Research confirms that myofascial trigger points are an element in most chronic pain including fibromyalgia (Melzak & Wall, Travell & Simons). Personal clinical research indicates that these are also key elements in chronic fatigue conditions especially when this involves accessory respiratory structures (scalenes in particular) in cases in which hyperventilation is a factor. Treatment of myofascial trigger points via inhibitory pressure (Nimmo) or muscle energy methods (Lewit) or Strain/counterstrain approaches (Jones) are all variably successful manual approaches in their treatment.
An integration of these three methods into one sequence is proposed (Chaitow) in which palpation leads to trigger point identification followed by use of one of several patterns of application of inhibitory pressure, followed immediately by Strain/counterstrain application to identify that points’ precise ‘position of ease’. After appropriate holding of this position to induce muscle spindle resetting of the tissues surrounding the trigger point a standard muscle energy method is employed to stretch the muscle to its normal resting length (Travell) either via post isometric relaxation or, if fibrosis is a feature, via an isolytic procedure (Mitchell).
Clinical results employing this combined approach of inhibition/positional release/Muscle energy (tentatively titled Integrated Neuromuscular Inhibition Technique – INIT) indicate it to be superior to use of single elements of the approach.
Myofascial trigger points, hyperventilation, Musculoskeletal dysfunction, Pain, Soft tissue manipulation, Inhibitory pressure, Muscle Energy Techniques, Strain/counterstrain, Integrated Neuromuscular Inhibitory Techniques.
Travell and Simons have demonstrated the clear connection between myofascial trigger point activity and a wide range of pain problems and sympathetic nervous system aberrations.
Melzack and Wall confirm that there are few chronic pain problems which do not have myofascial trigger point activity as a component, with these acting, in many instances, as prime maintaining factors of the pain.
Trigger (and other non-referring pain) points commonly lie in muscles which have been stressed in a variety of ways including postural imbalances congenital factors (warping of fascia via cranial distortions, short leg problems, small hemi-pelvis etc), occupational or leisure overuse patterns, emotional states reflecting into the soft tissues , referred/ reflex involvement of the viscera producing facilitated segments paraspinally and trauma.
The repercussions of trigger point activity go beyond simple musculoskeletal pain – take for example their involvement in hyperventilation, chronic fatigue and apparent pelvic inflammatory disease.
Trigger point activity is particularly prevalent in the muscles of the neck/shoulder region which also act as accessory breathing muscles. In situations of increased anxiety the incidence of borderline or frank hyperventilation is frequent, and may be associated with chronic fatigue problems. Clinically these muscles palpate as tense, often fibrotic, with active trigger points being common . Successful breathing retraining, and normalisation of energy levels, seems in such cases to be accelerated and enhanced following initial normalisation of the functional integrity of the involved muscles.
Slocumb has shown in a large proportion of chronic pelvic pain problems in women, often destined for surgical intervention, that the prime cause involves trigger point activity in muscles of the lower abdomen, perineum, inner thigh and even the vagina.
According to Korr a trigger point is a localised area of somatic dysfunction which behaves in a facilitated manner, i.e. it will amplify and be affected by any form of stress imposed on the individual whether this is physical, chemical or emotional.
A trigger point is palpable as an indurated, localised, painful entity with a reference (target) area to which pain or other symptoms are referred.
Muscles housing trigger points can frequently be identified as being unable to achieve their normal resting length using standard muscle evaluation procedures The trigger point itself commonly lies in fibrotic tissue, which has evolved as the result of exposure of the tissues to diverse forms of stress.
A wide variety of treatment methods have been advocated in treating trigger points, including inhibitory pressure methods (Nimmo , Lief) acupuncture and/or ultrasound (Kleyhans and Aarons), chilling and stretching of the muscle in which the trigger lies (Travell and Simon), procaine or xylocaine injections (Slocumb), active or passive stretching (Lewit), and even surgical excision (Dittrich).
Clinical experience, confirmed by the diligent research of Travell and Simons, has shown that while all or any of these methods can successfully inhibit trigger point activity short-term, in order to completely eliminate the noxious activity of the structure more is often needed.
