trigger point presentation workshop 01.04.17

@Physiocouk #manchesterphysio facebook.com/physiocouk

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Welcome

Trigger point therapy & soft tissue release for sports and massage therapists

With Louise Rigby and Zoe Killian


3@Physiocouk #manchesterphysio facebook.com/physiocouk

Who are we?

Louise’s LinkedIn: www.linkedin.com/louise-rigby

Twitter: @LouPhysiocouk

Zoe’s LinkedIn: www.linkedin.com/in/zoe-killian

Twitter: @ZoePhysiocouk


Let’s connect

Website: www.physio.co.uk / Massage.physio.co.uk

Twitter: @physiocouk

Facebook: www.facebook.com/physiocouk

http://www.physio.co.uk/

Aims of today


✓ Learn the theory of a trigger point ✓ Learn the theory of trigger point therapy ✓ Practice the trigger point technique to muscle groups ✓ Use other soft tissue release techniques along side TP release

Itinerary


10.00 - 10.30 - Induction / Arrival10.30 - 10.50 - Quiz – What do you know about trigger point therapy10.50 -11.30 - Theory: Trigger point therapy11.30 -12.00 - Indications/ outcome measures12.00 - 12.30 - Lunch12.30 - 13.00 - Theory: Trigger pointing technique13.00 - 14.00 - Practical: Muscle groups14.00 - 14.30 – Practical: Tools & other STR techniques14.30 - 15.00 - Case Studies/Quiz answers

Quiz…What do you know about trigger point therapy?


Question 1


What is a trigger point?

Question 2


How would patients describe Trigger Point pain?

Question 3


Name some indications for Trigger Point Therapy?

Question 4


Name 3 benefits of Trigger Point Therapy

Question 5


Name some contraindications for Trigger Point Therapy

Question 6


Where is the Trapezius muscle found?

Question 7


Where is the Sternocleidomastoid muscle found?

Question 8


What muscle group does Vastus Lateralis belong to?

Theory: Trigger Point Therapy


What are trigger points?


• Trigger points are hyperirritable areas of contracted muscle fibres that form a palatable nodule

• On a microscopic level, the contracted muscle fibres accumulate into a small thickened area causing the rest of the fibre to stretch

• The areas of contracted muscle restrict blood flow within the tissue causing an accumulation of waste products and reduced levels of nutrients available.

Brief History


• 1930s -Dr Hans Lange used sclerometer to prove that tender areas in muscles are 50% harder than surrounding areas.

• 1940s- Janet Travell developed trigger point injection therapy and termed the “tender areas” described by Dr Hans “Trigger points”.

• Travell's therapy called for the injection of saline (a salt solution) and procaine (also known as Novocaine, an anesthetic) into the trigger point.

• Travell mapped what she termed the body's trigger points and the manner in which pain radiates to the rest of the body.

• Travell's work came to national attention when she treated President John F. Kennedy for his back pain.

• Travell co-authored several books with David Simons which are considered the definitive reference for trigger point therapy.

• Travell & Simons' Myofascial Pain and Dysfunction: Upper half of body• Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual• Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2

Brief History


• 1976- Bonnie Prudden, a physical fitness and exercise therapist developed Travells trigger point therapy. She found that applying sustained pressure to a trigger point using thumbs, knuckles and elbows produced superior results to those treated with injections when followed by corrective movements and stretching. Prudden later went on to author two books:

• Myotherapy: Bonnie Prudden’s Complete Guide to Pain Free Living

• Pain Erasure the Bonnie Prudden Way

Different types of trigger points


• Trigger points are described according to location, tenderness and chronicity.

• The main types of trigger points are:

• Central/ primary trigger points

• Satellite/ secondary trigger points

• Active trigger points

• Latent trigger points

Central/ primary trigger points


• These are the most well-established and painful points

• Pain is felt by the individual when they are active, and are usually what people refer to when they talk about trigger points

• Central trigger points exist at a neuromuscular point, which is the meeting place of a nerve and muscle

Satellite/ secondary trigger points


• These trigger points are “created” as a response to the central trigger point in neighbouring muscles that lie within the referred pain zone.

