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Handling Pain at the Trigger Point
Handling Pain at the Trigger Point
By Debbie Cleveland
Tuesday, November 22, 2005 10:03 AM EST
When you wake up in the morning, and you have a knot in your shoulder, have you ever wished that there were some sort of “button” that you could push and have the pain go away? Well, if a trigger point causes the knot, then relief could be right under your fingertips, literally!
Janet Travell, who is recognized as the leading pioneer of diagnosis and treatment of trigger point therapy and referred pain, defined them as “a highly irritable localized spot of exquisite tenderness in a nodule in a palpable taut band of muscle tissue.” Which, in plain English, means a trigger point will really hurt when you press on it. The “nodule” she was talking about, is the actual trigger point. The “taut band” is your very tight muscle.
Trigger points will often feel like a knot, or a lump that can range in size from about the size of a pin “head” to about the size of a pea. In larger muscles, they may be about the size of your fingernail. Trigger points can cause headaches, neck and jaw pain, low back pain, tennis elbow, and carpal tunnel syndrome.
They are often the source of pain in joints, such as the shoulder, wrist, hip, knee, and ankle. In addition to pain, the effects of trigger points can include limited range of motion, muscle weakness, and numbness or tingling.
There are two types of trigger points, active and latent. All trigger points cause pain when pressed; however, “active” trigger points frequently refer pain to other areas of the body. This explains why the pain you are experiencing in your head may actually be coming from a trigger point in your shoulder, or the pain in your lower back may originate from the deep muscles in your hip.
A “latent” trigger point will still feel like a lump or knot, but only produces pain when pressed upon, and won't give the same referral pain as an active point.
Some of the causes of trigger points are stress, both external stresses and postural stresses, such as poor posture, prolonged isometric contraction, (working at the keyboard), and strain to the muscle.
Trigger points are also thought to be caused by poor nutrition, such as vitamin B, C or folic acid deficiency, hypothyroidism and depression and anxiety.
Trigger points will keep the muscles tight, restricting blood flow and compressing nerves, causing a vicious pain/spasm cycle in the muscles.
This may result in decreased flexibility, limiting movement and encouraging bad postural patterns that may continue the cycle for years.
Massage therapy, specifically trigger point therapy, is one of the best methods to help you get relief from the pain that trigger points bring.
Although this statement is true, one of the things my clients tell me that they dislike about this treatment is the fact that trigger points hurt when compressed.
Some people are reluctant to have trigger point therapy done, but the important thing to realize is that if done correctly, it will be a “good” pain.
Your massage therapist will be able to incorporate trigger point therapy into your session, so that by relaxing the muscle and attachments first, it is easier to access the trigger point, and the degree of pain may be somewhat less.
If you are doing self-treatment, you will want to use deep stroking massage prior to specific trigger point work. According to Clair Davies, who authored the book “The Trigger Point Therapy Workbook, compressing the trigger point is the right idea, but a repeated milking action moves the blood and lymph fluid out more efficiently.”
To work out your trigger point, begin by warming the affected muscle with slow, repetitive muscle strokes, along the entire length of the taut band within the muscle. Work from one end of the muscle to the other.
Your pressure should start out light, and gradually increase. Follow this with compression on the trigger point, using a trigger point tool if possible to save putting strain on your hands. Hold for 7 to 10 seconds, breathing deeply through the pain.
Then release, and move the affected muscle through its range of motion, so that you can feel the release of the trigger point.
When deciding what constitutes “good” pain versus “bad” pain, use your judgment. Davies states, “Aim at a pain level of seven on a scale of 1 to 10.” But only you will be able to decide what you can tolerate and what you cannot. Repeat this sequence of compression and movement; using the number scale suggested by Davies, until your pain level is about two or three.
Often you will see some immediate improvement, but don't worry if it takes you a few sessions to feel relief.
Used correctly, trigger point therapy can be a great tool in helping to reduce pain, and gain greater range of motion, as well as reduce chronic pain.
If you have questions about this type of self-massage therapy, ask your massage therapist or physician about trigger points and myofascial pain. I recommend reading “The Trigger Point Therapy Workbook,” by Clair Davies. (www.triggerpointbook.com)
Debbie Cleveland is a licensed massage therapist in Elbridge
The following is an excerpt from the book, "Taking Charge of Fibromyalgia", by Julie Kelly and Rosalie Deveonshire. It is written by Mary Biancalana, B.S., M.S., C.M.T.P.T. Contact her at MYOPain.com.
