What is the science behind Trigger Point deep muscle massage? Does it work? How many sessions does it take before you feel relief?

Posted on September 3, 2014 by Kate Simmons

The answer to this question will include current, state-of-the-art research, as well as my and my colleagues’ clinical experience over several decades. I will address each of the three questions in sequence.

1) What is the science behind trigger point deep muscle massage?

There are several theories for the etiology/pathophysiology of trigger points and myofascial pain syndrome. Research continues on each, as none have yet been decisively proven.[1][2] Massage therapy (MT) has been studied extensively, and has been shown to produce objective effects most notably in those bodily systems which interact locally with the myofascial (muscle and connective tissue) systems.[3] These include the local circulatory systems, local and central nervous systems, and the lymphatic system within the immediate vicinity of the area worked on. It should be noted that the fascial structures, which encapsulate the contractile structures and tissues, exert mechanical forces upon the other associated structures, thus affecting their physiological function. MT (specifically ischemic compression and friction massage) has been shown to be effective in releasing myofascial trigger points.[5] MT also has minimal side effects, no drug interactions, is low cost, and often includes positive patient-practitioner relations (which lead to a positive and productive mentality during therapeutic treatment and rehabilitation).

2) It does work. But how?

MT that successfully releases trigger points includes ischemic compression and friction massage. Ischemic compression involves holding pressure steadily on a trigger point until it softens/releases. Friction massage involves sliding the finger/hand/etc. along a (usually) venous direction of a muscle. This creates a vacuum/suction effect upon the circulation which quickly introduces freshened circulatory fluids to the area, and moves inflammatory chemicals present back into general circulation.[6] The freshened circulatory fluids include blood and lymph, which carry pain-relieving endorphins, as well as energy constituents for metabolic recovery for both the myofascial tissue and the neuromuscular junctions. Inflammatory chemicals removed include substance P, prostaglandins, bradykinin, etc.[7]

Dry Needling & Manual Trigger Point Therapy Courses and Training )

(image: Dry Needling & Manual Trigger Point Therapy Courses and Training)

If you’d like to see some of this for yourself, try this: locate the blue (venous) lines on the underside of your wrist. Press, then rub, slowly along the blue line toward the elbow. The blue line will go clear for a moment, then the blue, or venous, blood will return in a second or two. You have just performed friction massage to the veins which will drain blood and lymph from the tissues it serves. These tissues may contain nociceptive (pain inducing) and/or inflammatory biochemicals. If you flush the tissue of venous blood/lymph, creating a “quick-refresh” of arterial blood, the tissue will be flushed of painful biochemicals, while receiving pain-relieving biochemicals. This is the function of ischemic compression and friction massage for painful areas, including tissue with active trigger points.

3) How many sessions does it take before you feel relief?

If you have been properly diagnosed with MPS, and your practitioner is well-trained and experienced, you should feel immediate relief. Ischemic compression and/or friction massage releases a trigger point (and the attendant pain and tension) within a minute or two. If trigger points are extremely active, it may take several passes over an area to treat it completely.

There is a clinical understanding in our profession: the complex part of therapy is not releasing the patient’s pain (if you know what you are doing), but rather keeping them out of pain.

If your therapist is good, you will feel better, at least significantly, for a while. The task for you then is to:

learn to do effective self-care to release the trigger points,
stretch/strengthen the tissue, and
track when the pain recurs, so that your practitioner can superimpose the timeline of recurrence with functional tasks, to possibly trace those tasks that need to be modified or eliminated (which will remove the trigger point’s perpetuating factor).

When these have been accomplished, you should be solidly on the road to recovery. Progress often follows a “two steps forward, one step back” pattern, as perpetuating factors are gradually eliminated and the tissue rehabilitates successfully. How long that will take depends on many factors: your age, general health, metabolic factors, stress levels, fitness, ergonomic factors, daily functional tasks, diet, sleep, emotional state, etc. Your doctor and therapist should help you to minimize the impact of triggers, and also to bolster those areas of overall healthy living that need help. If symptoms don’t improve noticeably within several weeks, you should seek other opinions and help.

