THERAPIES

It is unlikely that any one therapy will entirely treat your pain. I use whatever combination of therapies and recommendations that I think will best benefit the patient. The therapies that benefit one patient may not be the best set for another. It depends on the person’s body, their particular set of symptoms, and their willingness to try certain therapies or perform the self-help techniques. I decide what I think they need, and then assess their acceptance of trying different modalities. For example, if I believe a vertebra or other joint needs to be manipulated in order to completely resolve the problem, I know that acupuncture and massage will unlikely effect the needed adjustment, but it will relax the surrounding muscles so a chiropractor or osteopathic physician can assist in solving the problem. But if chiropractic medicine is outside the realm of what the patient is willing to try, I do the best I can for them, but also let them know I don’t think I’ll completely resolve it with my modalities.

Don’t be afraid to ask any practitioner about their training in the treatment of trigger points. Even those trained in “trigger point therapy” or “neuromuscular therapy” may still be doing somewhat random searches for trigger points. For example, if you have heel pain, your therapist or health care provider should be able to tell you that the trigger points that could be causing the pain are likely located in the soleus, quadratus plantae, abductor hallucis, or tibialis posterior muscles, and then know how to search for and confirm the presence of trigger points.

Acupuncture

Most written attempts to clarify the difference between acupuncture points and trigger points have been unsuccessful. Other than searching for tender points when treating pain and sticking needles in the patient, classical acupuncture has nothing in common with trigger point needling. However, some acupuncture schools are also teaching trigger point referral patterns. This is a modern addition to acupuncture. Point selection is based on locating trigger points, as opposed to making point selections based on acupuncture diagnosis. (There are several types of acupuncture diagnosis and point selection methodologies including Chinese, Japanese and Five-Element acupuncture. I will only attempt to speak to Traditional Chinese Medical acupuncture, since that is where the majority of my training and experience lies.)With Chinese acupuncture, the practitioner will take a comprehensive medical history, asking in minute detail about the symptoms the patient is primarily seeking treatment for, and then also inquire about any other symptoms in the entire body, but not in as much depth. For pain diagnosis, they will want to know everything that makes it better or worse: heat/cold/dampness, activity/rest, what time of day it’s worse, what foods and drinks make it worse, if “stress” makes it worse, etc.

Let’s say a woman comes in for treatment of low back pain and she says it started with an injury, it’s worse with rest and first thing in the morning, and worse with alcohol, coffee, and stress. She also presents with urinary frequency and night urination, she gets cold easily and has a hard time warming up once she gets cold. The pain is usually dull and achy, but can be sharp at times, and her knees also bother her occasionally, especially when she’s fatigued and cold. There are four main Chinese Medical diagnoses for low back pain: Liver Qi Stagnation, Qi and Blood stagnation, Kidney Yin or Yang deficiency (some practitioners say “vacuity”), and Wind-Cold-Damp or Wind-Heat-Damp. Her symptoms fit into the “Qi and Blood stagnation” and “Kidney Yang deficiency” categories. The treatment principles are to “move qi and blood, tonify (or fortify) Kidney Yang, and stop pain.” Local points in the low back area are selected that will accomplish the treatment principles, but points may also be selected in the legs and feet, in the arms and hands, and perhaps other places. The acupuncturist will probably search in the immediate area for tender points (ashi points) and needle those, and perhaps consider acupuncture points in other areas (such as the back of the knee) that are known to be generally good for low back pain. They may burn an herb known as moxa (mugwort) over certain points known to tonify Kidney Yang, or put a “TDP lamp” over the area (a special type of heat lamp) and spray a warming herb combination on the area. There are a variety of other techniques an acupuncturist might employ depending on the symptoms and how the treatments are progressing.

In order to take trigger points into consideration, I would give this patient a “blank body chart” on which to draw her symptoms. Let’s say she has indicated the area of pain is over her sacrum and across the top of the pelvis. By comparing her areas of pain to well-documented common referral patterns, it is likely that there are trigger points in the gluteus medius. I would feel the area to verify my theory and mark points I might want to needle. I would also check the quadratus lumborum (in the low back area) and the paraspinal muscles to see if they have a role in causing and perpetuating trigger points in the gluteus medius. I would also formulate theories of perpetuating factors from a Western viewpoint based on the extensive initial interview.

