what is everyones personal experience of the best way to treat acute referring and non -referring trigger points?

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Permalink Reply by Clement Rhein on February 15, 2008 at 10:44pm

I feel it depends on the patient. Either a good sustained prod, and the trigger point may go straight away, or take a few seconds.

For others though, that doesn't seem to work (i've tryed it for minutes on end - poor patients :-)). So I try functional inhibition which I find works (more or less) prrety much everytime.

These two techniques seem to work best for me.

What do you do?

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Permalink Reply by Ross on February 17, 2008 at 1:44pm

I like to squash em too!, I also use a bit of short duration needling <3mins with an occassional twiddle but a way that i use a lot and that often works really well is leon chaitow's PINS (progressive inhibition of neuromuscular structures) It started when I found this old video in my college library of him doing it. It seems to be a combo of inhibition , counterstrain and post isometric relaxation and its quite a nice technique as it has a pleasant indirect but effective "feel" to it. It seems to me that it works slightly better in really resistant cases of refferring trigger points and that they stay away for a bit longer.\ obiviously every patient's mechanism is different but I found that this way seems to get the little blighters from all neurophysiological angles

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Permalink Reply by pierre de lasteyrie on February 17, 2008 at 3:10am

Trigger points ?

Effectively the good old prod is a way to do it. the sane with functional inhibition.
You can use the strain/counter strain techniques (personally I don't use i that much) it is said to be particularly effective on trigger points.
If you want to treat 2 patients at the same time you can use dry needles because you need to leave them for a good 15 min. This works really well when you hit the trigger point, which is not that easy.Some osteos use dry needles and some cranial techniques at the same time.
Another way to work on trigger points is to press on it and at the same time you lengthen/shorten rythmically the concern muscle.I think there is a special name for this technique that I don't know.

What is quite good generally is to apply a MET technique after your trigger point technique.

Good luck !

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Permalink Reply by Ross on February 17, 2008 at 1:58pm

I think thats called pin and hold, I quite like it but only tend to use it when theres abberations of passive/active insuffiency across one or more joints. I also dont use much stand alone counterstrain as it seems to work for a little while but then comes back just the same, dont know if I'd needle for 15mins though, I think that would possibly aggravate some presentations. I think needling works like a switch on the limbic system and it doesnt seem much sense to press it for a long time when just a wee while will do, the guy who taught me needling said that newish research showed that long duration often negated the effect. But I have no idea personally as ive never left one in for that long.

Do you find that some muscles need you to hit the Trp almost exactly (extensor digitorum longus) and others just need it anywhere in the myotactic unit (like trapezius) cos I do and I think thats strange and interesting

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Permalink Reply by Michael Kuchera_DO on February 18, 2008 at 1:57pm

David Simons and I have been discussing "triggerpoints as a specialized form of somatic dysfunction" and from this perspective I have to say that we should continue to do those things that we do as osteopathic practitioners ... namely look locally but think and treat globally as needed.

So sometimes treatment of the trigger within the taut band will undo the entire complex of findings while other times, unless the related cervical articular dysfunctions (for example) are specifically addressed t he muscle dysfunction (TrP) returns. For example:
• upper trapezius TrPs common with articular somatic dysfunction of C2 and/or C3 and hypermobility of C4
• splenii cervicis TrPs common with articular C4 and/or C5 dysfunction
• levator scapulae TrPs common with articular somatic dysfunction anywhere between C3 and C6

I also find for resistent/recurrent sternocleidomastoid TrPs that the combination of V-spread to the occipitomastoid suture (for CN XI) followed by counterstrain to the A7C &/or A8C (SCM points) and then (depending on the amount of swelling around the muscle and its residual irritability) I might add just a bit of Ruddy's Rapid Resitive Duction (as an SCM muscle pump).

The occipitomastoid release is also key in recurrent upper trapezius triggers.

I used to inject triggers quite a bit, then as I got better with my spray & stretch, I used vapocoolant ... until a small ozone hole opened over Kirksville ... and I all but abandoned the needles that my patients hated. Now with the prices on the vapocoolant, I find that treating the "patient" with OMT and using the point as feedback as to whether or not I found the right combination of local point and predisposing factor treatment seems to do the trick.

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Permalink Reply by Ross on February 18, 2008 at 2:57pm

Thankyou Dr Mike,

I think its very interesting how the articular dysfunctions associated with Trps are so often almost the same, patient after patient regardless of individual morphology. I presume this has got a lot to do with sites of muscle attachment but i also think that fibre length/arrangement plays a part too as it dictates vectors of mechanical pull and the pattern of endplate zones throught the muscle.

Whilst on perpetuating factors, Travell and Simons Myofascial pain and Dysfunction V1 has great sections at the start (for anyone whos interested...) about the various internal/external factors that influence trp formation, including nutritional defiency, postural considerations etc...

I once had a female patient for example who was suffering from progressively worsening occasional jerky spasm (resembling mild myoclonic jerks) and tender points in all limbs and had bounced off the neurolgist with a diagnosis of "nothing wrong" after CT MRI (no EMG!!!) After extensive clinical examination I put her on a folic acid supplement as a diagnostic manouver whilst waiting for the letter begging the neurologist to do an EMG and have another look was processed and the symptoms were all but completely resolved in a week. As far as I understand deficiency in any of the water soluble vits can perpetuate trigger points aswell as certain minerals and trace elements.

Here In the UK its illegal for anyone to use spray and stretch due to environmental concerns, but you could use an ice pack instead of vapocoolant, Ive tried with variable results but it does seem to work quite well for post radiculopathy soreness/referred spasm in the distribution of the sciatic nerve

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Permalink Reply by Michael Kuchera_DO on February 18, 2008 at 3:36pm

In response to the environmental concerns, Gebaur put out a new vapocoolant to replace the fluorimethane. If you use ice on a stick, then wrap in cellophane so that the melted water doesn't insulate the ability to stimulate the Krauss cold receptive fibers without chilling the muscle.

The Travell and Simons Myofascial Pain and Dysfunction texts are absolutely brilliant and a must for anyone seriously treating the musculoskeletal system osteopathically. If you get both volumes, make sure that you get the 2nd edition of vol I by Simons, Travell, and Simons because of the extensive integration of osteopathic contributions. (There is no 2nd edition of vol II -- below the diaphragm -- and the next stage will be a unified third edition that Simons has been working on).

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Permalink Reply by Ross on February 18, 2008 at 4:54pm

Absolutely agree with you on Travell and simons texts, as i dont think nearly enough is taught about mtps in UK osteopathic institutions(they dont have the time what with an already full syllabus), I would go on to say that Foundations for Osteopathic Medicine is also an essential resource for the prospective student/practicing osteopath.

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Permalink Reply by Kiran Ul-Haq on March 12, 2008 at 9:59pm

I also think that it depends on the patient and also where the particular point is.
I did a strain-counterstrain course last sunday and there were particular points on myself that were easily treatable, and there were a few points that just didnt seem to respond to treatment. I think it depends upon the complexity of the underslying problem as well as how long that particular trigger point has been "active". Though this is not based upon clinical experience yet so I am excited at the prospect of trying out this treatment method.
The occipitomastoid release, for example, was effective on some of my colleagues. Nice :) .... very nice! :)

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