Common sense as well as clinical experience dictates that the next stage of correction of such problems should involve reeducation (postural, relaxation etc) or elimination of factors which contributed to the problem’s evolution. This might well involve ergonomic evaluation of home and workplace as well as reeducation methods mentioned above.
Travell and Simons have also shown that whatever initial treatment is offered to inhibit the neurological over-activity of the trigger point, the muscle in which it lies has to be made capable of reaching its normal resting length following such treatment or else the trigger point will rapidly reactivate.
In treating trigger points the method of chilling the offending muscle (housing the trigger) while holding it at stretch in order to achieve this end was advocated by Travell and Simons, while Lewit has espoused the Muscle Energy method of a physiologically induced post-isometric relaxation (or reciprocal inhibition) response, prior to passive stretching. Both methods are commonly successful, although a sufficient degree of failure occurs (trigger rapidly reactivates or fails to completely ’switch off’) to require investigation of more successful approaches.
One reason for failure may relate to the possibility of the tissues which are being stretched not being the precise ones housing the trigger point.
A popular method for achieving tonus release in a muscle prior to stretching involves introduction of an isometric contraction to the affected muscle (producing post isometric relaxation) or to its antagonist (producing reciprocal inhibition).
The original use of isometric contractions prior to stretching was in Proprioceptive Neuromuscular Facilitation Techniques (PNF) which emerged from physical medicine in the early part of the 20th Century. In most forms of Muscle Energy Technique (MET) methodology, derived from osteopathic research and clinical experience, a partial (not full strength) isometric contraction is performed prior to the stretch in order to preclude tissue damage or stress to the patient and/or therapist which PNF quite frequently produces.
The author hypothesises that partial contraction (using no more than 20 to 30% of patient strength, as is the norm in MET procedures) may sometimes fail to achieve activation of the fibres housing the trigger point being treated since light contractions of this sort fail to recruit more than a small percentage of the muscle’s potential.
Subsequent stretching of the muscle may therefore not directly involve any of the critical tissues surrounding and enveloping the myofascial trigger point.
Failure to actively stretch the muscle fibres in which the trigger is housed may account for the not infrequent rapid recurrence of trigger point activity in the same site.
Repetition of the same stress factors which produced it in the first place could also be a factor in such recurrence of course.
A method which achieved precise targeting of these tissues (in terms of tonus release and subsequent stretching) would be advantageous.
Selye has described the progression of changes in tissue which is being locally stressed. There is an initial alarm (acute inflammatory) stage followed by a stage of adaptation or resistance when stress factors are continuous or repetitive.
In the stage of adaptation muscular tissue becomes progressively fibrotic, and if this change is taking place in muscle which has a postural rather than a phasic function the entire muscle structure will shorten.
Clearly such fibrotic tissue, lying in altered (shortened) muscle, cannot simply ‘release’ itself in order to allow the muscle to achieve its normal resting length (as we have seen, this is a prerequisite of normalisation of trigger point activity). This is not simply a case of altered tone, but of altered tone and structural change to the muscle fibres.
Normalisation requires ‘something’ to be done which effectively releases and stretches the tight fibrotic tissue housing the trigger point(s).
Along with various forms of stretch (passive, active, MET, PNF etc) it has been noted above that inhibitory pressure is commonly employed in treatment of trigger points.
Such pressure technique methods (analogous to acupressure or shiatsu methodology) are often successful in achieving at least short-term reduction in trigger point activity and are variously dubbed ‘neuromuscular techniques’.
Application of inhibitory pressure may involve elbow, thumb, finger or mechanical pressure (a wooden rubber tipped T-bar is commonly employed in the US) or cross-fibre friction.
All of these methods induce a degree of local trauma to the tissues when applied during treatment – although when the pressure is applied for a short period only or intermittently rather than constantly this tendency is minimised.
Is there another way of targeting precisely the tissues in which the trigger is housed so that when stretching is introduced, using Muscle energy or passive stretching, the offending fibrotic musculature is indeed treated?
Clinical experience indicates that by combining the methods of direct inhibition (pressure mildly applied, continuously or in a make and break pattern) along with the concept of strain/ counterstrain and MET just such a specific targeting can indeed be achieved.
