Trigger Point Therapy Workbook PDF

# The Trigger Point Therapy Workbook: Third Edition ## Trigger Points Ibrahim M. Hassan ### Definition of trigger points - A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. - This spot is painful on compression and can give rise to c...

# The Trigger Point Therapy Workbook: Third Edition ## Trigger Points Ibrahim M. Hassan ### Definition of trigger points - A hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. - This spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. ### Fibromyalgia Tender Points - In order to qualify for a diagnosis of fibromyalgia, a person needs to have at least eleven of these points for three months and must have tender points in all four quadrants of the body. ## Theory of Trigger Point Formation ### Energy Crisis Hypothesis **Mechanisms** - **Sustained Contraction**: Continuous contraction due to overload or injury leads to depletion of ATP and accumulation of calcium ions within the muscle cells, which contributes to the formation of taut bands characteristic of trigger points. - **Metabolic Disturbances**: The lack of energy and oxygen results in a local environment conducive to pain, characterized by increased acidity and inflammatory mediators. ### Polymodal Theory **Mechanisms** - **Sensitization**: Persistent stimulation from mechanical or chemical irritants can activate these receptors, resulting in heightened sensitivity and pain perception in surrounding tissues. ## Radiculopathy Theory **Mechanisms** - **Nerve Root Compression**: Irritation or compression of nerve roots may lead to altered sensory input and motor output, resulting in muscle dysfunction and the development of trigger points. ## Central Sensitization **Mechanisms** - **Amplified Pain Response**: Trigger points can contribute to central sensitization by continuously sending pain signals to the brain, which may lower the threshold for pain perception and increase sensitivity. ## Integrated Hypothesis **Mechanisms** - **Excessive Release of Acetylcholine**: Trigger points are associated with an abnormal release of acetylcholine at the neuromuscular junction, leading to sustained depolarization of muscle fibers. This results in prolonged contraction and increased metabolic demand on local tissues, causing ischemia and pain. - **Biochemical Changes**: Active trigger points exhibit elevated levels of inflammatory substances (e.g., bradykinin, substance P) and a lower pH (more acidic), which can sensitize nociceptive (pain) pathways. - **Local Ischemia**: Sustained contraction compresses blood vessels, leading to reduced oxygen supply and accumulation of metabolic waste, further exacerbating pain. ## Classification of Trigger Points (TrPs) ### Active Trigger Points - Defined as points that are symptomatic at rest or during movement. - They can cause spontaneous pain and may reproduce familiar pain patterns when palpated. - These points are associated with sensory, motor, and autonomic symptoms in their related transfer zones (areas where pain is referred). ### Latent Trigger Points - These points do not produce pain unless stimulated by pressure. - They may cause localized tenderness but are asymptomatic at rest. - While they do not elicit pain spontaneously, latent TrPs can still affect muscle function, leading to weakness or altered activation patterns. ### Primary and Secondary Trigger Points **Primary (Central) Trigger Points** - These are the original sites of TrP formation, often resulting from acute or chronic muscle strain, trauma, or overuse. - Primary TrPs are typically located within the muscle belly and are responsible for local pain and referred pain patterns. **Secondary (Satellite) Trigger Points** - These arise in response to existing primary TrPs in nearby muscles. - They often develop as a compensatory mechanism due to altered muscle function or increased strain on adjacent muscles. - Secondary TrPs may resolve once the primary TrP is treated. - Form in the referred pain zone of a primary TrP. ## Signs and Symptoms of Trigger Points - **Local Pain** - **Palpable Tenderness**: Trigger points are characterized by localized tenderness when pressure is applied. Patients often report pain directly the site of the trigger point. - **Taut Bands**: The affected muscle may exhibit a taunt band or nodule that can be palpated, indicating the presence of a trigger point. - **Referred Pain** - **Radiating Pain Patterns**: One of the hallmark features of trigger points is their ability to cause referred pain, which means pain that originates in one location but is felt in another area of the body. For example, a