by Ross Turchaninov, MD and Boris Prilutsky, MA, LMT
This article concludes our discussion of the science of Trigger Point Therapy (TPT). We would like our readers to reference our previous TPT articles as this latest instruction is discussed. It took us four issues to formulate the basic concept of the TPT for our readers. During this time we received many letters wherein our readers expressed great appreciation for the information discussed in all parts of the TPT article. The issue of TPT is a great example of how much the practitioners may learn even about what seems to be a commonly known subject if it is presented from the scientific point of view.
The final topic of our article is Trigger Point Therapy Protocol. We will provide this protocol in a step by step format that will enable practitioners to correctly treat the skeletal muscles in order to completely eliminate trigger points instead of transferring them into the latent or sleeping state. This protocol is a part of the vast collection of protocols and massage techniques to be found in Video Library of MEDICAL MASSAGE PROTOCOLs.
As stated in the first part of this article, the topic of Trigger Point Therapy (TPT) is the most frequently discussed and very frequently misrepresented subject in modern massage literature. The most common recommendation in TPT is the application of compression until the practitioner feels the tension in the compressed muscles is ‘released’. This is the most common mistake as it sends the active trigger into the ‘sleeping’ or latent state instead of eliminating it.
Let us review the step-by-step protocol of TPT based on science. As we mentioned in first article on TPT, the information we will share with you here is the best, scientifically-based way to work on the trigger points. There is always a way or desire to improve the already established treatment procedure. Thus, new approaches to TPT should be developed, but any new recommendation should be tested in the clinical setting first so massage practitioners can be sure they’re basing their therapy on science rather the author’s personal opinion or anecdotal claims. TPT is that rare instance in the massage therapy profession where the practitioner can actually harm the client (e.g., triggering the formation of myogelosis) if it is conducted incorrectly. The stable clinical results of the protocol presented below are based on the fact that it includes several healing factors which are critical elements for the overall success of TPT.
DIRECT THERAPY: TRIGGER POINT THERAPY PROTOCOL
This protocol of TPT includes application of electric vibration as an important component of the treatment. This requires the massage practitioner to have an electric massager. We also understand that this is not the best time for the investment in new equipment. It is up to the practitioner to decide this issue. This protocol will help clients without the application of permanent electric vibration, but at the same time, the addition of vibration makes the therapy much more efficient and the results more clinically stable.
In the videos below we will illustrate TPT protocol on the example of the active trigger point in the lower portion of the trapezius muscle.
To conduct TPT, the practitioner must accomplish the following steps:
Step 1. Be sure that the location of the active trigger point and its “entrance”was detected during diagnostic evaluation using the Compass Technique (see video below). Also don’t forget to use this information during the application of the ischemic compression part of this protocol (see Part 2 of this article in May-June issue of JMS).
Step 2. Start with preparing the entire muscle or group of muscles using theinhibitory regime of massage therapy (see Part 3 of this article in June-July issue of JMS).
Step 3. During the application of massage in the inhibitory regime, begin to activate the central control trigger (see Part 3 of this article in June-July issue of JMS). Start an active conversation with the client (if it is possible) on a subject interesting to him or her. Direct the conversation in such a way that the client tells a story to you and keep the conversation going by asking questions. Try to maintain the activation of the central control trigger during the entire TPT.
Step 4. To additionally activate the central control trigger and to close the gates in the posterior horns of the spinal cord, add high frequency permanent electric vibration (see Part 3 of this article in June-July issue of JMS) by placing the massager on the area of the trigger point in the direction of the entrance into the trigger point (see video below). Keep it still for approximately one minute.
Step 5. Move the massager slightly to the side, but still maintain vibration and place the fingertip or massage tool into the trigger point. Compress tissues in the direction of the “entrance” into the trigger point using the ‘stop and go’approach.