• The primary trigger point is still the key to trigger pointing intervention: the satellite trigger points often resolve once the primary point has been effectively rendered inactive.

• Satellite points may also prove unresponsive to treatment until the primary central focus is weakened. This is often the case in the paraspinal and/or abdominal muscles.

Active trigger points


• This can apply to central and satellite trigger points.

• A variety of stimulants, such as forcing muscular activity through pain, can activate an inactive trigger point.

• This situation is common when activity is increased after trauma i.e a road traffic accident, where multiple and diffuse trigger points may have developed.

• This trigger point is both tender to palpation and elicits a referred pain pattern.

• Pain can limit range of movement

Latent/Inactive trigger points


• This applies to lumps and nodules that feel like trigger points. These can develop anywhere in the body and are often secondary.

• These trigger points are not painful, and do not elicit a referred pain pathway.

• The presence of inactive trigger points within muscles may lead to increased muscular stiffness and tension. They can build up for years.

• It has been suggested that these points are more common in those who live a sedentary lifestyle (Starlanyl & Copeland 2001)

• These points are “potential” trigger points and may reactivate if the central or primary trigger point is (re)stimulated

• Reactivation may occur following trauma and injury

Symptoms of Trigger Points


Active trigger point referral symptoms

•Dull ache•Deep•Pressing pain•“Stabbing”•Burning•Referred pain

•Common reports of headaches, dizziness and pins and needles

Referral Pain GuideSternocleomastoid and Masseter


Referral Pain GuideTrapezuis


Referral Pain GuidePectorals


Referral Pain GuideQuadratus Lumborum


Referral Pain GuidePiriformis


Referral Pain GuideGlute maximus, medius and minimus


Referral Pain GuideTFL


Referral Pain GuideVastus Lateralis


Referral Pain GuideHamstrings


Other Symptoms


A sensation of:

•Numbness•Fatigue•Weakness

A loss of:

•Flexibility•Range of movement•Muscular power and strength

Why are they present?


• Repetitive overuse injuries (using the same body parts in the same way hundreds of times on a daily basis) from activities such as typing/mousing, handheld electronics, gardening, home improvement projects, work environments, etc.

• Sustained loading e.g heavy lifting, carrying babies, briefcases, boxes or lifting bedridden patients.

Why are they present?


•Poor posture due to our sedentary lifestyles, de-conditioning, poorly designed furniture and technology.

•Muscle clenching and tensing due to mental/emotional stress.

•Direct injury such as a strain, break, twist or tear e.g car accidents, sports injuries, falling down stairs.

•Trigger points can even develop due to inactivitysuch as prolonged bed rest or sitting .

Formation of a Trigger point


• Deep within muscles are spiral shaped nerve fibres called muscle spindles.

• When muscles are excessively stretched muscle spindles activate and send signals to the brain to promote a protective muscular contraction- stretch reflex arc.



• The problem occurs when the muscle spindle becomes sensitised.

• Injury or overuse can over stimulate muscle spindles which can cause contraction within the muscle and subsequently forming localised muscular spasm…. A Trigger point.



• Prolonged muscular contractions restrict blood flow through the area.

• This causes a build-up of waste products and toxins within the area and a reduction in fresh, nutritious blood flowing through.

• If the muscle spindle is active for prolonged periods of time the length of the muscle can shorten.

• Subsequently patients may experience a reduction in ROM.

Where are they formed?


• Trigger points are found all over the body.

.• Trigger points are located

within each sarcomere often where the nerve enters the muscle.

• The motor end plate.

Trigger point pain


• Chemoreceptors and mechanoreceptors are stimulated to send messages to the brain which results in the sensation of pain.

• The brain stimulates decreased movement into these muscles which further tightens the structure.

