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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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It was my birthday party in May and before we all started eating, Briana asked if I wanted to say something to my guests. Unbeknownst to them, I had been feeling a nauseous gurgling in my guts all day, so I was trying to hold it together and was caught a bit off guard. But I looked around at this group of shining faces and said the first words that came to me: “Community is medicine. Thank you for being here.” And that was enough.
Immersion in loving community is deeply fortifying, supportive, and uplifting. Studies show that when a suffering person holds someone’s hand, their suffering is reduced. I think the same is true of metaphorically holding many hands through community engagement. And while it’s therapeutic to be seen and held in our challenges, there’s also value in the way that being oriented to our community gives us a break from self-scrutiny and self-indulgence.
Like eating green vegetables or meditating, sometimes we can forget to prioritize community when we’re busy or immersed in a personal struggle. But as some wise person once said, our community is like our muscles. Besides supporting and empowering us, they need to be engaged regularly in order to stay strong. If you neglect your muscles, they get flabby. If you neglect your community, they probably won’t turn their backs on you, but for numerous reasons they won’t be able to support you as well as they could.
From our book, The Well Life, here are some actions you can take to mindfully build your community:
- Ask people for help – whether it be in your garden, with your taxes, or finding a great preschool. Learn what gifts and wisdom those around you have and give them opportunities to share.
- Be involved. Go to local meetings. Participate. Know your community’s plans for the future – and how you fit into them.
- Know the names of people you see often – the grocery cashier, the gas station attendant, the school principal, the guy who takes the same bus as you every day. Allow them to be real people in your life.
- Make eye contact with the humans you pass on the street. Be the one who says “Hi!” first.
- Protect the green spaces.
- Fix something that’s broken – a neighbor’s fence, your niece’s bike, the librarian’s flat tire.
- Support local businesses – even if it costs a little more.
- Learn about others’ traditions and celebrate together. Look for local festivals to attend, even if they’re for an event you wouldn’t normally observe.
- Stick up for someone – a disadvantaged person or population, someone being mistreated or disrespected, or someone who’s unable to stand up for themselves.
- Be curious. Attend lectures at the library, senior center, or local university, check out a high school science fair, and – foremost – learn what cool stuff people are up to in your town. What are people building? What are they learning? Who can tell you about the history of this place?
I want everyone to have the experience of being part of a healthy, loving, supportive community. I hope you’ll engage with your community today and be reminded of how nourishing it is.
Be well,
Peter
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In the early years of my practice, I studied with an expert in Chinese pulse diagnosis. He had studied under a Chinese doctor named John H. F. Shen who was something of a legend. Dr. Shen was known to treat 200 people in a day. He was a master of reading pulses and faces, and he had an uncanny ability to diagnose the cause of people’s illness – right down to the year it started. Of the countless impressive stories, my teacher recounted the time Shen was feeling an old man’s pulse and told him his problems stemmed from the guilt he felt about killing someone around 1940. The man admitted that during World War II he was part of the French Resistance and had shot a good friend upon discovering that the friend was a Nazi spy.
While I was learning useful pulse diagnosis techniques, I was eager to hear more about Dr. Shen (who had died a few years earlier). I asked my teacher if he’d ever been treated by him. “Yes,” he replied, “and it changed my life forever.” I was expecting to hear a story like the one above, so it was a little disappointing when my teacher said, “He felt my pulses and told me, ‘I won’t treat you. You need to rest. You are working too much.’ That was it.”
What? That was it? “Well, a year later,” he continued, “I tried again. I asked him to feel my pulses and write me an herbal formula. And he told me the same thing. ‘Go home and rest,’ he said. ‘I can’t do anything for you. You need to take a year off.’”
“To take a year off – it seemed unthinkable. But my health had been declining for a long time, so I decided to do it. I made plans to turn my practice over to someone else, I saved money, and I took a year off to rest. It had a more profound impact on me than anything else I’ve ever done. I think I wouldn’t be alive today if I hadn’t listened to him. From then on I have approached life differently.”
