Concept:Apropos Treatment

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Concept: Apropos of All Muscles — Treatment

Source: Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1, 2nd Ed. Chapter 3: Apropos of All Muscles, Sections 12–14, pp. 126–178. This page covers the treatment framework applied universally to every muscle chapter in the Manual.

For injection technique, see Concept: Trigger Point Injection. For assessment, see Concept: Apropos Assessment.

⚠ Clinical Note — Central vs. Attachment TrPs: When deciding which treatment method to use, it is important to consider whether the TrPs being treated are central TrPs in the endplate zone of the muscle belly, or attachment TrPs located where the muscle attaches to its aponeurosis, tendon, or bone. Stretching (lengthening) the muscle inactivates central TrPs, but may tend to aggravate the overloaded muscle attachments. Attachment TrPs are more likely to respond to manual therapy directed to the regions where central TrPs are located, and therapy that concentrates on relieving the strain on the attachments caused by the TrP-induced shortening of the taut band fibres.

12. Trigger Point Release

With Contributions by Mary L. Maloney, P.T.

The title of this section has changed from "Stretch and Spray" to "Trigger Point Release." The change reflects the shift in emphasis from only one manual therapeutic technique to an appreciation of the wide variety of effective techniques available and an indication of the clinical usefulness of each. This section presents a rationale for each technique that is based on the new understanding of the nature of TrPs.

When the simpler approaches fail to give satisfactory results, many times the addition of spray and stretch (often in combination with other techniques) brings success.

General principle: almost any method that gently stretches (lengthens) a muscle with TrPs and increases its pain-free range of motion is beneficial. The remarkable effectiveness of almost any technique that elongates the muscle and restores it to full stretch length can be explained by the integrated hypothesis (see Chapter 2: General Overview of Myofascial Trigger Points, Section D). Lengthening the muscle with gentle sustained stretch induces gradual reduction in the overlap between actin and myosin molecules and reduces the energy being consumed. When the sarcomeres reach full stretch length, there is minimal overlap and greatly reduced energy consumption. This breaks an essential link in the energy crisis vicious cycle.

The key to stretching for TrPs is to lengthen the muscle fibres that are shortened by the TrP mechanism. Following the first edition publication, a rather forceful passive stretch was sometimes associated with the application of vapocoolant spray. This second edition of Volume 1 emphasises a much more gentle stretch and uses the term "take up the slack" to identify just enough force to lengthen the muscle to the next barrier (to the onset of resistance to further elongation).

The "no pain–no gain" concept does NOT apply here. The operator must ask patients to speak up immediately if the procedure becomes painful.

Spray and Stretch

In 1952, Hans Kraus described how he discovered that spraying ethyl chloride on the skin relieves musculoskeletal pain. Dr. Travell became aware of his freezing spray technique through his 1941 paper on "surface anaesthesia." Spray and stretch is the single most effective noninvasive method to inactivate acute TrPs. In our experience, spray and stretch is the single most effective noninvasive method to inactivate acute TrPs.

Essential principle: the essential therapeutic component is the stretch. "Stretch is the action, spray is distraction." The spray is applied before or concurrently with, but not after, the muscle is stretched.

Spray procedure (Figure 3.11 — sequence of steps):

  1. Patient seated comfortably and well supported to permit voluntary relaxation.
  2. One end of the muscle (light red) anchored.
  3. Skin sprayed with repeated parallel sweeps of the vapocoolant over the length of the muscle in the direction of pain pattern (dark red dots). All of the muscle belly and its attachments are included.
  4. After the first sweep of spray, pressure is applied to take up the slack in the muscle and is continued as additional sweeps of spray are applied.
  5. Sweeps of the spray are extended to cover the referred pain pattern of that muscle.
  6. Steps 3, 4, and 5 may be repeated 2 or 3 times until the skin becomes cold to the touch or when the range of motion reaches maximum. Application of heat and then several cycles of full active range of motion should follow (see Figure 3.12 for details).

