How Does Trigger Point Therapy Work?

COMPONENTS OF TRIGGER POINT THERAPY.

Trigger point therapy, as practiced by Certified Myofascial Trigger Point Therapists, has three basic tasks.  Each component can be simple or complex:

1. Locate the trigger points causing the patient's pain and/or other symptom.
2. Eliminate these trigger points.
3. Help eliminate perpetuating factors. This means determining if the patient has habits that are perpetuating his trigger points and counseling him or her how to change or improve them.

1.  LOCATING TRIGGER POINTS.

FROM THE PAIN REFERRAL PATTERN.  Expensive scanning and testing equipment is of little use in locating the trigger points causing the pain problem.  The necessary detective work is accomplished with direct observation and testing.  The most important indicator is the pain pattern itself.  As noted in the section on trigger point characteristics, each muscle trigger point location has a characteristic pain referral pattern.

FOR EXAMPLE, if the patient has a severe headache behind the eyes it is probably caused by a trigger point in the sternal division of the sternocleidomastoid muscle.  Less commonly, it could be caused by a trigger point in the temporalis muscle, one in the upper portion of the splenius cervicis muscle, or even from one in the masseter, the suboccipitals or a couple other muscles.  Unless you are an orthopedist or physical therapist this list of muscles that can refer pain behind the eye may sound overly technical and boring.  That's because good trigger point work, though not boring, is technical.  Locating trigger points requires precise knowledge of anatomy and the pain referral patterns. 

FROM RANGE OF MOTION.  The second method used to track down the source of pain is range of motion testing.  As noted in the section on trigger point characteristics, a trigger point prevents the full extension of the affected muscle.  Arranging the patient's body in specific postures, the therapist tests the range of motion of the various muscles that are likely to be involved and notes which which ones restrict movement the most. 

AN EXAMPLE.  Consider a patient with pain in the front of the upper right thigh one third of the way to the knee. From the pain pattern the muscles most likely harboring trigger points are the psoas and the vastus intermedius . (Note that although the pain reported is on top of the rectus femoris rather than on the psoas or vastus intermedius, the rectus femoris is not a likely candidate because it typically refers pain to the knee).  Range of motion testing usually gives a good indication whether the psoas or the vastus intermedius is the more likely source of pain.  Thus if the patient cannot lunge well forward on his left leg while keeping the torso erect there is probably a restriction in the right psoas.  If, while lying on the back with a bent right knee the right heel cannot be brought back to the buttock the vastus intermedius may harbor trigger points.  Of course the tests could show restricted motion in both muscles.  This simplified example illustrates how muscle testing usually gives crucial clues as to trigger point location.  In actual practice the testing would probably begin with an assessment of the patient's hip alignment and would test psoas range of motion using a more-difficult-to-describe position.  But the example illustrates how a trigger point therapist uses knowledge of body mechanics and normal ranges of motion in his detective work.

FROM PALPATION.  Palpation is one of the more difficult skills to master.  It's one thing to point to a muscle in a diagram and quite another to locate it in a living body with your fingers -- especially if it is not right on the surface, or is surrounded by many others.  Then there is the further task of identifying the taut band and the trigger point.  Once located, pressure directly on a trigger point gives a final clue by producing an intense local sensation.  This stimulation may also cause a quick muscle twitch, and may reproduce the patient's pain or other symptom.  These signs tell the therapist that he or she is at the source, or one of the sources, of the problem.

FROM THE PATIENT HISTORY.  Most therapists take the patient's history at the outset.  While the pain pattern and range of motion restrictions reliably indicate trigger point location, more information may be needed.  Sometimes the most important trigger point remains elusive.  For example, the patient may complain of pain in the back and arm, but his history shows that the accident probably caused a side-bending neck injury, indicating that treatment might be better begun with scalene or other neck muscles.  The therapist thus could combine the history of neck injury with knowledge that trigger points in scalene muscles can entrap the brachial nerve plexus by compressing it directly, or by elevating the first rib, thereby compressing it indirectly.  Either way the scalenes are a possible cause of the shoulder and arm pain, and the detective work has been greatly assisted by knowing the patient's history.

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2.  ELIMINATING TRIGGER POINTS.

