photo credit: Pip R. Lagenta - Trigger point release

Massage Trigger Points Role in chronic pain relief

Despite significant back injuries this program achieved improvement in 86% of chronic cases and improvement in 100% of acute cases.

Acute and chronic pain are elusive for the clinician not only in defining treatment but also in measurement. Few treatments have been rigorously tested. Faced with rising health costs and poor clinical therapeutic outcomes, the author designed a medically-supervised program of Shiatsu, Swedish muscle massage, and trigger point suppression as a cost-effective alternative to conventional pain management.

Sixty-three patients with traumatically-induced spinal pain were enrolled, and 52 subjects completed a minimum, of 6 Trigger point massage treatments. The neuropathology findings of a herniated disc and/or spinal stenosis with denervation was present in 89% of acute cases and 68% of chronic cases. An 8-session treatment protocol was created with monitoring by a self-administered questionnaire. Current and maximal pain severity were assessed as well as mobility. Patients and massage therapists were blinded to prior responses. Statistical analysis revealed significant improvement in acute and chronic pain.

Trigger point massage treatments is a cost-effective alternative therapy that should be considered in both acute and chronic pain secondary to trauma. Future studies should determine the implications of these preliminary findings and more fully delineate the specific indications for Trigger point massage treatments in multidisciplinary pain management.

INTRODUCTION

A number of conventional and unconventional treatments are widely prescribed for the management of acute and chronic spinal pain, but few have been rigorously tested in controlled trials. The lack of clinical justification for prolonged and sometimes indiscriminate use of physical therapy and chiropractic treaments, as well as increasing health care costs, give sufficient cause to warrant a more thorough evaluation of the problem. Additionally, recent clinical trials have challenged the efficacy and cost of prolonged bed rest, traction, TENS and facet joint injections.

Similarly, investigators have reported improvement in only one-third of patients in multidisciplinary pain management programs. Perhaps in acknowledgment of the limits of conventional pain treatment, some pain patients have turned to an array of alternative therapies. In a recent Time/CNN poll, 30% of the patients reported use of some form of unconventional therapy

In general, American physicians have taken a skeptical view of alternative medical care, insisting that there is no scientific basis, despite some types being rooted in ancient Eastern healing traditions. Deyo, in a recent editorial has challenged and condemned non-conventional/nontraditional treatments as “fads.”

The concerned physician is frequently faced with therapeutic dilemmas that often result secondary to the limits of traditional modalities. Mindful of these dilemmas, the author, a community-based neurologist, designed a medically-supervised program of Shiatsu, Swedish muscle massage, and trigger point suppression in a hands-on attempt to interrupt the pain cycle and abnormal impulses generated from soft tissue injury.

Massage with stroking, kneading, and other friction techniques prepares the superficial and deep tissues by local involvement of circulation and energy. Shiatsu (Japanese acupressure) makes use of charted points which, when stimulated, lead to reflex relaxation. Trigger point suppression, by direct ischemic pressure, alters the reflex aspects of the pain cycle (10). In addition to the direct response, it is also presumed that these modalities stimulate enkephalin release.

The initial objective of this study was to identify a homogeneous population of pain patients with known underlying patho-physiology and measure pain intensity levels. With this as a baseline, an alternative treatment regimen with Trigger point massage treatments would be utilized to determined if clinical progress could be quantified.

DISCUSSION

Far beyond simply feeling good, Trigger point massage treatments leads to impressive therapeutic effects in pain reduction as well as greater muscle flexibility and tone. Despite the presence of herniated disc, spinal stenosis, denervation, litigation, and prior treatment failure, this program achieved improvement in 86% of chronic cases and improvement in 100% of acute cases. Although these preliminary observations need to be extended over longer periods to determined functional outcomes, they provide the first clinical study of the safety and efficacy of a medically-supervised program utilizing Trigger point massage treatments on a homogeneous population of traumatically-injured individuals. In addition, there was no diagnostic ambiguity as to the causation of pain with the demonstration of structural pathology in 89% of the acute cases and 68% of the chronic cases.

Limitations of study

Several limitation of this study deserve comment. First, the sample population consisted almost exclusively of vehicular trauma and no-fault cases which may not be a representative sample; it is well recognized that pain is a heterogenous problem. The size of the cohort may be considered too small, and the short follow-up of 8 sessions may not be adequate. Deyo and co-workers observed that one month of intervention may be insufficient to expect the full effect and benefits. It should be noted that 13 patients requested and received additional treatment. This represented 25% of the sample. The problem of patient drop-out (compliance) is inherent in all studies despite good intentions. The drop-out rate of 17% in the present study was deemed to be acceptable based upon prior studies.

Clearly, the study was an open, uncontrolled trial. Perhaps the greatest limitation, inherent in any treatment evaluation, especially in traumatically-induced spinal pain, is the degree of spontaneous improvement which may occur. In addition, the placebo effect is also a potentially significant factor in any hands-on treatment program. However, it must be recognized that patients in the acute category were in moderate to sever pain for a minimum of 2.3 months, and that 89% displayed a structural abnormality. In view of the high degree of organic deficit, as well as the prior treatment failure rate of 50%, it would be most surprising to see a significant spontaneous resolution of complaints. The patients in this study comprised a vastly different cohort when compared with those patients in acute cervical and lumbar distress without evidence of herniated disc, spinal stenosis, or denervation where resolution would be expected. Also, it is acknowledged that the influence of litigation plays a role in treatment outcome and cannot be underestimated.

Exclusive dependence upon pain questionnaires for understanding the complex aspects of pain for heterogeneous populations is unacceptable and may be fraught with error due to the subjective influences such as litigation and psychological factors. Thus, objective aspects are more relevant, and, in this regard, the arbitrary creation of the mobility index score is reasonable since the 3 most important aspects of mobility were addressed. This study could have been strengthened by use of objective computerized muscle testing initially and at end of study. Even though patient satisfaction is an important aspect, return to functional status is the critical measure of a successful therapeutic program.

Another limitation that must be addressed is the use of more than one therapist. This raises questions not only of standardization of technique, but also therapist bias and inter-therapist rating reliability. In addition, the issue of a placebo effect is always raised whenever a hands-on approach is utilized by both the patient and the therapist. These limitations notwithstanding, the observed scores were reproducible throughout the study, and each therapist received similar training, all graduating from the Swedish Institute.

CONCLUSION

Consideration should be given to non-traditional/non-conventional techniques that attempt to reduce pain and increase function. Based on these preliminary results, Trigger point massage treatments can be used safely and is deserving of increased attention and further study. It must be recognized that this unconventional therapy is not a panacea, but rather appears to be a useful alternative or adjunct to the treatment of the traumatically-injured patient. Deyo’s condemnation of “fads” may be a disservice to meaningful progress and clinical research. Few would argue that a critical appraisal of all modalities, traditional and unorthodox, is warranted if this sociologic and economic burden to society is to be resolved. It appears that a prospective, randomized trail will be necessary to judge definitively the merits of current modalities of treatment.

By I Weintraub

Weintraub, M. Shiatsu, Swedish Muscle Massage and Trigger Point Suppression in Spinal Pain Syndrome. Am. J. Pain Man. 2 (2): 74-78; Apr 1992.