By Valerie DeLaune, LAc
What You Don’t Know About Trigger Points, Will Hurt… Your Patients!
History
Dr. Janet Travell (1901-1997) initially specialized in cardiology but soon became interested in pain relief. She pioneered and researched new pain treatments, including systematically mapping pain referral patterns from what she called trigger points. Initially she inserted a hypodermic needle into these points, along with injecting a numbing agent. She later discovered that dry needling also worked, as did applying pressure to trigger points.
Other health care providers around the world were coming to many of the same conclusions, though Travell is credited with the most systematic research and extensive publications. Yet, in spite of decades of research, Myofascial Pain Syndrome caused by trigger points continues to be one of the most commonly missed diagnoses. With any pain- generating condition, trigger points will form if pain has lasted long enough. Today, massage therapists, physical therapists, and physiotherapists are the health care providers most likely to be familiar with trigger points.
Referred Pain
The most important thing to know about treating trigger points is that they refer pain both in the area in which the trigger point is located, and/or to other areas of the body, in fairly consistent common patterns. The most common referral patterns have been well documented and diagramed. At least half of commonly found trigger points are not located within either their primary or secondary areas of referred pain. Knowledge of referral patterns gives us a starting point of where to look for the trigger points that are actually causing pain.
You need to know that if your patient has pain in the area of the temple, you need to check the trapezius, sternocleidomastoid, posterior neck, and temporalis muscles. Of these, only the temporalis muscle may contain trigger points within the area of primary referral; all the other trigger points are remote to the area of pain referral. If you only work on the areas where your patient feels pain, you probably won’t help them gain relief.
There are book, charts, and websites available that contain “pain guides” that will help you figure out where your patient’s trigger points might be located. • The referral patterns only show the most common referral patterns; your patients’ referral pattern may be somewhat different, or even completely different. • Your patient may have overlapping referral patterns caused by trigger points in multiple muscles. These areas may be more extensive than the patterns common for individual muscles, and pain may be more intense.
For this reason, over time, be sure to search for trigger points in all the muscles that refer pain to that area. • There may be additional trigger points or they may be in different places, so search the entire muscle. • For some muscles, the trigger point may just be an example of its location and associated referral pattern, but they may occur at any level: for example, trigger points located anywhere along the thoracolumbar paraspinal muscles will have their own corresponding pain referral patterns. • A primary, or key, trigger point can cause a satellite, or secondary, trigger point to develop in a different muscle.
The satellite trigger point may have formed for one of three reasons: it lies within the referral zone of the primary trigger point; or it is in a muscle that is either substituting for or countering tension for the muscle that contains the primary trigger point. If some of your patients’ trigger points are satellite trigger points, they won’t get lasting relief until the primary trigger points have been treated. • Always have your patient complete a full medical history form, and at every visit color in where they feel their pain on some kind of body drawing.
Since many patients improve slowly, their perception may be that their symptoms are the same when in fact the area affected is smaller or the pain is less intense and/or less frequent. And if indeed their symptoms haven’t changed, then you know that you are either missing the trigger points, that the patient is missing the trigger points when doing self-treatments, or that perpetuating factors need to be addressed.
In addition to referred pain, your patient may also have symptoms they would not normally associate with muscular problems, such as menstrual pain, headaches, diarrhea, visual disturbances, or urinary frequency (to name a few), though these may also be caused by non-trigger point related causes. For example, the sternocleidomastoid muscle, in addition to causing a tension-type headache, can also cause dizziness, nausea, sinus congestion, eyelid twitching, hearing problems, eye problems, a chronic sore throat, and other symptoms.
It probably wouldn’t occur to most practitioners that these symptoms could be caused by a trigger point in a muscle.
What causes Trigger Points
Trigger points may form after a sudden trauma or injury, or they may develop gradually. Common initiating and perpetuating factors are mechanical stresses, injuries, nutritional problems, emotional factors, sleep problems, acute or chronic infections, and organ dysfunction and disease. Resolving these factors are crucial to your patient getting long-term relief.
Even if it is not within your scope of practice to diagnose and treat many of these perpetuating factors, as a health care provider, it is important that you have some ideas of who you can refer your patient to, who can diagnose and treat particular perpetuating factors that you suspect.
How to Treat Trigger Points
Trigger points typically feel like a “knot” or tight band in the muscle tissue, and will likely be tender with pressure. Your patient may also notice weakness or lack of range of motion. There are a number of techniques for successfully treating trigger points, including wet or dry needling (with a hypodermic needle), acupuncture, and pressure. Some practitioners follow pressure with a stretch. Pressure techniques can include a very brief “in-and-out” pressure, sustained pressure of eight seconds to one minute, repeated stroking over the area, and/or myofascial release.
Pressure should not be too hard; it shouldn’t be more painful than “hurts good.” One technique may work better over another for a particular patient, or you may combine these techniques for each patient. When you apply pressure to the trigger point, you can often reproduce the referred pain or other symptoms; however, being unable to reproduce the referred pain or other symptoms by applying pressure does not rule out involvement of that specific trigger point.
Trigger Point Charts
Keep a set of trigger point charts on your wall where you can see them while you treat patients. Bear in mind that with any chart showing common trigger point locations, it only maps the most common location for trigger points, and the most common pain referral areas for each trigger point. The more solid referral area indicates the primary area of referral, which is almost always present, and the lighter or stippled area (depending on the chart) shows the most likely secondary areas of referral, which may or may not be present. What You Don’t Know About Trigger Points, Will Hurt… Your Patients!
Consistent Success
Treating trigger points is like doing “detective work.” The particular technique is far less important than ensuring that you apply any one technique in the correct place. If you understand that if your patient feels pain in “X” area, then you need to check muscles “X,”, “Y,” and “Z,” and if you understand that all perpetuating factors need to be identified and resolved, your rate of success will be extremely high.
You will likely either give your patient complete relief or a great amount of relief if you have an opportunity to work with that patient over the time needed to solve the puzzle, and if they are compliant in resolving their perpetuating factors. Patient self-care techniques of applying pressure to their own trigger points and doing stretches, along with completing assignments to resolve their perpetuating factors can greatly speed their healing.
If they are unwilling to make the necessary changes, whether it involves changing their diet, reorganizing their office furniture, or changing their habits, your ability to help them will be diminished proportionately. A small percentage of people will get worse before they get better, mostly in complex cases. Or the pain may move around, or your patient may have the perception that the pain moved around only because the most painful areas have improved and now they are noticing the next most painful area more.
If you warn your patient about these possibilities ahead of time, they are far less likely to discontinue treatment in the initial stages.