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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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The other day a friend took out a cigarette and started smoking it in front of me. It was a bit of a surprise, and it made me reflect on how much less I encounter smoking than ever before in my life. Rates of smoking among adults in the U.S. have fallen from 42% in 1965 to 13.7% in 2018. Smoking in kids has fallen from 27.5% in 1991 to 8.8% in 2017. Both trends reflect a decline of about 68%. At the same time, smokers have greatly reduced the number of cigarettes they consume in a day.
This is great news, and I’d like to help the remaining smokers give it up. I used to run a successful program to help people quit, and I’d like to share the approaches that worked well for the participants. Clients would get acupuncture and herbs to help with the cravings; we would do some digging and releasing to clear the underlying psychological patterns associated with smoking; and finally I would tell them this:
“You are not forbidden to smoke. Don’t feed the inner conflict by saying to yourself, ‘I shouldn’t be doing this.’ If there’s a shouldn’t within you, then there’s also “but I am doing it,” and from that, it follows that you’re bad, you’re wrong, you’re breaking the rules, you’re a failure, you deserve to be punished, etc. It perpetuates a whole mess of negative thoughts, guilt, and shame which are arguably as bad for you as the smoking itself.”
If they felt like having a cigarette, I would tell them to do six things.
Number one: Use empowering language. Instead of telling yourself, “I can’t have this cigarette,” which feels like you’re being constrained by an outside force, use verbiage that implies your choice and power in the matter, such as: “I don’t smoke anymore. I just don’t put that stuff in my body. I’m not a smoker anymore. I choose to only breathe clean air now.” And rather than telling other people, “I’m trying to quit,” which gives you an out, tell them, “I quit!” Or, if that feels too big, “I’m in the process of quitting.”
Number two: Take a minute to slow and deepen your breathing. Much of the appeal of smoking is that smokers routinely take time to step outside and do some deep breathing. Aside from the smoke inhalation part, this is a great stress management practice, so we don’t want to take that away.
Draw your inhale the whole way down to your lower belly, imagining you’re filling up the bowl of your pelvis with it. Then make your exhale very long, getting all the air out. Do this several times. (If it’s helpful at first, you can hold your fingers to your lips as if drawing through a cigarette.) If the desire for a cigarette remains, continue on.
Number three: Connect to the want-a-cigarette feeling. How do you know it’s time to smoke? Most of the time you’re barely aware of the feeling; you just respond to it unconsciously and have a smoke. This step is about making conscious the connection between the craving feeling and the act of smoking.
Drop into your body and tune in to what’s coming up. Don’t try to define it; just feel what it feels like. What exactly is the feeling? Where is it concentrated? What can it tell you about yourself?
You may tend to regard it as a yearning, but what’s beneath the yearning? The yearning is a response to something deeper. There’s some form of discomfort there and smoking is the thing you do to get the feeling to go away. But there are other ways to release it. The feeling is just a feeling; it’s not going to harm you, and it doesn’t mean you have to smoke.
There are many approaches to dealing with the feeling. A good place to start is by simply allowing the feeling to be here without resisting it. Can you feel the feeling fully? Can you invite it to be experienced by your whole self? Can you breathe into it? And can you open yourself and allow it to leave?
Just follow the prompts above and see what happens. Don’t judge yourself if the feeling doesn’t go away. If the desire for a cigarette remains, continue on.
Number four: Uncouple the act of smoking from any other activity. We don’t want smoking to be linked to anything else, especially things you do all the time. So, if you tend to have a cigarette while on the phone, a cigarette after sex, a cigarette after eating, or a cigarette while driving, choose another time to smoke. You’re going to keep eating, having sex, and driving, so we want to clear the association with smoking. Before smoking, do everything reasonable to remove yourself from other activities and positive environments.
Number five: Talk to your body. If you still want to smoke, take out a cigarette, become aware of our lungs, your heart, and your whole body. Then ask inwardly, “Do you want this?” or “How do you feel about this?” Then listen and feel for a response. If the desire for a cigarette remains, continue on.
Number six: Give all your attention to the act of smoking. Be alone, tune out everything else, and smoke that cigarette. Be completely present to the act. At whatever point the urge to smoke has dissipated, stop and stub it out. When you’re immersed in it, this point tends to come well before the end of the cigarette. And even if you do smoke the whole thing, it will tend to satisfy you for much longer than if you smoked it mindlessly. While my hope for people is that they’ll quit entirely, cutting down from ten to three is a great and worthwhile accomplishment.
If you’re a smoker I’d love to hear about your experience with these simple steps. And if you know someone else who could benefit from this article, please pass it along.
Be well,
Dr. Peter Borten
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Once I went to see a spiritual teacher who planned to write a mantra on my tongue using a leaf dipped in honey. But she ran out of leaves. Or honey. I can’t remember which.
“It doesn’t matter,” she said. She told me the mantra and we repeated it together. She also told the same mantra to the other hundred or so people who came to see her. I’ve used that mantra off and on for the past 20 years.