Let us briefly review the ‘stop and go’ approach to TPT. Gradually increase applied pressure until the client reports the first sensation of pain in the compressed tissues. This is the threshold of the activation of the pain analyzing system in the area of treatment. Stop further increasing of the pressure but maintain it on the same level. Let the client adapt to it. Usually it takes 10-15 seconds and as soon as the client reports disappearance or significant decrease of the uncomfortable sensation in the compressed tissue the practitioner may slowly increase the pressure. However, further increase will again trigger the sensation of pain and the practitioner should stop one more time while maintaining the new level of compression. In another 10-15 seconds, the practitioner may additionally increase pressure. Use 2-3 of these ‘stop-and-go’ pressure increases (see video below). All during this time, keep the electric permanent vibration next to the finger and continue to communicate with the client.
The ‘stop and go’ approach allows complete submergence into the trigger point without generating protective muscular tension, which is the biggest obstacle for successful TPT.
Step 6. When it is time to exit the trigger point, do it as quickly as possible (see video below). This allows arterial blood from the “blood depot” to enter the trigger point tissue quickly and reflex vasodilation is much longer and more efficient.
Some healthy individuals like deep tissue massage but the practitioner shouldn’t apply excessive traumatizing pressure. Do not make a common mistake and use the “no pain, no gain” approach on clients with somatic or visceral disorders. The practitioner must apply pressure on the level of the client’s pain threshold trying to restore it to the normal level.
The excessive pressure on the soft tissue during TPT injures the client and damages the healing image of medical massage and manual therapy in the eyes of clients, physicians and other health practitioners. This delays the incorporation of medical massage into the arsenal of modern American medicine, where it belongs.
Why is this protocol of TPT the most scientifically correct one? It is based entirely on the Gate-control theory of pain (Mezlak and Wall, 1989) which is a major source of our understanding of the function of the pain-analyzing system. The main practical advantage of this protocol is that during the application of TPT, the client does not generate protective muscle tension because the pain stimuli are delivered to the spinal cord through the slow-pain analyzing system, instead of the pathway of the fast-pain analyzing system used in all other approaches.
This protocol also gives the practitioner a unique opportunity to exit the trigger point very quickly. This is another subject for discussion. The majority of publications on the subject of TPT will recommend entering and exiting the trigger point slowly. We also discussed that entrance into the trigger point as a gradual process. However, the exit must be quick because it allows blood from the “blood depot” to enter the trigger point rapidly and produce a more effective vasodilation. The slow exit from the trigger point should be used only in cases when the practitioner does not pay attention to the protective muscular tension. Under these circumstances the release of pressure must be slow in order to prevent pain and reflex contraction of the muscle which the client feels as an uncomfortable “jerking” and spasming. Thus, the down side of a slow exit is obvious: the slow exit produces slower and shorter vasodilation.
A slow exit from the trigger point does make sense at the beginning of the treatment when the active trigger point is very sensitive. As soon as the threshold of pain receptors is restored, the practitioner should make a quick exit. Usually it can be applied even during the second application of TPT.
There is another scenario of TPT the practitioner may face. The active trigger point very frequently forms in the area where the nerve which provides motor innervation of the muscle enters the muscle belly. This area is always in the middle of the muscle belly. As we discussed in Part 2 of this article, the active trigger point which formed there is called the motor trigger point. The area where the nerve enters the muscle belly is critically important for normal muscle contraction. Here motor commands which arrive from the central nervous system are transferred from one excitable tissue, i.e. peripheral nerve, to completely another type of the tissue which is the skeletal muscle.
As several studies (Gogoleva, 2001, Heine,1997) have shown in the area of the motor trigger point, so-called ‘collagen cuffs’ form in the tissue around the end plate of the nerve. These ‘collagen cuffs’ are one of the reasons for the constant irritation of the nerve and chronic nature of hypertonic abnormalities.
In cases of motor trigger points the TPT protocol is slightly different. First of all, at the end of Step 2 the practitioner must apply repetitive friction along the muscle fibers and after that across the muscle fibers while maintaining moderate pressure. The application of friction breaks the ‘collagen cuffs’ around the neuro-muscular junction and it greatly improves the outcomes of the treatment if the practitioner deals with the motor trigger point.
