Dealing with Trigger Points
What is Trigger Point Therapy?
Trigger point therapy is a hands on technique that locates and massages areas of the body (‘trigger points’) that are unusually sensitive and painful. Often these spots “trigger” a deep ache in nearby areas, hence the name Trigger Point. Traditionally, trigger points have been described as a local region of tension within a section of muscle. This popular understanding derived from the work of Janet Travell and David Simons in the 1980s. If you were to ask the average person on the street what a “trigger point” is, I’d hazard a guess that most would provide a vague offering about knots in muscles. On the back of this popularly held understanding, a treatment known as Dry Needling has emerged as a very popular treatment option for people suffering from pain or other symptoms. Dry needling is a treatment that involves the insertion of a thin needle into a specific target (typically a muscle) that has been assessed as “containing a trigger point”. Although a popular treatment option for manual therapists, the conceptual framework and theoretical reasoning used to justify the practice of trigger point therapy (by either dry needling or manual therapy) deserves some critical examination.
Before we do that however, let’s look at a typical example of trigger point therapy so that you, as a patient, can get a better idea of what it typically involves. In this example, we’ll use a patient who has frequent headaches that always throb in the same area of their head. The headaches tend to occur at the end of a long day’s work in front of the computer, and tend to coincide with a sense of stiffness and tightness in the neck and shoulder regions. The therapist palpates the patient’s neck and finds a point in the region of the neck and shoulder which, when pressed, reproduces the throbbing ache of the headache. Traditionally, this point would be described as a “trigger point”. This point would then be pressed or rubbed or massaged until the referring headache sensation diminishes or goes away entirely. Throughout the experience the therapist will check to make sure that the ache that they are reproducing is mild enough for the patient to stay relaxed.
Why is it problematic to treat “trigger points”?
Trigger point therapy suffers from a number of problems… let’s briefly look at two.
- Locating trigger points by feel is very unreliable! Even the top experts have not been able to consistently agree on trigger point locations in the same patient (Wolfe 1992). Findings since that date have not been any more positive; a more recent systematic review concluded that “physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points” (Lucas 2009).
- Trigger points are purported to be located within muscle (a short/taut band of muscle), but trigger point symptoms can be found all over the body, even by pressing on structures that are not muscle at all! This suggests that the source of point tenderness that is classically referred to as a muscle problem, must have another origin. This raises questions about any and all aspects of trigger point treatment that begin with the assumption that a “trigger point” is a muscle problem. Quintner (1994) has built a strong argument for the source being elevated sensitivity of peripheral nerve tissue.
Ok, but if we do “find one” we should still work on it, because the treatment is effective…right?
Yes, we’ll still work on areas that feel particularly significant or sore, but our view is that we have a responsibility to avoid perpetuating misinformation to our patients and the broader community. So although the application of pressure to a tender point in, for example, the region of a patient’s neck might provide relief of headache symptoms, we will always stop short of claiming that the tenderness is a manifestation of a discrete problem within the muscle tissue. In other words, we prefer not to describe painful areas as ‘trigger points’ that we – or anybody else – can specifically detect and resolve inside muscle. Pain problems are never that simple!
We also don’t support the claim that inserting a needle into a muscle is necessary to bring about a resolution of symptoms. That is not to say that the tension of a muscle is irrelevant to a patient’s symptoms; it is just a matter of avoiding the scenario where we too narrowly frame the patient’s symptoms as being a product of a singular cause.
“Concentrate upon patient needs rather than imposing your favourite narrative upon them (and the vice versa also holds true).” – Dr. John Quintner
Here at Coogee Bay Health and Injury Care, we are happy to massage tender points that feel relevant to your symptoms. Aspects of your treatment might appear similar to classical “trigger point” massage; but it won’t be accompanied by an explanatory narrative that isn’t supported by high quality research. So if we return to the example from above, we might note areas of the body that heighten or lessen the headache symptoms during the massage, and we would frame our efforts using a narrative that incorporates relevant information, terms, and concepts from broad streams of research such including, biomechanics, nociceptive drive, pathoanatomy, peripheral nerve sensitisation, central sensitisation and defensive motor output.
In the case of our hypothetical headache patient, we can thus see the presence of the headache itself as enough to stimulate the upper back muscles and cause them to become tender and firm to the touch. Massaging these sore muscles could stimulate a guarding reflex that intensifies the headache…not a ‘trigger point’ at all, despite being very sore and ‘triggering’ the headache symptoms.
If you’re looking for more information about how we try to reframe pain and injury to make your treatment more conservative, practical, and logically consistent, consider reading about the framework we use to approach other painful conditions.
Finding what works for you – without pigeon-holing your symptoms – enables us to treat you without trading comprehensive care for a catchy narrative.
Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain. 2009 Jan;25(1):80-9. doi: 10.1097/AJP.0b013e31817e13b6. Review.
de las Penas C F, Sohrbeck Campo M, Fernandez Carnero J, Miangolarra Page J C. Manual therapies in myofascial trigger point treatment: a systematic review. Journal of Bodywork and Movement Therapies 2005; 9(1): 27-34.
Quintner JL, Cohen ML. Referred pain of peripheral nerve origin: an alternative to the “myofascial pain” construct. Clin J Pain. 1994 Sep;10(3):243–51.
Wolfe F, Simons DG, Fricton J, et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol. 1992 Jun;19(6):944–51