Indications and Outcome

Measures


Indications Outcome measures

Pain NRS scale & subjective symptoms

Reduced AROM Active range of movement

Muscle tightness Palpation

Muscle weakness Oxford rating scale


Outcome measure:Numerical rating scale

• Simple and easy

• Before, during and after massage

• Record change

• Use with patient to see reduction in pain over the progression of treatments


Outcome measure:Range of movement

• Pre and post measurements• Goniometer or visual• Standardise to produce reliable results • Review each session • Used to distinguish areas to treat and

techniques types • Valuable in the success of treatment


Outcome measure:Muscle testing

• Measure nerve conduction and muscle recruitment.

• Compare both sides.

• If strengthening exercises are used alongside massage treatment patients will be able to feel a progression here.


Outcome measure:Palpation

Use palpation as a measure using “the four T’s”

• TemperatureIs the tissue hot? This could indicate presence of inflammation.

● TextureSwelling (acute-hard, chronic – “boggy”, congested)healthy tissues should have an even textureAdhesions feel like tissues are “stuck” and less mobile “audible crunching”.


Outcome measure:Palpation

● TendernessPain can be indicated through response. NRS can be used here.

● ToneTissues may be tense, always compare to other side to see what is normal for the patient.

Lunch


Theory: Trigger Pointing Therapy


How to treat a Trigger Point


Assessment

•Find the most painful TP using patient response and Numeric Rating Scale.

•Treat the highest rated point and radiate out from this point

•Once the points are found – a good amount of pressure is applied (perform with precaution - keep communication with patient)

•Initial pain is stimulated and you hold the pressure until the pain has eased completely or in some cases reduced slightly

•Re-apply pressure onto the same point until the pain eases off quicker or it isn’t felt anymore (roughly 3 times)

•Thumbs/elbows or tools can be used

How to treat a Trigger Point


Guidelines

Application of direct pressure onto the trigger points for around 30 seconds or until the patient’s pain has decreased to at least 3/10 NRS score.

The applied pressure help to break-up the adhesive fibre connections within the trigger points and push out blood containing waste products and toxins.

After 30 seconds, the pressure is released allowing a rush of fresh blood containing nutrients to circulate the trigger point.

Repeat 3 times in conjunction with deep massage strokes.

This can vary on the severity of pain/ how deep or superficial the TP is –subjective and variable to each patient

The Benefits


• Reduced pain

• Increased range of motion

• Decreased muscle stiffness and tension

• Reduction in headaches

• Improved flexibility

• Improved circulation

• Fewer muscle spasms

Precautions


• High pain scales• Patient Anxiety• Acute/ Inflammatory stage of healing• Hypersensitivity• Pregnancy• Epilepsy • Asthma• Hypertension• Prescribed medication

Contraindications


General Local

Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be general contraindication depending on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene, advanced heart or kidney disease or very unstable or high blood pressure

Local irritable skin condition

Hemorrhage Malignancy

Severe atherosclerosis Open wound or sore

Severe and unstable hypertension Recent burn

Shock Undiagnosed lump

Systemic contagious or infectious condition

Manual Handling and Body Position


• Posture– Bed height– Stance– Patient position

• Use different parts of your hands/ arms to apply pressure• Keep arms straight to utilise body weight when applying

pressure/resistance.• Move from the hips and knees as much as possible• Oil (or cream)- only needs to be a little bit, if any.

Look after yourself before you look after the patient!

Post Treatment Irritation


Very common for people to experience irritation for up to 72 hours after treatment.

Side effects can include:• Bruising• Redness• Tenderness/Increased Sensitivity• Increased symptoms• Aching similar to DOMS

Post Treatment Irritation


Causes

• The release of toxins/waste products from muscular tissue • Neurological sensitisation• Increased blood flow and micro trauma can lead to bruising and redness

Advice

•Reassure the patient it's a normal response to be sore after soft tissue treatment•Recommend they drink water to keep hydrated

Practical:

Trigger pointing muscles


• UFT• Sternocleomastoid • Rhomboids • QL • TFL • Vastus Lateralis • Gastrocnemius

Trapezius


The trapezius can be separated into three muscles:

•The upper trapezius•The middle trapezius•The lower trapezius

Anatomy: All three trapezius muscles originate along the spine to T12 and extend laterally to attach to the shoulder girdle.

