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Myofascial pain and dysfunction
- 1. Myofascial Pain andDysfunction II-XII Glossary of Terms
- 2. Terminology • Abduction-Movement fromthe body • Active Range of Motion-How much somebody can move a particular limb • Active Myofascial Trigger Point-Causes a clinical pain complaint. It is always tender, prevents full lengthening of the muscle, weakens the muscle, refers a patient-recognized pain on direct compression, mediates a local twitch response of muscle fibers when adequately stimulated, and, when compressed within the patient's pain tolerance, produces referred motor phenomena and often auto- nomic phenomena, generally in its pain reference zone, and causes tenderness in the pain reference zone. • Acute-Of recent onset; hours or days • Adduction-Movement towards the body
- 3. Terminology • Agonist-Muscle whodirectly contributes to movement • Allodynia-Pain due to stimulus that doesn’t ordinarily cause pain • Analgesia-Stimulus that ordinarily causes pain doesn’t cause pain • Anatomical Position-posterior (Back), anterior (Front), lateral (Sides), medial (Middle), superior (Above), inferior (Below) • Antagonist-Muscle who directly inhibits movement; opposite of agonist (e.g. Biceps/Triceps)
- 4. Terminology • Bruxism-Clenching andgrinding of teeth • Caudad-Inferior • Cephalad-Superior • Chronic-Long standing; months, years • Composite Pain Pattern-Pain Pattern of two or more adjacent muscles, such that no distinction is made of the individual muscles • Contraction-Muscle becomes shorter and tighter by firing action potentials • Contracture-Muscle becomes shorter and tighter without firing action potentials; condition of hardening of muscles
- 5. Terminology • Coordinated Respiration-Expansionof chest and contraction of diaphragm which increases intraabdominal pressure • Coronal Plane-Imaginary line that divides body into anterior and posterior, perpendicular to Sagittal Plane • Deep-Far from surface • Distal-Far from point of origin • Dysestesia-Any unpleasant, abnormal sensation • Enthesitis-Inflammation at tendons and ligaments • Enthesopathy-Any general disorder of bone attachment (tendons, ligaments, etc…) May develop into Enthesitis
- 6. Terminology • Erector Spinae-LowerBack Muscles, worked during deadlifts, back extensions, etc… • Essential Pain Zone-Pain that is present in every patient when a particular trigger point is active • Extension-Straightening of hinge joints • Flat Palpation-Examination of trigger points by finger pressure • Flexion-Bending of hinge joints • Function-Actions of a muscle • Functional Unit-Agonist/Antagonist groups which function together; Myotatic Unit
- 7. Terminology • Hyperesthesia-Increased sensitivityto stimulation • Hyperpathia-Abnormally painful reaction to a stimulus, in particular a repetitive stimulus • Hyperalgesia-Abnormally painful reaction to a stimulus that is normally painful • Hypoalgesia-Diminished painful reaction to a stimulus that is normally painful • Involved Muscle-Muscle with an active or latent trigger point • Jump Sign-Pain response of a patient in regards to trigger point stimulation • Key Myofascial Trigger Point-Trigger point that activates satellite trigger points
- 8. Terminology • Latent MyofascialTrigger Point-A trigger point which does not cause pain at the moment • Local Twitch Response-Twitch response of a trigger point to stimulation • Lumbago-Lower back pain • Muscular Rheumatism-Muscle pain attributed to inflammation in joints or soft tissue • Myalgia-Pain in muscles due either to infection or trigger points • Myofascial Pain Syndrome-Symptoms attributed to trigger points
- 9. Terminology • Myofascial TriggerPoint-A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena; a “knot” in the soft tissue or muscle • Paradoxical Respiration-Simultaneous expansion of the chest and contraction of abdomen that pulls abdomen inwards • Passive Range of Motion-Range of motion of a limb when moved by someone or something else • Pincer Palpitation-Examination of trigger point by using a pincer grip with thumb and forefingers
- 10. Terminology • Primary MyofascialTrigger Point-Trigger Point activated by overload or repetitive use of muscle, and not activated by another trigger point • Prone-Facedown • Referred Autonomic Phenomena-Vasoconstriction, coldness, sweating, ptosis, hypersecretion, and/or pilomotor response (hair standing up) in an area separate from the trigger point causing the symptoms • Referred Pain-Pain caused by a trigger point that occurs elsewhere • Release-Anything which reduces muscle stiffness • Sagittal Plane-Imaginary line which divides the body into left and right portions
- 11. Terminology • Satellite MyofascialTrigger Point-A trigger point caused by another trigger point • Scoliosis-Lateral curvature of the spine (Spine bends to sides) • Shortening Activation-Activation of latent trigger point due to shortening of antagonist when stretching agonist (hurting your back because you are stretching your chest) • Spasm-Sudden, involuntary firing of action potentials resulting in muscle contraction • Spillover Pain Zone-Region where some patients with particular trigger points feel referred pain, but others do not • Strain-Tissue and psychological response to sustained stress • Stretch-Anything which elongates muscles • Stress-Resistance force; physical or psychological overload • Superficial-Close to the surface