Spray technique details:

  • The bottle is held about 30 cm (12 in) from the skin.
  • Slow, even sweeps progress over the skin at about 10 cm (4 in)/sec.
  • Two or three superimposed sweeps are usually maximum; the skin must then be rewarmed.
  • The jet stream of vapocoolant is applied at an acute angle to the skin (approximately 30°), not perpendicularly, and in parallel sweeps along the direction of the muscle fibres.
  • Sweeps are applied in one direction only.
  • The bottle is held inverted so that the liquid will flow from the nozzle.
  • If the spray is too cold for the patient, moving the line of spray more quickly across the skin will help. If the spray is still too cold, the bottle or can should be held closer to the skin than the usual 12 inches. If a colder spray than usual is desired, the spray distance can be increased to 18 inches.

Vapocoolants available:

  • Fluori-Methane (85% trichloromonofluoromethane and 15% dichlorodifluoromethane) — the currently recommended product. Non-flammable, chemically stable, non-toxic, non-explosive, does not irritate the skin. Unfortunately, fluorocarbons cause serious degradation of the upper atmosphere ozone layer and Fluori-Methane is no longer manufactured or approved. A promising substitute ("Gebauer Spray and Stretch") is undergoing testing.
  • Ethyl chloride — too cold for optimum release of TrP tension as usually applied. A rapidly acting general anaesthetic that has a dangerously low margin of safety, is flammable, and is explosive when 4–15% of the vapour is mixed with air. If used, rigorous fire precautions must be observed. Never given to a patient for home use.
  • Ice stroking — the sensory and reflex effects of a jet stream of vapocoolant spray can be obtained to a considerable degree by stroking with ice. Water frozen in a plastic or paper cup is a convenient form. An edge of the ice is applied to the skin in unidirectional parallel strokes, following the spray patterns presented in each muscle chapter. Stroking movements progress slowly, at the same rate as the spray (10 cm/4 in per sec). The practitioner should hold a small cloth ready to blot the skin as needed to prevent melting ice from wetting the skin. May replace the spray for patients with respiratory conditions.

Patient preparation:

  • Adequate body warmth is critical for a favourable muscular response to treatment. If on arrival the patient feels chilly or the hands and feet are cold, a dry heating pad can be applied to the abdomen to raise the core temperature and cause reflex vasodilation in the limbs.
  • A blanket should cover the portion of the patient not exposed for treatment.
  • The patient should be asked before application whether he or she has eaten recently to avoid potential hypoglycaemia.
  • The portions of the skin to be sprayed should be bare.
  • Patients with asthma and other respiratory conditions may not tolerate vapocoolant spray near the face unless the practitioner covers the patient's nose with a small cloth or a hand.
  • When vapocoolant is applied to the face, the eye on that side should be covered. If Fluori-Methane spray accidentally hits the conjunctiva or the eardrum it is startling and painful, but not damaging.

After spray and stretch:

  • Application of moist heat over the areas sprayed with vapocoolant should be followed by a hot pack or pad placed over the area.
  • Several cycles of full active range of motion — the patient actively moves each muscle injected through its FULL range of motion 3 times, reaching its fully shortened and fully lengthened position. This is the most important poststretch (or postinjection) procedure.

Voluntary Contraction and Release Methods

These methods all employ some degree of voluntary (active) contraction followed by relaxation. A reduction in muscle stiffness (tension) following the contraction provides an increase in range of motion during the period of relaxation. This approach is the basis for some of the simplest, most available, most popular, and most effective techniques for inactivating myofascial TrPs.

The new understanding of the nature of TrPs provides a rationale: since the primary TrP etiology appears to be a contraction knot at a dysfunctional motor endplate, gentle intermittent muscular contractions may be very effective at normalising sarcomere lengths of involved muscle fibres. The action potentials resulting from the voluntary effort cause contraction of the elongated sarcomeres on both sides of the contraction knot. This added tension tends to pull open the contracted sarcomeres in the contraction knot. As soon as this process begins to separate the actin and myosin molecules in the contracted sarcomeres, those sarcomeres consume less energy because fewer myosin heads interact with actin. This tends to relieve the energy crisis.