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[1] “Etiology of Myofascial Trigger Points,” article on the National Center for Biotechnology Information, U.S. National Library of Medicine website.

[2] “Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome,” article on the Science Direct website.

[3] “Physiological and clinical changes after therapeutic massage of the neck and shoulders,” Article on the Science Direct website.

[4] “The Effects of Pressure Release, Phonophoresis of Hydrocortisone, and Ultrasound on Upper Trapezius Latent Myofascial Trigger Point,” article on the Science Direct website.

[5] “The muscular force transmission system: Role of the intramuscular connective tissue,” article on the Science Direct website.

[6] Myofascial Pain and Dysfunction: the Trigger Point Manual, pg. 86.

[7] “Changes in Blood Flow and Cellular Metabolism at a Myofascial Trigger Point With Trigger Point Release (Ischemic Compression): A Proof-of-Principle Pilot Study,” article on the Science Direct website.

What kind of doctor should I see if I have myofascial pain syndrome?

Posted on August 19, 2014 by Kate Simmons

This answer is based on my 25 years of teaming up with Bay Area physicians to help patients with myofascial pain syndrome.

To see the most effective and well-educated physician for myofascial pain syndrome, you should see a physiatrist, especially one specializing in pain management. Some other options include:

Physicians who specialize in occupational injury, as they seem to have greater training and understanding of myofascial pain syndrome, and
An increasing number of neurologists and orthopedists who specialize in pain management.

The first step to finding the right medical professional will be to do your own research on your condition, and thereby make sure that you actually have symptoms that fit the profile of MPS. While an official diagnosis will need to be done by a physician, your self-education will (or should) be welcomed by the physician, as it will save them time.

Next, you will want to do a cursory search on Google and Yelp to determine which physicians state a specialty in MPS. There may be many, as physicians seem to be racing to learn proper protocol for MPS treatment right now. The primary physiatrist I knew at Stanford Pain Management Clinic spends about 65% of his time traveling to educate physiatrists in MPS. Once you’ve decided a doctor might be right for you, you can always call their office, and ask the staff if they treat myofascial pain syndrome. You can even ask how they do it; or you can ask the physician at the appointment.

If they reply, “We inject cortisone into the sore/tender area,” they are probably not well-trained, as this doesn’t address the taut band and trigger point.

As part of a team with the well-trained physician, my job is to get rid of as much of the active/latent trigger points as possible. If there’s something I can’t address (too deep, too active, etc.), they inject it, because IT WORKS. However, they also realize that you can’t do more than 4 or 5 at a go, because they are painful.

The internet and the phone are your friends. Don’t be afraid to use them in order to find the best doctor to help you. Good luck!

Why Does Touch Feel Good?

Posted on August 19, 2014 by Kate Simmons

This is an extremely complex and interesting question. The answer is even more complex.

As mammals, and especially as primates, our bodies and minds have evolved to desire, seek and receive comforting touch. At every stage of our development as individuals, and as part of a community, it is inarguably healthy for our bodies and minds. It is, in fact, integral to our very survival.

I think that, in order for touch to feel good, it must meet two criteria:

The person being touched is honestly receptive, in the positive sense, to that touch; and
The person providing the touch has the intent to, on some level, provide “comfort” to the person they are touching. (This can have different connotations for different people in different situations).

“Let’s start at the very beginning; a very good place to start…”

Engaging in comforting touch is something that is a primal driving force for human beings and primates, in addition to all mammals, and (surprisingly) avians. For mammals, it begins in the womb, as the first sensory neural network develops. This neural network then continues as the basis for the development of the central nervous system. This system, of course, is key to experiencing touch, as we can’t feel what we are anatomically and physiologically incapable of feeling. This is shown in a study of warm, comforting touch between married couples [2]. We require comforting touch from the moment of birth, through the entirety of our lives, and even up to the moment of death. Whether we receive that touch or not has a great impact on our overall well-being.