- 12. Terminology • Supine-Face upwards •Synergistic Muscles-Muscles which complement each other (Chest and Biceps, etc…) • Taut Band-Group of tense muscle fibers extending from the trigger points to the muscle attachments • Trigger Area-Synonymous with Trigger Points • Zone of Reference-Area of the body where symptoms of trigger points occur
- 13. Background • Trigger Pointsare an exceedingly common source of pain amongst patients Trigger Points found in~ 50% of Shoulder-Girdle Muscles, with 25% showing referred pain Other muscle groups show similarly high prevalence of Trigger Points • In a sample of 96 patients, 93% of patients had pain partially attributed to Trigger Points, and in 74% Trigger Points were the primary source of pain • People are most likely to suffer Active Trigger Points when they’re in their mature years (Approx. 31-50)
- 14. Importance • Skeletal Muscleis the largest organ in the human body, accounting for nearly 50% of a person’s bodyweight • Amount of muscles varies by muscles, but there are approximately 200 pairs and 400 individual muscles in the body Any muscle can develop Trigger Points • Trigger Point pain can range from debilitating, incapacitating pain to painless restriction of movement and distortion of posture While not life-threatening, Trigger Points can impact quality of life Can lead to chronic injuries
- 15. Definition • Many advancementsin understanding myalgia (Muscle Pain) and fascia came about starting from the turn of the 20th century. By 1990, there was a concrete definition for fibromyalgia, or widespread muscle pain Although the cause in not yet fully known, it is firmly established that a Central Nervous System Dysfunction is primarily responsible for the increased pain sensitivity of fibromyalgia • Studies implicate a dysfunctional endplate region, which depolarizes skeletal muscle following an action potential, and the prime site of Trigger Points
- 16. Related Diagnostic Terms •The cause of musculoskeletal pain has perplexed the medical community • Anatomically Oriented Terms Pain Syndromes “Discovered” before the identification of Trigger Points • Fibromyalgia A different condition than trigger points with similar symptoms Abnormality in how pain signals are processed in the Central Nervous System, leading to deep tissue tenderness • Muskleharten/Myogelosen Palpable firmness of trigger points responsible for pain
- 17. Related Diagnostic Terms •Myofascial Pain Syndrome Two meanings; any pain in soft tissue, or any pain attributed to myofascial trigger points • Nonarticular Rheumatism General term for any soft tissue pain not associated with a specific joint dysfunction or disease • Osteochondrosis Term that refers to interaction of neural and muscular conditions
- 18. Symptoms • Active TriggerPoints can produce spontaneous pain, muscle shortening, and motor dysfunction Active Trigger Points can produce satellite trigger points throughout the body • Latent Trigger Points can produce many symptoms of Active ones, but will not produce spontaneous pain • Trigger points are often caused by abuse of the muscle, usually in the form of muscular overload, whether acute, sustained, or repetitive Leaving a trigger point untreated can cause the trigger point to progressively get worse • Nerve compression can cause trigger points in paraspinal muscles • Oftentimes, the most recently activated trigger point is the most painful When deactivated, the pain pattern may shift to an earlier trigger point Intensity of referred pain is based on intensity of trigger point, not size of muscle • Active trigger points may spontaneously revert to latent trigger points
- 19. Symptoms • Trigger pointsoften cause regional pain in soft tissue • People with sedentary lifestyles are more likely to develop trigger point pain • Trigger Points are most commonly found in postural muscles of the neck, shoulders, and pelvic girdles, and in the jaw muscles • Sleep positioning can be critical to the relief of trigger points
- 20. Physical Findings • Musclesharboring Trigger Points are prevented from reaching full stretch range of motion, and are also restricted in strength and endurance The Trigger Point is identified as a localized spot of tenderness in a nodule in a palpable taut band of muscle fibers A taut band is a group of tense muscle fibers extending from the trigger point to the muscle attachments • A tender nodule is the highly localized tender spot of a trigger point Movement of application of pressure by a millimeter can result in a markedly different pain response • Pressure on an Active Trigger Point can cause a twitch response in the muscle • A trigger point can impede range of motion; attempts to passively stretch beyond the range of motion can result in pain • Muscles with an active trigger point start out fatigued, fatigue more quickly, and become exhausted more quickly than unaffected muscles • When a trigger point is strongly contracted against, it causes pain
