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Trigger Point Therapy - Sciatica
by Judith Winer on Jan 04, 2016
When we analyse the traffic through our clinics at the end of each quarter, sciatica seems to be always up there in the top ten. There are probably two good reasons for this. The first is that sciatica is one of those conditions where the pain can be extremely severe. The second, is that manual therapy has long since been recognised as being effective for providing relief, even by most medical doctors. In fact, any therapist familiar with trigger point therapy will tell you that they're always upbeat going in to treat sciatica, as the effects of the therapy are in most cases, extremely positive. This is something that has been reaffirmed in a number of studies.
Myofascial Trigger Points
For those of you who have been treating patients and addressing myofascial trigger points (MTrPs) for 20 years or longer, you may remember a day when a diagnosis of trigger points were considered to be "alternative" or "hippie" medicine. "You think my patient has what?" was a common response from many physicians when told about trigger points. Getting health care providers to understand the concept of referred pain with relation to the muscular system was like trying to teach a lion to hate steak.
In recent times, however, there have been some interesting discoveries that are actually backed by good, solid science. Shah et al showed myofascial trigger points by using ultrasound vibration sonoelastography (VSE) which uses an external vibration source in conjunction with Doppler techniques. MTrPs vibrated at a different resonance than the surrounding "normal" tissue making trigger points appear as focal, hypoechoic regions on 2D ultrasound. This imaging technique helped the researchers determine that MTrPs are elliptical in shape, with a size of 0.16 ± 0.11 cm2.1
"But what is happening inside the purported myofascial trigger point?" you may ask. Shah et al gives us an understanding about this. In their paper, the researchers were able to gather extremely small amounts of fluid and determined that concentrations of protons, bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-alpha, interleukin-1beta, serotonin and norepinephrine were significantly elevated in active myofascial trigger points compared to controls.
We can image trigger points. We know they are different internally. How do we assess? Trigger points are best identified and treated when a practitioner follows a specific protocol that not only takes trigger points into consideration as a pain generator, but also other medical conditions that may be responsible for the pain complaint. In other words, they should be included in your differential diagnosis/assessment. Remember that trigger points can be a primary source of pain or secondary due to visceral disease, joint dysfunction, parasitic infection, systemic disorders and others, which is generally more apparent when response to therapy is negligible or transient.
First, a thorough history should be taken. Travell emphasized the importance of this step by saying, "The mystery is in the history." Patients should be instructed to provide a chronology of events that led up to the onset of their condition being sure to include all previous medical diagnoses (regardless of perceived relevance), a listing of all medications, nutritional supplements and any current lab and diagnostic imaging studies.
She said patients should provide dates and places of residence, education, marriages, children living (ages and where they live), sports, travel and employment (what kind, where, for whom). Chronology of medical events should include all illnesses, infections, accidents (e.g., fractures, falls), surgical procedures, pregnancies and miscarriages, allergies (tests and hyposensitizations) and vaccinations.3 She mentions that trigger points are aggravated by elevated histamine levels and active allergies. Testing the skin for dermatographia by marking it is a simple way to identify high histamine levels, according to Travell.
Patient Interview (The History)
When talking to patients about their pain, the practitioner should do two things. First, the patient should be instructed to use one finger and outline the areas of pain while the practitioner documents the described pain on a pain map. Secondly the practitioner should ask specific questions about the other areas of the body that the patient did not mention. This will help determine if there was ever pain in other places, which could indicate a myofascial condition that preceded the complaint with which the patient is presenting.
Discussing the patient's dietary intake is also of importance. Simply asking patients if they eat a "balanced diet" is not always a good practice. Many times patients will state that they are eating well despite having serious diet restrictions, most often vegetarianism. When a patient is not consuming meats, fowl, fish or dairy products, they are at high risk for vitamin deficiencies, including but not limited to deficiencies in iron, vitamin D, B12, etc. Many times the onset of pain can be related to a time that is soon after a dietary change where these types of restrictions are initiated.
Discuss the profession of the patient to determine the types of muscle strain that may occur. Have patients snap a picture of their workstation and include it with their history information. Some practitioners may ask for patients to get a picture taken while they are working. A picture can immediately identify a situation that can cause muscular strain and essentially explain the condition. Use similar techniques when looking at any activity with which the patient spends considerable time, including sports and hobbies.
