Dr .

Kasra Chehrazy
MD. MFHom
Dr. Janet Travell (1901-1997)served simultaneously on
pulmonary, cardiology, and general medical services.

According to her a patient who is dying of a serious illness
when is asked How are you? would answer: "Well, ok,
except I have this terrible pain in my shoulder. I can't sleep.
I can't lie on that side. when asked the cause of pain the
resident in the pulmonary service would say its a reflex
from the lung, in cardiac service they say its a reflex from
the heart, in general medicine its called psychosomatic
and so on? But nobody cared to examine the muscle!!
Drs. Janet Travell & David Simons (1993) described a trigger
point as, "A highly irritable localized spot of
exquisite tenderness in a nodule in a palpable taut band of
(skeletal) muscle.






Prevalence of trigger points in selected patient populations.


In 1957, Dr. Janet Travell discovered that trigger points
'generate and receive' minute electrical currents (EMG). As
trigger points are small part of muscle contracture, it causes
a small spike in the muscle activity and can be accurately
and reliably located by EMG.

Shan et al. (2003) performed a micro-dialysis experiment
with trigger points of upper trapezius muscle. The findings
suggested localized tissue hypoxia.






Micro-dialysis findings.
localized tissue hypoxia, increased acute inflammatory cascade, and
lowered pH (acidosis).
primary or central trigger points develop in the myofascia,
mainly in the centre of the muscle belly where the motor
end plate enters .
Secondary or satellite trigger points often develop in a
response to the primary trigger point. These satellite points
often develop along fascial lines of stress.
These lines of stress may well be 'built in' at the time of
embryogenesis.
Nearly 70% of trigger points overlap with acupuncture
points.
Meridians could be compatible with fascial lines of stress.



Important in chronic trigger points.
1- Mechanical stress
skeletal asymmetry (lower limb leg inequality)
misfitting furniture, poor posture, prolonged
immobility.
2- Nutritional insufficiency
-insufficient vitamins: B1, B6 (INH, Corticisteroids),
B12, C (low in smokers), folic acid, iron, ca++, K

3- Metabolic and Endocrine inadequacies
suboptimal thyroid function, hypoglycemia (increased
circulatory epinephrine, activation of SCM MtrP) hyperuricemia,
estrogen and testosterone imbalance.
4- Psychological factors:
depression, anxiety, good sport syndrome, learned
sick behavior.
5- Chronic Infection:
Viral, bacterial, parasitic.
6- Drugs:
statins (Lovastatin, Simvastatin,)
Bisphosphonate (Alendronate and risedronate )
7-Other Factors:
allergy, impaired sleep, radiculopathy, chronic
visceral illness, prolong treatment.
Nerve root irritation
Biomechanical factors after Simons et al. (1999).

lness, prolong treatment.

Trigger Point Formation and Posture:
Poor posture is a powerful 'activator and perpetuator'
of myofascial trigger points (Simons et al. 1999)
Upper Crossed Pattern Syndrome
'round-shouldered, chin-poking, slumped posture', which
also compromises normal breathing .
pain is often in the neck, shoulder, chest and
thoracic spine.

Upper Crossed Pattern Syndrome

Lower Crossed Pattern Syndrome
This can be observed in the 'sway back' posture, with weak
abdominals and gluteals muscle and overtight
erector spinae, quadratus lumborum, tensor fasciae latae,
piriformis and psoas major.
joint dysfunction, particularly at the L4-L5 and L5-S1 segments

1-Referred Pain Patterns
map of trigger points referred zones
2-Autonomic Effects
Autonomic nerve fibres are implicated in the pathogenesis of a trigger
point.





Known symptoms include:
Hypersalivation - increased saliva;
Epiphora - abnormal overflow of tears
down the cheek;
Conjunctivitis - reddening of the eyes;
Ptosis - drooping of the eyelids;
Blurring of vision;
Increased nasal secretion;
Goose bumps.
3-Physical Findings
Small nodules the size of a pinhead;
Pea sized nodules;
Large lumps;
Several large lumps next to each other;
Tender spots embedded in taut bands of semi-hard muscle
that feels like a cord;
Rope-like bands lying next to each other like partially
cooked spaghetti;
The skin over a trigger point is often slightly warmer than
the surrounding skin due to increased
metabolic/autonomic activity.

Examination can be done on sitting, standing or lying
position. Sometimes you need to put a load on the
muscle.

Examination of pectorallis major in
sitting position, trigger point could be
find at clavicular line:


Ask patient to abduct the arm 90 degrees
to put the muscle into moderate tension;
Palpate for nodule or tight band;
Feel for the jump sign or twitch response;
Pressure should reproduce symptoms
experienced by the patient;
Pressure should elicit a referred pain
pattern.
strengthening
stretching
posture
sleeping posture
work posture
hobbies, sport

1- FIND THE TRIGGER POINT
Palpation
Relax the patient, take history, make patient
involved
Symptoms of a trigger point



Stiffness in the affected/host muscle;
Spot tenderness (exquisite pain);
A palpable taut nodule or band;
Presence of referred pain;
Reproduction of the patient's symptoms (accurate);
May be hotter (or colder) than the surrounding tissues;
May be more moist than the surrounding tissues;
May feel a little like sand paper;
May be a loss of skin elasticity in the region of the trigger point.
How to palpate?
Finger pads palpation: remember to cut your finger nails (shorter
is better);
Flat palpation: use the fingertips to slide around the patient's skin
across muscle fibres;
Pincer palpation: pinch the belly of the muscle between the
thumb and the other fingers, rolling
muscle fibres back and forth;
Flat hand palpation: useful in the abdominal region (viscera);
Elbow: allows stronger leverage which can be an advantage.
How to palpate?




a) Flat finger palpation, b) pincer palpation.
Is any instrument needed?