Postisometric Relaxation (PIR)

The postisometric relaxation (PIR) technique introduced by Karel Lewit is a modified contract-relax method that for most muscles incorporates augmentation by coordinated respiration and eye movements. This technique has been specifically identified by Lewit as useful in the treatment of myofascial TrPs.

Basic concept of PIR: contract the tense muscle isometrically against resistance, and then encourage it to lengthen during a period of complete voluntary relaxation.

Procedure:

  1. The muscle is passively and gently lengthened to the point of taking up the slack (reaching the barrier or the point of initial resistance). Positioning should not be painful.
  2. The patient performs an isometric contraction of the tense muscle at its maximum pain-free length, while the clinician stabilises that part of the body to prevent muscle shortening. Contraction should be slight (10–25% of maximum voluntary contraction). Hold this contraction for 3–10 sec.
  3. The patient is instructed to "let go" and to relax the body completely. During this relaxation phase, the clinician gently takes up any slack that develops in the muscle, noting the increase in range of motion. Care is taken to maintain the stretched length of the muscle and not let it return to a more neutral position during subsequent cycles of isometric contraction and relaxation.

Augmentations:

  • Combining PIR with reflex augmentation of relaxation greatly enhances its effectiveness.
  • Augmentations include the use of coordinated respiration — the muscle contraction phase is synchronised with inhalation, and the relaxation phase with exhalation. Relaxation is naturally associated with exhalation as one leans away from an erect posture. Paradoxical breathing should be avoided.
  • Directed eye movement — clinical observations have shown that the direction of gaze facilitates the movement of the head and torso in the direction of the patient's gaze. By looking in the direction of movement needed to release specific muscle tightness, the release process is augmented.

Reciprocal Inhibition

Reciprocal inhibition is not only an involuntary spinal-level reflex but is effective when a contraction is initiated at the cortical level. When one muscle is activated, its antagonist is reflexly inhibited. To invoke reciprocal inhibition, the muscles that oppose the muscle being stretched are voluntarily contracted to actively assist the stretching movement. Thus, the muscle to be stretched is reciprocally inhibited.

This method can be used alone to augment a simple stretch, or it can be combined with other techniques such as spray and stretch. Apparently, this neuromuscular mechanism for releasing TrP tension involves more than inhibition of alpha motoneuron activity. The tension-release mechanisms also may be dependent on autonomic effects that are related to the inhibition of spontaneous electrical activity (SEA) and spike activity of TrPs during exhalation, and their augmentation by inhalation and mental stress.

Contract-Relax

The principle of contract-relax appears in many forms with many names throughout the musculoskeletal treatment literature. In this volume, contract-relax used for treating TrPs is a gentle, voluntary, minimally resisted contraction of the tight muscle. The contraction is followed by relaxation of the muscle to permit passive elongation of the muscle to a new stretch length. Contract-relax is the basic procedure in the PIR method of Lewit.

Hold-Relax

Hold-relax is a variant of the contract-relax technique. It consists of isometric contraction of the tight muscle followed by relaxation, but not by elongation of the tight muscle. When used in the treatment of muscles with TrPs, hold-relax is commonly combined with manual techniques applied directly to the muscle, such as deep stroking massage and TrP pressure release.

Muscle Energy Technique

Muscle energy techniques are closely related to techniques used for release of TrPs. Three techniques:

  1. Isometric contraction — the one most commonly used; generally for improving restricted motion at an articulation (caused by muscle tightness due to TrPs). This corresponds to the contract-relax method.
  2. Isotonic contraction — commonly identified as a concentric (shortening) contraction that in this case is resisted by the clinician.
  3. Isolytic contraction — the same as what is commonly identified as an eccentric (lengthening) contraction, but again resisted by the clinician.

