Treatment Options for Trigger Points and Fascia

Some patients move too much or too often in a repetitive way, while some don't move enough at all. Either way, these patients often present with poorly localized pain in muscles and joints with sensory disturbances. Tendons and myofascia are susceptible to varying degrees of injury from acute episodes (patients that become worse after they attempt exercise and/or stretching for the first time in a long time) to chronic overuse (athletes, manual laborers).

Fascia is the matrix of collagen that links the entire musculoskeletal system into one unit. Fascia is capable of sliding independently of the contraction of the muscle it surrounds. It is possible for myofascial structures to be the primary cause of pain, which may be related to joint pathology, sensorimotor system dysfunction or other soft tissue dysfunction such as scars and hypomobile fascia.

The evaluation process can start by feeling for palpable nodules or taut bands of fibro-connective tissue. Some of these bands or fibers may be hypersensitive or painful and have a direct referral or "echo" sensation to the body and skin surface. Our efforts to identify theses soft tissue nodules or taut bands that cause soft tissue dysfunctions can be helped by using some modalities. I use a deep muscle stimulator, lymphatic treatment, radial pulse wave and laser as part of my in-office treatments. These devices are particularly useful for treating poorly localized muscle pain and decreased range of motion (ROM). If I can clear fascial restrictions and trigger points in the office, it makes the patient less vulnerable to hurting themselves during exercise. Reducing fascial adhesions and muscle tension makes my manual adjustments easier. Using the deep muscle stimulator over the soft tissues can reveal dense tissue, tender points, sore spots and trigger points and is a very relaxing treatment.

In my day-to-day practice, I use the top tier Selective Functional Movement Assessment (SFMA) tests to help me isolate decreased ranges of motion and painful regions within the musculoskeletal kinetic chain system. The SFMA is performed standing with the feet together (shoes off) and includes the patient moving through these ranges of motion: cervical flexion, extension and rotation; shoulder flexion/external rotation and shoulder extension/internal rotation; lumbar flexion, extension, rotation; hip rotation; thoracic flexion, extension and rotation; a one legged stance for balance; and a squat assessment. The SFMA is easy to perform and only takes about three to four minutes to test and record. The SFMA is part of my objective evaluation and helps me decide on additional testing (called breakouts) that I may need to perform on the patient. It will also help me decide on the type of treatment needed, such as mobilization/manipulation, proprioception training and exercise therapy. When I need to direct treatment to the soft tissues, I can use the ddep muscle stimulator. The hand held DMS device is especially useful for decreased ROM revealed during the SFMA. I apply the deep muscle stimulator vibration and percussion over the muscles or chain of muscles suspected to be related to the decreased range of motion i.e., if the combination of cervical rotation and flexion are decreased I can start with the deep muscle stimulator treatment over the levator scapula and upper trapezius muscles. A simple re-test of the ROM will tell me and the patient if I am on the right treatment path. If I see the feet externally rotate and or the heels rise while the patient is doing the squat, I use the deep muscle stimulator over the bottom of the feet, gastrocsoleus and peroneals, all the while feeling for the tight muscles, dense tissues, taut fibers, and twitch responses within the muscles. If hip ROM is decreased, I use the deep muscle stimulator to check the hip capsules, piriformis, gluts, TFL, adductors and hamstrings. After a few minutes of deep muscle stimulator treatment, I re-test the restricted or painful ROM. The test, treat with deep muscle stimulation, re-test routine is extremely useful for the in-office patient outcome.

The majority of the body "real estate" I cover using the deep muscle stimulator is mostly the superficial fascia also called the hypodermis. This is made of loose connective tissue formed by a connective membrane that sheaths all muscles. It aids in muscle movements, provides passageways for nerves and vessels, provides deep fascia muscle attachment sites and cushions muscle layers. This is the fascia with sensory nerve endings and is thought to be elastic as well as contractile. The deep muscle stimulator treatment influences the fascia that supports and stabilizes, helping to maintain balance. It doesn't matter if the onset is acute (after a specific event) or chronic from overuse or poor posture. I use the deep muscle stimulator as an extension of my hands to feel for characteristic trigger points that are specific hyperirritable and tender spots within taut bands of skeletal muscle. For the patient with tendinosis and deeper fascial stiffness, treatment with the more intense shockwave therapy (radial pulse therapy) enhance outcomes, especially with athletes.

I frequently ask patients, "What percentage of your body is water?" Ask a few patients and see what number they think it is. I remind them that the body is approximately 70 percent water and it is possible for areas within soft tissues to become dehydrated. The ground substance tends to lose fluidity when it goes through trauma or an inflammatory response and it tends to become dense or solidify. The modalities I mentioned above are very useful at moving around fluids (especially the lymphatic device) and mixing the fluids within tissues so that dehydration of the tissue is improved. Dehydration can put enormous and excessive pressure upon pain-sensitive structures and limit the fascial system's ability to glide.

Dense fascial tissue, trigger points, and taut fibers are palpable through these modalities. If the patient tries to exercise or stretch these areas that are "all glued up," the tissue may have sensitive nerves within the interstitial spaces that are cemented and may become irritated when compressed or stretched. Releasing the dense, tight fascial structures with the DMS and EnPuls, then teaching my patients to perform at-home-stretches to maintain the fluidity and normal fascial glide makes sense to the patient. Compliance with my exercise recommendations goes up. The combination of deep muscle stimulator fascial release and home stretching exercises puts the patient at less risk of movement and sports injuries. When I reassess with the SFMA, patients feel the post-treatment effects and they understand that stretching or strengthening exercises reinforces what we did in the office.

The trend within all popular soft tissue techniques is to apply the technique with passive and/or active movement. For example, the deep muscle stimulator application starts with passive stretching techniques of the affected muscle(s). Position the patient for maximum decrease in muscle tension. Clearly identify the dense tissues or trigger points and mark them. Apply the deep muscle sitmulator in a sweeping motion over the entire length of the affected muscle. Passively stretch the muscle by applying gentle pressure with the deep muscle stimulator. Repeat until full range of motion is attained.

If you are a "kinetic chain" thinker and deal with stubborn soft tissue cases, you will appreciate the common measurable change in reduction or perception of pain and improved motion using these newer soft tissue modalities and the SFMA approach.

Resources:

1. www.D-M-S.com
2. www.FunctionalMovement.com
3. J Can Chiropr assoc. 2012:56(3):179-91.
4. J Bone Joint Surg AM. 2013:95:1620-8.
5. J Sports Rehabil 2012 Nov;21(4):343-53.