Trigger Point Therapy for Myofascial Pain (5 page)

Myofascial meridian therapy operates from this simple unifying construct. Movement, harmonious activity, unimpeded flow of bodily fluids, unimpaired nerve transmission, and the free range of motion of muscles and joints are all connected to health and life: this movement can be collectively described as qi manifesting. Constriction, impingement, entrapment, ischemia, and excessive tightness, all associated with dysfunction and pain, can thus be considered in terms of some reduction in movement. Be it of an organ, muscle, fluid, or electrochemical impulse, with pathology there is some interference with flow, with movement, with qi. Death is the result of its ultimate withdrawal.

Given the functional definition of qi as movement, myofascial meridian therapy is concerned not with “moving” some substance called qi,
but rather with removing or minimizing disruptions to movement itself.
Our inclination is to trust the inherent wisdom of the body; we endeavor to provide an optimum environment in which the body can heal itself. Therefore it is the role of the myofascial meridian therapist to release constrictions and promote flow. While the fundamental approach is myofascial, the broad concepts and patterns of the meridian system are also embraced. The successful release of myofascial constriction comes from applying knowledge and understanding of these meridian patterns in conjunction with the ability to palpate and release constrictions within the muscular and fascial systems.

Diagnosis, therefore, is intimately associated with treatment, since the diagnosis is neither of internal diseases or patterns of disharmony as theorized from an Eastern perspective nor the expression of Western medical pathologies. Rather, to diagnose from a myofascial meridian perspective the practitioner palpates the body to locate patterns of constriction and then uses acupuncture or manual techniques to release these constrictions. Principles of Oriental medicine guide the direction of care.

Myofascial meridian therapy is concerned with constriction not only in the muscles but also in the fascia. The fascia is unique in human physiology, existing as a single continuous sheath that extends from the head to the toes, encasing every organ, muscle, and muscle fiber as it winds through the body. Consider the definition of fascia as proposed by Dr. William Henry Hollinshead:

When the normal connective tissues of the body are arranged in the form of enveloping sheaths, they are usually known as
fasciae
(fascia means a bandage or band, and thus connotes a layer binding together other structures). Thus, the subcutaneous tissue or tela subcutanea is frequently called the
superficial fascia
. Numerous examples of well developed, tough, deep fasciae occur, especially in the limbs, where fascia forms heavy membranes surrounding the entire limb. Individual muscles are also surrounded by thin fascia called perimysium and are separated from each other by looser connective tissue. . . . From the fascia surrounding a muscle, connective tissue septa pass into the muscle and subdivide it into bundles; these septa, in turn, divide until delicate connective tissue fibers surround each muscle fiber within a muscle.
⁹

The superficial fascia covers the entire body subcutaneously. It is composed of two layers: the outer layer contains fat; the inner layer is thin and elastic. Lying between the layers of superficial fascia are the arteries, veins, lymphatics, mammary glands, and facial muscles. The deep fascia lines the body wall and the extremities; it holds the muscles together and separates them into functional groups. Deep fascia allows for the movement of muscles. It assists in support and stabilization, aiding in the maintenance of balance. It carries nerves and blood vessels, fills spaces between the muscles, and sometimes provides attachments for muscles. Fascia facilitates circulation of the lymphatic and venous systems. Differentiation of the deep fascia begins with the envelopment of the individual muscle by the epimysium, the external sheath of connective tissue. The epimysium further differentiates into the perimysium, the fascia that wraps bundles of muscle fibers (fascicles), and this further differentiates into the endomysium, which penetrates the interior of each fascicle to enwrap each muscle cell. This system is continuous with the structure of tendons that attach muscle to other structures.

Doctor of osteopathy John Upledger describes the fascia as “a maze which allows travel from any one place in the body to any other place without ever leaving the fascia.”
¹⁰
Fascia's pervasive, continuous nature may explain many of the distal effects of acupuncture or other meridian-based forms of bodywork. Paula Scariati, D.O., observes that changes in the fascia due to age or trauma “set off chain reactions that may compromise the vasculature, nervous system and muscle as well as change the movement of body fluids through the fascia.”
¹¹
It logically follows, then, that if constriction of fascia can produce dys-function, the release of constriction within the fascia can lead to a return of function.

There has been much speculation on the functional mechanism of acupuncture; much has been made about the activation of betaendorphins, a powerful pain supressant, resulting from acupuncture treatment. Actually, the experience of any systematic minor pain will give rise to the inhibitory response of endorphins—pinching the skin anywhere will produce endorphins. It is conceivable that endorphin activity is a pleasant secondary effect of acupuncture treatment and is unrelated to the mechanism that underlies its more powerful effects.

It is more probable that the answers to the question of how acupuncture works lie in the study of the little understood and complex mechanisms that govern the fascia, muscles, skin, and adipose tissue of the body. The fact that dramatic releases of muscular constriction can be affected by surface needling is well documented by Travell and Simons on a muscle-by-muscle basis. Such release is also capable of exerting powerful visceral effects. The probability of understanding acupuncture lies in the reality of what is actually being done to the patient: a needle is being inserted into tissue, and such insertions and manipulations have extensive local and distal effects.

Ultimately we should consider the simple fact that, in the realm of acupuncture treatment and bodywork, practitioners insert needles or apply manual-therapy techniques to skin, adipose tissue, fascia, and muscle. Significant effects are exerted by such treatment. Practitioners can say they are manipulating qi by treating points on the meridians, but they cannot deny that they are also manipulating skin, adipose tissue, fascia, and muscle.