Function: Each muscle has a different direction of pull. Movements facilitated include scapula elevation, depression, retraction, upwards and downward rotation.

Trapezius


The whole trapezius muscle creates various movements of the shoulder blade, neck, and head.

To move your arm above your head you need muscular contraction pulling in opposite directions.

Muscular contraction in both lower and upper fibre traps to upwardly rotate the scapula.

This type of complexity makes it easy for trigger point activity to spread quickly through the muscle group as a whole.

Trapezius Trigger Points


Four primary trigger points in the trapezius muscle group; two trigger points in the upper fibers, and one each in the middle and lower fibers.

• The anterior trapezius trigger point

• The upper trapezius trigger point

• The middle trapezius trigger point

• The lower trapezius trigger point

Trapezius Pain


Causes● Poor posture- shoulders, neck and back● Stress● Carrying heavy handbags/ laptop bags on one side● Dysfunction/ pathology within the shoulder complex

Symptoms● Ache and tightness in shoulders and neck● Tension headaches● Upper cross syndrome● Struggle to look over shoulder

RX: UFT


• Tip: squeezing UFT between finger and thumb can be very effective with upper and anterior trigger points.

Sternocleomastoid


Anatomy:● Originates from the mastoid process.● The sternal division runs diagonally downward to attach to the

sternum.● The clavicular division attaches right behind it on the medial

clavicle.

Function: ● Turn head towards opposite side and bilaterally side flex the neck.● Control and monitor the head’s position in space. Proprioceptive

feedback from the SCM is essential to being able to maintain one’s balance.

Sternocleomastoid Trigger Points


• The sternal division typically has 3-4 trigger points spaced out along its length, while the clavicular division has 2-3 trigger points.

• Trigger points are usually present in both left and right SCM muscles as they work together to control the head.

Sternocleomastoid Pain


Each SCM division has a separate and distinct referred pain pattern:

• The sternal division’s referred pain is felt deep in the eye socket (behind the eye), above the eye, in the cheek region, in the back of the head, and on the top of the head.

• The clavicular division’s referred pain is felt in the forehead, deep in the ear, behind the ear, and in the molar teeth on the same side.

Causes/ symptoms:•Sore Neck•Tension Headaches•“Heavy head”•Poor head posture•Poor exercise technique (sit ups)

RX: Sternocleomastoid


• Locating and releasing these trigger points can be complicated due to their proximity to many blood vessels and nerves in the neck region.

• Caution: do not massage somewhere you can feel a pulse.

• Tip: Rotate head to side to find muscle but rotate back to neutral to treat.

Rhomboids


Anatomy:● The rhomboid muscle group originates

from the spinous process of C6-T4 and inserts onto the medial border of the scapula.

● It is separated into rhomboid major and rhomboid minor muscles.

Function:● scapula retraction and slight elevation

Rhomboid Trigger Points


3 primary trigger points

• The rhomboid minor trigger point lies just medial to the inside edge of the scapula, level with the scapular spine.• The rhomboid major trigger points lie one above the other, along the lower part of the scapular border.

•Referred Pain: The pain concentrates in the region between the spine and the shoulder blade.

Rhomboid Pain


Causes•Poor posture•Rhomboid weakness •Scapular instability •Winging scapula

Symptoms:•Pain Between the Shoulder Blades•Pain is usually felt at rest and not typically affected my movement.•Patients may hear snapping or grinding noises from the region around the shoulder blade during movements of the arm.

RX: Rhomboids


● Make sure that you have released any trapezius trigger points first otherwise they may block you from reaching rhomboid trigger points.