Next I would select points to needle based on Chinese acupuncture diagnosis and Western trigger point diagnosis. I would insert somewhere between 14-20 needles, selecting points from both systems. Heat or possibly other techniques would be considered. I would evaluate perpetuating factors taking into account both Chinese Medicine and trigger points, and make appropriate recommendations to the patient from both systems.

I have found that I am more successful in treating trigger points with acupuncture than trigger point massage techniques. Symptoms are relieved more quickly and relief lasts longer. At least some of the underlying causes can be treated with acupuncture in addition to treating the trigger points. Massage can only treat the trigger points, which may afford only temporary relief. The advantage of massage is that spending an hour working on the muscles gives the practitioner a good idea of how the muscles feel and allows them to make an assessment of all the muscles that could be involved with the problem. There are also many more massage therapists than acupuncturists trained in trigger points. Massage also lends itself better to teaching trigger point self-help, since there is not usually adequate time to teach ball work and stretches in conjunction with an acupuncture treatment. Some patients like to receive both acupuncture and massage, but unless they can come at least twice per week, they aren’t receiving enough treatments of either therapy often enough to be the most helpful. If you can only get one therapy once per week, you are better off choosing one and sticking with it for a while, and then trying another for a time period.

The advantage of acupuncture over trigger point injections is that a greater number of trigger points can be needled in a session, it is usually painless, the needles can be left in for 20-30 minutes, and patients are rarely sore the next day. In addition, the body doesn’t have to process and eliminate the anesthetic that is used with injections. The needles are so small a diameter that there isn’t a concern about endangering arteries or nerves, or slicing through the muscle cells (which repairs with scar tissue and will never be available for use again). The trigger point is relieved even if it is not pierced directly with the needle.

A special word about a technique called “cupping“: a large round glass ball that is open on one side is placed over the area of pain, and suction is produced by one of a couple different methods. The glass ball may be placed and left in one spot for several seconds, or some type of oil may be used as a lubricant and the “cup” moved around (“running cupping”). This ancient technique is particularly effective for pain of the “stagnation” type. It feels like a good, deep massage, and most patients find it very helpful. If there is “stagnant blood” present, however, it does leave discoloration ranging from purple blotches to little red dots that last for (generally) three to five days. I tell patients “it will look like you got hickeys from a giant octopus!” The “stagnant blood” comes to the surface and is removed by the subsequent increased circulation. Over time, the discoloration will decrease with each treatment, until the skin looks normal after cupping. Before I became an acupuncturist, I thought the marks were bruising, and couldn’t understand how this was helping the patient. I now understand it is not bruising, since less discoloration appears each treatment and after a few treatments doesn’t appear at all. In any case, whatever the mechanism, cupping can provide great relief and large areas can be treated quickly.¹

Massage

Massage has the advantage of simultaneously identifying and treating trigger points. Massage may help flush histamine and serotonin out of the trigger point, thereby decreasing its sensitivity.² Massage therapists must hold trigger points in order to be effective, in addition to stoking maneuvers, in order not to activate trigger points. Usually some other type of massage, such as Swedish massage, will be combined with trigger point therapy. This helps relax the patient, increases circulation, and allows the practitioner to begin to identify tight areas and the overall pattern of a larger area. They will then begin focusing on the muscles they believe are causing the symptoms, and start searching for and treating trigger points. I like to end with Swedish massage to again relax the patient and flush the tissues and improve circulation.

There are many types of massage available, but unless the therapist has a working knowledge of trigger points, they can inadvertently activate trigger points rather than inactivate them, and may work on the area of pain rather than the source. ³

Chiropractic and Osteopathic Medicine

Chiropractic doctors seek to identify joint dysfunction and mis-alignment (referred to as “subluxation”), and correct those problems. A subluxation can be a source of pain, and may also interfere with the function of the nervous system within the spinal column and in the rest of the body.⁴ Skeletal manipulations do not treat trigger points directly but can help with the pain and help take strain off the muscles.

There are different chiropractic methods, and you may prefer one over another. What comes to mind for most people is probably the manual adjustments — where you hear sounds as mis-alignments are corrected. There are other non-force techniques that consist of pushing with fingers, or using a spring-loaded gadget called an “activator.” If you don’t like manual adjustments, look for a practitioner that advertises a non-force technique. As with any doctor or other practitioner, there is great variation between practitioners and some methods will work better for you than others, so don’t be afraid to shop around until you find the person and method that is right for you.

