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A couple weeks ago, I wrote about the differences between acupuncture and “dry needling” to alleviate pain, and in that article I explained a bit about the phenomenon of myofascial trigger points. After I said I believe these are the cause of most of the physical pain humans experience, a number of readers asked me to explain more. For the science lovers out there, I’m going to dive deeper this week.
Besides the most common forms of pain, like lower back and headaches, I’ve had patients with digestive problems, sinus congestion, chest pain, ear ringing, numb hands, painful intercourse, acid reflux, vision changes, and other health issues that were eventually discovered to be due to myofascial trigger points. I believe everyone should know about them and how they work – it could save us a lot of time and worry.
Basically, a trigger point is a small, irritable region in a muscle (or the surrounding connective tissue – “fascia”) that stays stuck in a contracted state, making the muscle fibers taut. This can cause reduced muscle strength and range of motion, pain, numbness, itching, and other forms of dysfunction. Sometimes a trigger point feels like a palpable nodule or “knot,” but to untrained fingers they’re often tricky to find.
A unique property of trigger points is that they’re able to produce symptoms in other parts of the body – from a few inches to a couple feet away. For instance, there’s a trigger point that can form in the soleus muscle of the calf that’s capable of producing pain in the lower back. For this reason, the work of Janet Travell, MD and her colleague David Simons, MD, was groundbreaking. For each muscle in the body, they mapped where trigger points tend to form and what kinds of symptoms they cause.
If you were experiencing pain along the outside of your leg, you might assume that something was wrong with that part of your leg, perhaps with the often-tight iliotibial band (IT band). But this diagram might be helpful. The X’s show where trigger points can occur in a muscle called gluteus minimus above the hip socket. The red shading shows the potential areas of pain that can result. You might not suspect this muscle because, as you can see, there’s no pain at the site of the problem!
There are a handful of mechanisms that can promote trigger point formation, such as irritation of nerves, chronic organ problems, nutritional deficiencies, and autoimmune disorders. Most often, though, the cause is trauma to our connective tissue. When a muscle is strained by being worked too hard, too fast, or beyond its natural range, there is frequently a sort of “recoil” that occurs as segments of the muscle fibers bunch up and remain that way.
This is especially common when someone works out without warming up; when someone does a very ambitious workout after not having exercised for a long time; when someone makes a sudden movement (like reaching out to catch something or trying to stop oneself from falling); and especially when someone does any of the above when in a state of diminished resilience (e.g, when stressed, upset, sleep deprived, eating poorly, etc.).
Even more commonly, the trauma is a form of “postural stress” that’s demanding on muscles in a way that’s difficult to perceive at the time – such as doing the same relatively motionless activity (like sitting at a desk or driving) for hours, days, months, or years. One possible mechanism is known as the “Cinderella hypothesis.” During static muscle exertion – holding a position for a long time, as dentists, musicians, typists, and others engaged in precision handwork do – the body tends to engage a certain group of small muscle fibers, called Cinderella fibers because they’re put to work first and are the last to be disengaged. Even though they’re not doing heavy lifting, these muscle fibers (often in the neck, shoulders, back, and forearms) are continually activated and overworked, which makes them susceptible to trigger point formation.
Whatever the cause, the result is that eventually the muscle never completely relaxes. Muscles are composed of numerous parallel fibers that work together to shorten (contraction of the muscle) and lengthen (the return of the muscle to its relaxed state). Within each of these fibers are many end-to-end contractile units called sarcomeres, and in the case of a trigger point, a group of sarcomeres gets “stuck” in a shortened state. This makes the affected fibers taut and often “stringy” feeling.
To make matters worse, the contracted region clamps down on tiny blood vessels causing local ischemia (inadequate blood supply), reducing in-flow of fresh, oxygenated blood and out-flow of toxins. This leads to a localized hypoxic state (not enough oxygen). The tissue pH changes, local metabolism is impaired, and fluid and waste products tend to build up in the area. This combination of factors ultimately activates pain receptors – it starts to hurt – and when this happens you use the affected muscle less.
Instead, you overload “synergists” – nearby helper muscles. The body makes the surrounding musculature tense as a protective mechanism. Meanwhile, there’s a disruption of the balance between the affected muscles and their “antagonists” – those muscles that lengthen when the primary muscles shorten and vice-versa (for example, the triceps is an antagonist of the biceps). Altogether, this restricts natural movement of the original muscle, which just perpetuates the imbalance. Finally, with longstanding trigger points, the body may deposit gooey lubricant compounds called glycosaminoglycans (GAGs) between these triggered muscle fibers, resulting in a gummy lump called a “myogelosis.”
