Week 7: Trigger Points, dry needling, cross friction massage

8 effects of manual therapy

hypoalgesic, physcosocial, mechanical, autonomic, neuromuscular, chemical, neuroplastic, socioeconomic

certain chemical environments yield

more nociceptive activity

painful tissue characteristics

hypoxic(low o2), more acidic (low ph), increased presence of inflammation related cytokines

Chemical characteristics in/around trigger points

low ph, low O2, vasoconstruction, increased level of substance P, increased bradykinin and seratonin, abnormal levels of TNF, excessive ACh

autonomic functions related to manual therapy

vascularity, BP, heart rate, etc

what 2 things are powerful mediators of pain

blood flow and respiration

Each muscle has a pain pattern, how does this sometimes have an autonomic component?

goosebumps, HR changes, emotive releases

nociceptive stimulus from a trigger point can accompany

autonomic vasoconstriction

neuroplastic changes in primary somatosensory cortex occur with what conditions?

radioculopathy, CRPS, CTS, pain expectations, amputees, obesity, pregnancy, knee OA, immobilization, post-stroke, chronic lbp, aging, arm/hand pain, surgery, headaches, facial pain

if nociception (pain) is left untreated or uncorrected (by body or other mechanism)

sustained activity results in the tissue become peripherally sensitized.

peripheral sensitization def

persistent nociceptive activity leads to primary afferent nociceptors showing increased responsiveness to natural stimuli

As the person's pain becomes chronic, what happens to the nociceptive pathways

work their way to spinal pathways and cortical processes (central)

with central sensitization, what do neuroplastic changes result in?

cortical remapping and reorganization

-hyperalgesia, allodynia

hyperalgesia

increased sensitivity to feeling pain/extreme response to pain

allodynia

a sensation of pain to a stimulus that should otherwise ilicit a differnet response

how does peripheral sensitization lead to central sensitization

(IRS)

intense, repeated, sustained

Neuroplastic effects on central sensitization

Louw showed 35% reduction in pain area for patient drawn body charts following spinal manipulation

-improves pain and movement

What is a trigger point

hyperirritable point within a taught band of skeletal muscle or associated fascia that is painful on compression and evoked a characteristic refered pain pattern

3 criteria for ID trigger point

hyperirritable point/spot, palpable taught band with subject recognition of pain, referred pain/numbness on compression

NO LONGER REQUIRES TWITCH

trigger points as a spinal cord reflex

person can jump or have mm twitch, pain can be referred to different area

who calls trigger points myofascial triggers

janet travell

Etiology (causes) of trigger points

muscle ischemia and hypoxia from overuse, muscle spindle dysfunction due to underlying neural hypersensitivity, emotional stress, visceral diseases, arthritic joints, ischemia and hypoxia (tissue damage)

how does muscle ischemia and hypoxia result from muscle overuse

unnaccustomed eccentric exercise, eccentric exercise of unconditioned muscle, concentric muscle activity that results in fiber damage.

how does muscle spindle dysfunction due to underlying neural hypersensitivity cause trigger points

peripheral sensitization

how does ischemia and hypoxia cause trigger points

causes tissue damage because of activation of nociceptors within the muscle releases chemicals that increases ACh activity in motor end plate.

3 classifications of trigger points

active, latent, satellite

active trigger points

pain at rest, more symptoms with palpation but doesnt require it

latent trigger points

no pain at rest "clinically silent", pain and referred symptoms with palpation

satellite trigger points

secondary, develops in same muscle or nearby muscle as the primary active trigger

The redness on the drawings relates to...

the frequency of pain, not intensity

trigger point release

eliminates trigger point and affects the muscle and surrounding tissues (including secondary and satellite TP)

when does long term release work

only for primary TP

when does secondary/satelite TP come back

released visit after visit but come back prior to patient leaving

3 trigger point release techniques

ischemic compression, ischemic compression with elongation, strain-counterstrain

Expected response to TPR

good pain while performing, less tender, improvements in perceived stiffness, reduction in pain symptoms

Dont's for trigger point

chase trigger points at the expense of other impairments, flare a patient up

Do's for trigger point

know difference between trigger point and something else (contusions), and know when to give up on a trigger point

