You may have received some trigger point training as part of your acupuncture schooling, or at least have purchased charts with referral patterns and books on trigger points. But did you learn a systematic approach to identifying likely culprits and resolving perpetuating factors – the things that cause and keep trigger points activated?
About 75% of pain is caused by trigger points and about 74% of commonly found trigger points are not located within their area of referred pain. Searching locally for ashi points will only locate about 26% of trigger points.
Trigger point therapy is like doing "detective work," you need to know how to use the "pain guides" to determine which muscles to search for trigger points. You also need to know how to assess your patients for perpetuating factors; the conditions that cause and keep trigger points activated. Teaching self-help techniques helps your patients participate in their healing process and provides them with tools they can use in the future.
By using the six following steps, you can achieve consistent results.
Medical Histories and Pain Mapping
It is helpful if your medical history form includes all of the potential perpetuating factors that may be causing their trigger points. Trigger points may form after a sudden trauma or injury or they may develop gradually. Common initiating and perpetuating factors are mechanical stresses, injuries, nutritional problems, emotional factors, sleep problems, acute or chronic infections, and organ dysfunction and disease, though there are many more.
Have them mark their pain patterns on some kind of outline of the body before each treatment (known as "pain mapping") and ask them to rate the intensity and frequency of their symptoms so you can track progress, or lack thereof. Try and get them to be as specific as possible so you can match their referral patterns with common patterns on charts. Don't let them mark "x"'s or big circles or color in large areas a solid color. Show them your trigger point referral pattern charts and explain to them that you are trying to match their pain patterns with some common patterns so you will know where to start looking for the source of their pain.
Even if they are not improving, you can use that information to modify your treatment. Chances are you haven't located all of the trigger points that need treatment, there are perpetuating factors that still need to be addressed, or you need to refer them out for further evaluation since about 25% of pain is caused by conditions other than trigger points.
Use Pain Guides
Since about 74% of commonly found trigger points are not located within their area of referred pain, unless you know where to search for trigger points, you may only locate a fraction of the pertinent trigger points, and your patients may not get as much relief as they could. Familiarity with referral patterns gives you a starting point of where to look for the trigger points that are actually causing pain, but you must understand how to use the pain guides so you will know which muscles to check.
For example, if your patient has pain in their temple area, you need to know to check the temporalis, upper trapezius, sternocleidomastoid, and some of the muscles in the posterior neck. Of these muscles, only the temporalis may contain trigger points which are located within the area of pain referral, so most of the time, unless you know which muscles to check, you won't come across the trigger point by accident.
It's not sufficient just to have a set of charts on your wall to look at and try to find referral patterns, since none of them have all of the potential referral patterns diagrammed. You also need to keep in mind that the books and chart sets only diagram the most common referral patterns and trigger point locations. Your patient may have an uncommon referral pattern and trigger point locations. Pain guides and referral pattern diagrams are only a starting point.
Also keep in mind that trigger point referral patterns from multiple trigger points can overlap, causing a composite referral pattern, as is often the case with migraines and other headaches. Buy at least one comprehensive trigger point book that includes pain guides so you can see a list of muscles to check for any given part of the body, and buy a set of referral pattern charts to keep on your treatment room walls. (As a courtesy to readers, I have posted a set of pain guides at http://triggerpointrelief.com/pain_guides.html.)
Other Clues to Identifying Trigger Points
Often, trigger points in different muscles can cause very similar referral patterns. For example, common referral patterns caused by trigger points in the supraspinatus, infraspinatus, and scalenes are almost identical. One way to narrow down the culprit(s) is to know the symptoms and perpetuating factors for each muscle.
Spend some time reviewing your patients medical history form, pain mapping diagrams, and your chart notes and compare them with information for each muscle found in a comprehensive trigger point book. Trigger points can cause many non-pain symptoms which can help you narrow it down. For example, if your patient comes to you with symptoms such as headaches in the frontal area and/or base of the skull, but also reports eye or ear symptoms such as tinnitus or eyelid twitching, that would be a clue to check the sternocleidomastoid muscle for trigger points. Trigger points can cause symptoms such as diarrhea, urinary frequency, menstrual cramps, dizziness, and buckling or locking knees – symptoms most patients or health care providers wouldn't think to associate with trigger points.
Decide Which Trigger Points to Needle First
Doctors Travell and Simons, who wrote the two-volume set of medical texts on trigger point treatments, listed muscles in their book's pain guides in the order they found were most likely to be causing the pain referral. In the example given above, they list the trapezius first and the posterior neck muscles last. But keep in mind, depending on your geographic locale and practice specialty, you may find the order might be different for your practice; your patients will have different patterns depending on their work and hobbies and underlying medical conditions.
You also need to be familiar with primary trigger points and satellite trigger points. Once a trigger point has referred symptoms to any given area for any length of time, trigger points will form within the zone of referral, known as satellite trigger points. Then the satellite trigger points will cause their own symptom referral pattern, causing what I call a "trigger point chain-reaction." For example, there are at least eleven muscles that may contain trigger points which refer pain to the posterior portion of the deltoid muscle (the levator scapula, scalenes, supraspinatus, teres major, teres minor, subscapularis, serratus posterior, latissimus dorsi, triceps, and iliocostalis thoracis). If you only needle the satellite trigger points in the deltoid, the deltoid pain will keep returning because you didn't treat the primary trigger points.
If your patient has multiple symptomatic areas, don't try to treat everything in one session. Have your patient prioritize their two areas of most concern and focus on those. If you try to do too much, you likely won't treat any one area well. If your patient has widespread pain, chances are they have some kind of systemic perpetuating factor that needs to be addressed and you may need to refer out to a practitioner who can order laboratory or other tests. During subsequent treatments, you may decide to continue treating the same area before moving onto another symptomatic area, or you may decide that other areas of pain are related and need to be addressed before the primary area of pain can be completely resolved.
Any decrease in intensity and/or frequency of symptoms, or decrease in size of the symptomatic area is an improvement that indicates that you needled at least some of the pertinent trigger points. Be sure to ask how they felt immediately after the last treatment. If they felt better even for awhile, ask what they were doing when their symptoms returned. Often, that is a clue to at least one of their aggravating perpetuating factors, and an indication that it needs to be addressed for lasting relief.
Identify and Eliminate Perpetuating Factors
If perpetuating factors aren't identified and treated, your patient may improve temporarily but their symptoms will keep returning. Most patients will have multiple perpetuating factors. When you buy a trigger point book, make sure it contains extensive sections on perpetuating factors and become very familiar with each factor and its symptoms.
Because resolving these factors are crucial for long-term relief, you need to be familiar with all of the potential perpetuating factors and the symptoms of each. For example, if your patient is suffering from fatigue, depression and insomnia, you might suspect anemia or hypothyroidism and you may need to refer your patient to a health care provider who can order laboratory tests. One of the great things about treating trigger points with acupuncture is that many of the common perpetuating factors can also be treated with acupuncture.
Even if it is not within your scope of practice to diagnose and treat many of these perpetuating factors as an acupuncturist, it is important that you have some ideas of whom you can refer your patient to, who can diagnose and treat particular perpetuating factors that you suspect.
Self-Help Techniques
Learn self-help techniques so you can teach them to your patients. Refer them to books that reinforce self-help techniques for perpetuating factors, pressure techniques, and stretches. Patients who use self-help techniques and eliminate their perpetuating factors get better at least five times faster than those who just have you treat them.
Be careful not to overwhelm your patient with too many suggestions; if you give them too many, they likely won't do anything. My recommendation is to recommend to patients no more than two self-help techniques per session, typically one pressure and stretch combination, and one perpetuating factor to resolve. Help them find a way they can be successful so they will want to do more. For example, if you think walking would be beneficial for your patient, suggesting an hour per day five days per week might be unrealistic for that patient. Ask them if they could manage 20 minutes per day for three days per week. At their next visit, ask them how it went. If they weren't able to do it, find out why and problem-solve with them to see if you can find something they can/will do. Once they feel the benefits, they will likely want to do more. Above all, don't criticize them for failing to follow your suggestions. Keep a problem-solving dialog going with them to try to find something they can achieve and feel successful.
Trigger point therapy is a protocol, not a technique. The trigger point protocol developed by Dr. Janet Travel and Dr. David G. Simons includes additional diagnostic techniques such as range-of-motion evaluation and gait analysis, but the treatment tips given here are the most easily integrated into your acupuncture practice.
While there is a lot of information to learn about trigger points and how they develop in each muscle and manifest symptoms, fortunately there are now several good sets of charts and reference books to choose from. Trigger point continuing education classes are offered around the country, including several 100+ hour programs that teach the full protocol. Learning about trigger points will improve both your trigger point assessment skills and your success rate.
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