Trigger Point Arguments
Truthaches and Trigger Point Therapy
by Gregory T. Lawton, DN, DC, MAc
No, this is not an article about dentistry and massage therapy. It is an article about trigger point therapy that was triggered in part by an article that appeared in one of the "other" massage magazines that attempted to inaccurately explain trigger points. It's also an article about all of the past articles written on the subject, those being written at this very moment, and those yet to be written. The point of the title is that truth hurts.
If you are in a hurry and want to save yourself the trouble of reading the rest of this article on trigger point therapy, you can save yourself some time if you just read and agree with the
following:
• Pain does not cure pain.
• Trigger point theory is wrong.
• Stop hurting your patients.
• Stop hurting your hands.
• Stop losing patients because of poor results and unnecessary pain.
• Make more money by helping your patients and not hurting and losing them.
The theory of trigger points has gone through several changes in recent years. The original theory of Travell and Simons was that a trigger point was (you know this already) a palpable nodule or taut band of fibro-connective tissue in muscle. The problem with the original theory is that fifty-five years later, researchers and proponents of this concept still are attempting to find those pesky little nodules and taut bands. There is, unfortunately, a lack of histological evidence that they actually exist, which led most established members of the research community to abandon that idea all together. Even Travell and Simons dropped the idea of applying ischemic compression on the trigger point and opted for cortisone and other "exciting" chemotherapeutic drug injections.
Over the years, there have been numerous studies that have either attempted to prove or disprove trigger point theory. The Prover's have failed to prove their point and the Disprover's have made some significant discoveries that have turned the entire idea of trigger points on its head. One of the best rebuttals of trigger point theory and citations of the current literature in the field is the article by John L. Quinter and Milton L. Cohen entitled, "Referred Pain of Peripheral Nerve Origin, An Alternative to the 'Myofascial Pain' Construct." This is an excellent review of the historical development of trigger point theory and concepts and a step-by-step refutation of the theory, along with some outstanding ideas about what this painful condition really is.
The supporters of trigger point theory and trigger point therapists cite research that has been discredited as either inaccurate, having technical procedural flaws or that contains artifacts that have been caused by false positive readings in equipment such as electromyographic instruments (EMG). Needle biopsy of supposed trigger points identified by trigger point "experts" has consistently failed to show any difference between the muscle tissue within the borders of an "identified" trigger point and any other normal muscle tissue. So much for the idea of ischemic alternations in trigger point tissue. A number of states and (Medicare) insurance carriers have stopped reimbursement for medical trigger point therapy, pointing to a lack of research that supports the theory and frequent failure of the techniques pioneered by
Travel and Simons.
In an article titled, "Update of Myofascial Pain from Trigger Points," Professor David Simons reviews many of the concepts of the last several decades and then ends the article by describing the newest hypothesis the involvement of the motor endplate.
So what is all this leading to? No one argues that there are area "points" that generate pain. The question remains that if this is not muscle tissue pain, what kind of pain is it? Well, this question led to the discovery that what had erroneously been labeled as trigger point pain and attributed to pathological changes in muscle tissue, is most likely (new theory) peripheral nerve pain at the motor end plate. This bears repeating so this idea can replace all of the wrong information you previously have been taught in massage school and seminars, and keep reading about in massage magazines. This is where the story gets interesting for the
massage therapist.
As a medical massage instructor, I believe it's important that the massage therapist knows the truth about the conditions they treat and the techniques they use. Consider this: If trigger points are not a fibrotic alteration in muscle tissue, then what is with all of this ischemic compression, deep tissue break down of adhesions, knobbles, knuckles, rigid fingers, elbows and knees all about? If, as the current research strongly suggests, these pain sites are inflamed and abnormal nerve endings, then what in the world are we doing poking things into excited, painful nerves? Imagine you have a painful tooth. Do you want me to poke a fork into it? Does that sound therapeutic to you?
Of course there are massage students standing at massage tables at this very moment being taught to push their elbows into that "trigger point."
As a medical massage educator, I have taught and written about the non physiological methods of massage therapy currently being taught to new massage students with wide open minds and expectations. What does nonphysiological mean? Simply that you are being taught something about a condition or the effects of a massage technique that simply is not true. This also is why there is a difference between medical massage instructors who teach nonphysiological theories and techniques and those teaching valid technique from the current research and scientific literature. As one of my teachers said to me yearsago, "You teach what you are, you cannot give a gift you do not possess and you cannot teach what you do not know."
It does not matter what a massage system is called, there are dozens and dozens of kinds and types of massage therapy and techniques. What matters is our understanding of body function based upon universal physiological principles and can our techniques effectively affect the body's natural corrective and restorative processes? From the example provided in this article, when our original theory is incorrect, that leads to unnecessarily causing increased pain and suffering in our patients.
Many massage schools that purport to teach effective massage techniques and the various groups and organizations claiming to follow the research literature, are more interested in the number of course hours in a massage program than the quality of course content and have not even begun to address the task of validating massage techniques and procedures to assure their safety and efficacy for patients. This especially is problematic when this kind of poor instruction is taught in a medical massage school or seminar because medical massage therapists unabashedly do claim to treat patient conditions.If the truth hurts, that means there was a problem to begin with.