A great deal of research has determined that our bodies and minds require such touch in order to function properly. However, the variables in development regarding neurotransmitter levels and cultural parameters involving touch are still being studied in depth. The neurotransmitter/hormone oxytocin has been dubbed both the “love hormone” and the “cuddle hormone”, because it becomes highly expressed in the brain during comforting and/or erotic touch. Endorphins, the “feel-good” neurotransmitter/hormone is also highly present during physical interactions that make us psychologically or physically comforted or “attended to.” [3]

The differing parameters of sensory sensitivity levels have been accurately and somewhat humorously depicted in the following educational pictogram of the sensory “homunculus”:

(Image credit: www.mhhe.com)

The human sensory net‘s “input parameters” are heavily loaded in favor of areas specifically developed and utilized in various stages of life, which translates functionally into sensory systems required for learning, and ultimately, survival.

What specific examples can be found in different stages of life?

As a fetus:

– touch of skin into the amniotic fluid, sac, womb, and surrounding/enveloping anatomy/physiology, to determine spatial parameters, due to the developmental nature of the integumentary (skin) system, in primary relation to the development of the central nervous system.

“From early days,
Beginning not long after that first time,
In which, a Babe, by intercourse of touch,
I held mute dialogues with my Mother’s heart
I have endeavour’d to display the means
Whereby this infant sensibility,
Great birthright of our Being, was in me
Augmented and sustain’d”
– William Wordsworth
The Prelude, 1850, II, 1. 265-272

As a newborn:

Touch and smell, predominantly, of the mother (or whatever caretaker is most present)
Rooting mechanisms in physiological/psychological reaction and behavior, in order to find FOOD
Regulation of heat/cold independent of the mother

If any of these needs are not met, discomfort will result, and subsequent developmental, psychological, and behavioral complications will occur.

Through early life, ages 1-12:

Comforting touch is absolutely required for positive and functional development of the body and mind of the toddler, through to the adolescent. Positive, comforting touch from a parent or primary caregiver forms sensory feedback associations in the body and mind that set the course for positive inter-relational associations in their future, including dating, mating, sex, and parenthood. The effect of early comforting touch has been shown to help with early learning of physical comforting of friends, bonding of friends, development of communication with known or potential friends, and simple nonverbal, interpersonal communication (via facial expression and “body language”).

Early adulthood: ages 13-21:

At this stage, the young adult will have developed physical, psychological, and social awareness in relation to experiences gleaned from earlier stages of life. We are all works in progress. We take what we intuitively feel, then we take a chance via social experience, and then we process what happens. We either learn from these experiences or progress our awareness and forthrightness, or we become stuck in conceptual and social feedback loops – which can eventually “jump the fence” and progress anyways. Or not. These years are most often our first stages of sexual experience. If touch has not been recorded in our bodies and minds as “good” at this point, there’s trouble for the person. It can be changed, in one’s psyche, but the body is a bit harder to reprogram. Patience, understanding, and a willingness to affect change within oneself are paramount. It sounds trivial and easy, but it’s not.

Mature adulthood: ages 22-? (The next boundary in age is usually “senior”, age 60-70+, but it is variable):

These are the years when body awareness, habits, and customs reach their fruition through repetition. We are hopefully “comfortable in our own skin”, physically, psychologically, and socially. We not only rely on the ingrained senses of self and familiar patterns of interaction with others in order to survive and mature, but we also, as parents, are in the position to set the stage for our children in the same stages we ourselves have gone through. In fact, these experiences are so ingrained, not only in action and thought; they have made their way into common parlance of everyday experiences. Consider the phrases, “Rubbing people the wrong way,” “Having a prickly or abrasive personality, or alternately, a soft touch, or magic touch,” “Someone having to be ‘handled with kid gloves,’” “Someone being touchy, or thick/thin-skinned,” “Someone being ‘out of touch’ or ‘having lost their grip.’” Even a deeply “touching” experience is described also as “poignant (Middle English directly from Old French “poindre,” by way of Latin “pungere,” meaning to prick or touch). Metaphor for touch in language is deeply ingrained in us. Why? Because language is one of our main ways to communicate our experiences as a person.

