Trigger Point Therapy

Trigger Point Therapy is a tool in my treatment toolbox that I use often with helping to relieve pain symptoms that the client is experiencing. They can vary from localized pain of taut bands of muscles that can occur throughout the body from feet to the top of the head. They can also exist with symptoms like jaw pain, neck pain, headaches, pain down the arm or leg or into the hips. They occur where there is a taut band in a portion of a muscle. There is debate as to the actual physiology behind trigger points but the symptoms or undeniable. These taut bands (trigger points) in hypothesis occur when the muscle tightens/ shortens due to fatigue or being put into a shortened position for an extended period of time, trauma, dysfunction of a nearby joint that it is involved in movement or stabilization of including anything from foot, knee, hip, spine, shoulder, elbow or hand. Often it will produce a vague, dull achiness, which can help to differentiate is from a nerve related pain. When there is pain down the arm or leg, it can often be misdiagnosed as a nerve related pain but special assessment can be done to determine if it is nerve or trigger point related. The tricky thing is that the trigger point can refer pain to another area, making it seem that there is a dysfunction in that distal area. For example, the outside of the thigh muscles can refer deep achiness right into the knee. The rotator cuff muscle trigger points can refer down the arm to the hand. Neck muscles can produce head aches in different areas of the head by different neck muscles.

Each person experiences a reduction of symptoms in different ways so there is no one way to relieve a trigger point. In addition to releasing the trigger point, it is important to determine why that muscle, or portion of the muscle is tightening and help educate the client to avoid a reoccurrence in the future. Writing this entry reminds me of trigger points that can occur in the upper back and neck that can produce head aches. We are in a society that is spending a lot of time in a slight forward slouched upper back and head forward position and the end result is that the muscle in the back of the upper back and neck just get tired. Our heads are heavy and produce a greater force the more forward they are. Good upper body and head position is important as it dramatically reduces the exertion put on the upper back and neck muscles. It is part of the posture and movement pattern re-education that I teach in treatment so that a client can be empowered to make posture/ movement changes when the symptoms of trigger points occur (in addition to others). It’s about treating the symptoms, finding the cause and helping the client to make movement/ postural changes to avoid reoccurrence in the future.

Here is an interesting tidbit

I remember in my 30’s I had a reoccurring issue with my low back. There were acute back spasms, pain going down the leg, numbness and tingling on the shin. I was often in getting treatment and trying to figure out what was happening. I remember getting an x-ray done of my low back through a walk in clinic. I got the results and was told that I have some arthritis in my back. Honestly, it felt like it was the beginning of the end. Arthritis. They talk about how pain is a signal elicited by the brain if it feels like you are under a threat. This can be cause by tissue damage, visual, audio, tactile and many other stimuli. There is a good possibility that if I am told that I have arthritis in my back, and that is responsible for my pain then the pain can become chronic. I have learned to become careful in practice with the language that I use when talking about what I find or what they have found out about their pain/dysfunction. I found something interesting (below) that talks about how things like arthritis/ bulging discs/ torn rotator cuff and meniscus/ osteophytes may not be responsible for the pain being experienced. These different studies/ scans, in the study that I am attaching, were done on asymptomatic people. The result of the attached study is that there are all these people in the pool that have no symtpoms, yet here they are with torn this and that and bulging discs and arthritis ect. Maybe the Orthopedic world is looking too hard for something to be wrong or something to blame for the pain if they find something on a scan. Arthritis, for example, is a totally natural occurrence. Everyone gets it. Maybe in extreme cases of advanced arthritis or rheumatoid arthritis can perhaps cause some pain/stiffness, but for the most part it can be a perfect benign presentation. Maybe the symptoms are just from the way we are moving or sitting. Something that we can remedy easily and quickly. The picture below shows the studies, the number of participants and the results from the scans. There are lots of special tests to rule out and scan results like meniscus or rotator cuff, disc issues but we shouldn’t depend just on the scans to make determinations as to the source of the pain. It’s good to ask questions like “I see that I have a bit of a rotator cuff tear, but how can we know for sure that is what the issue is?”. When we see someone about an injury or pain we are feeling, we need to be part of the conversation.