The good news is that there are now books, charts, online tools, and practitioners that can help track down likely trigger points that may be implicated in your discomfort. I have such a tool in my online pain relief course, Live Pain Free, and I teach many approaches for deactivating trigger points.
The most basic methods involve simple mechanical disruption of this holding pattern. First, drink some water if you’re not well hydrated. Second, you or a friend can methodically feel around (ideally guided by a trigger point chart) for points that are sore, and ideally that reproduce the very sensation you’ve been experiencing. Third, maintain firm pressure on the epicenter of the point (with a finger, elbow, ball, or other tool) for about half a minute, consciously breathing into the area and intending to let it go, until there’s a palpable release. Then move on to all the other nearby points that are tight and tender and do the same.
This approach is called ischemic compression. By compressing the tissue enough to block blood flow, the body responds with reflex vasodilation, meaning it opens these vessels and flushes the tissue with a dramatic increase of blood. This will usually produce a significant improvement in the pain or dysfunction, though it will typically return sooner or later. These points tend to go from being active trigger points to “latent” trigger points, which have a certain “memory” (not the good kind of muscle memory) and are capable of getting reactivated. For this reason, persistence is important. The best results come from working on a trigger point consistently – usually from one to several short sessions per day (or less frequent if the sessions are intense) – and continuing for a while even after everything seems better.
As I said, this is a most basic approach, and while it’s often effective, sometimes a more nuanced intervention is required. There are many techniques that build on compression. We can replace fixed pressure with slow, deep strokes in the direction of the muscle fiber, as if re-lengthening this segment. We can work the trigger point back and forth across the direction of the muscle fibers. We can combine pressure on the trigger point with engagement of the affected muscle or antagonistic muscles. We can combine manual work on trigger points with topical herbs and/or internal herbs and nutrients that improve circulation and reduce inflammation. We can utilize release points on the same acupuncture meridian as where the trigger point occurs - or complementary points on other parts of the body. And more.
If all of this sounds interesting and relevant to you, I encourage you to do a little research. It might well be the end of a problem you thought had no solution. And if you need more guidance, check out my online course, Live Pain Free, where I go deeper into trigger points and much, much more to help people get out of pain of all kinds.
While I said I believe trigger points are the cause of most of our physical pain, I think it’s worth mentioning there are usually even deeper causes, such as stress and withheld emotions, poor body mechanics, dehydration, and an inflammatory diet. Holistically addressing these issues will lead to a more complete resolution of the condition. Always look at the big picture.
Be well,
Dr. Peter Borten
[post_title] => The Science Behind Our Pain: Inquiring Minds Want to Know
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Countless medical studies have shown just how dramatically our beliefs influence our health. People who believe they’re getting a new drug or treatment can experience improvements in mood or profound relief from pain – even when they’re in the placebo group. Our beliefs can alter how toxins affect us. And on the “nocebo” side of the equation (a negative placebo effect) we can even generate signs and symptoms of diseases we don’t have.
In one Japanese study, subjects known to have a strong reaction to poison ivy were told that one of their arms was being rubbed with poison ivy. Yikes! But researchers actually touched them with the leaf of a harmless plant. Every participant broke out in a poison-ivy-like rash.
The subjects were told that their other arm would be rubbed with a harmless plant. Instead, the researchers rubbed real poison ivy on them! But only two out of thirteen people had a reaction to it.
We can make ourselves sick and we can make ourselves well. The key is the incredible power of belief. It’s been thoroughly and indisputably proven, yet few people consciously exploit this magic on a regular basis. I’d like to change that.
As a start, I suggest we practice observing positive belief every time we put something into our bodies.
When you eat, try getting yourself mentally and emotionally enrolled in a positive expectation about how you’ll be affected by it. Admire the food. Tell yourself it’s going to be deeply nourishing. Your body is going to efficiently extract the nutrients and deliver them to all your tissues. It’s totally reasonable to expect that it will support clear thinking, high energy and mental calm, glowing skin, efficient digestion, optimal organ function, strong immunity, etc.
