What is a Trigger Point (TP)?

  • a highly irritable spot within a muscle that often result in reduce ROM and muscle weakness. It where sensory receptors (nerves) become over excited and the client may be in some pain.
  • A muscle is traumatised when the muscle shortens (actin and myosin contract) either by a trauma or overuse of a specific muscle. This causes a taunt band, which temporarily stabilises the effected tissues during the acute stage of injury. Other tissues in the area stretch to accommodate the contracted tissue, causing imbalances of movement.
  • Trigger points are a protective response to  to injury. When releasing a trigger point, there is a risk that the lengthened muscles in the local area are not strong enough to stabilise the joint once the trigger point has been released, therefore, post-care advice should support the treatment and be observed by the client.

Protocols:

  • Providing detailed information to the client on what a TP is and the risks associated
  • Prep the area with effleurage/petrissage to avoid damage and remove waste products
  • 10 second test - this identifies if the tissue is in acute, sub-acute or chronic repair
  • If the 10 second test increases in intensity remove pressure and potentially refer to a medical professional
  • If the 10 second test remains constant, perform frictions on the area
  • If the 10 second test decreases, use TP technique
  • Continuously communicate with the client

Advantages of TPs:

  • Increased flexibility and contractibility of the affected muscle
  • Improved ROM
  • Reduced local pain
  • Reduced referred pain (pain felt in another area of the body)
  • Improved circulation
  • Increased local and general relaxation

Risks:

  • Area can become aggrevated/sore
  • Painful when first applying the TP
  • Redness to the surface of the skin
  • Can cause more harm and damage than good
  • Can cause joint instability

What is Positional Release?

  • Indirect manual therapy techniques in careful passive positioning of the client
  • Aims to reduce the hypersensitivity and hyperactivity of muscle spindles
  • By using positional release to passively move tight and shortened muscle fibres into an even shorter position, the absence of a threat leads to a decreased in nerve tension, enabling the muscle spindles to relax

Protocols:

  • Find the tight tissue and tenderness
  • palpation is maintained and the client is asked to report on their experience of the pain at the pain point (scale of 1 - 10)
  • SMT supports the client's joints appropriately to allow the client to relax
  • SMT moves the joints passively to reduce tightness and tenderness (shortening affected muscles)
  • The position is held for 90-120 seconds
  • The depth of the palpating the pressure should slowly be reduced - light contact should be maintained
  • SMT returns client to the original position, ensuring the muscles don't reactivate
  • Repeat as necessarily, depending upon client's response

Advantages:

  • Pain/tenderness is minimal compared to other techniques
  • Client is actively relaxed
  • Increased ROM
  • Improved circulation
  • Increased local and general relaxation

Risks:

  • May not be as effective as other techniques
  • Can put a lot of stress on the SMTs body as holding for long periods of time

What are Muscle Energy Techniques?

  • Post-isometric relaxation (PIR)
    • A form of stretching used to aid recovery
    • Use autogenic inhibition - tension built up in a muscle stimulates the Golgi tendon organ that in turn override the muscle spindles. this facilitates relaxation to reduce the tension in the muscle
    • Manipulation of the reactions of muscle spindles and Golgi tendon organs
    • Lengthen muscle that is limited by neurological restrictions (proprioceptors)
    • Rrociprocol Inhibition (RI)
      • As an agonist muscle contracts, the neural activation of its antagonist is inhibited, this means that as an agonist contracts, the antagonist relaxes.
      • Very useful when supporting the soft tissue repair process for sub-acute tissues

Protocols:

  • Client adopts a comfortable manageable position for the MET
  • SMT clearly explains to the client the technique to be used and what's required from the client
  • SMT slowly moves the limb to the first point of bind
  • SMT palpates key structures to ensure that any small compensations the client may subconsciously make can be perceived and prevented
  • RI is used instead of PIR to use the opposite muscle (antagonist) to stretch the agonist

Advantages:

  • Improved ROM
  • Alignment of the collagen through tensile pressures in the affected area

Risks:

  • Requires the client to have good body awareness in order to make sure over-stretching doesn't occur
  • Requires good communication with the SMT
  • Can be harmful if too much pressure is applied or an incorrect technique is used (joint is misaligned)

What is Soft Tissue Release?

