by Ross Turchaninov, MD and Boris Prilutsky, MA, LMT
Trigger point therapy (TPT) is perhaps the most controversial topic in modern-day massage literature. At the same time it is one of the cornerstones of medical massage and manual therapy. From journal to journal, we read articles which frequently are inconsistent with the scientific principles of massage therapy, written by authors who, moreover, frequently contradict each other. Periodically, so-called new approaches are published, and authors of these articles declare new breakthroughs in TPT. Usually, these “new discoveries” are not founded on any scientific basis nor have been confirmed by clinical testing, and are based solely on anecdotal claims.
Many practitioners are not aware of the fact that there exists a TPT protocol based strictly on science, which has been put through extensive clinical testing against placebo, and that there is thus no need to re-invent the wheel. This article presents the safe and clinically effective protocol of TPT based on the science.
We can appreciate that the readers could entertain doubts as to the basis of the authors of this article resisting further developments in the area of TPT, and instead insisting upon the application of TPT according to only one protocol. It could reasonably appear as if our intention is to promote our own ideas. We would like to assure our readers that such concerns as to our motives are unjustified.
Firstly, we did not develop the scientifically grounded protocol of TPT (unfortunately for us); rather, we see it as our goal to deliver this existing information to practitioners. This protocol slowly emerged within the scientific publications of many authors, from different Western countries, who greatly contributed to the science of manual therapy and medical massage (Macknenzie, 1923; Travel and Rnzler, 1952; Glezer and Dalicho, 1955, etc.)
Secondly, we will illustrate every small detail of the TPT protocol in video format, and the reader/viewer will have no further need to attend a seminar, or buy a book or DVD, in order to master it.
Thirdly, we fully support any new development in the field of TPT, so long as such development is tested in a clinical setting, and its efficacy confirmed. The moment a new protocol is tested against placebo and is found more effective than the current one, we will be the first to enthusiastically implement it.
Why do we feel that a standard as rigorous as this is called for in regard to the questions of TPT and the hypertonic muscle abnormalities it has been designed to address? Overall, massage therapy is a field in which one rightly encounters a great degree of freedom of choice. For when one works within the classic safety guidelines taught in massage schools (endangerment sites, contraindications, etc.), it is usually very hard to actually harm the client; and in the most common worst-case scenario, the therapist’s treatment will simply be without therapeutic effect. You work on a client with plantar fasciitis applying protocol of the connective tissue massage, while your friend uses myofascial release on someone else with the same condition, and both of you are successful. In contrast to this, the inappropriate application of TPT represents an instance where the practitioner consciously (as opposed to inadvertently) applies a technique in such a way that can invite truly dire consequences upon the client’s health. This is why there can be no compromising on the issue of TPT. One either does it according to the scientifically developed protocol, or one risks doing harm to the client.
We understand that some readers may have been using TPT for years and may have seen positive clinical outcomes in their work. In such a case, the reader may pose the reasonable question: Where can the harm come from? Let us enumerate the major negative outcomes of inappropriate application of TPT:
1. The “No pain, no gain” approach fosters a negative perception of the massage therapy in general and especially TPT because those clients are in real pain or have a very low pain threshold. We have seen it over and over again in our clinics, where clients who have had previous bad experiences with TPT conducted according to the “no pain, no gain” approach have been very uncooperative at the beginning of the treatment, expecting, as per their previous experience, significant worsening of their symptoms.
2. An incorrect protocol of TPT does not eliminate active trigger points, but instead transfers them into a latent or “sleeping” state. This is the reason why the treatment can appear, to the practitioner and the client, to have been successful; however, a latent trigger point will sooner or later reactivate itself in response to one or several triggers such as physical overload, emotional stress, sharp fluctuations of temperature or barometric pressure, etc. In such a case, the incorrect protocol of TPT applied by a practitioner has, rather, transferred an acute trigger point into a long, sometimes life-long, chronic problem for the client.
3. Excessive application of pressure to the part of the skeletal muscle which carries a trigger point produces extensive damage to the myofibrils. Application of such unnecessarily strong pressure over and over again in the same area triggers the deposit of glycosaminoglycans between damaged myofibrils, and this represents the beginning of the formation of the core of myogelosis. Myogelosis is degenerative changes inside a skeletal muscle, which the practitioner may feel as dense, round nodules. These changes develop over a period of years, in areas where trigger points have been reactivated, frequently as an outcome of prior inappropriate treatment of active trigger points. Thus, the practitioner who does not apply the correct protocol of TPT is directly responsible for the formation of myogelosis in the muscles of his or her client. Myogelosis is an irreversible condition which stays with the client for the rest of his or her life.
4. Many trigger points are located near peripheral nerves or arteries, and the practitioner can severely damage these vital anatomical structures during incorrectly applied TPT.
