by Ross Turchaninov, MD and Boris Prilutsky, MA, LMT
This is the third part of our article. In the first two parts we discussed the nature of trigger points in the skeletal muscles, as well as their differentiation and evaluation. In this part we will discuss how Trigger Point Therapy (TPT) works and what mechanisms the practitioner employs when he or she treats the hypertonic muscular abnormalities. In the final part of our article, in the upcoming issue of Journal of Massage Science, we will discuss the step-by-step application of TPT protocol.
Trigger point, as well as hypertonus and myogelosis, should be treated with the combination of the two approaches; direct (local) and indirect (reflex) therapy. Only in such cases the practitioner has a chance to completely eliminate the hypertonic muscle pathology, instead of suppressing it into the latent state.
THERAPEUTIC OUTCOMES OF TPT
There are three local therapeutic outcomes of TPT: stimulation of local metabolism, release of the vasoactive substances, and reflex vasolidation after termination of ischemic compression.
Stimulation of local metabolism
As we discussed before, an active trigger point is the epicenter of a local spasm, which is the leading factor in the formation of local ischemia (i.e. insufficient arterial supply) as well as insufficient venous and lymph drainage.
During the TPT, the practitioner applies compression of the soft tissue, which should reach the patient’s pain threshold. Because of the muscle spasm, even such moderate pressure will cause mild trauma to the capillary bed within the trigger point.. When capillaries are damaged, microhemorrhages occur and blood cells enter the soft tissue.
The body will react immediately to the appearance of free blood cells in the tissue by sending killer cells (macrophages, T-cells) to eliminate them and dispose of their remains. For this process to occur as well as a result of it, the local metabolism within the area of the trigger point must be significantly increased.
Release of the vasoactive substances
As discussed above, the application of direct pressure in the area of the trigger point causes mild local trauma. As a result of every trauma of the soft tissue, the vasoactive substance – histamine – is released from the tissue.
Histamine is a very potent vasodilator, and it is also the main messenger that the body uses to signal the fibroblasts about tissue damage. Fibroblasts are special repair cells, which produce collagen, the major structural protein of all tissue and organs.
As a result of local histamine release, fibroblasts migrate into the area of the trigger point and begin the collagen production. Thus the release of histamine from the compression tissue additionally activates local metabolism, supports vasodilation, and plays a key role in tissue repair.
Reflex vasodilation
The trigger point is within the area of muscle spasm where the rate of the arterial perfusion is significantly lower. The blood flow in the trigger point is still maintained to the degree needed for the minimal oxygenation of the muscle tissue, but its volume is not sufficient enough to allow the affected part of the muscle to effectively contract.
However, the blood flow around the area of the trigger point is not affected. During TPT, the practitioner compresses the area of the trigger point and abstracts blood perfusion through the capillaries, i.e. he or she uses ischemic compression. As a result of this compression a condition of local hypoxia (i.e. lack of oxygen) is created.
While the practitioner compresses the tissue, the client’s heart continues to pump arterial blood and its pressure creates a so-called ‘blood depot’ around the practitioner’s finger. As soon as the practitioner releases the pressure, the body will take the extra measures to restore proper oxygenation of the compressed tissue and fresh arterial blood from the ‘blood depot’ is right there and available.
To let this extra amount of blood to satisfy the tissues which are ‘hungry’ for oxygen and eliminate hypoxia, the nervous system produces reflex vasodilation of the constricted capillaries in the compressed area. What is more important, reserve capillaries which did not work initially become open as well to accommodate the oxygenated blood from the ‘blood-depot’. As a result, vasospasm is eliminated, and the blood perfusion is restored.
Correlation of the contact area of the hand and trigger point area
The concept of ‘blood depot’ and reflex vasodilation lead to another important subject: the correct correlation of the contact area and trigger point area.
The video shows two examples of TPT conducted in the biceps femoris muscle. In the first part of the video the practitioner uses the elbow and in the second part the thumb is used. If one compares the contact areas of the thumb and elbow, he or she will see that, in the case of the elbow, the practitioner compresses the area of the trigger point and the surrounding unaffected tissue. When the tip of the thumb is used, the ischemic compression closely matches the size of the trigger point.
