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Why Physical Therapy does not work?

What is Trigger Point?

A Trigger Point (TrP) is a hyper-irritable spot, a palpable nodule in the muscle fiber. In this small area, the muscle fiber is always being contracted and shortened since the receptors inside of the muscle are over-activating (Muscle Spindle). This area becomes acidic which results in tightness of the surrounding tissue. Tight tissues restrict blood supply which results in poor metabolism and energy crisis. Trigger Point is the most common cause of the musculoskeletal pain.

In 2008, the Mayo Cinic announced it had photographed the taut bands of TrPs (Chen et al 2008). The National Institutes of Health mentioned that “as many as 85-93% of chronic pain patients” in pain clinics have TrPs.

Main Features of Trigger Points

  1. Trigger Point increases pain – muscles having TrP increases pain with or without movement
  2. Trigger Point causes referred pain – pain perceived at a location other than the spot of the trigger points. Once TrP is active or being compressed, the patient feels pain in other areas of body
  3. Trigger Point causes muscle weakness – muscles can not perform maximum contraction with TrP
  4. Trigger Point decreases joint flexibility – muscle length is shortened with TrP
  5. Direct compression on TrP can elicit muscle twitch response and the patient will be startled by the intense pain.

What can cause Trigger Points?

  1. Any types of trauma such as a falling accident or whiplash injury from automobile accident
  2. Lack of exercise – commonly in sedentary persons
  3. Bad posture – slouched sitting posture, telephone posture, cross-legged sitting
  4. Muscle overuse and repetitive micro trauma – weightlifting, cycling or running
  5. Chronic stress condition – anxiety, depression, psychological stress trauma,
  6. Vitamin deficiencies – vitamin C, D, B; folic acid; iron;
  7. Sleep disturbance,

How to diagnose Trigger Points?

Diagnosing TrPs is a challenge with radiography (X-ray, CT scan, MRI). However, there are four diagnostic criteria for myofascial trigger points which have been proposed in the literature and through clinical practice.

  1. a taut band (muscle fiber bundle) in the muscle
  2. a pressure-sensitive area within the taut band
  3. referred pain from a trigger point
  4. a local twitch response of the trigger point or taut band in response to mechanical stimulation of the trigger point.

Why sometimes Physical Therapy aggravates symptoms?

If there are active Trigger Points or Myofascial restriction (densified muscle and fascia), it can aggravate symptom while doing exercise. The provider should be able to locate the place of TrP or myofascial restriction, and release it before doing the rehab exercise. As mentioned above, it is difficulty find the trigger point or myofascial restriction through radiographic exam such as MRI. It is required for the provider to have a good knowledge and delicate palpation skill since TrP is a small spot and oftentimes it is difficult to identify it from other tissues.

Why Trigger Point Therapy is so effective?

Trigger Points are the most common source of pain in any types of musculoskeletal condition. Even though the patient was diagnosed with a certain disease such as arthritis, ligament sprain or herniated disc, there are multiple TrP around painful area and pain diminishes after successfully releasing it. Additionally, strength and flexibility increase immediately. It can be checked from pre and post treatment exam.

Blood circulation is the most important aspect in healing process since it carries nutrients and oxygen into the cells. Released TrP increases blood circulation around that muscle which will decrease inflammation.

How to release TrP?

1. Ischemic compression method

Find a TrP with palpation. If you compress it, it will be extremely sore and will radiate referring pain in the other body part. Compress the TrP with moderate intensity (you should feel some discomfort) for 30 seconds and relax. Try this method 3-5 repetitions for one spot. Try 3 spots at a time everyday. If you continue to do it, the intensity of pain will decrease overtime.

2. Apply body weight on a ball

Using a ball is one of the most efficient way to release TrP. Go against wall and put the ball between your body and the wall. Keep your knee slightly bent in a squat position and lean on the ball applying some body weight. Do squatting movement and slide your body against the ball. Once you hip the TrP, you will feel pain, roughness and radiating pain. Stay on the hot spot for 20-30 seconds depending on your tolerance. Repeat this for 3 to 5 times. Try 3 TrPs at a time. After doing this method, roll over the broader area giving some massage around TrP using your body weight.

3. Stretching

After doing TrP release, lengthening the target muscle doubles the effect of treatment. Do stretching on that muscle for 20 to 30 seconds for 3 times.

Trigger Point Therapy Protocol

  1. Find muscle weakness through movement test and resistance test
  2. Find main trigger points and myofascial restriction which are causing the issue
  3. Apply trigger point release and myofascial release technique
  4. Teach stretching for the target muscles to restore normal length or the muscle
  5. Begin the balance exercise program
    Exercise program aims to balance agonist and antagonist development. For example, if you over develop your chest muscles and not doing your back muscles, you will have TrP in pectoralis and rhomboid muscles much easily.
  6. SSC Method Exercise (It is our unique exercise method developed by Dr. Jimmy Jo)
    Strenghening – Stretching – Compression Method: If you train your muscles with strengthening which is followed by stretching and compression method (using a ball or form roller to release tightness), you can keep your muscle condition the best quality
  7. Learn self treatment technique to apply it in your daily exercise routine

Perpetuating Factors of Trigger Points

If Trigger Points occur repeatedly or it is resistant to treatment, you need to think about Perpetuating Factors.

  1. There can be high energy demand or overwork on the muscle
    If you are an office worker, slouched posture can be a big reason why your posture muscles get TrPs so easily. Using a standing desk or using a back supporter in the chair can be a solution.

    If you have a poor movement pattern such as shrugging your shoulder when you are having stress, it can be a reason why you have TrPs in your shoulder muscle.
  2. Poor oxygen intake from rib and diaphragm tightness
    Stiff ribs and inactive diaphragm decrease oxygen in your body. If your rib expansion decreases, you will have less oxygen in your body and you will feel fatigue easily. So does your muscles and cells. In this environment, it is much easier to have trigger points in your muscles.
  3. Poor Nutrition and Mineral intake
    One of the pioneers in Trigger Points, doctor Travell and Simons, found that almost half of their patients required treatment for vitamin inadequacies to obtain lasting relief from the pain and dysfunction of trigger points, and thought it was one of the most important perpetuating factors to address. They found the most important were the water-soluble vitamins B-1, B-6, B-12, folic acid, vitamin C, and the minerals calcium, magnesium, iron and potassium. The more deficient in nutrients you are, the more symptoms you will have, and your trigger points and nervous system will be more hyper-irritable. Even if a blood test determines you are at the low end of the normal range, you may still need more of a nutrient, since your body will pull nutrients from the tissues before it will allow a decrease in the blood levels

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