- Trigger Points, Pain Relief, and Trigger Point Therapy
- Pain Diagnosis
- "I kept thinking it would go away!"
- Breaking the Pain Cycle
- Why Trigger Point Therapy Works
- How Long Will Therapy Take?
I first went to massage school in 1989 and learned Swedish Massage. I learned to give a very good general massage, but actually trying to solve a patient's muscular problems was often frustrating and elusive. I saw a class on "Neuromuscular Therapy" in the Heartwood Institute catalog, and was very intrigued by the description. I attended the class in 1991, taught by Jeanne Aland, and it opened up a whole new world for me. I learned that "trigger points" often are not located in the area in which the patient is actually feeling symptoms, and that working on the area of pain would not necessarily solve the problem. I also learned that trigger points are areas of cells that are locked in a dysfunctional cycle -- blood flow has been reduced and metabolic wastes are not being exchanged for oxygen and nutrients, and that these were the "knots" I could feel when I was working on a patient. Suddenly I was able to start solving problems consistently, even in cases where patients had been lead to believe they "would have to live with it." I bought Dr.'s Janet Travell and David Simon's first volume "Myofascial Pain and Dysfunction: The Trigger Point Manual," and then anxiously awaited completion of the second volume, which came out in 1992.
The Neuromuscular Therapy class taught me about trigger point referral patterns and how to search for and work on trigger points, but the books taught me so much more -- about other symptoms in addition to pain referral patterns -- causative factors, perpetuating factors, and some self-help techniques to teach to patients. In addition, I have since added my own observations and self-help techniques, and I am grateful to the many patients who have shared with me their own experiences of what worked for them.
This Book-on-CDROM draws heavily from Dr.'s Travell and Simon's books, which are written for physicians. It is intended for use by the lay public, massage therapists, physical therapists, and any others who don't require the in-depth expertise required for trigger point injections, and I have purposely attempted to use lay terms as much as possible rather than medical terminology. The exception to this is medical terminology used to describe conditions that may need to be ruled out or diagnosed by a doctor, and the names of muscles. Often trigger point referral symptoms mimic other more serious conditions or occur concurrently with them.
Unfortunately, all too often, you may be diagnosed with general terms such as a "rotator cuff injury," "frozen shoulder," "carpal tunnel syndrome," "thoracic outlet syndrome," "sciatica," "arthritis," or "tendonitis," without the true cause being identified. Often the cause is trigger points in one or more muscles, and the diagnosing practitioner is unfamiliar with trigger points. If you are not able to get relief with the self-help techniques and something other than trigger points is causing or contributing to your symptoms, MRI's and other tests can specifically identify conditions such as muscle tears, tendon inflammation, anatomical abnormalities, nerve root irritations, and nerve entrapments.
I recommend that you have your trigger points identified by a trained trigger point or neuromuscular therapist, and use the book to supplement their work. In my experience, patients who perform self-help techniques at home in addition to weekly acupuncture or massage treatments improve at least five times faster than those who only receive treatments.
Often a patient will tell me they have "arthritis," "tendonitis," "carpal tunnel," "bursitis," a "rotator cuff injury," "sciatica," or some similar term all too often used loosely to describe pain in a certain area of the body. I try to find out whether the area was loosely diagnosed by a practitioner based on the affected area (i.e., if its elbow pain, then it's tendonitis), whether it's been diagnosed by a blood test (i.e., Rheumatoid arthritis), x-rays, or an MRI, or if the patient has self-diagnosed. Even with a laboratory-confirmed diagnosis, I assume I can most likely help my patient to some degree with trigger point therapy.
Joint pain will often be caused either by trigger point referral to the joint area, or tight muscles crossing the joint and jamming it together, thereby causing pain. With a confirmed diagnosis of a condition such as a herniated disc or carpal tunnel syndrome, trigger point therapy can still offer pain relief, relax the muscles, and possibly even ward off surgery. Any surgery has inherent risks and may not solve the problem, and may even make the condition worse. It is almost always worth it to try alternative methods to see if you can avoid surgery. If surgery is the best option, trigger point therapy, acupuncture, and other "complementary" therapies can help prepare you for surgery and hasten your recovery afterwards.
When pain is more widespread, it is usually given the diagnosis of Fibromyalgia or Myofascial Pain Syndrome. If I see body-wide pain and tender points, I wonder what is going on systemically -- that is, what could be affecting the body as a whole? Anemia, hormonal imbalances (including menopause), nutritional deficiencies, hypoglycemia, and allergies are examples of conditions that could cause widespread trigger points. In cases of what I consider "true" fibromyalgia, the tissues feel "spongy" to the touch, an indication that there is fluid in the interstitial space (see the fibromyalgia section of What Are Trigger Points)
Regardless of your Western diagnosis, my general treatment principle is the same: identify and eliminate all the underlying causes (if possible) and treat the trigger points.
