mayofascial trigger points

5 October 2009

Taking Control of TMJ: A Review of the Book

Most people will understand why we’re talking about a book on TMJ – that is, temporomandibular joint disorders, on a site about headache and migraine. What not everyone understands is the complex relationship that TMJ can have with various other disorders.

In his book Taking Control of TMJ, Dr. Robert O. Uppgaard does give us some insight into how issues in the TMJ, the jaw joints, can come from problems in the rest of the body, and can also cause problems all over the body. Headaches in the temple, migraine, fibromyalgia, whiplash, mayofascial trigger points – this is not a simple linear relationship, but a web of relationships that Dr. Uppgaard takes seriously.

Trigger point diagram from Taking Control of TMJ

At only 184 pages (included a glossary, index and appendices), there’s a lot of information packed in a small space, which most people will appreciate. And this isn’t just a book of information on TMJ disorders – it really is a workbook.

And I think that’s what I like best about Taking Control of TMJ – it’s very practical. It’s packed with tips and how-tos, diagrams and charts, but also simple checklists for you to work through.

The smallest tips can be the most helpful. For example, I always used to end up with migraine attacks on days I visited the dentist. Dr. Uppgaard’s tip, slipped in on the end of page 51? "Tell your dentist to allow you to exercise your jaws intermittently during dental work."

I wonder how much pain that simple tip could have saved me?

And how many books have I said that give vague instructions about how to do various exercises, leaving me with no idea if I’m doing it right? The clear and specific instructions, with diagrams, leave me with something I can actually use. Dr Uppgaard even gives examples of case histories and why, from his experience, these exercises can benefit you.

Here’s an example:

Exercise 2: Stretching the Jaw and Increasing Range of Motion

Purpose: This exercise helps you to relax the opening muscles, stretch the closing muscles, and remediate limited jaw opening.

Precautions: Do not do this exercise if your jaw is is acutely strained or if you experience grating, clicking, or popping.

The Exercise: Do the exercise for one to two minutes, twice a day. Use ice or moist heat, whichever feels comfortable to you, over the sore area of the muscle as you do this exercise.

Gradually increase your jaw opening by placing one knuckle or an object of equivalent size between the teeth.
Rest on knuckle or object for sixty seconds.
Increase to two knuckles and finally three, as you feel comfortable.

Of course all this is in a context of many exercises and tips and what needs to be used when and by whom.

Another thing I appreciate about this book is that it draws (selectively) from a wide range of other experts. There are other sources you can read for more information, of course, but a lot of the research from various other sources is right here in the 184 pages. You’re not left feeling like you have incomplete information.

Not that you’ll agree with every expert. There’s a difference of opinion, for example, on the significance of the origins of yoga. Dr. James Baltzell, the book’s expert on the topic, differentiates between yoga and religion, but doesn’t take into consideration the importance of yoga’s religious roots. In my opinion, it’s important to understand clearly where treatments come from and what they’re attempting to accomplish before choosing what to focus on.

That aside, the majority of the information here is excellent, and for such a short book the breadth of practical information is amazing.

As I started out saying, the connection between TMJ disorders and migraine or headache disorders is complex, and Dr. Uppgaard recognizes this. Now many people have had almost complete healing after dealing with TMJ issues, and the book has many amazing examples. On the other hand, for many people TMJ is one of a complex web of problems.

But the fact is, many people with chronic migraine or headache diseases have major TMJ disorder related problems and don’t realize it. By dealing with the issues that Dr. Uppgaard will take you through, I’m convinced many people can see a significant improvement.

This is one book I will actually be able to use, because it’s so easy to pick up and work with a few minutes at a time. Without presuming to be the solution to everyone’s problems, Dr. Uppgaard provides practical, easy to follow tips that more of us need to pay attention to.

9 March 2009

Trigger Points: Identification, Myths, and Preparing to Fight them

James Information, Treatments 1

This is the third in our series on mayofascial trigger points, headache, and migraine. We started with Trigger Points and headache – Fakery or Fact? Then we tried to figure out if they’re a factor when it comes to headaches and migraine with Trigger points – do they trigger headaches? (I know, I’m taking a long time to get through the series. But a significant amount of research is going in to this one!)

So what’s next? Well, we’re going to find out how to treat them, of course. But before we get into specifics (in the next post in the series), we’re going to get some background on trigger point treatment – things you need to know before you’ll see it really work for you.

Blasting Myths about Trigger Points

Trigger Points - causing you a headache?