Dry needling

monofilament needle penetrates skin, subcutaneous tissue, and muscle with intent to mechanically disrupt tissue without any meds

what to use dry needling for

trigger points, painful movement, muscle funciton

what does dry needling lead to

reduced local (peripheral) and central sensitization to pain, activating descending control systems

-increase pain threshold, ROM, and reduced pain and muscle tone

MPTA on dry needling

no data , may conduct survey in future

Personal scope of dry needling

not considered entry level, must prove you got good training and are competent

What is considered dry needling?

trigger point dry needling, functional dry needling, integrated dry needling, electrical stimulation, periosteal needling

deep friction massage developed by

james cyriax

what is deep friction massage theoretically useful for treating?

post-surgical scars, chronic tendinopathies, chronic ligamentous injuries

intent for deep friction massage

mobilize scar tissue, normalize alignment of collagen, produce acute inflammation in presence of chronic inflammation(tendonosis), facilitate healing, mechanoreceptor stimulation(modulate pain)

what does mobilizing scar tissue do?

breaks up crossbridges/adhesions

how are you facilitating heeling

traumatic hyperemia (lots of quick blood flow)

when to do deep friction massage

recommended to be performed on alternating pain

why wait to do deep friction massage

to stimulate optimal fibroblast proliferation and recruitment of inflammatory cells as well as to allow for response.

reputation of deep friction massage

being painful, can lead to no pain

contraindications of deep friction massage

open wounds, infection, cancer, edema, arterial/venous pathology, acute injury, hyperesthesia

what type of movements for deep friction massage

small, localized, deeply penetrating

2 types of deep friction massage

transverse friction and circular friction

transverse friction

short, deep strokes perpendicular across fibers of tissue

circular friction

deep circular movements performed on same spot, gradually get deeper to tissue

how long/often to do deep friction massage

2-10 minutes, 2-3x a week

where is tissue placed during technique

on stretch

any lubricant for deep friction massage?

no, fingers do not move across skin

Tapotement

percussive manipulations consisting of various parts of hand striking tissues at rapid rate

Tapotement over muscle tissue stimulates

activation of muscle spindle afferents and mechanoreceptors in the skin

how do the hands move in tapotement

hands alternating, keep wrists flexible, not just elbow motion, movements are light/springy/stimulating

4 types of tapotement

clapping/cupping, beating, hacking, pounding

the effects of tapotement are through ____ mechanical impact

direct

effects of tapotement

-stimulation of mechanoreceptors in skin, muscle, tendons to facilitate contractions

-stimulation of circulation of blood and lymph

-loosen mucus of lungs

-pain relief

contraindications of tapotement

open wounds, cancer, infection, presence of rib fractures in chest area, not over thorax if acute heart failure/severe hypertension/pulmonary embolism, arterial or venous pathology, acute mm tears, variscosities, LE chronic swelling due to CHF

ischemic compression

find trigger point, maintain pressure until pain is decreased by 50%, increase pressure again and hold up to 90 sec

ischemic compression with elongation

find trigger point, maintain pressure until decreased by 50%, keep same pressure adn elongate muscle slowly until pain increases, wait until decreased by 50%, repeat until no change or no more length

strain-counterstrain

find trigger point, passively position body part into position of comofrt, maintain shortened position for 90-120m reduce pressure but keep finger in same spot, return to original position and reassess

how to do transverse friction

applied at right angle, delivered by index finger reinforced by middle finger.

-place structure on full stretch

how to do circular frictions

along paraspinals or around joints/bones

-index middle and ring fingers together

-move in small circles going deeper with each

clapping

cupped hands strike skin, catching air and compresing to cause a wave to penetrate tissues

-may help secretions of lungs

-flex MCP and extend PIP, DIP

Beating

similar to clap but with closed hand (more stimulating)

-losely flexed fingers into palm

hacking

use lateral edges of hands to strike, strong stimulation effect, at right angles to long axis of muscles being treated

pounding

ulnar borders of loselt clenched and extended fists

-deeper than hacking and clapping