Pressing Matters, Part 2
In Part 1 I discussed the various lengths of time and depths of pressure that practitioners applied on their victims (sorry, patients). I would love to feel your preferred techniques at our next conference in Herndon, VA in September. This followup article
is written to explore palpation terminology, communication and rapport that can be mutually agreed upon that is helpful to paint a picture the patient can understand.
When you ask your client =91how does this feel=92 when you=92re pressing on their tissue the most common answer they give is the word =91tight=92. Right? Where did they get this word? In my mind tightness is a measured thing. Shortened range of motion = tight. I play
a game whereby they have to come up with another word. What other words can we use, both for us and them to describe the tissue we=92re dealing with and the changes we are attempting to make?
The soft tissue that we are working on is a combination of skin, fascia, muscle protein, neurons, blood vessels and fluid etc. The most abundant muscle protein is titin. We feel a lot of titin. This muscle tissue may be traumatized, inflamed, fibrotic, contracted,
stiff, taut (stretched long =96 like a guitar string), spastic, inhibited, and boggy (a Leon Chaitow favourite). It may be resistant to shear forces in certain directions. Texture-wise it might be ropey, stringy, fasciculated, resistant, homogenous, or uneven.
In the case of myofascial trigger points there may be discrete nodules found within taut bands, as opposed to lypomas and lymph nodes. Focal points may be warmer or cooler than surrounding tissue.
Chaitow loved to use the word =91induration=92, meaning hardness when describing dense tissue. It never really caught on. In Europe they may use =91gelosis=92 or =91myogelosis=92. Many of us may describe =91fibrosis=92, but I think this should be reserved for excess collagen
deposition. An better alternative to fibrosis could be =91densification=92 or =91congestion=92.
Back in the day I was taught to differentiate between a =91gel=92 state and a =91sol=92 state. Therapists had to change the gel to sol; hard to soft, using direct pressure, stretch, heat, vibration etc. Officially this reduction in viscosity is called =91thixotropy=92
(think of a vigorous shake of the ketchup bottle with the lid on so as to get the last drop out). The outcomes, although still unproven, may be increased perfusion, and improved blood flow and tissue nutrition. We are turning a stagnant swamp turning into
a babbling brook.
When a patient asks you what you are feeling you should communicate something as quickly and accurately as you can to show knowledge, and gain trust and rapport. Come up with your own list of descriptors as medically accurate as you can. You can also turn it
around. What do they feel? Successful treatment requires a two-way relationship. Their own words may be on the affective side; sore, tender, deep, burning, local, spreading, dense, but discourage the word =91tight=92.
At the end of a treatment I like to describe the changes I=92ve made in the tissue. These may include improvement in ROM, temperature change, and especially the reduction in muscle tone. This, I may describe as an increase in the =91wobble=92 factor, found by repeatedly
stroking or flicking the tissue, as in playing a guitar. It=92s an easier word for the patient to understand than changes in thixotropy.
Ciao for now,
~Stew
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Tools Of the Trade
Richard Finn, CMTPT
There are a number of things that we need to run a practice. We need expensive things like adjustable tables, computers, smart phones, and especially – gadgets! I=92ve talked about many aids that I use to help me and which I hope might help you. Now I=92m going
to talk about something that I marketing person might describe as =93cost effective.=94 I just call it cheap. My other descriptors are effective and essential.
The prerequisite of effective treatment, in my opinion and experience, is calming or down regulating the nervous system. There are a number of modalities that can be used to accomplish this. I use a little piece of nonslip rubber like material called Dycem=99.
Did I mention it=92s cheap?
Here are some steps:
1. The way to use this is to locate a tender area. I often use the skin overlying a TrP. This will often involve asking the patient to tell you when they are feeling tender. This is most effective when the patient is actively involved. Press into the skin gently
in an area and ask them to let you know when they feel the discomfort.
2. Lighten your pressure until it is no longer uncomfortable but stay right on the spot.
3. Lay your Dycem=99 some distance away. When treating the lumbar region I often treat in supine. My upper cephalad hand is the palpating /monitoring hand. I palpate the skin overlying the parapinals. My second hand goes to the patella. I distract the patella
caudally with a slight twist in either direction until I can barely sense the movement under my fingers. I then hold it for about 2-4 minutes.
