by Ross Turchaninov, MD and Boris Prilutsky, MA, CMT
This article concludes our discussion of the science of Trigger Point Therapy (TPT). We would like our readers to reference our previous TPT articles. It took us four issues to articulate the TPT’s basic concept for our readers. We received many comments from our readers expressing great appreciation for the information we already discussed.
Part I: Nature of TPs – Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy. Part I: Nature of Trigger Points
Part II: Types of TPs and Their Evaluation – Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy. Part 2: Types of Trigger Points and Their Evaluation
Part III: Active TP and Central Nervous System – Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy Part 3: Active TP and Central Nervous System
The final topic of our article is Trigger Point Therapy Protocol. We will provide this protocol in a step-by-step format that enables practitioners to correctly treat hypertonicity in the skeletal muscles, completely eliminating trigger points rather than transferring them into a latent or sleeping state. This protocol is a part of the vast collection of protocols and massage techniques published in the SOMI’s Video Library of Medical Massage Protocols: Medical Massage Courses & Certification | Science of Massage Institute » Welcome to the Video Library!
As we mentioned in the first part of this article, Trigger Point Therapy (TPT) is the most frequently discussed and most frequently misrepresented subject in modern massage literature. The most common recommendation in TPT is to apply compression until the practitioner feels the tension in the compressed muscles ‘released’. This is the most common mistake, as it sends the active trigger into a ‘sleeping’ or latent state rather than eliminating it.
Let us review the step-by-step TPT protocol based on clinical science. If new approaches to TPT are developed, they should be tested in the clinical setting first by independent sources, and the results must be published. Otherwise, they are personal opinions or anecdotal claims. TPT is that rare instance in the massage therapy profession where the practitioner can actually harm the client (e.g., triggering the formation of myogelosis) if it is conducted incorrectly. The stable clinical results of the protocol presented below are due to its inclusion of several healing factors, which are critical to the overall success of TPT.
Ultimate elimination of heprtonicity in the form of TP requires that the therapist combine direct therapy in the form of TPT Protocol and indirect or reflex therapy. Only the combination of both allows for the elimination of muscle hypertonicity
DIRECT THERAPY: TRIGGER POINT THERAPY PROTOCOL
TPT protocol includes the use of electric vibration as an important component of the treatment. This requires the practitioner to have an electric massager. The therapist may use manual vibration, but it is very tiring and less effective. Adding steady electric true vibration at a frequency of at least 60Hz makes the therapy very effective and yields more clinically stable results.
In the videos below, we will illustrate the TPT protocol on the example of the active trigger point in the lower portion of the trapezius muscle. To conduct TPT, the practitioner must accomplish the following steps:
Step 1. Be sure that the location of the active trigger point and its “entrance” was detected during evaluation using the Compass Technique (see video below and Part 2 of this article: Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy. Part 2: Types of Trigger Points and Their Evaluation ).
Step 2. Start with preparing the entire muscle or group of muscles using the inhibitory regime of massage therapy (see Part 3 of this article Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy Part 3: Active TP and Central Nervous System).
Step 3. During the application of massage in the inhibitory regime, begin to activate the central control trigger (see Part 3 of this article Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy Part 3: Active TP and Central Nervous System). Start an active conversation with the client (if possible) about a subject that interests them. Guide the conversation so the client tells you a story, and keep it going by asking questions. Try to maintain the activation of the central control trigger during the entire TPT.
Step 4. To additionally activate the central control trigger and to close the gates in the posterior horns of the spinal cord, add high-frequency permanent electric vibration (see Part 3 of this article Medical Massage Courses & Certification | Science of Massage Institute » Science of Trigger Point Therapy Part 3: Active TP and Central Nervous System) by placing the massager on the area of the trigger point in the direction of the entrance into the trigger point (see video below). Keep it still for approximately one minute.
Step 5. Move the massager slightly to the side while maintaining vibration, then place the fingertip or massage tool on the trigger point. Compress tissues in the direction of the “entrance” into the trigger point using the ‘stop and go’approach.
