Trigger Point Therapy for Myofascial Pain (6 page)

Myofascial meridian therapy embraces the concept of qi in a manner that focuses on a clear and present palpable reality:
If Qi is life force and life force is movement, then Qi is movement.
This model of qi and how it relates to health has a number of distinct advantages over an herbalized acupuncture or bodywork that first and foremost regards pathology from an internal medical model. First, this model of qi is clearly understandable to both patients and other health care practitioners. The focus of treatment is on myofascial release by extremely effective means; and while the mechanism may not be fully comprehended, the concepts of somatovisceral effects and referred pain patterns can be readily understood, particularly once the pathways of the pain patterns are pointed out on pain pattern charts. The effects of this approach are also easily explained, since the rapid myofascial release produced by a needle contacting the fascia or trigger points is well documented by Travell and others, as are the effects of ischemic pressure. Through experience in treatment the effects are also clearly observable, to patient and practitioner alike.

It is also important to recognize that this model falls well within a complementary medical model rather than an alternative medical approach. By and large myofascial meridian therapy is complementary to Western medicine, which does not focus on myofascial problems and associated release of constrictions; often the medical approaches to myofascial constriction, which include medications or surgical intervention, produce unsatisfactory results. Herbal medicine, like Western medicine, is another form of internal medicine. It is alternative to the conventional Western medical model, rather than complementary.

Certainly regarding qi as movement is not the only way to conceive of qi within the framework of Oriental medicine. The fluidity and relativity of the philosophical constructs that underlie Oriental medicine require that ideas such as this one be examined in relation to their applications. Acupuncture and associated bodywork methods have enormous power to heal in a manner that is distinct and separate from internal medicine applications—this is observed repeatedly in a clinical setting. This power can be actualized within an approach that looks at qi in a way that is useful and practical.

Models are ideas that help to frame reality in a complex world, and thereby allow some effective action to be taken. They are not
the
Truth, but
a
truth that guides activity.

CHAPTER 3

I
NFORMED
T
OUCH

I
t is currently estimated that at some point in their lives approximately 90 percent of all Americans will experience some sort of myofascial pain—back pain, shoulder pain, neck pain, elbow pain—that has its roots in some dysfunction of the musculoskeletal system.

Regardless of method, the successful treatment of myofascial pain disorders ultimately rests on a singular skill. This is the ability to palpate, the ability to discern our patients' needs through touch.

Since the rise of modern technological health care, surface palpation has been the skill most overlooked in the training of health professionals. Palpation of the musculature—assessment through touch of the muscles, tendons, and fascia—is a fine and discerning art, one that is becoming lost in the morass of technologies now applied to health care. The health professions have generally forgotten the effectiveness of touch in both determining the extent of patients' pains and disabilities and in the treatment and resolution of that pain. Through palpation we can discriminate normal, supple musculature from musculature that is constricted or contains trigger points; palpation can also assist in discerning the source of myofascial pain. Our hands tell us about the alignment of the joints, about skin and body temperature, and about the flow of life on the body's surface. When trained well, our hands can “see” the structures that underlie the skin: the muscles, skeletal structure, and organs. In myofascial work the hands are our greatest tool, as long as we train them to the nuances of touch perception and learn to use them properly.

Training of the hands begins with bringing awareness to them. Practice placing your awareness in your hands. The ongoing effort to intentionally connect your mind to your hands is the key to successful training. This is not only true when touching the body, but when touching anything, all day long. Touch with attention—all touch explorations begin with this new focus. For specific exercises in palpation see Leon Chaitow's
Palpatory Literacy
(see bibliography).

The second essential requirement for the development of excellent palpation skills is the presence of a clear mental image of the structures being palpated. This requirement cannot be emphasized enough. You must be able to clearly visualize the anatomic structures of the human form as you try to palpate them; it is therefore necessary to study the anatomy of the musculoskeletal system. A keen knowledge of skeletal structure and the attachments, fiber direction, and function of each muscle is essential. Begin with knowledge, the idea, and the image, and then train your hands to “see” what you know is there.

It is important to recognize that the qualities of musculature exist on a continuum. Hypotonic or flaccid muscle, that is, muscle that has reduced tone, lies on one end of this continuum; hypertonic or excessively constricted muscle lies on the other. What you feel within any given muscle will fall anywhere within this continuum. Healthy muscle tissue is soft, supple, and resilient to pressure. The underlying structures are easily palpated through such muscle. Muscle tissue that is healthy is pain-free when palpated.

As you move through the continuum you will encounter muscle that is somewhat tight, not as resilient to the touch as supple muscle. This tissue feels harder and tougher than surrounding musculature, and a stronger, firmer touch is required to palpate the underlying structures. Firm palpation may produce some discomfort in the patient. This type of muscle we call
constricted muscle
.

The degree of constriction is dependent upon the muscle's state of contraction. When a muscle is held in a partially contracted position, groups of fibers that form the muscle may be identified and discerned. There may be taut bands of tissue within such muscle. These taut bands may feel thready or ropelike—not unlike a small cable; they can feel resistant to pressure and be somewhat uncomfortable to the patient when pressed. In addition, through palpation you might identify a particular region within the taut band that the patient experiences as particularly sore to the touch. To the practitioner this region feels more constricted, harder, than the areas immediately adjacent to it along the band. This region characterizes what Travell and Simons have termed a
trigger point
. When a trigger point is palpated it can cause significant local discomfort in the patient. In addition, pressure to the point can initiate the characteristic radiating pain pattern charted by Travell and Simons and others. This radiating pain is the distinguishing characteristic of trigger point activity within the myofascia.

