PT II: Myofascial Release/Trigger Point Therapy – Flashcards
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What is the largest organ in the body, by weight according to Travell?
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Voluntary muscle
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Who began to develop the concept of trigger points?
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Trigger points first described by Travell in 1942. Earlier authors began to develop the concept as early as 1843 (Froriep)
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What are the characteristics of active trigger points?
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Active TrPs produce pain, with referral, that can be duplicated on digital compression
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What are the characteristics of latent trigger points?
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Latent TrPs do not produce spontaneous pain but shorten muscle and increase muscle tension. Have pain on compression.
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Describe the characteristics of trigger points?
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PT usually presents with complaints due to most recently activated trigger point. Often when that trigger point is eliminated, the pain pattern may shift to earlier "key" TrP. If the "key" is deactivated first, further treatment is often unnecessary Sometimes, with rest, TrP's revert to latent state but are occasionally reactivated to produce recurrent episodes. TrP's can result in spasm of muscle or inhibition of muscle TrP's in one muscle, i.e. soleus, can result in spasm of paraspinals
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What are some Common muscles with Trigger Points?
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• Postural muscles of the neck • Shoulder girdle • Masticatory muscles • Upper trapezius • Scalenes • SCM • Levator scapulae • Quadratus lumborum.
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What are some Autonomic Disturbances that may happen with Trigger Points?
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• Abnormal sweating • Persistent lacrimation • Excessive salivation • Pilomotor activities (goose bumps)
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What Proprioceptive Disturbances occur with trigger points?
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• Imbalance • Dizziness • Tinnitis
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What are the physical findings with trigger points?
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• Muscle is prevented by pain from reaching its full stretch ROM and is restricted in strength and endurance • Identified as a local tender nodule in a palpable taut band of muscle fibers which extend from nodule to the attachment at each end of muscle. • Recognition of patient as "their pain" when compressed • Snapping palpation evokes "twitch response" • Painful contraction in isometric contraction.
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Define a trigger point.
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Identified as a local tender nodule in a palpable taut band of muscle fibers which extend from nodule to the attachment at each end of muscle.
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How are trigger points tested?
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• Needle EMG and SEMG: Investigational but promising at this time. More research required to develop reliability and validity • Thermography: Also investigational but promising.
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What is Algometry?
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• Response to measured pressure • Three endpoints Pressure pain threshold Onset of referred pain Intolerable pain • Best measured with foot plate of 1 square centimeter • Must be precise in measurement.
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What are some cautions with trigger points?
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Pain and referred pain can be elicited in areas where TrP's are NOT present if enough pressure is applied.
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What are some Misconceptions about trigger points?
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• Simply treating the TrP is not sufficient • Perpetuating factor must be removed • Muscle must be rehabed if TrP has been present long enough to shorten or weaken muscle • Pain cannot be as severe as the PT says and must be psychogenic. • Myofascial syndromes are self-limiting • The active to latent TrP sometimes gives this impression as a result of the exacerbation/remission pattern • Relief of pain rules out serious visceral disease • Vapocoolant spray and local anesthetic injection can mask pain of MI, angina or acute abdominal disease.
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What are some common differential diagnosis for trigger points?
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• Fibromyalgia • Articular dysfunction (Subluxated) • TMJ dysfunction • Nonmyofascial TrP's • Occupational myalgia.
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Differentiate between Trigger Points and Fibromyalgia.
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Trigger Points • Female/male: 1/1 • Local pain • Focal tenderness • Muscle tense • Decreased ROM • 20% also have FM Fibromyalgia • Female/male: 9/1 • Widespread pain • Widespread tenderness • Muscle soft and doughy • Hypermobile • 72% also have TrPs
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Where are the tender points for Fibromyalgia?
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They need 11 out of the 18 for Fibromyalgia
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What is Occupational myalgias?
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AKA repetitive strain injury, overuse syndrome, cumulative trauma disorder
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Where are Non myofascial TrP's?
