Understanding Pain

INTRODUCTION - THE BRAIN INFLUENCES HEALING

Most people would accept that the human brain has a remarkable ability to drive healing processes in the body. Consequently, a treatment can be expected to be most successful when the brain is enlisted to work with the therapy to bring about the healing. And your body will be able to work through the healing process more successfully when there is understanding:

  • understanding of what may well be causing the problems.
  • understanding of how the treatment can may on the cause to initiate a return to good health.

That is why the first Bowen Plus session will include a brief explanation of how latent and activated trigger points affect your muscles causing stiffness and pain, and also how Bowen therapy can work to bring about muscle release and initiate a return to good health. While there are a variety of other reasons why people may suffer pain, there is no doubt that treatments targeting myofascial pain (pain arising from the muscles) bring significant relief for many, many people.

Please click on links below to view the associated topic What are Trigger Points How do Trigger Points (TrPs) Affect US? What Causes Trigger Points (TrPs)? Some Indirect Effects of Trigger Points (TrPs) Trigger Points (TrPs) Affect the Skeleton Trigger Point (TrP) Tricks Will Treatment Bring Lasting Improvement Summary (For those too busy to do a lot of reading):

What are Trigger Points?

(References to “Travell & Simons” are short for “Myofascial Pain and Dysfunction The Trigger Points Manual” by Travell & Simons, Published – Lippincott, Williams & Wilkins 1983)

“…. Trigger points (TrPs) are extremely common and become a painful part of nearly everyone’s life at one time or another. Latent TrPs, which often cause motor dysfunction (stiffness and restricted freedom of movement) are far more common than the active TrPs, which in addition cause pain.” (Travell & Simons p 12)

Think of trigger points (TrPs) as small regions of abnormality that commonly form in muscles. Healthy muscle tissue typically has a resilient, pliable texture. TrPs feel like toughened nodules or ropey, sinewy regions embedded in the muscle. They can be extremely sore when you press down on them, but people often are unaware of their presence until pressure is applied.

Two hundred pairs of voluntary muscles are responsible for working the human skeleton. “Any one of these muscles can develop … TrPs that refer pain and motor dysfunction, often to another location” (Travell & Simons, p13). This would explain why massaging a painful area may bring only short term relief. The TrPs causing the pain may be somewhere else.

The number of TrPs that may form is specific to each different muscle. Extensive research has shown the location of each TrP to be predictable, and trigger point charts have been developed which detail all possible locations.

How do Trigger Points (TrPs) Affect Us?

Latent (hidden) TrPs cause the muscle to tighten and shorten, without actually causing pain symptoms. But they will be tender if probed and tend to restrict freedom of movement – you feel stiff.

Understanding Pain

Activated TrPs are more intensely abnormal regions in the muscle. They make their presence known by causing pain as well as restricting movement, but that pain often is experienced in other locations (“referred pain”). The diagram shows the locations of the three TrPs that can form in the infraspinatus muscle on the back of the shoulder blade (Travell & Simons Vol. 1, p553). See how the pain (red shading) resulting from the activation of those TrPs is felt down the outside of the upper arm. Some TrPs refer pain much further than this. For example, TrPs in the scalene muscles, in the neck, refer pain to the back of the upper arm and the back of the hand, as well as the thumb and forefinger (Travell & Simons Vol. 1, p506). You can imagine that in these cases, even if massaging the painful region brings temporary relief, treatment of the TrPs will be needed to bring the muscle back to good health and enable a lasting improvement.

Pain caused by acutely activated TrPs can be sudden, sharp and extreme. Travell & Simons (page 13) describes the case of a housewife who activated a TrP in her lower back while she was bending over cooking. So savage was the pain that she fell to the floor and could not reach up to turn the stove off, to stop the pot burning through its bottom. One patient of this clinic experienced sudden, almost incapacitating pain in her lower back muscles when she sneezed while cleaning her teeth. Another was awoken suddenly by severe pain in her back, apparently the result of turning over in bed.

In many other cases, the onset is gradual and the pain feels dull, deep seated and nagging in character.

What Causes Trigger Points (TrPs)?

Imagine a TrP as a small region of muscle tissue which has become locked into contracting and cannot stop.