Another issue during TPT protocol on the motor trigger point is the correct amount of pressure used during the ischemic compression. While applying Step 5 of TPT, decrease the number of submergences into the tissue during the stop and go approach. In the active motor trigger point use two submergences. While in the active trigger point you may use 3-4 applications of the pressure.
Application of ischemic compression on different levels
The application of ischemic compression on the trigger points within skeletal muscles anatomically located in the different levels is the final issue we would like to address. If the muscle which carries the trigger point is located superficially (e.g., trapezius muscle), the application of ischemic compression is a simple task, as soon as the practitioner has found the entrance into the trigger point. The situation is much more complicated when the muscle which carries the trigger point is located in the middle or even in the deep layer of skeletal muscles. In such a case, the practitioner should apply pressure to the superficially located skeletal muscles first and only after this will ischemic compression reach the deeper muscle. As discussed above, the practitioner should elicit the least possible damage to the muscle fibers during ischemic compression. From this point of view, the practitioner should use two tools before applying ischemic compression to the deep muscles: preparation and mobilization of the superficially located muscles.
Preparation
Preparation of the superficially located muscles is a must, because they will always generate protective muscular tension over the more deeply located muscle which carries the active trigger point. The best combination is kneading techniques and the application of repetitive friction along the fibers of the superficial muscle, trying to penetrate between them. The applied pressure should target only the superficial muscle.
Mobilization
Mobilization of the superficially located muscle is more tricky, but at the same time is a very rewarding aspect of TPT. In many cases the practitioner is able to shift the superficially located soft tissue to the side to expose the deeply located muscle, then work with its fibers directly without unnecessary damage of the fibers of the superficial muscle. This recommendation is very easy to follow as long as the practitioner remembers muscle anatomy. The technical ability to mobilize the superficially located muscles dramatically increases the effectiveness of TPT conducted on the deep skeletal muscles.
INDIRECT THERAPY
In the previous section we discussed the direct therapy of the trigger point. However, the overall success of somatic rehabilitation in general and TPT in particular is based on the combination of the local and reflex mechanism of the massage therapy. We would like to emphasize that hypertonic muscular abnormalities can be completely eliminated only with a combination of direct and indirect treatment. If TPT alone is used or only indirect therapy (e.g. PIR) is employed, the trigger point is frequently transferred into a latent state instead of being eliminated. In this case, any pathological factor, such as muscle overload, exposure to cold weather or infection may easily reactivate the trigger point. The back and forth re-activation of the trigger point in the same area sooner or later will trigger formation of the myogelosis, which is irreversible muscle pathology. Thus the practitioner who uses incorrect protocol of TPT is directly responsible for the worsening of his or her client’s condition in the long run, despite the bringing of temporary relief. The indirect treatment of trigger points consists of the inhibition of the H-reflex by repetitive compressions on the muscle’s tendon, passive stretching or Postisometric Muscle Relaxation (PIR).
1. Inhibition of the H-reflex
Repetitive compression applied to the tendon of affected muscle reduces the excitability of the motor neurons in the anterior horns of the spinal cord which innervate this muscle, and decreases muscle tone overall (Burke, et al., 1971; Kukulka et al., 1986). This phenomenon is the result of inhibition of the H-reflex. Decrease of muscle tone is immediate but short-lived and it is “…useful in cases requiring a transient reduction in muscle activity” (Kukulka, et al, 1985). This is the exact outcome the practitioner needs from the application of repetitive compression just before passive stretching or PIR. Thus, this simple procedure helps to additionally reduce muscle tone and makes the passive stretching or PIR more effective. The practitioner should apply 5-7 intermittent compressions. It is better to fit these compressions into the client’s prolonged exhalation.
2. Passive Stretching
If the reader is not familiar with the PIR method, passive stretching has to be the final part of the treatment of reflex zones in the skeletal muscles. It makes the treatment quicker and more efficient. Passive stretching helps to relax skeletal muscles, eliminate hypertonuses, and decrease the size of the myogelosis. Despite its apparent simplicity, passive stretching must be done correctly or the practitioner may easily damage already affected muscle fibers. We will discuss this subject in one of the future issues of our journal.