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Can be present in skin, fascia, ligaments and joint capsules.
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What are the similarities between Acupuncture and TrP's?
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High degree of similarity between published locations of TrP's and acupuncture points for pain relief Similar "Deqi" phenomenon.
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What are some of the Aggravating factors with trigger points?
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• Strenuous use of muscle in shortened position • Passive stretch • Pressure on TrP • Involved muscle in shortened position for prolonged time....getting up in the morning • Cold draft, cold damp weather.
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What is the Nature of pain for a trigger point?
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Steady, deep, and aching Occasionally sharp, lancinating, lightning type pain
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What is the Pattern of pain for trigger points?
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Reproducible and predictable
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What is the Compression test?
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Myofascial pain on movement can be relieved by pressure on muscle during movement. TQ!!!
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What is the Most reliable diagnostic criterion for a trigger point?
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"Presence of exquisite tenderness at a nodule in a palpable taut band" If patient recognizes pain the TrP is active Characteristic referred pain pattern, twitch response, limited passive ROM are strong supportive evidence.
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What is Flat palpation?
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Superficial muscles with one surface accessible TQ!!!
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What is Pincer palpation?
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Opposite sides of muscle are accessible (SCM, lateral border of latissimus dorsi, biceps brachii) TQ!!!
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What is Deep palpation?
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For deep muscles with considerable tissue between them. TQ!!!
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What is Local Twitch Response?
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• Transient contraction of those fibers in a taut band • May be seen as a twitch or dimpling of the skin near the terminal attachment • Sometimes felt • Elicited by transverse snapping of TrP across the direction of muscle fibers.
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What is a Key Trigger Point?
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• A key TrP is one that is responsible for activity in satellite TrP's • If the key is deactivated the satellite points are also deactivated.
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What are some Trigger Point Release Techniques?
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• Spray and stretch • Voluntary Contraction and Release Methods • Trigger point pressure release • Deep stroking Massage • Myofascial release
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Review some Accessory Techniques.
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• Phased respiration • Directed eye movement • Skin rolling • Biofeedback • Heat and cold • Iontophoresis and phonophoresis
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What Modalities are used with trigger point therapy?
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• Therapeutic ultrasound • HVG • TENS
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What is considered by Travell and Simons the most effective noninvasive way to inactivate acute TrP's?
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Spray and Stretch
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How effective is spray and stretch?
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An acute single muscle syndrome can respond to pain-free within two or three sweeps
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What type of spray is used for spray and sweep?
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• Fluori-methane spray - OZONE DEPLETING • Ethyl chloride spray • "Gebauer Spray and Stretch".
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What are some of the mechanics of spray and stretch?
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• PT must be warm and relaxed prior to TX • Skin should be bare • One end of muscle should be anchored • Spray first and stretch second
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How is spray and stretch applied?
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• Hold bottle 12 inches from skin, angle at 30 degrees, spray at 4 inches per second • Spray applied in parallel sweeps, 1 cm apart, in the direction of referred pain • After S & S and part is warmed do several cycles of active ROM.
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Review some
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• Can spray area larger than referred pain pattern • PT can often aid in pattern of spray by identifying taut bands • Re-warm PT after TX with HP.
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What are some Cautions with spray and stretch?
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• Demonstrate to PT feel of spray • Hypoglycemia aggravates TrP's • Cover eyes and ears if used over face • If PT has asthma or other respiratory condition cover nose • If to cold for PT move spray quicker or hold closer to skin • Do not S;S over hypermobile segments.
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What are some of the Reasons for Failure of spray and stretch?
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• Perpetuating factors not addressed • Inadequate coverage • Patient tension • Poor spray technique • Incomplete S;S • Incomplete or inadequate stretch technique • Poor post-treatment, PT not re-warmed.
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What is Trigger Point Pressure Release?
