Positive Health Online

In the seventh century, during the Tang Dynasty (618 AD – 907 AD) a renowned physician by the name of Sun Ssu-Miao wrote a textbook (Thousand Golden Prescriptions) which actually described a different type of point. These were not fixed in position along recognised meridians as are acupoints, but appeared on the body if disease or injury occurred. They were points which became spontaneously tender, and were detected by palpation when the troublesome part of the body was examined. When the physician pressed on the point, the patient would cry out 'aah shi!' meaning 'ah yes'. These are still referred to as ah-shi points, or 'points of pain'.

'Ah-shi' may be described as any local tender points to be found in the area of pain that give a reaction when stimulated but which are not recognised acupoints on any actual meridian.

It is important in the examination of a patient that careful examination of the total body is carried out. During the examination it is important to talk with the patient and enquire whether they have had any physical injury, strain, knock, bump and so on. A bruise may not necessarily manifest itself visually and since part of the discomfort from a bruise is the broken blood vessels or capillaries which give the discoloration it may require different treatment to acupressure; one should be careful not to be misled in diagnosis. Time is well spent in diagnosis so that the correct treatment is carried out.

It is by experience and correct use of the hands that one can "feel" this 'ah-shi' point and distinguish it from an acupoint on a definite meridian.

Sir Thomas Lewis, director of clinical research at University College Hospital, London found an interesting phenomenon when he was working on an artificial method of producing muscle pain. He found that injections of saline into muscle produced quite intense pain. Not only that, however, but the pain often extended or radiated a considerable distance from the site of the injection. For example, a saline injection in the triceps muscle often produced pain all the way down into the little finger. Similarly, an injection in the trapezius muscle often produced an occipital headache. The triceps muscle links to the tip of the baby finger along the small intestine meridian. The trapezius muscle links to the back of the head along the bladder meridian.

It was a short step from this to find that certain points were particularly tender in painful conditions with a wide area of pain. When these points were injected with local anaesthetic, the pain in the wider area could be made to disappear.

This phenomenon is the effect of trigger points radiating to other points along the relative meridians.

'Myofascial' (the term comes from 'myo' = muscle, and 'fascia' = connective tissue which envelopes muscles, tendons and joint capsules).

The muscles are the active organs of locomotion. They are formed of bundles of reddish fibres, consisting of fibrine, and endowed with the property of contractility.

The fascia (bandage) are fibro-areolar or aponeurotic laminae, of various thickness and strength. It is the aponeurotic or deep fascia which form sheaths for the muscles, tendons and connective tissues.

Every muscle has a potential 'trigger point'. When this trigger point flares up, goes into spasm and becomes painful often that one trigger point radiates its pain to another muscle. It triggers off pain from the source point to the satellite point.

It is necessary to distinguish between 'myofascial pain' and 'nerve root pain'. The irritation of a nerve and thus nerve root pain, even if in the same distribution, is not to be confused with myofascial pain. Myofascial pain is due solely to activation of trigger points and their associated zones of activity.

There are three kinds of trigger points which develop in the muscles, tendons and joint capsules.

These trigger points can be
(1) INACTIVE
in which case, although they are there, they are like a dormant volcano.

They can be
(2) LATENT
like a rumbling volcano which can erupt at any time.

They can be
(3) ACTIVE
like a volcano in action and erupting.

Each muscle has its own characteristic pattern of pain referral. Often this can cause another trigger point to become active in another muscle within the zone of radiation of the original trigger. These are called 'satellite' trigger points.

The moving parts of the body were created, and intended to move through a specified range of motion freely, easily and completely. When for any number of reasons they lose the ability to do this, there will be a problem. The most prevalent reason for the original loss of free motion is the residual muscle tightening which develops as a result of strain and exertion. Other factors are age, nervous tension, mechanical or emotional stress, infections, inflammatory conditions, exposure to draughts, the over-development of muscle, the secondary effects of injury, maximum effort, and/or the residual effects of previous maximum efforts.

Muscles are arranged in pairs of opposites. a muscle has two main functions. It contracts (shortens) and by this contraction moves the bone of its attachment in the direction of the contraction. The muscle then must release itself completely and be stretched so that no opposition is provided to the opposing contraction. All skeletal motion is produced in this way.

A muscle contracts not in the manner of an elastic band, but by a multiple folding over upon itself many, many times. It must release by a multiple unfolding so that it may be easily stretched to full length. The contraction process is a generated process. The release process is not. It is in the release process rather than the contraction process that motion problems will develop.

