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.).

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