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• Applying pressure to the trigger point. • Gentle pressure (4 kg) • Hold for 10 seconds • Repeat up to four times, using less force each time • Schedule TX few days apart, 3X per week if acute • Warn PT they might be sore the next day • Overtreatment is the most common cause of failure.
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97113
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Therapeutic procedure, one or more areas, each 15min. Aquatic therapy with therapeutic exercises
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97110
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Therapeutic procedure, one or more areas, each 15min. Therapeutic exercises to develop strength and endurance, range of motion and flexibility.
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97112
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Therapeutic procedure, one or more areas, each 15 min. Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception.
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97150
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Therapeutic procedure(s), group (2 or more individuals). Therapeutic exercises to develop strength and endurance, range of motion and flexibility for 2 or more individuals.
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97530
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Therapeutic activities,directhands-on, each 15 minutes..Use of dynamic activities to improve functional performance with direct contact by the provider.
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97140
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Soft Tissue Code for Graston, ART, Deep Tissue Message, etc
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Describe Deep Stroking.
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• PT positioned so muscle is completely relaxed and lengthened • Using thumbs or fingers of both hands, trap taut band just beyond TrP • Pressure exerted along longitudinal axis, passing over TrP, progressing no faster than release • Reverse direction.
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Describe Strumming.
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• Similar to deep stroking but ACROSS taut band at the level of the TrP. • Best used when TrP is near muscle belly • Again progress as release occurs. Cross friction massage.
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Perpetuating Factors (Patching the Hole)
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• Mechanical stresses • Nutritional inadequacies • Metabolic and endocrine inadequacies • Psychological factors • Chronic infection • Other factors Be able to describe. You need to address the underlying cause of the trigger point.
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Structural inadequacies
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• Short leg syndrome as little as 3/16 inches can be significant • Short arms leave shoulders unsupported when sitting.....trapezius • Morton's toe (up to 40% of population)
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Postural stress
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Poor posture, poor body mechanics, immobility, repetitive movement.
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What are the indicators of a Thiamine (B1) Inadequacy?
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Night calf cramps, mild edema, constipation, fatigue, decreased vibratory sensation, alcoholism, heavy tea drinkers
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What are the indicators of a Pyridoxine (B6) Inadequacy?
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Alcoholism, corticosteriods, hyperthyroidism, pregnancy, lactation, high protein diet, oral contraceptives. Deficiency signs are poorly defined
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What are the indicators of a Cobalamin (B12) and folic acid Inadequacy?
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Insufficiency has been related in studies to myofascial pain syndromes (FM, 43%) Indicators: Pernicious anemia, neurologic dysfunction, diarrhea, constipation, fatigue, restless legs, diffuse muscular pain. Mega doses of Vit C
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What are the indicators of a Ascorbic acid (Vit C) and folic acid Inadequacy?
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Alcoholism, cigarette smoking, concurrent use of antacids, weakness, vague aching in muscles and joints, easy bruising Also need for iron, calcium, potassium, iron.
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What are the indicators of a Hypothyroidism?
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Muscle pain, stiffness, cramps, cold intolerance, weight gain
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What are the indicators of a Hypoglycemia?
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Sweating, shakiness, rapid heart rate, anxiety.
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What Psychological Factors should be considered with Trigger Point Therapy?
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• Hopelessness and depression - feel pain is due to untreatable factors and is more aware of their pain. PT must be convinced their pain is muscular in origin and treatable • Anxiety and tension - Carry tension in muscles • "Good Sport" syndrome - Ignores pain and pushes on.
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What Chronic Diseases should be considered with Trigger Point Therapy?
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• Viral disease Flu: increases presence of TrP's that may last for weeks Herpes simplex • Bacterial infection - Abscessed tooth, sinus infection, urinary tract • Infestations - Tapeworm.
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What are some other Factors that may need to be considered?
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• Allergic rhinitis • Impaired sleep • Nerve impingement.