Why is it so important that the contact area matches the trigger point area as closely as possible? The Part 1 of the video below shows the trigger point in the biceps femoris muscle (black dot) and the Part 2 shows trigger point compression using the elbow. The circular line with solid arrows in the Part 3 represents the border of ‘blood-depot’ formed around the elbow.
The Part 4 of the video shows the same trigger point compressed by the thumb. In the Part 5 the smaller solid circle with dashed arrows represents the border of the ‘blood-depot’ formed around the thumb.
In the Part 6 of the video the operator indicates the distance the arterial blood from the ‘blood-depot’ needs to flow before it reaches the area of the trigger point if the practitioner uses the elbow. This additional distance slows the blood flow and diminishes the effect of the reflex vasodilation within the trigger point. Thus, reflex vasodilation occurs later and persists for a shorter time.
Conversely, the small solid circle around the trigger point (i.e., compression using the thumb) means that the distance the blood needs to pass from this ‘blood-depot’ to enter the trigger point is much shorter. In such cases, at the moment of the compression’s release, blood from the ‘blood-depot’ formed around the thumb flows directly into the trigger point, producing stronger and longer vasodilation.
The following question is frequently asked: How will I be able to maintain efficient ischemic compression if this patient has a large and powerful layer of skeletal muscles? In such cases the ‘elbow approach’ seems the only possible one. However, we would like to remind the readers of the application and clinical value of the Compass Technique which we discussed in the second part of this article (see April-May issue of our Journal). The Compass Technique provides the practitioner with very important clinical information about the ‘entrance’ into the trigger point.
If the practitioner detects the entrance into the trigger point during diagnostic evaluation of the muscles using the Compass Technique, and uses this exact direction during the application of ischemic compression he or she does not need to generate a lot of pressure to provide efficient compression.
If the practitioner is in the entrance into the trigger point, he or she will need to decrease the amount of pressure during ischemic compression because the patient will feel strong pain and generate protective muscular tension. Thus the Compass technique helps the practitioner to conserve energy and prevent possible injury while completely eliminating the unnecessary trauma of the soft tissue, which is a very frequent outcome of inappropriate application of the TPT.
AXON REFLEX
Another less known mechanism, which is responsible for reflex vasodilation is called axon-reflex, which was originally described in 1941 (LeRoy 1941; Jacobs 1960). This is important information rarely mentioned in medical and massage publications, but it has great practical value.
Lets start with the role of the central nervous system in the peripheral vasodilation (i.e. increase in the blood perfusion). The peripheral sensory receptors in the area of the active trigger point have a very low threshold of activation. For example: even moderate pressure triggers the pain ( i.e. earlier activation of pain receptors), the affected area is sensitive to the fluctuations of the body and the environmental temperature (i.e., earlier activation of muscle spindle receptors), etc. As soon as the practitioner places hands on the affected area, the client’s body will respond with local reflex vasoconstriction to all organs and tissues innervated by this segment of the spinal cord. This is a normal protective reaction.
If the practitioner continues to apply massage strokes in the affected area and uses the correct massage protocol, the spinal cord will recognize that the activation of sensory receptors in the affected area is harmless, and the spinal cord has ceased motor response (i.e. signals to trigger the vasoconstriction) with following local vasodilation in the affected area.
To reinforce the peripheral vasodilation the body employs the axon-reflex, which is an important mechanism the practitioner uses to increase and maintain local vasodilation. Let’s review the mechanism of the axon reflex with the help of the interactive diagram presented below. First we will indicate the major anatomical components presented on the diagram.
The solid vertical arrow indicates massage strokes.
A – Indicates the skin
B – Indicates subcutaneous fat
C – Indicates the subcutaneous fascia
D – Indicates the superficial skeletal muscles
E – Indicates the loop of the axon reflex
F – Indicates the ascending sensory fibers from the peripheral receptors to the spinal cord
G – Indicates the posterior horn of the spinal cord which processes sensory information arriving from the peripheral receptors
H – Indicates the anterior horn of the spinal cord which controls the motor response to the tissue and organs
I – Indicates the descending motor fibers from the spinal cord to the soft tissue
Blue dot – Indicates sensory stimuli which travel to the spinal cord
White dot – indicates the nerve impulses which travel inside the spinal cord between the sensory center in the posterior horn and the motor center in the anterior horn
Red dot – Indicates vasodilatory response from the spinal cord to the soft tissue
Green dot – Indicates the pathway of the vasodilatory impulses which travel to the soft tissue using the loop of the axon reflex
To start the interactive diagram, please click play button below. To replay the diagram please click at the beginning of the sliding bar (blue line) located just below the diagram.
