Prologue

To a National Board Certified Myofascial Trigger Point Therapist, Myofascial Trigger Point Therapy (or, as it is commonly known, myofascial release), is not just a treatment modality, but an entire treatment protocol. The first step to that protocol is an in-depth history of all relevant traumas to a person's body. To what degree is a trauma relevant? Briefly, I'll site an example. Physical Therapist, Mr H., suffered with chronic right knee pain. In taking an initial history, Mr. H. insisted he never suffered any trauma to the right knee. I persisted.

Later, as he lay on my treatment table visibly perturbed by my persistence, he explained that when he was 12 years old, he fell off his bicycle and landed on his right knee. "But that was thirty years ago. What's that got to do with my knee pain"?

A very close examination of the texture of the skin over the patella revealed a tiny scar of approximately 1/8 of an inch in diameter. With the leg fully extended, I began to test the mobility of the patella. I found that it moved about axes whose center was that tiny scar. As I held the patella superior to the knee joint, I had him slide his heel towards his buttocks. With knee flexion at approximately 20 degrees, a loud "click" was heard. The adhesion that was created when Mr. H. fell on his knee at 12 years old had caused his patella to track incorrectly for these many years. His knee pain was significantly decreased after one or two treatments to inactivate trigger points laid down in the quadriceps that were due to a dysfunctional patella. In the case histories that follow, the "mysteries of the histories" were not always revealed until after much client/therapist interaction had taken place.

After an in-depth history is taken, a charting of the patient's pain is completed. Pain, referred by an active myofascial trigger point in a muscle, is the "signature" or pain pattern of an affected muscle. Based on analysis of the history and careful review of pain patterns, ROM testing is employed to locate restriction in a muscle or muscle group. This restriction is further verification of myofascial trigger point activity. Another objective sign is observed when palpation of a myofascial trigger point in a taut band of muscle elicits a local twitch response.

Treatment involves a variety of myofascial release techniques including but not limited to ischemic compression and Fluori-Methane Spray and Stretch. A home exercise program is prescribed, including stretching and appropriate strengthening, to maintain functional release achieved during treatment. During each treatment, continuous inquiries by the therapist begin to uncover perpetuating factors such as inappropriate ergonomics, poor nutrition, inadequate water intake, ADL's and more.

Myofascial Trigger Point Therapy is not a cure for all pain. However, the authors of Myofascial Pain and Dysfunction, The Trigger Point Manual, Janet Travell and David Simons, MD's report that "voluntary skeletal muscle is the largest single organ of the human body and accounts for 40% or more of body mass." They go on to say that there are "347 paired and 2 unpaired muscles for a total of 696 muscles" in the human body. Further, they state that "any one of these muscles can develop myofascial trigger points that refer pain and other distressing symptoms usually to a remote location." In spite of this, "the muscles receive little attention in modern medical school teaching and medical textbooks."

More than 40% of the mass of the human body, consisting of muscle tissue, is capable of developing active myofascial trigger points. Myofascial trigger points, in turn, refer pain to a location other than the site of the lesion, often confounding conventional models. Is it any wonder why this treatment protocol is effective with pain patients who have had no relief from pain pills and muscle relaxants? It is my hope that the following case studies will shed light on the efficacy of Myofascial Trigger Point Therapy, by a board-certified practitioner, for the treatment of both acute and chronic pain.

Case History 1

Diane M., a 62 year old retired female attorney, was involved in a motor vehicle accident in March 1997. She was wearing a shoulder and lap seatbelt. She was moving very slowly through an intersection with her body rotated to the left when she was rear-ended. After one month of physical therapy, her doctor decided to include Myofascial Trigger Point Therapy in her overall treatment plan. Diane presented with diffuse low back pain which was worse at the left SI joint and a considerable amount of neck pain, worse on the left at the angie of the neck. Myofascial Trigger Point Therapy and soft tissue mobilization to inactivate trigger points in the SCM, scaieni, trapezius, latissimus dorsi and paraspinals, provided a modest decrease of her pain.

During intake, on her fifth treatment, Diane reported that the "butterfly stretch" for the adductors was very tight and restricted with pain in the medial thighs. She stated that her low back pain was becoming more specific at the SI joints, left worse than right. She had been experiencing vaginal pain with intercourse during the past 10 years. This pain had increased along with her back pain. Diane wondered if there might be a connection.