To stretch or not to stretch

With Massage Therapy, part of our focus is on the muscular system and maintaining good function allowing the client to reduce their pain and stiffness. In addition to releasing the muscle tightness/stiffness, it is also important to be able to determine why the muscles are tightening up. Often I find that a client may come in and say that they have been stretching and stretching but to no avail. This may be due to the tightness occurring when the muscles are activated to try to stabilize a part of the body that is too mobile. If you take, for example, the low back, the range of motion is limited by a few factors including the surrounding connective tissue. The connective tissue that surrounds the spine will stop you from bending too far backwards, forwards, side to side or rotation. Connective tissue is comprised of collagen fibres for strength and elastin fibers for flexibility. A certain part of the population, including me, have a little more elastin fibers to collagen fibers so we can bend a little more than everyone else. With a little less stability from the surrounding connective tissue, the muscles are recruited to work harder to stabilize our low back. If we use our backs too much, the muscles begin to fatigue and the brain says “stop what you are doing” and uses pain to get us out of the perceived threat. So the muscles are functioning overtime because of lack of stability. When our low backs begin to tighten and we begin to experience pain, we are inclined to stretch those muscles. If the muscles are short and tight, they will not want to lengthen as they are doing a job of trying to stabilize so they will respond to our stretching by tightening more. Our stretch becomes a tug-of-war and will ultimately end up not being successful. During the assessment portion of a treatment, I like to look at the joints and move them passively (without the client’s involvement) to determine if the motion in the joint is not enough or too much. If there is too much motion, the direction to go in is not to stretch the muscle but to help to stabilize the low back joints in the spine to reduce the need for the muscles to tighten so much. This is a much different approach from standard Massage Therapy where there is more focus on “releasing the muscles”. Make the body more stable and reduce the need for muscles to work so hard. Going back to my previous entry about movement patterns and pain/dysfunction it is also important that we learn to move around the joints that are strong and stable. The low back is a perfect example as really it is a very unstable structure. The spine is essentially a bone on top of a gelatinous disc on top of a bone on top of a gelatinous disc all the way to the top of the spine. We are not really designed to move mainly through the spine and especially not exerting a force. Keep the spine as still as possible and move through the two hip joints, for example. As someone that is hypermobile through my joints, this has been an essential component to maintaining a healthy, pain free back and I’m always happy to share with others what I found has worked for me.

The other component is that with most movement through the body, there are the muscles that move the joints and those muscles that help to stabilize the joints through that movement. It is essential that we maintain strength and function of the stabilizers to match the strength of the muscles that are primarily moving a joint (or group of joints). Someone once said, not having this support is like having a tree where the brances are  stronger than the trunk. If the proper stabilizing muscles are not recruited, other muscles are activated that are much less efficient as stabilizing also producing and short, tight, fatiguing group of muscles and consequently pain and dysfunction.

So muscles that have tightened may not need to be stretched. Of course we work on those muscles during the treatment to reduce the reactivity and pain but we also help the client to support and improve the way they move in preventing pain the future. The courses that I have taken in Mat Pilates Teacher Training provide a really good base of support to create a strong, mobile, well supported body.

The long stretch…

There are generally two schools of thought with stretching in terms of how long you hold the stretch. There is the 30 second stretch and the 3 minute stretch. I come from the place of the longer stretch in increase range of motion and the 30 second stretch in terms of maintaining the increased stretch. I think the important thing to think about with a stretch is that it is not just the mechanical stretch of the muscle but also the aspect of allowing the nervous system to adjust to the increased length of the muscle. Someone once described a 3 minute stretch in 3 parts.

1)The first minute of the stretch, there is a bit of resistance or protective shortening of the muscle as you are taking the muscle a little further than where it is used to going so you wait for that first minute for the nervous system to feel comfortable with the lengthening of the muscle.

2)The second minute, the protective tightening of the muscle reduces allowing the muscle to begin to lengthen.