For best results I recommend building your expectations for a minute at the beginning of the meal, remembering this from time to time during the meal, and then happily anticipating the benefits after the meal.
You might even try bringing your attention inward, visualizing the nutrients being absorbed through your intestines and flowing into all of your cells, and telling yourself, “I allow myself to receive the fullest, most complete health benefit from this food” – or whatever words feel natural to you.
What happens when you say to yourself or a dining partner, “I feel really good from this food. My body thrives on good food. I can already tell that this meal is exactly what I needed”?
This should be even easier to do with supplements, herbs, and drugs, since you’re consuming them with a specific healing purpose and outcome in mind. Don’t forget it. Tell yourself as you swallow them (or apply them, if topical) that they’re going to do what they’re intended to do, that they’re perfectly compatible with your body, that the benefits are already starting (whether you can feel it or not).
If you make a practice of priming yourself to expect good things you’re significantly more likely to experience good things, to notice the good things, and to be grateful for them.
Be well,
Peter
[post_title] => Expect Good Things: A Practice for Getting the Most Out of Food, Medicines, and Supplements
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When I was learning acupuncture I heard about a phenomenon called “needle shock” (AKA “vasovagal response”) where someone suddenly feels lightheaded, nauseous, or passes out when a needle is stuck in their body. It’s rare and usually harmless but pretty unpleasant for the person experiencing it. So all interns were instructed in ways to alleviate it – have them lie down, take the needle out, press on certain points, etc.
During my internship I was paired with another intern who was rather eccentric but full of good ideas. As we were stepping into a treatment room, I mentioned that the woman we were about to treat had a history of needle shock. He smiled at me and said, “I saw that in her chart.” Then he pointed to the pocket of his lab coat which seemed to contain a small ball. I didn’t have a chance to ask what it was as we greeted the patient.
We made sure the woman was lying down and relaxed before inserting any needles, but as soon as the first one went in her face turned pale and her skin became cold and clammy. As she told us, “I’m going to faint,” and I scrambled to remember what to do, my partner pulled out a small orange and tore open the peel right beneath her nose.
She looked a bit shocked but also awake and clear. Immediately the color came back to her face and she appeared more grounded. “Is that an orange?,” she asked, “I feel better.” We proceeded to insert another dozen-or-so needles and she did fine.
This kindled my interest in aromatherapy, a field that was rather small at the time but has exploded in the decades since. Meanwhile, numerous studies have shown that inhaling citrus oils can have positive effects on mood.1 In one, patients in a dental office who were exposed to orange oil felt less anxious.2 In others, inhalation of bergamot oil (the bitter orange that gives Earl Grey tea its characteristic flavor) has demonstrated benefits against anxiety and depression.3
For what it’s worth, I think it wasn’t just the biological effect of orange oil that produced the dramatic shift in this patient, but also the role of the unexpected, the value of distraction, the intense stimulus of the release of orange oil beneath her nose, and perhaps her own positive associations with the scent. But these factors are part of what makes aromatherapy fascinating. It’s not just a matter of physiological impact, but also the roles of memory, association, and pleasure.
Generally speaking, all the citrus peel oils – orange, bergamot, lemon, lime, grapefruit, and tangerine –have these calming/uplifting effects when inhaled, with slight nuances between them. (I think of tangerine as the most uplifting and lime as the most calming, but you can experiment and see for yourself.) Diffusing a combination of a few – or using citrus peel or essential oil around the house, in homemade cleaners, as a spritz for laundry, or in your drinking water – is often most effective.
Despite my love of essential oils, I don’t feel altogether great about the aromatherapy field today. As a medical system, it’s in its infancy. There’s very little historical use and literature on essential oils and not much of a scientific framework for when and how to use which oils. They’re often overused, taken internally without good evidence of safety, and touted as panaceas. Much of this trend has been promoted by the manufacturers and multi-level-marketers of the oils. Essential oil production can also be rather wasteful. In many cases it takes vast amounts of dry plant matter to produce a minuscule amount of essential oil, which is really something of a luxury.
So I recommend treating these oils as the precious and potent substances they are. But I have less concern with citrus oils because they’re cheap, abundant, and generally very safe. Squeeze (the orange side of) an orange peel at a candle flame and you’ll see it flare – that’s orange oil, and there’s lots of it. The citrus oils are easily cold-pressed or distilled from peels, which are often left over from juice producers anyway. The main constituent of these oils, a compound called d-limonene, is used as a cleaner and degreaser and is also taken internally in capsules for alleviating heartburn, dissolving gallstones, and may have some value in cancer treatment.