I find that skeletal mobilization works well in conjunction with massage and acupuncture, and frequently refer to chiropractors when I believe a mis-alignment needs to be resolved in order for pain to be eliminated.⁵

Osteopathic physicians also use manipulation techniques, in addition to being a fully licensed physician qualified to practice all branches of medicine and prescribe drugs. There are fewer osteopathic physicians than chiropractors, so it may be more difficult to find a practitioner.

Stretching & Yoga

Dr’s. Travell & Simons felt that gentle persistent stretch was very important in the management of trigger points.⁶ The stretches they specifically recommend in their books are found on this CD. It is best to work with a trained therapist who can check your techniques and make recommendations about which stretches you should and shouldn’t do.

Many of my patients have reported that they feel best when they regularly attend yoga classes. There are many kinds of yoga, and you may want to make sure you begin with a type that emphasizes stretching. The instructor should also know how to modify poses or eliminate ones that can cause problems for you. Be sure you are not causing yourself pain with any kind of yoga or other exercise. If in doubt, don’t do it!⁷

Physical Therapy

A physical therapist may employ a wide variety of techniques depending on their training and area of expertise. The goal is usually to restore range-of-motion and function with stretching, and strengthen weak muscles with conditioning exercises. Some use ultrasound, massage, heat/cold, electrical stimulation, joint mobilization, corrective lifts and pads, and shoe orthotics. Since muscles with trigger points cannot be strengthened (and will cause additional pain if you attempt to do so) be sure to pick a physical therapist who is familiar with trigger points, who uses a variety of techniques, and will not rush into conditioning exercises until the trigger points have been inactivated. Once trigger points have been inactivated, the muscles will tolerate a gradual increase in strengthening. If you experience an increase in pain, stop doing the assigned exercise and check with your therapist, as it may need to be modified or eliminated.

Many physical therapists are now being trained in “dry needling.” Instead of using a hypodermic needle combined with an anesthetic, they are using solid-core needles, usually acupuncture needles. However, just because they are using acupuncture needles, this does not mean that they are practicing acupuncture. Acupuncture is the system of diagnosis, treatment, and acupuncture point selection. The needles are not the system, just a tool. Solid-core needles have the advantages listed above under “acupuncture,” but PT’s are searching for trigger points, not acupuncture points.⁸

Ultrasound

Ultrasound uses high frequency sound waves to treat injuries to muscles, ligaments, and tendons. The treatment reduces inflammation and speeds healing by improving blood flow. The heating effect of ultrasound penetrates deep into the muscle, and may have added benefit due to agitation of the molecules by the high frequency sound waves.⁹ Physical therapists and some chiropractors employ this technique.

Heat and Cold

Application of cold is more commonly recommended by Western therapists. However, with some people, cold makes their symptoms worse. In the first 48 hours of an injury, cold/ice application is always used. However, once swelling has disappeared and there is no feeling of heat when the patient touches the area, I now go with the Chinese recommendations — use whatever makes you feel better, and avoid what makes you feel worse. Try heat, try cold, and try alternating the two, and see what works best for you.

If you have an injury to a lower leg or lower arm, try submersion instead of a cold/ice pack. Get a rectangular garbage can and put ice in the water if necessary (in colder climates the water is cold enough without adding ice). Place your lower arm or leg in the water and move it in and out until it isn’t so cold you can’t keep it there. Try 20 minutes in and 10 minutes out, repeating that cycle a few times.

If you are using hot packs, use moist heat such as a damp piece of flannel wrapped around a heat source, such as a heating pad or rubber hot water bottle. If your sensations are impaired for some reason (such as a diabetic), be especially careful to avoid burns.

Whether using heat or cold packs, be sure to lay the pack on you instead of you lying on the pack. If you lie on it, it will cut off needed circulation and you can get burned or frostbite. Improving circulation to the area is the desired effect. Also be sure to place the pack on the muscles containing the trigger points, and not just the pain referral zone.¹⁰

Homeopathy

Homeopathic medicine uses the “law of similars” — the remedy is made from the same substance that would normally cause the same symptoms as those to be treated, through a series of dilutions and shaking the substance multiple times. For example, to treat poison ivy exposure, the remedy is Rhus Toxicodendron — made from the poison ivy plant! Homeopathic remedies are hard to understand from the Western medical viewpoint, and therefore are not accepted by the majority of allopathic doctors. But in spite of that, they do work, so I can suspend understanding it from a scientific point of view.