3)The third minute is the time that the muscle is left in the lengthened position to allow the nervous system to experience not just the muscle in the lengthened position but also the joint going into that position. An example is the hip joint and a hamstring stretch. The stretch is not just intended for the hamstring but also for all the deeper tissue surrounding the hip joint.

When people ask me if I prefer foam rolling vs stretching, I think that both have their place but for allowing a muscle to lengthen and increase the joint movement in that direction, I always advise the stretch.

I always like to think of a stretch as slow cooking. A more gentle stretch for a longer period of time. All we want with muscle/skeletal system is for the body to be able to move in the manner to which it is designed.

 

Mat Pilates Training

I’m very excited to announce that I will be taking a Mat Pilates Teacher Training course in April. The skills that I learn in the course with be very helpful for teaching good core strength and proper movement pattern to my clients. I find myself being drawn more and more into the benefits of good movement patterns as often I find that pain and dysfunction occur when we move in patterns which our bodies do not function well in. As I mentioned in my previous post, evolution has designed us to move in a certain way. Some areas are much more stable than others. One teacher said that it is a simple decision when we choose how to move. It is like coming to a crevasse and you have two bridges. One is a strong cement bridge and the other is an old unstable wood bridge. Which would we choose to cross. My job is to reveal those options to you so you can be empowered to make the right choice.

Be Strong + Move well = Less pain.

Myofascia, Tension and Stability

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During the Myofascial Release courses that I have taken, a common comparison was made between the fascia in the human body and a tent. I think it is a great example of how Fascia maintains structure, function and stability in the human body. It holds us together and allows us to move and be flexible, yet strong. The function of the skeletal system and the fascial system act like the poles of a tent and the ropes that hold up a tent. The poles are the skeletal system that create the shape of the tent but it is the importance of the tension of the ropes, which are the fascial system of the body, which maintains the integrity and holds the shape of the tent. Without the ropes, the tent, even with the poles, will fall over in the presence of an internal or external force. It is the fascia, which allows the tent to hold it’s shape and provide the function.

An example of dysfunctional fascia, which may be adhered and/or shortened would be like pulling one of the ropes too tightly. Think of the whole tent being pulled to that side. The same thing can happen with the body which adhered, shortened fascia can pull the body out of it’s center of gravity causing dysfunction, instability, weakness, reduced range of motion and pain. There are various causes of fascia that can become short, dehydrated and dysfunctional. When it comes to shortened fascia, everybody presents differently. It can begin at child birth or be present after even a minimally invasive surgery.

It’s finding the fascial restrictions that pull the body out of it’s center of gravity. The philosophy is to find the pain but look for the cause elsewhere as the cause and effect may not be in the same area. As a therapist, I’ve learned to treat without feeling that I know what it happening. There is a process, but I have to learn to be a good listener to find where the cause is.

Post Operative Myofascial Release

When a person has had surgery, whether it be abdominal, cranial, shoulder, back, hip, knee or any joint surgery, often a neglected portion of the recovery is Myofascial Release of joints and tissues affected by the surgery. Adhesions can occur in the joints or tissues as a result of the surgery itself or the period where the person has to keep themselves, or a portion of their body, immobile during the healing phase immediately after the surgery.

I became acutely aware of this necessity after my heart surgery, where I had a heart valve replaced. To do the surgery, they had to cut through my breast bone to access the heart and do the surgery.  So for the next month, I had to keep my arms and shoulders pulled forward. I wasn’t able to open up my chest and bring my arms up and stretch them back while the sternum repairs itself. As a result, all the tissues around the front of my chest, my upper abdomen and the front of my neck were put in a shortened position for an extended period of time. All the tissues in the front will become adhered to each other and keep the tissues shortened which dramatically alters the center of gravity with the body and the shoulders and neck/head are pulled in a forward position. This is just a quick example of the effects of immobilization after surgery but doesn’t include the effect of the scar tissue created by the surgery itself.