- 21. Testing • While thereis no laboratory testing of Trigger Points, there are three measurable methods to detect trigger points. • Needle Electromyography There is a specific EMG for finding Trigger Points, as well as motor endplate activity that, while not confirming a trigger point, is characteristic of a trigger point • Ultrasound Imaging • Surface Electromyography Measuring effects of Trigger Points on muscle activity, and their influence on motor functions in both the muscle where they occur, and other muscles
- 22. Testing • Muscles withTrigger Points tend to exhibit three issues Increased Responsiveness Some muscles may become inhibited, while others may become excited and tend to “overreact,” depending on the muscle; these muscles become more sensitive to pressure Accelerated Fatigability Muscles with trigger points fatigue more quickly than normal, unaffected muscles Delayed Relaxation Common when muscle is overworked Testing shows low levels of EMG activity when muscle should be relaxed, which contributes to fatigue
- 23. Testing • Oftentimes, spasmoccurs in muscles with TrP, particularly the upper trapezius, masseter (upper jaw responsible for chewing), posterior cervicals, and lumbar paraspinal muscle • Spasm doesn’t necessarily indicate pain referral, particularly with lumbar paraspinal muscles • TrP in a muscle oftentimes causes inhibition in other muscles, which affects normal muscle function. Oftentimes, this inhibits an antagonist muscle See: My hip surgery, tight psoas and quads leads to underactive gluteal muscles Fixing TrP returns normal muscle function
- 24. Testing • Algometry Way oftesting pain from TrP by applying direct pressure Three Levels of Pain Localized Pain Referred Pain Intolerable Pain Three things to keep in mind when testing Test reveals nothing about source or cause of pain Thinner muscules will yield pain more easily than thicker muscles Specific testing is very skilled. I cannot do this personally, but I can use this testing to get an idea of my own TrP so I know what to focus on
- 25. Testing • Algometry Referred paincan be extracted from all active TrP in a clinical setting, but only about half of Latent TrP Pain threshold for Active TrP is significantly lower than for Latent TrP • Thermography TrP correlates with areas of higher temperature A hot spot does not necessarily indicate the presence of a TrP When referred pain is caused by pressure in a TrP, the TrP region becomes hyperthermic
- 26. Treatment • To treatTrP we must consider and deal with the cause that activated the TrPs, to identify and correct any perpetuating factors (which often are different than what activated the TrPs), and to help the patient to restore and maintain normal muscle function. • Treatment options that are of interest to me include the use of simple muscle stretch, augmented muscle stretch, post-isometric relaxation, reciprocal inhibition, slow exhalation, TrP pressure release, massage, range of motion, heat
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- 29. Diagnostic Criteria • JumpTest/Spot Tenderness Easy, but test is very ambiguous as to cause of pain. For reliable clinical results, must be tested with quantifiable methods • Pain Recognition Luckily, I know what a TrP feels like. With experience, you will too • Palpable Taut Band Ambiguous as Taut Band can be observed without pain The presence of spot tenderness combined with a palpable band and nodule is highly reliable Detecting a palpable nodule in a taut band increases reliability
- 30. Diagnostic Criteria • TwitchResponse The single highest correlation with TrP Very difficult to elict, sometimes cannot be elicted, especially near areas with Enthesopathy TrP tend to be in the belly of muscle rather than where muscles are attached Needle penetration of TrP will easily elict trigger response • Range of Motion Fundamental characteristic of TrP
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- 32. Diagnostic Confusions • Musculoskeletalpain is often attributed to myofascial TrPs, fibromyalgia, and articular dysfunction that requires manual mobilization • All three need significantly different treatments, and different diagnostic exams • Refer to page 37 of Vol. 1 for a chart of common conditions, and their common TrP culprits
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- 34. Diagnostic Confusions • Non-myofascialTrP Can occur in skin, etc… Scar TrP (in skin or mucous membranes) refer burning, prick- ling, or lightning-like jabs of pain, can have alcohol injected to fix • Acupuncture Pain relief experienced from classical acupuncture points is associated with an endorphin response in the central nervous system Frequently the acupuncture point selected for the treatment of pain is actually a TrP. Sometimes, it is not a TrP.