Let us briefly review the ‘stop and go’ approach to TPT. Gradually increase applied pressure until the patient reports the first sensation of pain in the compressed tissues. This is the threshold for activating the pain analyzing system in the treatment area. Stop further increasing the pressure, but maintain it on the same level. Let the patient adapt to it. Usually, it takes 10-15 seconds, and as soon as the patient reports a decrease in the uncomfortable sensation in the compressed tissue, the practitioner may slowly increase the pressure. A further increase will again trigger the pain threshold, and the practitioner should stop immediately while maintaining the new level of compression. In another 10-15 seconds, the practitioner may increase the pressure further. Use 2-3 of these ‘stop-and-go’ pressure increases (see video below). Throughout this time, keep the electric permanent vibration next to the finger and continue communicating with the client.
The ‘stop and go’ approach allows complete immersion in the trigger point without generating protective muscular tension, which is the biggest obstacle to successful TPT.
Step 6. When it is time to exit the trigger point, do it as quickly as possible (see video below). This allows arterial blood from the “blood depot” to enter the trigger-point tissue quickly, and the resulting reflex vasodilation is much longer and more efficient.
Some healthy individuals like deep tissue massage, but the practitioner shouldn’t apply excessive, traumatizing pressure on patients with somatic or visceral disorders. Do not make a common mistake and use the “no pain, no gain” approach. The practitioner must always apply pressure at the patient’s pain threshold. Otherwise, the therapist fights with the patient’s brain, and the brain always wins!
Why is this protocol of TPT the most scientifically correct one? It is based entirely on the Gate-Control Theory of Pain (Mezlak and Wall, 1989), which is a major source of our understanding of the function of the pain-analyzing system. The main practical advantage of this protocol is that, during TPT application, the patient does not generate protective muscle tension because pain stimuli are delivered to the spinal cord through the slow-pain analyzing system rather than the fast-pain analyzing system used in all other approaches.
This protocol also gives the practitioner a unique opportunity to exit the trigger point very quickly. This is another subject for discussion. Most publications on TPT recommend entering and exiting the trigger point slowly. We also discussed that entrance into the trigger point is a gradual process. However, the exit must be rapid because it allows blood from the “blood depot” to enter the trigger point more quickly, producing more effective vasodilation. The slow exit from the trigger point should be used only in cases when the practitioner does not pay attention to the protective muscular tension. Under these circumstances, the release of pressure must be slow to prevent pain and reflex muscle contraction, which the patient exhibits as an uncomfortable “jerking” and spasming. Thus, the downside of a slow exit is obvious: it produces slower, shorter vasodilation.
There is another scenario of TPT that the practitioner may face. The active trigger point forms where the motor nerve innervating the muscle enters the muscle belly. This area is always in the middle of the muscle belly. As we discussed in Part 2 of this article, the active trigger point that formed there is called the motor trigger point. The area where the nerve enters the muscle belly is critically important for normal muscle contraction. Here, motor commands that arrive from the central nervous system are transmitted from one excitable tissue, i.e., the peripheral nerve, to another, completely different type of tissue – skeletal muscle. It happens within so-called neuromuscular junctions.
As several studies (Gogoleva, 2001; Heine,1997) have shown in the area of the motor trigger point, so-called ‘collagen cuffs’ form in the tissue around the neuromuscular junction. These ‘collagen cuffs’ are among the reasons for the constant nerve irritation and the chronic nature of hypertonic abnormalities. Unnecessary force of compression additionally contributes to collagen cuffs formation and the development of chronic hypertension in the affected muscle.
In cases of motor trigger points, the TPT protocol differs slightly. First of all, at the end of Step 2, the practitioner must apply repetitive friction along the muscle fibers and then across them while maintaining moderate pressure. Applying friction breaks the ‘collagen cuffs’ around the neuromuscular junction and greatly improves treatment outcomes when the practitioner addresses the motor trigger point.