I have seen the same effects with shoulder surgery, back surgery, hip/knee/ankle surgery. A bit portion of the rehab process is the return the joint or body part back to it’s normal mobility with myofascial release and strengthening. A body just wants to move in the manner in which it’s designed to do. That’s the best way to return a body to normal. The techniques are different for scar tissue release, for soft tissue release and for release of tissue surrounding the joints like ligaments, tendons or the capsule that surrounds joint. All can shorten, but all can be returned back to a good functional range of motion.

The principals of Myofascial Release are adhered to (pardon the pun) to create an increase of mobility that is gentle, effective and creates a long term effect. Every release will last a while but it’s so important that the patient has a full understanding of how they are presenting and how they can maintain the work that we do at home. It should never be about depepnding on the therapist to “fix” you. We assess the condition, educate, we begin the process to facilitate and allow the patient to help maintain the progress with home exercises.

Creating a long term effect of Fascial Release

Of the Fascial Release Course I attended, probably one of the most important things I brought home was reiterating the importance of stretching the fascial tissue to it’s stretch barrier and holding it until it lets go. That sometimes the stretch may have to be held for 3-5 minutes. When we complete the fascial release, we want it to stay there. Very often, the question I get from patients is, how do we get it to stay there so it doesn’t bounce back. I can give stretches to do at home to maintain our progress but it’s my job to release the specific fascial adhesions so that the home stretches are effective. To fully understand what fascia is, and what we are working with, we look at what makes up fascia.

Fascia in the body is described as: Fascia is a specialized system of the body that has an appearance similar to a spider’s web or a sweater. Fascia is very densely woven, covering and interpenetrating every muscle, bone, nerve, artery and vein, as well as, all of our internal organs including the heart, lungs, brain and spinal cord. The most interesting aspect of the fascial system is that it is not just a system of separate coverings. It is actually one continuous structure that exists from head to toe without interruption. In this way you can begin to see that each part of the entire body is connected to every other part by the fascia, like the yarn in a sweater.Fascia plays an important role in the support and function of our bodies, since it surrounds and attaches to all structures. In the normal healthy state, the fascia is relaxed and wavy in configuration. It has the ability to stretch and move without restriction. When one experiences physical trauma, emotional trauma, scarring, or inflammation, however, the fascia loses its pliability. It becomes tight, restricted, and a source of tension to the rest of the body. Trauma, such as a fall, car accident, whiplash, surgery or just habitual poor posture and repetitive stress injuries has cumulative effects on the body. The changes trauma causes in the fascial system influences comfort and function of our body. Fascial restrictions can exert excessive pressure causing all kinds of symptoms producing pain, headaches or restriction of motion. Fascial restrictions affect our flexibility and stability, and are a determining factor in our ability to withstand stress and perform daily activities. 

Fascia is comprised mainly of three things: Elastic fibers, Collagen fibers and Ground Substance that surrounds the Elastic and Collagen fibers. With fascial adhesions, it’s the collagen and elastic fibers that become bound to each other, greatly affecting the elasticity of the tissue, affection local movement, where ever that tissue is in the body, as well as movement and function of other areas of the body, as the fascial system is continuous throughout the entire body.

As an example, having a fascial restriction in the low back is like wearing a wet suit, leaning back, and having glue poured on the wet suit at your low back, and letting the glue dry. The glue will continue to pull you back and somewhere else in the body will have to compensate for that pull so your are balanced. It’s the systemic response to a local fascial adhesion.

Someone once said that releasing Fascia is like cooking stewing beef cubes. You can do it quickly and throw it into a pan on high (hard stretch for short periods) and it will cook but it will still be really tough or you can slow cook it at a lower temperature for a longer period of time and get a much better result (more pliable, elastic tissue as a result).

So as I locate a fascial adhesion, I apply a stretch only to the barrier. I could push harder, but I just go to the barrier and wait. During the stretch heat will be created that will warm the tissue, allowing the collagen fibers to stretch. You can feel the tissue slowly softening and elongating over the 3-5 minutes. But you just wait for the tissue to naturally lengthen. By doing this, the tissue will reform under the heat, same as plastic does under heat, and as you let go gently, the tissue will now remain in that lengthened position. Now the patient can go home with specific stretching to maintain that lengthened tissue with any other exercises given for that specific condition that they’ve come in for.

