Trigger Point Assessment (and Palpation)

In this course, we cover a topic that has only recently become controversial. Trigger point therapy has a relatively long history in medicine, including publications referencing trigger point injection for muscle pain in the early 1900s. Additional papers referencing the treatment of pain by addressing a trigger point, muscle knot, muscle spasm, or pressure point, start to increase in number in the 1960s. Travell and Simons published the 1st edition of their classic 2 volume set, "Myofascial Pain and Dysfunction", in the early 1990s, including definitions of the terms trigger point, latent trigger point, active trigger point (painful trigger point), trigger point pain, and a detailed description of how trigger points may develop in muscle fibers and how they may affect normal movement. In the 1990s and early 2000s, EMG research correlated trigger points with an increase in muscle activity and muscle spasm. In the early 2000s, microdialysis was introduced, providing a more detailed account of the chemical environment of trigger points. Finally, more recent advances in imaging technology have provided the first images of active trigger points within a contracting muscle.

Additionally, in the last 3 decades, randomized controlled trials (RCTs) have compared the efficacy of conventional treatment methods to a trigger point therapy session, trigger point massage, pressure point massage, trigger point acupressure, and trigger point injections. As well as, research investigating therapies that may affect trigger points such as massage therapy and specific therapeutic exercise. The superior efficacy of adding trigger point therapy sessions to conventional treatment methods has been demonstrated for the treatment of neck pain, tension headache, whiplash syndrome, chronic pain of the low back, knee pain, general leg pain, pain management for fibromyalgia, sports injuries, connective tissue disorders, and nerve pain.

It is rather unnerving to witness a young, under-educated group of new therapists, condemn nearly 100 years of scientific inquiry, research, and refinement. Trigger point therapy (including self-administered, manual, and needling techniques) is one of the most effective techniques available for addressing muscle tension and muscle spasm that often accompanies an increase in muscle activity, with the presence of latent trigger points and active trigger points. Further, the research is clear, that locating a trigger point in an affected muscle via palpation is reliable, with a relatively small amount of training.

We hope this course aids in providing clarity around a topic that has been confounded by a recent proliferation of misinformation. Further, this course is pre-approved for credits toward the Integrated Manual Therapist (IMT) Certification, and pre-approved for continuing education credits for sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.).

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Massage Therapists
• Occupational Therapists - Advanced
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Study Guide
• Text and Illustrations
• Audio Voice-over
• Research Review
• Practice Exam
• Pre-approved Final Exam

Brookbush Institute's Position Stand: Trigger Point Assessment

The majority of research investigating the reliability of trigger point assessment demonstrates moderate to excellent reliability (1- 3, 5 -8, 10- 26, 33 - 37), with only a few studies demonstrating less than moderate, or variable reliability (4, 9, 27, 32). A review of all published original research has highlighted several modifications that may improve reliability in practice. The one systematic review that could be located by Myburgh et al. (1) makes similar suggestions as below; however, ads that more high-level randomized control trials (RCTs) should be a focus of future research on this topic. Muscle-specific recommendations based on all relevant research lean heavily toward moderate to excellent reliability and are also discussed below.

Brookbush Institute Evidence-based Trigger Point Assessment

1. Identify muscles to be treated via movement assessment.
2. Palpate muscles to be treated and strum fascicles perpendicular to fiber direction to identify taut bands.
3. Search the taut band for a tender spot, nodule, or area of increased tissue density.
   • Note: Based on the current studies, trigger point assessment may use "taut bands" for direction, and referral pain patterns as confirmation, but should rely on point tenderness for identification.

For a review of muscle fiber dysfunction and trigger point etiology:

• Muscle Fiber Dysfunction and Trigger Points

1. Myburgh, C., Larsen, A. H., & Hartvigsen, J. (2008). A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Archives of physical medicine and rehabilitation, 89(6), 1169-1176.
2. Gerwin, R. D., Shannon, S., Hong, C. Z., Hubbard, D., & Gevirtz, R. (1997). Interrater reliability in myofascial trigger point examination. Pain, 69(1-2), 65-73.
3. Sciotti, V. M., Mittak, V. L., DiMarco, L., Ford, L. M., Plezbert, J., Santipadri, E., … & Ball, K. (2001). Clinical precision of myofascial trigger point location in the trapezius muscle. Pain, 93(3), 259-266.
4. Hsieh, C. Y. J., Hong, C. Z., Adams, A. H., Platt, K. J., Danielson, C. D., Hoehler, F. K., & Tobis, J. S. (2000). Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Archives of physical medicine and rehabilitation, 81(3), 258-264.
5. Myburgh, C., Lauridsen, H. H., Larsen, A. H., & Hartvigsen, J. (2011). Standardized manual palpation of myofascial trigger points in relation to neck/shoulder pain; the influence of clinical experience on inter-examiner reproducibility. Manual therapy, 16(2), 136-140.
6. Persson, A., Brogardh, C., & Sjolund, B. H. (2004). Tender or not tender: test-retest repeatability of pressure pain thresholds in the trapezius and deltoid muscles of healthy women. Journal of Rehabilitation Medicine, 36(1), 17-27.
7. Lew, P. C., Lewis, J., & Story, I. (1997). Inter-therapist reliability in locating latent myofascial trigger points using palpation. Manual therapy, 2(2), 87-90.
8. Hong, C. Z., Chen, Y. N., Twehous, D., & Hong, D. H. (1996). Pressure threshold for referred pain by compression on the trigger point and adjacent areas. Journal of Musculoskeletal Pain, 4(3), 61-79.
9. Levoska, S., Keinänen-Kiukaanniemi, S. I. R. K. K. A., & Bloigu, R. (1993). Repeatability of measurement of tenderness in the neck-shoulder region by a dolorimeter and manual palpation. The Clinical journal of pain, 9(4), 229-235.
10. Barbero, M., Cescon, C., Tettamanti, A., Leggero, V., Macmillan, F., Coutts, F., & Gatti, R. (2013). Myofascial trigger points and innervation zone locations in upper trapezius muscles. BMC musculoskeletal disorders, 14(1), 179.
11. Jones, D. H., Kilgour, R. D., & Comtois, A. S. (2007). Test-retest reliability of pressure pain threshold measurements of the upper limb and torso in young healthy women. The Journal of Pain, 8(8), 650-656.
12. Hong, C. Z., Kuan, T. S., Chen, J. T., & Chen, S. M. (1997). Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison. Archives of physical medicine and rehabilitation, 78(9), 957-960.
13. Hong, C. Z. (1998). Algometry in evaluation of trigger points and referred pain. Journal of Musculoskeletal Pain, 6(1), 47-59.
14. do Nascimento, J. D. S., Alburquerque-Sendín, F., Vigolvino, L. P., de Oliveira, W. F., & de Oliveira Sousa, C. (2018). Inter-and intraexaminer reliability in identifying and classifying myofascial trigger points in shoulder muscles. Archives of physical medicine and rehabilitation, 99(1), 49-56.
15. Fischer, A. A. (1987). Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain, 30(1), 115-126.
16. Bron, Carel, Jo Franssen, Michel Wensing, and Rob AB Oostendorp. "Interrater reliability of palpation of myofascial trigger points in three shoulder muscles." Journal of Manual & Manipulative Therapy 15, no. 4 (2007): 203-215.
17. Mayoral del Moral, O., Torres Lacomba, M., Russell, I. J., Sánchez Méndez, Ó., & Sánchez Sánchez, B. (2017). Validity and reliability of clinical examination in the diagnosis of myofascial pain syndrome and myofascial trigger points in upper quarter muscles. Pain medicine, 19(10), 2039-2050.
18. Al-Shenqiti, A. M., & Oldham, J. A. (2005). Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis. Clinical rehabilitation, 19(5), 482-487.
19. De Groef, A., Van Kampen, M., Dieltjens, E., De Geyter, S., Vos, L., De Vrieze, T., … & Devoogdt, N. (2017). Identification of myofascial trigger points in breast cancer survivors with upper limb pain: interrater reliability. Pain Medicine, 19(8), 1650-1656.