trigger point in the upper trapezius may refer pain to the shoulder, arm, or even the head. - **Specific Referral Zones**: Each muscle with trigger points has specific referral patterns that can help clinicians identify the source of pain. - **Local Twitch Response** - **Twitch Response**: Palpation of a trigger point may elicit a local twitch response, which is a small contraction of the muscle fibers in the area. This response differs from a full muscle spasm and indicates heightened irritability in the muscle. - **Decreased Range of Motion** - **Functional Limitations**: Trigger points can lead to decreased range of motion in the affected muscle, making it difficult for patients to perform daily activities or engage in physical exercise. - **Muscle Weakness**: Patients may experience weakness in the affected muscle group, further limiting functionality. - **Associated Symptoms** - **Muscle Stiffness**: The presence of trigger points often leads to stiffness in the affected muscles, contributing to overall discomfort. - **Fatigue**: Patients may report fatigue in the muscles associated with active trigger points due to continuous contraction and tension. - **Other Sensory Symptoms**: Some individuals might experience additional symptoms such as headaches (e.g., tension headaches), tinnitus (ringing in the ears), or temporomandibular joint (TMJ) pain related to trigger points in surrounding musculature. - **Psychological Factors** - **Stress and Anxiety**: Psychological factors such as stress and anxiety can exacerbate trigger point formation and contribute to chronic pain conditions. ## Causes of Trigger Points - **Muscle Overuse** - **Repetitive Strain**: Trigger points often arise from repetitive motions or sustained low-level contractions, which can lead to muscle fatigue and overload. Activities such as lifting heavy objects, typing, or performing repetitive tasks can contribute to the development of TrPs. - **Eccentric Contractions**: Eccentric muscle contractions (where the muscle lengthens under tension) are particularly associated with trigger point formation. This type of contraction can cause microtrauma to muscle fibers, leading to localized areas of hyperirritability. - **Poor Ergonomics**: Improper posture and ergonomics during work or daily activities can exacerbate muscle strain and contribute to the formation of trigger points. - **Direct Trauma** - **Injury**: Acute injuries, such as strains or direct blows to a muscle, can initiate the development of trigger points. The trauma may lead to local muscle damage and subsequent hypercontracture of muscle fibers. - **Collision Trauma**: Events such as car accidents that stress multiple muscles simultaneously can also result in immediate trigger point formation. - **Psychological Stress** - **Stress Response**: Psychological factors such as stress and anxiety can lead to increased muscle tension and clenching. This sustained tension may create an environment conducive to trigger point formation. - **Hormonal Influence**: Stress can elevate levels of certain hormones (e.g., cortisol), which may increase sympathetic nervous system activity and contribute to muscle contraction at the neuromuscular junction. - **Homeostatic Imbalances** - **Metabolic Factors**: Trigger points may develop due to metabolic disturbances within the muscle tissue, including reduced blood flow (ischemia) and decreased oxygen supply. This condition can lead to a buildup of metabolic waste products, resulting in pain and dysfunction. - **Biochemical Changes**: The environment around active trigger points is often characterized by lower pH levels (increased acidity), elevated levels of inflammatory mediators (such as bradykinin and substance P), and neurotransmitters (like acetylcholine), which can sensitize nociceptive pathways. - **Other Health Conditions** - **Radiculopathy**: Nerve root compression or irritation can lead to referred pain and the development of trigger points in associated muscles. - **Infections**: Certain infections may also contribute to the formation of trigger points due to inflammation and increased sensitivity in affected muscles. - **Chronic Conditions**: Conditions such as fibromyalgia or chronic fatigue syndrome may predispose individuals to develop trigger points due to generalized muscle tension and pain sensitivity. - **Metabolic Disorders** - hypothyroidism, low testosterone, low estrogen, hypoglycemia, anemia, prolonged breastfeeding, and high levels of uric acid in the blood (uricemia). Nicotine, caffeine, and alcohol cause enough irregularity in metabolism to make it difficult to