Even though it was nothing like the almost-magic readings Dr. Shen was famous for, this story hit me hard. I had spent years studying texts of Chinese medicine that explain the process a healer must understand – the earliest roots of imbalance, how this imbalance progresses into illness, discerning the patterns involved in the illness, and finally, treating the illness and attempting to restore balance. Like almost all my fellow students and practitioners, I had gradually come to focus almost entirely on the last steps – diagnosing and treating the consequences of longstanding imbalance. Meanwhile the early stages had become almost irrelevant. Who cares how it started 50 years ago when the person in front of you needs help now?
Then I remembered, as these ancient books state: “the superior physician” cares – and focuses on correcting imbalance before it becomes disease. Though it’s often impossible to cure advanced disease, in a way it’s a greater challenge to address oneself to the origins, because few people take seriously the early imbalances that aren’t yet causing much suffering.
These early forms of imbalance, by the way, are pretty simple and exceedingly common. They include the unhealthy expression of emotion (suppressing or resisting the experience of an emotion and/or harboring it for a prolonged time), improper eating (too much, too fast, while stressed, low quality food, etc.), and overwork. It was this last issue – overwork – that Dr. Shen was pointing to.
It’s often difficult for people to make the connection between overwork and degradation of health, especially because we’ve all known of a few remarkable and robust individuals who seem able to work tirelessly, sleep minimally, and live for a century. But they are the outliers.
Most of us can’t do this. There is simply no substitute for rest. You can eat well, do yoga, take vitamins, and drink wheatgrass juice, but none of these will allow you to deprive yourself of rest without paying for it.
The simplest advice I could give on rest is this: every day, use less than your total daily allotment of energy. Each day we have a certain amount of energy to work with. This is replenished through good sleep, high quality food digested well, ample clean water, fresh air, our nourishing connections with the world (love and affection, inspiring and affirming conversation, etc.). When we go to bed without having used it all up, we’re investing in ourselves and prolonging our lives. When we use it all up each day, we’re neither serving ourselves nor particularly harming ourselves (as long as our replenishing factors are in good shape). When we use it all up and keep going, we draw on our reserve energy – a reservoir we should rarely need to tap.
This reservoir can be thought of as our store of “life force.” It is what Ayurvedic medicine calls ojas, what Chinese medicine calls jing (“essence”), and what biomedicine understands largely as a function of the endocrine system (especially the adrenal glands). When we deplete our reserve energy, we speed up the aging process and reduce our resistance to disease. Lack of rest also makes us more prone to weight gain. Physiologically this toll may involve depletion of our adrenal glands (a first responder to stress), low thyroid function (a decline in metabolism), low stomach acid and digestive enzyme production, diminished sex hormone production, low immune function, and chronic inflammation.
Everyone can learn to feel when they are running on “good” energy versus tapping into their reserves. When using our “good” energy (the daily allotment discussed above) we have enough fuel to get through our tasks for the day without the need of stimulants, and we feel grounded and solid. When tapping our reserves, we tend to feel a bit jittery, edgy, ungrounded, foggy, weak, or faint. We may feel like we could fall asleep in an instant if we put our head down. If you habitually rely on stimulants (coffee, tea, sugar, chocolate, media, etc.) to get through the day, chances are, you’re tapping into reserve energy on the daily.
If you’ve been out of whack for a while, first stop exceeding your limits. You may also need a period of dedicated rehabilitation like my teacher. This rehabilitation period should include: plenty of clean, fresh air, time in nature, an optimal amount of pure water, a diet of fresh, healthy foods appropriate for your condition, all the sleep you need, a peaceful and positive atmosphere, a personalized health care plan, and you must never use more than your daily allotment of energy. During this period (and always) it’s beneficial to abstain from engaging your energy on anything that doesn’t serve some higher purpose. For instance, if watching vampire movies activates your stress responses (you can tell if you’re on the edge of your seat or feeling tense), this is an energy sink that yields no positive return.
Winter is naturally the ideal time for rest. Just look at how many plants and animals out there have gone dormant for the season. If your mind protests, “But I need to be productive” remind it that this is productive – it’s just a long game. As difficult as it may be to go to bed early, to leave an exercise class before it’s over, or to decline a night out with friends, listening to and honoring your system is a form of growing up. Notice what happens to your mental clarity, mood, self-trust, and quality of life when you prioritize yourself and get the rest you need.
Be well,
Peter
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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
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