Trigger Point Therapy

Pembimbing: dr.Semuel A.Wagiu, Sp.S

By: Hapsah Faradina Umarella
2012-83-023
Introductions
1. How many here know what myofascial pain is?
2. How many know what a trigger point is ?
3. How many have experienced a tightness in your muscles causing you
to lose ROM and cause pain ?
Objectives
1. Provide facts and understand of myofascial pain syndrome (MPS)
and trigger points (TrPs)
2. Provide you with techniques to self treat MPS and TrPs
3. Provide guidelines for the prevention of MPS and TrPs
Facts
1. Currently reported to affect approximately 85% of the population at
some point during their lives
2. The mean prevalence of this condition among middle-aged adults
(30-60 years) is reported to be 37% in men and 65% in women
3. In the elderly (>65 years), in the prevalence reaches 85%
What is Myofascial
Combination of two Latin words:
“Myo” meaning muscle
“Fascia” meaning connective tissue surrounding the muscle
What is Fascia ?
1. Tough connective tissue that
lies just under the skin
2. It surrounds every organ,
muscle, bone, nerve and blood
vessel
3. Extends uninterrupted from
head to toe
What is a Trigger Point (TrP)
1. Hypersensitive areas
2. Palpated as a nodule within a tight band of muscle
3. Can cause pain, tingling, burning, weakness and loss of range of
motion (ROM)
 Brief History
1. 1930s- Dr. Hans Langue used sclerometer to prove that tender areas in muscles are
50% harder than surrounding areas
2. 1940s- Janet Travell developed trigger point injection therapy and termed the
“tender areas” described by Dr.Hans “Trigger Points”
3. Travell’s therapy called for the injection of saline (a salt solution) and procaine
(also known as Novocaine, an anesthetic) into the trigger point
4. Travell maped what she termed the body’s trigger points and the manner in which
pain radiates to the rest of the body
5. Travell’s work came to national attention when she treated President John
F.Kennedy for his bak pain
Correlation Between TrP and MFP
1. MFP is an umbrella term that is given to TrPs and referred pain
2. TrPs are the TRUE source of soft tissue pain
3. MPS is more of a medical “garbage” term expressing the fact that the
person is experiencing broad soft tissue pain unrelated to any
possibly the results of multiple TrPs with referred pain
4. Tight MF and or tight, fatigue, strained muscles can develop active
TrPs therefore creating pain
 Myofascial Pain Syndrome
a. Chronic or acute pain disorder
b. Initiated trough TrP’s, inducing referred pain into a specific body
region depending on the muscle involved
c. Typically occurs after a muscle has been contracted repetitively
d. Untreated it can cause tightness, tenderness, stiffness, popping and
clicking, loss of ROM
 The Trigger Point Complex
How are they formed ?
Increased neural input to muscles, macrotrauma, or repeated microtrauma  Ca
release  prolong muscle contraction  depress circulation  lack of O2 intake
 ATP decreases  muscles are unable to relax.
The Trigger Point Complex
 Different Types of Trigger Points
The main types of trigger point are:
a. Active trigger points
b. Latent trigger points
Latent Trigger Point
Latent MTrPs are usually asymptomatic, do not cause pain during daily
activities, but are painful when given external stimulation, such as
palpation, and can be activated if muscles are tense, tired, or injured.
Active Trigger Point
Active myofascial trigger points
will cause pain, thereby preventing
maximal muscle lengthening,
muscle weakness, mediating local
twitch response when stimulated,
and causing referred pain in the
area of pain concerned.