Pressure Algometer
The Jump and Twitch sign





It is easier to locate a central trigger point. Firmly
pressing it produces exquisite pain and often causes the
patient to jump away.

An active central trigger point commonly causes a
reproducible specific referred pain pattern.

Using a quick snapping pincer will often elicit a
localized twitch response within the muscle.


Injections:
Procaine hydrochloride 1% solution;
Lidocaine hydrochloride (0.5%);
Long-acting local anaesthetics;
Isotonic saline;
Epinephrin;
Corticosteroid;
Botulinum toxin A.
1ml, inside trigger point with twitch response. EMG
control increases accuracy.
Dry needling:
Using an acupuncture needle, the same response to
injections

Spray and stretch technique
Other manipulation methods
Massage therapy
Manual Lymphatic Drainage Technique (MLD)
Homeopathy?





Homeopathy

Injections, S/C:
1-Traumeel: Traumeel is a homeopathic combination
drug which reduces inflammation, swelling and oozing.
The pharmacology involved is not yet understood; studies
suggest that the drug modifies the action of neutrophils
and the release of inflammatory mediators .
Weleda company:
1- Bryonia /formica:






Principles of action: (anti-homotoxic medicine)

Based on low dose antigen reaction.

Medications act in the range of 1X-14X with 4X -8X
appearing to be the most favorable.

Higher potencies are not favorable in this treatment.




Headache:






Vertex: S
Back of head (Sternal, Clavicular)
Temporal,: S
Frontal: S & C
Cheek & jaw: S
Throat & front of neck: S
Headache:






38 year old lady, housewife with one kid. CC: Headache, anxiety.
Physical exam: trigger points in Lt SCM muscle.
Headache frontal, temporal, << 11-12 am, pulsating
Rx: Bryonia/Formica at SCM muscle. Cimicifuga 30C tds.
Headache stopped for two weeks.

FU: 5 months later. Headache again. Cimcifuga 30C every 30 min,
Headache decreased by 80% after 2 doses.
Patient 1:

51 y/o Lady, Architect, home decoration. Dx: Stiff shoulder,
ROM: 30 degree, Muscles: rotator cuff involvement.
Supraspinatus muscle , infraspinatus, teres minor,
subscapularis
1 injection Bryonia/formica on supraspinatus.
10 min later pain decreased to 80%, ROM: 70 degree.
Patient didnt come back for 3 months.







Patient 2:

60y/o Lady, housewife, had gynecological operation, 2
weeks later pain started in pelvic area. Walks very slowly
due to pain, limping. Multiple trigger point inc girdle
muscles.
Injections: Bryonia formica in the points, ROM increases
after 10 min, pain decrease by 70%. She is heavy smoker,
domestic problem, too much stress. Used to come back
twice a week for inj.








Patient 3:

65y/o Lady, school teacher. Has carpal tunnel syndrome.
Operated once, cannot close her point and wring fingers,
claw hand. Pain.
Bryonia/formica inj in pronator teres






Palmaris longus
Patient 4:

30 y/o Lady, house wife, married with one 16 m/o boy the
boy is 20kg.
CC: Severe anxiety, mental obsession (death, disaster, )
after 1st period. Crying, weeps alone, recurrent fight or
flight response, < one week from period.
Headache: cervicogenic, lots of trigger points in SCM,
infraspinatus (scapuloclavicular joint) with radiation to the
right arm on pressing and upper trapezius muscle with
headache and pain in the external throat (globus
hystericus).






Patient 4:

1
st
consultation: Had severe headache at consultation room,
lots of trigger points in SCM muscle.
Rx: Cimicifuga 30c tab repeated 30 min later.
D/W injection slow drip.
headache gone after 2
nd
dose.
Tab Chromium (to balance Bs and insulin)
Ignatia 10m as needed.
Nat.m 30-30-200c in three successive days.





Patient 4:

2nd consultation: two wks.
Fight and flight syndrome, headache. Trps at infra scapular
and middle trapezius.
Rx:
Acoite 30c stat, Ign 10m stat. Inj. Bryonia/Formica. At trps.
Pain gone in the office.
Nat.m 30,200,1m.
Lachesis 30, 30, 200 to be taken. Repeat on day 16 of each
cycle.




Infraspinatus
Point of injection
Upper trapezius
Point of injection

Data gathered from 1693 doctors experienced in S/C use of
homeopathic injectables based on 36million patient
contacts.
96.4% of doctors never, very rarely or rarely observed any
adverse effect.
Reported adverse reactions are harmless (local redness,
hematoma , local pain).