In the healthcare community there are many different types of practitioners as well as different thought processes in which those practitioners utilize to determine a clinical impression. The common denominator amongst all practitioners is they pretty much all treat pain to some degree or another. The most difficult thing for practitioners to do is see outside their training, which many times focuses on a specific organ or system of the body.
"The common denominator amongst all
practitioners is they pretty much all treat pain..."
What if a condition existed that could negatively afflict the lives of your patients, by causing restricted range of motion and pain and is common in a vast majority of chronic pain sufferers – and you didn’t know about it? This could very well be the case because of a little known (but widely gaining) problem called myofascial trigger points (MTrPs).
Trigger points have a very long history and have been documented as far back as the 1800’s. It was not until an American physician, Janet Travell, MD began to document her findings of trigger points and myofascial pain that we have been able to enjoy a better understanding of these muscular ‘knots’ and the plethora of research which has spawned as a result of her work.
Although Janet Travell gets most of the credit for her research on trigger points, it is important to realize there have been many other contributions to this work. Hans Kraus MD was an Austrian physician who migrated to the US in the 1930's who contibuted heavily to our understanding of myofascial pain as well. His premise helps us to understand the role of the muscles with a particular emphasis on exercise as the primary therapeutic intervention.
How the Muscular System Causes Pain
There are four specific ways in which muscles cause pain as outlined by Dr. Hans Kraus who was considered to be the Father of Sports Medicine in the USA.
Let us first look at how the muscles of the body can cause pain and dysfunction. According to specialists in the field of myofascial pain, there are 4 major causes of pain from the muscular system.1
- Muscle tension comes from not working off the stresses of life and is one of the most common reason for chronic pain. Because the muscles are staying tighter than normal the muscles actually begin to cut off their own circulation and place additional pressure on surrounding nerves and eventually irritating them.
- Muscle Deficiency (weakness and stiffness) is a part of both muscular tension and spasm. Underexercised muscles may contribute to much, if not all, pain supposedly caused by arthritis.
- Muscle spasm is when a muscle contracts strongly and won’t let go. This is what is usually responsible when a person says their “back went out”.
- Muscle trigger points are small tender nodes of degenerated muscle tissue which develop as a result of prolonged spasm or tension and have the ability to send pain to areas distant to their location. These trigger points need to be addressed first as any type of strengthening tends to make pain from trigger points worse.
A great test to determine where muscle weakness or deficiency is occurring is called the Kraus-Weber test. This test looks at determining the strength and flexibility of the core muscles of the body. The test was developed by Drs. Hans Kraus and Sonya Weber. Hans and Sonya determined that if a person failed any of these tests, they were much more likely to have or develop back pain. The test consists of 6 separate tests which evaluate the strength of the abdominals, erectors (muscles which run up and down both sides of the spine), and flexibility of the hamstrings.
Quick Fact: The President’s Council on Physical Fitness was founded because of the results of this test in American children. Kraus and Weber performed the test and found that American children failed the test in 57.9% of the cases, compared to 8.7% of their European counterparts.2
Kraus Weber Test No. 1. The subject lies flat on his back with his legs flat on the ground and his hands behind his head. The examiner stabilizes the subject’s feet to the ground and has the subject perform one sit-up.
Kraus Weber Test No. 2. The subject lies flat on his back as in test #1, but this time pulls his knees up and has his ankles close to his buttocks. The examiner stabilizes the feet again and has the subject perform one sit-up.
Kraus Weber Test No. 3. The subject lies flat on his back with his hands behind his head and the knees straight and flat on the surface of the examining area. The examiner instructs the subject to lift the legs 10 inches off the ground and hold for 10 seconds.
Kraus Weber Test No. 4. The subject lies on his stomach with a pillow under his low abdomen and pelvis. The examiner stabilizes him at his feet and pelvis at the level of the sacrum. The subject is instructed to lift his head, shoulders, and torso off the table for 10 seconds.
Kraus Weber Test No. 5. The subject keeps the same starting position as in test #4, but the examiner holds the shoulders and back down. The subject is instructed to lift the legs off the surface of the table, with the knees straight, and hold for 10 seconds.
Kraus Weber Test No. 6. The subject stands up barefooted and feet together. The examiner keeps the knees straight and instructs the subject to bend over slowly and touch the fingertips to the floor and hold for 3 seconds.
Failure of this test is not being able to complete any one of the 6 individual tests.
Once deficiencies in strength and flexibility were noted, a specific exercise program, consisting of 21 exercises, was instituted to rehabilitate the patient. The patient was also examined for muscle trigger points, which were treated prior to beginning any strengthening or stretching exercises as trigger points are aggravated by stretching and strengthening.
This information was used to develop and implement a program for the YMCA called “The Y’s Way to A Healthy Back”, which became a national YMCA program. The program was developed by Hans Kraus, MD who was considered the father of sports medicine in the USA and Alexander Melleby, MS. In a study, performed by Melleby, which examined the effectiveness of the program looked at close to 12,000 subjects and it was determined that 80% of the participants of the program enjoyed moderate to complete relief of their pain and so did 82% of back surgery patients. The program was taught twice a week for six weeks and was taught in levels 1, 2, and 3. Unfortunately the program was discontinued once the original founders retired and other professionals made “improvements” which curtailed the overall effectiveness of the original protocol. This program was hinged on the endorsement of the medical community at the time to recognize the need for this type of physical reconditioning and required a prescription for participation.
A BIG part of the exercises is relaxing so that tension is relieved (remember, tension is the #1 cause of muscle pain listed above). DO NOT SKIP THE RELAXATION PARTS!!! This program is based on relax, limber, stretch, and strengthen.
Trigger Points and Referred Pain
Let’s look at the example of a cardiologist who sees a patient presenting with chest pain which extends into the left upper extremity, however diagnostic testing rules out an infarct, pulmonary and other visceral conditions – so where does the patient end up? In some cases the patient is then discharged and then ends up back in the ER with another recurrence, and yet another clean batch of diagnostic testing.
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Scalenes
In this case it would be good to know how trigger points may be responsible for the pain the patient is experiencing as well as how to quickly assess and differentiate which muscle(s) may be responsible.
The muscles most likely to be responsible for chest pain with pain in the left upper extremity are the pectoralis major/minor (Images A, B, and C) or even the scalene muscles in the neck.
Many times palpation of these muscles will reproduce or exacerbate the pain complaint of the patient which is clinically diagnostic of the presence of trigger points.
The patient may then be referred out to a practitioner who knows this work and is capable of producing results.
A few words of caution:
- Strengthening exercises make trigger points WORSE.
- Stretching without deactivation of the trigger points may potentially make the pain worse.
There are also a specialized group of blood tests, listed in Medical Perpetuating Factors, which may be performed to help determine if there are other systemic considerations acting upon the muscular system.
Note: The tests you will see listed here are not the ONLY tests which should be done and are merely an example of the ones which are not routinely performed, but possibly pivotal in attaining a resolution. Also, the notes on interpretation of the suggested “Laboratory Reference Interval” are derived from specialists in the practice of myofascial pain and should be considered in all chronic pain patients.
Footnotes:
- Marcus NJ, Arbeiter JS. Freedom from Pain. New York: Fireside; 1994
- Boyle, RH. The Report That Shocked the President. Sports Illustrated. August 15, 1955. Available here in the online Sports Illustrated Archive Accessed November 16, 2009.