Although it is possible for trigger points to cause constant pain, more often than not the pain is intermittent and aggravated by specific movements. Many people have found that certain positions can alleviate their trigger-point pain and unknowingly avoid certain movement due to the pain produced while moving through range of motion. Generally, pain from trigger points is described as steady, deep, dull and aching, and rarely as burning or throbbing. Occasionally, trigger-point pain is described as sharp or "lightning-like" stabs of pain.3 Referred tenderness is also a symptom where the area that is sensitized is extremely painful to the lightest palpation, especially when multiple trigger points refer to one area or in a naturally sensitive zone of the body.
Be as specific as possible in questioning. I can recall a situation where I noticed fasciculation of muscle as I was working with a client and also noticed that he was extremely fidgety and talked fast. I looked at the intake form I used at the time that asked about caffeine intake, and the client checked the box next to coffee and listed "one cup." I asked again about coffee, and he confirmed his "one cup" as on the form. Because it really wasn't relevant to me at that time, I let it go. When he came in the next time presenting as even more fidgety, I laughed and asked, "How BIG is that cup?" The client went out to his vehicle and brought in what looked like the coffee dispenser in a convenience store! I immediately changed the "how much" part of my intake to ask for ounces consumed.
This article is the first of three. The next two will discuss medical perpetuating factors for myofascial pain due to trigger points, and useful treatment techniques and self-treatment.
1. Sikdar, S., Shah, J., et al. (2009). Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Archives of Physical Medicine and Rehabilitation, 11(90), 1829-1838.
2. Shah, J., Phillips, T., Danoff, J., & Gerber, L. (2005). An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology, 5(99), 1977-1984.
3. Simons, D., Travell, J., & Simons, P. (1999). Travell and Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. Upper Half of Body. 2nd ed. Baltimore: Williams and Wilkins.
Jeffrey A. Lutz is board certified in myofascial trigger-point therapy and has two offices in western Pennsylvania. He is president-elect of the National Association of Myofascial Trigger Point Therapists, an organization of therapists who specialize in trigger-point therapy (www.MyofascialTherapy.org) and is the technical writer for www.TriggerPointProducts.com. This article was reviewed by Timothy Taylor, MD, CMTPT, director of Pain Relief Home, a practice specializing in the treatment of myofascial pain located in Richmond, VA (www.PainReliefHome.net).
Another book, Why You Really Hurt: It All Starts in the Foot, Dr. Burton S. Schuler highlight Dr. Travell's important contributions to the study of muscle pain, also known as Myofascial Pain Syndrome
Pain research ran in Travell's family. In 1901, Dr. Janet Travell was born in New York City in a family of physicians. (Her father was recognized as an early pioneer in the treatment of pain.) She attended Wellesley College, and then graduated from Cornell University Medical School in 1926, and graduated top of her class. She became a leading expert in treating muscle pain (Myofascial Pain Syndrome) and general pain management http://whyyoureallyhurt.com/resources/dr-janet-travell/).
Because he was suffering from severe pain, President John F. Kennedy, Jr. was fortunate to cross Dr. Travell's path. He also asked her to become his private physician in the White House. She first met Kennedy in 1955, at her office in New York City while he was on crutches. He could not bend his right knee or put any weight on the left foot or side of his leg. After being treated by Travell, he was sworn in as US President 5 years later in 1961. His brother, Robert, credits Travell as the reason Kennedy was able to manage his pain and ascend to the presidency.
What pain management techniques specifically did Travell utilize that would help her treat people such as Kennedy so successfully, earning her the distinguised position of White House physician for both Kennedy and Johnson? The theory of Myofasical Pain Syndrome includes trigger points, which are described in both authors websites and books
Travell co-authored with David Simons a book Myofascial Pain and Dysfunction: The Trigger Point Manual. In this book, they explained how "myofascial trigger points are tiny contraction knots that develop in a muscle when it is injured or overworked. The part of a muscle fiber that actually does the contracting is a microscopic unit called a sarcomere, and millions of sarcomeres have to contract in your muscles to make even the smallest movement. A trigger point exists when over stimulated sarcomeres are chemically prevented from releasing from their interlocked state
It's the innovative research on trigger points that distinguishes Travell's pain research, and it is for this reason she is acknowledged by the Davies' and Dr. Burton S. Schuler in their respective books.