Another issue with the TPT protocol for the motor trigger point is determining the appropriate amount of pressure to apply during ischemic compression. While applying Step 5 of TPT, decrease the number of submergences into the tissue during the stop-and-go approach. In the active motor trigger point, use only two submergences. While in the active trigger point, you may use 3-4 applications of pressure.
Application of ischemic compression on different levels
The application of ischemic compression to trigger points in skeletal muscles located at different anatomical levels is the final issue we would like to address. If the muscle that carries the trigger point is located superficially (e.g., trapezius), applying ischemic compression is simple once the practitioner has found the entrance to the trigger point. The situation is much more complicated when the muscle that carries the trigger point is located in the middle or even in the deep layer of skeletal muscles. As discussed above, the practitioner should minimize damage to the muscle fibers during ischemic compression. Thus, the practitioner should mobilize the superficial muscle layer to expose and apply direct compression to the hypertonic middle or deep muscles. To do it correctly, the practitioner should use two tools before applying ischemic compression to the deep muscles: preparation and mobilization of the superficially located muscles.
Preparation
Preparation of the superficially located muscles is a must because they will always generate protective muscular tension over the more deeply located muscle that carries the active trigger point. The best combination is kneading techniques and the application of repetitive friction along the fibers of the superficial muscle, which prepares its body for mobilization.
Mobilization
Mobilization of the superficially located muscle is trickier but, at the same time, a very rewarding aspect of TPT. In many cases, the practitioner can shift the superficially located soft tissue aside to expose the deep muscle, then work directly on its fibers without unnecessary damage to the superficial muscle fibers. This recommendation is very easy to follow as long as the practitioner remembers muscle anatomy. The technical ability to laterally mobilize the superficial muscles dramatically increases the effectiveness of TPT applied to the deep skeletal muscles.
INDIRECT THERAPY
In the previous section, we discussed the direct therapy of the trigger point in the form of TPT. However, the overall success of somatic rehabilitation depends on the combination of local, direct, and reflex, indirect mechanisms. We would like to emphasize that hypertonic muscular abnormalities can be completely eliminated only with a combination of direct and indirect treatment.
If TPT alone is used, or only indirect therapy (e.g., PIR) is employed, the trigger point is transferred into a latent state rather than eliminated. Now, any factors, such as muscle overload, exposure to cold weather, or infection, may easily reactivate the trigger point with the same clinical picture. The back-and-forth reactivation of the trigger point in the same area will, sooner or later, lead to the formation of myogelosis, an irreversible muscle pathology. Thus, if we use the incorrect TPT protocol, we are directly responsible for worsening muscle hypertonicity while providing only temporary relief. The indirect treatment of trigger points involves eliciting the H-reflex through repetitive muscle-tendon compression, passive stretching, and Postisometric Muscle Relaxation (PIR). We will shortly review them.
1. Engagement of the H-reflex
Repetitive compressions, or better yet, percussions applied to the tendon of the affected muscle, temporarily reduce the excitability of the motor neurons in the anterior horns of the spinal cord that innervate this muscle and overall decrease resting muscle tone (Burke et al., 1971; Kukulka et al., 1986). This phenomenon results from the H-reflex. Decrease of muscle tone is immediate but short-lived, and it is “…useful in cases requiring a transient reduction in muscle activity” (Kukulka et al, 1985).
This is the exact outcome the practitioner needs from applying repetitive compression or percussion just before passive stretching or PIR. Thus, this simple procedure helps further reduce muscle tone and makes passive stretching or PIR more effective. The practitioner should apply 5-7 intermittent compressions. It is better to fit these compressions into the client’s prolonged exhalation.
2. Passive Stretching
If the reader is not familiar with the PIR method, the ultimate tool for resetting muscle spindle receptors and restoring muscle’s anatomical length, passive stretching can be used as the final step in treating muscle hypertonicity. It makes the entire treatment more efficient. Passive stretching helps relax skeletal muscles, eliminate hypertonus, and reduce the severity of muscle spasms. Despite its apparent simplicity, passive stretching must be done correctly, or the practitioner may easily damage already affected muscle fibers. We will discuss this subject in a future issue of our journal. Each passive stretching must be done during the patient’s prolonged exhalation! Without this important component, passive stretching has very limited clinical benefits.