Two caveats though: (1) citrus oils on the skin can sometimes cause irritation or make it easier to get a sunburn (this is probably more common with cold pressed citrus oils and less common in steam distilled citrus oils), (2) citrus and many other essential oils may be toxic to cats, so be safe if you have feline companions.
Enjoy the spring weather with the bright scent and uplifting effect of these amazing peels!
Love,
Peter
- Agatonovic-Kustrin, S. Anxiolytic Terpenoids and Aromatherapy for Anxiety and Depression, Springer, 18 Apr. 2020, link.springer.com/chapter/10.1007%2F978-3-030-42667-5_11.
- Lehrner J;Marwinski G;Lehr S;Johren P;Deecke L; “Ambient Odors of Orange and Lavender Reduce Anxiety and Improve Mood in a Dental Office.” Physiology & Behavior, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/16095639/.
- Watanabe E;Kuchta K;Kimura M;Rauwald HW;Kamei T;Imanishi J; “Effects of Bergamot ( Citrus Bergamia (Risso) Wright & Arn.) Essential Oil Aromatherapy on Mood States, Parasympathetic Nervous System Activity, and Salivary Cortisol Levels in 41 Healthy Females.” Forschende Komplementarmedizin (2006), U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/25824404/.
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A couple weeks ago, I wrote about the differences between acupuncture and “dry needling” to alleviate pain, and in that article I explained a bit about the phenomenon of myofascial trigger points. After I said I believe these are the cause of most of the physical pain humans experience, a number of readers asked me to explain more. For the science lovers out there, I’m going to dive deeper this week.
Besides the most common forms of pain, like lower back and headaches, I’ve had patients with digestive problems, sinus congestion, chest pain, ear ringing, numb hands, painful intercourse, acid reflux, vision changes, and other health issues that were eventually discovered to be due to myofascial trigger points. I believe everyone should know about them and how they work – it could save us a lot of time and worry.
Basically, a trigger point is a small, irritable region in a muscle (or the surrounding connective tissue – “fascia”) that stays stuck in a contracted state, making the muscle fibers taut. This can cause reduced muscle strength and range of motion, pain, numbness, itching, and other forms of dysfunction. Sometimes a trigger point feels like a palpable nodule or “knot,” but to untrained fingers they’re often tricky to find.
A unique property of trigger points is that they’re able to produce symptoms in other parts of the body – from a few inches to a couple feet away. For instance, there’s a trigger point that can form in the soleus muscle of the calf that’s capable of producing pain in the lower back. For this reason, the work of Janet Travell, MD and her colleague David Simons, MD, was groundbreaking. For each muscle in the body, they mapped where trigger points tend to form and what kinds of symptoms they cause.
If you were experiencing pain along the outside of your leg, you might assume that something was wrong with that part of your leg, perhaps with the often-tight iliotibial band (IT band). But this diagram might be helpful. The X’s show where trigger points can occur in a muscle called gluteus minimus above the hip socket. The red shading shows the potential areas of pain that can result. You might not suspect this muscle because, as you can see, there’s no pain at the site of the problem!
There are a handful of mechanisms that can promote trigger point formation, such as irritation of nerves, chronic organ problems, nutritional deficiencies, and autoimmune disorders. Most often, though, the cause is trauma to our connective tissue. When a muscle is strained by being worked too hard, too fast, or beyond its natural range, there is frequently a sort of “recoil” that occurs as segments of the muscle fibers bunch up and remain that way.
This is especially common when someone works out without warming up; when someone does a very ambitious workout after not having exercised for a long time; when someone makes a sudden movement (like reaching out to catch something or trying to stop oneself from falling); and especially when someone does any of the above when in a state of diminished resilience (e.g, when stressed, upset, sleep deprived, eating poorly, etc.).
Even more commonly, the trauma is a form of “postural stress” that’s demanding on muscles in a way that’s difficult to perceive at the time – such as doing the same relatively motionless activity (like sitting at a desk or driving) for hours, days, months, or years. One possible mechanism is known as the “Cinderella hypothesis.” During static muscle exertion – holding a position for a long time, as dentists, musicians, typists, and others engaged in precision handwork do – the body tends to engage a certain group of small muscle fibers, called Cinderella fibers because they’re put to work first and are the last to be disengaged. Even though they’re not doing heavy lifting, these muscle fibers (often in the neck, shoulders, back, and forearms) are continually activated and overworked, which makes them susceptible to trigger point formation.
