Travell And Simons Trigger Point Pdf


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Siddhartha Sikdar. Download PDF. A short summary of this paper. Siddhartha Sikdar, Ph. Jen Hammond, B. Jay Shah, M. Introduction This paper discusses the definition of a common, but incompletely understood syndrome associated with soft tissue pain, referred to as myofascial pain syndrome MPS. It begins with a description of the syndrome and its frequently associated finding, the myofascial trigger point MTrP. The paper describes current published data about biochemical, mechani- cal, and physical properties of the MTrPs and the sur- rounding tissue.

There are no proven models explaining the cause of MPS or MTrPs, and the pathophysiology of both is con- jectural at this point. Therefore, the majority of the dis- cussion will center around descriptions of the syndrome, hypotheses, and data supporting the etiology based on existing literature and approaches toward treatment of MTrPs and symptom control of myofascial pain.

Image reprinted with permission from Medscape. It is characterized by sensory, motor, and autonomic findings associated with myo- fascial trigger points MTrPs. It often involves the neck and back1 and Chronic soft tissue pain, of which MPS may be has a high prevalence in primary care settings. Its origin may be secondary to tissue damage in which there is a lowering of pH and release of hista- This research was supported in part by the Intramural Research Program, National Institutes of Health NIH , and the Clinical Center and Office mines and bradykinin locally.

Substance P may also be released sient, rapid contraction of a taut band of muscle fibers peripherally with resultant increase in peripheral vaso- and is characteristic of MTrPs. In someone with C fibres, generating an electrical impulse which travels a spontaneous pain complaint, thorough palpation of the to the dorsal horn of the spinal cord. The condition resulting from MTrPs are highly prevalent in selected populations: the upregulation is peripheral sensitization.

These types of sensitization involve nociception, a phenomenon which results from an actual or potential tissue damaging event transduced and encoded by nociceptors. Nociceptors are sensory receptors that are capable of transducing and encoding noxious stimuli. Persistent symptoms may be the result of peripheral sensitization of nociception. In addition, central sensitization, modulation, and structural modi- fication also play an important role. Signs of peripheral and central sensitization are allodynia pain due to a stimulus that does not normally provoke pain and hy- peralgesia an increased response to a stimulus that is normally not painful.

MTrPs are hard, palpable, discrete, localized nod- ules located within taut bands of skeletal muscle, which are painful on compression.

This spontaneous pain can be at the site of the MTrP or remote from it. Peripheral sensitization of group IV afferents in graines, carpal tunnel syndrome, whiplash-associated the muscle is especially effective at driving central disorders, spinal dysfunction, post-herpetic neuralgia, sensitization.

In animal models of pain, nociceptive and complex regional pain syndrome. This may lead to changes in function and con- to deep and distant somatic tissues. Muscle pain acti- nectivity of sensory dorsal horn neurons via central vates unique cortical structures in the central nervous sensitization. Muscle tive neuroplastic alterations in the central nervous pain is inhibited more strongly by descending pain- system.

For example, there may be loss of inhibitory modulating pathways, and activation of muscle noci- neurons at segmental levels affected by the persis- ceptors is much more effective at inducing maladap- tent noxious input.

Image courtesy of www. As a result, pain , and expansion of the receptive field of pain. Accordingly, sub-maximal result in an intensified pain experience, are very dis- muscle exertions e.

Continuous ac- tivation of muscle nociceptors leads to the co-release of substance P and glutamate at the pre-synaptic ter- minals of the dorsal horn. Moreover, prolonged noxious input may lead to long-term changes in gene expression, somatosensory processing, and synaptic connections in the spinal cord and other higher struc- tures. These mechanisms of peripheral and central sensitization lower the activation threshold of afferent nerves and their central terminals, allowing them to fire even in response to daily innocuous stim- uli.

Consequently, even non-noxious stimuli such as light pressure and muscle movement can cause pain. Biochemical and Tissue Properties of MTrPs Although the specific pathophysiological basis of MTrP development and symptomatology is unknown, several promising lines of scientific study i.

Slow motor units are always stiffer than fast units, although fast units can produce more force. Traumatic muscle fiber injury during sus- tained sub-maximal level exertions could lead to the development of an MTrP.

Acute muscle overload can Figure 4. Simultaneous 2D grayscale and color variance imaging A and B of normal upper trapezius muscle. The normal muscle ap- occur with direct impact and lifting injuries. The Cin- pears isoechoic and has uniform color variance C and D.