Palpation of taught bands of muscles in the lower rectus abdominis referred pain to the vaginal area as well as her low back and recreated the pain of dysmennorhea. I treated the lower abdominal muscles including the pyramidalis and released trigger points in the adductors, bilaterally. I then used a muscle energy technique to mobilize the pubic symphysis and a loud "pop" was heard followed by a nearly complete release of her pelvic pain. Despite the dramatic release of the pubic symphysis, abduction of the thighs was still considerably restricted, right greater than left. There was however, an improvement of approximately of 20% in abduction, bilaterally. Pain at the SI joints was decreased to a 1-2/10.

During the sixth treatment, Diane stated that her vaginal pain had decreased from as much as an 8 or 9/10 to a 1 or 2/10. Her low back pain at the SI joints had decreased considerably and was only slightly felt on the right. After a very thorough treatment of the abductor muscles, bilaterally, using ischemic compression and soft tissue mobilization, I used a muscle energy technique to mobilize the right hip joint. A loud cascade of 2 or 3 "pops" came from the right hip joint and the pelvic region. ROM in abduction increased to almost 90 degrees.

Although I saw Diane for three more treatments, most of the pain she suffered since the car accident was gone. On her ninth and final treatment, Diane was both very happy and very angry. She was in tears as she recounted the pain she suffered over the course of ten years while trying to have normal relations with her husband. She was angry after thousands of dollars on ineffective treatments and tremendous emotional suffering, it took only three treatments to rid her of pain that almost destroyed her marriage. Needless to say, Diane was greatly relieved that this pain was gone.

Case History 2

Cathy C. is a 42-year-old employee on the housekeeping staff at a local hospital. Cathy presented with pain at the lateral epicondyle of the right elbow. This was the result of a sprain/strain of the right forearm and elbow, which occurred while lifting an unexpectedly heavy trash bag filled with books and periodicals, instead of the usual crumpled pieces of paper. Whenever Cathy used her right arm to lift an object of any appreciable weight, such as a 6 oz tumbler of iced tea or heavier, she experienced pain from the lateral epicondyle down into the right hand and simultaneously up to the right shoulder.

Since the pain pattern for scaleni muscles fit Cathy's pain almost to a "T", I did ROM testing for active myofascial trigger points in the scaleni muscles. Of all the tests I did, the scaleni cramp test was the only one that proved negative. All the rotator cuff muscles, coracobrachialis and anterior deltoid were positive for active myofascial trigger points as demonstrated in the Backrub and Hand to Shoulderblade tests. Both tests were also painful at the extensors of the right forearm when supinating the hand and forearm. The handgrip test was positive for trigger point activity in the brachioradialis and extensors of the right hand and fingers. Testing of pronation and supination against resistance was positive for active myofascial trigger points in the supinator and pronator teres, respectively.

This evaluation indicated to me that the right epicondyle pain was the result of continuous subclinical trauma to most of the musculature from the shoulder girdle to the hand. Lifting the unexpected weight of books and periodicals in a trash bag was simply "the straw that broke the camels back."

When Cathy first came in for treatment, she stated that her pain was as much as an 8/10. By the sixth treatment, the pain never rose above a 4/10. During those 6 treatments, continued release of active myofascial trigger points in the entire right arm, coupled with a home exercise program, was successful in decreasing the intensity of Cathy's pain.

Although the six treatments reduced the right epicondyle pain by 50%, it seemed there was a piece of the puzzle I had not yet discovered. After much discussion and inquiry, I learned that Cathy not only slept face down, but also with her right arm overhead, under the pillow and with her elbow flexed to approximately 90 degrees. This position keeps the brachioradialis, biceps brachii, pronator teres and extensors shortened, thereby perpetuating the pain.

After discussing various methods to change her sleep position, it was agreed that Cathy would sleep with her right arm inside a T-shirt instead of through the normal arm opening. This would prevent her from sleeping with her arm in the usual position that was perpetuating the pain. A week later, Cathy returned with very little pain with normal daily activities, including lifting. There was still pain upon palpation at the right lateral epicondyle, but pain no longer traveled up to the shoulder and down to the hand.