- 35. Muscle Structure andFunction • Striated Skeletal Muscle Composed of fascicles, bundles of muscle fibers Muscle fibers cover roughly 1,000 myofibrils, composed of chains of sarcomeres Sarcomere’s are the basic unit of the muscle cell • Sarcomere Connected to each other by bands, in a chain-like fashion Consists of actin and myosin molecules which interconnect to produce force to contract Myosin heads are a form of ATP that interacts with Actin to produce contractile force Ionized Calcium triggers interaction, and ATP provides energy Sarcomere produces maximum force in the midrange, but expends energy at either extreme to prevent further shortening or lengthening
- 36. Muscle Structure andFunction • The Motor Unit The Central Nervous System controls voluntary muscle activity through motor-neurons Motor Neurons controls hundreds of muscle fibres The fewer muscle fibres a neuron controls, the finer the movement control of that neuron is • Motor Point Area where visible twitch could be elicited using electro-stimulation
- 37. Muscle Structure andFunction
- 38. Integrated Trigger PointHypothesis • Energy Crisis Component Calcium intake by muscle is created and sustained; recall this tells muscle to contract Sustained contractions use energy and prevent flow of oxygen into region Circulation in a muscle fails at 30-50% effort Because of the energy shortage, due to sustained contraction, the Ca pump that returns calcium to tell muscle to stop doesn’t have necessary ATP
- 39. Integrated Trigger PointHypothesis
- 40. Integrated Trigger PointHypothesis • Taut Band Forms because trigger point contracts at nodule, and then pulls on rest of muscle fiber, increasing tension • Palpable Nodule These feel swollen because sarcomeres must maintain a constant volume Therefore, they broaden as they shorten • Spot Tenderness Caused by sensitized pain receptors, caused by energy crisis in region • Enthesopathy Caused by tendons being unable to withstand tension of taut band • Response to Massage TrP myoglobin response to massage differs from normal muscle Massage ruptures cell and relieves the myofascial impingement Response for TrP fades dramatically with repeated interests
- 41. Integrated Trigger PointHypothesis
- 42. Integrated Trigger PointHypothesis • Histopathological Complications Adjacent TrP can cause shear forces with other muscle, causing more TrPs If a taut band goes untreated for too long, it can cause sarcolemma (tube that envelops muscle fibers) to have regions of emptiness (no fibres) This is where condition becomes chronic
- 43. Local Twitch Response •Mechanical stimulation of TrP can cause twitch in taut band, primarily through needles • Very useful for confirmatory purposes • For needle stimulation, if LTR is activated, that signals • LTR can be prohibitively painful • Difficult to elicit from manual stimulation like massage because of surrounding muscle and fat • Requires meticulous accuracy to stimulate LTR from taut band/TrP • Can also occur in regions of Enthesopathy or bursitis
- 44. Referred Pain andTenderness • Pattern of referred pain is vital to identifying cause of myofascial dysfunction • Referred pain is usually felt at the muscle attachments of the taut band • TrP referred pain is usually steady, deep, or aching, occasionally sharp • TrP pain patterns are predictable and reproducible • Trigger points may refer pain in three directions Peripheral, away from center of body Central, in center of body Local, immediate vicinity • Peripheral is most common (85% of patterns)
- 45. Referred Pain andTenderness
- 46. Referred Pain andTenderness
- 47. Referred Pain andTenderness • Referred pain can come from overlapping TrP pain patterns, and may require inactivation of multiple TrP to resolve • Keep in mind, pain can return to TrP, and in the event it does, it may be required to treat underlying causes AS WELL AS TrP (Such as poor muscle movement)
- 48. Anatomy • In thistext, descriptions of muscle attachments assume anatomical position Above implies Cephalad, superior, or proximal Below implies Caudad, inferior, or distal • Fiber Length Cross-Sectional Area is proportional to relative strength of a muscle Force producing muscles such as the quadriceps have a low fiber length:muscle length ratio Muscles with low ratio have endplate zones that run along the muscle High Velocity movements muscles such as the hamstrings have high fiber length:muscle length ratio Muscles with high ratio have endplate zones that ran transverse to the muscle