● Try in both prone lying and side lying position.

Tips: • Placing hand behind back can help to lift scapula out of the way.• Side-lying position to allow more forward movement of the scapula.• Prone to allow more pressure to be applied.

Have a go!


QL – Quadratus Lumborum


Anatomy: • Originates from the iliac crest and runs upwards and

medially to attach onto the 12th rib and transverse process of L1-L4.

Function: • Stabilise movement of spine and pelvis.• Control a upright posture.• Produce extension and side flexion of the lumbar spine.

QL Trigger points


• If one muscle develops trigger point activity, the muscle on the other side will become overloaded and develop trigger points as well.

• From a clinical perspective, you should always address the trigger points in both the left and right QL muscles, even if the pain is limited only to one side.

QL Trigger points


There are four potential trigger points in the QL muscle:

• The upper QL trigger point is found just lateral to where the lumbar paraspinal muscles and the twelfth rib meet.

•The middle or deep QL trigger points lie closer to the spine next to the third and fourth lumbar vertebrae.

•The lower QL trigger point lies deep in the region where the paraspinal muscles meet the iliac crest.

QL Pain


Causes ● Carrying children on hip● Sitting with poor posture for prolonged periods of

time● Poor manual handling technique● Poor workstation ergonomics

Symptoms:• Usually described as an intense, deep ache• Occasionally can produce a sharp, knifelike symptoms

particularly during movement. • Ache pain into small of back.• Pain when bending down.

RX: QL


• The first step in the effective treatment of the QL trigger points is being able to accurately locate and contact the trigger points.

• Try in both Prone and a extended side-lying position.

• Tips: Angle inwards towards spine rather than directly posterior.

TFL - Tensor Fasciae Latae


Anatomy: •Originates from outer aspect of the Iliac Crest and Anterior Superior Iliac Spine (A.S.I.S) it runs through illiotibial band which inserts onto lateral epicondyle of tibia.

Function:• Its function is primarily to control movement of the leg during the stance phase of walking.•Assist with hip abduction, flexion and internal rotation on the hip.

TFL Trigger Point


• There is only one trigger point found in the TFL and it is located in the upper region of the muscle just below where it attaches to the A.S.I.S.

• The referred pain pattern covers the entire hip joint and extends down the outside aspect of the thigh, sometimes nearly to the knee joint.

TFL Pain


Causes•Over foot pronation•Valgus knee position•Weakness in gluteus/ trendelenburg sign•Poor squatting/ lunging techniques•Poor landing biomechanics

Symptoms:• Pain in the hip joint (greater trochanter) and down the outside thigh during movement of the hip.• Pain when sitting in low chair or flex their hip more than 90°.• Unable to lie on the affected hip during sleep and unable to lie on the unaffected side during sleep without a pillow between their knees.• Pain and limited ROM in hip adduction.

RX: TFL


Tips: Find ASIS drop fingers down and laterally.

• If struggling can ask pt to flex and medially rotate hip joint to feel contraction.

Vastus Lateralis


Location: The quadriceps femoris muscle group form the thigh musculature found on the front of the upper leg. The group is comprised of four muscles:

• The Vastus Lateralis

• The Rectus Femoris

• The Vastus Medialis

• The Vastus Intermedius

Vastus Lateralis


Anatomy:•Vastus lateralis originates lateral aspect of the superior femur bone and runs down the outside of the thigh to attach to the lateral aspect of the patella.

Function:•The vastus lateralis is the largest muscle in the group.•Contraction of this muscle produces extension of the lower leg at the knee.•Helps to stabilise the patella in patellofemoral groove.

Vastus Lateralis Trigger Points


There are two sets of trigger points in the vastus lateralis muscle:

• The upper vastus lateralis trigger points are located in mid-thigh region on the outside aspect of the leg. They refer pain all along the outside of the thigh and knee.

• The lower vastus lateralis trigger points are found just above and to the outside of the knee joint. They refer pain around the outside aspect of the knee joint and below it.

