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Pain referral
Trigger points
Cranial nerve
Spinal nerve
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Body posture is more comprehensively addressed
in the somatic extended exams. In those areas we will be addressing dysfunction
and compensation for dysfunctions and therefore we will be omitting them here.
In this area we will be addressing issues that are predominantly attributed to
psychosocial or situational somatic factors.
As youths we frequently develop poor posture
to appear cool or to be ultimately comfortable. By the time we reach adulthood
if this lack of social amenity is not corrected our posture can be the
perpetuating factor for numerous myogenic and or segmental neurogenic
complaints. Individuals, whom hold themselves in high esteem or have a good
self-concept or image, usually have erect posture, are open as it pertains to
body positioning, allude confidence, and are attentive.
Individuals with diminished self-concept have
a tendency to exhibit indirect gaze, persistently look down, avoid social
interactions, will allow their shoulders to droop and round and will slump while
seated or standing. These body mechanics, frequently referred to as body
language, are regarded as closed. With this closed posture there is a
correlation with depressive states. Not only are muscles abnormally lengthened
and shortened while persistently assuming these body positions, but also the
tendency of psychogenic manifestation under-lying their pain complaint is
greatly increased.
However, the observation of persons constantly
exhibiting poor posture is not presumptive of clinical depression or neurosis.
As an example: I had a young female under my care that alluded self-confidence
in every area of her personal and professional interaction. However, she
persistently sat with her shoulders rounded and experienced myofascial and
structural complaints consistent with this posture. After numerous
recommendations to correct this posture, I was informed she had developed this
tendency as a form of guarding against taunts of her breast size as a young
teen.
There was also a male individual who had an absolute aversion to soft
tissue work being performed on his hip even though it was dysfunctional,
effecting his structural alignment and perpetuating low back pain. He attributed
this aversion to severe spankings received as a child and therefore, constantly
kept his gluteal in a state of contraction. This resulted in persistent
bilateral external rotation of the femurs. Therefore, we constantly see
individuals whom are guarded due to previous psychological or physiological
trauma, which results in chronic postural change.
When pain has been persistent and finally
eliminated, sometimes there is a tendency to still protect that region. This
physical adaptation frequently leads to structural misalignment, and the
mechanical overloading of muscles resulting in the referral of pain to unrelated
and previously unaffected parts of the body. When we use the term, “Mechanical Overload”, it should not be
confused with the sudden overloading of a muscle where the resulting effect is
trauma. Our usage applies to normal gravitational forces persistently placed on
structure and the soft tissue’s adaptation or compensatory quality to address
those forces.
Just as the young lady adapted her posture in
an attempt to conceal her bodily features, it is not uncommon to observe
individuals adapting their posture when they’ve experienced sudden weight gain
or pregnancy. Thus, providing a two-fold dilemma for the practitioner as it
pertains to perpetuating factors, and the individual’s ability to respond to
care.
Dr. Travell was not only renowned for her
prodigious works and her appointments as a presidential physician but was
acclaimed for reintroducing the benefits of properly fitting furniture
(predominantly the rocking chair) as ergonomic devices which could minimize
mechanical overload or perpetuate TrP’s if selected improperly.
If the seat of a
chair is too high, a femoral and/or hamstring compression may ensue resulting in
the activation of TrP’s and/or paresthesia due to neurovascular impingement.
Should the seat be too low, with the knees being elevated above the level of the
hip, iliopsoas syndrome can occur.
With persistent sitting all ergonomics are
critical. Dr. Travell recommended that within the office setting a timer be used
to serve as a reminder for the individual to get up, walk and stretch,
approximately every twenty minutes.
Varying
degrees of lumbar support should be calibrated to provide proper ergonomics for the
concavity of the lordotic curve of the lumbar spine. Failure to support this
region mechanically overloads the low back extensors and the activation of
triggers. This area is also compromised during sleep if support is insufficient.
Persons who sleep on their side or stomach with their knees elevated frequently
do so to shorten the iliopsoas or hip rotators. When these muscles are
dysfunctional and abnormally shortened, it is uncomfortable to obtain rest while
in their lengthened position. However, giving in to their dysfunction by
allowing them to remain in a shortened position only exacerbates the degree of
dysfunction.
The rhomboids and pectoralis muscles are compromised by
round-shouldered posture or improperly designed furniture, which has the
tendency to translate the shoulders forward. This can give rise to upper back,
chest and shoulder pain. Occasionally, individuals persistently sit backwards in
low back chairs which can again result in deep aching upper back pain from
rhomboid, trapezius, subscapularis, infraspinatus and pectoralis major TrP’s.
If
the arms of a chair are too low, which can be determined by their ability to
support the forearms when the upper arms are at their normal resting length,
this mechanical overload does not only effect the pectoral skeleton but can
result in a multiple group dysfunction of the levator scapulae and the posterior
cervical muscles.
Conversely, if the arms are too high, there is a tendency to
shorten the pectoralis muscles, the upper trapezius, and the levator scapulae
with a possible resulting of multiple group dysfunctions of the anterior as well
as posterior cervical muscles. Individuals exhibiting this trait appear to be
persistently shrugging their shoulders while in a seated position. Frequently,
persons under chronic stress maintain this shrug-shoulder appearance. It is more
comfortable for them to sit at a desk or in a chair with elevated arms to avoid
the pulling sensation of having unsupported elbows; this compounds their
dysfunction by giving in to the contractile response of persistent tension.
