In the Center of It All The 7-Step Trigger Point Protocol by Mary Biancalana, L.M.T., M.Ed., C.M.T.P.T. ’m sure we all have had clients who report feeling For example, many of our clients spend all day in front of a computer nagging pain or tension in their chest or mid-back hunched over. In this position the back and front of the upper torso are two between or below the shoulder blades. To really get key areas that are in direct opposition I of each other during work. As a busy to the center of it all there may be a bit of detective day goes on, they continue to use the work needed to find the true source of the problem. arms in front of the chest and lean NICOLE SCHOLPP | www.massagemag.com | June 2017 | MASSAGE Magazine 44 MASSAGE magazine—reprinted with permission Pressing where the client feels pain may not be the technique to use if the goal is to get rid of the pain. over a desk. This leads to myofascial The untrained massage therapist Take chest pain dysfunction and problems in the might spend a whole hour working seriously muscles. These problems can grow on the area where it hurts, but the According to Renee Hartz, M.D., a from a slight twinge of discomfort pain will not go away until the source retired cardiac and thoracic surgeon into burning, stabbing, aching, or trigger points are identified and who is now a trigger point expert and just shadowing pain that they wish eliminated. This is where the complete medical director of The Chicago Center they could have someone just press an trigger point protocol guides clinical for Myofascial Pain Relief, it is always elbow into it to make it go away. reasoning. best to refer clients for a visit to their That’s where we come in—but a bit primary care physician if they present more training is necessary. • The scalenes are in the neck, yet chronic pain in the chest area. Pressing where the client feels pain refer strong pain into the mid- The physician can do an assessment may not be the technique to use if the scapular area. to rule out any cardiac or vascular goal is to get rid of the pain. We need conditions and clear the person for to follow the road map given to us by • The levator scapulae and serratus treatment. Hartz reminds us that trigger point pioneers Janet Travell, posterior superior can cause mid- many patients with true coronary M.D., David G. Simons, M.D., and back pain, but they arise from artery disease are misdiagnosed Bonnie Prudden. What they taught us near the superior scapular border because their chest pain is is finding the source of the problem will and end at the cervical vertebra. reproducible. offer the long-lasting relief we all seek. In other words, his or her doctor Myofascial trigger points can • The infraspinatus—a shoulder presses somewhere on the chest, cause many problems in muscles, girdle muscle—can cause referred the patient has pain, so the doctor including, but not limited to: referred pain in the front of the arm and presumes the patient has chest wall pain, reduction in range of motion into the mid-back. pain and sends the patient home—and (ROM), weakness, loss of endurance, the patient then has a heart attack. numbness, tingling and a host of other • Finally, don’t even get me started Trigger points and coronary heart often overlooked symptoms. on those pesky latissimus muscles, disease can co-exist so be sure a full always overused by novice work-up has been done. Back pain from a neck massage therapists when they If your client has chest, neck, arm, muscle work. When harboring trigger or jaw pain or pressure, especially with According to Travell and Simons, points the latissimus dorsi can nausea, think heart disease and refer who co-authored Myofascial Pain and cause referred pain down the them to his medical doctor—and by all Dysfunction: The Trigger Point Manual, inside of the arm to the pinkie means call 911 if he or she is sweaty or there are nine muscles that, when or a strong, almost stabbing pain feels anxious along with the pain. harboring trigger points, can cause into the mid-back to just about For clients with no medical reason pain into the mid back. Of these nine, the medial edge of the inferior for chest pain, trigger points can often five are not technically located in the scapulae border. be the cause. Knowing which muscles mid-back. are the culprits requires a bit of www.massagemag.com | June 2017 | MASSAGE Magazine | 45 detective work. Of the 12 muscles that You can see that it is important For our clients, sitting all day cause chest pain, seven of them are to understand the full trigger point working on a computer can train not located in the chest area: protocol to ensure identification of the the muscles and fascia of the front key muscles causing pain no matter of the chest and the arms, including • The scalenes and what area that pain is felt in. pectoralis, coracobrachialis, pectoralis sternocleidomastoid are both major, pectoralis minor and rectus located in the neck The short and long of it abdominis, to be short. This, in turn, For every action, there is an equal and creates a classic hunched, or kyphotic, • The illiocostalis thoracis and opposite reaction. In the human body, mid-back and spine with retracted cervicis and serratus posterior it is all too easy to see how habitual scapulae because the posterior muscles superior are located in the back actions and postures lead to problems and fascia, including the rhomboids, in other, often opposite areas. The mid and lower traps, latissimus and • The external abdominal obliques chest and mid-back are probably the serratus anterior are spinal erectors and diaphragm are located in most obvious examples to see how and are inhibited. the abdomen. short muscles in one area pull another It is the job of the clinically minded area on the long. massage therapist to return full function to the chronically shortened tissue in the anterior torso and to improve function of the tissue chronically inhibited in the stretched position in the posterior torso. So, how do we do this and where do we start to figure out what needs to be addressed for any given problem? 3 There is a system for that. The 7-step protocol Because I run a clinic that works directly with medical doctors, chiropractors and osteopaths, it is very important that all my massage 1 therapist clinicians have a set protocol to follow to best guide treatment and communication with medical care providers. When beginning a treatment relationship with someone who presents mid-back or chest pain, 4 a full and complete trigger point protocol is just the ticket for gathering information that will inform the treatment plan and will guide the implementation of therapeutic interventions used. Mid-back pain, knee pain, shoulder pain or any other pain problem can then be seen through this framework. The only thing that ever changes are 2 5 the muscles being treated. NICOLE SCHOLPP To replicate clinical reasoning for all client problems, follow these seven Lasting change to the fascia and muscles comes with dynamic interaction between the practi- tioner and client. This includes treatment in active stretched positions with and without resistance. key steps and you will be on your way Photos: 1& 2 multifidi on stretch with resistance. 3 latissimus dorsi and serratus anterior. 4 & 5 to becoming a trigger point therapist pectorals and deltoids. or a successful pain-relief practitioner 46 | www.massagemag.com | June 2017 | MASSAGE Magazine who serves as a valuable option for between practitioners as each one can adaptations to her poor habits and life your clients and nearby health care clearly see the outcome goals and areas postures. providers. needing to be addressed. Keep this in mind The client history. A full and Use of trigger point pressure Chest-area pain and mid-back pain 1detailed client history tells a 5 release techniques. Once the due to myofascial trigger points can story of each client’s current and key muscles have been identified seem like challenging problems to past events. This can uncover key and goals have been set, systematic fix in a client, but with the road map perpetuating factors that create the treatment of muscles gets underway. given to us by trigger point pioneers, problems or are preventing them Dynamic treatment positions are used the massage therapist can effectively from going away. These factors might that allow for the most supported and eliminate and rehabilitate these include sleeping with arms overhead, most stretched position, while also muscles and fascia. for example, which can stress the allowing for full, active ROM during Keep in mind the suggestions muscles and fascia in the chest and treatment. (This is a very participatory provided by Hartz to consider true shoulder, leading to the formation of treatment—no lounging around cardiac-origin chest pain; referring a trigger points, subsequent chest pain allowed! See photos, page 46.) client to a physician for assessment and muscle dysfunction. A constant dialogue occurs can be a necessary step. Once cleared, between the practitioner and client follow the 7-Step Trigger Point The assessment-of-pain chart. to communicate details about the Protocol for any area of the body. 2 When the client draws her pain on sensation during treatment and to You will find it is easy to get to the this chart, we can compare it to the be sure the discomfort level is kept point.