Although I was not able to relieve all of Cathy's pain using Myofascial Trigger Point Therapy, I was able to greatly decrease her pain and return her to nearly normal function. Since the muscles were shortened and contracted, due to myofascial trigger points, a long time before the actual injury, the chance of inflammation at the attachment of the tendon to the periosteum of the lateral epicondyle was considered. I sent Cathy back to the referring physician to be evaluated for the possibility of injection of an anti-inflammatory to resolve the remaining pain.

Case History 3

Mr. H is a 47 year old male employed as an Adaptive Physical Education Teacher. During class, while sitting on a bench in the school gym, Mr. H odserved an autistic child, with tendencies toward uncontrollable physical behavior, running across the room. When Mr. H realized this child was out of control, he held out his right arm to catch the child as he ran by him. As he caught him, Mr. H's torso twisted to the right and he immediately felt a sharp pain across his low back, left worse than right.

During my initial history intake, I learned he was an avid body builder and, for a few years, had been a "power lifter." Mr. H had terrible difficulty rising from or sitting down in a chair and was barely able to get on the treatment table without assistance. He stated that his typical pain level was 7/10 and he experienced this pain no matter what activity he was doing or not doing. He had been diagnosed with a herniated disc at L4-5 several years before and he feared he re-injured himself. He had not had surgery for this problem and feared he may need that now.

After performing several ROM tests for the lower half of the body, I was surprised to find most of those tests within normal limits. For someone in as much pain as Mr. H, his ROM for most tests were either well within limits or better. At this point, although his pain complaint was his low back, I asked him to perform a simple test for the mouth opening. Normal interincisal opening should accommodate 3 knuckles of the non-dominant hand, his was nearly 3 1/2. I also observed his ability to hyperextend his elbows. These two tests showed that hypermobility was part of the problem. In the presence of hypermobility, ROM testing can often be misleading. When the joints are considerably "lax", muscles must work harder to control them. This extra effort is a considerable factor in the perpetuation of pain following muscle trauma.

Of all the tests I had Mr. H perform that day, only one proved to be clearly positive. The hip extension test for the iliopsoas is performed with the patient supine and one knee held to the chest. The opposite leg is extended and a measurement taken between the horizontal surface and the popliteal fossa. Mr. H was positive by a width of approximately 16 centimeters on the left and 12 centimeters on the right. Negative result would be 0, bilaterally.

The psoas muscle attaches to the anterior lumbar spine, attaching not only to the vertebral bodies but also to the discs. It then travels caudally through the "well" of the pelvis, joining the tendon of the iliacus as it inserts at the lessor trochanter. It is the primary hip flexor.

In almost every case treated by this therapist, when there is low back pain and a history of disc bulge or herniation, the psoas is found to be not only hypertonic, but frequently found to be disproportionately more shortened on one side than the other. We find that as the shorter psoas muscle pulls the lumbar spine into increased lordosis, it also rotates it to the contralateral side. This in turn narrows the intervertebral space on the side of the shorter psoas, while allowing the psoas on the opposite side to pull on the discs where the space between the vertebral bodies is greater. This can contribute to a disc bulge and/or herniation. I believe this was the case with Mr. H.

I used Myofascial Trigger Point Therapy and soft tissue mobilization in conjunction with other techniques to release the psoas muscle. As a result, Mr. H experienced a dramatic decrease in his pain by the second treatment. After releasing the psoas, quadratus lumborum, lateral aspect of the obliques, lumbar paraspinals and the latissimus dorsi, I was able to mobilize his lumbar spine. Mr. H was able to get off of the treatment table with almost no pain, as well as sit and rise from a chair without hesitation. He reported his pain level as a 1-2/10. Needless to say, we were both delighted with the outcome.

As Mr. H began to increasingly engage in normal activities, there were minor exacerbations of his pain to a level of approximately 3-4/10. He was usually able to control the pain with his home exercise program, which included a specific stretch for the psoas muscle. After considerable modification of Mr. H's workout routine at the gym, he is now pain free and does not require the surgery that he so dreaded.