5. Incorrectly applied trigger point therapy can also trigger various abnormalities in the functions of the inner organs.
The last two points far from being overstatements, we provide below, in support of them, a very short list of articles published in medical journals, by physicians who have dealt with medical consequences of inappropriate application of pressure to the soft tissue during deep tissue massage and TPT. Unfortunately, there are many more articles like these ones in the literature.
Tachi et al. (1990) describe a case of autoimmune thyroiditis, or Hashimoto’s disease, triggered by very painful massage on the posterior and lateral neck conducted by a massage practitioner seeking to treat active trigger points in the cervical muscles.
Herkovitz (1992) reported a case of massage-induced injury of the median nerve after incorrect treatment of Carpal Tunnel Syndrome conducted by a massage practitioner above the carpal tunnel on the lower third of the forearm.
Danchink et al. (1993) reported a case of muscle ossification developed after an injured athlete was treated with deep-tissue pressure. The ossificated part of the muscle required surgical removal.
Liu (1993) reported a case of dissection of the wall of the internal carotid artery, with subsequent formation of a mural hematoma, after deep-tissue compression and massage were performed on the lateral neck. This is a case of a life-threatening complication.
Mumm (1993) reported a case of severe vesicular zoster infection along the C1 to C8 dermatomes on the neck, upper shoulder, arm, forearm and hand. The patient reported that this re-activation of her viral infection occurred shortly following very painful massage conducted by a practitioner to relieve cervical and upper shoulder pain. The author concluded that excessive damage of the cutaneous branches of the peripheral nerves during massage reactivated the virus which had been in remission for more than 50 years.
Medvedev (1994) reported a case of neurosensory hearing loss caused by excessive pressure applied to the tapezius muscle below the occipital ridge. The author concluded that the damage to both occipital nerves triggered the patient’s hearing loss.
Geise (1998) reported a case of severe damage to the posterior interosseous nerve caused by deep pressure on the forearm, with subsequent development of long-lasting paresis of the hand and finger extensors.
The authors of these and similar articles all mention that the patients informed their practitioner about the high intensity of pain during the treatment session, but that he or she persuaded the patient that such pain was a normal part of the treatment.
We would hope that readers can now appreciate why we have such deep concerns about this issue, and we want to set the record straight. Considering the importance of this topic and the absence of a unified view in its regard, we would like to provide massage practitioners with clear guidelines. Anyone who may find this information too complicated to bother with could stand to bear in mind that he or she may not violate the First Principle of medicine established long ago by Hippocrates: Do no harm! In this and the following two issues of this journal, we will go over the science concerning trigger points and Trigger Point Therapy in its smallest detail.
Let’s begin with a short historical trip back to 1843, when the German physician F. Froriep, MD first described dense (and to the patient, painful) areas in the skeletal muscles. This is the first description in modern medical literature of hypertonic muscle pathology.
In 1909, another German scientist, A. Cornelius, MD theorized the formation of painful nodules in the skeletal muscles as being one of the body’s reflex reactions to trauma. Dr. Cornelius strongly believed that only massage could eliminate muscle spasm and restore normal muscular contraction. He was the first scientist to develop a treatment protocol to deal with muscle spasm — a protocol which most aptly carried his name, Cornelius’ Massage.
For the reader’s information, all authors of modern publications addressing the issue of massage as treatment for TPT based their work, without even knowing it, on principles established by Dr. Cornelius. We invite the reader to trust our expertise when we say that, technically, TPT has not change much since 1909. Thus, the entire conception of modern TPT is based on Dr. Cornelius’ foundational principles.
What has changed dramatically however, since Dr. Cornelius’s work, is our understanding of the mechanisms responsible for the formation of trigger points in the skeletal muscles. This process began with Dr. H. Schade, who in 1921 examined hypertonic muscular abnormalities and developed the concept of myogelosis.
The next cornerstone in the field is the work of the British scientist Dr. J. Mackenzie, who in 1923 proved that changes in the motor activity of the patient’s nervous system are key components in the development of hypertonic muscular abnormalities, especially trigger points. Thus, Dr. Mackenzie was the first to formulate the concept of reflex zones in the skeletal muscles, including trigger points. Prof. A. Sherbak, MD of Russia, as well as A. Glezer, MD and V. Dalicho, MD of Germany, all three of whom developed the concept of reflex massage therapy, based their work on Dr. Cornelius’ and Dr. Mackenzie’s earlier discoveries.
The final major contributions to the field is the work of Prof. I.M. Korr, DO and J.J. Travell, MD and D.G. Simons, MD of America.
