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Why do trigger points keep coming back
The main reasons trigger points keep coming back is because they usually never really go. Courses of trigger point therapy are only designed to temporarily relieve their pain, not eliminate them.
Overview
Trigger points start as small lumps that are only noticed when a therapist presses upon them, but if untreated they slowly develop until they hurt all the time. The clinical trials that trigger point therapy treatments are based upon typically only evaluate whether a course of treatments can diminish the trigger points enough that they stop hurting all the time. Patients feel better, but the trigger points are still there, so of course they continue to develop until they hurt again. Further treatment is needed to diminish them further and eliminate them.
In this article we will explain what a trigger point is, how the scientific community is influencing treating professionals to provide this sort of totally inadequate treatment, then present our own solution to help you eliminate your trigger points for good.
CONTENTS
Trigger point basics
What is a trigger point
Active vs non-active (latent)
How common are "non-active" trigger points
Clinical trials of trigger point therapy
Summary of the problem
Poor and misleading treatment plans
The three exceptions
The solution
Which therapy to use
Appendix: latent trigger points
Professionals
References
Trigger point basics
What is a trigger point
Trigger points are described as being palpable lumps within taut bands of muscle that have characteristic pain referral patterns. They are a key issue in most muscloskeletal pain syndromes (1–4). They are thought to start from microscopic damage to muscles caused by injury or overuse, especially if blood flow is reduced due to chronic tightness. The science behind them can get quite involved, but in summary:
- part of the muscle goes into spasm forming a palpable lump.
- The spasm is locked on by a positive neurological feedback loop.
- Because the spasmed part of the muscle is shortened the remainder of the muscle becomes tight.
- With tightness restricting blood flow and the continued contraction of the spasmed section of muscle there is a build up of neurotransmitters and metabolic wastes, and a depletion of oxygen and nutrients.
Active vs Latent (non-active)
Trigger points are describes as being active or latent (non-active). This is arguably misleading because as discussed in our section on latent trigger points, although not spontaneously painful latent trigger points actively cause a host of other problems. When a latent trigger point starts shooting pain in addition it is then called "active".
How common are "non-active" trigger points
Overuse and chronic tightness of muscles are a major cause of trigger points, and they can exist in their latent state not noticed. Because of this trigger points are highly prevalent in asymptomatic people (5).
Clinical trials of trigger point therapy
Summary of the problem
There have been huge numbers of trials into the efficacy of trigger point treatments. What they typically do is identify the trigger points then apply a course of treatments. As confirmed in the quote below, they measure "success" by whether they de-activate the trigger points. By definition, a trigger point is "active" when it spontaneously produces pain, so the goal is to reduce pain. The researchers do things like use various questionnaires relating to pain and disability. They very conveniently neglect to check or note whether the trigger points were still present. If pain is reduced the trial is published as a success, regardless of whether the offending trigger points are still there.
The three trials we found that did check for trigger points clearly show that most trigger points remain, and of course as discussed in the section on latent trigger points they will continue to cause issues then eventually re-aggravate and become painful again.
To quote a review of trigger point therapies: (7)
"Most physical therapy treatments of MPS (myofascial pain syndromes) are targeted at deactivation of MtrPs (myofascial trigger points)."
Poor and misleading treatment plans
We would strongly argue that following these protocols is not only poor practice, it is highly misleading. To illustrate this we will show two different ways the facts from facts from trial (8) could be presented to a patient. Which is the most honest?
The facts from trial 8
A course of three weekly applications of dry needling gave symptomatic relief. Checking post trial found that 71% of the original trigger points were still present.
Version one
Make three weekly appointments for dry needling. It is a clinically proven treatment so you should feel a lot better.
Version two
I'll give you three sessions of dry needling. You'll feel better, but 71% of your problems will still be there. They'll still be causing you some issues but you won't feel them, then probably the next time you do something they will start hurting again so you can make an appointment for three more sessions of dry needling
The three exceptions
We were able to find three trials that investigated the presence of trigger points after therapy. Note that all found that the majority of trigger points were still there after a course of treatments.
Trial one (8)
52 active trigger points were treated with three weekly applications of dry needling. Symptoms were of course reduced. However, after treatment 11 were still active, 26 had deactivated, and only 15 (29%) were eliminated.
Trial two: (9).
Patients received 12 weekly therapy sessions, with each using multiple trigger point therapies. This is way in excess of what happens in most clinical practices, both in the number of sessions and what was done at each session. Patients did report symptomatic relief, but upon examination approximately 2/3 of the trigger points remained.
Trial three (10)
Patients were given three sessions of manual therapy plus a home exercise program. After treatment 32% of trigger points were eliminated
The solution
Unfortunately the scientific community has wasted a huge amount of funding and resources only to provide evidence that a course of treatments can (temporarily) deactivate trigger points. Therefore most "evidence based" trigger point therapy is not supported by any evidence that the treatment can eliminate the problem. So, lets look at what we actually do know.
