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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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A couple weeks ago, I introduced some concepts on the workings of pain that I think are useful for everyone to know. They’re derived from my explorations into Traditional Chinese Medicine. Here’s a synopsis:
- Virtually all pain is due to stagnation
- Resistance promotes and worsens stagnation
- All levels of our being are interconnected, so
- Stagnation can spread between levels
- Movement on one level can alleviate stagnation on multiple levels
- Relinquishing resistance restores the flow
When I speak of pain here, I don’t just mean physical pain, but also emotional pain and even “existential pain.” Understanding the workings of our pain can be tremendously useful in liberating ourselves from it. Working from this model, our main goal is to get back into a flow state, and there are lots of ways to do this.
First and foremost, when we feel uncomfortable on any level, we can cause an immediate shift by not resisting what we’re feeling. Ultimately this is simply a choice – a choice that’s always available (albeit a choice we usually have to make over and over). However, it’s a choice that sometimes eludes us, so we can employ some methods to facilitate it. Breathing is a good place to start.
When we are in a state of active resistance, this is usually reflected in the state of our breathing, which is restricted. Opening up the breath – breathing deeply and fully into the body and specifically into the area that’s restricted – can help us to feel willingly what’s up and to let go of resistance. Breathing promotes movement and helps to clear stagnation. I cover many different breathing methods in the Live Pain Free course, but the most basic approach is just to lengthen the exhale – that is, emphasizing the letting go phase of the breath. As we do this, we can visualize that the breath is opening and flowing through the body – or a particular region of the body – improving circulation, bringing in fresh blood, and encouraging the removal of waste.
Exercise and stretching are also great for facilitating movement and clearing stagnation for the alleviation of pain of any kind. We can get more out of mobilizing the body if we actively intend that our movement is shaking up, dismantling, and releasing stuck emotions, negative thoughts, and other painful patterns.
Using our voice is another way to promote movement. Whether through toning, singing, chanting, or speaking the truth, both the meaning and the sound vibration we express can have an opening effect on us.
These are just a few of the many ways to restore flow when there is stagnation and thereby alleviate pain. Acceptance, forgiveness of oneself or someone else, letting go, trusting in the process, laughter, loving connections, and spending time admiring beauty such as in nature – all of these tend to have an opening or expansive effect on us that can profoundly affect our experience of pain.
Now, let’s look at a progressive way to understand pain from a scientific lens. A good starting definition is: Pain is the brain or mind telling you it thinks something is wrong. Whether it’s physical pain, emotional pain, or existential pain, there’s an implicit interpretation that this is not how things should be. The pain of depression, for instance, involves an interpretation that, “I shouldn’t feel this way. I should be happy.” The pain of arthritis involves a brain interpretation that a joint shouldn’t be grinding and inflamed the way that it is. In both cases, pain could be seen as an alert that the situation is threatening and requires intervention.
This alert system is more often accurate and useful with acute pain than with chronic pain. For example, you feel burning pain in your fingertips, you move your hand without thinking, and you avoid skin damage from the hot iron you accidentally touched. Chronic pain, on the other hand, is almost always a mistake.
A broader, more technical definition of pain can help us understand why these mistakes occur. Pain is an output – the result of processing in your nervous system – that’s unique to the person that’s experiencing it, and it involves numerous elements – nerves, immune cells, chemical messengers, memory, and emotion – that interact and combine to form a pattern that the brain labels as PAIN. (Thanks to pain researcher Ronald Melzack at McGill University for developing this definition.) This pattern is known as a neurotag or neurosignature and it’s more complex than we tend to think. Pain is as dependent on our psychology as it is on our physiology.
For example, if you were once attacked by a dog and it was frightening and traumatic, something as minor as a dog swiping you with its paw in an attempt to get your attention could be experienced as severely painful because of the elements of memory, emotion, and interpretation. So it’s easy for inaccuracy to enter the pain equation. In this case, there is no danger, nothing wrong that needs to be addressed, but your brain sounds a loud alarm anyway.
Even looking strictly at the biological workings of pain, there is still room for error, though. Acute injuries are usually completely healed within a matter of three to six months at most. The body part can be used normally at that point, so there should be no need for pain after that. However, during the initial event and the healing process, a persistent neurosignature may develop. During all the yelling, crying, and wincing, the nervous system can become sensitized in such a way that the alarm won’t turn off and/or it’s easily retriggered by related images, scents, sounds, thoughts, feelings, and memories.