Now let us put the chain of events into motion. When the sensory receptors are activated by massage strokes they send signals to the central nervous system (moving blue dot) using the ascending sensory fibers of the peripheral nerve (letter F on the diagram). While the sensory information starts to travel from the peripheral receptors to the spinal cord the part of the nerve fibers form the so-called axon reflex arc (letter E on the diagram) using short collateral nerve branches to the capillaries of the tissue where the activated peripheral receptors are located. When these stimuli (moving green dot) reach the local capillary network using the axon reflex pathway they trigger peripheral vasodilation BEFORE vasodilation stimuli from the anterior horns of the spinal cord (moving red dot) are able to reach the soft tissue in the massaged area.
Thus the short and quick operating nerve fibers, which form the axon reflex, are responsible for the additional vasodilation in the massaged soft tissue. Interestingly enough, the axon reflex also plays a significant role in the long lasting vasodilation, which stays in the affected area after the client has left the massage therapy room.
TPT AND CENTRAL NERVOUS SYSTEM
To conduct TPT correctly, the practitioner must consider and understand the importance of several factors: the affected area must be prepared using the massage in the inhibitory regime, the high frequency electric vibration has to block the pain-analyzing system before and during an application of ischemic compression, and the contact area of the hand has to match the area of the trigger point. To fully understand and use the first two components of TPT we should quickly discuss the relations between the pain analyzing system and TPT.
Control of the pain-analyzing system during the ischemic compression part of TPT is an extremely important subject, because inappropriate application of the pressure without the practitioner paying attention to the client’s pain analyzing system has many negative effects, which we discussed in the first part of our article.
Thus, the application of the correct amount of pressure, and control of the patient’s pain analyzing system are two critical elements of TPT. The “no pain no gain” approach to TPT which is frequently advocated is a grave mistake which the practitioners frequently make when addressing hypertonic muscle abnormalities.
The entire TPT protocol has one particular goal, to mislead the client’s central nervous system and prevent the generation of the protective muscle tension during ischemic compression to effectively eliminate the trigger point. Let us illustrate this statement using the following analogy. To hunt buffaloes, the Native Americans used coyote skin to get as close as possible to the herd without early detection. This was the only way to achieve success.
A similar principle is used in the TPT protocol, because the practitioner must do everything in his power to hide the application of the ischemic compression from the client’s central nervous system which is on a 24 hour alert guarding the affected area. The recommendations of simply pressing and holding the area of the trigger point does not have anything in common with real massage science.
The scientifically based protocol of TPT requires at least a basic understanding of the following concepts of the nervous system: desensitization of the peripheral receptors, the activation of the central control trigger, and closing gates in the spinal cord.
All of these elements were developed by Prof. Mezlack and Prof. Wall who are fathers of the ‘Gate-control’ theory of pain, and their work was one of the greatest medical breakthroughs of the 20th century.
As readers know, there are two equally important parts of the pain-analyzing system: fast pain (evolutionary younger) and slow pain (evolutionary older). The fast pain analyzing system (FPAS) is activated as soon as the body is exposed to very strong and damaging stimuli. One does not discuss if he or she needs to withdraw the hand from a hot stove. It happens very quickly on the level of the spinal cord without involvement of the brain. FPAS is also responsible for the conduction of acute pain from any part of the body, including the area of the active trigger point.
The slow pain analyzing system (SPAS) is responsible for the conductance of low grade chronic pain from any part of the body. For example, the chronic somatic pain in cases of Fibromyalgia is conducted through the SPAS.
If the practitioner applies TPT without tools to control the pain analyzing systems, he or she additionally activates FPAS and the client’s central nervous system will immediately generate protective muscle tension. The protective muscle tension will enforce already existing circulatory abnormalities and will spasm while sending all the practitioner’s efforts down the drain.
Desensitization of the Peripheral Receptors
To switch the activity of FPAS to SPAS in the area of the active trigger point, the practitioner must desensitize the peripheral (first of all pain receptors) as a first step in TPT. This process is frequently referred to as the elimination of the condition of the hyperirritability of the pain receptors.