- 49. Anatomy • A functionalunit includes muscles that reinforce and counter the movements of a given muscle, as well as joints that the muscle crosses A TrP in a muscle in a functional unit usually leads to TrP in other muscles in the functional unit Dysfunction of a given muscle leads to overload of muscles in the same functional unit • Myotatic Unit Composed of agonist, synergists, and antagonists
- 50. Anatomy • Posture isvery important, and it is important to be aware of this Common issues: Leaning forward, not maintaining normal lumbar-spine curve, not engaging core/slumping in chair, feet not touching floor, elbows not touching armrests • It is also essential to be aware of pain and dysfunction in the body “Doesn’t everybody’s feet hurt?” This is a problem that should be solved and acknowledged
- 51. Patient History • Everypatient has unique dietary needs Even if on surface they are reaching those needs, they may not be E.g. reheating food or keeping under warming light may cause vitamins to leach out of food, specific methods of preparation may change nutritional value of food • Sleep is a big issue for people If someone is cold, muscles often contract to keep warm, which can cause activation of TrP and pain • TrP may flare up when hungry, because energy crisis becomes worse with less available energy in body
- 52. Myofascial Pain Onset •Abrupt Onset Due to a singular event or action • Gradual Onset Due to chronic overload of muscle • Other Can be caused due to psychological stress, viral infection, illness
- 53. Myofascial Pain Onset •Aggrevating Causes Strenuous use of muscle, especially when shortened Passive stretching of muscle Pressure Being placed in shortened position for extended time period Usually worst after long period of sitting or after waking up In cold environments When ill
- 54. Myofascial Pain Onset •What decreases pain Short period of rest Slow, long passive stretches Moist heat directly over the TrP Short period of light activity with plenty of movement, which causes blood to pump Myofascial Therapy
- 55. Myofascial Pain Onset •TrP can lead to limited range of motion, as muscle limits full stretch with TrP • Weakness can be caused by TrP inhibiting muscle contraction Additionally, body can learn to limit contraction to stay below pain threshold • Chronic pain and depression go hand in hand, and TrP can help further depression and visa-versa • TrP can cause sleep disturbances • If TrP is progressively getting worse, then perpetrating factors must be eliminated before treating myofascial condition
- 56. Activation and Perpetration •One time trauma can activate a TrP, but will not necessarily perpetrate them • Any repeated or chronic muscle overload can lead to TrP • Sudden onset Mechanical stresses that tend to lead to TrP are wrenching movements, automobile accidents, falls, fractures, joint sprains, impact, or dislocations TrP from one time traumatic issues are easily treated Latent TrP in a fatigued muscle can be activated by direct cooling
- 57. Patient Examination • Notethe spontaneous movement of a patient in a clinical setting Patients with painfully active TrP tend to move slowly and protectively, and avoid movements that will lead to activation of TrP pain Key observations Does body turn, or body and head turn Are shoulders level while sitting Is spine rounded in resting position Does patient stretch passively • Neuromuscular Functions Different populations inherently behave differently and develop different problems Some people are jerky, some people misuse their muscles Athletes tend to avoid movements that cause discomfort, which leads to the development of weakness
- 58. Patient Examination • RelevantTrP Can be done by performing range of motion stretches Taking slack to point of tension Ask patient where tension occurs Palpate area to look for a taut band These TrP can cause dysfunction with or without pain • Compression Test When a patient complains of TrP pain only during movement, compressing the agonist muscle of the movement can sometimes temporarily relieve pain Can convince patient of nature of issue, especially if patient has tried many times to have issue fixed to no avail
- 59. TrP Examination • Oneway to confirm location is to resist movement of patient to contract muscle with one hand manually, and palpate muscle with second hand Patient must be warm and muscle must be relaxed, otherwise distinction between tense bands and adjacent slack muscles is lost • Fingernails must be properly trimmed to avoid distracting pain • Examining muscle for TrP can lead to pain for a day or two, so examination should be followed by specific myofascial therapy, such as spray and stretch or moist hot packs
