Author: Lukáš Kasala, Physiotherapist, RehaThink Instructor
Most of the patients which visit us in our ambulance suffer from some type of pain. Most often the pain they perceive comes from Myofascial Painful Syndrome, which is caused by trigger points. Trigger points are one of the most often reason for patient's pain (28). If you know how to assess trigger points, understand its neurophysiology and choose appropriate therapy, then you are able to reliev patient's pain quickly and effectively.
If you would like to read more about trigger points, their neurophysiology, read this article!
If I explain what are trigger points in a very simple manner - they are like "protection" points created by brain. For example, typical trigger points after ankle sprain are in soleus, tibialis posterior, tibialis anterior, fibularis longus and brevis (29, 30). Persistence of trigger points cause painful walking in situation when soft and hard tissues are healed. During walking muscles are activated (contracted and stretched) , as well TrP within them, so it leads to irritation of trigger points and pain. Patient still feel pain, instability in ankle joint (again because of pain perception) long time after injury (up to 6 month and more). In acute stage of ankle injury, brain creates protection bangade from muscles and TrPs within muscles . To fix injured ankle muscles increases tonus and creates TrP. It is very important to work with a trigger points to restore normal muscle tone around ankle and lower leg (31).
Which physiotherapy technique Do you use for treating TrP?
Czech physiotherapist PhDr. Petr Bitnar (2th Faculty of Medicine, Charles University) developed method based on neurophysiological principles and development kinesiology. This method he named Global Trigger Point Therapy. What stands behind this method? The main principle of method lays on basic neurophysiological principle which provides smooth and presise movemet. It is Reciprocal inhibition (RI). If RI do not work properly, it appears as a CNS disorder - spasticity or rigidity. A lot of researches describes reciprocal inhibition as part of muscle energy technique.
Using RI in TrPs therapy has good evidence. There is a lot of researches (32, 33, 34,35, see sources below) proving that RI is helpful in therapy. What stands behind? Principle is quite simple. If we activate agonist, for example, biceps brachii and want to bend the elbow, antagonist, triceps brachii, have to lower tension or "switch off". If in triceps are muscle wires with TrP, they will lower tension and irritability as well. And then we can with pressure or deep massage relax TrP (2).
Why Global Trigger Points Therapy? Because Global trigger point therapy was created in Czech Republic, in therapy it uses positions from developmantal kinesiology or motor control, which has described Prof. V. Vojta. Why to use position from developmental kinesiology in therapy? (More here). During child development muscles and their chains activates gradually in different positions, creating muscle synergy and cocontraction. Through this muscle synergy we are able to facilitate or inhibit muscle. As well in development position joints are in centrated position, which is crucial for physiological and balanced muscle work around joint. Joints centration means that contact surfaces between joint head and joint socket is as great as possible. Muscles, ligaments, joint capsule around joint are relaxed. And when the muscle is relaxed, we can effectively work on TrP. Whole body works in muscle chains. If there is trigger point in one muscle, other muscles, belonging to the same muscle chain, will react. For effective therapy, we use knowledges from development kinesiology and muscle neurophysiology.
Examples
Example nr. 1. This 3-month prone position we use for hamstrings relaxation. In this position patient presses with elbows and forearms to the table what activates frontal muscle chain and based on RI inhibit dorsal muscle chain into which hamstrings belongs. And when hamstrings relax, muscle wires with TrP also lowers activity and we can treat TrP. We can also do pelvis caudalization what will contribute to hamstrings relaxation and frontal muscle chain activity.
Example nr. 2. can be this 3-month supine position. This we can use for rectus abdominis or psoas major TrP therapy. Patient presses with heels to our hand and forearm and also presses with head to the table very slightly, what activates dorsal muscle chain and inhibit frontal muscle chain into which rectus abdomins and psoas major belongs. Hips are in centrated position what causes eutonization between internal and external hip rotators and also lowers psoas major activity. Patient have to press with little effort. Under your hands you feel, if done correctly, that muscle which you want to relax, really relaxed. If patient will press too much, muscle on both sides will increse activity.