The best way to accomplish this is to apply massage strokes in the inhibitory regime (Ivanichev, 1990; Goldberg et al., 1992) on the entire segment where the client has active trigger points. The inhibitory regime requires the application of similar massage strokes applied in the same direction with the same speed and pressure. The practitioner should mostly use the kneading or a combination of effleurage (30%) and kneading (70%). Direct all strokes along the lymph and venous drainage. Usually 2-3 minutes of preparation is enough.
Central Control Trigger
The second concept we need to address here is the central control trigger (CCT). Prof Mezlack and Prof Wall were aware of the cases where seriously wounded people were able to function without even a trace of the pain, despite the intensity of the somatic trauma. Both scientists were sure that there is supposed to be the mechanism inside the central nervous system which blocks the cortex from bombardment by the pain stimuli despite the fact that the pain receptors continue to send massive sensory input (i.e. pain) to the brain. They called this hypothetical mechanism CCT.
For some time Prof. Mezlack and Prof Wall examined different parts of the central nervous system as potential candidates to the CCT. Finally, they experimentally proved that posterior columns of the spinal cord, in fact, act as CCT. These sensory highways conduct information to the brain with great speed. If information arrives just a fraction of a second before the actual activation of the pain analyzing system, the hypothalamus, which is the major control station inside the brain, will refuse to accept pain stimuli from the damaged part of the body. As a result the injured person will be able to act, despite the severe trauma. Function of the hypothalmus can also be altered by correct sensory stimulation (i.e. visual or sound stimuli).
How can the practitioner activate the CCT and use it as an additional tool to control the patient’s pain analyzing system during the TPT? The solution is very simple. During the application of massage strokes in the inhibitory regime on the segment or part of the body where the active trigger point(s) is/are located, the practitioner must start an active conversation with the client arranged in such a way that the client does all of the talking while the practitioner encourages further conversation with new questions or remarks. Don’t let the conversation die. Think about new questions or remarks while the patient answers the previous questions. Of course, this practical recommendation is difficult to apply while the practitioner works on the new client, but it is worth the effort to try for the clinical benefits f the TPT. Another powerful way to activate CCT is the application of permanent electric vibration in the area of the trigger point.
Closing Gates in the Spinal Cord
Prof. Mezlack and Prof. Wall also examined the various sensory stimuli, which practitioners may use to control the pain analyzing system in the affected area, for example: an application of ice, heat, electric therapy, etc. These treatments have mostly a local impact, because they desensitize all sensory receptors, including the pain receptors.
However, permanent electric vibration has a much more profound inhibitory impact on the pain analyzing system. Based on their own experimental studies and a classic study conducted by Dr. Zotterman in 1939, Prof. Mezlack and Prof. Wall proved that the application of permanent electric vibration has a dual therapeutic effect: it desensitizes the pain receptors, and, what is more important, it closes sensory ‘gates’ in the spinal cord and inhibits the acceptance of the pain stimuli on the level of the central nervous system. The last analgesic effect is much more profound and long lasting.
The final part of our article in the upcoming issue of Journal of Massage Science will present in detail the step-by-step application of the TPT and reflex treatment of hypertonic muscular abnormalities.
REFERENCES
Golberg, J., Sullivan, S.J., Seaborne, D. E. The Effect of Two Intensities of Massage on H-Reflex Amplitude. Phys. Ther., 72(6), June, 449-457, 1992
Jacobs, M. Massage for the Relief of Pain: Anatomical and Physiological Consideration. Phys. Ther. Rew., 40(2): 93-98, 1960
Ivanichev, G.A. Painful Muscular Hypertonus and Trigger Points. Kazan Medical University, Kazan, 1990
LeRoy, R. La vie du Tissue Conjonctive et sa Defence par le Massage. Rev. De Me. Paris, 58, 212, 1941
Mezlack, R., Wall, P. Pain Mechanism: A New Theory. Science, 150 (Nov): 971-979, 1956
Zotterman, Y. Touch, Pain and Tickling: an Electrophysiological Investigation on Cutaneous Sensory Nerves. J. Physiology, 95:1-28, 1939
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 #4