At this point – and this is true of virtually all chronic pain – it serves no useful purpose. So there’s little value in trying to track down a tissue pathology, and even less in utilizing an addictive mind-numbing pharmaceutical to make it go away. Instead (or in combination with pharmaceutical interventions, if necessary) we can utilize approaches that take advantage of the phenomenon of neuroplasticity – the ability to change our wiring.
We explore many, many such approaches in my online course, Live Pain Free, and I encourage you to check it out if you struggle with pain. The most useful thing, as I discussed in the last installment of this article, may be simply knowing how pain works. I sincerely hope these articles have given you a new way to understand pain that helps liberate you from its grasp.
Be well,
Dr. Peter Borten
[post_title] => Getting Smarter about Pain
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What do you know about hormesis? It’s the phenomenon that (kind of) explains the expression “what doesn’t kill me makes me stronger.” Technically, hormesis refers to biological processes in which a certain amount of exposure to a stress or toxin stimulates a favorable response, even when other amounts are deadly. For instance, while a high dose of radiation is often fatal, small doses have in some cases been shown to stimulate a positive adaptation leading to lower than average rates of cancer. A hormetic response to certain adverse influences sometimes leads to an evolution.
Last week I wrote about suffering and our complicated relationship with it. Perhaps we could see it as a hormetic relationship. In low to moderate doses, suffering is purely degrading. We tolerate it but it erodes our presence, our performance, and our patience. In extreme doses it kills us. But sometimes there’s a sweet spot in between where it’s bad enough that it can’t be tolerated in the usual way, something cracks open, and a breakthrough occurs.
One of the key ingredients in a favorable response to suffering is consciousness. I could never say it as well as Eckhart Tolle, so here’s a quote (slightly abridged) from his book, A New Earth:
Humanity is destined to go beyond suffering, but not in the way the ego thinks. One of the ego’s many erroneous assumptions is “I should not have to suffer.” That thought itself lies at the root of suffering. Suffering has a noble purpose: the evolution of consciousness and the burning up of the ego. As long as you resist suffering, it is a slow process. When you accept suffering, however, there is an acceleration of that process which is brought about by the fact that you suffer consciously. In the midst of conscious suffering, there is already the transmutation. The fire of suffering becomes the light of consciousness. The truth is that you need to say yes to suffering before you can transcend it.
Suffering isn’t intrinsically useful or noble. When we suffer “unconsciously” – resisting it and turning away from it – it just becomes part of the tragic degradation of life that Buddhism speaks to when it says the nature of the world is to suffer (dukkha). Bringing consciousness, acceptance, and curiosity to it makes it something entirely different.
In her book, Loving What Is, Byron Katie shares an exchange she had with a client who is incessantly angry at big corporations that pollute the planet. On examining the client’s psychology, we see that she is conducting a campaign of violence against these corporations and their faceless leaders in her mind. Katie asks the client if this suffering is necessary in order to feel that she’s doing something about the situation. Through some digging they get down to a troublesome belief at the heart of it: If I don’t suffer, I won’t care.
This is a big one for many of us. Is it true? If we didn’t suffer would we be complacent? Is it suffering that makes us care to be productive or helpful?
This is a question that can only be answered for oneself.
I believe we have a natural, transpersonal inclination toward serving, loving, and awakening. It doesn’t need to be prompted by suffering. But as we see, it’s common for humans to stifle or undermine this inclination. And so, suffering, it turns out, may sometimes be what gets us to recognize it and prioritize it.
When you meet suffering consciously, you may find that it dissolves. You may find that it’s been perpetuated by untrue beliefs, like “I should suffer for my sins,” or “I don’t deserve to be happy.” You may find that the suffering is generated by a part of you that’s just trying to get you to feel. You may find that it’s trying to draw your attention to something, to show you there’s a better, freer way to operate. You may find that the suffering is coming from the last part of you that’s afraid to embody your power, and that with trust it disappears. You may find that the suffering is the feeling that arises from being afraid of suffering. You may find that the suffering is actually an invitation to pass through a gate to a new way of being.
The only way to know is to visit with it. There's nothing in any book, no teaching from any guru that lets you bypass the need to directly encounter what's stirring in YOU.
I always love to hear what you think of these “deep” ideas, and hope that we can make such depth part of our everyday conversations and experiences.
Be well,
Peter
[post_title] => The Gift Inside Our Pain
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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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