Musculoskeletal Trigger Points:
Pathophysiology and Implications for Evidence-Informed Clinical Practice
by Dan Steele, SPT, CSCS, PES, CES
Background:
During my six years as a personal trainer before my acceptance to and enrollment in PT school, I would frequently talk to my clients about foam rolling and self-myofascial release, which has been a hot topic in the fitness world for the past 10-20 years. I would talk about “knots” and “adhesions” and while my training certifications were based in scientific evidence, and I was quoting reliable sources, I myself had little in the way of a deeper understanding of the cellular structures beneath the skin and in what ways they might or might not be affected by what I was encouraging my clients to do. A chance encounter with a physical therapist as I was in the process of applying to PT school led to an invitation to complete some of my required shadowing hours with him at the clinic where he worked. I took him up on his offer and it was there that I had my first exposure to a number of advanced concepts in human movement and helping patients relieve musculoskeletal pain, increase mobility, and improve motor control. One of the techniques I saw for the first time was trigger point dry needling and that began a fascination with the concept of musculoskeletal trigger points and referred pain that has only increased throughout my three years of this doctoral program.
Research:
Informally, the research for this project began during my first year of the program. I was eager to collect textbooks on the subject of trigger points and I read several of them in the rare moments that were not fully occupied by studying and class. The online third year of the program represented an opportunity to truly delve into current peer reviewed research on trigger points and dry needling. The textbooks I had read gave me the necessary foundation with which to interpret the studies and journal articles, and I was able to critically appraise the state of the research pertaining to trigger point resolution and muscle length for Evidence-Based Practice class, as well as write my term paper for Advanced Ortho on the pathophysiology of trigger points.
The Need:
A key requirement of a capstone project is that it must fill a need. It was in the process of completing these two large projects during fall semester that I realized this information I had amassed for myself regarding trigger points was largely due to my independent study throughout PT school rather than through our required academic coursework. I felt it was important for entry level physical therapists to have had exposure to this concept in depth because of the profound ways in which it affects our clinical reasoning when addressing a patient’s pain and movement dysfunction.
The Solution:
I felt that I could make a contribution to the education of future doctors of physical therapy by developing this self-study educational module to be added into the Modalities curriculum for first year students. I worked to create a presentation that would arm future students with a baseline understanding of what musculoskeletal trigger points are, how they form, and their implications for patient care. It has been an extremely rewarding process to present this important concept in a way that I feel can potentially have real impact for patients under physical therapy care.
Evaluation:
The Modalities course is taught in the spring of first year. Because I will not be presenting this information personally to the students who will study it, I sought feedback from Mike Gross and Jon Hacke to assess the appropriateness and thoroughness of the content. They helped me decrease the wordiness of my slides and present the information in a way that was clearer and more visually appealing. I also sought the advice of Will Freres and Andrew Ball who are mentioned below in the acknowledgements. Their expertise in the area of trigger points and dry needling was invaluable and they both provided helpful feedback as to where I had misinterpreted particular points of research or where I had missed a relevant study in my database searches. With the advice of these seasoned clinicians and educators, I feel confident in presenting this product to future students. The folder with my presentation and summary handout can be found here: narrated presentation and summary handout
Acknowledgements:
Will Freres, PT, Dip. Osteopractic, CMTPT, Cert. DN, Cert. SMT, FAAOMPT – Will has tirelessly invested in me since before I was accepted to PT school. His mentorship has been of inestimable value and encouragement throughout my schooling and I can honestly say I would not be as passionate as I am about the true potential inherent in the profession of physical therapy were it not for the concepts and ideas he has exposed me to. He provided many thoughtful and valuable edits to this project.
Andrew Ball, PT, DPT, MBA/PhD, OCS, CMTPT, CertMSKUS, PES – Drew brought a wealth of knowledge and an unapologetic passion for methodological rigor to helping me edit my learning module. I appreciate his willingness to donate his time and expertise out of his busy schedule and multiple professional roles. I was always fully confident that if my work could pass muster with Drew, I could rest easy knowing the future DPT students who will be learning from my project will receive valuable information that is both clinically useful and factually accurate.
Mike Gross, PT, PhD, FAPTA – Mike taught me to never be satisfied with a surface level understanding of an intervention or testing procedure. His challenges to strive for excellence and his wealth of highly quotable sayings have helped me become a better clinician and student.
Jon Hacke, PT, DPT, MA, OCS, ATRet – Jon generously accepted my project to be a part of his syllabus for the modalities class. Although he was not formally on my committee, he freely donated his time to providing feedback on my presentation. His good humor and challenging questioning have been greatly appreciated not only throughout this project, but throughout the entirety of this program.
5 Responses to “Musculoskeletal Trigger Points”
Monica Anderson
Dan,
I agree completely with all the comments above. I just wanted to say thank you for tackling this topic! I 100% relate to your background comments and the need for this information. I will absolutely be referring to your products in the future.
thanks!