It’s taken some trust and open mindedness to adopt this treatment philosophy but I’m so grateful that I did as it has dramatically helped patients with mobility, strength, stability and reduced pain as a result.

What is Myofascia and Myofascial Release

I heard the perfect analogy for what fascia is in the body, from a structural standpoint. Take a jar and put all sorts of little things in it like golf tees, marbles, string, pencils and fill up the jar with it. Then pour in this liquid, to the brim of the jar, that will set, but remains 70 – 80% liquid (as that is what we are). When this liquid sets, it will also be very structurally strong as well as being fluid. Almost like a super-jello. So now in the jar, you have all those items listed above and poured between those spaces is this liquid that will set. When it sets, you can crack the jar and this structural jello will hold the shape of the jar with all the items listed above set within it. What the items listed above represent are our cells and to a larger scale, things like our bones, nerves, muscles, brain, arteries/veins and holds them all in the shape that is what we are.

It is an extremely strong, 3 dimensional, gelatinous web that surrounds everything in our body that allows us to move but also holds us in our shape. It is crucial that it maintains that fluid content in the same way that it is crucial that leather maintains that moistness to remain soft and flexible. If for some reason parts of our fascial system loose that fluid content, it becomes dry, it loses it’s flexibility and pliability and as the fascial system is continuous through the entire body, can affect the biomechanics through the entire body. There is never a predictable way that it can affect the body.

Fascia can lose it’s fluid content for many different reasons including trauma, surgeries (joint replacement/abdominal surgeries/child birth), inflammatory responses (IBS, Crohns,Pneumonia) and chronic longer term shortening of tissues (poor posture, sitting), microtrauma to muscle tissue from heavy activity like biking, running, weight lifting. Shortening of the fascia may have occurred recently or may have occurred as long ago as a traumatic childbirth. The body is able to compensate for where ever the fascial restriction are for a long time before the presentations may occur.

Two of the most common major presentations of fascial adhesions that I see are low back pain from adhesions occurring at the front of the pelvis/hip regions and back/shoulder/posterior neck pain occurring from adhesions forming at the front of the neck and chest area pulling the head and the shoulders forward. When you are pulled forward by fascial adhesions at the front of the body, the muscles that pull you back up (whether they be the low/mid/upper back or the back neck or shoulder muscles) become strained, fatigue and ultimately produce pain and spams.

The main mantra with this work is find the pain but look for the cause elsewhere.

In our original training, we were very symptoms oriented and it took a leap of faith to pull myself away from that to move towards this philosophy but it has been so affective. Deal with the fascial restrictions so the body can move in the manner to which it was designed to do. Just let the body move like it should. That’s what it really wants to do.

How does one release fascia back to it’s original property? That’s worth another blog entry. 🙂

Pelvic Myofascial Release Course

I’m just back from Vancouver having done a 3 day course on Myofascial Release for the Pelvis. From a structural/ biomechanical standpoint, the pelvis is the center of the universe, being the transition between the weightbearing legs/hips and the spine/ torso.

What the course reaffirmed for me is that the skeletal system swims in a pool of connective tissue and the skeletal system relies on the healthy state of the connective tissue to move in the manner to which it is designed to. The pelvis is an extraordinarily strong structure but is the fascia that surrounds it pulls it out of position, then it can be the surrounding, weaker systems that can be affected, such as the spine or the hip or knee and even ankle.

Imagine if the pelvis is pulled forward and to the left. Obviously we are not going to have our entire body leaned forward and to the left. So what does the torso do to pull us upright? It’s these compensations at the weaker structures, like the spine, that produce the symptoms. It really all is about cause and effect. Often the cause doesn’t produce symptoms but the effect does. In this case, pelvis is the cause (pulled forward and left by the fascia (connective tissue)) and the spine is the effect as it pulls in the opposite direction to pull us back level and the pain is produced around the spine.

The properties of this connective tissue is savable for another post.