Trigger Point Pressure Release

The new term trigger point pressure release replaces the previous term and concept of ischemic compression. TrP pressure release is known to be effective at central TrPs where there is a rationale for its use. However, its value when applied to attachment TrPs needs to be evaluated experimentally.

The technique that was previously described as ischemic compression is essentially what Prudden called myotherapy, and was adopted by a group of practitioners who identified themselves as myotherapists. Instead of ischemic compression, we recommend the application of TrP pressure release. This technique is less vigorous than ischemic compression and employs the barrier release concept. The pressure release approach seems to be equally or more effective clinically and is NOT likely to produce appreciable additional ischaemia.

Procedure:

  1. The clinician lengthens the muscle to the point of increasing resistance within the comfort zone.
  2. Then applies gentle, gradually increasing pressure on the TrP until the finger encounters a definite increase in tissue resistance (engages the barrier).
  3. This pressure is maintained (but not increased) until the clinician senses relief of tension under the palpating finger.
  4. The palpating finger increases pressure enough to take up the tissue slack and to encounter (engage) a new barrier (the finger "follows" the releasing tissue).
  5. The clinician again maintains only light pressure until more of the muscle tension releases ("lets go") under the finger.
  6. During this period the clinician may change the direction of pressure to achieve better results.
  7. This process of TrP pressure release can be repeated for each band of taut muscle fibres in that muscle.

Advantages: painless, imposes no additional strain on any attachment TrPs, thereby avoids aggravating them. Particularly well suited to muscles like the infraspinatus and serratus muscles that are relatively thin and overlie bone.

This technique is particularly effective at self-treatment by the patient — the patient learns what optimal pressure feels like for subsequent self-treatment. The barrier release approach, however, does require a higher order of manual skill.

Deep Stroking (and Other) Massage

The technique of deep-stroking massage (also called stripping massage) was historically the first widely accepted technique for treating fibrositis (many descriptions of which fit myofascial TrPs) and was widely practised at the beginning of the 20th century. This method is probably the most effective way to inactivate central TrPs when using a direct manual approach, and it can be used to treat TrPs without producing excessive joint movement.

Procedure:

  1. The patient must be positioned comfortably so that the muscle to be treated is completely relaxed and lengthened without pain to the point that there is no residual slack in the muscle as a whole.
  2. The skin should be lubricated if the subcutaneous tissues are tense and immobile.
  3. The thumbs or a finger of both hands are placed so they trap a taut band between them just beyond the band's TrP.
  4. As the digits encounter the nodularity of the TrP caused by its contraction knots, pressure is exerted to engage the restrictive barrier. The digits progress no faster than tissue release occurs as the nodularity "gives" to some extent.
  5. The purpose of the pressure directed along the length of the taut band is to elongate the maximally shortened (contracted) sarcomeres of the contraction knots to release their tension.
  6. The stroking massage should be continued along the length of the remaining taut band beyond the TrP to the attachment of the band, helping to restore the stretched sarcomeres to normal length.
  7. The next stroke should go in the reverse direction starting on the same taut band but on the other side of the nodule, to further release the contractured sarcomeres and release the abnormal tension on the other half of the taut band and at the other muscle attachment.

Caution: excessive pressure or speed of movement is likely to rupture contraction knots, destroying the corresponding motor endplates as functional structures and increasing the painfulness of the procedure.

Strumming is similar to deep-stroking massage except that the strumming finger runs across the taut bands at the level of the TrPs over the nodules from one side of the muscle to the other. The operator's finger pulls perpendicularly across the muscle fibres rather than along the length of the fibres. Applies specifically to central TrPs near the middle of the muscle belly.

Indirect Techniques

The osteopathic technique for releasing tender points described by Jones in 1981 in terms of strain and counterstrain (the term still used by osteopathic physicians) has now evolved into a positional release therapy. This indirect technique uses body positioning for releasing tender points which are conceived of as foci of constriction in the myofascial tissues. The tender points they describe appear to have little relation to fibromyalgia tender points, but may fit the concept of myofascial attachment TrPs.

