This is part 2 of a two-part article.

As I stated in part 1 of this article (ADVANCE, Sept. 22, 2008), trigger points may refer pain both in the local area and/or to other areas of the body, and the most common referral patterns have been well documented and diagrammed.

Approximately half of the time, trigger points are not located in the same place as the symptoms. For example, trigger points in the upper portion of the trapezius muscle can cause headache pain in the temples, the base of the skull, in the angle of the jaw, and possibly above the ear and over the eye. As a practitioner, if you aren't familiar with referral patterns, you can't treat pain adequately, because you won't know which potential muscle(s) are harboring the offending trigger points.

I asked two very successful physical therapists about their experiences with incorporating trigger-point therapy into their practices. Wendy Larsen, MSPT, works and lives in Portland, OR, and is owner of Centre Point Physical Therapy, an orthopedic outpatient practice, with a focus on manual therapy techniques. Patrick Ripp, PT, OCS, is an orthopedic physical therapist at Juneau Physical therapy in Juneau, AK. He graduated from the University of Wisconsin-Madison School of Physical Therapy in 1990. He completed his certification in manual therapy from the North American Institute of Manual Therapy (NAIOMT) in 1998 and became an orthopedic clinical specialist in 2004.

When did you add trigger-point therapy to your practice?

Larsen: Trigger-point therapy treatment has been an integral part of my physical therapy practice for the past 14 years, since treating exclusively in the orthopedic outpatient setting.

Ripp: I recall learning trigger-point techniques while doing my physical therapy internships. During that time I was first exposed to Travell and Simon's book Myofascial Pain and Dysfunction. Since those formative days, trigger-point techniques have been a part of many of the continuing education courses I've taken.

Where did you get your trigger-point therapy training, and what did it entail?

Larsen: Initially, I was introduced to this body of work in graduate school. At that time, a general overview and basic techniques were taught. However, it was in my training for pelvic pain disorders that I received extensive training in myofascial pain and specifically, trigger-point therapy. One of my instructors, Tim Sawyer, PT, the senior physical therapist working with Dr. Wise of Stanford in the area of pelvic pain, has been instrumental in my training and integration of these techniques into my practice.

Ripp: I have attended several continuing education courses in which trigger-point release was a part. Kinetic Control and NAIOMT courses come to mind. Additionally, I enjoy reading physical therapy-related articles covering all aspects of PT with trigger-point therapy as one component. The NAIOMT trained me to become a better problem solver.

How do you incorporate it into your practice?

Larsen: Typically, I introduce this technique to my patients early in their rehabilitation process, usually on the first day of treatment. I work primarily with clients who present with subacute and chronic-pain injuries. Therefore, the trigger-point work is perfect to begin straight away on the focus of their self-help treatment, education on the causative factors such as overuse, posture, stress and how to manage flare-ups of pain and re-injury.

The effectiveness for trigger-point therapy depends on the client learning self-treatment techniques. Therefore, I spend a great deal of time demonstrating and instructing clients in how to use tools such as a curved pressure device, tennis balls, supported fingers and of course, a willing partner at home. I teach them about strumming and milking a trigger point, compression of a trigger point and if appropriate, ice sweeps with an ice cube. After release of the trigger-point, they apply brief heat and gentle stretching of the muscle that was harboring the offending trigger point.

However, if patients present with an acute injury such as s/p MVA, I will focus on indirect techniques such as positional release and supplement trigger point work as their tolerance of direct techniques increases.

Ripp: I'll give you an example that illustrates one approach. A client arrives with shoulder pain and the exam reveals that the scapula is essentially locked into an anterior tilt (presumably from a hypertonic pectoralis minor muscle). In my experience, if pec minor locks the scapula in this anteriorly tilted position, it must be released prior to implementation of conditioning exercises. For example, if this client was given rotator cuff strengthening exercises prior the pec minor release, his symptoms would likely increase secondary to decreased subacromial space as a result of the anteriorly tilted scapula. To effectively retrain a proper movement pattern, the deeper local musculature must be reactivated while the global musculature is quieted or inhibited. Trigger-point work, like acupuncture or massage, is one method to decrease global muscular activation.

How has it changed your practice?

Larsen: It has significantly changed my practice in many ways. It provides a wonderful evaluation tool, especially with clients who are dealing with chronic-pain issues. Often their symptoms are complex, long-standing and can be misleading clinically. However, with the understanding of myofascial pain dysfunction and trigger-point characteristics, the presentation of active and latent trigger points, many answers regarding the causative effects can be found.

In my treatment room I have two large color poster charts of the Travell Trigger Points. This is an invaluable visual aide in that my clients tend to go straight to the charts and claim "that is my pain." Not only does this give the clinician a good place to start the evaluation process, but the patient also feels more confident and better understood during the history-taking part of the evaluation process.

Ripp: Manual trigger-point compression can potentially advance my assigned exercise programs more quickly and in a pain-free manner. Since the effects can be immediate, changes in muscle recruitment, pain or movement pattern can be seen during the treatment session. This immediate change establishes trust between the client and practitioner. As a direct result, I believe it assists with improved home-exercise compliance.

Have you found that conditioning exercises aggravate active trigger points, and have to be stopped until the trigger points are inactivated, as Dr. Janet Travell suggested?

Larsen: Ideally, for a swift return to pain-reduced or pain-free conditioning exercises, clients should follow the protocol to sustain participation in their sport or activity until the trigger points are resolved. However, most patients are reluctant or unwilling to stop conditioning exercises. I have found clinically if clients are diligent with treating the trigger points before and after their exercise, and follow the trigger point protocol with daily self-treatment, they can often continue with their conditioning exercises without significant flare-ups.

Ripp: Yes and no. In the example I described earlier, regarding the hypertonic pec minor-yes, I would agree with Dr. Travell. Conversely, I've seen conditioning exercises eliminate trigger points. One example may be shoulder or scapular pain with weak and long rhomboids. As the rhomboids gain better motor control and strength, the trigger points can become deactivated. I would argue that a physical therapist shouldn't rely on only one single methodology, but rather stay open-minded and begin to note these patterns in practice.

What words of advice would you have for other physical therapists?

Larsen: If you have not been exposed to Dr. Travell and Simons' work, then I would encourage them to gather some information and integrate it into your practice. No one escapes developing trigger points throughout the life cycle, and with this practice you can greatly help patients lead more active and pain-free lives and empower them with this safe and effective self-care treatment technique.

Ripp: This is what I tell my students: Ask yourself many questions. What is the primary cause for this dysfunction? Are you addressing the primary cause of the dysfunction in the treatment, or merely treating the result? Is your goal to provide short-term palliative care or long-term management? Are you seeing an objective change in his/her condition? Does it correlate to subjective complaints? You should be constantly reassessing whether the objective problems you're addressing are bringing about the desired change in function and pain. Also, keep an open mind. Listen to your client. Be objective. Always question what you're doing and why. In other words, keep learning.

Valerie DeLaune is the author of Pain Relief with Trigger Point Self-Help and Trigger Point Therapy for Headaches and Migraines. She treats patients at the Natural Health Center in Anchorage, AK. She can be contacted through her website triggerpointrelief.com, or at 907-653-1979.