First, let’s clear up some common myths about mayofascial trigger points (MTPs):

Trigger points are not consistent. Some people think they always get them in the same pattern causing the same pain – sometimes there can be consistency, and there are patterns, but you can’t rely on them. Just when you think you have it figured out, something changes.
MTPs are not always in the same location as your other symptoms. In other words, just because you have a headache in your temples, that doesn’t mean that the MTP is in your temple.
You can’t necessarily feel a trigger point. Some people associate MTPs with muscles that feel "tight", or little "lumps" or "knobs" in muscle tissue. That could be a MTP, but some are small enough (or hidden enough) that you can’t feel them, but big enough to cause problems.

Are Trigger Points causing YOU problems?

Sometimes it’s very hard to tell. I’m willing to bet, however, that if you’re having any kind of consistent headache, or migraine attacks, or cluster headaches, that MTPs are a factor. Sometimes they’re a hidden factor, but other times they’re quite obvious. When they are more obvious:

Part of your muscle is intensely sensitive when moderate pressure is applied
Pressing on some MTPs make the muscle twitch
You might feel muscle "tightness"
The pain you feel when applying pressure on the trigger point may be "good pain" – in other words, it hurts, but feels like something that is "needed"
Your body often makes more "noise" where trigger points are – such as popping, crunching noises
Your muscles feel tired and heavy, or stiff, or there is a dull, nagging pain
Heat makes it feel better

On the other hand, if the pain is due to a recent injury, or it comes on suddenly, it’s extremely sensitive to light pressure, the muscle is sore all over, or you have consistent sharp pain – that’s probably not a trigger point (and may be a reason to see your doctor!).

You should especially see your doctor if you have pain that is consistently getting worse and worse. Trigger points tend to come and go, or stay the same.

How to make Trigger Points worse

We’ll talk more about the practical side of treating trigger points in the next article. But today, let’s see a few things that can make the problem worse, and stop treatment from being as effective as it could be.

Not dealing with stress. If you’re letting yourself get stressed-out, this could make MTPs flare up
Shallow breathing. Deep breathing from time to time can help keep MTPs away.
Awkward positions. Especially those you stay in for a long time. Weird sleeping positions, sitting standing…
Actually, staying in one position for a long time, even if it’s not awkward.
Muscle relaxants. Actually, they don’t make the situation worse so much, they just don’t help.
Over exertion. Over exercising, or trying to do something that’s just over the top.
Not treating another problem. Yes, treating trigger points may help cut down your migraine attacks. However, you will likely still need to treat migraine itself, especially if you’re in a bad cycle. You may need to break the cycle first, then in the future trigger point therapy may be all you need. This goes for any headache or condition that may cause a pain cycle, or make your MTPs worse.
One more great way to make MTPs worse. Don’t be flexible in your treatment. Learn one way from Uncle Joe, then stick to it forever, no matter what your body is telling you.

Coming up…

What if I told you that trigger point therapy is better than Botox? Many of you know that Botox has become a treatment for more than wrinkles. Some migraine patients have found that it helps (more on Botox for migraine).

The amazing thing about Botox is that it kills MTPs – temporarily. Sounds great, right?

Well, it’s pretty good for that one trigger point. But MTPs that are setting off your headaches or migraine attacks could be almost anywhere on your body – and it’s different for everyone! An invasive procedure, such as a Botox treatment, is still a lot of guesswork when it comes to an individual. You’re only treating a few specific locations.

Mayofascial Trigger Point therapy has some advantages. You can treat more areas with a less invasive treatment. You can learn over time where the offending MTPs are.

And best of all, it’s usually a lot cheaper. Very often you can do trigger point therapy all by yourself!

And that’s what we’re going to look at in the next article – how to start knocking out those trigger points on your own, to cut back on those headaches and migraine attacks.

Once again, this information comes from a variety of sources, but I’m especially indebted to Trigger Point Therapy for Headaches & Migraines: Your Self-Treatment Workbook for Pain Relief by Valerie Delaune and Save Yourself from Trigger Points and Myofascial Pain Syndrome! by Paul Ingraham.

9 February 2009

Trigger points: A key to stopping Cluster Headache Pain?

James Discoveries & Stats 2

I was mentioning in a previous article that I would like to see more studies on cluster headache and trigger points. Well, looks like researchers are getting going with making my wish come true!

The question is this: do myofascial trigger points have anything to do with cluster headache pain? And if they do, what if you could desensitize the trigger points – would the pain decrease?

One small study found the answer to be yes. Patients with both episodic cluster headache and chronic cluster patients were evaluated. They all had mayofascial trigger points. Then they were given anaesthetic injections – some before an attack, and some in an attempt to stop an attack.

The injections were successful in almost 85% of patients. Researchers feel that, along with other preventative medication, injections in trigger points may be a significant treatment for cluster.

Of course, this research isn’t just for the purpose of using anaesthetic injections for treatment – it also confirms that trigger points are a factor in cluster headache pain. That means that other trigger point treatment could lead to significant improvement in cluster headache patients.

23 October 2008

Trigger points – do they trigger headaches?

