trigger points and chronic pain

TRIGGER POINTS AND CHRONIC PAIN

In Clinical Application of Neuromuscular Techniques by Dr Leon Chaitow and Judith DeLany list some of the primary and secondary causes of Trigger Points.

  • Continual intense muscular contraction.  Can be due to injuries, repetitive strain, or emotional issues
  • Trauma
  • Cold, hot, or damp conditions
  • Long periods of immobility
  • Fever
  • Nutritional or hormonal imbalances / Nutritional deficiencies / Endocrine issues
  • Muscle compensation in synergistic or antagonistic muscles

  • Organic (organ) problems can refer pain / triggers along specific pathways or patterns
  • Infections
  • Chronic dehydration
  • Allergies or Sensitivities to food or environment
  • Hypoxia or diminished tissue oxygenation

Or, if you had an extra $200 laying around, you could purchase the ‘bible’ on Trigger Point therapy — Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual.  You see; Dr Janet Travell was, for a time, JFK’s physician.  She figured out a way to help him with the pain he had due to injuries he received in WWII (PT 109), and along the way, developed the current theory of Muscle Trigger Points (MTrP’s).  Then in the early 1980’s, along with a doctor named David Simmons (a disciple of hers), published the fore mentioned book.  According to Drs. Travell and Simons, Trigger Points are defined as, “hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.”  In other words, they are small, hard muscle knots.  A review of the scientific literature on Trigger Points was published in a 2007 issue of The Clinical Journal of Pain, describing the four most common diagnostic criteria of Trigger Points. 

  • Tender spot in a taut band of skeletal muscle 
  • Patient pain recognition
  • Predictable pain referral pattern 
  • Local twitch response

This went along hand in hand with what Dr. Travell herself had described in her work.

  • Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
  • The painful point can be felt as a nodule or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point.
  • Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point.
  • The pain cannot be explained by findings on neurological or radiological examinations.
In other words, Trigger Points are hard (pea or marble-sized) nodules of tissue that cause pain, but have no specifically known causes or findings that can be determined from X-rays, MRI, or neurological examinations.  Not only this but they tend to refer pain along very specific patterns.  And although not as common, they can involve a “Twitch Response” (if you run your fingers along a Trigger Point perpendicular to the direction of the muscle fibers themselves, it can cause the “triggered” portion of the muscle to fire or ‘twitch’).  Although Trigger Points can be found anywhere in the body, by far the most common place people get them is in the upper trapezius (shoulder muscle).   There are not only all sorts of theories as to how Trigger Points start, there are a wide variety of methods used to treat them as well.  The three methods described by Dr. Travell include,

  • Injection of the Trigger Point with a local anesthetic.
  • The use of vapocoolant sprays such as “Spray and Stretch“.  
  • The application of direct pressure to the Trigger Point to eliminate tenderness — always looking for and concentrating on those that create a specific pattern of pain referral.

Other methods of dealing with Trigger Points include, modalities such as Electric Stimulation, Ultrasound, COLD LASER THERAPY, various forms of VIBRATION, a wide variety of massage and body-work methods, CHIROPRACTIC ADJUSTMENTS, Dry Needling (using a heavy gauge needle to repeatedly poke / puncture a MTrP, acupuncture (very different than dry needling), and numerous others, including our SCAR TISSUE REMODELING (a popular online encyclopedia states that, “Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop“).  This would make sense as I believe that FASCIA is often times a missing link in helping people struggling with various CHRONIC PAIN SYNDROMES.

I have found to effectively deal with the Trigger Points that occur so frequently in the trapezius muscle, one must address the Structural / Functional model.   No one would argue that structure and function are intimately related.  However, because so few people have a proper LORDOTIC CURVE in their cervical spine (neck), most physicians consider this loss of curve a “normal” finding.  This is absolutely not true.  Even the medical community is starting to admit this.  As a primary example, we can look at last August’s study (Cervical Spine Alignment, Sagittal Deformity, and Clinical Implications: A Review) from the Journal Neurosurgery, Spine.   I am going to cherry-pick some sentences from this study —- a study that was written by surgeons, for surgeons, about people they believe need surgery.

“This paper is a narrative review of normal cervical alignment, methods for quantifying alignment, and how alignment is associated with cervical deformity, myelopathy [neurological problems caused by cord irritation], and adjacent-segment disease (ASD) [DEGENERATION], with discussions of health-related quality of life (HRQOL).  Popular methods currently used to quantify cervical alignment are discussed including cervical lordosis….    Evidence from a few recent studies suggests correlations between radiographic parameters in the cervical spine and HRQOL. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is critical. The article details mechanisms by which cervical kyphotic deformity potentially leads to ASD.  Sagittal alignment of the cervical spine may play a substantial role in the development of cervical myelopathy as cervical deformity can lead to spinal cord compression and cord tension.”

What is dumbfounding when reading this article is that the authors — spinal neurosurgeons — almost sound like chiropractors.  They say things like, any amount of FORWARD HEAD POSTURE causes “an increase in cantilever loads…“.   Furthermore, they unequivocally tell us that the worse the Forward Head Posture, the worse the quality of life (HRQOL).  But here is where the rubber meets the road.  According to these surgeons, the various regions of the spine (cervical, thoracic, lumbar and pelvic areas) are not independent from each other.  The alignment of one affects the alignment of the others.  To top it all off, they admit that alignment affects function; and loss of function causes pain and degeneration (ASD).  The bottom line is that things like alignment and posture matter (the next thing you know they will be telling us that these problems could actually lead to sickness and disease — HERE).  Interestingly enough, loss of normal cervical (neck) curve can not only be measured, but it can effect the cord itself and lead to DJD and severe neurological problems.  I bring all this up because of the work of Dr. Donald Harrison.

It’s almost comical to watch the medical community make these huge “breakthroughs” —- particularly when the chiropractic profession has been saying these very things for decades.  Although he passed away in 2011 leaving his son Deed and others to carry on his work, the elder Harrison’s accomplishments cannot be overlooked.  Dr. Harrison received a doctorate in Applied Mathematics and a master’s degree in mechanical engineering after becoming a chiropractor.  He eventually founded Chiropractic Bio-Physics (CBP), which, over the past two-plus decades, has published approximately 150 peer-reviewed papers in scientific / medical journals on this very topic.

I have found that simply adding “EXTENSION THERAPY” to my clinical protocols (I personally like the Dakota Traction device from Dr. Mark Payne) can not only dramatically improve outcomes, it seems to help many people who struggle with hardcore Trigger Points of their upper traps.  But, in order for Cervical Extension Retraining Devices to be effective, range of motion in the cervical spine must be dealt with on both a sectional basis (Tissue Remodeling) and a segmental basis (Chiropractic Adjustments).  Trying to create cervical extension (put your head back as far as you can to see what I mean) without addressing both the sectional and segmental motion abnormalities (SUBLUXATION and FASCIAL ADHESIONS) can cause real problems as well as pain    (WARNING: Do not try Cervical Extension at home without a trained individual first determining if you are a good candidate, and then receiving instruction on how to proceed). 

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