4. Release the second hand gently and press deeper with the first hand. The discomfort has almost entirely decreased. It=92s time to look for another spot or to treat the desensitized TrP.
The reason for the effectiveness is the activation of ruffini and merkle nerve endings in the skin. The stretch of the skin between the two hands stimulates stretch activated ion channels that actually cross dematomes to send non-threatening proprioceptive
information to the brain. Due to the non threatening nature and perhaps client expectation the brain often chooses to down regulate the output of pain. I see this in the decrease of pain that is reported as well as in the changes of ROM and even holding patterns
in the body.
This approach is often called Dermoneuromodulation. It was developed by Diane Jacobs, a PT. You can learn more about it at
www.dermoneuromadulation.com. There are links to classes, videos, and an extensive bibliography. The author is a trigger point skeptic and no fan of what we do. She is also very good at what she does and is worth learning from.
Here is a link to purchase the Dycem=99:
https://www.amazon.com/Dycem-Non-Slip-Material-Roll/dp/B01M4KKWCP
I hope you will give this a try. Feel free to call with any questions. I=92d love to help!
~ Richard Finn
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From The Archives: Janet Travell, MD
JANET G. TRAVELL, M.D. – A Daughter’s Recollection
by Janet Travell’s Daughter, Virginia Street
(published in 2003 by the Journal of the Texas Heart Institute, Houston, TX, Vol. 30, No. 1, p. 8)
PART TWO:
From 1936 to 1945 my mother “served as assistant, then associate, visiting cardiologist at Sea View Hospital in Staten Island, and, under a fellowship grant from the Josiah Macy, Jr. Foundation, she studied arterial disease at Beth Israel Hospital in New York
City from 1939 to 1941. There she became absorbed in the study of new pain-relieving techniques.” (2) Later, she joined the staff of the hospital “and, at the time of her White House appointment, was an associate physician in Beth Israel’s cardiovascular research
unit. . . . After working as a cardiologist, with particular emphasis upon chest pain, she moved into the field of orthopedic medicine, where she specialized in the relief of musculoskeletal pain.” (2)
My mother wrote in her autobiography that “the Cardiac Consultation Service at Sea View, the city hospital for tuberculosis on Staten Island to which I was appointed in 1936, supplied the conditions that crystallized my emerging interest in muscular pain. Most
patients there had life-threatening pulmonary disease, but some of them complained more about devasting pain in their shoulders and arms than about their major illness. When I examined them by systematic palpation of the scapula and chest muscles, I easily
uncovered the presence of trigger areas.” (1) It was during this time that Janet came across an article in the British Medical Journal titled, “A Preliminary Account of Referred Pains Arising From Muscle,” (3) which strongly influenced her thinking.
Unknown to Janet Travell, she was 1 of 3 clinicians – the others were Michael Gutstein (later known as Gutstein-Good and then as Good) (4) in Germany and Michael Kelly (5) in Australia – working “on three separate continents [who] simultaneously and independently
published a series of papers in English” (6) about myofascial pain. They all emphasized “four cardinal features [of the condition]: a palpable nodular or band-like hardness in the muscle, a highly localized spot of extreme tenderness in the band, reproduction
of the patient’s distant pain complaint by digital pressure on that spot [referred pain], and relief of the pain by massage or injection of the tender spot. Each author reported pain syndromes of specific muscles throughout the body in large numbers of patients.