Whatever the cause, the result is that eventually the muscle never completely relaxes. Muscles are composed of numerous parallel fibers that work together to shorten (contraction of the muscle) and lengthen (the return of the muscle to its relaxed state). Within each of these fibers are many end-to-end contractile units called sarcomeres, and in the case of a trigger point, a group of sarcomeres gets “stuck” in a shortened state. This makes the affected fibers taut and often “stringy” feeling.
To make matters worse, the contracted region clamps down on tiny blood vessels causing local ischemia (inadequate blood supply), reducing in-flow of fresh, oxygenated blood and out-flow of toxins. This leads to a localized hypoxic state (not enough oxygen). The tissue pH changes, local metabolism is impaired, and fluid and waste products tend to build up in the area. This combination of factors ultimately activates pain receptors – it starts to hurt – and when this happens you use the affected muscle less.
Instead, you overload “synergists” – nearby helper muscles. The body makes the surrounding musculature tense as a protective mechanism. Meanwhile, there’s a disruption of the balance between the affected muscles and their “antagonists” – those muscles that lengthen when the primary muscles shorten and vice-versa (for example, the triceps is an antagonist of the biceps). Altogether, this restricts natural movement of the original muscle, which just perpetuates the imbalance. Finally, with longstanding trigger points, the body may deposit gooey lubricant compounds called glycosaminoglycans (GAGs) between these triggered muscle fibers, resulting in a gummy lump called a “myogelosis.”
The good news is that there are now books, charts, online tools, and practitioners that can help track down likely trigger points that may be implicated in your discomfort. I have such a tool in my online pain relief course, Live Pain Free, and I teach many approaches for deactivating trigger points.
The most basic methods involve simple mechanical disruption of this holding pattern. First, drink some water if you’re not well hydrated. Second, you or a friend can methodically feel around (ideally guided by a trigger point chart) for points that are sore, and ideally that reproduce the very sensation you’ve been experiencing. Third, maintain firm pressure on the epicenter of the point (with a finger, elbow, ball, or other tool) for about half a minute, consciously breathing into the area and intending to let it go, until there’s a palpable release. Then move on to all the other nearby points that are tight and tender and do the same.
This approach is called ischemic compression. By compressing the tissue enough to block blood flow, the body responds with reflex vasodilation, meaning it opens these vessels and flushes the tissue with a dramatic increase of blood. This will usually produce a significant improvement in the pain or dysfunction, though it will typically return sooner or later. These points tend to go from being active trigger points to “latent” trigger points, which have a certain “memory” (not the good kind of muscle memory) and are capable of getting reactivated. For this reason, persistence is important. The best results come from working on a trigger point consistently – usually from one to several short sessions per day (or less frequent if the sessions are intense) – and continuing for a while even after everything seems better.
As I said, this is a most basic approach, and while it’s often effective, sometimes a more nuanced intervention is required. There are many techniques that build on compression. We can replace fixed pressure with slow, deep strokes in the direction of the muscle fiber, as if re-lengthening this segment. We can work the trigger point back and forth across the direction of the muscle fibers. We can combine pressure on the trigger point with engagement of the affected muscle or antagonistic muscles. We can combine manual work on trigger points with topical herbs and/or internal herbs and nutrients that improve circulation and reduce inflammation. We can utilize release points on the same acupuncture meridian as where the trigger point occurs - or complementary points on other parts of the body. And more.
If all of this sounds interesting and relevant to you, I encourage you to do a little research. It might well be the end of a problem you thought had no solution. And if you need more guidance, check out my online course, Live Pain Free, where I go deeper into trigger points and much, much more to help people get out of pain of all kinds.
While I said I believe trigger points are the cause of most of our physical pain, I think it’s worth mentioning there are usually even deeper causes, such as stress and withheld emotions, poor body mechanics, dehydration, and an inflammatory diet. Holistically addressing these issues will lead to a more complete resolution of the condition. Always look at the big picture.
Be well,
Dr. Peter Borten
[post_title] => The Science Behind Our Pain: Inquiring Minds Want to Know
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