released back to normal again.
At the heart of this technique is the supposition that muscles are sprained when placed under a physical load, usually when the muscle is at maximal stretch. The control system for that muscle then exhibits a form of "memory" keeping the sprained part of the muscle in a contracted state. Minimising the length of the muscle for 90 seconds helps to reset the control system by reducing the degree of dorsal horn sensitisation and also by reducing the abnormal muscle position receptors activity.
Muscle Energy Technique (also known as Post Isometric Relaxation)
Ischaemic Compression Treatment
TrP's are deactivated by the therapist applying firm pressure with a finger or thumb for at least 3 - 5 minutes. This renders the point temporarily short of oxygen (ischaemic) allowing it relax.
Myofascial Trigger Points v's Acupressure Trigger Points
Acupressure trigger points are always in the same locations on the body, they do not move. Myofascial trigger points are located wherever the muscle fibres have been put into an overloaded state. Both trigger points will have associated projected pain locations, which will help to determine the points to be treated. The points can be treated with the same methods, although the Acupressure trigger points can be treated by use of traditional Acupressure palpataions, sensing for "a Pulse".
Treatment, whether by self or by a professional, has some inherent dangers. It may lead to damage of soft tissue and other organs. The trigger points in the upper quadratus lumborum, for instance, are very close to the kidneys and poorly administered treatment may lead to kidney damage. Likewise, treating the masseter muscle may damage the salivary glands superficial to this muscle
Julian A Phillips
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