Trigger Point Therapy

Trigger Point Therapy				be logical to assume that something must irritate
				the terminal parts of sensory and motor neurons.
Introduction				This something is a tension in the skeletal muscles,
Medical massage therapy procedure consists of				including trigger points that are not associated with
mobilization of skin, fascia and muscular tissue,				motor trigger points (since they are located in
trigger point therapy, and post-isometric relaxation				other parts of the skeletal muscle). Keep in mind
techniques. Each of these modalities is equally				that any inflammatory condition, whether in motor
important in order to reach rapid and sustained				end plates or in muscular tissue, means that there
results. For decades, massive utilization of medical				is a decreased amount of blood supply to this
massage has proven to be a safe and very				inflamed tissue. From this it follows that gradual
effective method of treatment for the support				ischemic compression can be viewed as an
and movement system disorders, inner organ				anti-inflammatory effort.
disorders, stress management, and more.				There is no doubt that myofascial pain can be the
In the last few years, there have been numerous				result of peripheral nerve abnormalities. An
arguments in within the professional community				example of this would be the irritation of the
about practitioners utilizing manual therapy and				sciatic nerve by an over-tensed piriformis muscle
trigger point therapy. In recent professional				resulting in the formation of trigger points in
publications many authors have been raising the				muscles innervated by the sciatic nerve. This list
following questions: Is a trigger point a formation				can be continued because any peripheral nerve's
of fibroconnective tissue in muscles? Have				entrapment in the key areas will cause formation
histological studies ever been done on trigger				of trigger points in muscles innervated by this
points? Is there a theory of peripheral nerve pain				nerve.
at the motor end plate a new theory and the				If one examines a patient with peripheral arterial
only theory? Are ischemic compression techniques				disorder (e.g., Buerger’s disease) one will find
for trigger point therapy safe and effective?				numerous active and dormant trigger points in the
The brief answers on aforementioned questions				leg and foot muscles. It would most certainly be
are:				agreeable that insufficient arterial blood supply as
1. Fibroconnective tissue formation in muscles is				a result vascular abnormality is responsible for the
myogelosis, an incurable muscular pathology.				formation of trigger points in the skeletal muscles
2. In many cases myogelosis is the result of				rather than abnormalities in the motor end-plates.
inadequate treatment of trigger points.				The same is true for trigger points in the skeletal
3. A trigger point is a pinpoint localization of pain				muscles, which are developed as a result of
that can be found in muscles, connective tissue,				chronic visceral disorders (e.g., patients with
and periosteum. The morphology of this point of				cardiac disorders exhibit active trigger points in
pain is such that the demand of blood supply is				the trapezius, levator scapulae, and rhomboideus
much higher than the actual blood supply.				muscles). In such cases the end-plate
4. The theory of peripheral nerve pain at the				abnormalities do not have anything to do with
motor end plate is not a new theory.				formation of trigger points in the skeletal muscles.
5. Any theory must be supported by clinical				They are the result of the phenomenon of
output.				convergence of pain stimuli within the same
6. Ischemic compression as a method of trigger				segments of the spinal cord, which are responsible
point therapy has been proven by at least 4				for the innervation of both the affected inner
decades of massive utilization as a safe and				organ and the skeletal muscles. In 1955 Dr. Glezer
effective method.				and Dalicho formulated the theory that still stands
7. Ischemic compression techniques are applied by				clinically proven. They proposed and developed
gradually increasing pressure, thus excluding the				maps of reflex zone abnormalities of the skin,
possibility of doing harm to the patient and to the				fascia and muscles, including trigger point
therapist.				development.
In the search for true understanding of				The Energy Crisis Theory
pathophysiology, the body’s sophistication and				There is another theory, which links formation of
complexity requires us to take an integrative				trigger points with the shortage of ATP in the
approach to any issue. Thus I would like to				affected muscles as a result of insufficient arterial
present to the reader a short scientific review of				circulation. ATP is the energy source for cellular
the trigger point issue and the trigger point				function, including muscles. Authors of this theory,
therapy concept.				called the Energy Crisis Theory, pointed out the
If you would like to view hands on demo, please				formation of the trigger points in very healthy
click the link below:				athletes who did not have signs of peripheral
The Nature of Trigger Points				nerve abnormalities and still developed active
There is no statement in the modern scientific				trigger points. Gradual increase of the resting
literature that calls a trigger point a "taut band of				muscular tone in normal muscles triggers local
fibro-connective tissue." However, it was once				vasoconstriction, interstitial edema, and ATP
used in the late 19th/early 20th century until				exhaustion with the subsequent formation of
histological studies conducted by German scientists				active trigger points. Prof. D. Simons reviewed this
(Glogowski, and Wallraff, 1951; Miehlke et al., 1950)				theory as well, and even used extensively works
showed that there is no connective tissue				done by his colleagues, Dr. D.R Hubbard and Dr.
