Trigger Points Therapy

Trigger Points Therapy is the treatment of rigger points (Deactivation) or Release of trigger
point.

What are trigger point?

A Myofascial Trigger Point (MTrP) is a hyperirritable spot, a palpable nodule in the

taut bands of the skeletal muscles' fascia. Direct compression or muscle contraction can
elicit jump sign, local tenderness, local twitch response and referred pain which usually
responds with a pain pattern distant from the spot. MTrP is a distinct, discrete and constant
pattern or map of pain with no gender or racial differences able to reproduce symptoms.

Reproduce Symptoms
1- Jump sign is the characteristic behavioral response to pressure on a MTrP. Individuals
are frequently startled by the intense pain. They wince or cry out with a response
seemingly out of proportion to the amount of pressure exerted by the examining fingers.
They move involuntarily, jerking the shoulder, head, or some other part of the body not
being palpated. A jump sign thus reflects the extreme tenderness of aMTrP. This sign
has been considered pathognomonic for the presence of MTrPs.
2- Local twitch response - defined as a transient visible or palpable contraction of the
muscle and skin as the tense muscle fibers contract when pressure is applied. Coursed
by needle penetration or by transverse snapping palpation.
3- Referred pain, also called reflective pain, is pain perceived at a location other than the
site of the painful stimulus. Pain is reproducible and does not follow dermatomes,
myotomes, or nerve roots. There is no specific joint swelling or neurological deficits.
Pain is from a myofascia.

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 How does it develop?
Trigger points develop in the myofascia, mainly in the center of a muscle belly where the
motor endplate enters (primary or central MTrPs)[5]. Those are palpable nodules within the
tight muscle at the size of 2-10 mm and can demonstrate at different places in any skeletal
muscles of the body. We all have MTrPs in the body. Can be present even in babies and
children, but their presence does not necessarily result in the formation of pain syndrome.
When it happens, MTrPs are directly associated with myofascial pain syndrome, somatic
dysfunction, psychological disturbance and restricted daily functioning.
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Trigger points (TrPs) have the potential to:

1- create pain. 2- limit range of motion (ROM). 3- restrict functional activities.

- All these 1, 2 and 3 should be addressed as part of a comprehensive physical therapy

management.
Types of Trigger Points
Inactive /Latent and Active Trigger Points
1- Inactive or Latent TrPs:
• can develop in anywhere and under fingertips feel like lumps, but are
not painful.
• Inactive TrPs can eventually become active if there is a provocative
factor.
2- Active TrP
• is the point that causes tenderness and referral pain pattern on
palpation.
• Almost always central TrPs are active and some satellite TrPs are also
active (but not necessarily all of them).
Activators factors for trigger points
Any kind of muscle overuse or direct trauma to the muscle can lead to the
development of TrPs.
Causes of trigger points development

1- Ageing.
2- Injury sustained by a fall, by stress or birth trauma.
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 3- Lack of exercise - commonly in sedentary persons.
4- Bad posture - upper and lower crossed pattern, swayback posture, telephone posture,
cross-legged sitting.
5- Muscle overuse and respective micro-trauma – weightlifting.
6- Chronic stress condition - anxiety, depression, psychological stress trauma.
7- Vitamin deficiencies - vitamin C, D, B, folic acid and iron.
8- Sleep disturbance.
9- Joint problems and hypermobility.

Physiology of trigger points

There are several theories on the pathogenesis and pathophysiology of trigger points
development in myofascial pain syndrome (MPS). The most important: Muscle spindle,
the neuropathic process, scar tissue and terminal buttons and dysfunctional energy crisis.
1- Muscle spindle hypothesis
2- Neuropathic process hypothesis
3- Scar tissue hypothesis
4- Dysfunction of Endplate

Examinations of trigger points

1- Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal

consistency. Localization of a trigger point is based on the therapist sense of feel,
assisted by patient expressions of pain and by visual and palpable observations of local
twitch response. This palpation will elicit pain over the palpated muscle and/or causes
radiation of pain toward the zone of reference in addition to a twitch response. The
commonly encountered locations of trigger points and their pain reference zones are
consistent.