keep trigger points deactivated. - **Vitamin and Mineral Insufficiencies** - These critical nutrients include the water-soluble vitamins B1, B6, B12, C, and folic acid. Lack of vitamin D also plays a significant role in chronic pain. - The minerals calcium, iron, magnesium, potassium, and zinc are also critically important. their elimination. Smoking destroys vitamin C. Alcohol, antacids, and the tannin in tea impair absorption of B1. ## Treatment of Trigger Points - **Manual Therapy Techniques** - **Trigger Point Therapy** - **Sustained Pressure Approach** - **Integrated Neuromuscular Ischemic Technique** - **Spray and Stretch Technique**: This method combines the application of a topical anesthetic of a topical anesthetic spray (such as ethyl chloride) with passive stretching of the affected stretching of the affected muscle. The spray helps to reduce pain perception while perception while stretching helps to relax the muscle. - **Massage Therapy**: Various forms of massage, including deep tissue massage and myofascial release, can effectively relieve muscle tension associated with trigger points. - **Dry Needling** - **Description**: Dry needling involves inserting thin needles into the trigger points without injecting any substance. This technique aims to elicit a local twitch response and promote muscle relaxation. - **Mechanism**: The insertion of needles stimulates the muscle fibers, causing them to contract and then relax, similar to progressive muscle relaxation techniques. This can also promote blood flow and healing in the affected area. - **Effectiveness**: Studies suggest that dry needling is as effective as trigger point injections with anesthetics in reducing pain and improving function. - **Trigger Point Injections** - **Procedure**: Trigger point injections involve injecting a local anesthetic (such as lidocaine) or saline directly into the trigger point. Corticosteroids may also be used in some cases. - **Benefits**: The injection can provide immediate relief by interrupting pain signals and promoting muscle relaxation. - **Indications**: This treatment is particularly beneficial for patients with symptomatic active trigger points that produce a twitch response and referred pain patterns. - **Physical Therapy** - **Stretching**: Physical therapists may prescribe specific stretching exercises to improve flexibility and reduce muscle tightness associated with trigger points. - **Strengthening**: Strengthening Exercises: Gradual strengthening of affected muscles can help prevent recurrence of trigger points by improving overall muscle function. - **Training**: Posture Training: Education on proper posture and ergonomics can help alleviate strain on muscles that contribute to trigger point formation. - **Other Modalities ** - **Ultrasound Therapy**: Therapeutic ultrasound may be used to promote healing in affected tissues by increasing blood flow and reducing inflammation. - **Cold Laser Therapy**: Low-level laser therapy can help reduce pain and promote healing in areas affected by trigger points. - **Transcutaneous Electrical Nerve Stimulation (TENS)**: TENS units can provide pain relief by delivering electrical impulses that interfere with pain signals sent to the brain. - **Medications** - **Over-the-Counter Pain Relievers**: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or acetaminophen can help manage mild pain associated with trigger points. - **Prescription Medications**: In cases where over-the-counter medications are ineffective, doctors may prescribe muscle relaxants, anti-anxiety medications, or antidepressants for chronic pain management. - **Acupuncture** - Acupuncture has been shown to be effective in treating trapezius trigger points by promoting relaxation and reducing pain. ## Practical Applications ### Locating Trigger Points - **STAR Palpation** - **Sensitivity (or Tenderness)** - This is the one feature that is almost always present when there is soft tissue dysfunction. - **Tissue texture change** - Tissues usually 'feel' different (for example they may be tense, fibrous, swollen, hot, cold or have other 'differences' from normal; and/or the skin overlying dysfunctional tissues usually palpates as different from surrounding tissues). - **Asymmetry** - There will commonly be an imbalance on one side, compared with the other, but this is not always the case. - **Range of motion reduced** - Muscles will probably not be able to reach their normal resting length, or joints may have a restricted range. - **If two or three of these features are present this is sufficient to confirm that there is a problem, a dysfunction** - **Drag Palpation** - It is possible to assess the skin for variations in skin friction, by lightly running a fingertip across the skin surface (no lubricant should be used). This palpation method can be used to compare areas that are palpated as 'different' from surrounding tissues, or to rapidly investigate any local area for trigger point activity. - **The degree of pressure required is minimal - skin touching skin is all that is necessary - a 'feather-light touch'.