Kuchera and Kuchera characterise Jones's strain-and-counterstrain technique clinically as follows: About 146 tender points can be identified. The muscle pain, weakness, and subjective hurt is on one aspect of the body and the Jones tender point is characteristically on the other aspect of that part of the body, usually in a muscle antagonist. At the position of comfort, the point becomes flaccid on repeated testing and the position is one of mild strain. The position of comfort is generally held for up to 90 seconds, until release is detected by gentle intermittent test palpations, then the body parts are returned SLOWLY to their neutral position.

Myofascial Release

Myofascial release is a system of therapy that combines principles and practice from soft tissue technique, muscle energy technique, and inherent force craniosacral technique. It includes a highly subjective transfer of energy from the therapist to the patient. It is another example of a clinical practice that is sometimes effective for myofascial TrPs, but the patient is not examined for them, so the extent to which the patient is benefitting from relief of TrPs goes unrecognised.

Accessory Techniques

A number of techniques can assist and supplement the specific TrP therapies described above. Controlled respiration and directed eye movement are two techniques of great value and are applicable to many of the TrP release techniques. The others have more limited application.

Phased Respiration. As one slowly exhales, muscles throughout the body generally tend to relax. With inhalation, muscular activity is facilitated. Since exhalation encourages relaxation of most muscles, it can be very helpful to co-ordinate an exhalation phase of respiration with the release phase of most muscle-stretching techniques. Abdominal (diaphragmatic) breathing is particularly important when attempting to relax neck muscles.

Directed Eye Movement. Clinical observations have shown that the direction of gaze facilitates the movement of the head and torso in the direction of the patient's gaze and inhibits movement in the opposite direction. This applies to lifting the head and torso as well as to stooping and trunk rotation. However, looking upward does facilitate straightening up from the side-bent position. These eye movements should not be exaggerated, because a maximum-effort movement may have an inhibitory effect.

Skin Rolling — as described in Chapter 2 with regard to panniculosis. Has been found to be clinically useful both for diagnosis and treatment of panniculosis. Therapeutically, skin rolling seems to work best over the shoulders and upper back and least well over the buttocks.

Biofeedback — helpful in two ways: (1) can be used to help the patient avoid unnecessary increased resting muscle activity which contributes to TrP irritability and activation; (2) surface EMG as feedback to retrain the affected muscles to normal muscle balance and function following inactivation of the responsible TrPs.

Modalities

Therapeutic Ultrasound. Clinically, many therapists find the application of ultrasound an effective means of inactivating TrPs. Ultrasound transmits vibrational energy at the molecular level, approximately 50% of which reaches a depth of 5 cm. These vibrations not only generate heat within the tissue, but can have additional, but less clearly understood, chemical effects. A clinically successful technique starts with a setting of 0.5 watt/cm² and uses a slow dwell technique with a circular motion that completes one circle in 1 or 2 sec.

High Voltage Galvanic Stimulation. The waveforms of this kind of electrical stimulation are relatively high-frequency brief spikes of at least 150 volts with very rapid rise times. This form of stimulation is selectively more effective on large diameter motor nerves than on smaller diameter sensory nerves, which makes it better tolerated than square-wave potentials as a way of stimulating muscle nerves electrically. It is sometimes used as primary modality for TrPs or as preliminary treatment, and more commonly applied following stretch and/or injections.

Iontophoresis and Phonophoresis. Iontophoresis uses low voltage direct current to move a solute of ions across a membrane into underlying tissues. Although no scientific papers are known to have been published on the usefulness of either of these techniques for the treatment of TrPs, some clinicians have found them useful for administration of steroids into an active TrP area.

TENS (Transcutaneous Electrical Nerve Stimulation). Well established as one means of obtaining temporary, sometimes prolonged, pain relief. Although it is not a treatment modality for myofascial TrPs, it is an accessory technique. Useful for alleviating the postinjection soreness that is likely to peak a day or two after injection.