WHAT IS WHY YOU REALLY HURT: IT ALL STARTS IN THE FOOT
Why You Really Hurt: It All Starts in the Foot, tells the story of two famous physicians and their association with the common, but painful, medical condition known as the Morton's Toe. Millions of people suffer everyday with chronic aches and pains from head to toe and don't know why. Many of them have lost all hope, and believe they will have to live with these pains for the rest of their lives. The book is significant because for the first time in seventy years the public is made aware of the importance of the Morton's Toe, and the fact that could be the real unidentified reason (the "medical missing link") for their unending torments. This book will also show how Morton's Toe can also cause fibromyalgia, arthritis, sleep disturbances (RLS), temporomandibular joint pain, and numerous other problems through out the body The good news is that all of these problems can be treated with a simple pad that costs about two to three dollars. The bad news is that in spite of the fact that two of the most famous doctors of the twentieth century were behind the Morton's Toe, most modern day physicians are not aware of Morton's Toe or of it ability of causing pain all over the body. This book took six years to research and write, but Dr. Schuler feels it was worth it because it should be able to help many people get out of pain. The book is disturbed national by the Cardinal Publishing Group. It will be translated to Greek this Year.
If you have ever suffered from the debilitating effects of headaches accompanied by neck and shoulder pain you know firsthand just how important it is to identify the cause of the problem and do everything you can to prevent future incidents.
There are a multitude of causes contributing to headaches and neck pain ranging from overuse or injury of the delicate soft tissue of the neck region to more generalized factors such as occupation, physical, or emotional stress. A long list of other causes can lead to this widespread condition, as well. Recent research suggests that frequently, the causative factors are multilayered and not simply the result of one specific reason.
Pain is often a warning sign from your body and serves the purpose of getting your brain’s attention. For this reason, acute and chronic pain resulting from headaches and neck pain should be taken seriously. It is always a good idea to consult your primary health care provider and make a concentrated effort to determine the cause of your specific condition. It is often necessary to seek help from a specialist who deals specifically with the type of headache that you are experiencing.
Millions of people find relief from pain and discomfort by utilizing the services of Alternative and Holistic health care providers who treat the body as a whole. These natural practitioners may often recommend lifestyle changes or nutritional therapies as well.
Health care providers such as Doctors of Chiropractic and licensed Massage Therapists specialize in treating headaches and neck pain that are due to musculoskeletal imbalance and dysfunction.
Fortunately, there are some things that you can do on your own, naturally, to help ease the pain and discomfort due to a specific type of headache known as a tension headache. Tension headaches are characterized by a band of tightness, pressure or pain around the forehead, temples, and back of the head. Frequently, the pain or pressure in the head is accompanied by stiffness, pain or discomfort in the neck and upper back region.
Often, the pain begins as tightness in the neck and shoulder region and gradually progresses to a full blown headache that can be severe and disrupt every aspect of your busy day. These headaches can last anywhere from 30 minutes to several days and can dramatically decrease the quality of your life and your energy level.
If the above scenario sounds familiar to you, the following information could help you take charge of your health and possibly prevent the frustration and challenges related to tension headaches and neck pain in the future.
Perhaps the most important thing that you can do to end the vicious cycle of muscle related pain is to simply listen to the constant feedback that your amazing body is constantly providing you. If you find yourself in a stressful situation, make an effort to stop, take a few deep diaphragmatic breaths and tune into your physical body.
Most of us have “trigger points” or localized areas of tenderness and tightness in our neck, shoulders, and upper back that serve as red flags or reminders that we are entering into a cycle of muscle tension due to stress. Almost everyone has specific, localized areas that seem to flare up in these areas when they are tired, overworked, or experiencing negative emotions.
If we simply try to ignore these trigger points, they usually increase in strength and become more knotted, tight, and painful, significantly decreasing blood flow and the flow of oxygen and energy to all parts of your body. Often, if we are thinking negative and unproductive thoughts, we are attracting even more stress and tension to ourselves simply by repeating old neural patterns and mental scripts.