Which also leads to the obvious: SEX and the human experience.

“Sex has been defined as, ‘the harmony of two souls and the contact of two epidermes.’ This elegantly emphasizes a basic truth: the massive involvement of the skin in sexual congress. The truth is that, in no other relationship is the skin so totally involved as in sexual intercourse. Sex, indeed, has been called the highest form of touch. In the profoundest sense, touch is the true language of sex.” [4]

“For touch,
Touch, by the holy powers of the Gods!
Is the sense of the body; whether something makes its way in
Or when a thing, which in the body had birth,
Hurts it, or gives pleasure issuing forth
To perform the generative deeds of Venus.”
-Lucretius (c. 96 B.C-c. 53 B.C)
De Rerum Natura, II, 434

If sexual intercourse did not feel as compelling and stunningly good as it does (or can), we would have long ago become extinct.

*And in our final years, the contacts we have grown to cherish and need from ourselves and all our family and communities, in our deepest being – physical, psychological, and social, will fade, even as the memory of its pleasures will be a secret fire in the deep recesses of the mind.

[1] Touching: The Significance of the Human Skin, Ashley Montagu, 1986

[2] Page on lww.com “Influence of a “Warm Touch” Support Enhancement Intervention Among Married Couples on Ambulatory Blood Pressure, Oxytocin, Alpha Amylase, and Cortisol”

[3] Behavioural function and neurobiological mechanisms

[4] Touching, pg.204

What can cause muscles to be sore for weeks to the point that they’re painful when used?

Posted on October 1, 2013 by Kate Simmons

Unfortunately, there are quite a few diagnoses that are relevant to muscle soreness and weakness beyond a week’s span. Be sure to have a physician examine you to at least rule out some of the more basic physiological diseases.

Once those are cleared satisfactorily, ask yourself the following questions:

Was there a precipitating event? That is, did it happen all of a sudden? If so, how?
Where in the body did the pain originate? What was the quality of the pain (sharp/burning/dull & aching/sore/tingling/numbness)?
How long did the pain last?

If the pain began with a precipitating event (e.g. “I lifted something;” “I slept funny;” “I twisted in the shower;” “I leapt to catch a ball;” etc.), it usually indicates a sprain or strain to muscle, tendon, or ligament. If you hear a “pop” or “crack” in a joint, it is most likely a connective tissue rupture. If this is the case, you will need a good interview by a sports medicine physician (MD/DO) and probably a scan of some kind (x-ray or CAT scan for bony/cartilage tissues; MRI for muscle/tendon/ligament tissues). This will help to determine what damage, if any, has been done, and if the issue warrants surgery and/or therapeutic intervention. This needs to be your first port-of-call for pain lasting longer than 1-2 weeks.

Once you have determined that there is minimal damage, and therefore, that surgery is unwarranted, you can determine that the cause is one of the following:

Not normal delayed onset muscle soreness (lasting 24-72 hours): See my answer to What causes delayed onset muscle soreness?
A sprain or strain: See Sprains, Strains and Other Soft-Tissue Injuries
If there are multiple areas around the initial location of pain and injury, you may have developed myofascial pain syndrome: “Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension. While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens.”

Myofascial pain syndrome (Mayo Clinic)

As a bit of an aside, sub-acute (1-6 months) and chronic (more than 6 months) of myofascial pain are treated thus:

“A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 1–3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.” (Wiki: Trigger point)

(PS – I’m really proud of the Wiki on this. They nailed it, spot on.)

In a standard clinical interview, you have to go over all the aforementioned patient history, physicians’ reports, scans and anything else you can tell or show the practitioner about what may be the cause of the pain. Your practitioner can then figure out what muscles do the motion that produced the injury & other perpetuating factors, which allows the practitioner to decide what to treat first. This is the general clinical starting point for therapeutic focus.

Myofascial Pain Syndrome