Vastus Lateralis Pain


Causes● Weakness in gluteus● Over pronated feet● Valgus knee position● Overload from gym routine● Skiing activities

Symptoms:● Pain on outside of thigh● Pain into and behind the knee● Pain on resisted knee extension● Anterior knee pain● Stuck patella● Crepitus● functional limitations.

RX: Vastus Lateralis


Tips: try sliding thumbs up the outside of thigh until you feel the resistance of the trigger points.

Gastrocnemius


Anatomy:● Largest muscle in the calf ● Originates from the achilles tendon and splits

into two heads to attach onto the medial and lateral condyles of the femur.

Function: ● plantarflexion of the foot and assists with

knee flexion.

Gastrocnemius trigger points


Gastrocnemius may contain up to four trigger points.

•Two medial trigger points found in the medial head. One just below the knee crease and the other an inch down.

•Two lateral trigger points mirror the medial trigger points except they are slightly more distal.

Gastrocnemius Pain


Causes•Prolonged wearing of high heels can leave gastroc in a shortened position•Achilles tendinopathy•foot pronation•Sudden increases in training programmes•Prolonged immobilisation e.g. cast•Sleeping on front for prolonged periods

Symptoms•Pain in calf•Pain behind the knee•Pain when standing on top toes•Pain going upstairs•Suffer from calf cramp regularly

RX: Gastrocnemius


• Tip: try using your elbow to trigger point.

Have a go!


Supporting Evidence


Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self-Stretching Protocol for the Management of Plantar Heel Pain: A Randomized

Controlled Trial


Renan-Ordine et al, (2011)

•Aim: to assess the effect of trigger point therapy and stretching or stretching alone in the treatment for plantar heel pain.

•Method: 60 patients with plantar heel pain were divided into 2 groups a)self-stretching b) self-stretching and trigger point therapy.

•Outcome measures: assessed at baseline and at a 1-month follow up.

– Physical function and pain assessed using a quality of life questionnaire.

– pressure pain thresholds were assessed over affected gastroc, soleus muscles and over the calcaneus using a mechanical pressure algometer.

•Results: trigger point therapy and self-stretching is superior to stretching alone in the treatment of patients with plantar heel pain.

•Link: http://www.jospt.org/doi/full/10.2519/jospt.2011.3504

http://www.jospt.org/doi/full/10.2519/jospt.2011.3504

Comparative study on effects of manipulation treatment and transcutaneous electrical nerve stimulation on patients with cervicogenic headache


Li et al, (2007)

•Aim: To compare the effects of trigger pointing and transcutaneous electrical nerve stimulation (TENS) on patients with cervicogenic headache.

•Method: 70 patients with cervicoigenic headaches were randomly allocated to receive trigger pointing or TENS every other day for 40 days.

•Outcome measures: Taken 2 weeks pre-treatment and 4 weeks post-treatment.

– headache degree, frequency and lasting time using a numeric rating scale

– ROM of cervical spine.

•Results: Trigger pointing was superior to TENS in headache frequency, lasting time and ROM scores. Response rate of trigger pointing treatment was 94.5%, significantly higher than 64.5% of TENS treatment.

•Link: http://europepmc.org/abstract/med/17631795

http://europepmc.org/abstract/med/17631795

Immediate effect of activator trigger point therapy and myofascial band therapy on non-specific neck pain in patients with upper trapezius trigger points compared to

sham ultrasound: A randomised controlled trial


Blikstad and Gemmell, (2007)

•Aim: To determine the immediate effect of activator trigger point therapy and myofascial band therapy compared to sham ultrasound on non-specific neck pain

•Method: 45 patients with non-specific neck pain of at least 4 on an 11-point numerical rating scale and upper trap trigger points, decreased cervical lateral flexion away from the active trigger points participated. Participants were assigned to one of three treatment groups; trigger point therapy, myofascial band therapy or sham ultrasound.

