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.
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.
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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.
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