Arnica montana, or some preparation with arnica in it, is frequently used for pain (both topically and orally). Traumeel™ (made by Heel-) is my favorite ointment for strains, sprains, and general soreness, and something everyone should have in their medicine cabinet. Most health food stores stock homeopathic remedies, as do some grocery stores and pharmacies. Those remedies available over-the-counter are in low enough doses that the remedy with either work, or have no effect. If you take the wrong remedy of the incorrect strength in anything above the 30c strength, you can “prove” the remedy, which means you can actually cause the symptoms you are trying to treat. Seeing a Naturopathic doctor or Homeopathic practitioner will ensure that you have the proper remedy in the correct strength for your set of symptoms and constitution.¹¹

Counseling, Biofeedback, Meditation

Counseling, biofeedback, and meditation can help you become aware of areas in your body that you hold tension. You can re-train yourself to relax by working on the source of the tension and consciously relaxing the areas repeatedly. This will treat the emotional component of trigger point perpetuating factors, but will not physically treat the trigger points themselves.¹²

Trigger Point Injections

Physicians needle five to ten trigger point areas per treatment. The doctor needs to be trained in referral patterns and locating trigger points. The injections in themselves can be very painful, since hypodermic needles are large enough to cause pain, but this can be reduced by applying a topical numbing agent. Since trigger points are so small, it is easy to miss them with the needle and they easily roll out from under the needle. The advantage is that the numbing agent (usually procaine or lidocaine) spreads out a bit, and helps the trigger point anyway. Injections may cause increased local muscle soreness for several days and may exacerbate rather than relieve trigger points if the patient is deficient in B- or C-vitamins.¹³

My patients who have had both injections and acupuncture have told me they felt acupuncture was easier to tolerate and as effective as injections. Some of my patients will come to me for massage and won’t try acupuncture, but will get injections. For these patients I mark trigger points with a permanent marker (which lasts 2-3 days) and send them to a local doctor who will then inject the marked trigger points. Just keep in mind that unless the patient is in the same position as when they were marked, the skin will move over the trigger point and the mark may be slightly off, so the doctor will still need to feel for the trigger point before inserting the hypodermic needle. Marking the patient would also work for a massage therapist referring to an acupuncturist.

A special word about cortisone — it is now known that cortisone breaks down muscle fibers and should not be used repeatedly, and it is not recommended for trigger point injections. In most cases there are alternatives to cortisone, but it is very effective in reducing inflammation for certain conditions. Cortisone can increase the danger of muscle and connective tissue tears, can increase the danger of a systemic Cushingoid reaction with repeated injections, and is generally irritating to nerves and can produce complications.¹⁴ My rule of thumb is that if your doctor is willing to inject the same area with cortisone more than three times, you need to find another doctor.¹⁵

Drugs

Dr.’s Travell and Simons believe muscle relaxants are of limited value for patients with myofascial pain, because the drug first releases the muscles that provide protective splinting (some muscles may contract to protect the weakened muscles containing the trigger points). Removing the protective splinting increases the load on the muscle containing the trigger points and leads to additional pain.¹⁶

Anti-inflammatories help break the pain cycle, and actually help a patient tolerate the initial stages of treatment if they are in extreme pain. However, if you are medicating for the pain, you should also work on the trigger points and any other related problems unless you intend to (potentially) stay on drugs for the rest of your life.¹⁷

Many of the Common Symptoms, Causes of Trigger Points, Helpful Hints, Stretches, and Exercises are drawn from Travell and Simons Myofascial Pain and Dysfunction: The Trigger Point Manual. Please assume that any text prior to a footnote is attributed to the source noted in the footnote.

1. Author’s experience or education
2. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, The Upper Extremities, (Baltimore: Williams & Wilkins, 1983), pg. 34.
3. Author’s experience or education
4. Andrea Iverson, D.C.
5. Author’s experience or education
6. Travell & Simons, M.D.s, Vol. I, pg. 64.
7. Author’s experience or education
8. Author’s experience or education
9. Travell & Simons, M.D.s, Vol. I, pg 27.
10. Author’s experience or education
11. Author’s experience or education
12. Author’s experience or education
13. Janet G. Travell , M.D., David G. Simons, M.D., and Lois S. Simons, P.T., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, Upper Half of Body, 2nd ed. (Baltimore: Williams & Wilkins, 1999), pg. 151.
14. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 153.
15. Author’s experience or education
16. Travell & Simons, M.D.s, Vol. I, pg 91.
17. Author’s experience or education