Case History 4

Marilyn C., a 53-year-old physical education teacher, was demonstrating a round-off dismount from a low balance beam, when she landed "hard" on her left leg and heard something "snap." This incident took place a year and a half prior to her doctor's referral for Myofascial Trigger Point Therapy. She had been for other therapies including strengthening of the hamstring muscles under the direction of a physical therapist, deep tissue massage and injection "in the rear of the thigh." In spite of this, Marilyn continued to have pain in the left buttock and posterior thigh with considerable pain at the proximal, medial thigh, as well. Her pain went as high as a 10/10 if she sat for any considerable period of time.

After taking an in-depth history, I discovered she had a serious trauma to the left foot in 1966 and a "very hard fall" landing on the buttocks in 1977. There was also orthoscopic surgery of the right knee in 1998 for torn cartilage. This current injury occurred 11/97. It seemed that what we were dealing with were the remnants of more than one injury to the muscles of the lower limbs and pelvis. According to Travell, MD, once trigger points are laid down in a muscle, they can continue to cause referred pain autonomic phenomenon indefinitely.

After performing several ROM tests for the pelvic and lower extremity muscles, I found trigger point activity in the right quadratus lumborum and left erector spinae muscle group. Curiously, the Straight Leg Raise test for the hamstrings was nearly normal at 85 degrees, bilaterally.

It was not until the fourth treatment, that Marilyn began to experience some relief from her pain. She noticed she could sit for longer periods of time. When her pain did commence, it was not as intense as it had been prior to the treatment. Up to this point, treatment had consisted of Myofascial Trigger Point Therapy and soft tissue mobilization focusing on the hamstrings and lateral rotators of the hip. As her pain continued to decrease and she was able to sit for longer periods of time, I began to treat the tensor fasciae latae, quadriceps and the adductors which I felt were secondary to the problem. Although Marilyn reported decreased pain in the left medial proximal thigh, palpation of the left adductor magnus minimus revealed taught bands of muscle that were very painful to treat. By the sixth treatment, Marilyn was able to sit for a period of up to 3 hours at a time with her pain level at a 2-3/10, at most. She was very excited about this and optimistic that this therapy would be able to resolve her pain after a year and a half of suffering.

By the tenth treatment, Marilyn was still having occasional exacerbation of her left posterior thigh pain. She still had pain in the left buttock just above and below the gluteal fold, as well as three or four points of pain over the proximal half of the left posterior thigh just lateral to the midline. Muscle testing and palpation did not reveal the source of this continued pain.

When Marilyn came in for her eleventh treatment, we reviewed her entire home exercise program. During that time, Marilyn reported an increase in the intensity of pain in the left buttock and posterior thigh while performing an exercise that involved abduction of the hip allowing the gluteus medius to shorten. When muscles harboring trigger points are shortened, often times the signature pain pattern of that muscle will be revealed or intensified. Such was the case with Marilyn. Deep palpation of the left gluteus medius did indeed recreate Marilyn's pain pattern. Using Myofascial Trigger Point Therapy and soft tissue mobilization of the gluteus medius and minimus, Marilyn's pain was decreased to zero.

At the time this case study is written, Marilyn has not completed therapy and is still experiencing pain at a level of 1-3/10, but has been able to return to normal activities such as playing softball, going on light day hikes and playing golf. When Marilyn was leaving my office following her most recent treatment, she said she was on her way to play golf with her daughter and was anxious to see how this most recent treatment would improve her golf score. As Marilyn's therapist, I share her optimism.

Epilogue

Although these four case histories show remarkable results in alleviating pain, there are those cases where relief of pain and recovery is not as dramatic. Often times, when there is a patient that is refractory to treatment, there are systemic perpetuating factors. These perpetuating factors can be but are not limited to structural variance, nutritional inadequacies, metabolic and endocrine inadequacies including sub-optimal thyroid, hypoglycemia, and hyperuricemia. Other perpetuating factors include depression, anxiety, and chronic infection due to either viral or bacterial disease, parasitic infestations, allergy, impaired sleep and chronic visceral disease. Although the therapeutic procedures performed by a Board Certified Myofascial Trigger Point Therapist can appear to work miracles, this does not take place in a vacuum. Human physiology is a very complex and often times quite perplexing. It is only through the combined efforts of other disciplines and the patient's commitment to resolving their pain that they can truly be restored.