The facts we do know
Treatment results
The three trials that investigated the presence of trigger points post treatment all found that some of the trigger points were eliminated. The most significant trial found that 12 weekly treatment sessions eliminated approximately 1/3 of the trigger points.
The aetiology and physiology of trigger points
Scientists studying trigger points have identified many causes, plus now understand that simply speaking a trigger point comprise the following factors in a positive feedback loop.
- a "spasm" caused by a positive neurological feedback loop
- hypertonicity of the muscle
- a buildup of neurotransmitters and waste products compounded by a reduction in blood flow
The key
The key to successfully eliminating trigger points is to be able to:
- identify and manage causative and aggravating factors
- have an effective therapy that can be applied a large number of times
Which therapy
You need some professional help
Trigger points are almost always part of a more complex musculoskeletal problem, plus there are usually causative and aggravating issues that need to be identified and eliminated. Because of this you should always consult a professional who deals with musculoskeletal problems and is knowledgeable about trigger points, and discuss incorporating the strategy below to eliminate trigger points in your management.
Cannot rely on professionally administered therapies
Given that 12 weekly 45 minute trigger point therapy sessions (9) eliminated only 1/3 of the trigger points it is reasonable to presume that elimination would require a much larger number repeated over time. Having these administered by a professional would be prohibitively time consuming and expensive.
The best self applied alternative
We recommend that the use of vibration massage would be the only practical effective alternative.
Easy to self apply
When given basic instructions, and advised where, when and how often vibration massage is easy to self apply. Please see our instruction page for details.
Addresses all the key elements of a trigger point
Vibration penetrate well and are shown to address all the key elements of a trigger point. For more information please see our article on the scientifically proven effects of vibrations massage.
How to use vibration massage
Using vibration massage is extra-ordinarily easy. We ask you to check our our instructions for the fine points and precautions, but basically all you need to do is place the vibration massager on the muscle over the trigger point and let the vibrations penetrate for 30-60 seconds. This can easily be repeated every day.
How to choose a massager
For how to choose an quality massager that will do a great job and that you will be extremely happy with please see our article How to choose a massager, or you can go straight and check out our economical, easy to use professional standard machines: the General Purpose Massager or our Ultimate Quad Head Massager.
Latent trigger points are still a problem
Apart from being just one step from becoming symptomatic, having part in continuous spasm with reduce blood will of course be detrimental for the muscles, and the hypertonicity and reduced functionality will adversely effect posture and biomechanics. Even without referring pain, the consequences of latent trigger points have been summed up as follows. (5)
- restrict ranges of motion
- cause muscle weakness
- cause muscle fatigue
- alter muscle activations
- induce muscle cramps, and
- affect posture and joint function, creating further issues.
On top of that, scientists are now finding that latent trigger points still produce sub-threshold levels of pain that over time sensitises the nervous system. This is a major cause of issues such as fibromyalgia and migraines (6).
Professionals
DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.
References
- Chiarotto A, Clijsen R, Fernandez-De-Las-Penas C, Barbero M. Prevalence of Myofascial Trigger Points in Spinal Disorders: A Systematic Review and Meta-Analysis Presented as an abstract and poster to the World Confederation of Physical Therapy Congress, May 1-4, 2015, Singapore. Arch Phys Med Rehabil. 2016;97(2):316–37.
- Castaldo M, Ge HY, Chiarotto A, Villafane JH, Arendt-Nielsen L. Myofascial trigger points in patients with whiplash-associated disorders and mechanical neck pain. Pain Med (United States). 2014;15(5):842–9.
- Ge H, Wang Y, Fernández-de-las-peñas C, Graven-nielsen T, Danneskiold-samsøe B, Arendt-nielsen L. Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients. 2011;
- Fernández-de-las-Peñas C, Simons DG, Cuadrado ML, Pareja JA. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007;11(5):365–72.
- Celik D, Mutlu EK. Clinical implication of latent myofascial trigger point topical collection on myofascial pain. Curr Pain Headache Rep. 2013;17(8).
- Shah J et al. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. HHS Public Access. 2015;7(7):746–61.
- De Las Peñas CF, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: A systematic review. J Bodyw Mov Ther. 2005;9(1):27–34.
- Gerber LH, Shah J, Rosenberger W, Armstrong K, Turo D, Otto P, et al. Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects With Chronic Myofascial Pain. PM&R [Internet]. 2015;7(7):711–8. Available from: http://dx.doi.org/10.1016/j.pmrj.2015.01.020
- Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB. Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
- Grieve R, Barnett S, Coghill N, Cramp F. Myofascial trigger point therapy for triceps surae dysfunction: A case series. Man Ther. 2013;18:519–25.
- DrGraeme. The scientifically proven effects of vibration massage- with clinical applications
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About Dr Graeme
Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more
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