Pain Relief

No nonnarcotic medication is known that is specific for the pain generated by central myofascial TrPs. The new understanding of the pathophysiology of TrPs opens the door to identifying drugs that specifically inactivate the TrP mechanism.

Available nonsteroidal anti-inflammatory drugs given orally afford little relief from pain originating in central TrPs. However, they can be very helpful for alleviating the postinjection soreness that is likely to peak a day or two after injection, especially when dry needling without a local anaesthetic has been used.

Muscle Relaxants. The rationale for the use of muscle relaxants has been based largely on the erroneous concept that muscle pain causes spasm of the same muscle, which in turn causes more muscle pain. Since this pain-spasm-pain concept has failed the test of experimental investigation, there is no rationale for muscle relaxants in the treatment of myofascial pain caused by TrPs. Often the increased muscle tension that is identified as "spasm" related to musculoskeletal pain is actually caused by taut bands of TrPs. Muscle relaxants have no effect on muscle fibres that are in contracture because of dysfunctional endplates.

Sleep medications — three non-habit-forming antihistamines are recommended for better sleep: Dimenhydrinate (Dramamine), Diphenhydramine hydrochloride (Benadryl), and Promethazine (Phenergan). Melatonin is now available without prescription and is specifically useful to reestablish a normal sleep-waking cycle. A dose of 200–500 μg taken one-half hour before bedtime will expedite going to sleep and help to prevent early awakening.

Caveats

Hypermobility. Treatment with a stretching technique that fully lengthens a muscle is contraindicated across joints that are truly hypermobile. When there are TrPs in muscles that cross hypermobile joints, these TrPs should be inactivated using techniques applied directly to the central TrPs without stretching the muscle as a whole. These alternative therapies include TrP pressure release, deep stripping massage, hold-relax with mild (not vigorous) contraction, indirect techniques, TrP injection, high voltage galvanic stimulation, and ultrasound.

Shortening Activation (Reactive Cramping). When a tight muscle (e.g., right middle scalene) is suddenly released, shortening activation (a reactive cramp) may develop in an antagonist muscle (e.g., the left levator scapulae). As the tight muscle (right middle scalene) is lengthened well beyond its accustomed limit in the process of inactivating its TrPs, the antagonist (left levator scapulae) is simultaneously shortened to less than its accustomed minimum length. If the antagonist harbours latent (or mildly active) TrPs, they suddenly and strongly may be activated by being placed (and held briefly) in this unaccustomed shortened position. Shortening activation can be avoided by systematically treating both the agonist and antagonist groups of muscles partially, one after the other.

Reasons for Failure of Spray and Stretch:

  • Perpetuating factors — probably the most important reason. When active myofascial TrPs do not subside after correctly applied spray and stretch, one or more perpetuating factors are usually responsible.
  • Inadequate coverage — if the spray is applied only to the reference zone, it usually misses the skin overlying the TrP that is causing the pain.
  • Patient tension — for effective passive stretch, the patient must fully relax the muscles being treated.
  • Poor spray technique — the vapocoolant is less effective if the stream of spray is passed too quickly over the skin, or if the spray container is held too close to the skin.
  • Incomplete spray and stretch — additional cycles of spray and stretch, with rewarming after each cycle, need to be repeated as long as the range of motion increases significantly with each cycle.
  • Inadequate stretch technique — the TrPs will persist if too much or jerky force is used to passively stretch the muscle.
  • Incomplete stretch — residual tautness remains when the muscle is stretched to less than its FULL range of motion.
  • Poor posttreatment — muscle soreness is likely to be greater if the skin is not rewarmed immediately.
  • Chronicity — pain recurs when aggravating or perpetuating factors are present and reactivate the TrPs. However, chronicity alone need not prevent an immediate but temporary response to specific myofascial therapy.

14. Corrective Actions

This section reviews what the patient must do or avoid to achieve lasting recovery; Chapter 4 reviews the perpetuating factors that the doctor and therapist must identify and manage.

Patient Compliance

Patients may fail to perform corrective actions effectively because of over-enthusiasm, misunderstanding, or lack of interest and motivation.