- 60. TrP Examination • “Ataut band feels like a palpable cord of tense muscle fibers among the normally pliable fibers. Such palpable tense muscle fibers were described as "matted together" by Wilson. The examiner should palpate along the taut band to locate the nodule that corresponds to a circumscribed slightly enlarged region of decreased compliance. This nodular region is also the location of maximum tenderness “
- 61. TrP Examination • Canuse Flat Palpation, Pincer Palpation, or Deep Palpation for examination • Flat Palpation
- 62. TrP Examination • PincerPalpation
- 63. TrP Examination • DeepPalpation Place finger deep in tissue for deep muscle and feel for tenderness • Sufficient pressure on active TrP will elict response from patient in most cases A jump sign means the response is vigorous • Two types of TrP, Central and Attachment • Central TrP The primary central TrP abnormality is associated with individual dysfunctional endplates in the endplate zone (or motor point). This dysfunction produces a local energy crisis that results in sensitization of local nociceptors. This dysfunction can produce contraction knots which then produce a nodule and a taut band of tense muscle fibers.
- 64. TrP Examination • AttachmentTrP The attachment TrPs result from the sustained increased tension of these muscle fibers at the attachment point. This sustained tension can produce enthesopathy with swelling and tenderness where the muscle fibers attach to an aponeurosis, tendon, or bone. Some muscles have sufficient separation between the muscle fiber-to-tendon attachment and tendon-to-bone attachment that one end of the muscle may have two distinctly different attachment TrPs. • Some TrP may be related to each other Key TrP can induce Satellite Trp, which cannot be fixed without root TrP being fixed first
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- 67. Trigger Point Release •The Treatment of a TrP depends on the type of TrP Central TrP Respond well to stretching Respond well to warmth Deactivating Attachment TrP may help fix Attachment TrP Respond well to manual release Respond well to cold, especially if inflamed Central TrP must be deactivated to prevent reactivation of Attachment TrP • TrP recovery often involves relieving pain, deactivating TrP, then reeducating muscles on proper movement patterns
- 68. Trigger Point Release •Spray and Stretch Stretching is the “action,” and spraying is the “distraction” Ethyl Chloride Spray This spray has been shown to work as a surface level anesthesia, especially regarding myofascial pain The spray does not relieve any of the underlying issues, but will help with the pain This can cause health issues; there are replacements, but none are fully accepted yet Spray and Stretch is a very effective non-invasive method, but there are more effective methods that a patient can use at home Spray and Stretch works well for children Advantages Spray and Stretch does not require finding precise TrP, only region of taut bands and discomfort
- 69. Trigger Point Release Sprayand Stretch
- 70. Trigger Point Release •Stroking With Ice Cooling effect of spray can be achieved with ice, but skin must be kept dry • When coldness is applied, skin temperature drops which causes alarm reactions to appear in the region This input has an inhibitory effect on pain, which can help patient with stretch when it would normally be painful to perform the stretch • Keys to stretching Any gentle lengthening of muscle is shown to reduce Central TrP Push to boundary until muscle relieves tension, then push further, until lowered slowly, standard stuff
- 71. Trigger Point Release •Post isometric Relaxation Done by supporting muscle to prevent shortening of muscle , client performs isometric contraction for 3-10 seconds then relaxes and muscle lengthens Can be combined with reflex augmentation, such as synchronized breathing or eye movements, for greater effect • Reciprocal Inhibition Contracting the antagonist to the muscle being stretching will allow the target muscle to stretch more E.G. contracting hamstring during quad stretch • Contract-Relax Gentle, minimally resisted contraction of tight muscle followed by relaxation
- 72. Trigger Point Release •Trigger Point Pressure Release Here’s a surprising fact; when using pressure release, don’t need enough pressure to produce ischemia in muscle to be effective Lengthen muscle to point of increasing resistance within comfort zone Apply gradually increasing pressure until tissue begins to increase resistance against touch Continue until tissue relaxes This is good for central TrP, and should not be brought to pain It is worth nothing that Shiatzu and Accupuncture, while conceptually different, have similar treatments to the treatment of TrP
