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Do we still need to press on individual points?
The basic idea of pressing on points (trigger, tender, acu, whatever) has been around for a LONG time. We have a zillion modalities that use some version of the concept, of which trigger point therapy one of the leaders. However, trigger point therapy as taught by Travell and Simons didn't have much to do with the manual stimulation of those points. What most of us learned in massage school and/or seminars is an adaptation of their original material, which tended to emphasize injections and/or spray-and-stretch.
For many of us, the basic idea was to find those spots, then statically press on them until they let up - the "release" so often sought after. Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news.
However, it is less and less clear whether we need to press on individual points at all. Methods such as Active Isolated Stretching, Muscle Energy Technique, Strain Counterstrain, Kinesiotaping, Trager Work, Feldenkrais, etc. seem to be very effective at eliminating trigger points without ever pressing a point to "release" it. In my own work, I have found my results improving as I move away from "traditional" trigger point work. I can eliminate many points in the time I used to spend on 2-3 points. More importantly, I can teach my clients how to keep them gone.
What do you think? Do we still need to keep pressing on individual points, or is it time to find a more efficiently effective approach?
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Replies to This Discussion
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Permalink Reply by Larry Warnock on
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Yes, Dr. Travell and Dr. Simon emphasized spray-and-stretch and needling, but remeber...back in the 60's when they did their amazing work, massge therapy was still relegated to spas, etc. In discussions with Dr. Travell years ago, she did believe that individual attention should be paid to each trigger. That is why the trigger maps are so important. Trigger Point Therapists have memorized those maps. Each individual trigger plays a role in pain and eliminating each one is paramount. As long as any trigger is present, stretching and strengthening cannot be completed.
The technique is more than just pushing on the trigger. Direct pressure for a count of ten, followed by cross-fiber friction and repeated several times will melt" the trigger. The client helps monitor this process by relating the pain level to the therapist. This process also has a another gain...involving the client in his/her remediation.
All the devices in your message can help but are not sufficient. Taking a global approach is ineffective. Active Isolated stuff, kinesiotaping, etc. and now the graston technique (wow...hurt me more...it must be helping!!) are used in place of understanding each trigger and its role in pain/rehab. Its much easier to pay thousands of dollars for the Graston Kit than learning about each trigger...It's kinda like Rock 'n Roll...just think Active Isolated being performed tdo Chubby Checker. -
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Permalink Reply by Stephen Jeffrey on
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Hi Jason,
I'm still only too happy to press on individual points as this is such an effective technique if done correctley.
So, its much much more about having found the TP how you engage it's demise. I'm afraid any research saying you should be doing it this way or that...... or oh my godness "this the brand new way" although noted is rarely needed.
The sea of clients that have sought and found relief/eradication of TP's this way are my ultimate masters. :) -
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Permalink Reply by Alexei Levine on
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I've had better luck on most trigger points with stroking movements, however with trigger points that are highly active static pressure seems to work better. Using stroking movements also seems to reduce the chances of causing bruising.
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Permalink Reply by Allison Ishman on
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"Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news."
Just out of curiosity, what research are you referencing? -
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Permalink Reply by Jason Erickson on
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To Allison: Just rechecked a source, and I misstated. It was actually Travell & Simons, in their 2 ed., that indicated that stroking movements are more effective than simple ischemic pressure. I have that edition on my shelf as I type this. For convenience, you can read about it here, on page 4 of this article:
http://www.learnmuscles.com/mtj%20TrP%20article%20-%201-08.pdf
To Larry: I emphatically disagree that "stretching and strengthening cannot be completed" if all TPs are not first individually eliminated. Every day I work, I prove that statement to be utterly without merit. The fact that you made that statement, and later followed with "Taking a global approach is ineffective" shows me we have clearly arrived at very different points of view. Rather than argue, let me give you some background on why I asked the question:
Trigger Point Therapy is the primary modality I learned, and well, in school. My primary instructor had been an NMT instructor for nearly 20 years by that point, and upon graduation I quickly gained a large clientele and referral network based on what I could do with it. For a good while, I was completely in agreement with what Stephen and Alexei said in their posts, and mostly agreed with what you said in yours.
However, early on I noticed that some clients responded well to more pressure, while others responded better to less pressure. This variation in individual responses made me curious about WHY such differences existed. My instructor had taught both basic ischemic pressure and stroking movements, plus introduced us to some more advanced "layering" concepts for use in areas where TPs might coexist in several layers of tissue. I began experimenting with varying my level of pressure, angle of pressure application, different patterns of treating affected areas, etc., etc. All the while, I made many, many observations. In time, I realized that I could achieve better, more consistent results with less client discomfort. However, there were still some who were simply unable to bear TP work, or who had contraindicated conditions, etc.