Over-enthusiasm — some patients are hard-driving over-achievers who live by the philosophy that if one is good, two must be better, and three much better. They tend to be Spartan and are determined to be "good sports," performing activities regardless of exhaustion or pain, and they refuse to quit. These patients abuse their muscles, rather than use them within their normal limitations.

Misunderstanding — people routinely misunderstand verbal instructions. By having the patient demonstrate the exercises on return to the office, the clinician learns: (1) what exercise the patient has actually been doing; (2) how the patient has been doing it; and (3) how much improvement in function has occurred.

Lack of Interest and Motivation — patients with chronic myofascial pain will not do well unless they understand that this is their muscle problem and that the clinician's essential role is to help them learn how to deal effectively with their muscles.

Appropriate Activities

After a treatment session, the patient must understand what kind and dose of activity are appropriate, and must eliminate or modify habitual movements that are perpetuating TrPs.

Posttreatment activity: strenuous activities should be avoided for at least the 2 or 3-day period of muscle soreness, and preferably for about 1 week. This includes avoidance of tennis playing, serious gardening, moving furniture, and travelling to conventions. However, patients are encouraged to use their muscles in a gentle, normal way through their full range of motion. They must avoid placing their muscles in a fixed, shortened position for a prolonged length of time.

Basic rules:

  • NEVER bend over and lift, or pull something, with the back twisted. ALWAYS lift by extending the knees and hips, holding the back in an erect-forward-facing position.
  • NEVER get up from, or sit down in, a chair while leaning forward in the stooped position with the trunk rotated.
  • Patients with acute scalene, serratus anterior, or quadratus lumborum TrPs (muscles with rib attachments) — sneezing or coughing can be exquisitely painful. The sneeze may be inhibited by promptly biting high on the upper lip.

Activity Goals

Not only is WHAT to do important, but also HOW to do it. On performing a task, the patient MUST learn to keep the muscles mobilised, and not held fixed in a contracted position. Muscle fibres need to alternately contract and relax to provide blood flow and replenish their energy supply.

Strenuousness of effort: the patient must avoid using the muscles at maximum effort, when they are most likely to be strained. Lifting, pulling, or pushing something should use less than maximum strength, always leaving some reserve, especially in the case of muscles susceptible to TrPs.

Mobility: lying still in bed with muscles in a shortened position aggravates TrP activity; being up and doing non-strenuous activities help to mobilise the muscles and reduce TrP activity. A mobilising and relaxing activity is rocking in a physiologically well-designed rocking chair.

Principles for activity (from Travell):

  1. Vary your task each day so as not to overuse any one group of muscles in repetitive work.
  2. Slow your working pace to a speed no faster than your muscles will tolerate.
  3. Cultivate a rhythm of movement. It discourages the prolonged fixed contraction that tires a muscle, and it encourages pauses during which the working muscles fill up with new blood and fresh fuel.
  4. Take short rests frequently.
  5. Don't sit too long in one position.
  6. Don't try to lift a heavy piece of furniture by yourself, or carry large awkward things that extend the leverage length of your arm.
  7. When standing or walking, focus on the floor under the feet.

Application of Heat

Allowing the body to become chilled invites activation of TrPs. A sweater in the home by day and an electric blanket at night can make the differences between comfort and pain.

Cold applied to the skin penetrates quickly due to progressive vasoconstriction. Surface heat does not penetrate; the excess heat is quickly carried away by the increased blood flow due to vasodilation. Prolonged cold over a TrP tends to activate it, but prolonged cold applied over the pain reference zone may relieve discomfort by partially anaesthetising sensory nerve function locally.

Moist heat — Heat that the patient applies to sore muscles is usually more soothing if it is moist rather than dry. Either a wet pack soaked in hot water, or a wet-proof heating pad covered with a damp cloth, serves the purpose. The moist heat is applied over the TrP, if its location is known. Daily application of moist heat to active TrPs can progressively quiet them.