Muscle derella Hypothesis28 postulates that during low-level with a palpable MTrP. A hypoechoic region and a well-defined focal decrease of color variance indicating a localized stiffer region is static continuous muscle contractions, smaller type 1 visible E and F.

Muscle with a palpable MTrP. Multiple hypoechoic muscle fibers are the first to be recruited and the last to regions and multiple focal nodules are visible. Sikdar, These resulting lesions have been hypoth- tor weakness and stiffness as a result of restricted esized to be similar to MTrPs. In the last decade, a new modality ture. EI or elastography has emerged. EI is based on gen- A key aspect of the Integrated Hypothesis is that erating a stress in the tissue using various static or muscle fiber contracture at MTrPs can cause capil- dynamic means and measuring resulting strain by ul- lary constriction, decreasing perfusion and leading trasound or MRI.

There are an increasing number of to tissue hypoxia. A study of tissue oxygenation in publications on elastography that have been applied MTrPs using a customized oxygen sensor indicated to most organ systems. Magnetic resonance elastog- a focal region of hypoxia35 at the center of the pal- raphy MRE , which uses a modified gradient echo pable nodule and a surrounding region of hyperoxia.

Inflammation, hemodynamic stress, viscoelastic properties of skeletal muscle. Recently, and hypoxia, and tissue distress may lead to vascular one study utilized MRE to show that the shear wave remodeling35 in the neighborhood of MTrPs.

One in- propagation pattern in the taut band in the upper tra- vestigation has demonstrated that circulatory distur- pezius was different compared to palpably normal bances secondary to increased intramuscular pressure muscle.

Our group has shown that ultrasound may be a plausible explanation for the pathophysiol- elastography can be used for imaging MTrPs and that ogy.

Nonetheless, small muscle tears, due to persistent muscle surrounding MTrPs appears stiffer on ultra- contraction has not been ruled out as a contributor to sound scanning. MTrPs in histological studies in animals are lo- The biochemical conditions associated with this calized contractions of sarcomeres into knots or nod- hypothesis asserts that the primary dysfunction is an ules with disruption of normal fiber structures.

Simi- abnormal increase in the production and release of Figure 5. A Subject with an active MTrP visible as a hypoechoeic region on the grayscale image arrow , and an artery running through the MTrP visible on color Doppler. B High-resistance blood flow waveform with reverse diastolic flow in the artery through the a-MTrP.

C The same subject had a latent MTrP on the contralateral side with an artery running through it, which showed no reverse diastolic flow. This sustained borhood of MTrPs showed high-resistance blood depolarization causes the continuous release and in- flow with retrograde diastolic flow in the region adequate uptake of calcium ions from the local sar- of the A-MTrPs. This differed from the blood flow coplasmic reticulum, producing sustained sarcomere from the surrounding tissue of the L-MTrPs and contraction and an increase in energy demand.

The normal uninvolved myofascial tissue. We believe sustained muscle fiber shortening contracture com- that an increase in vascular resistance in A-MTrPs presses local blood vessels, which reduces the nutri- is consistent with blood vessel compression due to ent and oxygen supplies and leads to a local energy sustained contracture at or near the trigger point, or crisis.

Sensitizing substances, including substance there may be vessel constriction due to oxidative P SP and calcitonin gene-related peptide CGRP stress or hypoxia. The blood vessel compression are released, which can interact with autonomic may be sufficient or one of a number of contributing and sensory some nociceptive nerves traversing factors that lead to local hypoperfusion or hypoxia. Subsequent release of neurovasoactive Ischemic tissue is often associated with pain, tender- substances bradykinin, prostaglandins, histamine ness, and nodularity of an A-MTrP.

The retrograde could, in turn, contribute to excessive ACh release diastolic flow suggests a substantial vascular vol- from the nerve terminal, completing a self-sustaining ume upstream of the constriction, where the blood vicious cycle. This ceived some attention from our group, and preliminarily is consistent with vascular remodeling in the neigh- findings have been reported. How- pathophysiology of MTrPs. Biochemical analyte levels in active, latent and normal trigger points in the upper trapezius and at control locations in gastro- cnemius.

Shah, et al, Not only does a lower pH enhance the re- arachidonic acid derivatives, and inflammatory medi- lease of CGRP, it also contributes to a further down- ators, among others. The multiple chemicals and our investigative group 39, 27 using a microdialysis lowered pH found in active MTrPs can contribute to technique confirmed that patients with A-MTrPs in the chronic nature of MTrPs, enhance the segmental the upper trapezius have significantly elevated levels spread of nociceptive input into the dorsal horn of of protons, bradykinin, pro-inflammatory cytokines the spinal cord.