Example nr. 3. can be position for upper trapezius relaxation. Muscle, which is very often overloaded. Again we can use 3-month supine position. Scapula is actively caudalizated what activates lower trapezius and based on RI inhibit upper trapezius. Patient tries to be as tall as possible and presses with upper extremities to the table what activates frontal muscle chain. In this position upper trapezius always perfectly relax and we can easily relax TrPs in upper trapezius. This my patients loves a lot :)
Some last questions...
Is this method painful? If you activate correct muscle chain correctly, TrP which you want to relax lowers activity and pressure is not painful. Patient will immediately say that there is no pain or just a little. We do not increase pain. Smartly we are able to switch the pain off.
Can this method use patient as a home therapy? Sure. Just staying in position for some time inhibit TrP.
Can i use this method with every patient? Yes, you can. There are just some contraindications, for example general body inflamation or TrPs shortly after injury serving as a "protectors" in acute stage. Be careful with some muscles in pregnancy.
More about this technique you will learn on our course which is the most popular in Latvia: "Globālā trigerpunktu terapija: I daļa "!
In the course you won´t get cook book. You will learn way of functional thinking, principles of therapy, stategies to some patologies and then you will be able to apply knowledges to any muscle. You will be able to create your own position for any muscle relaxation. Course is based on Czech School of physiotherapy, which has a strong traditions and knowledges about rehabilitation.
Literature:
Books
Kolář P. et al. 2014. Clinical Rehabilitation. Prague Rehabilitation School.
Joseph M. Donnelly et al. 2018. Myofascial pain and dysfunction the trigger point manual 3rd edition.Lippincott Williams and Wilkins.
Lewit, L. 2009. Manipulative Therapy: Musculoskeletal Medicine 1st Edition. Churchill Livingstone.
Articles, Guidlines, Researches
1. Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, Willems J,
Winters J, van der Woude HJ; Dutch Orthopaedic Association. Guideline for
diagnosis and treatment of subacromial pain syndrome: a multidisciplinary
review by the Dutch Orthopaedic Association. Acta Orthop. 2014 Jun;85(3).
2. Chen Z, Wu J, Wang X, Wu J, Ren Z. The effects of myofascial release technique
for patients with low back pain: A systematic review and meta-analysis.
Complement Ther Med. 2021 Jun;59:102737. doi: 10.1016/j.ctim.2021.102737. Epub
2021 May 10. PMID: 33984499.
3. Ughreja RA, Venkatesan P, Balebail Gopalakrishna D, Singh YP. Effectiveness of
myofascial release on pain, sleep, and quality of life in patients with fibromyalgia
syndrome: A systematic review. Complement Ther Clin Pract. 2021 Nov;45:101477.
doi: 10.1016/j.ctcp.2021.101477. Epub 2021 Aug 27.
4. De Groef A, Van Kampen M, Vervloesem N, Dieltjens E, Christiaens MR, Neven P,
Vos L, De Vrieze T, Geraerts I, Devoogdt N. Effect of myofascial techniques for
treatment of persistent arm pain after breast cancer treatment: randomized
controlled trial. Clin Rehabil. 2018 Apr;32(4):451-461. doi:
10.1177/0269215517730863. Epub 2017 Sep 15. 9/10