20. Jalil, N. A., Prateepavanich, P., & Chaudakshetrin, P. (2010). Atypical chest pain from myofascial pain syndrome of subscapularis muscle. Journal of Musculoskeletal Pain, 18(2), 173-179.
21. Hollingworth, G. R., Ellis, R. M., & Hattersley, T. S. (1983). Comparison of injection techniques for shoulder pain: results of a double blind, randomised study. Br Med J (Clin Res Ed), 287(6402), 1339-1341.
22. Fryer, G., Gibbons, P., & Morris, T. (2004). The relation between thoracic paraspinal tissues and pressure sensitivity measured by a digital algometer. Journal of osteopathic medicine, 7(2), 64-69.
23. Binderup, A. T., Arendt-Nielsen, L., & Madeleine, P. (2010). Pressure pain sensitivity maps of the neck-shoulder and the low back regions in men and women. BMC musculoskeletal disorders, 11(1), 234.
24. Potter, L., McCarthy, C., & Oldham, J. (2006). Algometer reliability in measuring pain pressure threshold over normal spinal muscles to allow quantification of anti-nociceptive treatment effects. International journal of osteopathic medicine, 9(4), 113-119.
25. Koo, T. K., Guo, J. Y., & Brown, C. M. (2013). Test-retest reliability, repeatability, and sensitivity of an automated deformation-controlled indentation on pressure pain threshold measurement. Journal of manipulative and physiological therapeutics, 36(2), 84-90.
26. Nice, D. A., Riddle, D. L., Lamb, R. L., Mayhew, T. P., & Rucker, K. (1992). Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Archives of physical medicine and rehabilitation, 73(10), 893-898.
27. Hua, N. K., & Van der Does, E. (1994). The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice. Pain, 58(3), 317-323.
28. Rozenfeld, E., Finestone, A. S., Moran, U., Damri, E., & Kalichman, L. (2017). Test-retest reliability of myofascial trigger point detection in hip and thigh areas. Journal of bodywork and movement therapies, 21(4), 914-919.
29. Walsh, R., Kinsella, S., & McEvoy, J. (2017). The intra-rater reliability of locating and measuring the severity of latent trigger points in the quadriceps. Journal of bodywork and movement therapies, 21(4), 926-932.
30. Botter, A., Oprandi, G., Lanfranco, F., Allasia, S., Maffiuletti, N. A., & Minetto, M. A. (2011). Atlas of the muscle motor points for the lower limb: implications for electrical stimulation procedures and electrode positioning. European journal of applied physiology, 111(10), 2461.
31. Zuil-Escobar, J. C., Martínez-Cepa, C. B., Martín-Urrialde, J. A., & Gómez-Conesa, A. (2016). The prevalence of latent trigger points in lower limb muscles in asymptomatic subjects. PM&R, 8(11), 1055-1064.
32. Sanz, D. R., Lobo, C. C., López, D. L., Morales, C. R., Marín, C. S., & Corbalán, I. S. (2016). Interrater reliability in the clinical evaluation of myofascial trigger points in three ankle muscles. Journal of manipulative and physiological therapeutics, 39(9), 623-634.
33. Zale, K. E., Klatt, M., Volz, K. R., Kanner, C., & Evans, K. D. (2015). A mixed-method approach to evaluating the association between myofascial trigger points and ankle/foot pain using handheld sonography equipment: a pilot study. Journal of Diagnostic Medical Sonography, 31(4), 210-220.
34. Ohrbach, R., & Gale, E. N. (1989). Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain. Pain, 39(2), 157-169.
35. Rasmussen, J. O., Smidth, M., & Hansen, T. M. (1990). Examination of tender points in soft tissue. Palpation versus pressure-algometer. Ugeskrift for laeger, 152(21), 1522-1526.
36. Wolfe, F., Simons, D. G., Fricton, J., Bennett, R. M., Goldenberg, D. L., Gerwin, R., … & Sanders, H. O. (1992). The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. The Journal of rheumatology, 19(6), 944-951.
37. Tunks, E. L. D. O. N., McCain, G. A., Hart, L. E., Teasell, R. W., Goldsmith, C. H., Rollman, G. B., … & DeShane, P. J. (1995). The reliability of examination for tenderness in patients with myofascial pain, chronic fibromyalgia and controls. J Rheumatol, 22(5), 944-52.
38. David G. Simons, Janet Travell, Lois S. Simons, Travell & Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens