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Do we still need to press on individual points?

The basic idea of pressing on points (trigger, tender, acu, whatever) has been around for a LONG time. We have a zillion modalities that use some version of the concept, of which trigger point therapy one of the leaders. However, trigger point therapy as taught by Travell and Simons didn't have much to do with the manual stimulation of those points. What most of us learned in massage school and/or seminars is an adaptation of their original material, which tended to emphasize injections and/or spray-and-stretch.

For many of us, the basic idea was to find those spots, then statically press on them until they let up - the "release" so often sought after. Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news.

However, it is less and less clear whether we need to press on individual points at all. Methods such as Active Isolated Stretching, Muscle Energy Technique, Strain Counterstrain, Kinesiotaping, Trager Work, Feldenkrais, etc. seem to be very effective at eliminating trigger points without ever pressing a point to "release" it. In my own work, I have found my results improving as I move away from "traditional" trigger point work. I can eliminate many points in the time I used to spend on 2-3 points. More importantly, I can teach my clients how to keep them gone.

What do you think? Do we still need to keep pressing on individual points, or is it time to find a more efficiently effective approach?

Replies to This Discussion

Permalink Reply by Jeffrey A. Lutz on September 18, 2010 at 10:17am

Alexei,

Dry needling is not with in the scope of practice for a MT, making it illegal for them to perform trigger point dry needling (TDN). I believe TDN has a certain place in the realm of trigger point treatment, but that it should be more of a last resort. While it is not a horribly invasive procedure, it can be extremely painful. I find needling is best for chronic trigger points that have had years to harbor vs ones that have recently formed.

Currently practitioners who can do this work are a MD, DO, DC (in some states), PT (in some states), RN (under physician orders), and AP.

Jeff -

Alexei Levine said:

Jeffrey,
Can you explain a little more about the legality issues of dry needling?
Thanks!

Permalink Reply by Alexei Levine on September 18, 2010 at 11:40am

Jeffrey,
Thanks, that's good info. I am a physical therapist as well as a massage therapist and I've always thought about taking the dry needling training. In my own mind I've always imagined that sticking a needle into a chronic trigger point would be very effective. I've never before had the opportunity to hear from anyone who had any knowledge of the modality.
Thanks again!
Alexei

Permalink Reply by Jeffrey A. Lutz on September 19, 2010 at 12:00am

Alexei,

I recommend Myopain Seminars for TDN. The educators are Dr. Robert Gerwin, MD and Jan Dommerholt, PT (maybe DPT now). They write the BEST seminars for TDN as well as addressing the systemic component of TrPs, such as but not limited to: thyroid, vitamin D, iron (via serum ferritin), among others.

www.myopainseminars.com

Let me know if you have any other questions!

Best,

Jeff -

Alexei Levine said:

Jeffrey,
Thanks, that's good info. I am a physical therapist as well as a massage therapist and I've always thought about taking the dry needling training. In my own mind I've always imagined that sticking a needle into a chronic trigger point would be very effective. I've never before had the opportunity to hear from anyone who had any knowledge of the modality.
Thanks again!
Alexei

Permalink Reply by Boris Prilutsky on September 19, 2010 at 12:04pm

Dear Stephen.
Thank you very much for posting trigger point overview article .The full extended version of this article originally was written by me and Ross Turchaninov MD.Phd who is brilliant scientist and great hands-on therapist. I would recommend to everyone who are looking for scientific data that is applicable to massage therapy, to purchase his text books. In my opinion this is the best massage therapy texts existed in English and probably including other languages. Would like to declare that I have no financial interest in distribution of Ross Turchaninov’s books. To get more information about his books please visit www.aesculapbooks.com
Or call 602-404-1583
Best wishes.
Boris

Permalink Reply by Cicely T. Penn on November 1, 2010 at 2:02am

wow! Jason that was very interesting...cause I do a lot of tp work and most of the time its hard work and painful for the client. Plus the client sometimes still have the tp. I want to know more about you technique. Jason Erickson said:

To Allison: Just rechecked a source, and I misstated. It was actually Travell & Simons, in their 2 ed., that indicated that stroking movements are more effective than simple ischemic pressure. I have that edition on my shelf as I type this. For convenience, you can read about it here, on page 4 of this article:
http://www.learnmuscles.com/mtj%20TrP%20article%20-%201-08.pdf

To Larry: I emphatically disagree that "stretching and strengthening cannot be completed" if all TPs are not first individually eliminated. Every day I work, I prove that statement to be utterly without merit. The fact that you made that statement, and later followed with "Taking a global approach is ineffective" shows me we have clearly arrived at very different points of view. Rather than argue, let me give you some background on why I asked the question:

Trigger Point Therapy is the primary modality I learned, and well, in school. My primary instructor had been an NMT instructor for nearly 20 years by that point, and upon graduation I quickly gained a large clientele and referral network based on what I could do with it. For a good while, I was completely in agreement with what Stephen and Alexei said in their posts, and mostly agreed with what you said in yours.