Patients often assume that if a parent had the same type of condition, "it must be genetic and I'll just have to learn to live with it." While it may or may not be true that your condition is genetic, I never operate on the assumption that it is, or that it can't be improved even if it is genetic. Many things are learned from your parents -- eating habits, exercise habits, emotional holding, even posture and gestures. So assume you can change your medical condition, at least until you have exhausted all therapy options.
A frequent phrase I hear patients have been told by practitioners is "you're just getting older" or "you'll just have to learn to live with it." How depressing! I never assume I can't help someone, or that I can't think of someone to refer them to, such as a chiropractor, naturopath, or surgeon who can help them. I've actually treated several fairly simple cases where the patient had been told their only recourse was to learn to live with it, only because the doctor didn't know about trigger points, or was unwilling to refer to an "alternative" modality. Thankfully, I see that changing with new doctors being exposed to a wider range of alternatives in medical school, and some doctors who have been out of school for some time getting excited about exploring some other options.
I've only had a few cases where I was not able to help someone, but these people had frustration levels so high (understandably so) from seeing professional after professional with little or no help, that they only allowed me to treat them a few times before giving up, even if they had improved. Sometimes a patient will get a little worse before they get better, especially in complex cases, so they will give up easily in the initial stages of treatment. I encourage you to give any treatment you try some amount of time before you decide it is not working, even if it initially gets worse. Most professionals have numerous tools in their bag, and if something isn't working, they can try something else. Just give them some time to learn your body and get to know how you use it. If they don't seem to care or have time for you, then by all means find someone else who cares about you getting better.
So often I get patients in my office who say "I kept thinking it would go away." Occasionally symptoms will go away in a few days and never return. But more often, the longer you wait to see if it will go away, the more muscles become involved in what I call a "chain reaction." A muscle hurts and forms trigger points, then the area of referral (where you feel the pain or other symptoms) starts to hurt and tighten up and forms its own trigger points ("satellite" trigger points), and so on down the line, so to speak. Or the pain may improve for a while, but the trigger points are really just lurking, waiting to activate and cause pain or other symptoms once again. The problem gets more complex the longer the trigger points are left untreated, resulting in it being more painful, more debilitating, more frustrating, more time-consuming, and more expensive to treat. Plus the longer you wait the less likely you are to get complete symptom relief, and the more likely that trigger points will be reactivated chronically and periodically.
Something starts to hurt, then you tense the area up. Then it hurts more, so the muscle tightens up more . . . and the pain cycle ensues. People are often surprised that I support the use of analgesics, such as aspirin and ibuprofen, but whatever will break the pain cycle as soon as possible helps prevent the symptoms from getting worse or spreading to other muscles. (Icing will also numb out the pain). But be aware that just because the pain level has decreased does not mean the trigger points are gone. You still need to seek treatment, preferably as soon as possible. Analgesics will most likely take the edge off the pain, but unless you plan to take them as a long-term solution, you will also need to treat the source of the problem.
Massage and self-help techniques on trigger points helps reverse the dysfunctional metabolic cycle of the muscle cells. It allows them to start exchanging oxygen and nutrients for metabolic wastes again, the proper cell metabolism process. Also, by pressing on the trigger points and making it hurt a little bit more than it's already hurting, it causes your body to release pain-masking chemicals such as endorphins and enkephalins, thereby breaking the pain cycle.1
~~ Dr.'s Travell and Simons2
A common question I get in the beginning of therapy is "how long will it take?" There is no quick-fix when it comes to treating pain. My general rule of thumb is that longer the condition has been going on and the more medical conditions (of any kind) the patient has, the greater number of muscles will have become involved, and the treatment will be more complex and take longer. If a patient is perfectly healthy and has only a recent minor injury, I may only see them a few times. Patient compliance is a big factor -- whether they follow my recommendations and participate in their healing by performing the self-help techniques. I can usually give the patient a pretty good indication of how many treatments they may need by the end of the second or third treatment, based on their medical condition, how their muscles feel to me, their compliance to date, and how much they have improved (or not) within the first few weeks.
A small percentage of patients will get worse before they get better, mostly in complex cases. Or pain may move around, or the patient may have the perception pain moved around only because the most painful areas have improved and now they are noticing the next most painful area more. I encourage you to stick with the treatments and find ways to make the self-help techniques comfortable, such as reducing the frequency or decreasing the amount of pressure. Keeping good records will demonstrate progress, even if you perceive that your symptoms haven't changed.
© Copyright Valerie DeLaune, LAc, 2004-2018
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- Neuromuscular Therapy Training, Fall 1991, Heartwood Institute, Jeanne Aland, instructor.
- Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities vol. 2 (Baltimore: Williams & Wilkins, 1992), pp. 548-549.
- Janet G. Travell , M.D., David G. Simons, M.D., and Lois S. Simons, P.T., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, Upper Half of Body, 2nd ed. (Baltimore: Williams & Wilkins, 1999), pp. 44-45.