Fibromyalgia and Self care: Self-care: Treating Trigger Points and Myofascial Pain Yourself
A good Self-Care routine consists of:
- Warm-up or heat
- Use of compression tools
- Stretching and relaxation of the muscles
- Full range of motion of the joint close to the compression
These steps are extremely important in coping with and decreasing the pain from trigger points or fibromyalgia pain symptoms if trigger points are present. By using simple, self-care protocols, you will gain power over your pain, feel less helpless, and begin to live a fuller, more pain-free life. Compression helps you become aware of areas held in chronic tightness. By becoming aware of tightness or tension in the muscles, you will be able to begin to notice when the muscles are contracting for no reason, and you can breathe and concentrate on relaxing held tension. This self-care technique helps to break up the pain-tightness-pain cycle present in myofascial pain and fibromyalgia patients.
Self-care activities allow you to feel empowered and proactive in your journey to achieve reduced pain and fuller function in your life. Because a large percentage of fibromyalgia patients may have developed trigger points in their muscles (myofascial pain syndrome), it is important that you evaluate your pain on a muscle-by muscle basis to determine if trigger points are a source of pain for you. Many muscle pains are actually referred from a distant trigger point location. In realizing that muscle pain from trigger points is referred to a distant area, it is important to know that pressing where it hurts probably will not help much with reducing your pain. A far distant muscle may actually be causing the deep ache, sharp pain, or weakness you are feeling. To effectively reduce the pain, it is important to locate the exact trigger point area that is causing the referred pain.
Recommended Self-Care Protocol
Warm-up or heat
Try to apply some form of heat to the area that you will be compressing. A warm shower, bath, hot tub soak, water bag, or another type of moist heat wrap will provide heat to areas that have hard, tight muscles or dysfunctional tissue. This heat helps to provide local circulation and will help you break up the pain-tightness-pain cycle. A warm-up can also be five to ten minutes of light exercise or local movement.
Compression: Using a good referred pain index or chart, locate muscles and trigger points you intend to treat. This can help you determine exactly where to apply compression. Press on the area of hard, tight tissue, gently but firmly, breathe, and continue pressing for 30 to 60 seconds. Try to relax any tightness in the area that you are compressing. It is important to keep the muscle in a position of good neutral posture or on a slight stretch. Breathe from the diaphragm, not from the chest, and hold for a cycle of three relaxed breaths. Slowly remove the pressure and relocate your tool (or finger) to another spot. As you become experienced with this technique and learn what feels best, you may hold for a shorter or longer time depending on your ability to relax the area.
Follow immediately with the next step in the protocol, which is stretching.
Stretch or actively contract and relax:
After you have compressed a particular group of muscles or area, you are ready for a gentle and relaxed stretch of those muscles. Breathe in as you begin the stretch. Stay relaxed and do not pull to the point of pain, just a feeling of stretch. Hold and try to relax into the stretch as far as you can. Take a final breath and exhale as you complete your stretch. Actively contracting the muscle, holding, then exhaling and releasing into a further stretch is another technique to use. Go on to the next and final stage.
Range of motion movement
This component is extremely important when you have fibromyalgia or myofascial pain syndrome, because having pain usually causes us to hold and guard a joint or area. When muscles are inhibited, they develop more trigger point areas and worsen the pain-dysfunction-pain cycle. Remember, we are trying to break up these muscle-holding patterns. Movement should be done in all different planes: forward, back, rotation, twist, flex and extension are all important. Put on your favorite music and breathe while aiming for a smooth, gentle range of motion and movement.
*This self-care protocol can help you improve your function and experience less pain. Follow this sequence as many times a day as possible. Enjoy and feel empowerment over some of your fibromyalgia symptoms!
Examples of trigger point therapy or self-care: (Back to Top)
A tennis ball in a stocking or sock can be a useful tool for myofascial compression in many areas. The key is to be relaxed and not to use any muscular effort in the area that you are compressing.
The Trigger Point Therapy Workbook, 2nd Edition by Clair Davies, is an excellent resource to help guide you in treating your trigger points. This book shows where trigger points are located in every muscle of the body and how to treat them.
You must eliminate or correct perpetuating factors before eradicating trigger points indefinitely. If you have abnormal bone structure or postural problems due to poorly designed chairs or work stations, perform repetitive movements that aggravate muscles, or are sedentary, you may have to change those factors before feeling better. Sometimes, your sleeping position can aggravate symptoms, particularly if you sleep on your stomach or in a fetal position. Using a pillow between your knees while sleeping can help relieve knee, leg, or back pain, and a pillow at your chest to rest your arm on while sleeping can help reduce arm, neck, or shoulder pain. Some people have one leg that is shorter than the other, differences in their hips, short arms, foot or toe abnormalities, or spinal rotation that can contribute to pain. Specially trained myofascial trigger point therapists, hands-on therapists, physicians, or chiropractors can evaluate these problems and help correct them.
