A couple of years ago I taught manual trigger point therapy to a large group of physical therapists in Salinas, California. After ending my opening lecture someone in the class asked me if I knew why I was there. A strange question I thought. Well it turned out that all these therapists worked in the emergency department. I had never considered manual trigger point therapy being used in acute situations, but why not?
A month after I had delivered the first workshop I contacted one of the physical therapists to ask how it was going. Very well, she responded. Well enough to be invited back to deliver workshop number two six months later. In six days I had taught techniques relating to about 140 palpable muscles.
Performing manual trigger point therapy in an ED situation invites a few questions. People attend the ED because it’s an emergency. Myofascial pain is generally not considered an emergency. Myofascial pain is likely to be chronic, achy, deep, diffuse, and as we all know, where the pain is experienced is not necessarily where it’s coming from. How do you convince somebody with pain in the sacroiliac area that you want to work on a calf muscle? How do you convince somebody with hand pain that you want to work on a pectoral muscle? How much undressing would there be to get direct contact on each individual muscle, or do you work through the clothing? How much time would you allocate for the treatment? And crucially, what metrics are incorporated prior to, and who makes the decision to call in a trigger point therapist?
In April 2019 my mentor, Jan Dommerholt, sent me a case report published in the journal ‘Clinical Practice And Cases In Emergency Medicine’. The title of this case report was long winded and read ‘Atraumatic Back Pain Due To Quadratus Lumborum Spasm Treated By Physical Therapy With Manual Trigger Point Therapy In The Emergency Department’. The authors were all from Salinas, California. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682240/
A 42-year-old female had presented in the ED with left-sided, atraumatic back pain upon waking in the morning, with pain centered around the lower posterior ribs. She had an unremarkable X-ray, and passed tests for serious pathologies like pulmonary embolism, pneumothorax and occult rib injury. The emergency doctor determined the pain to be of myofascial origin, specifically a spasm in QL, and so called in a PT trained in trigger point therapy.
The protocol that I would have taught addresses QL in a rectangular way starting at the twelfth rib, and can be performed prone or in side-lying, clothed or directly on the skin, mostly using thumb compression. The next contact points are on the transverse processes of L1-2-3-and 4. Pressure is then applied over the pelvic crest attachments, followed by compression on the lateral margin of the muscle back up to the 12th rib. Theses compressions follow David G. Simons’ ‘Barrier Release’ method with up to a minute contact as the tissue softens. Reinforcement techniques include cranial glides, caudal glides, myofascial release, active 90/90 stretches, and maybe even the ‘banana stretch’.
Upon reassessment by the emergency physician, the patient described being pain-free. She did not require any medication at the time. This is very important. In order to reduce the use (and misuse) of medication, especially opioid medication for musculo-skeletal pain relief, a conclusion here is that emergency providers should consider trigger point therapy instead. To quote; ‘manual trigger point therapy is an inexpensive and effective way to treat myofascial pain and can be used in an ED situation’.
This is the first journal report ever published describing a physical therapist successfully providing manual trigger point therapy in the Emergency Department to relieve pain. Hopefully the first of many.
Cheerio for now,
Stew