  • Enables joint mobilisation to stretch and mobilise the muscle (part of, or the whole muscle)
  • Examples:
    • Active
    • Passive
    • Active assisted
  • The primary aim is to remove adhesions

Protocol:

  • Place the muscle in a shortened position
  • SMT applies pressure to the restricted soft tissues and 'locks' the tissue in place
  • Maintain pressure on restricted tissues, the joint closest to the area is moved to create a stretch
  • The stretch should be passive to begin with, moving to active
  • Repeat up to 2 minutes, depending upon the client's response

Advantages:

  • Increased mobility of soft tissues
  • Promotion of good scar tissue formation
  • Breaking down fibrous adhensions
  • Positive influence on soft tissue repair
  • Improved ROM in joints
  • Promotion of muscular balance

Risks:

  • Over treatment can lead to more damage to the tissue
  • The treatment can be uncomfortable/painful
  • There can be a negative neuromuscular response, which will contract the tissues

What is Connective Tissue Therapy?

  • Treats the whole body, rathe than specific areas using the superficial fascia
  • The SMT uses connective tissue therapy to reduce myofascial restrictions
  • Connective tissue has the ability to remodel in certain conditions

Protocol:

  • Remove medium from the skin
  • Using a hand or thumb and forefinger, the tissues should be pushed slowly in multiple directions
  • Once restrictions have been ascertained, the SMT will hold the tissues until the changes in properties have occurred (30 sec)

Advantages:

  • Focuses on the whole body, rather than specific areas
  • Is less invasive than other treatment methods
  • The client will feel a pleasant sensation

Risks:

  • Client must hydrate afterwards to flush toxins
  • SMT must remove medium in order not to slip while using this technique

What is a Transverse Friction?

  • They knead across (right angle) an adhesion, instead of along (parallel) an adhesion to reduce tension

Protocol:

  • Apply the 10 second test, if the pain doesn't stay the same or decrease, then cease the treatment
  • Use multiple, short frictions at right angles to the fibres
  • Effleurage in-between frictions to make the client relax and to clear toxins to the lymphatic system
  • Use ice to alleviate discomfort post-massage and minimise the effects of possible bleeding and bruising

Advantages:

  • Realigns collagen fibres
  • Removes excessive scar tissue
  • Removes adhesions
  • Reduces congestion in the local area
  • Increases circulation
  • Increases ROM

Risks:

  • Requires good knowledge of the anatomy is required to successfully apply these
  • The client can experience some discomfort

Acute stage treatment:

  • When does this occur?
    • The acute stage of an injury lasts 3-7 days post injury
  • What are the signs?
    • The injury will be very painful, you may also experience some inflammation, swelling and redness
  • What are the aims of the treatment at this stage?
    • The SMT will aim to minimise:
      • risk of further injury
      • swelling
      • risk of further bleeding
      • risk of secondary cell death
      • pain
  • How will the acute stage be treated?
    • The SMT may perform a couple of tests in order to clarify how serious an injury you have sustained. If necessary, they will refer you to seek further medical advice. If the injury is deemed treatable the SMT will apply the PRICE protocol:
    • Protect and Rest the limb
    • Apply Ice, Compression and Elevate the limb (usually only 2 of 3 of these, as all 3 can limit blood flow)

Sub-acute stage treatment:

  • When does this occur?
    • The acute stage of an injury lasts 3-6 weeks post injury
  • What are the signs?
    • Function may be significantly limited
    • There may still be some swelling, bruising, redness and pain
    • Scar tissue will have started to form
  • What are the aims of the treatment at this stage?
    • This is the repair phase, which is key to soft tissue repair
    • Treatment will help:
      • Reduce swelling
      • Develop mobility
      • Increase blood flow to supply area
      • Minimise excessive scar tissue formation
      • Minimise pain
      • Minimise the risk of further bleeding (over enthusiastic intervention may cause further bleeding)
  • How will the sub-acute stage be treated?
    • General Massage - effleurage and petrissage increase circulation and help with pain relief
    • Soft tissue mobilisation techniques (STRs) - discourage/reduce adhesions built up from scar tissue, realign collagen fibres and minimise how much scar tissue forms
    • Neuromuscular techniques - this is a form of stretching, which helps minimise the build-up of neural inhibitors that restrict muscular function
    • Heat/Ice - depending upon the injury either of these could be used to help reduce pain. Both of these influence circulation (heat = encourage circulation, ice = discourage circulation). Depending upon the time period that has elapsed since the injury, the SMT will advise the correct form of treatment
    • Mobility exercises - this increases tensile stresses on the injury, helping gain flexibility, realign the muscle fibres and increase function
    • Gentle stretches - at this time over-stretching the muscle can damage the newly formed repair, therefore gentle stretching will have a shearing effect on the tissues which helps to discourage adhesions
    • Muscle Energy Techniques (METs) - these encourage the muscle to return to their pre-trauma length