I studied fascial work and found that it could often reduce/eliminate many TPs and tender points. Pretty cool, but the method I learned was relatively slow, making it hard to get as much done in a single session. However, by combining TP and fascial work, I could sometimes get the best of both worlds. Still, I felt that there must be a way to rapidly improve my efficiency and effectiveness. I obtained some basic training in positional release concepts, and was impressed by my newfound ability to immediately eliminate 70-100% of a client's TP/tender point symptoms by merely repositioning their body for a short time. With practice, I learned to combine TP and cross-fiber frictioning with PRT, thereby achieving great improvements with little/no client discomfort during the session.
Over the years, I had also studied 9 forms of stretching technique (static, ballistic, isometric, hatha yoga, PNF stretching, CRAC/"Facilitated" stretching, AIS, dynamic joint mobilization, and myofascial stretching). I learned the various pros and cons of each, and found that some worked better for some client situations than others. Intrigued by the differences, I studied and practiced and eventually found that I could eliminate most of my own TPs and tender points with stretching and strengthening alone. As a personal trainer, I used this knowledge to quickly help sore clients improve function and become nearly or completely pain-free.
Now I have continued my learning journey, becoming acquainted with neurophysiological, neurodynamic, and neuroplastic concepts. Though still at an early stage of this period of my development, I have found that I can eliminate TP/tender point discomfort with very simple techniques that don't require direct, deep pressure, and which are far faster and more comfortable than the fascial work I had learned... all without having to reposition the client's skeletal structure as in PRT.
Tonight I worked on a fellow MT who is a skeptic, who LOVES trigger point therapy (and is quite skilled herself), and who had many sore spots all over her body. In 30 minutes she was virtually pain-free, and I never had to directly address any of her TPs/tender points. She was surprised and somewhat perplexed, as the experience contradicts much of what she has been educated to expect.
So now I am attempting to understand exactly how the work I am doing now actually works. I have found some neuro-oriented references, but don't pretend to understand them completely (yet). However, all of my accumulated experiences have lead me from being a Trigger Point Therapist to being something else. I do not believe that my current work requires an esoteric explanation, nor do I think it will require a complicated one. However, I find myself questioning many of the assumptions made by Travell & Simons about the nature of pain, how it is perceived, how TPs and tender points may be related to it, etc., etc.
If you get the chance, watch one of Travell's old videos in which she demonstrates spray-and-stretch techniques. The method works very well, but certainly not due to any direct manipulation of the TPs. There are other mechanisms at work, yet the TPs are resolved and function is improved. This, to me, is direct confirmation that TrPT as we know it is just one approach... and this opens the possibility of finding a better way.
Travell & Simons did us an enormous service with their work, giving us a much greater understanding of common symptom patterns and a variety of different treatment methods (ischemic pressure, deep stroking, injections, spray-and-stretch, etc.). However, they continued their research and treatment observations until the end, massively revising their material in the 2nd edition. If they had eventually released a 3 ed., we can only guess at what additional changes they might have made.
Now that you know more about where my question comes from, can you understand why I asked it? If yes, what are your thoughts? If not, why not?
Thanks! I look forward to your replies. :)
~ Jason
Allison Ishman said:"Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news."
Just out of curiosity, what research are you referencing? -
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Hi Allison, some more related articles.
http://www.massagetherapy.com/articles/index.php/article_id/485/Tri...
http://www.articlesbase.com/alternative-medicine-articles/trigger-p...
The reason I would not trust the research is, I would need to know that slow compression release of TP's was the therapists number one favoured technique !!
As you know yourself, a technique applied without empathy or good intention is not going to be anything like as effective as one that is:).
Allison Ishman said:"Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news."
Just out of curiosity, what research are you referencing? -
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Interesting article. I was gratified to see that they recommend stroking with the muscle fibers not across them, I've always felt that was slightly better for trigger point work.
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Permalink Reply by Jeff Sims on
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i love the discussion and am impressed with the information shared. efficiency is very important in our work and avoiding the agony of pain, as some clients are very sensitive, during trigger point release is also very important.
i'd like to add that Travell, et al, first suggest correcting the perpetuating factors (or better yet prventing the intiating behavior) when possible.
on a related note, research today also reveals that postural patterns and movement patterns very often become compromised (causing pain & dysfunction) after traumatic or repetitive injuries and until stability is restored and functional movement patterns are relearned, the dysfunction and pain will return. -
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Permalink Reply by Jeffrey A. Lutz on
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I am very happy to see this discussion on myofascial pain/trigger points and the different approaches to their treatment. I have been teaching trigger point therapy to massage therapists since '04 and have always worked very hard to teach more about why trigger points form and remain and a little (not much) less on the actual techniques themselves. There was a small study in either the Journal of Bodywork & Movement Therapies or The Journal of Muskuloskeletal Pain that compared different techniques against each other in the treatment of upper trapezius trigger points. The study looked at around 30 subjects and determined that stroking massage and trigger point pressure release, as described by Travell and Simons, have around the same efficacy. I also remember reading similar papers when looking at treatment methods and have always made the statement to my students (when it comes to trigger points), "it's far better to provide sloppy treatment in the right place, instead of perfect treatment in the wrong place." Because the referred pain of trigger points being in a place different from the actual trigger point 80% of the time, a therapist needs to know the pain patterns to evaluate properly.