However, early on I noticed that some clients responded well to more pressure, while others responded better to less pressure. This variation in individual responses made me curious about WHY such differences existed. My instructor had taught both basic ischemic pressure and stroking movements, plus introduced us to some more advanced "layering" concepts for use in areas where TPs might coexist in several layers of tissue. I began experimenting with varying my level of pressure, angle of pressure application, different patterns of treating affected areas, etc., etc. All the while, I made many, many observations. In time, I realized that I could achieve better, more consistent results with less client discomfort. However, there were still some who were simply unable to bear TP work, or who had contraindicated conditions, etc.

I studied fascial work and found that it could often reduce/eliminate many TPs and tender points. Pretty cool, but the method I learned was relatively slow, making it hard to get as much done in a single session. However, by combining TP and fascial work, I could sometimes get the best of both worlds. Still, I felt that there must be a way to rapidly improve my efficiency and effectiveness. I obtained some basic training in positional release concepts, and was impressed by my newfound ability to immediately eliminate 70-100% of a client's TP/tender point symptoms by merely repositioning their body for a short time. With practice, I learned to combine TP and cross-fiber frictioning with PRT, thereby achieving great improvements with little/no client discomfort during the session.

Over the years, I had also studied 9 forms of stretching technique (static, ballistic, isometric, hatha yoga, PNF stretching, CRAC/"Facilitated" stretching, AIS, dynamic joint mobilization, and myofascial stretching). I learned the various pros and cons of each, and found that some worked better for some client situations than others. Intrigued by the differences, I studied and practiced and eventually found that I could eliminate most of my own TPs and tender points with stretching and strengthening alone. As a personal trainer, I used this knowledge to quickly help sore clients improve function and become nearly or completely pain-free.

Now I have continued my learning journey, becoming acquainted with neurophysiological, neurodynamic, and neuroplastic concepts. Though still at an early stage of this period of my development, I have found that I can eliminate TP/tender point discomfort with very simple techniques that don't require direct, deep pressure, and which are far faster and more comfortable than the fascial work I had learned... all without having to reposition the client's skeletal structure as in PRT.

Tonight I worked on a fellow MT who is a skeptic, who LOVES trigger point therapy (and is quite skilled herself), and who had many sore spots all over her body. In 30 minutes she was virtually pain-free, and I never had to directly address any of her TPs/tender points. She was surprised and somewhat perplexed, as the experience contradicts much of what she has been educated to expect.

So now I am attempting to understand exactly how the work I am doing now actually works. I have found some neuro-oriented references, but don't pretend to understand them completely (yet). However, all of my accumulated experiences have lead me from being a Trigger Point Therapist to being something else. I do not believe that my current work requires an esoteric explanation, nor do I think it will require a complicated one. However, I find myself questioning many of the assumptions made by Travell & Simons about the nature of pain, how it is perceived, how TPs and tender points may be related to it, etc., etc.

If you get the chance, watch one of Travell's old videos in which she demonstrates spray-and-stretch techniques. The method works very well, but certainly not due to any direct manipulation of the TPs. There are other mechanisms at work, yet the TPs are resolved and function is improved. This, to me, is direct confirmation that TrPT as we know it is just one approach... and this opens the possibility of finding a better way.

Travell & Simons did us an enormous service with their work, giving us a much greater understanding of common symptom patterns and a variety of different treatment methods (ischemic pressure, deep stroking, injections, spray-and-stretch, etc.). However, they continued their research and treatment observations until the end, massively revising their material in the 2nd edition. If they had eventually released a 3 ed., we can only guess at what additional changes they might have made.

Now that you know more about where my question comes from, can you understand why I asked it? If yes, what are your thoughts? If not, why not?

Thanks! I look forward to your replies. :)
~ Jason

Allison Ishman said:
"Now research has shown that static pressure is less effective than using small stroking movements over the affected "point" and its immediate area. This change seems new and momentous to some, while to others it has long been old news."

Just out of curiosity, what research are you referencing?

Permalink Reply by Gordon J. Wallis on June 25, 2011 at 12:18am

Truth be known..You can eliminate any trigger point in 20 seconds, with out ever working the trigger point itself, and only using light finger pressure. I know no one will believe me..But thats ok...