When your body perceives a situation as being stressful, it reacts the same as it would to an imminent physical threat. At these times, you may experience some of the same symptoms that are a specific response to the “fight or flight” instinct that helps protect us in times of danger.
These instincts (such as rapid breathing and tightening of your muscles to prepare for flight) come in handy if you are being chased by a bear in the woods, but only make matters worse when you are stuck in a traffic jam or dealing with high stress deadlines and events.
We have all noticed people in stressful situations grab and squeeze the muscles of the upper shoulder near the neck when they are feeling tense and frustrated. Perhaps this is something that you do on a regular basis while sitting at your desk or computer or talking on the phone. You may even stretch your neck from side to side or sigh deeply.
Using your hands and fingers to apply pressure to tight, knotted muscles is a natural response from your innately intelligent body that can help instantly relieve pain and pressure and begin the process of relaxation. Your body gets your attention by sending signals of pain and you recognize and respond to this warning sign by applying acupressure (localized sustained pressure) to specific areas, often without even being aware that you are doing it.
This pressure helps relax and flatten the muscle and keeps the kinks and spasms from knotting up even more. There are many other ways to keep the cycle of muscle spasm and pain from accelerating rapidly. Taking the time to practice meditation or deep breathing, getting a good spinal adjustment or massage, or engaging in cardiovascular exercise can all make a profound difference.
Luckily, there are several safe and effective self care tools that you can use in the privacy of your own home to immediately relieve trigger point pain and prevent tension headaches originating from muscle spasm.
My favorite self care tool designed specifically for this purpose is the Original Backnobber II, manufactured by The Pressure Positive Company.
I like the fact that anyone can use this device at any time in the privacy of their own home or office without having to wait for an appointment. By taking just a few minutes to relax, listen to your body and do something about the cause of muscle related pain, you can prevent a stressful situation from taking a major toll of your body.
When an individual combines the use of the Backnobber with the stretches recommended in the accompanying User Guide, they are also helping to elongate and lengthen tight muscles, decompress joints, and increase range of motion and flexibility throughout the body. Stretching the muscles of the neck and shoulder region naturally decreases painful spasms and increases blood flow to affected areas.
Utilizing self care tools such as the Backnobber can also help the headache and neck pain sufferer gain a measure of control over their symptoms and lead to an increased awareness of other related factors that may be causing their pain and dysfunction.
As a retired Chiropractor and active health and fitness educator, I have treated thousands of individuals and researched numerous products that help relieve pain and discomfort. Over the years, I have heard and seen more positive testimonials related to this product than any other health and fitness tool on the market. I have also used it personally with excellent results.
I like the fact that hundreds of thousands of users have benefited from this simple yet effective product since 1979 and that the company that manufactures this product is passionate about myofascial therapy education and research.
Anyone who has experienced the frustration, challenges, and obstacles that accompany neck pain and headaches can attest to the fact that they can literally control your life and take the fun out of living. Although the causes of headaches and neck pain are numerous, sometimes the sufferer gets lucky by finding one solution to their problem. Hopefully, the information above may just the weapon you need to help yourself or someone you love change their life for the better by permanently eliminating tension headaches and neck pain.
About the Author:
Since 1986, Dr. Suzanne Osborne, aka Dr. Suzy, has earned a reputation as one of the nation’s leading holistic health and fitness experts. Her sincere and passionate “Back to Basics” philosophy has helped countless individuals across the world create healthier, stronger, and more energetic lifestyles.
Dr. Osborne is a cum laude graduate of Life Chiropractic College, a diplomat of the National Board of Chiropractic Examiners, and an active member of the Florida Chiropractic Association.
After treating thousands of patients while in private practice (including World Class and professional athletes) she retired from active chiropractic practice in 2002. Since that time, her primary focus has been on education and helping individuals make positive permanent changes in their daily lifestyles via her website www.pure-life.com .
Dr. Suzy is the author of the book “Pure Life, The Pura Vida Journey" a powerful, groundbreaking guidebook to optimal health. Her articles in magazines and publications such as Chiropractic Wellness and Natural Awakenings have been enjoyed by millions of readers across the world.
Dr. Osborne has appeared frequently on national and international television as a health and fitness expert and is regarded by many to be an early leader in the natural health movement. For reprints of Dr. Suzy’s articles, click on Publications link above.