proliferation (myogelosis) in the area of a trigger				G.M. Berkoff, in his own research.
point in muscles. "In our opinion, fibrositis (in regard				Trigger Point Therapy Protocol
to trigger points) has become a hopelessly				Ultimately trigger point therapy has the following
ambiguous diagnosis... is best avoided" (Travell,				goals:
Simons, 1983). However, connective tissue will				1. Eliminate protective muscular tension in the
grow between muscle fibers when a core of the				muscles that harbor active trigger points.
myogelosis is formed (Glogowski, and Wallraff,				2. Eliminate condition of the hyperirritability of the
1951). Myogelosis is a clinical outcome of years of				peripheral receptors, especially pain receptors.
reactivation of the active trigger point in the				3. Block the pain-analyzing system of the patient.
same area. At the same time, trigger point				4. Produce reflex vasodilation.
therapy is useless if the core of the myogelosis is				5. Eliminate local ischemia.
already formed.				To effectively achieve these goals the practitioner
In 1843, for the first time, the German physician				should conduct trigger point therapy utilizing
Dr. F. Froriep described trigger points as painful				several equally important components:
formation in skeletal muscles. In 1921 another				1. Detect location of the active trigger point.
German scientist, Dr. H. Schade, examined them				2. Detect the pathway of pain radiation and
histologically and formed the concept of				examine tissues along this pathway in case
myogelosis. In 1923 the British physician Dr. J.				satellite trigger points are formed.
Mackenzie offered the first pathophysiological				3. Place finger in the trigger point. Slowly apply
explanation of the trigger point formation				vertical compression of the tissues until the
mechanism and formulated the concept of the				patient feels the first sign of pain. As soon as he
reflex zones in the skeletal muscles where the				or she reports it stop increasing pressure but
central and peripheral nervous system play a				maintain it at that same level. After 10 seconds of
critical role. The reflex zones concept was further				pressure application, the pain that the patient
developed by the American scientist Prof. I. Korr				initially felt will disappear. The patient should
in 1941 in a series of brilliantly designed				immediately report to you as soon as he or she
experimental studies. Thus, the trigger point				feels the pain cease. During the next 20 seconds
concept was developed long before the work of				the practitioner will be able to get to the "bottom"
Travell and Simons, who based their publication				of the trigger point without unwanted activation
(see references in "Trigger Point Manual" by				of the pain analyzing system and generating
Travell and Simons) on the works of the				protective muscular tension in the affected
scientists mentioned.				muscle or muscles in the region.
There are numerous published results of				4. To accomplish the first three goals apply
histological evaluations of the trigger point areas.				effleurage and kneading techniques on the
Even in the short list of references at the end of				affected muscles in the inhibitory regime for 5-7
this article you can find ample evidence under				minutes (comfortable gradual increase of
references 5, 6, 7, 13, and 15.				pressure, in the same direction of the strokes).
It is misleading to state that Dr. Travell and Dr.				5. Exit the trigger point as fast as possible to
Simons recommended using ischemic compression				produce quick and effective vasodilation and
for trigger point therapy. They advocated				elimination of the local ischemia.
injection, stretch and spray techniques, and				The correct protocol of trigger point therapy
muscle energy techniques for trigger point				does not have pitfalls. This protocol is equally
therapy. Although, Travell and Simons did mention				effective for the motor trigger points, as well as
ischemic compression as an option based on the				for other trigger points. The applied pressure is
European medical sources, they never				never strong enough to go over the patient's
recommended it as a treatment method.				threshold of pain, causing the pain and injury of
The Role of Vasodilators in Local Ischemia				motor nerve endings. Peripheral vasodilation
Awad (1973) examined biopsy tissues from				restores local pH to normal, increases oxygenation
trigger points using an electron microscope and				of the tissues in the area of the trigger point, and
detected a significant increase in the number of				gradually eliminates the trigger point.