Monica
Kip Stromberg
Dan,
Great capstone project! Trigger Point Dry Needling is something that really interests me and I have heard many success stories in using this modality. I really enjoyed your presentation which was both entertaining and very educational (I loved the Monty Python reference). You did a great job of including the current research and discussing different trigger point theories. I know there are a lot of different beliefs out there about trigger points. Great discussion of the “all-or-none” principle. I had the same thought as Jon, and you did a great job in addressing that dilemma. I also really liked that you didn’t just read off your slides. You did a great job of referring to your slides and summarizing the key points. I feel like your material is well made and easy to understand. I also like how you discussed different arguments and points of view throughout the presentation. You are very aware of your biases and noted that in your presentation. Clearly, you have a great in-depth knowledge of the subject. Trigger Point Dry Needling is a tool that I hope to add to my “tool box” in the future. I will definitely use your capstone products (with your permission) to help in my professional development and in helping my future patients. I also appreciate your recommendations in texts that are specific to Trigger Point Dry Needling. Do you have a recommendation for which text to start studying (for those of us with limited funds)? I think that this presentation and handout will be a great resource for future DPT students (and clinicians). Great job!
Honoree Mcgraw
Dan,
I’ve been excitedly waiting to check out your capstone project for a while now! I’ve had a specific interest in learning more about myofascial trigger points since I received dry needling in my iliopsoas earlier this year. I had been experiencing hip flexor tightness, irritability and sometimes pain for over a year and was severely limited (compared to my baseline) in the types of activities I could perform without discomfort. The PT I was seeing at campus health, Dan Hooker, PT, ATC, PhD, had tried several interventions to mitigate the pesky trigger points but nothing worked until he tried dry needling. The relief was instantaneous and long lasting (still reoccurance of the trigger points). Completing your self-study module helped me understand the mechanisms behind why I may have developed the trigger points and how dry needling was able to help me so much. I was really impressed with how you integrated past and present research into an evidence informed, self contained learning module. I enjoyed hearing your synthesis of pivotal studies and theories. You did a wonderful job of recapping anatomical structures in enough detail to illustrate concepts, without losing or boring the listener. No matter how many times I’ve tried to memorize the actin myosin sliding filament theory components, a refresher is always needed! Your description of the history of the study of myofascial trigger points was particularly fascinating. I had no idea how little we knew about muscle and nerve function even 100 years ago. I felt that your use of humor was very tastefully done and added a nice lightheartedness to the presentation. I’m sure future students will wish they knew you after participating in the module. Your slides and narration were easily comprehensible. I appreciate how much effort you put into the organization and conciseness of the text. The handout you made was very effective and will make a great addition to my PT “bible”. Your passion for educating others and dedication to improving your skills and knowledge base was really on display in this project. Congratulations on a job well done and best of luck in your career. I know you will help many, many people!
Cristina Raiti
Great work Dan!
I enjoyed reading your Capstone page, as well as your handout and listening to your presentation! I think it is awesome that you were able to do this project in an area that you have had a long growing interest in!
The resources you provided were very helpful and I think you will definitely be adding much needed knowledge to future clinicians, which is very cool! I have found in my own clinical experience that it is very difficult to explain to someone what a trigger point actually is, and thanks to you now I have a good idea of how I can educate them properly. I appreciate you sharing your knowledge of this topic and I am glad I have you as a resources for future questions in this area!
When I was looking at the the Common Mechanisms of Injury section, I noticed that unaccustomed eccentric and concentric loading and low load repetitive tasks are on the list. While both of these mechanisms make sense based off of what a trigger point actually is, I was wondering how we can avoid causing trigger points in our sedentary patients? Low load repetitive tasks and unaccustomed concentric and eccentric loading are common ways that physical therapists help patients gain strength and improve their fitness level. Maybe trigger points are just something that we should be aware could happen and treat for as they appear and cause problems? Or maybe there is some way to avoid these hyperirritable spots from occurring and causing further discomfort in some of our lower level patients.
Anthony Pastore
Dan,
Excellent job! Trigger points and dry needling are two areas that I have also started developing an interest in, as many of the patients I have treated during ICE this past Spring have had trigger points. When treating these patients (usually with some form of soft tissue massage and ischemic pressure) I am inevitably asked what a trigger point is. While I believe I can explain the topic at a superficial level, I sometimes have difficulty sufficiently explaining to patients what they actually are. This is why I really appreciated both your handout and powerpoint presentation. I don’t think that time allows us to go into an in-depth discussion of trigger points during our curriculum, so your presentation will be a good resource for future DPT students who wish to gain a deeper understanding of this topic. I also believe that your presentation is of sufficient detail to serve as an excellent resource for seasoned clinicians. Your delivery of the presentation was great. You are a natural speaker and you are obviously very knowledgeable about this topic. I would venture to say that you now have a better understanding of trigger points than many clinicians in the profession. I also appreciated how you were able to take a dense topic and make it digestible and easy to follow.
As I stated previously, dry needling is something I have started gaining an interest in. From what I have read, dry needling can be a great tool for clinicians to use with patients and may be better than various soft tissue techniques. However, it has come up at various points in our curriculum that we should avoid over-utilizing passive modalities with a patient. So how do you foresee yourself utilizing dry needling in the future (hopefully once our use of it is unrestricted and is reimbursable)? Is it something that you may use for a couple sessions before moving on to a more active intervention technique? Basically, how does dry needling fit into your overall treatment plan?
Thanks for sharing your extensive knowledge of this topic, Dan! I’ve enjoyed getting to know you over the past three years. I’ll make sure to give you a call whenever I have questions regarding trigger points and dry needling!