2- Algometers are:
- devices that are designed to quantify and document of pain intensity
level.
- The rate at which manual force is applied should be consistent to provide
the greatest reliability.
- Algometer easily measures pressure pain thresholds and pain tolerances
reported by patients. Algometry is ideal to evaluate trigger point
tenderness.
- Pressure algometry is a reliable measure of pain in muscle, joints, ….
- Used to determine the effect of a treatment by measuring the
tenderness; pain threshold level of these points before and after
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 treatment. If the points decrease in pain after treatment, the treatment
may have had a positive global effect.
- No laboratory test or imaging technique has been established for
diagnosing trigger points. However, the use of ultrasonography,
electromyography, thermography, and muscle biopsy has been studied.

Deactivation (Release) of Trigger Points Techniques

Deactivation trigger points techniques include:

1- Manual deactivation trigger points techniques application of ischemic pressure
and stretch, the muscle energy technique and the Strain-counter strain
technique.
2- Non manual deactivation trigger points techniques
a- Botulism toxin injections. b- dry needling. C- Acupuncture.
d- Ethyl chloride spray. e- Spray-Stretch technique.

f- Integrated neuromuscular inhibition.

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 1-Manual Approaches to Trigger Points Deactivation (Release)

a- Ischemic compression
It is another manual therapy technique which is frequently employed as a means of
deactivating TrPs. It involves applying direct sustained digital pressure to the TrP with
sufficient force over dedicated time duration, to slow down the blood supply and relieve
the tension within the involved muscle. The pressure is gradually applied, maintained
and the gradually released. One proposed mechanism for the benefit of ischemic
compression was explained by Hou et al. Hou and colleagues suggested that pain and
muscle spasm relief from direct digital pressure may result from the reactive hyperemia
produced in the area, or from the spinal reflex mechanism.

b-Muscle energy techniques (METs): (as studied before)

METs have been recommended as a means of managing TrPs .METs are a commonly
utilized method for achieving tonus release (inhibition) in a muscle before stretching. The
approach involves the introduction of an isometric contraction to the affected muscle
producing post-isometric relaxation through the influence of the Golgi tendon organs
(autogenic inhibition). It may also be applied to the antagonistic muscle group producing
reciprocal inhibition in the offending agonistic muscle(s). It is hypothesized that the
sequence of muscle and joint mechanoreceptor activation evokes firing of local somatic
efferent. This in turn leads to sympatho-excitation and activation of the periaqueductal gray
matter, which plays a role in the descending modulation of pain. Owing to stimulation of
mechanoreceptors, simultaneous gating of the nociceptive impulses takes place in the
dorsal horn of the spinal cord.

c- Strain–counter strain (SCS) techniques (as studied before)

SCS has also been utilized in the manual treatment of TrPs. This approach involves
identification of the active TrPs, followed by the application of pressure until a nociceptive
response is produced. The area is then positioned in such a manner as to reduce the tension
in the affected muscle and subsequently the pain in the TrP. When the position of ease/pain

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 reduction is attained, the stressed tissues are felt to be at their most relaxed and a local
reduction of tone is produced.

d- Integrated Neuromuscular Inhibition (INIT)

It is suggested that combination of ischemic compression, MET, and SCS produces the
most effective, targeted approach to TrP release. This method is termed the integrated
neuromuscular inhibition technique (INIT). He has suggested that the benefit of the
technique lies in its multifaceted approach. The INIT approach allows for delivery of the
techniques in a single coordinated manner

Main components of INIT

1-Ischaemic compression. 2-SCS technique.

3- Isometric contraction.