Posture and Positioning

Activity posture: good posture avoids sustained contraction or prolonged shortening of muscles. Strain of the upper trapezius is lessened by providing armrests that properly support the elbows. These are needed when sitting, reading, telephoning, and driving or riding in a car. Placing the work level low enough so that the shoulders need not be raised to reach it (e.g., a keyboard) is also important.

Correct standing and sitting posture — criteria and techniques for achieving it are presented in Chapter 41, Part C.

Reading position — tilting the plane of reading glasses so that the lower rim is against the cheek allows the patient to read by turning the eyes downward, rather than by bending the neck forward.

Sleeping position — muscles should rest in a neutral or slightly stretched position at night and NEVER be kept in the fully shortened position.

  • The shoulders should not be allowed to creep up toward the ears when lying in bed. Correct positioning is helped by tucking the corners of the pillow between the chin and shoulder on each side.
  • When lying on the side, the patient should pull the corner of the pillow around between the lower-most shoulder and chin, to avoid shortening the front-of-the-neck muscles.
  • The patient should use only one comfortable pillow under the head (not under the shoulders) to keep the head and neck in a neutral position.
  • Tilting the entire bed frame by elevating the head end of the bed with 3.5- to 4-inch blocks under its legs creates helpful gentle traction on the neck, elongating the scalene and sternocleidomastoid muscles.
  • The elbows and wrists should not be held sharply flexed at night. A pillow in the axilla, between the arm and chest wall, prevents painful shortening of muscles in TrP syndromes that can occur in the subscapularis, pectoralis major, latissimus dorsi, triceps brachii, infraspinatus, and teres major and minor muscles. A pillow at the feet lengthens the gastrocnemius/soleus calf muscles and prevents sustained plantar flexion.

Exercises

An exercise should be designed primarily for lengthening, strengthening, or conditioning specific muscles. Exercise to lengthen the involved muscles is the key to sustained relief of myofascial pain.

Exercise should be regarded as a prescription, much as one prescribes medication. Like a drug, there is a right kind, dose, and timing of exercise. The exact exercise to be performed should be demonstrated and explained to the patient, who then does a return demonstration to confirm understanding of the instructions. The rate, number of repetitions, frequency in one day, and the conditions under which it should be done should all be specified.

Stretch Exercise. In this manual, muscle lengthening exercises are described and illustrated in detail because they are so important to the recovery from dysfunction and pain due to active TrPs. A daily home programme of stretch exercise that achieves FULL range of motion of the affected muscles helps to insure continued relief. Postisometric relaxation (PIR) and combinations of it with reciprocal inhibition are the preferred approach to home exercises.

Strengthening Exercise. To strengthen a muscle, one needs to hold a maximal contraction for only 5 or 10 seconds, once a day. An isotonic exercise is preferable to a fixed position isometric exercise. A muscle has significantly greater strength and efficiency during a lengthening contraction than during a shortening contraction.

Conditioning Exercise. Swimming, bicycling, tennis, treadmill, jogging, and jumping rope are examples of conditioning exercises. The least traumatic bicycle exercise is on a machine that the patient pedals from behind, while lying supported in the semi-recumbent position. When riding an upright stationary bicycle, the patient should not hold the handlebars, but should sit up straight and swing the arms from time to time. A regular conditioning exercise programme at least twice a week, or preferably every other day, is strongly recommended for optimal health and to minimise the chance of reactivating TrPs.

Key exercise principle: as the TrPs are inactivated and rest pain fades, a carefully graded exercise programme is needed to improve conditioning and endurance. The programme should start with lengthening, not shortening, exercises.

Patients should avoid activities that produce repetitive muscular loads, such as shovelling snow, raking leaves, vacuum cleaning, painting a wall, or unloading a dishwasher. If such tasks must be performed, then the movements should be varied and sides of the body alternated so that contralateral muscles are used in turn.

See Also

References

This page is based entirely on: Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1: Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 3: Apropos of All Muscles, pp. 126–178.

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