Trigger points can be eliminated by a variety of techniques, including certain kinds of manual pressure, specialized stretching techniques sometimes including the use of cold spray, injection, dry needling and others.  David Simons MD, Janet Travell's co-author, provides an up-to-date review of the most effective manual methods, including important variations on the pressure release and stretching themes (2002).

REQUIRES ACCURACY.  Knowledgeable physicians can treat trigger points by injection.  Injections in expert hands can provide lasting relief, but not all physicians who inject for "myofascial pain" know where the trigger points are, a fact I have ascertained many times talking to my patients.  Certain trigger points are too dangerous to inject, e.g., those over the lung area.  Manual techniques have the added advantage that many trigger points in different muscles can be treated in one session.

IS LABOR-INTENSIVE.  Trigger point therapy takes time and in this sense is labor intensive.  The front-line health care system often cannot allocate enough time to any one patient to treat myofascial pain successfully, a gap which can be filled by non-physician therapists who can allocate more time to the individual.  In chronic pain syndromes in particular, time must be taken to ferret out the underlying key trigger points, and further time must be spent reviewing stretching routines and figuring out life-style changes that may be necessary to finally end the pain.

3.  PERPETUATING FACTORS. 

IF IT DOESN'T WORK THERE MUST BE A REASON.  After Dr. Travell's research and clinical work had convinced her how widespread trigger point pain was, and how effective the treatments were, she began to teach others.  She would speak before groups and do demonstrations on pain patients she had never seen before, apparently with skilled showmanship.  Dr. David Simons reported that on one occasion, when asked afterward how the demonstration went, "she replied with a sense of spiritual reverence 'the magic never fails'" (Simons 2003).  A corollary to her conviction about the effectiveness of trigger point work is that if the treatment was not effective then there must be a reason. This reason was usually a perpetuating factor.  Simons goes on to report that in her practice,

She looked under every physical and medical stone imaginable until she found why that patient had failed to respond to treatment as expected.  The answers ranged from relatively short upper arms or leg-length discrepancies to inadequate vitamin intake.

SOME EXAMPLES can illustrate factors that perpetuate myofascial pain. The history of a patient with long-standing pain may reveal that the person never eats vegetables or takes vitamins.  The therapist would suspect that folate deficiency is helping perpetuate the pain (Travell and Simons 1999, Vol.1:198fl).  Or the therapist may notice that a patient with chronic pain in the lower back has unusually short arms.  Short arms can cause a person to habitually slump forward or sideways because elbows don't reach the arms of chairs or surface of desks, thereby perpetuating the lower back pain.  The patient may be an avid reader who always adopts a slumped position, thereby perpetuating trigger point pain in the neck and shoulder.  Computer work with poor posture likewise takes a toll.

AN ESSENTIAL PART OF THE THERAPIST'S WORK.  Travell and Simons' two-volume trigger point manual provides a chapter for each muscle.  Each chapter discusses what factors in a person's body configuration, posture or living habits can perpetuate trigger point pain in that muscle.  The doctors unearthed scores of factors that can perpetuate trigger points.  Though not always easy to ferret out, identifying the perpetuating factors is often the key to ultimate success in treatment, so a good trigger point therapist pays close attention them.  In sum, an important part of the therapist's training is identifying perpetuating factors and helping patients understand and deal with them.

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This page is part of a larger website intended to educate people about trigger point bodywork and other methods of non-invasive, drug-free pain relief.  Myofascial therapy was developed by physicians in the last few decades.  Its primary purpose is to eliminate myofascial pain, but it also improves movement and posture.

I offer myofascial treatment and pain management services for the Bloomingdale, Lincoln Park, Mountain View and North Haledon area of northern NJ, though I am not immediately nearby. If you live in a town such as Packanack Lake, Pequannock, Pompton Plains or Wayne NJ I would still be the closest certified therapist. Allendale, Darlington, Mahwah and Preakness NJ also fall into this category, as do Oakland, Ramsey, Upper Saddle River and Wyckoff NJ and much of the rest of New Jersey. Somewhat distant towns are mentioned because I have seen many times that people are glad to travel even several hours to get rid of pain. If you live elsewhere you may be able to find a practitioner nearby.

Copyright 2007 Joseph Hoane