Strain/Counterstrain (SCS) briefly explained.
Jones has shown that particular painful ‘points’ relating to joint or muscular strain, chronic or acute, can be used as ‘monitors’ – pressure being applied to them as the body or body part is carefully positioned in such a way as to remove or reduce the pain felt in the palpated point.
When the position of ease is attained (using what is known as ‘fine tuning’ in SCS jargon) in which pain vanishes from the palpated monitoring ‘tender’ point, the stressed tissues are felt to be at there most relaxed – and clinical experience indicates that this is so since they palpate as ‘easy’ rather than having a sense of being ‘bound’ or tense.
SCS is thought to achieve its benefits by means of an automatic resetting of muscle spindles – which help to dictate the length and tone in the tissues. This resetting apparently occurs only when the muscle housing the spindle is at ‘ease’ and usually results in a reduction in excessive tone and release of spasm.
Osteopathic functional technique achieves a similar positional release, without use of a pain-point monitor, relying instead on the palpatory sensitivity of the operator who is constantly monitoring for a sense of ‘ease’ in the tense tissues while trying to avoid any position which increases a sense of ‘bind’.
When positioning the body (part) in Strain/counterstrain methodology a similar sense of ‘ease’ is noted as the tissues reach the position in which pain vanishes from the palpated point (‘tender point’ in Jones’ terminology).
INIT Method 1
It would be reasonable to assume that were a trigger point being palpated by direct finger or thumb pressure, and were the very tissues in which the trigger point was lying to be gently positioned in such a way as to take away the pain (entirely or at least to a great extent), that the most (dis)stressed fibres in which the trigger point was housed would at that time (when the pain is reduced) be in a position of relative ‘ease’.
This is at what palpation seems to indicate.
We would then have a trigger point under direct inhibitory pressure (mild or perhaps intermittent) which had been positioned so that the tissues in which it lay were relaxed (relatively or completely).
In Strain/counterstrain methodology the position of pain-free (relative) ease is held for a period of time – anywhere from 30 to 90 seconds – so that (it is considered) the muscle spindles can reset themselves and spasm/contraction can be released.
Following such a period – if the patient were asked to introduce an isometric contraction into the tissues – involving the very fibres which had been repositioned to obtain the strain/counterstrain release – there would subsequently occur a degree of reduction in tone in these tissues (post isometric relaxation). These could then be gently stretched as in any Muscle Energy procedure with the strong likelihood that specifically involved fibres would be stretched.
There is another possibility – a variation in which, instead of an isometric contraction followed by stretch being commenced following the period of ease (Strain/counterstrain position) an isolytic approach could be used.
In MET, isolytic methods utilise an eccentric isotonic manoeuvre. The muscle receiving attention is actively contracted by the patient at the same time that a stretch is introduced – resulting in mild trauma to the muscle and the breakdown of fibrous adhesions between it and its interface and within its structures.
To introduce this method into trigger point treatment, following the application of inhibitory pressure and SCS release, the patient is asked to contract the muscles around the palpating thumb or finger (lying on the now inhibited pain point) with the request that the contraction should not be a full strength effort since the operator intends to gently stretch the tissues while the contraction is taking place.
This isotonic eccentric effort – designed to reduce contractions and break down fibrotic tissue – should target precisely the tissues in which the trigger point being treated lies buried.
Following the isolytic stretch the tissues could benefit from effleurage and/or hot and cold applications to ease local congestion. An instruction should be given to avoid active use of the area for a day or so.
Summary and Comment
The integrated use of inhibitory pressure, Strain/counterstrain and a form of Muscle Energy Technique – applied to a trigger point or other area of soft tissue dysfunction involving pain or restriction of range of motion (of soft tissue origin), is a logical approach since it has the advantage of allowing precise targeting of the culprit tissues.
Clearly the use of an isolytic approach as part of this sequence will be more easily achieved in some regions rather than others – upper trapezius posing less of a problem in terms of positioning and application than might quadratus lumborum.
No claim of absolute originality is made for this integrated approach which has evolved out of years of teaching the elements separately in the USA and Europe.