Trigger Point Therapy for Myofascial Pain (7 page)

We had the privilege of watching Dr. Janet Travell treat a number of patients. She began formulating her treatment the moment she saw the patient enter the room. She took note of the person's shape, size, asymmetries, gait, posture, and the many ways he was holding himself, particularly when in pain. When the patient pointed out his problem, Dr. Travell was already aware of the muscular patterns involved—the history expanded the data she had already collected through observation. Before Dr. Travell touched the patient she knew a great deal about him; in fact, after fifty years of clinical experience she was so integrated in her awareness that she often saw the problem in seconds.

Dr. Travell trained herself as a better clinician with each patient she treated, which left us with another tenet for good practice: Do not assume that you know anything. Be it through palpation or questioning, in every treatment with every patient
always
seek more information about the problem (and the person) at hand.

Evolve palpation skills.
Through touch the patient discovers much about the nature of the practitioner. That first touch tells the patient whether you are gentle or rough, respectful or invasive, careful or careless, and most importantly, if you know what you are doing. It is a good idea to first palpate the area where the patient is complaining of pain, since it demonstrates, in a matter of seconds, that you understand that he or she has pain and that the pain is there, where you are palpating. So often patients will exclaim, “That's it,” and with those two words they have begun to accept and trust you as a practitioner. As the practitioner explores related areas the patient will often remember pains or injuries that were not mentioned in his medical history. It is as if the palpation examination opens new doors in the patient's understanding of his own problem and encourages him to come to some insight regarding the direction of treatment.

Palpation is an art and a skill. It requires work, practice, and the constant awareness that you are touching a
person
, not just a muscle. As most myofascial problems involve sequences of numerous associated muscles, effective examination will generally involve extensive palpation around the area of most acute presentation. In acupuncture, a common assessment principle has the practitioner examine left and right, up and down, and front and back relative to the presenting region. This simply means that if a patient is complaining of pain in the left lumbar region, examination should include the right lumbar region, the upper back and shoulders, the buttocks and legs, and the abdomen. Such wide examination not only renders significant information but also respects the patient as a whole person.

Learning to touch another person includes awareness that the body will often tense to “guard” itself against invasive touch, particularly in painful areas. Such responses mitigate effective palpation, so the practitioner must learn
how
to touch, gradually applying pressure and earning the trust of his patients to allow for accurate palpation.

Regardless of the particular method of treatment employed, skillful palpation is the defining factor differentiating highly successful practitioners from those who obtain erratic results. Regardless of theory, method, or amount of treatment, skillful palpation is without question the singular most important component of treatment.

Listen closely.
First, the patient has direct experience of the problem. His descriptions of what he feels and when and how he feels it are extremely important pieces of data. Second, many patients with chronic pain have suffered the experience of being told that the pain is “in their head” or “isn't real.” They will often feel they have to convince you of the reality of their experience. Listening and confirming their reality is important in developing the trust necessary for treatment. Educating patients about the nature of myofascial pain syndromes, showing them wall charts of pain patterns, describing postures and movements that can trigger pain patterns as well as what kinds of organic dysfunctions might be associated with such syndromes is important. We have seen patients lose their tension and anxiety as soon as they saw their pattern on a wall chart; many have exclaimed, “I'm not crazy!” This kind of confirmation and education goes a long way in establishing a relationship that leads to effective treatment.

Additionally, it is important to remember and respect the subjective nature of the experience of pain. What might seem to be a mildly constricted area to your touch can in fact be a source of considerable pain to the patient. As you listen to your patient, hear him and embrace his reality.

Treat with precision and attention.
The following approach to patient care is designed to help to focus in on the problem at hand and its resolution.

1. Clearly define the areas of pain and restrictions of movement that the patient is experiencing. Have him delineate, and perhaps draw, the areas of the body that feel painful. Have him demonstrate the movements that cause pain. Be certain that you understand, to the best of your ability, what he is experiencing.
   
2. Determine the various muscles that might be the source of your patient's pain and restriction. Utilizing the pain pattern and symptom indices (see pages 229–242) will be useful in this determination.
   
3. Palpate for constrictions and taut bands in the individual muscles that you have hypothesized to be the source of the difficulty.
   
4. Palpate associated regions for additional constrictions and taut bands. It is important to palpate the entire body, anterior and posterior, to determine associated constrictions. Additionally, awareness of the pathways of meridians and cutaneous zones will provide a guide for identifying restrictions that might lie outside of the affected quadrant.
   
5. Locate individual taut bands in the involved muscles. “Capture” the band with precise palpation and compression. Define the specific trigger point along the taut band through focused palpation.
   
6. Apply treatment to the trigger points. Once the bands and trigger points are captured, maintain pressure through ischemic compression until softening of the point occurs. This can be used for treatment in and of itself; however, if acupuncture needling is used, lightly peck the point until you feel a softening of the band under the hand that is compressing the muscle. Palpation of the region after treatment will provide feedback as to whether or not there has been a complete release of the muscle.
       Repeat this process of treatment with each area of constriction in each region that you identified as having restrictions. This is an essential component in obtaining complete release.
   
7. Apply moist heat. Whether in the office or at home, moist heat should be applied to the treated regions to increase blood flow to the areas. This should be done for at least twenty minutes each day for three days following treatment.
   
8. Provide a stretching program. Once the patient has had moderate release of muscular constrictions, instruct him in appropriate stretching exercises to maintain the release of the muscle. These should be done several times a day. Performance of the stretch should not produce pain.
   