James Discoveries & Stats, Treatments 4

Mayofascial trigger points (MTPs or TrPs) may cause the odd muscle pain. But what about headache? What about migraine? Is there really a relationship? If so, is it only in a few people, or is it widespread?

This is the second in our series on mayofascial trigger points. In part 1 – Trigger Points and headache – Fakery or Fact?, we found out what MTPs are, and we talked about how they may trigger headache or migraine. But could this be you? Let’s take a look.

Referred pain?

The first thing you have to remember about headache and MTPs is the concept of referred pain. You probably already know what it means – the source of the pain is in a different spot than where the actual pain seems to be coming from.

Then again, it might not be all that simple. What if a trigger point made you more susceptible to, say, a migraine attack? What if it just lowered your threshold?

Tension type headache

There are actually a whole host of things that can trigger the tension type headache reaction. Tension type headache (TTH) can be chronic, and can be seriously disabling. These headaches are usually a steady band of pain. We know things like insomnia, painkiller overuse, bad posture and caffeine withdrawal seem to trigger TTHs, but we’re still learning about why some people get them frequently and others don’t.

In fact, the whole idea that these headaches are caused by muscle tension is highly questionable – which is why they’re usually called "tension type headache" now.

It does seem that people with chronic TTH have more trigger points. There may be an underlying factor that contributes to both. However, there’s a good chance that massage of MTPs will help you if you have tension type headache, and may help you avoid a lot of pain if you have a chronic headache.

There’s more information about massage in general than MTPs in particular. A 2002 study found that massage of neck and shoulders made a significant difference (Massage Therapy and Frequency of Chronic Tension Headaches by Christopher Quinn, DC, Clint Chandler, BS, and Albert Moraska, PhD).

Migraine

In the first part of this series, I mentioned that a study in 1998 found a relationship between trigger points and the location of migraine pain. Massage of trigger points does seem to improve quality of life – especially helping with the daily headache migraineurs often get between attacks. It may be that trigger points are simply another migraine trigger – always there, sometimes worse and sometimes better, but also making you more likely to go over the edge when yet another trigger is added in.

A 2006 study (A randomized, controlled trial of massage therapy as a treatment for migraine by Lawler, S. P. and Cameron, L. D.) found that massage in general did help fight migraine attacks. And they noticed one more interesting thing – the massage also helped with sleep. Generally, if you can improve sleep you can cut down on the intensity and frequency of migraine attacks.

Cluster

As usual, cluster headaches are the least studied of these three. However, we do know that sleep problems are also related to cluster, as is oxygen deprivation in the body. Even if MTPs and cluster are not directly related, it seems likely that we can improve the situation for cluster patients by treating trigger points.

I would really like to see a long term study on this one, because it does seem intuitive that treating trigger points could make a significant difference.

The strange connection

One final note. Studies are showing a strange connection between "headache disorders" and trigger points. Quite simply, one seems to follow the other (though we don’t know who is following who!). People with headache or migraine tend to have more trigger points. If they have both tension type headache and migraine, even more. Plus, if the pain tends to be one-sided, the trigger points on that side are worse! (from Trigger Point Therapy for Headaches and Migraines by Valerie DeLaune, L.Ac.) Those with worse headaches tend to have more "active" trigger points (see this study for example).

We mentioned one more thing in our last report – it also seems that, the longer you have migraine, the more trigger points you get! Things seem to get worse over time.

These are reasons why some researchers believe that most people with headache or migraine can be helped with trigger point therapy (not cured – I’m saying their quality of life can be improved; less attacks and/or less severe attacks).

Conclusion (and coming up!)

There are a few studies showing that trigger point therapy can help, but we are looking for more studies to show how strong the relationship is, and what kind of therapy can help the most with each issue. Meanwhile, there is reason to believe that there is a strong connection between mayofascial trigger points and migraine, tension type headache, cluster, and other headache disorders.

In upcoming parts of this series, we’ll be exploring not only what kind of professional help to get, but how you may be able to help yourself – significantly.

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30 August 2008

Trigger Points and headache – Fakery or Fact?

James Discoveries & Stats, Treatments 14

Has this happened to you? You have a headache, and a friend says,"Here, just press your finger there and it will help you feel better". They explain to you that it’s a trigger point, and that they learned all about it from their Mom/massage therapist/Uncle Frank. So what is all this Trigger Point Therapy stuff? Is it just folk remedy mumbo-jumbo, or does Uncle Frank know what he’s talking about?

I’ll tell you right up front – Frank is not completely out to lunch. Still, he may be confused about exactly what trigger points are. But trigger point therapy is a real and well researched treatment, with great potential to keep the pain in your head away.

Muscles

To understand what trigger points are, you need to understand how muscles work. A muscle’s job is to contract. So how does it do that?