- 73. Trigger Point Release •Deep Stroking Massage Arguably the most effective way to inactivate TrP Should pay close attention to barriers and release in body Muscle to be treated should be relaxed to point of no slack, and lubricated if subcutaneous tissues are tense Start on TrP, apply pressure, then apply deep massage along taut band Pressure applied should be in response to body; applying too vehemently or quickly can destroy muscle endplates as functional structure and cause pain or discomfort Be sure to apply massage in both directions of TrP
- 74. Trigger Point Release •Strumming Similar to deep tissue massage, but motion is directed perpendicular to the length of the muscle, rather than with the length of the muscle Finger runs along muscle belly until it comes into contact with Nodule, and is strummed Very useful for thin muscles like the masseter • Myofascial Release Therapeutic System for soft tissue recovery A clinical practice that is often effective for TrP, but the specific TrPs are not diagnosed, so it is hard to say how much pain is attributed to TrP from patient to patient with this
- 75. Trigger Point Release •Accessory Techniques Exhalation tends to make most muscles in body relax, so it can be used with stretching to increase effectiveness Phased respiration Eye movement facilitates movement in head and trunk of patient and inhibits opposing movement By looking in direction of movement needed to release muscle, it will be help Avoid exaggerated movements, as they will inhibit effect and become distracting Heat penetrates skin poorly, and works to increase circulation in an area and relaxation Cold penetrates skin deeply, and will offer pain relief Muscle relaxants don’t help
- 76. Trigger Point Release •Vitamin C deficiency is often caused by tobacco smoking Sufficient Vitamin C should be available in body for TrP therapy • Reactive Cramping Sometimes, deactivating a TrP will cause cramping in antagonist This can be avoided by treating both agonist and antagonist at once • It didn’t work!? Many reasons Patient not fully relaxed Inadequate Stretch Technique Not enough ROM for stretch Poor posttreatment (if cooled, skin should be warmed after)
- 77. Trigger Point Injection •This section (P1.C3.S13) is irrelevant for my purposes, but I welcome you to read and notate the section. • I have read it, will not notate because I do not plan on treating TrP with injection due to lack of availability of anesthetic, and more importantly, lack of training and environment in which to perform injection • Page 150-166
- 78. Corrective Actions • CorrectiveActions can be impinged on three factors by patient Overenthusiasm These people may abuse their muscles, ignore what their body tells them, etc… Misunderstanding Patient misunderstands what they need to do Lack of Interest Patient must learn that Dr/Therapist/Anybody can only give them the tools to treat their muscle pain THEMSELVES Sometimes, patient will take a declaration, such as “I have arthritis of the spine,” as a condemnation and sentence themselves to a life of pain medicine instead of corrective action
- 79. Corrective Actions • Propermuscle mechanics It is important to keep simple rules in mind Do not lift with rounded back Do not apply force with a rotated joint Do not bend forward and twist when getting up from a seated position Jerky, rapid movements are poorly coordinated, and should be replaced by habitual smooth, controlled movements Keep in mind height level when sitting down to avoid neck strain; as a taller person, I should set my chairs lower to the ground
- 80. Corrective Actions • Itis usually best to avoid using maximal effort in muscles, in order to avoid strain • Posture when laying down should not be contracted for extended periods (Hello my legs are always up) • Movement and full ROM stretching will help muscles to remain limber and healthy • Mix up housework so as to not perform the same activity for hours on end • Cultivate a rhythm of movement • Take short breaks every hour, especially during activity. Laying down will relax anti-gravity muscles • Don’t sit in one place for too long; take short walking breaks, move neck and shoulder blades, use a rocker, etc
- 81. Corrective Actions • Relaxation Relaxationis an active process that requires focused attention to accomplish Muscles relax more fully following a light contraction • Heat following exercise will aid in muscle relaxation and recovery
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