Resources:
1. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams & Wilkins, 1983.
2. Simons DG. Update of Myofascial Pain from Trigger Points, Medical Pain Education, www.pain-education.com.
3. Lawton, GT. Medical Acupuncture, A Rational and Scientific Approach, American Health Source Publishing, Grand Rapids, Michigan
4. Hromada J. On the nerve supply of the connective tissue of some peripheral nervous components. Acta Anat 1963; 55: 343-51.
5. Devor M. Neuropathic pain and injured nerve: peripheral mechanisms. Br Med Bull 1991; 47:619-30.Gregory T. Lawton, DN, DC, Mac
Muskegon, Michigan
www.americanmedicalmassage.com
Trigger Points: A Different Version of the Truth
Submitted by Leon Chaitow, DO, ND, and Judith DeLany, LMT
Editor's Note: This article is in response to an article by Gregory T. Lawton, "Truthaches and Trigger Point Therapy," published in the December 2005 issue of Massage Today.
A variety of grossly inaccurate and unsupported assertions in the article by Mr. Lawton in Massage Today 1 (December 2005) call for rebuttal, and in the limited space available, we will attempt to offer a different, scientifically supported, perspective.
Mr. Lawton asserts that almost as a matter of course, massage therapists treating myofascial trigger points (MTrPs) are simultaneously hurting people, injuring themselves and getting poor results. No evidence for these statements is offered. Where is the research evidence, or mention of a nationwide (or worldwide) survey that documents these purported poor results and/or injuries? The readership of Massage Today deserve more than statements of "fact" with no validating support.
As research evidence emerges, theories change over time. Scientific protocol demands that we formulate theories, then go about proving, improving or abandoning them. Mr. Lawton's statement that "most established members of the research community" have abandoned the theory is untrue. Where is the evidence for this assertion? Have researchers worldwide been questioned as to their position on MTrP theories? Again, we have a statement without any supporting evidence.
Mr. Lawton states that Travell and Simons dropped the idea of applying ischemic compression in MTrP deactivation. This is inaccurate, as is the claim that they opted for injections to replace compression. They did indeed abandon the term "ischemic compression," which was replaced by the term "trigger point pressure release" (i.e., the term was changed, but not the modality). Simons, Travell and Simons,2 and other leading clinicians3 continue to support the use of applied pressure. They also advocate (pages 140 to 145) application of massage therapy, strain-counterstrain, muscle energy technique, myofascial release, and a variety of other manual modalities and objectives, including "spray and stretch," specific exercises and postural rehabilitation. They do discuss injection materials, including local anesthetics, and the advantages of manual versus injection methods, depending upon the presenting case details, but dedicate more pages to manual applications than to injections.
Regarding the Quinter and Cohen article4 of which Mr. Lawton makes so much, this discusses old theories of MTrP pathophysiology, with its most current citation being 1993. Major research-based advances in the understanding and treatment of MTrPs by Simons, et al., and Mense and Simons5 emerged in 1999, however, none of these developments are discussed in Mr. Lawton's article or, of course, by Quinter and Cohen in their decade-old paper. Changes included the distinction between central and attachment trigger points, which altered the way tissues housing trigger points are treated, including variations as to where to (and where not to) apply pressure or friction, how much pressure to use (minimal), where to use ice/heat, and so forth.
Regarding references, there are NONE in Mr. Lawton's article. Casual mention of untitled articles does a disservice to readers who might wish to judge for themselves – if only a citation (or even title) were provided. Where is the support for statements intended to replace all the misinformation that Mr. Lawton claims everyone else is teaching their students? Full citations are needed so readers can follow through and form their own opinions.
Mr. Lawton is correct to say that inappropriate or heavy-handed manual treatment of trigger points can leave the patient in pain with the problem unresolved (and can potentially stress therapists' hands). However, advances in our understanding of trigger points, and the use of gentle deactivation methods,6 reduces these possibilities significantly.
Mr. Lawton states, "There is, unfortunately, a lack of histological evidence that they [trigger points] actually exist, which led most established members of the research community to abandon that idea all together." He also says, "Needle biopsy of supposed trigger points identified by trigger point 'experts' consistently failed to show any difference between the muscle tissue within borders of an 'identified' trigger point and any other normal muscle tissue." These statements are blatantly inaccurate – and are once again unsubstantiated.
in the level of these analytes between people who have pain and those who do not and between those us do. In fact, isn't that what science and medicine are all about?who have active myofascial trigger points (MTrPs) versus those who have latent or no MTrPs." (emphasis added) In conclusion, we believe it's possible that referred pain from trigger points is due to more than one factor. It's possible a local energy crisis catalyzes endplate chemical changes, inducing the formation of taut bands, creating additional localized ischemia, resulting in enthesopathy and local compression, us do. In fact, isn't that what science and medicine are all about? |
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