5. Arguisuelas MD, Lisón JF, Sánchez-Zuriaga D, Martínez-Hurtado I, Doménech-
Fernández J. Effects of Myofascial Release in Nonspecific Chronic Low Back
Pain: A Randomized Clinical Trial. Spine (Phila Pa 1976). 2017 May 1;42(9):627-
634. doi: 10.1097/BRS.0000000000001897. 9/10
6. Kalamir A, Pollard H, Vitiello A, Bonello R. Intra-oral myofascial therapy for
chronic myogenous temporomandibular disorders: a randomized, controlled
pilot study. J Man Manip Ther. 2010 Sep;18(3):139-46. doi:
10.1179/106698110X12640740712374. 9/10
7. Hains G, Descarreaux M, Hains F. Chronic shoulder pain of myofascial origin: a
randomized clinical trial using ischemic compression therapy. J Manipulative
Physiol Ther. 2010 Jun;33(5):362-9. doi: 10.1016/j.jmpt.2010.05.003. 9/10
8. Valiente-Castrillo P, Martín-Pintado-Zugasti A, Calvo-Lobo C, Beltran-Alacreu H,
Fernández-Carnero J. Effects of pain neuroscience education and dry needling for
the management of patients with chronic myofascial neck pain: a randomized
clinical trial. Acupunct Med. 2021 Apr;39(2):91-105. doi:
10.1177/0964528420920300. Epub 2020 May 5. 9/10
9. Mansoori SS, Moustafa IM, Ahbouch A, Harrison DE. Optimal duration of
stretching exercise in patients with chronic myofascial pain syndrome: A
randomized controlled trial. J Rehabil Med. 2021 Jan 11;53(1):jrm00142. doi:
10.2340/16501977-2781. PMID: 33367925; PMCID: PMC8772376. 8/10
10. Zago J, Amatuzzi F, Rondinel T, Matheus JP. Osteopathic Manipulative Treatment
Versus Exercise Program in Runners With Patellofemoral Pain Syndrome: A
Randomized Controlled Trial. J Sport Rehabil. 2020 Dec 17;30(4):609-618. doi:
10.1123/jsr.2020-0108. 8/10
11. Cuesta-Barriuso R, Pérez-Llanes R, Donoso-Úbeda E, López-Pina JA, Meroño-Gallut
J. Effects of myofascial release on frequency of joint bleedings, joint status, and
joint pain in patients with hemophilic elbow arthropathy: A randomized, single-
blind clinical trial. Medicine. 2021 May 21;100(20):e26025. doi:
10.1097/MD.0000000000026025. 8/10
12. Arjona Retamal JJ, Fernández Seijo A, Torres Cintas JD, de-la-Llave-Rincón AI,
Caballero Bragado A. Effects of Instrumental, Manipulative and Soft Tissue
Approaches for the Suboccipital Region in Subjects with Chronic Mechanical
Neck Pain. A Randomized Controlled Trial. Int J Environ Res Public Health. 2021
Aug 16;18(16):8636. doi: 10.3390/ijerph18168636. 8/10
13. Birinci T, Mustafaoglu R, Kaya Mutlu E, Razak Ozdincler A. Stretching exercises
combined with ischemic compression in pectoralis minor muscle with latent
trigger points: A single-blind, randomized, controlled pilot trial. Complement
Ther Clin Pract. 2020 Feb;38:101080. doi: 10.1016/j.ctcp.2019.101080. Epub 2019
Dec 18. PMID: 32056816. 8/10
14. Rodríguez-Huguet M, Rodríguez-Almagro D, Rodríguez-Huguet P, Martín-Valero R,
Lomas-Vega R. Treatment of Neck Pain With Myofascial Therapies: A Single
Blind Randomized Controlled Trial. J Manipulative Physiol Ther. 2020
Feb;43(2):160-170. doi: 10.1016/j.jmpt.2019.12.001. Epub 2020 Apr 18. 8/10
15. Lytras DE, Sykaras EI, Christoulas KI, Myrogiannis IS, Kellis E. Effects of Exercise
and an Integrated Neuromuscular Inhibition Technique Program in the
Management of Chronic Mechanical Neck Pain: A Randomized Controlled Trial.