Anti-inflammatory, analgesic, and narcotic We did not assay for possible contributors of the medications have been used for symptomatic control. The reduced oxygen levels in A- decades among a broad based group of investigators. Decrease in ATP leads single-assessor controlled trial.

Calcitonin gene-related peptide can enhance The lack of objective clinical outcome measures has the release of ACh from the motor endplate and si- been a barrier for critically evaluating the efficacy multaneously decrease the effectiveness of acetyl- of these therapeutic methods. All of these factors cholinesterase AChE in the synaptic cleft, which have led to a lack of consensus on myofascial pain decreases the removal of AChE.

Therefore, there is a need to de- docking stations for ACh. Miniature endplate ac- velop objective, repeatable, and reliable diagnostic tivity depends on the state of the AChR and on the tests for evaluation and treatment outcome measures local concentration of ACh, which is the result of for MTrPs.

In erly diagnose and understand the natural history of summary, increased concentrations of CGRP lead to MTrPs and to determine the underlying mechanisms a release of more ACh, and increase the impact of and relevance to the development and resolution of ACh by reducing AChE effectiveness and increasing myofascial pain. AChR efficiency. Miniature endplate potential fre- Gerwin and Dommerholt have written extensively quency is increased as a result of greater ACh effect.

Local and oxytocin, but these have not been conclusively anesthetics e. Studies have found that 0.

Travell And Simons Pdf Viewer

Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. Travell and D. Travell , D. Simons Published Medicine, Psychology. Lower torso pain and muscle guide hip, thigh and knee pain and muscle leg, ankle and foot pain and muscle guide.


Pages·· MB·28, Downloads·New! Load more similar PDF files. PDF Drive investigated dozens of problems and listed.


An expansion of Simons’ integrated hypothesis of trigger point formation

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An expansion of Simons’ integrated hypothesis of trigger point formation

We propose an expansion of this hypothesis to account for new experimental data and established muscle pathophysiology. This is a preview of subscription content, access via your institution. Rent this article via DeepDyve. Baltimore: Williams and Wilkins; This is the authoritative work in the field.

Now all the upper and lower extremity pain patterns and their corresponding trigger points are clearly illustrated on convenient flip charts, ideal for patient education. Trigger Point TrP : A focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness and, sometimes, to referred autonomic phenomena and distortion of proprioception. Types include myofascial, cutaneous, fascial, ligamentous, and periosteal trigger points. Each of the illustrations has a figure legend that provides easy reference to the volume number and figure number where the drawing originated in Myofascial Pain and Dysfunction: The Trigger Point Manual-Volumes 1 and 2 by Janet G. Travell and David G. Original drawings by Barbara D. Cummings; adaptations by Diane Abel off.

Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. If you continue browsing the site, you agree to the use of cookies on this website. See our User Agreement and Privacy Policy. See our Privacy Policy and User Agreement for details. Published on Jul 30, It includes new drawings, a number of trigger point release techniques in addition to spray and stretch, and a new chapter on intercostal muscles and diaphragm. SlideShare Explore Search You.


Travell & Simons' myofascial pain and dysfunction: the trigger point manual. 1, Pages·· MB·10, Downloads·.


Myofascial trigger points are painful, tense areas that are found in muscles. MTrPs affect muscles and fascia. Myofascial trigger points can be found anywhere on the body and are one of the most common causes for chronic musculoskeletal pain, also known as myofascial pain. A certified DGSA Trigger Point Therapist can release these painful and tense points in a muscle and assist in achieving long-term results. John F.

McPartland JM. J Am Osteopath Assoc ; 6 — The proposed etiology of Travell trigger points TrPs has undergone a fundamental revision in recent years. New research results suggest that TrPs are evoked by the abnormal depolarization of motor end plates.

Travell and Simons’ Trigger Point Flip Charts PDF

В разделе Служба сопровождения в справочнике было только три строчки; впрочем, ничего иного все равно не оставалось. Беккер знал лишь, что немец был с рыжеволосой спутницей, а в Испании это само по себе большая редкость. Клушар вспомнил, что ее звали Капля Росы. Беккер скорчил гримасу: что это за имя.

 Куда. - В ее трахнутый Коннектикут.  - Двухцветный снова хмыкнул.

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