This malfunction can easily result when a healthy muscle is suddenly stressed well beyond its ability to cope. When a TrP activates, the associated pain may take 12 to 20 hours to appear. On the other hand, the pain can be immediate when a latent TrP in a stiff muscle suddenly activates. Situations that frequently cause the sudden activation of TrPs include sudden wrenching movements, falls, car accidents, fractures, joint sprains, dislocations or a direct blow to the muscle. An episode of excessive or unusual exercise also could cause a sudden activation. (Travell & Simons p111)

Trigger points may also develop gradually, when a muscle experiences chronic or repeated strain at, or close to, the limits of its capacity. These cases typically are associated with postural stresses, where the muscles are asked to withstand loads, for long periods of time, which ideally should be taken by bones. Poor work habits such as slouched posture or the need to work in cramped positions are typical causes of these muscle problems.

Latent TrPs in fatigued muscles of the neck, shoulders or calf can even be activated by a cold draft on the overlying skin.

Some Indirect Effects of Trigger Points (TrPs)

It is not hard to imagine how trigger points must also affect the body in more subtle and complex ways, as well as causing stiffness and pain.

Consider the general health of the muscle itself. Muscle cells have ongoing needs for oxygen, energy rich molecules and other nutrients. Circulating blood is responsible for the transport of those substances. Imagine a muscle becoming tighter and tighter as the TrPs intensify. The circulation of blood into that muscle will become less and less efficient. Deprived of adequate nutrition, any damaged tissue will take longer to repair (sprains, broken bones etc). Muscle function in general will be limited too.

What about the toxic waste products being produced continuously in muscles as the cells perform life’s processes. Those wastes should be removed as they are produced, to ensure good muscle health. Lymphatic drainage plays an important part in this continuous cleansing, but the tighter the muscle the less efficient the cleansing process will be. And if the concentrations of wastes build up too high, crystalisation can occur, solid deposits can form, leading to further deterioration in health of the muscles and joints in that region. Travell & Simons (p 792) states that inactivating the related myofascial TrPs appears to be an important part of early therapy, to delay or stop the progression of some kinds of osteoarthritis.

Trigger Points (TrPs) Affect the Skeleton

Trigger POints Affect the SkeletonPossibly the most profound, indirect effects of TrPs arise when they cause distortion of the skeleton. Imagine the muscles of the lower back tightening up more on the right side than on the left. This would if TrPs form only in the muscle (Quadratus lumborum) on the right of the lower back. The diagram shows how this will pull a right hand curve into the lumbar spine as the ribs and pelvis are winched closer together on that side. One consequence of this will be that the right leg behaves as if it is shorter than the left. With each step taken there will be unbalanced stresses on the left and right sides of the body. Eventually a “knock on” effect may will occur as the muscles of the legs, buttocks and pelvis are repeatedly asked to move or support the bones at angles slightly different from what is ideal. This, in turn, will cause leverage changes and then the muscles become more easily stressed. New TrPs then develop in different muscles, followed by movement restrictions, stiffness and pains emerging in new places – knees, ankles, buttocks, hamstrings etc. Pressure on various nerves and blood vessels will develop too.

The activated TrPs in the right lower back muscles typically will cause a chain reaction effect further up the body as well. The brain will not tolerate the skull being displaced to the right of the mid-line. It sets up compensating tensions in the spinal muscles, between the shoulder blades on the left hand side of the body.

So the top of the spine and the head are brought back to the centre line. But that results in an “S” shaped lateral distortion in the spine (scoliosis) and a lowering of the right shoulder. This condition encourages the activation of TrPs in the neck and shoulders and may also cause problems to develop in the arms as well (depending on other stresses deriving from work and recreation). So it is not surprising that patients complaining of lower back pain often turn out also to be suffering other, lower priority symptoms further up or down the body. This also explains why treatments typically require a holistic approach rather than simply focusing on the most painful symptom (which may well be referred pain associated with TrPs located elsewhere anyway).

Trigger Point (TrP) Tricks

“…. muscles in general and TrPs in particular receive little attention as a major source of pain and dysfunction in modern medical teaching and in medical text books. …… but it is the bones, joints, bursae and nerves on which physicians usually focus their attention.” Travell & Simons (p 13), believed that to be the case in the 1980s and it may well still be true, to some extent at least. So it is possible that, in searching for the cause of a particular set of painful symptoms, a physician will overlook the possibility of activated TrPs being responsible. Travell & Simons (p 37) list many cases of referrals for different diagnoses, when the reason for the symptoms actually turned out to be activated TrPs. For example, activated TrPs in the lower abdominal muscles can cause symptoms that could be mistaken for appendicitis. Problems diagnosed as earache have sometimes turned out to be the result of activated TrPs in the deep masseter muscle (that helps work the jaw).

Different diagnoses appear to have been the case for a number of patients at this clinic too:

One example involved a patient who had come for treatment of shoulder pain. She mentioned she was also suffering gastritis and had been told by her doctor that it was probably a side effect of immune suppressing drugs she had been taking since she had a kidney transplant some years previously. She was expecting to have to put up with the symptoms indefinitely. The ENAR Space Healer was used in an exploratory way to see if it might be able to ease the symptoms. A spot was found on the edge of the front right side of the rib cage where the ENAR caused a strong tingling/prickling reaction. Ten minutes of ENAR treatment brought lasting relief from the gastritis and a subsequent check of Travell & Simons (p 942) revealed the presence of a “heart-burn” trigger point that refers pain into the stomach region.

Another patient came with mid-thoracic back pain and also had been told that she had pleurisy. Her pleurisy symptoms included severe pains in the ribcage and knifing pains when she coughed. She had been suffering from a “cold” which had caused lots of exhausting coughing for a number of days. Use of Bowen therapy to treat the diaphragm and muscles between the ribs brought rapid relief from the painful symptoms, which did not return.

The human body is very complex and there are many different ways something can go wrong. It is hardly surprising that different explanations are possible for a particular set of symptoms, and that doctors sometimes select a treatment for what turns out not to be the real cause of the problem. The important lesson to take from this is that other solutions may well be possible where traditional medical treatments have not been able to help. It usually will be obvious within one or two treatments whether a muscle release therapy such as Bowen or Emmett will be able to make a difference. It can in many, many cases.

Will Treatment Bring Lasting Improvement?

Lasting improvement is possible in many cases. In other cases the patient may decide to seek treatment every so often, to help maintain a reasonable quality of life. It all depends on what caused the TrP activation in the first place.

Suppose physical damage to a bone, a joint or a disc caused aggravation of the muscles and TrP activation. Then healing of the underlying problem may be necessary before work on the TrPs will last. But don’t forget that muscle release therapies such as Bowen also can improve speed of healing by enhancing circulation and lymphatic drainage.

One good example of this involved the treatment, at this clinic, of a woman with a broken left collar bone. Despite regular physiotherapy after the breakage, X-rays showed the bone was not healing. The patient was horrified to hear that use of a steel pin and a bone graft from the hip would be necessary if the next set of X-rays (scheduled for 10 weeks time) showed the bone still was not mending. She decided to stop the physiotherapy (which she felt was making the shoulder feel worse) and try a sequence of Bowen treatments at weekly intervals. Prior to treatment, the muscles all around the left shoulder and shoulder blade were much, much tighter, than those on the right. One week later, just before the second treatment, the muscles of both shoulders felt very similar and healthy. The patient said things were feeling much improved at that stage, and the improvement continued with further treatments. Altogether, eight treatments were given, and the follow up X-rays showed good bone growth was under way. But the muscles seemed unable to maintain a healthy condition for long while the collarbone was still unstable. The gap between the sixth and seventh treatments was two weeks rather than one. Immediately prior to the seventh treatment the muscles of the affected shoulder had slipped back similar to their original condition before treatment began. They were all knotted up again.

Sometimes the cause of the problem is a “one off” in that person’s life. A relatively small number of muscles are affected and the person had no such problem prior to the event. In these cases, correction through muscle release treatment may well last for years.

Many problems are work and posture related. While Bowen treatment will bring total or significant relief in many cases, it cannot protect the muscles from relapse if they continue to be subjected to the conditions that produced the problem in the first place. Travell & Simons refer to the need to eliminate perpetuating factors. Gradual conditioning and strengthening of muscles seems to make them more resistant to activation of TrPs. Making changes to heights and angles of chairs and work stations can make a big difference. Less time spent at the task before resting and stretching is important too, and so is good posture while working. Appropriate changes in all of these can be expected to lengthen out the time before further treatment is needed. Then, an occasional maintenance treatment may be all that is needed to keep things going well. One patient of this clinic was able to change the frequency of treatments for migraines and shoulder pain from six weeks to six months by regular involvement in a fitness programme at a gym. The frequency of treatment increased again when she found it too difficult to keep up the fitness programme owing to pressures of work.

Sometimes the fundamental cause of the muscle stress is a permanent feature of the person’s body. For example the bones of one leg may be shorter than the other. Then lasting improvement would require additional intervention, such as a built up shoe. But don’t forget that an unequal leg length condition may not be the result of differences in bone length. Activated TrPs and tight muscles, more on one side than the other, can cause distortion of the pelvis. This, in turn, can bring about an apparent difference in leg length which will disappear when the muscles are treated and return to good health.

Once the muscles have been released, it is common for the skeleton to straighten out and the mobility of joints to increase, without any specific manipulation. Often it all happens as a byproduct of healthy balanced movement such as walking and swimming (but not to the point of fatigue). The body may be able to achieve the return to good health step by step only, rather than reaching the desired end point after a single treatment. Sometimes patients reach a stage where they decide to try forcing the issue by means of skeletal/joint manipulation of some type. It is not difficult to imagine that such manipulations are more likely to be successful if the muscles have already been released, where possible.

Summary

Healthy muscle has a resilient, supple feel to it. Trigger points (TrPs) feel like toughened nodules or ropey, sinewy regions within the muscle. They can be extremely sore when you press down on them, but people often do not know they are there until pressure is applied. TrPs are extremely common and become a painful part of nearly everyone’s life at one time or another.

Think of TrPs as small regions in the muscle where contraction locks on and will not stop, even when the muscle has no work to do and should be relaxed. They make the whole muscle shorten up, causing stiffness and restricted movement. Each different muscle has characteristic places where TrPs will form if the muscle experiences too much stress.

TrPs may be latent, where the abnormality in the muscle is not extreme but the muscle feels tight and uncomfortable. With further stress and aggravation, the abnormality in the muscle intensifies and we say the TrPs have activated. Activated TrPs cause pain, sometimes very severe, and that pain may feel as though it is located some distance away from the TrP (referred pain).

Trigger points often form when a muscle is suddenly loaded up well beyond what it is strong enough to cope with (eg whiplash). TrPs are also likely to form when a muscle is required to work close to its capacity, over and over again without being given time to rest and recover (eg RSI and bad posture problems). The stronger and better conditioned the muscle, the more resistant it will be to TrP formation.

In addition to causing stiffness and pain, trigger points can also have indirect and more subtle effects on general health and well being. Circulation of the blood will be inefficient within tight muscles. The result will be inadequate nutrition for the cells in that region. Healing of damaged tissue will be slower than it would be in healthy muscle. Removal of toxic waste products by the lymphatic system will be affected also.

The skeleton will be twisted out of alignment when muscles tighten up more on one side of the body than the other. The spine, for example, may develop unhealthy bends and curves, affecting the action of other muscles and causing a chain reaction of new problems. Pressure on various blood vessels and nerves may result. Abnormal angles between bones may affect the action of joints causing abnormal wear and tear.

Muscle release therapies can bring profound relief from these problems, by initiating the return of muscles to a relaxed, healthy state. The therapy kick starts a healing sequence in the body. As the muscles relax, removing distorting tensions from the skeleton, normal balanced movement (eg walking) helps circulation, lymphatic drainage and the re-alignment of the body.

Trigger points often cause symptoms that can be mistaken for other conditions. For example, trigger points in one of the jaw muscles can result in pain that feels like ear ache. In another facial muscle, trigger points may cause what seems to be tooth ache. Even apparent appendicitis symptoms can actually be referred trigger point pain. All of this adds to the difficulties associated with working out the causes of pain and other health problems. It also explains why muscle release therapies such as Bowen, and Emmett Technique often can make a beneficial change when other methods have been unsuccessful.

Often only 1 – 3 treatments are needed and long lasting improvements are possible. However, the problem can be re-created just as it was created in the first place. Changes in life style and/or the work place may be needed to help maintain a lasting improvement in health. Regular activity that gradually strengthens and stretches the muscles will make them more resistant to trigger point problems. This helps us understand why Yoga, Pilates and Tai Chi are so beneficial.