What is the difference? Why make an issue about qi? Consider this perspective: Rather than moving some invisible, untouchable “substance” (that is, qi),
treatment tissue opens constrictions and promotes the movement of all bodily functions and activities
. The point is to focus our attention, and therefore
of the skin, muscle, fascia, and adipose
to focus our skills, on what we definitely can and do affect: physical structures, such as the muscles and fascia. Just as qi cannot be experienced directly, in a model where qi cannot be manipulated directly the increase in movement, or flow, occurs as a consequence of releasing myofascial constrictions. The easing of myofascial restriction therefore results in improved circulation, lymphatic drainage, and nerve conduction. Additional results may include improved organ function (such as lung tidal volume, digestive activity, or uterine function), depending upon the location of release. Such focus on myofascial constriction, instead of on qi, allows for a shift of perception to a readily identified source of pain or pathology, which, when released, results in improvement of the condition.

These basic tenets of such a physical medicine underlie treatment effects that go beyond pain management. This is best understood by considering the somatovisceral and viscerosomatic reflex connections—that is, the relationships between the soma (the musculature) and the viscera (the organs), a phenomenon recognized by the fields of osteopathy and chiropractic and utilized in their diagnoses and treatments. The
somatovisceral reflex connection
is defined as muscular disruptions that alter the ability of related visceral organs to function properly. These are situations in which myofascial constriction directly results in visceral symptoms such as tachycardia, angina pectoris, diarrhea, vomiting, food intolerance, and dysmenorrhea. (The phenomenon of somatovisceral effects is also discussed in detail by Travell and Simons.) Conversely, the
viscerosomatic reflex connection
is defined as dysfunction of the myofascia resulting from disease or dysfunction of a related visceral organ. When applying the basic principle of myofascial meridian therapy, the identification and release of patterns of myofascial constriction includes but is not limited to the release of trigger points in individual muscles. Myofascial meridian therapy involves the release of a region, a quadrant, and ultimately the complete body. This leads to freedom of movement throughout the organism on multiple levels, superficially as well as deeply, directly or indirectly affecting the viscera and resulting in improved health.

Clearly this physical approach to diagnosis and treatment differs from the traditional Chinese medical model in that the prominent use of herbs parallels the use of pharmaceuticals in Western conventional medicine; neither has proven to be markedly effective in treating chronic and acute myofascial pain. This failure lies in the inability of such medications, Eastern or Western, to focus on the central issue of these patterns of pain. Acupuncture and associated bodywork therapies, when utilized as myofascial meridian therapies,
do
in fact focus on the central issues of movement and constriction, and as a result have demonstrated that their greatest power lies in their specifically physical approach.

Many within the conventional medical establishment have noted the often remarkable effects of acupuncture and bodywork therapies on patients who suffer from chronic pain. Herein lies the source of increased communication among practitioners. Medical doctors are beginning to recognize the difficulties in the medical/surgical approach to treatment of chronic pain and are viewing, with greater respect, meridian acupuncture and bodywork therapies as effective
physical
treatment methodologies.

Meridian therapies are based upon the palpatory experience. The exacting nature of myofascial meridian therapy requires enormous emphasis on palpation, with the therapist evolving great skill in identifying myofascial constrictions. The charts of meridians and acupuncture points are used as general maps of areas where specific loci may be identified. Locating acupuncture points is thereby not a function of measurement but rather of palpation, connected to the skill of the practitioner's hands. The points are moving realities that shift on the body landscape. Everything about our bodies is dynamic, moving, changing; in the same way, acupuncture points exist as dynamic rather than static entities. The focus is therefore on constriction, on the real and present reality—treatment decisions are based not on cerebral or intellectual construction but on the practitioner's palpatory experience. Because a fundamental component in the evolution of palpation skill is the ability to visualize and understand what you are feeling with your hands, a working knowledge of the meridian system is necessary and a careful study of anatomical structure, with an emphasis on myology, becomes crucial.

In the practice of myofascial meridian therapy, assessment and treatment happen differently than they do within the Western medical model. Treatment within the conventional medical model focuses on the administration of a drug to effect a change in the symptoms experienced by the patient, without regard for myofascial constrictions that may accompany the symptoms. For example, it is not uncommon for a patient who is suffering with a digestive disorder, such as esophageal reflux, irritable bowel syndrome, or chronic constipation, to be prescribed a medication without attention being given to concurrent myofascial constrictions. This is not to suggest that medications are unnecessary; however, it is becoming increasingly clear that medications are often overutilized to the exclusion of other treatment methodologies from which the patient may also benefit. Using the myofascial meridian therapy model, diagnosis follows not only from the description of the pathology as experienced by the patient, but also from the practitioner identifying associated myofascial constrictions. Treatment is focused on releasing those myofascial constrictions through needling or through manual techniques.

Successful treatment of a patient who presents with irritable bowel syndrome will thus involve the therapist releasing areas of muscle and fascia that commonly relate to such bowel symptoms, and may in fact be reflections of the bowel symptoms—these areas include the rectus abdominis and external obliques. Utilizing principles rooted in the ancient Oriental texts, treatment might also include needling or massaging areas of the Hand Tai Yang Small Intestine and Hand Yang Ming Colon meridians, which pass along the posterior aspect of the shoulder and thus coincide with the infraspinatus and posterior deltoid. Palpation of this region may identify constrictions within local musculature, which would then be treated with needling or manual techniques. This approach to irritable bowel syndrome might therefore also result in improved movement of the shoulder and arm.

Additionally, in assessing the patient the therapist might note a “tautness” or “fullness” associated with the tissues overlying the tibialis anterior muscle distal to the knee, which coincides with the pathway of the Foot Yang Ming Stomach region that is associated with its Hand Yang Ming Colon pair. Treatment by needling or manual techniques to these areas will result in reduction of fullness or a softening of the tautness. The result of this treatment will likely be a deeper, more complete release of tissues leading to an improvement in the patient's overall condition. The therapist is guided by such relationships.