Every move produces its greatest stress upon a specific point. For example: as a result of excess tension of muscle tightening, a muscle containing a quarter of a million fibres forms a spasm of approximately ten thousand fibres. It can be so small that you do not realise its presence. With continued use, the spasm becomes aggravated and begins to add more fibres to itself. As it enlarges, it causes pressure. Pressure causes discomfort and pain.

A muscle that cannot accommodate the movement placed upon it will pull or even tear. Thus, a movement normally within the safe context becomes unsafe when shortening and spasm are present.

Because of the interrelationship between muscles, so you have the development of trigger points manifesting themselves on other muscle areas rather than the original source of pain. These are referred by the term 'satellite trigger points'.

Trigger points may be found in muscle which feels perfectly normal, or they may cause two distinctive signs:-

a) Fibrositic nodules – actual round lumps felt in the muscles on palpation. these are commonest in the shoulder and neck areas and the lumbar area.

b) Palpable taut bands – rope or string-like taut muscle fibres around the trigger point. They are likeliest to occur at the edges of large muscles. They run in the direction of the fibres of the muscle.

Trigger points must become deactivated or their effect will linger and become chronic. Then they will extend their activity by activating other trigger points.

Direct pressure with the finger, fingers or thumb are all very penetrating movements. Pressure is magnified many times when applied in this manner. The hyperaemia this produces will last for several hours causing capillary dilation to be retained while excess blood and oxygen softens and prepares the spasm for cross-fibre friction.

Cross-fibre friction may be applied along with any of the direct pressure techniques by simply moving the fingers to and fro across the muscle fibres. The hand should not slide on the surface because the depth and effect will be lost. Hand and tissue must move together.

This cross-fibre action forces adhesed fibres apart freeing them up to resume their normal activity of lengthening and shortening. the entire muscle must be relaxed. This can be done by a series of compression applied to the length of the muscle. Compression is the rhythmic thrusting along the muscle with the heel of the hand or the loosely clenched fist. Remember the spasm was the cause of the problem whilst the tightened muscle was the cause of the spasm.

The use of steroids (cortisone) can initially remove the pain but this is more than often short lived and the pain returns magnified. This is because although the injection of cortisone settles the primary trigger point, it fails to take out the satellite trigger points in the surrounding muscles. These satellite trigger points start exerting pain in their own area of radiation and are quite likely to reactivate the primary trigger point, the cause of the original problem.

The detection of trigger points should not be difficult as the pressure on the point produces what has been described as the 'jump sign'. The patient will tell you of the pain experienced by wincing or crying out.

Be that as it may, it is essential that no trigger point is missed as just missing one trigger point may well reactivate the original problem. Reassure the patient that the slight discomfort experienced during examination is well worth while enduring to ensure the long term relief correct treatment will provide.

The whole area of pain should be palpated for trigger points, tight bands occurring most likely at the edges of muscle . . . and ensure that the adjoining zone of radiation is thoroughly examined to ensure no satellite trigger point has been missed.

Several orthodox medical textbooks and more and more 'open minded' doctors accept that there is a relationship between myofascial trigger points and the acupoints of traditional Chinese medicine.

Just as this open minded approach from the medical profession will accept that myofascial trigger point pain and nerve root pain are to be distinguished one from the other, so it is very important that a practitioner of acupressure also appreciates this difference.

Nonetheless be aware that obvious nerve root pain may also at the same time exhibit less obvious myofascial trigger point pain and vice versa. It is wise, even if in doubt, to treat the trigger point with acupressure. You will do no harm if it is not myofascial trigger point pain by treating it in this way. You may well be able to establish that it is nerve root pain.

It can also be demonstrated that satellite trigger points are on the same meridian as the source myofascial trigger point. But a word of caution – in certain instances the meridian can transfer the 'pain flow' over to a linking meridian and you can find a satellite trigger point on the linked meridian acupoint that is not obviously linked to the source trigger point. These are 'lo points' which connect coupled meridians by a secondary vessel. Coupled meridians are meridians which follow one another in the superficial circulation of energy and, at the same time, are of opposite sign, the one being yin, the other yang. It follows that the former lies on an embryological anterior surface, while the latter lies on an embryological posterior surface.

From the above observations I trust it is evident that myofascial trigger points coincide with the acupoints of traditional Chinese medicine. Normally these trigger points are relatively simple to detect but as I have indicated, be open minded when doing a diagnosis for the obvious diagnosis is not always correct. However experienced the practitioner is, he must be humble and realise that he will not always be right.