Your muscle is made up of bundles of cells called fibres (fibers), smaller around than one of your hairs. A fibre contains myofibrils, which are made up of protein filaments. These proteins slide past each other, which causes the "contraction" or movement of your muscle. This complex system in the myofibril is called a sarcomere. (we’re focusing on skeletal muscles here – other types are arranged differently)

We could get a lot more complicated, but I just want you to remember these tiny sarcomeres are contracting, and that means the muscle is contracting.

When trigger points appear

So when we’re talking about trigger points, (more properly mayofascial trigger points or MTPs) what do we mean? Once in a while, these sarcomeres go crazy. A bunch of them all contract together – a part of the muscle contracts, as opposed to a full muscle cramp. The muscle actually ends up in a tug-of-war with itself, meaning that some of it is pulled together, and some is stretched tight. The patch of clenched muscle actually gets very sick, actually cutting off its own blood supply.

Now the problem is you can’t really use the part of the muscle that’s "stuck" like this. You can’t strengthen it, you can’t stretch it – it just stubbornly folds its hands and refuses to do anything.

Where do they come from?

People who have regular headache or migraine attacks will appreciate this one – we have an idea what gets them going, but in the end they’re very unpredictable. Certainly an injury or poor posture can aggravate a muscle. But there are also major trigger points that seem to appear out of nowhere. Or, pain itself could actually trigger them – chronic headache, anyone?

Tracking down trigger points

So is that what we call a knot, or a tight band? Well, it could be. But the truth is, you can’t always feel trigger points, and sometimes something that feels like one isn’t. A trigger point could actually be tiny – even microscopic – making it very tricky to find!

The most common way to identify trigger points is how they feel to the patient – they’re often sensitive and painful – but strangely it’s a "good pain" – there’s a feeling like release when the trigger point is worked on.

Trigger points and your head

There are a lot of things going on in a trigger point. Not only is the muscle tissue unnaturally contracted, there is also a soup of metabolic waste around the area. These acidic chemicals could have a lot to do with the pain – and may show why the problem of trigger points goes beyond the exact area.

MTPs not only cause pain where they are, they can mysteriously cause pain in other parts of the body. Just because you have pain in the back of your head doesn’t mean the MTP is there – it could be in your lower trapezius muscle – in the middle of your back!

What kinds of signals are these chemicals sending to the rest of your body? We don’t understand everything that’s going on, but we do know that migraine, for example, is tightly connected to the pain signals and sensitivity of your body. Recent studies have shown that a) migraine patients very often have trigger points related to their areas of pain (Calandre et al. 2006) and b) working on trigger points can improve quality of life for those with chronic migraine, especially helping with the headache pain people often get between the major attacks (Jensen et al. 1988).

Ignoring mayofascial trigger points

Ignoring these problems is not a good idea. In fact, if left long enough, serious MTPs may cause permanent damage.

The researchers in the study mentioned above discovered that people who had had migraine symptoms longer also had more trigger points. That’s right, it looks like there is a cumulative effect! The pain of a headache may bring on MTPs which can trigger more headaches… More evidence that you should not just "hope the problem goes away" – whether it be chronic headache, migraine, or the trigger points themselves!

Coming up

This is the first post in a series on mayofascial trigger points and headache. Later on, we’ll go more in-depth on how trigger points may be involved in the cluster headache, migraine or tension type headache scenerio, how they can be treated, and what you can do on your own to fight back. Stay tuned!

Fakery or fact?

Fact, but regularly misunderstood or ignored. To quote Paul Ingraham, Registered Massage Therapist and trigger point researcher/writer:

Trigger points are not a flaky diagnosis.

You can take photomicrographs of them, measure their electrical activity, take samples of their acidic and toxic tissue chemistry, and a new MRI-like technology can now show them as well. They rest on a bedrock of thousands of scientific papers published in mainstream, peer-reviewed medical scientific journals. Detailed charts of the patterns of pain that they cause, as seen at the right, are widely available.

The pioneers of trigger point research still are and always have been medical doctors like Janet Travell1, David Simons, Siegfried Mense, and Chan Gunn.

You can take pictures of trigger points, and take samples of their toxic tissue chemistry.

So, I repeat, the existence and importance of trigger points is not scientifically controversial. The problem is educating health care professionals and getting the word out.

Paul Ingraham from his article Save Yourself from Trigger Points and Myofascial Pain Syndrome!

Credits/To find out more

Some of the sources I consulted for this article: An overview of how muscles work here. Study New Views of Myofascial Trigger Points: Etiology and Diagnosis, and definitive manual (for professionals) Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, materials from Paul Ingraham including this article on the physiology of sarcomeres, and Trigger Point Therapy for Headaches & Migraines: Your Self-Treatment Workbook for Pain Relief by Valerie Delaune.