9. Provide a strengthening program. When the patient has been pain free for seven to ten days, instruct him in appropriate strengthening activities, if the muscle needs reconditioning.
   
10. Teach your patient how to breathe.
    

Poor breathing patterns connected to stress, muscular problems, or respiratory trauma can directly affect myofascial problems. The single biggest offender is paradoxical breathing, a phenomenon in which the movements opposite to those required for a full, relaxed breath occur. Instead of the abdominal muscles relaxing in order for the contracted diaphragm to fully enlarge the thoracic cavity, the abdominals contract and the chest lifts, inhibiting the tidal volume of the lungs. Watch a patient breathe and you may notice a raising of the chest and pulling in of the abdomen. Many people reflexively do this when they try to hold the breath. It is simply incorrect breathing and often nothing more than a bad habit.

Since it can be a perpetuating factor for a number of pain syndromes, as well as part and parcel of many stress-related disorders, this type of breathing should be corrected.
¹

The following exercise can help retrain breathing patterns.

1. Direct the patient to sit or stand with the body naturally erect and yet relaxed. Keep the spine elongated and allow the musculature and the surrounding bony structure—the shoulders and rib cage—to relax and drop down toward the pelvic region. Allow the chest to relax; let the muscles of the abdomen and stomach relax. Let the buttocks and lower abdomen relax.
   
2. Take a slow breath, allowing the musculature of the stomach and abdomen to expand somewhat with the breath. Breathe in this way for a few moments, allowing the breath to move down into the lower portions of the thorax. As constrictions of abdominal and/or thoracic musculature are felt, intentionally relax the area. If the chest or shoulders rise up, return to the focus of dropping the breath into the lower areas of the body.
   
3. Now inhale deeply. Allow the musculature of the thorax to relax. As the musculature relaxes the chest will expand slightly in an anterior direction, in a lateral direction, and in a posterior direction. This will happen naturally in the relaxed body. Sense that a container is being filled: first the lower portion fills, then the upper portion.
   
4. Now exhale, emptying the upper portion first and then the lower portion. Allow the body to deflate as a balloon deflates; it will do so evenly—anteriorly, posteriorly, and laterally.
   
5. Relax the breath and continue to breathe fully and completely, paying attention to the pitfalls: the shoulders may want to rise up, the abdominal muscles may tighten. Keep them relaxed.
   
6. Instruct the patient to practice in front of a mirror at first. The reflection might demonstrate what is not yet felt—the chest rising, not dropping; the abdomen pulling in, not relaxing out.
   
7. Practice. Learning requires successful repetition over time.
   

Extend treatment beyond the office.
Your job goes beyond releasing myofascial constrictions and trigger points. The treatment of myofascial pain is multifaceted and includes involving the patient in home care, such as applying moist heat; attending to postural, visual, work habit, or sleeping corrections; addressing stress management and nutritional considerations; correcting sports movements; or even suggesting new arrangements for furniture and computer stations. We often have asked patients to bring their bicycles or tennis racquets to the office if we suspected such activities were directly connected to the generation of their pain. The clinician as detective, one who sorts out and identifies the perpetuating factors associated with the patient's condition, is only one of the roles we must assume. We must also be educators, prodding parents, or sometimes simply friends who care about the fact that a person is in pain. Familiarity with simple exercises, nutritional considerations, stress management techniques, breathing exercises, methods of changing eye-dominance, and furniture and exercise-equipment ergonomics is part of the diverse knowledge necessary for treating myofascial pain in a complete sense.

Soften the dichotomy between treatment and examination.
From the outset the practitioner should view examination as treatment and treatment as examination. Failing to recognize the ongoing feedback involved in this process can result in the loss of important information. As you gather information by palpating the myofascial constriction, you are engaged in treatment. Just so, as you seek to release myofascial constrictions, you are engaged in evaluation. The act of treatment can show you the correctness of your palpation, the reactivity of the muscle, the extent of the problem, and possibly the approximate length of time this muscle has experienced distress. Further, each release can guide you to associated areas of constriction. Watching the skin surface and carefully feeling for the type and direction of the release provides evaluative information that directs the course of treatment. The patient will often describe loci of pain that are experienced at the time of palpation or treatment that correlate with the referred pain pattern, though he might also describe a distal location, demonstrating additional muscular constriction. Evaluation, treatment, and treatment planning are processes that occur simultaneously in working with myofascial pain syndromes. Therefore a certain mental framework—a diffuse state of attention coupled with a constant vigilance that records cues and transforms them into treatment modifications—is central to this approach. Such activity becomes part of a practiced process that is carried out in treatment.

While a diagnosis is made after the history is taken, the examination is finished, tests are reviewed, and palpation is completed, it should be considered preliminary. The treatment of myofascial pain problems is also diagnosis. Whether you are injecting trigger points, releasing tender points with acupuncture, applying ischemic pressure, or performing a spray-and-stretch technique, all procedures reveal further information about the patient's condition. Attention to how the muscles respond, how the pain is experienced, the nature of the fasciculations, and how the patient responds to treatment are all pointing to the next steps of treatment. To make a firm diagnosis and carry out a rigid treatment plan is contradictory to the experience of interacting with myofascial problems. This is a world where as muscle fibers release others may constrict; where simple movements could drastically affect a recently released, but highly reactive, muscle. It is a world that is so interconnected it is impossible to understand one muscle in isolation from the whole body. The successful practitioner understands this deeply and engages in a practice that involves a kind of passive vigilance and fluidity of thought that allows for constant change. The idea that X, and X alone, is the problem and that Y will fix it is a classic error common in health care but disastrous in the world of treating myofascial pain.