All three had identified myofascial TrPs [trigger points]. However, each had used different diagnostic terms,” (6) and was apparently unaware of the others: “the commonality of their observations passed unnoticed for decades. . . . Of those three pioneers,
only Travell’s influence withstood the test of time.” (6)
When my mother began the practice of medicine from her father’s offices in the 1930s, she was able to observe him with his patients. In the 1920s, Willard Travell had acquired a “Toepler-Holtz static machine that was employed then to treat painful conditions
of the muscles, nerves, and joints.” (1) In 1941, father and daughter wrote a scientific paper together, “Modifications and Effects of the Static Surge of the Static Wire-Brush Discharge.” (7) Willard Travell’s unique methods of relieving pain became the impetus
behind my mother’s search for effective clinical methods to treat and manage the myofascial pain syndrome. A few years later, my grandfather “dismantled his static machines when newer methods of treatment became preferable.” (1)
When my mother herself began to suffer from shoulder and arm pain, my grandfather used the new procedure that his daughter had been exploring – injection into muscles – “to rid [her] of [her] own pain.” (1) In 1942, Janet Travell, Seymour H. Rinzler, and Myron
Herman published, “Pain and Disability of the Shoulder and Arm: Treatment by Intramuscular Infiltration with Procaine Hydrochloride.” (8) Ten years later, she and her Dr. Rinzler “reported the pain patterns of TrPs in 32 skeletal muscles, as ‘The Myofascial
Genesis of Pain,’ (9) which quickly became the classic source of this information.” (6)
In August 1944, my parents, my sister, and I moved from Manhattan to the small commuter town of Pelham, New York. My grandfather had married again. His 2nd wife was a widow and close family friend, Edith Talcott Bates. (Janet Travell’s stepbrother was then
Talcott Bates, later Talcott Bates, M.D., who published 2 papers on myofascial pain (10) (11)). The 2 Drs. Travell, Willard and Janet, continued to practice medicine at 9 West 16th Street.
I first met Senator John F. Kennedy in front of 9 West 16th Street in the summer of 1955 or 1956. My husband and I had arrived there by car just as Kennedy finished a medical treatment with my mother and they walked outside together. In her autobiography, Janet
described how the Senator, who was on crutches when he first came to see her as a patient in May 1955, could barely navigate the 3 or 4 steps down from the curb to the front door, below street level. By the time that I met him, he was no longer on crutches.
After we had chatted for a minute or two (he always asked when we were going to our summer home “in Western Massachusetts”), Senator Kennedy stepped forward and signaled to his driver to pick him up. I still remember how he looked, a tall, thin man with an
intense, friendly, and energetic manner and thick brown hair.
Senator Kennedy received so much relief of pain from my mother’s medical treatments that he had “new hope for a life free from crutches if not from backache,” wrote his friend and Special Counsel, Ted Sorensen, in his book, KENNEDY. (12) The Senator told my
mother that he was not going to change doctors. (1) She became “the first woman ever to hold the post” of White House physician “and the first civilian to do so since the administration of Warren G. Harding. . . . Kennedy described her ‘as a medical genius.'”
(2) To show his appreciation for her efforts on his behalf, Kennedy gave her a framed color photograph of himself which hung in my mother’s White House Office during her years there. At the bottom of the picture, the President had written in his scrawling
hand, “For Dr. Travell – Who made the smile possible – With affectionate regards, John Kennedy.”
References
1. Travell J. Office hours: day and night. The autobiography of Janet Travell, M.D. New York: World Publishing Co.; 1968.
2. Current biography yearbook 1961. New York: HW Wilson Company; 1961. pp. 37 – 8.
3. Kellgren, J H. A preliminary account of referred pains arising from muscle. Br Med J 1938; 1:325 – 7.
4. Gutstein, M. Diagnosis and treatment of muscular rheumatism. Br J Phys Med 1938;1:302 – 321.
5. Kelly, M. The treatment of fibrositis and allied disorders by local anesthesia. Med J Aust 1941;1:294 – 8.
6. Simons D G, Travell JG, Simons LS. Travell and Simons’ Myofascial pain and dysfunction. The trigger point manual, upper half of body. Vol. 1. 2nd ed. Baltimore: Williams & Wilkins; 1999.
7. Travell W, Travell J. Modification and effects of the static surge of the static wire-brush discharge. Arch Phys Ther 1941;22:486 – 9.
8. Travell J, Rinzler S, Herman M. Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride. J Am Med Assoc 1942;120:417 – 22.
9. Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med 1952;11:425 – 34.
10. Bates T. Myofascial Pain. In: Green M, Haggerty RJ, eds. Ambulatory pediatrics II: Personal health care of children in the office. WB Saunders: Philadelphia; 1977. p. 147 – 8.
11. Bates T, Grunwaldt E. Myofascial pain in childhood. J Pediatr 1958;53:198 – 209.
12. Sorensen TC. Kennedy. New York: Harper & Row; 1965. p. 40.
( to be continued in the next newsletter … )
For the complete article, please see:
https://www.janettravellmd.com/
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