Another spiritual teacher gave me a mantra, but it was just for me. He told it to me privately in a closed room, and he instructed me to never repeat it to anyone. He said that keeping it a secret was part of the power of the mantra. I wasn’t sure whether I believed that, but I have kept it a secret for several years.
You probably know what a mantra is, but I’d like to tell you about a woman who found a magic lamp in her backyard. Well, she rubbed it of course, because that’s what you do, and a genie came out.
“Tell me what to do,” he said.
“Is this one of those three wish deals?” the woman responded.
“Not at all,” said the genie. “I’m at your service forever.”
The woman had the genie clean the house, do the laundry, and cook dinner.
“What next?” asked the genie.
“Oh, neuter the cat, I guess.”
“Done!” the genie reported. “What next?”
“Umm, shear the hamster?” the woman offered.
“Done! What next?” asked the genie.
“That’s it!” exclaimed the woman, “why don’t you take a break.”
“It doesn’t work that way,” the genie said, now beginning to appear more oppressive than helpful. “Give me something to do or I’ll eat you!”
The startled woman was quick on her feet and answered, “Ok, I’ve got it. Climb up that flagpole. When you get to the top, slide down. Then climb up again, slide down again, and just keep doing that until I think of something else for you to do.” It worked, and the woman didn’t get eaten.
The genie is like the mind. The flagpole routine is the primary role of a mantra. Not only does the genie/mind demand constant attention, it gets in the way of our accessing the spiritual dimension and experiencing spaciousness in our consciousness. It tends to take up the whole frame.
A mantra gives the mind something to focus on, which, over time (meaning both over the course of each meditative session and over the course of using it day after day), greatly diminishes the degree to which the mind dominates our awareness. Often, what starts out as a mechanical recitation of a word or phrase (usually silently) becomes something more like a self-replicating wave that occupies the mind while our consciousness expands and transcends it. Of course, every time we sit to recite a mantra doesn’t produce a transcendent or mystical experience, but it’s quite common to feel peaceful and expansive.
Besides simply occupying the mind to facilitate meditation, mantras sometimes have other purposes. Some believe that mantras, through their sonic quality and/or meaning, produce a spiritual or therapeutic effect. Certain mantras are meant to be spoken aloud; others can be “spoken” mentally. Some are meant to open a particular part of the body or aspect of consciousness, to express devotion, to invoke or “install” a certain deity, or to elicit a change of fortune. Using a mantra with a meaning you understand may have the additional benefit of aligning your intention around a positive idea. On the other hand, using a mantra in a language you don’t know or one without any meaning frees you from getting analytical about it.
There are short mantras and long mantras. I recommend a shorter one for silent meditation, since it’s easier to remember. The shortest one syllable mantras are sometimes called bija or “seed” mantras, such as Om, Aim (“aeem”), Shrim (“shreem”), Hrim (“hreem”), Krim (“cream”), Hum, Hu (“hue”), Ram (“rahm”), Vam (“vahm”), Ham (“hahm”), Ong, God, and Love.
Two-syllable mantras go well with the breath, since you can say/think the first syllable on the inhale and the second on the exhale. Some common ones include Shanti (peace), So-Ham (I am that [Divine]), Ham-sa (swan, also an inversion of So-Ham), Sat Nam (I am Truth), and one of my favorites, Open.
Common longer mantras include Om Namah Shivaya, Om Mani Padme Hum (or Om Mani Peme Hung), and Nam Myoho Renge Kyo. There are thousands more. Read about these if you're interested. You may wish to find one that seems suited to your spiritual sensibilities, or one that just feels good to say. There are lots of great books and sites on mantras to explore.
As for the notion that a mantra should be kept secret, some teachers will say that a mantra loses its power if it’s shared. At best this is superstition. At worst, it’s a pretentious attempt to control students, maintain hierarchy, generate mystique, and keep people coming back to pay for increasingly “higher level” mantras. And now I’m going to tell you the “secret” mantra I received: it’s hring. Try it out if you feel like it.
Though I have some disdain for secrecy around mantras, I do believe there’s sometimes value in being selective about sharing the details of your spiritual experiences. Attempts to explain these experiences in words often fall short, and if you share with someone who isn’t receptive, doesn’t understand, or criticizes the experience, this may diminish its significance for you or cause you to doubt yourself. It’s also worth asking yourself why you’re sharing these experiences. Sometimes we do so to better understand them or to be instructive or inspiring to others. Other times it’s because the ego has co-opted our spiritual experiences and is using them to get approval. So it’s a good idea to make sure you’re sharing for the right reasons, you can withstand judgment without losing conviction in your practice, or otherwise to share only with those who can hear you in a non-critical way.
This week I recommend that you try meditating with a mantra. Choose one from above or find one you like online or from a book. Sit comfortably and repeat your chosen mantra silently, at a speed that feels comfortable to you. If your mind wanders, just bring it back to the mantra. See if, compared to simply watching the breath, this makes it easier to enter a relaxed or expansive state.
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
[post_title] => The Science Behind Our Pain: Inquiring Minds Want to Know
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