FORMATION OF TRIGGER POINTS
We would like to state, at the outset, that there are three types of trigger points: cutaneous trigger points (in the skin), trigger points in the skeletal muscles, and periostal trigger points (in the periosteum). The periosteum is a thin connective tissue membrane covering bones, and into which all tendons and ligaments insert. We will discuss here only trigger points in the skeletal muscles.
However, each type of trigger point has its respective set of clinical and diagnostic symptoms, and all three types are equally responsible for the pain in the affected area. The practitioner must retain this fact and have enough expertise to differentiate between them, otherwise the treatment results in a pure waste of the client’s money with no stable clinical results. Pain originating from a periostal trigger point must be treated differently from that originating from a trigger point in the skeletal muscle.
It goes without saying that for optimal performance, the entire muscle needs to contract. Each muscle has two major points of stabilization: its origin and its insertion. Thus, during muscle contraction two biomechanical forces are created, and they are directed from their respective point of stabilization toward the middle of muscle belly.
Unfortunately, the nerve impulses (or action potentials) which, from the central nervous system, deliver the command to the muscle to contract are not distributed equally throughout the entire muscle, and biomechanical forces from the origin and insertion collide with each other mostly in the same areas.
Thus, tension during contraction is not generated in a balanced way. As a result, the entire muscle belly becomes slightly twisted during each contraction. This factor does not cause any problems if the muscle performs a lot of isotonic work — as in the case, for example, of the gastrocnemius muscle of a construction worker. However, the situation changes dramatically if the muscle performs a lot of isometric, or static, contractions — as with, for example, the gastrocnemius muscle of a bank teller. In this case, constantly arriving new waves of nerve impulses support the deformation of the muscle belly because there is much less contraction and relaxation and the muscle is under the constant pressure.
When the same type of isometric work is performed daily for several hours at a time (another example being that of a computer programmer), the constant moderate tension and slight twisting of the fibers triggers the elevation of the resting muscle tone.
Resting muscle tone is the degree of muscle contraction which the muscle maintains at rest. Each of us has a basic resting muscle tone assigned to each muscle by the motor cortex according to our age, weight and activity level. When this tone increases, the muscle is not completely relaxed at rest and muscle tension builds up.
The formation of hypertonic muscle abnormalities is a very complicated chain of events which includes local and general changes in the body. It will be easier to discuss it with the help of Fig. 1. As a result of any, or of any combination, of the following factors, muscular hypertonus with trigger point(s) can form: trauma; chronic muscle overload owing to a lot of isometric contractions; irritation of the spinal or peripheral nerves; chronic visceral disorders; autoimmune abnormalities; nutritional deficiency; as well as some medications.
The first clinical outcomes of these initial factors are vasoconstriction and increased resting muscle tone. Both these outcomes contribute equally to the development of local ischemia or to insufficient arterial blood supply, which results in changes of the local pH. A decrease of arterial supply is also accompanied by a diminishing of the local metabolism. At this initial stage, the mismatch between for the oxygen needs of the working muscle and the ability of the circulatory system to deliver the necessary oxygen to the tissue plays a critical role.
While the resting muscle tone increases and subsequently the arterial blood perfusion decreases, the muscle continues to receive motor commands from the CNS to perform contractions. Thus, this (again) mismatch between the demands for contraction and the inability of the muscle to fulfill them becomes the final trigger of hypertonic muscular abnormalities (Bernstein, 1947; Ivanichev, 1990).
At the same time, chronic muscle tension delays venous and lymphatic drainage from the affected area, and venous stasis — and later, interstitial edema — are formed. The accumulation of waste products in the area of the hypertonus additionally contributes to the chemical compound changes of the local pH.
It is only as of this point that pain receptors are activated and begin to send sensory afferent discharge to the brain. After the pain stimuli reach the thalamus and the cortex, the patient’s behavior and emotional status are changed. He or she starts to avoid using the affected muscles and instead overloads the muscle synergists. Thus, the balance between muscular groups is greatly affected, and the relationships between the muscle antagonists are changed. As a result, the body forms additional protective muscle tension in the affected area (the threshold of muscle spindle receptors decreases), restricts movement in the hypertonically changed muscles, causing postural balance to be affected as well.
The combination of insufficient arterial circulation, delayed venous and lymphatic drainage, changes in the local pH, activation of the pain-analyzing system, and behavioral changes is responsible for the development of hypertonus and trigger point(s). Without correct treatment, these will in time progress to the stage where the core of myogelosis starts to form as a result of glycosaminoglycans (GAG) deposited between muscle fibers.
GAGs are complex chemical compounds which consist of the large carbohydrate part and small protein part. GAGs are substantial part of any connective tissue structure.
Fig. 1. Formation of hypertonic muscular abnormalities
Without appropriate treatment, hypertonic pathology becomes a chronic problem with alternating periods of remission and reactivation. Many factors may trigger such reactivations: exposure to cold, stress, physical overload, etc.