Symptoms of Trigger Points
Active trigger point referral symptoms:
1. Pressing Pain
2. Stabbing
3. Burning
4. Referred Pain
5. Common reports of the headaches, dizziness
Referred Pain
“Pain that arises in a trigger point, but is felt at a distance, often entirely
remote from the source”
Referred Pain Patterns
Prevalent in the head, neck, shoulders, hips and low back
Referred Pain Guide
Sternocleidomastoid and Masseter
Referred Pain Guide
Trapezius
Referred Pain Guide
Pectorals
Referred Pain Guide
Quadratus lumborum
Referred Pain Guide
Piriformis
Referred Pain Guide
Glute maximus, medius and minimus
Referred Pain Guide
Tensor Fasciae Latae
Referred Pain Guide
Vastus Lateralis
Referred Pain Guide
Hamstrings
 Sign and Symptoms
a. Tight muscle
b. Tender points in muscle
c. Palpable nodules
d. Decreased range of motion
e. Weakness without atrophy
f. As dull, achy, or deep pain the radiates and is non specific
g. Local spasm in affected muscle
 Other Symptoms
A sensation of: A loss of:
a. Numbness a. Flexibility
b. Fatigue b. Range of movement (ROM)
c. Weakness c. Muscular power and strength
Diagnose
The typical findings complained of by myofascial pain patients include:
•The range of motion (ROM) of the servical spine is often limited and
painful
•The patient may describe as a lump or painful lump in the trapezius or
cervical paraspinal muscles.
•Massages can often help, as can provide a burning sensation to the
surface of the skin
•The patient's sleep may be disturbed by pain
Diagnose
•Turning the neck while driving is difficult
•The patient may describe pain radiating to the upper limb, accompanied
by numbness and tingling, making it difficult to distinguish from
radiculopai or peripheral nerve displacement.
•It is possible for the patient to feel dizzy or nauseous
•The patient experiences pain radiating in a characteristic pattern that
switches from trigger points.
Diagnose
Common findings on physical examination include:
1. Bad posture
2. Trigger points are often seen on m. trapezius, m. supraspinatus,
m.infraspinatus, m. rhomboids, and m. levator scapula
3. Tight muscle protrusions are palpable on the skeletal muscles
4. ROM in the cervical spine can be limited
Differential Diagnose
1. Sciatica
2. Migraine headaches
3. Fibromyalgia
4. Plantar fasciitis
5. Thoracic outlet syndrome
Predisposes
Treatment
1. Self treatmens: Strecthing, massage, heat or ice, foam roller, trigger
ball, strengthening
2. Medical treatments: Trigger point injection, acupuncture
3. Rehabilitation: Ultrasound, stretch and spray, therapeutic massage,
electrical stimulation
Myofascial Release
1. Technique used to help lengthen the muscle and fascial layers and
enable them to remain in the lengthened state
2. Goal is to decrease the amount of tension to the trigger points and
decrease their hypersensitivity
 Pharmacologic Management of
Myofascial Pain/Trigger Points
a. NSAIDS (ibuprofen)
b. Muscle Relaxants (Cyclobenzaprine, Methocarbamol,
Baclofen,Tizanidine)
c. Injections: Saline, corticosteroids, lidocaine/bupivicaine
d. Topical Therapies: NSAIDS, capcasin, analgesics, methyl
salicylate/menthol cream
 Trigger Point Injection
Set Up:
1. Lidocaine 1 % & Bupivicaine
2. Sterile gloves
3. Alcohol swab
4. 1.5 inch needle
5. Tape/plester
6. Have assistant to help you draw up
lidocaine/bupivacaine
Trigger Point Injection
Mark your patient
Trigger Point Injection
One technique
Post Procedure Care
1. Stretch
2. Heat
3. Will be sore for 2-3 days but effects can last several days to weeks
4. May have some bruising
 Prevention
a. Ergonomics
b. Posture training
c. Exercise
d. Stress management
Prognosis
If patients with myofascial pain receive appropriate treatment (eg,
physical therapy, massage therapy, stretching techniques, injection at
trigger points), the prognosis is generally good. However, relapses can
be common
Take Home Points
1. Myofascial pain and TrPs are cause from a contraction of the muscle
fibers, such as repetative motions or injury
2. Self techniques that help enchance the treatment of MPS and TrPs
include stretching, strengthening, foam rolling and massage
3. Techniques involved in the prevention include ergonomic, postural
training, exercise and stress management