I use most of the tools listed in the above posts (except needles -- because it's illegal :-)), including Graston and the spray and stretch technique (to avoid the $3000 price tag I use Gua Sha tools to perform Intrument Assisted Soft Tissue Mobilization or IASTM). The key with tools is knowing the physiological effect they have on the body along with the effect you are looking to apply. For instance, the IASTM* is supposed to create local inflammation to cause the body to lay down new collagen fibers and draw circulation to the area, while vapocoolant spray and stretch works by distracting the central nervous system. Vapocoolants work extremely well for spasm and joint sprains as well and it is amazing how quick the response. As a side note, Travell came up with the spray and stretch technique after reading a paper written by Dr. Hans Kraus, who was the first person to use vapocoolants (in the 1930's) to locally anesthetize and mobilize joint sprains, cutting the healing time from weeks to days! Dr. Kraus later became the "Father of Sports Medicine" and contributed much to what we know about how muscles cause pain.
*IASTM is the 'Americanized' version of Gua Sha. Gua Sha has been around in traditional chinese medicine for thousands of years. Tools used for Gua Sha are much less expensive than the Americanized counterparts. Perform a search on Gua Sha and see what you get. As a warning, some pictures can look quite bad -- be sure you read through...
Another VERY important element in treating trigger points (as Jaya Jeff Sims mentioned in a post) is realizing that the internal environment of body, as well as external forces, play a vital role in determining if trigger points will resolve. Travell and Simons called these "perpetuating factors" and came right out and said in chapter 4 of their text that unless you resolve these -- the pain many times will not completely stop. Perpetutaing factors can be lumped into 3 categories: mechanical, systemic, and vitamin/nutritional. To avoid writing a book about what most of you have probably read by now, I will simply say the biggest 3 systemic issues are with subclinical hypothyroidism (TSH between 2.0/2.5 and the upper end of the lab reference value WITH clinical symptoms), vitamin D deficiency (serum 25-OH vitamin D) of less than 50, and low serum ferritin (iron binding storage in the muscle/liver) of less than 50. Since I am not licensed to get these tests, we simply co-ordinate with the client's primary care doctor for the labs and help guide the doctor into understanding the treatment for the respective condition by providing the current information. (These days, a request like this is taken much more seriously as most of the doctors have been reading about these things in their journals.) Once a deficiency is detected in a client, we let them start their supplementation and schedule our next appointment for 1 month, which is usually the time it takes to get the deficiencies to begin resolving.
At home self care is very important as well to allow the client to get "mini-sessions" between their regular appointments. There are various tools/balls and other devices which can be recommended, those of which I am leaving out so this post looks more like good unbiased information and less like a commercial!
To sum it up, it takes a skilled assesment, identification/treatment of perpetuating factors, targeted treatment, and 'at home self care' which incorporates self treatment and movement exercises to be comprehensive in your treatment of myofascial pain and trigger points. -
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Jeffrey,
Can you explain a little more about the legality issues of dry needling?
Thanks! -
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Permalink Reply by Boris Prilutsky on
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Dear Jason.
For a sake of adequate treatment I wouldn't recommend to skip trigger point therapy from comprehensive multimodality treatment. Practically in massage therapy procedure we don't have modalities that use the some version of the trigger point therapy concept. No doubt that utilization of other modalities can inhibit active trigger point and will convert them to sleeping trigger points. Only question of time and this slipping trigger points will be a reactivated which is not good and even dangerous phenomena. Classically we utilizing comprehensive soft tissue mobilization such as fascia release, muscular mobilizations, trigger point therapy as well as:”and/or post isometric relaxation techniques and /or Active Isolated Stretching and/ or Muscle Energy Technique. All this modality is equally important for sustained results and cannot be used instead of each other. Exemption is post isometric relaxation techniques , Active Isolated Stretching , Muscle Energy Technique which can be used as substitutes each of other .For many years I have worked with Olympians and other professionals. Because their life is very physically active and in case if not adequate treatment will be provided very soon original disorders symptoms including dysfunctions will come back, re-injury will happen most likely, and much more difficult conditions can be developed. With general public and because they are not under physical overload like a professionals are, in case of not adequate treatment but just an inhibition of pain it can take a bit time until old injury symptoms will come back but at this time, most likely with much more arthritis, possible some tendon/muscles tears est. Again, each modality targeting different goals that have to be achieved for sustained and stable results. Will be important to mention that implementation of trigger point therapy helping faster to achieve pain sensation decrease which is very important.
Best wishes.
Boris. -
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Sorry my link to this article in an earlier post is not working hopefully this one is, :)
http://www.articlesbase.com/alternative-medicine-articles/trigger-p...
PS please don't assume I only use static TP work. As Boris has made clear TP work involves many diffirent approaches including deep stroking.... but for the most critical TP's = those causing medical conditions, slow compression is the most safe and effective way of eradication. ................imo -
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