platelets, which caused the release of serotonin				References
and mast cells, which in turn released histamine.				1. Awad, E.A.: Interstitial myofibrositis: hypothesis
Both serotonin and histamine are potent				of the mechanism, Arch. Phys. Med. Rehab,
vasodilators and their increase is a clear sign that				54(10):449-453, 1973
body is trying to fight the local ischemia in the				2. Fassbender H.G. Pathology of the Rheumatic
trigger point area. In his now classical work,				Diseases. Springer-Verlag, New York, 1975
Fassbender (1975) conducted a histological				3. Froriep, F. Ein Beitrag zur Pathologie und
examination of the circulation in the area of the				Therapie des Rheumatismus. Weimar, 1843.
trigger point and proved once and for all that "...				4. Glezer, O., Dalicho, V.A. Segmentmassage.
the trigger point represents a region of local				Leipzig, 1955
ischemia." The same results were obtained by				5. Glogowski, G., Wallraff, J. "Ein beitrag zur Klinik
Popelansky et al., (1986) who used radioisotope				und Histologie der Muskkelharten (Myogelosen)", Z.
evaluation of blood circulation in the area of the				Orthop., 80:237-268, 1951
trigger point.				6. Gogoleva, E.F. "New Approaches to Diagnosis
The End Plate Theory				and Therapy of Fibromyalgia associated with
The end plate theory is not a new theory. Travell				Spondylosis." Ther. Arch., 4:40-45, 2001.
and Simmons constantly emphasize the nervous				7. Heine, H. Lehbruh der biologischen Medicine.
system as a critical factor in the development of				Stuttgart, Hippokrates, 1997.
the trigger point and point out the importance of				8. Hubbard, D.R., Berkoff, G.M. "Myofascial trigger
end-plate zones. They even name special types				points show spontaneous needle EMG activity",
of trigger points called “motor trigger				Spine, 18:1803-1807, 1993.
points,” which are located in the middle of the				9. Korr, I.M. "The Neural Basis of the Osteopathic
muscle belly at the neuromuscular junction. "The				Lesion." JAOA, 47(4): 191-198, 1947.
functionally significant structure with regard to the				10. Kreymer, A.Y. Vibration Massage in Diseases
innervation of muscle fibers is the myoneural				of the Nervous System.
junction (end-plate zone)..." and "Some trigger				Tomsk University, Tomsk, 1987.
points are closely associated with myoneural				11. Mackenzie, J. Angina Pectoris. Henry, Frowde &
junctions, others not." (Travell and Simmons,				Hodder & Stroughton, London, 1923.
1983). The idea of the nervous system and the				12. Mezlack, R., Wall, P. “Pain Mechanism: A
role of end-plate zones is not a new concept. As				New Theory.” Science, 150 (Nov): 971-979,
early as 1947 Prof. Korr addressed the same				1965.
issues in his research.				13. Miehlke, K., Schulze, G., Eger, W. " Klinische und
According to histological studies (Heine, 1997;				experimentelle Untersuchungen zum
Gogoleva, 2001) chronic pain and low grade				Fibrositis-syndrom. Z. Rheumaforsch, 19:310-330,
tension in the skeletal muscles and fascia are				1960.
responsible for the low grade inflammation around				14. Popelansky, Y.Y., Zaslavsky, E.S., Veselovsky,
the terminal parts of the sensory and motor				V.P. Medicosocial significance, etiology,
neurons which end in the soft tissues. This chronic				pathogenesis, and diagnosis of non-articular
inflammation activates the local fibroblasts, which				diseases of soft tissues of the lims and back.
deposit collagen around the nerve endings forming				Vorpr. Rheumat., 3:38-43, 1986.
so-called "collagen cuffs.” This additional				15. Schade, H. "Untersuchungen in der
irritating factor triggers an afferent sensory flow				Erkaltungstrade: III. Uber den Rheumatismus, in
to the central nervous system, which is				besondere den Muskelrheumatismus (Myogelose)."
interpreted by the brain as pain. This mechanism				Munch. Med. Wschr., 68, 95-99, 1921.
is partially described by the generation of pain in				16. Travell, J.G., Simons, D.G. Myofascial Pain and
the area of motor trigger points. We have to				Dysfunction. The Trigger Points Manual. Williams &
consider that the terminal parts of the sensory				Wilkins, Baltimore, 1983.
and motor neurons are located in the soft tissues,				17. Wall, P.D., Crowly-Dillon, J.R. “Pain, Itch and
including skeletal muscles. In other words, it would				Vibration.” A.M.A. Arch. Neurol., 2: 19-29, 1960.

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Trigger Point Therapy