** - **Movement of a single palpating digit (pad of the index or middle finger is best) should be Locating trigger points 249 purposeful, not too slow and certainly not very rapid. Around 3-5 cm 0-2 inches) per second is a satisfactory speed. (If movement is too slow it will not easily pick up differences, and if too fast information may be missed.)** - **What is being sought is any sense of 'drag', suggesting a resistance to the easy, smooth passage of the finger across the skin surface.** - **A sense of 'dryness', 'sandpaper', a slightly harsh or rough texture, may all indicate increased presence of hydrosis (sweat) on, or increased fluid in, the tissues.** - **The method of drag palpation is extremely accurate and speedy. It is thought to indicate a localised area of increased sympathetic activity, manifested by sweat. Lewit (999) describes such regions as hyperalgesic skin zones'. A trigger point will commonly be found in such zones.** ### Upper Trapezius - **TrP1** - **Location**: Found in the upper fibers of the trapezius, typically at the posterolateral neck area, near the base of the skull and extending towards the shoulder. - **Referral Pattern**: Pain may radiate to the posterior lateral neck, mastoid process, and temple area. It can also cause jaw pain. - **TrP2** - **Location**: Located slightly lower than TrP1, often in the upper trapezius region. - **Referral Pattern**: Produces pain in the posterior neck without headache and may lead to stiffness in the neck. ### Suboccipital Trigger Points - **Location**: Suboccipital trigger points are typically found just below the occiput (the base of the skull) and between the mastoid process and the midline of the upper neck. They may be palpated in the region where these muscles attach to the skull and cervical spine. ### Trigger Points in the Supraspinatus Muscle - **Location**: Trigger points are typically found in the muscle belly of the supraspinatus, which is located just above the spine of the scapula. They can also be palpated near the insertion point on the humerus. ### Trigger Points in the Pectoralis Major Muscle - **Location**: - **Clavicular Trigger Points**: Located near the lateral aspect of the pectoralis major, close to where it attaches to the clavicle. These points are often associated with pain referring to the anterior shoulder region. - **Sternal Trigger Points**: Found centrally along the sternal head, just above the ribcage. This area may contain multiple closely clustered trigger points. ### Trigger Points in the Iliopsoas Muscle - **Location**: - **Psoas Major Trigger Points**: Located deep within the abdominal cavity, typically near the lumbar vertebrae (T12 to L5) and extending down to the lesser trochanter of the femur. The trigger point in the psoas major is often too deep for direct palpation but can be accessed through specific stretching techniques. - **Iliacus Trigger Points**: Found in the iliacus muscle, which lies along the inside surface of the ilium (the large bone that forms the pelvis). The upper iliacus fibers are commonly targeted for trigger point therapy. ### Trigger Points in the Hamstring Muscle Group - **Locations**: - **Medial Cluster**: This cluster can contain up to five trigger points located about mid-thigh along the inside of the leg, primarily in the semimembranosus and semitendinosus muscles. Common Trigger Points: The medial hamstring trigger point is often identified as being particularly active. - **Lateral Cluster**: This cluster can contain up to four trigger points located about mid-thigh along the outside aspect of the leg, primarily in the biceps femoris muscle. Common Trigger Points: The lower and middle hamstring trigger points are typically found in this cluster. ### Piriformis Trigger Points - **Location**: - **Medial Trigger Point**: Positioned near the origin of the piriformis muscle on the anterior surface of the sacrum, typically about an inch outside the edge of the sacrum. - **Central Trigger Point**: Found roughly in the middle of the muscle belly. - **Lateral Trigger Point**: Located closer to the greater trochanter of the femur where the piriformis muscle inserts.