Ischemic compression

Ischemic compression using elbow

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The therapist utilizes a pincer grasp, placing the thumb and index finger over
the active TrP. Slowly, increasing levels of pressure was applied to the trigger
point, but not sustained Rather an on and-off pressure application was
suggested, 5 seconds of pressure, 2-3 seconds release, following by a further
5 seconds of pressure, and so on repeated until a perceptible change was
palpated.

NB:

1- The target muscle should be relaxed as much as possible.

2- Knowledge of the anatomy and mechanical actions of muscles is
important for locating the muscles.
3- Active contraction is performed initially by the patient in order to
help therapist locate the muscles of intere, therapist should be
sure that the patient is completely rested before beginning
palpation.

Palpation Techniques

1- Three key palpation techniques: flat, snap- ping, and pincer palpation.
2- These methods are differentiated for teaching purposes, but therapist
often overlap them once expertise is established

Flat Palpation

3- In flat palpation, the clinician uses the pads of the fingers to move across
the fiber orientation of the muscle while compressing over a firm or bony
underlying structure . This movement allows detection of changes in the
underlying structures. In this way, a TrP can be trapped and the nodule
assessed. Further direct compression over the nodule often provokes a
pain response from a patient and concomitantly elicits a stereotypical
referral pattern. Flat palpation works well on broad, flat muscles as well as
muscles that are not easily accessible.

Snapping Palpation

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 4- When a taut band is detected by flat palpation, the clinician uses a rigid
finger to perform a brisk transverse snapping of the taut band (see figure
). A local twitch response is elicited when a TrP is provoked. Snapping
palpation is quite effective on superficial long muscles such as the erector
spinae and rectus abdominis.

Pincer Palpation

To form the pinch position, the thumb and a rigid finger assume a C shape
(see figure ). The target tissue is pinched to locate TrPs between the thumb
and finger while allowing the tissue to roll between the fingers. The therapist
assesses for local taut bands and a local twitch response.

Snapping palpation.

Pincer palpation.

Application of Ischemic compression

The therapist again utilized a pincer grasp, placing the thumb and index finger
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over the active TrP. Slowly, increasing levels of pressure was applied to the
trigger point, but not sustained Rather an on and-off pressure application was
suggested, 5 seconds of pressure, 2-3 seconds release, following by a further 5
seconds of pressure, and so on repeated until a perceptible change was
palpated. Pincer Palpation/Compression
Muscles that present a considerable amount of tissue above the surface
of the body can be examined and treated very effectively with pincer
palpation and compression. Examples are sternocleidomastoid (
pectoralis major, the portion of trapezius that lies on top of the
shoulder, and the more proximal aspects of the hip adductors.
To perform this technique, grasp the tissue between the thumb and the tips of the
first two or three fingers, or the outside of the bent index finger. Each then
provides a firm surface against which the other can palpate and compress.
Search the tissues carefully for trigger points or other sensitive points. When you
find such a point, hold it until you feel it release, and then continue the search.

The elbow is far less sensitive than the tips of the thumb or fingers. The
tissues should be explored first with the fingers, and the elbow used
primarily for compression once the need and location have been established.

NB:
Avoid use of the elbow in highly sensitive areas, such as the face, neck, and
groin.
INIT Practical application

1- Locate the trigger point, by means of palpation, using methods as described.

2- Apply ischemic compression (sustained or intermittent) until the pain

changes or until a significant 'release' is noted in the palpated tissues.

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3- Positionally release trigger point tissues. Pressure is applied and the
patient is asked to ascribe this a value of '10', and then tissues are
repositioned (fine-tuned) until the patient reports a score of '2' or less.

4- With the tissues held in this 'folded' ease position a local focused
isometric contraction of these tissues is done.

5- This is followed by a local stretch of the tissues housing the trigger point,
in the direction of the muscle fibers.

6- The whole muscle is then contracted isometrically as in all MET

procedures.

7- This is followed by a stretch of the whole muscle, as in all MET procedures

for muscles.

8- Facilitation of the antagonists may be considered, as a home exercises to

encourage inhibition of the muscle housing the trigger point.

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