Tichy and Seidel (1969) showed that autoimmune mechanisms are also responsible for the chronic character of hypertonic muscular pathology. Autoimmune reactions are triggered in the affected muscles and connective tissue structures (as a result of factors as yet unknown), and the immune system proceeds to consider the muscle tissue of the affected area as a foreign antigen.
The formation of reflex zones in the skeletal muscles may also be caused by chronic visceral disorders through autonomic reflex pathways, endocrine pathology (e.g., hypothyroidism, hypoglycemia), menopause, some nutritional deficiencies (in vitamins: C, the B group, folic acid; in minerals: potassium, iron, calcium), as well as some medications (e.g., cholesterol-reducing drugs).
The trigger point never appears first. Muscle abnormality starts with the formation of hypertonus. Hypertonus may either form slowly in response to chronic muscle overloading (a lot of isometric contractions) or to chronic inner organ disorder, or it may form quickly as a result of trauma to, or irritation or compression of, spinal or peripheral nerves. In any case, one or more trigger points will quickly form within the hypertonus, and will be perceived by the patient as areas of maximal pain.
Any prolonged existence of a hypertonus with trigger point(s) will eventually form one or several myogelosis(es) inside the affected muscle. Generally, it is rare to see such a precise sequence of pathological events in clinical practice, but we refer to it only for the sake of systematization and logical order. In most cases, the formation of muscle abnormalities may stop at any stage; or, the simultaneous co-occurrence of hypertonus with trigger point(s) and myogelosis may be hold.
In the next issue, the second part of this article will cover the diagnostic evaluation of trigger points in the skeletal muscle.
REFERENCESBernstein N.A. The Structure of Movements. Academy of Science, Moscow, 1947
Cornelius A. Nervenpuncte, ihre Entstehung, bedeutung und behandlung mitters Nervemassage. Thime, Leipzig, 1909
Danchik J.J., Yochum T.R., Aspergen D.D. Myositis Ossificans Traumatica. J. Manip. Phys. Ther., 16(9);605-614, 1993
Froriep R. Ein Beitag zur Pathologie und Therapie des Rheumathismus. Weimar, 1843
Geise S. Posterior Interosseus Syndrome Resulting from Deep Tissue Massage.Plast. Reconstr. Surg, 102(5):1778-1779, 1998
Glezer O., Dalicho V.A. Segmentmassage. Leipzig, 1955
Herkovitz S. Shiatsu Massage-Induced Injury of the Median Reccurent Motor Branch. Muscle Nerve, 15(10):1215, 1992
Ivanichev G.A. Painful Muscular Hypertonus and Trigger Points. Kazan Medical University, Kazan, 1990
Korr, I.M. The Neural Basis of the Osteopathic Lesion. JAOA, 47(4):191-198, 1947
Liu B. Extracarnial Internal Carotid Artery Dissection Secondary to Neck Massage. Vizualization of Mural Hematoma by MRI. Kao. Hsiung I Hseeh Ko Hsuenh Tsa Chin., 9(5):332-327, 1993
Mackenzie J., Angina Pectoris. Henry, Frowde & Stroughton, London, 1923
Medvedev E.A. Case of Acute Unilateral Neurosensory Hearing Loss Caused by Massage of Trapezius Muscle. Vest. Otorinolaringol, 3:38-39, 1994
Mumm A.N. Zoster After Massage. Lancet, 341(8842):447, 1993
Schade H. Untersuchungen in der Erkaltungstrade: III Uber den Rheumatismus, in besondere den Muskelrheumatismus (Myogelose). Munch Med Wschr 68, 95-99, 1921
Sherbak A.E. The Physiological Effect of Reflex Massage. Medgiz, Moscow, 1936
Tachi J., Amino N., Myai K. Massage Therapy on neck: A Contributing Factor for Destructive Thyrotoxycosis. Thyrology, 21(1):25-27, 1990
Tichy H., Seide K. Reitrage zur Rheumatologie. Berlin, 1969
Travel J.G., Rinzler S.H. The Myofascial Genesis of Pain. Postgrad. Med.,11:425-434, 1952
Travel J.G., Simmons D.G. Myofascial Pain and Dysfunction. The trigger Point Manual. Williams&Wilkins, 1983
For Dr. R. Turchaninov bio click here
Mr. B. Prilutsky, practices and teaches Medical and Sports Massage for more than 30 years. He has master degree in physical education and rehabilitation from Ukraine.
Mr. Prilutsky has worked with athletes and world dignitaries throughout Europe, Israel and USA. He is the founder of the Institute of Professional Practical Therapy in Los Angeles and to date, he has trained thousands of therapists world-wide. Boris Prilutsky has published extensively on various topics of physical medicine and rehabilitation.
Category: Medical Massage