J Manipulative Physiol Ther. 2020 Feb;43(2):100-113. doi:
10.1016/j.jmpt.2019.03.011. Epub 2020 May 30. 8/10
16. Cabrera-Martos I, Rodríguez-Torres J, López-López L, Prados-Román E, Granados-
Santiago M, Valenza MC. Effects of an active intervention based on myofascial
release and neurodynamics in patients with chronic neck pain: a randomized
controlled trial. Physiother Theory Pract. 2020 Sep 15:1-8. doi:
10.1080/09593985.2020.1821418. 8/10
17. Lindfors E, Magnusson T, Ernberg M. Effect of Therapeutic Jaw Exercises in the
Treatment of Masticatory Myofascial Pain: A Randomized Controlled Study. J
Oral Facial Pain Headache. 2020 Fall;34(4):364-373. doi: 10.11607/ofph.2670. 8/10
18. Rodríguez-Huguet M, Gil-Salú JL, Rodríguez-Huguet P, Cabrera-Afonso JR, Lomas-
Vega R. Effects of Myofascial Release on Pressure Pain Thresholds in Patients
With Neck Pain: A Single-Blind Randomized Controlled Trial. Am J Phys Med
Rehabil. 2018 Jan;97(1):16-22. doi: 10.1097/PHM.0000000000000790. 8/10
19. Rodríguez-Fuentes I, De Toro FJ, Rodríguez-Fuentes G, de Oliveira IM, Meijide-
Faílde R, Fuentes-Boquete IM. Myofascial Release Therapy in the Treatment of
Occupational Mechanical Neck Pain: A Randomized Parallel Group Study. Am J
Phys Med Rehabil. 2016 Jul;95(7):507-15. doi: 10.1097/PHM.0000000000000425.
8/10
20. La Touche R, París-Alemany A, Mannheimer JS, Angulo-Díaz-Parreño S, Bishop
MD, Lopéz-Valverde-Centeno A, von Piekartz H, Fernández-Carnero J. Does
mobilization of the upper cervical spine affect pain sensitivity and autonomic
nervous system function in patients with cervico-craniofacial pain?: A
randomized-controlled trial. Clin J Pain. 2013 Mar;29(3):205-15. doi:
10.1097/AJP.0b013e318250f3cd. PMID: 22874091. 8/10
21. Ramos-González E, Moreno-Lorenzo C, Matarán-Peñarrocha GA, Guisado-Barrilao
R, Aguilar-Ferrándiz ME, Castro-Sánchez AM. Comparative study on the
effectiveness of myofascial release manual therapy and physical therapy for
venous insufficiency in postmenopausal women. Randomized-controlled trial.
Complement Ther Med. 2012 Oct;20(5):291-8. doi: 10.1016/j.ctim.2012.03.005. Epub
2012 May 3. 8/10
22. Hsieh CY, Adams AH, Tobis J, Hong CZ, Danielson C, Platt K, Hoehler F, Reinsch S,
Rubel A. Effectiveness of four conservative treatments for subacute low back
pain: a randomized clinical trial. Spine (Phila Pa 1976). 2002 Jun 1;27(11):1142-8.
doi: 10.1097/00007632-200206010-00003. 8/10
23. Ajimsha MS, Al-Mudahka NR, Al-Madzhar JA. Effectiveness of myofascial release:
systematic review of randomized controlled trials. J Bodyw Mov Ther. 2015
Jan;19(1):102-12. doi: 10.1016/j.jbmt.2014.06.001. 8/10
24. Huang H, Young W, Skaper S, Chen L, Moviglia G, Saberi H, Al-Zoubi Z, Sharma
HS, Muresanu D, Sharma A, El Masry W, Feng S; International Association of
Neurorestoratology and The Chinese Association of Neurorestoratology. Clinical
Neurorestorative Therapeutic Guidelines for Spinal Cord Injury (IANR/CANR
version 2019). J Orthop Translat. 2019 Nov 11;20:14-24. doi:
10.1016/j.jot.2019.10.006. PMID: 31908929; PMCID: PMC6939117.8/10
25. Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Haskett D, Hincapié
C, Pagé I, Passmore S, Srbely J, Stupar M, Weisberg J, Ornelas J. Spinal
Manipulative Therapy and Other Conservative Treatments for Low Back Pain:
A Guideline From the Canadian Chiropractic Guideline Initiative. J Manipulative
Physiol Ther. 2018 May;41(4):265-293. doi: 10.1016/j.jmpt.2017.12.004. Epub 2018
Mar 30. PMID: 29606335.
26. Wilke, J., & Krause, F. (2019). Myofascial chains of the upper limb: A systematic
review of anatomical studies. Clinical Anatomy. doi:10.1002/ca.23424.
27. Burk C, Perry J, Lis S, Dischiavi S, Bleakley C. Can myofascial interventions have
a remote effect on ROM? A systematic review and meta-analysis. Journal of sport
rehabilitation. 2019 Oct 18;29(5):650-6.
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