Dr. Travell believed that vitamin deficiencies must be cleared up before trigger points can be defeated. Vitamins that she felt are important and may be deficient are B1, B6 and B12, C, folic acid, calcium, iron, magnesium, and potassium. She also theorized that metabolic disorders such as thyroid insufficiency, estrogen insufficiency, hypoglycemia, and high levels of uric acid present in the blood must be corrected before trigger points can be erased. Dr. Travell believed that nicotine, caffeine, and alcohol should be avoided because of their negative effects on metabolism. Many physicians and patients are finding that in order to help reduce FMS symptoms, patients must improve their nutrition, balance their hormones and watch their diet.
Some other modalities which help relieve trigger points include spray and stretch, trigger point injections, botox injections, myofascial release, acupressure, and compression and stretch.
*Myofascial trigger point therapists are specially trained in treating this problem. To find a trained therapist in your area, contact the National Association of Myofascial Trigger Point Therapists.
- Promotes deep muscle relaxation s Loosens tight muscles
- Increases circulation
- Relieves pain and spasms
- Reduces stress
Heat is often used before massage to help relax painful and tight muscles. While many people with fibromyalgia initially receive massage as a part of their physical therapy, many continue massage with a massage therapist after physical therapy has been completed. Massage therapists often practice in health clubs, local YMCA or YWCA facilities, or private offices. Check your yellow pages for certified massage therapists and ask to be scheduled with a therapist who has worked with clients who have FMS. Although massage therapy is often not covered by insurance, it may be well worth the cost if it helps you to feel better and remain active and productive.
- Frees up constricted areas
- Releases pressure
- Relieves pain
- Promotes the flow of blood and lymph
- Improves range of motion
The fascia is a tough connective tissue that surrounds every muscle, bone, nerve, blood vessel, and organ of the body. When it surrounds muscle, it's called myofascial tissue. It can be described as a three-dimensional stocking that runs from head to toe. Fascial restrictions often occur in people with fibromyalgia and feel like "knots" or "bands" of tight and painful muscle. The fascial restrictions may be altered by myofascial release. When the therapist has determined where the contracted "bands" or "knots" are in the muscle, he or she applies gentle pressure in the direction of the restrictions. This gentle, hands-on technique can free up constricted areas, release pressure, relieve pain, promote the flow of blood and lymph, and improve range of motion.
Spray and Stretch
- Use to manage myofascial pain
- Spray skin over tight muscle group
- Stretch muscle gently
This technique uses a vapo-coolant spray on a particularly tight muscle group or to manage myofascial pain. The spray deadens the pain while the contracted muscle is stretched by the therapist. This technique can help stretch tight muscles and deactivate trigger points. After receiving instructions on how to perform spray and stretch from your therapist, you may use the technique at home. It is helpful to request that a family member or friend also be instructed in this technique by your therapist because it is difficult to do by yourself. Ice can be used instead of the spray to elicit a similar response. Cooling, topical analgesics may also be used.
Stretching with Heat
- Apply moist heat.
- Stretch muscle gently.
It can also be helpful to use heat before stretching a muscle group. In order to facilitate stretching, the muscle must be as relaxed as possible. This can be accomplished through moist heat in the form of hot packs, a hot tub, or by directing a hot shower on the muscle. Apply the moist heat for 10 to 20 minutes.
Then gently stretch the muscle until an easy stretch is felt; hold for 10 to 20 seconds or a bit longer and then relax. This technique can gradually stretch out the contracted muscle and surrounding myofascial tissue. Adding epsom salts or essential oils to the bathwater may be helpful.Stretching without the use of ice or heat throughout the day can also be helpful, but remember to stretch gently.
*Important Note: If you have had recent surgery or have a muscle or joint problem, including hyper-mobility, consult your healthcare professional before stretching.
Heat, Ice, and Acupressure
Heat may be helpful before a massage and before your stretching exercises; heat may also be used to aid relaxation, pain relief, and muscle stiffness. Microwavable gel packs, heating pads, warm baths and showers, whirlpools, down quilts, long underwear, and paraffin baths are examples of heat sources. Paraffin baths are designed to be used especially on hands and fingers. Liquid paraffin has the advantage of applying even heat to all joints of your hands and fingers, decreasing pain and stiffness and increasing blood flow. If you choose to use a hot pack, place a light towel between your skin and the hot pack and leave it on the area for approximately 20 minutes.
- Avoid prolonged exposure to heat sources that could cause burns and check your skin periodically
- Do not go to sleep with a heating pad on. The local application of ice can decrease pain, muscle spasms and swelling.
- Frozen gel packs, ice packs, and packages of frozen vegetables are examples of ice sources. Place a light towel between your skin and the ice pack and leave the pack on the area for approximately 10 to 20 minutes.
- Check your skin periodically. If the area being treated turns white or blue, discontinue treatment immediately.