In contrast to the partially contracted muscle just described, a deeply contracted muscle is one that remains in the muscle's extreme contracted position. This contracture may be the result of neurological dysfunction, chronic structural imbalances, trauma, or extreme repetitive strain. In cases of contracture, circulation to the muscle is reduced, and as a result the muscle becomes more fibrous, losing its elasticity. The muscle becomes fixed in a shortened position. Trigger points may or may not be present; pain and dysfunction will more likely be due to loss of full range of movement. The condition will be chronic and complete recovery improbable. With practice the practitioner can discern these various characteristics of the musculature.

When palpating it is essential to identify and differentiate skeletal structures under your hand. This ability is an essential prerequisite to muscular palpation. Locating and differentiating the bony structure will provide the structural awareness to image, first with your mind and then with your hands, the attachments of muscles to be palpated.

The ability to clearly identify a muscle under one's hand (for example, differentiating the deep thoracic paraspinal muscles from the more superficial trapezius and rhomboids) is often contingent upon the practitioner's ability to follow the course of the muscular fibers. Herein lies another reason for knowing bony landmarks by touch—it is difficult to feel for fibers and fiber directions when there is no awareness of where the muscles attach. An awareness of fiber direction in both superficial and underlying musculature is necessary to evolve the skill of differentiating muscular layers. In addition, it is important to have a working knowledge of other structures that might be within the region being palpated, such as lymph nodes in the anterior and posterior triangles of the neck and in the femoral triangle.

Attentive practice will provide you with the skill that is desired—and that is truly required—to understand the dysfunctions causing pain and discomfort to your patients. Skilled hands not only can ascertain the muscle or muscles that are involved, but as you follow constricted muscle fibers through their course you can arrive at an image of the habitual physical postures your patient assumes that could be the source of the myofascial problem. For example, in palpating his neck and shoulders you may “see” with your hands that the left side is considerably more relaxed than the right: the right sternocleidomastoid is contracted, the right trapezius is contracted, and the right levator scapulae is contracted. What posture could this person be taking to produce this muscular configuration? He might possibly be sitting in front of a computer with the monitor off to the left instead of directly in front of him. Perhaps he elevates his right shoulder in directing his cursor around the computer screen. Maybe his television at home sits to the left of his favorite chair. At least you have a mental image, an initial clue, a place from which to question your patient to find out what his habitual activities might be. Knowing the muscular action, knowing the postural habits and feeling the muscular configurations, allows you to do effective detective work. You are then able to help your patient change his habits in order to alleviate perpetuating factors giving rise to his difficulties. This discernment is essential to helping the patient rectify the muscular problem.

To palpate most effectively, the following basic principles should be embraced and practiced:

1.   Clearly image the area to be palpated.

2.   Soften and relax your fingers, hands, and arms in order to make full, firm contact with the area under palpation.

3.   As you palpate, use as broad a surface area of your hand as possible. Palpation, as a method of gathering information, is far more effective if practiced using the palmar surfaces of the hands rather than the tips of the fingers. In using a broad hand you cover more “ground” and can thus evolve a clearer mental image of the area under palpation.

4.   Identify pertinent bony structures in the region.

5.   Palpate each muscle in at least two directions:

•  along the muscle fiber, from its proximal to its distal attachment, to locate the muscle and identify its size and shape; and

•  across the muscle fibers, to isolate areas of constriction, taut bands, and trigger points.

6.   Limit pressure to the point of muscle resistance. When you feel the muscle providing some resistance to pressure, keep your contact at that level of pressure. Deep, excessive pressure that causes some pain will produce an automatic tightening of the body and will prevent you from clearly identifying underlying structures; pressure that is too light will not allow you to contact the muscle properly, and a great deal of information will be overlooked as a result.

7.   Palpate each muscle bilaterally to provide direct comparison. Remember that bilateral musculature should optimally be equally soft and supple and have the same shape and form. By comparing sides you can easily note areas of constriction that may exist in one side and not the other.

In summary, palpation is an essential diagnostic and treatment tool that requires attentive practice, an ability to clearly visualize musculoskeletal anatomy, and a state of relaxation that helps maximize information gathering skills. It is through extensive clinical practice that one can evolve a clear sense of the continuum of myofascial states and an understanding of the habits of action that are the source of an enormous percentage of pain syndromes.

It is important to remember that when a patient experiencing pain is touched by a practitioner in the “right” places, a level of trust develops immediately, alleviating a great deal of the patient's fears and tension. This alone provides enormous therapeutic benefit. It begins with understanding hands, with informed touch.

CHAPTER 4

D
IAGNOSIS
AND
T
REATMENT

I
t is assumed that the reader of this book has some experience in working with myofascial pain. However, a few basic ideas, perhaps known in some disciplines but not in others, may serve as common ground in delineating a broad protocol for the diagnosis and treatment of myofascial disorders.

Spend some time looking at the patient.
Observe how he or she walks, stands, sits, breathes, holds his hands, crosses his legs, reads intake forms, rubs his neck, carries a purse, backpack, or briefcase. These and myriad other behaviors provide clues regarding the nature of his condition. While some patients will have difficulty identifying the sites or patterns of their pain, the observant clinician can learn a great deal by paying close attention to this person who has come for help. It is rare that muscular constrictions and trigger points exist in an isolated, single muscle. Careful attention can reveal a great deal about the unique and often complex pattern presented by each patient. Watching how the patient rises from a chair, gets on or off a treatment table, removes a coat, or wears out his shoes can provide valuable information leading to the effective treatment of his complaint. As in many medical therapies the clinician must be part detective, developing an ability to pick up on these clues, since they can be as important as any diagnostic testing procedure.