•Outcome measures: assessed before and 5 min after treatment

– pain levels assessed using numerical scale

– cervical ROM using goniometer

– pain perceived thresholds using pain pressure algometer.

•Results: For the primary outcome measure of pain reduction the odds of a patient improving with activator trigger point therapy was 7 times higher than a patient treated with myofascial band therapy or sham ultrasound.

•Link: http://www.sciencedirect.com/science/article/pii/S1479235407001083

http://www.sciencedirect.com/science/article/pii/S1479235407001083

The use of other STR


•Helps warm up an area

•Removes waste products

•Increases oxygenation

•Increases new blood flow

•Further breaks down collagen

•Helps sooth an area after deep pressure has been applied

•Nice, relaxing end to a treatment


Effleurage • Technique used to warm up or warm down the tissues

• Tensile force, works as a mechanical pump

• Increases fluid flow encourages venous and lymphatic return

• Increases tissue mobility

• Dilation of capillaries

• Can increase or decrease tone depending upon speed


Petrissage

• Examples of petrissage- Kneading, wringing & skin rolling

• A group of deep style techniques that are applied with pressure and compress the underlying muscles

• Movements should be slow and repetitive with pressure in order to loosen the muscles and increase blood flow to the area

• Promotes relaxation • Increases fluid flow• Increases mobility of fibrous tissue• Decreases tone


Why should you stretch post-massage?

• Excessive tension may still remain post-massage.

• It takes up to two days post-massage to experience full effects.

• Essential to use other techniques to restore good functioning and reduce tension.

• need to stretch the collagen fibres that have been “knotted” to allow them to regain their full length.


Post treatment stretches

Passive static stretching

•Involves taking the muscle belly to its outer range until you can feel a gentle stretch.

•Static stretches are usually held for at least 30 pain free seconds.

•Research suggests static stretches should be repeated from 2 to 4 times. As further repetitions do not promote any further muscle elongation (Bandy, 1997).

Practical:Tool and other STR techniques


Supporting Evidence:

Other STR techniques


Therapeutic evaluation of lumbar tender point deep massage for chronic non-specific low back pain


Zheng et al, 2012•Aim: To investigate the effects of lumber traction along and in combination with deep tissue massage in patients with chronic low back pain.

•Method: 64 patients with LBP were divided to two groups A) lumber traction and deep tissue massage or B) lumber traction who both received treatment twice a week for 3 weeks.

•Outcome measures: tissue hardness meter/algometer and VAS pain scores.

•Results: Patients receiving deep tissue massage and traction experienced significant decreases in muscle hardness and pain intensity when compared to those who received lumber traction alone.



Massage therapy as an effective treatment for carpal tunnel syndrome


Elliott and Burkett, 2013

•Aim: To investigate the effects of massage therapy as the treatment for carpal tunnel syndrome.

•Method: 21 participants received 30 min of massage including trigger point therapy twice a week for 6 weeks.

•Outcome measures: Carpel tunnel questionnaires, Phalen and Tinel test assessment.

•Results: Participants experienced a significant reduction in symptom severity and improvements in physical function.



Case Studies


Case Study: Shoulder pain


PC/HPC -21 year old female with an gradual onset of ache pain in shoulders over past 1/12 rating 4/10 on VAS scale. The pain is aggravated by sitting at a desk for long hours and eased with the application of heat.

SH- final year art student with a sudden increase in workload as final project is due in 2/12. Carry heavy art portfolio to and from university. Attends a LBP class at the gym 1 x a month.

PMH- nil to note

DH- paracetamol when needed



Objective signs

• Increased UFT tone

• Reduced cervical lateral flexion due to UFT tightness

• TOP of L and R UFT and Rhomboids

• Active Trigger points in R and L Rhomboids

• No neurological symptoms

Case Study: Lower back pain


PC/HPC – 39 year old male 8/10 sharp pain in R lower back. Pain began suddenly when after lifting heavy box up which sent shooting pains down R leg. Aggravated by bending down and putting shoes on and eased by lying down flat.