Passive stretching also has another important benefit: the examiner may use it as a diagnostic tool to check treatment progress. If the practitioner performs gentle passive stretching of the affected muscle in the direction opposite to its contraction before every new session, he or she will be able to estimate the degree of positive changes (intensity of pain, stiffness and range of motion).
3. Postisometric Muscular Relaxation (PIR method)
PIR is a highly effective method in the treatment of hypertonic muscular abnormalities. PIR should be used as the final part of a medical massage session. PIR is part of the Muscle Energy Techniques and it requires special discussion. The practitioners may know PIR under different names (e.g. Isolative Stretching). Some authors slightly modify already existing and clinically proven modality, and sometimes that creates confusion.
Overall, PIR is one of the most popular and clinically valuable methods of Muscle Energy Techniques (MET). Variations of these methods have been used by bone setters since antiquity. However, the first scientific conception of MET was developed in the USA by Dr. F.L. Mitchell Sr., DO in 1948. The work of Dr. Mitchell, along with the theoretical concepts developed by Prof. I. Korr, DO, comprise the greatest contribution by American scientists to the Western school of manual medicine and medical massage.
There are several methods of treatment of hypertonic muscular abnormalities. These are united under the same name: Muscle Energy Techniques. Though all MET have different names and approaches, they are united by one basic principle: the patient actively participates in the treatment The most universal, safe and clinically effective method is Postisometric Muscular Relaxation (PIR) which uses isometric contraction against operator resistance as the main component of therapy. Its clinical effectiveness exceeds all other methods of Muscle Energy Techniques. As it is correctly stated by Dr. F.L. Mitchell Jr. (1995), “postisometric stretch techniques are now the principal muscle energy technique procedures…”.
The combination of the TPT with following application of PIR creates a uniquely effective clinical tool. We highly recommend to all massage practitioners who are involved in the somatic rehabilitation and work with active trigger points to combine these two methods. No matter how stubborn the active trigger point or how severe the muscle spasm, the combination of TPT and PIR will always be able to eliminate hypertonic muscle abnormalities quickly and efficiently.
REFERENCES
Burke, D, Andrews C., Ashby, P. Autogenic Effects of static Muscle Stretching in Spastic Man. Arch Neurol, 25:367-372, 1971
Gogoleva, E.F. New Approaches to Diagnosis and Therapy of Fibromyalgia associated with Spondylosis. Ther. Arch., 4:40-45, 2001
Heine, H. Lehbruh der biologischen Medicine. Stuttgart, Hippokrates, 1997
Kukulka, C.G., Beckman, S.M., Holte, J.B., Hoppenworth, P.K. Effect of Itermittent Tendon pressure on Alpha-Motorneuron Excitability. Phys Ther., 66(7), July, 1091-1094, 1986
Mezlack, R, Wall, P. The Challenge of Pain. Penguin, NY 1989
Mitchell, F.L. Sr. The Balanced Pelvis and Its Relationship to Reflexes. Academy of Osteopathy Yearbook, 146-151, 1948
Mitchell, F.L. Jr., Mitchell P.K.G. The Muscle Energy Manual. Met Press, East Lansing, 1995
For Dr. R. Turchaninov bio click here
Mr. B. Prilutsky, practices and teaches Medical and Sports Massage for more than 30 years. He has master degree in physical education and rehabilitation from Ukraine.
Mr. Prilutsky has worked with athletes and world dignitaries throughout Europe, Israel and USA. He is the founder of the Institute of Professional Practical Therapy in Los Angeles and to date, he has trained thousands of therapists world-wide. Boris Prilutsky has published extensively on various topics of physical medicine and rehabilitation.
Category: Medical Massage
Tags: 60 Variations of 7 Basic Techniques, Journal of Massage Science 2009 #5