- Passive stretching also has another important benefit: the examiner may use it as a diagnostic tool to check treatment progress. If the practitioner performs gentle passive stretching of the affected muscle in the direction opposite to its contraction before each new session, he or she will be able to estimate the degree of positive change (pain intensity, stiffness, and range of motion).
3. Postisometric Muscular Relaxation (PIR method)
PIR is a highly effective method for treating hypertonic muscular abnormalities. PIR should be used as the final part of a medical massage session. PIR is part of the Muscle Energy Techniques and warrants special discussion.
Overall, PIR is one of the most popular and clinically valuable methods of Muscle Energy Techniques (MET). Variations of these methods have been used by bone setters since antiquity. However, the first scientific conception of MET was developed in the USA by Dr. F.L. Mitchell Sr., DO, in 1948. The work of Dr. Mitchell, along with the theoretical concepts developed by Prof. I. Korr, DO, comprises the greatest contribution by American scientists to the Western school of manual medicine and medical massage.
There are several treatment methods for hypertonic muscular abnormalities. These are united under the same name: Muscle Energy Techniques. Though all METs have different names and approaches, they are united by one basic principle: the patient actively participates in the treatment. The most universal, safe, and clinically effective method is Postisometric Muscular Relaxation (PIR), which uses isometric contraction against operator resistance as the main component of therapy. Its clinical effectiveness exceeds that of all other Muscle Energy Techniques. As Dr. F.L. Mitchell Jr. (1995) correctly stated, “postisometric stretch techniques are now the principal muscle energy technique procedures…”
The combination of the TPT with the following application of PIR creates a uniquely effective clinical tool. We highly recommend that all massage practitioners involved in somatic rehabilitation and working with active trigger points combine these two methods. No matter how stubborn the active trigger point or how severe the muscle spasm, the combination of TPT and PIR will always eliminate hypertonic muscle abnormalities quickly and efficiently.
SOMI’s Medical Massage Training
For the ultimate clinical training in Medical Massage based on scientific data, join SOMI’s Live Webinars and hands-on training Seminars. Here is SOMI’s schedule for 2026:
REFERENCES
Burke, D, Andrews C., Ashby, P. Autogenic Effects of static Muscle Stretching in Spastic Man. Arch Neurol, 25:367-372, 1971
Gogoleva, E.F. New Approaches to Diagnosis and Therapy of Fibromyalgia associated with Spondylosis. Ther. Arch., 4:40-45, 2001
Heine, H. Lehbruh der biologischen Medicine. Stuttgart, Hippokrates, 1997
Kukulka, C.G., Beckman, S.M., Holte, J.B., Hoppenworth, P.K. Effect of Itermittent Tendon pressure on Alpha-Motorneuron Excitability. Phys Ther., 66(7), July, 1091-1094, 1986
Mezlack, R, Wall, P. The Challenge of Pain. Penguin, NY 1989
Mitchell, F.L. Sr. The Balanced Pelvis and Its Relationship to Reflexes. Academy of Osteopathy Yearbook, 146-151, 1948
Mitchell, F.L. Jr., Mitchell P.K.G. The Muscle Energy Manual. Met Press, East Lansing, 1995
ABOUT THE AUTHORS
For Dr. R. Turchaninov’s bio please click here: Who is Dr. Ross Tourchaninov?
Mr. B. Prilutsky has practiced and taught Medical and Sports Massage for more than 34 years. He has a master’s degree in physical education and rehabilitation from Ukraine.
Mr. Prilutsky has worked with athletes and world dignitaries throughout Europe, Israel, and the USA. He is the founder of the Institute of Professional Practical Therapy in Los Angeles and, to date, has trained thousands of therapists worldwide. Boris Prilutsky has published extensively on various topics of physical medicine and rehabilitation.
Category: Medical Massage
Tags: 60 Variations of 7 Basic Techniques, Journal of Massage Science 2009 #5