SH- full time receptionist, doesn’t perform regular exercise.

PMH- history of lower back pain

DH- analgesics



Objective signs

•Limited Lumber range of movement

•Increase in pain during flexion and L lateral flexion

•Pain eased during extension.

•PALP – pain on palp of QL and L3 spinous process

Case Study: Calf pain


PC/HPC – 35 year old male runner. Felt a 6/10 sharp pain in R calf towards the end of a 5K run 2/52 ago. Had to stop running. No swelling or bruising was present. Pain reduced since 3/10 ache pain, tried running again but still feels painful.

SH- work in a warehouse, on feet all day up and down ladders.

PMH- prev R lateral ankle sprain 12/12 ago

DH-nil to note



Objective signs

•Increased calf bulk L side

•Thickening of R Achilles tendon

•Reduced dorsiflexion of R ankle

•Reduce muscular strength in R resisted plantarflexion

•Reduced R calf length

•PALP- pain on palp of medial gastroc

•-ve Thomas test

Case Study: Buttock pain


PC/HPC- 25 year old male 5/10 pain in L buttock. 1/12 ago increased pain following legs gym session, gradually worsening since. Aggravated by climbing multiple flights of stairs at work. Eased by resting.

SH- Started going to the gym 1/12 ago after a 5 year break. Doesn’t do any stretching because he doesn’t know how to. Works on the 8th floor of a office building.

PMH- over pronate both feet, especially bad in L side.

DH- nil to note



Objective signs

•Over pronation in L > R foot

•Valgus position of knees

•Poor hamstring flexibility on 90/90 test in L>R legs

•No neurological symptoms during SLR

•PALP: tension L>R hamstring, glutes and piriformis

•Very tender on PALP of piriformis



Diagnosis?

How would treat this?

Quiz…Answers


Question 1


What is a trigger point?

• Trigger points are hyperirritable areas of contracted muscle fibres that form a palatable nodule

• On a microscopic level, the contracted muscle fibres accumulate into a small thickened area causing the rest of the fibre to stretch

• The areas of contracted muscle restrict blood flow within the tissue causing an accumulation of waste products and reduced levels of nutrients available.

Question 2


How would a patient describe trigger point pain?

• Dull ache• Deep • Sharp• Pressing pain • Stabbing • Burning • Travelling pain • Head pain

Question 3


Name some indications for Trigger point therapy

• Pain • Reduced AROM• High muscle tension or tone• Muscle tightness

Question 4


Name some benefits of Trigger point therapy

•Reduced pain

• Increased range of motion

• Decreased muscle stiffness and tension

• Reduction in headaches

• Improved flexibility

• Improved circulation

• Fewer muscle spasms

Question 5


Name some contraindications for Trigger point therapy

General Local

Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be general contraindication depending on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene, advanced heart or kidney disease or very unstable or high blood pressure

Local irritable skin condition

Hemorrhage Malignancy

Severe atherosclerosis Open wound or sore

Severe and unstable hypertension Recent burn

Shock Undiagnosed lump

Systemic contagious or infectious condition

Question 6


Where is the Trapezius muscle found?

The trapezius can be separated into three muscles:

•The upper trapezius•The middle trapezius•The lower trapezius

Anatomy: All three trapezius muscles originate along the spine to T12 and extend laterally to attach to the shoulder girdle.

Question 7


Where is the Sternocleomastoid muscle found?

Anatomy:● Originates from the mastoid process.● The sternal division runs diagonally downward to attach

to the sternum.● The clavicular division attaches right behind it on the

medial clavicle.

Question 8


What muscle group does Vastuslateralis belong to?

The quadriceps muscular group.

Anatomy:•Vastus lateralis originates lateral aspect of the superior femur bone and runs down the outside of the thigh to attach to the lateral aspect of the patella.

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trigger point presentation workshop 01.04.17

Healthcare