While they have a tendency to roll their shoulders to stretch these muscles and
gain relief, they will inevitably adopt ergonomic positions that elevate
shoulders in their course of daily living. Thus, positions that are frequently
employed for comfort are the chief cause of perpetuation of active TrP
complaints and the practitioner will only be successful in reducing a phase one
or two trigger to a phase three if they have not corrected this perpetuating
factor.
Individuals that have articular disease or are
infirmed to the degree they are either bedfast or wheel chair bound have a
combination of perpetuating factors. Not only do they experience shortened
muscles from immobility but often experience mechanical overload from poor
posture and chronic psychic stress from diminished productivity. Additionally
they may experience the nutritional and metabolic dysfunction associated with a
sedimentary life style and extensive pharmaceutical profiles.
Congenital or developmental structural
abnormalities such as scoliosis, hyperkyphosis, hyperlordosis, a long second
metatarsal, small hemipelvis, or long bones, which are asymmetrical in length,
frequently result in mechanical overload resulting in the perpetuation of TrP’s
and pain. While this dysfunction usually occurs on the same side as the
structural inadequacy, frequently the unaffected side develops active TrP’s due
to compensation for inadequacy or pain.
Development of a biomechanical short leg
or scoliosis perpetuates TrP’s. Through corrections of the pelvis, low back and
cervical regions clinical short leg, curvature and TrP concomitance may be
remedied. Pathological developmental osseous malformation is usually addressed
through the utilization of shoe inserts or in the most severe cases, surgical
intervention. However, manual technique may be employed, if not surgical grade,
to temporarily remedy triggers. Some of the other structural stresses can result
from a short first metatarsal bone or from short upper arms in relation to torso
height.
Compensatory posture due to shortened or
abnormally lengthened muscles can result in biomechanical structural asymmetry,
which will elicit mechanical overload and active TrP’s as in developmental or
congenital abnormalities. Obviously, the corrections afforded to either the
soft tissue or structure with no underlying pathology are longer in duration
providing that the perpetuating factors for those abnormally lengthened or
shortened muscles are identified and remedied. Usually ergonomics, repetitive
usage resulting in over development, under development of the contralateral side are
the primary considerations for muscle length, strength and function. Their
tensile compressive forces must be thoroughly evaluated to understand their net
effect on structure.
Degenerative disease of the bone and joints is
usually gradual in onset and also gives rise to postural change and mechanical
overloading. When we use the term, “Mechanical Overload”, it should not be
confused with the sudden overloading of a muscle where the resulting effect is
trauma. Our usage applies to normal gravitational forces persistently placed on
structure and the soft tissue’s adaptation or compensatory quality to address
those forces.
Thus, degenerative conditions of the bone and joint while usually
discernible through radiograph can yield mechanical overload as a secondary
effect to that osseous pathology. Therefore, persons who develop hyperkyphosis,
osteoporosis or slipped rib syndrome may have a long period whereby, in the
developmental stage of these conditions, they are clinically silent for pain.
Inevitably as the disease progresses there will be compensation or deformation
in posture resulting in persistent mechanical overload, or myogenic
dysfunction and pain.
Unfortunately, without the ability to
surgically intervene, palliative relief is all that is possible. However, a
periodic application of manual care, which provides relief, is superior to no
relief at all. While it should be the goal of every practitioner to avoid
treatment dependence of an individual, in cases of chronic, recurring pain, it
is justified when other treatment options are inappropriate, ineffective or
nonexistent.
Repetition of action causes muscle fatigue.
Fatigue frequently escalates clinically silent latent trigger points to an
active phase. While often observed with assembly line workers and transcriptionists, this perpetuating action is frequently performed
unconsciously in other areas of the population.
Just as muscles that are
fatigued test weak so does a muscle that contains TrP’s. Therefore, should the
practitioner observe deficient testing, scrutiny should be utilized to determine
between fatigue, trigger point or possible segmental neurologic involvement.
Excessive usage of a muscle or traumatic
overload will result in a muscle strain or tearing. This tearing of muscle
and fascia will result in the formation of adhesions. Within these
adhesions trigger points may form. Therefore, anytime a practitioner has
an individual with a history of a soft tissue injury, they should suspect
possible TrP development within the site of injury with its TrP referral being
unique to that individual and that trigger point formation.
Frequently individuals wear either restrictive
clothing or develop habits, such as carrying a shoulder bag in the same
location, which constrict muscles and decrease blood or lymphatic supply or
drainage. Such is the case with tightly banded socks, belts, and watches.
Dr. Travell, in addition to these authors, noted the tendency of trigger points to
form in the latissimus dorsi and the trapezius of large-breasted women whom wore
bras, which either had thin straps that cut into their shoulders or lateral
straps that were secured too tightly. More recently, there have been studies
performed pertaining to the under wire support and its propensity to restrict
lymphatic drainage and vasal circulation.
Additionally, individuals who persistently
wear under wire support appear to have a higher propensity for breast
cancer. Practitioners will note significant tissue change while palpating
slightly inferior to the mastic cleft. It should be noted that these
preliminary findings are not considered scientific fact at this time.
However, common sense would dictate that normal tissue function cannot be
conducted when a self-imposed tourniquet is applied. © Copyright
Myofascial trigger point perpetuating factor: mechanical stress