April 7, 2011

Trigger Point

Last week, after doing some strenuous work on my son's shoulders, I felt a sharp pain. The pain every massage therapist dreads: a deep twinge in the saddle joint of the thumb. The joint that, by some accounts, makes us distinctively human, that makes our thumbs truly opposable; the joint that's the first to go if you wear out your hands doing massage.

With visions of arthritis and bony deformation dancing in my head, and gloomily recalling how long injured tendons and ligaments take to heal, I put it through the standard active range of motion tests. Adduction and abduction, extension and flexion, fine. I could spread my thumb and fingers, and clench my fist, with no pain. How about opposition?

Ow. Put my thumb in just the right position, and push its tip against the base of the ring-finger, and the pain was exquisite. Okay. How about passive range of motion? Now that was interesting. That, in fact, was fantastic. I was flooded with relief. If I relaxed my thumb and put it through the same motion with my other hand, there was no pain at all. Not a joint problem. Contractile tissue. There was a good chance that it was purely muscular.

The opponens pollicis is a little muscle. We didn't have to study it in school, but I learned it anyway, and now I could see it in my mind's eye, a short, triangular muscle, running from the transcarpal ligament of the wrist up to the base of the thumb. Not where the pain was -- further wristwards than that.

I probed it, working methodically along its two inch length. Sure enough. The band of of taut muscle, distinctly palpable. And in the middle of it --

Ow, again. Yes. The trigger point. Hurt like blazes. And it made the saddle joint hurt too, to press on it.

But press on it I did, deliberately, seven or eight squeezing rolls. And again, at intervals, half a dozen times during the day. Next morning it was fading. I kept working it that day. And now it's gone, completely gone, and so is the saddle-joint pain, like magic.

Trigger points often -- usually -- "refer" their pain elsewhere, generally to a joint moved by the muscle, but sometimes further afield: points in the hands and forearms can result, famously, in headaches. A good proportion of the pain that's diagnosed as various joint problems, arthritis and carpal tunnel syndrome and so forth, are nothing of the sort. Sure, if you x-ray the painful joint, you'll see bony deformations. But most joints, including painless ones that work fine, show bony deformations over time.

Arthritis and carpal tunnel syndrome are real -- don't get me wrong. But you shouldn't accept them as an explanation of joint pain unless ordinary, very treatable trigger points have been ruled out.

I don't really like doing trigger-point massage, as a modality -- as a massage specialty. It's a great party-trick to push on a trigger point till it resolves, and pain elsewhere magically goes away, but more often than not trigger points won't resolve that way. Entrenched ones almost never do. They need to be worked over and and over. And you need to discover how you're abusing the muscle, and stop it, or they'll come right back. As I watched carefully what I was doing with my thumb, I realized that massage had little or nothing to do with my pain: it was the way I kept my mouse-tap thumb tensed as I typed on my laptop keyboard. That's much more the sort of muscle use that results in trigger-points -- long-term motionless or fine-work tension. Human muscles aren't designed for that. They're designed to contract and release, to shorten and lengthen, not to sit still at low tension for hours at a time. That's what people do with their neck muscles as they sit at a desk all day, and that's why practically every desk-worker who comes under my hands has a rich array of trigger-points in the neck and upper back.

We need to learn to stop periodically and stretch and move around. We also need to learn to locate and work our own trigger points. It's much easier to find and work your own than to find and work someone else's. Some people are gifted at finding other people's trigger points; I'm not, particularly. But anyone can find their own.

Travell and Simons, in their two-volume bible of research on myofascial pain, estimate that seventy-five percent of pain presented to physicians is due to trigger-points. Very little of it is diagnosed and treated as such.

There are plenty of other causes of pain. Trigger point therapy is not a cure-all. But it should be in the standard owner's manual for anyone who has a body. You might need to consult with someone who has a good working knowledge of muscular anatomy to locate them at first. Some bodyworkers have this knowledge and some don't; most physical therapists do, though many of them know nothing of trigger points. Few physicians have that sort of practical working knowledge of which muscles govern which movements, so most of them will have no idea where to look when confronted with myofascial pain.

Clair Davies' Trigger Point Workbook is an excellent handbook to start with. It's a book I think everyone should have. But no book is of any use unless you take the time to explore your own body, experiment with it, and work with it.

April 6, 2011


The Quadratus Lumborum -- universally pronounced Kyoo-Ell -- runs from the back hip-bone to the bottom rib, on both sides, with connecting service to the sideways prongs of the lumbar vertebrae. Anglo-Saxons injure it a lot, because we generally hold our hips stiffly in line with our chests, and never give the poor QL a chance to completely contract or to really stretch. Belly-dancing would be impossible without the QL, as would climbing a ladder: any activity that hitches up one side of the pelvis up closer to the ribs requires that this muscle contract on the hitching side, and stretch on the other side.

Back when I used to "throw my back out" periodically -- before I learned the back exercises (really unattributed yoga, I learned later) that made those incredibly painful, disabling bouts a thing of the past -- it was the QL that I injured. So when I learned about it in massage school I was anxious to work with it.

But it was disappointing, at first. It was hard even to find it, especially on someone fleshy (like me). It's a back muscle, but it's mostly on the other side of the muscles, which at this point are pretty thick and powerful, right alongside the spine. If you try to get into it by pushing hard on the paraspinals, not much happens, because the paraspinals (being a cluster of mostly short-stranded muscles) hit their stretch limit before the QL's even started; and you can't squeeze it against anything, because there's nothing on the other side but intestines.

Well, that's one trouble with learning out of picture books: if you think of the muscle as a back muscle, then you only try to work it while someone's prone. You're stuck in two dimensions. There are a couple good ways to work the QL, but neither are from the back. Sidelying, you can bring the bottom thigh up (headwards) and nearly-straighten the top leg out to get a bit of a sideways stretch (you may need to tuck a towel or cushion under the side to make this work). then you can reach to the forward edge of the paraspinals and press nearly straight down: you've got the QL pinned against the spine, and you can really work it. Or -- this is my favorite -- with someone supine, you can reach underneath on both sides, and make fists of your hands, and simply roll their body back and forth over your fists. You can catch the edge of the QL with your thumb-knuckles and really stretch it. Their body weight does all the work. The intestines are free to get out of the way: they have all the room in the world. Most people are really grateful to get this kind of stretch -- similar to a toe-touching stretch, as far as the back muscles go, but a safe one. (I wince when I see people doing toe-touches, with a hundred pounds of torso or so pushing down on a three-foot lever; I'm always relieved when I see them come back up uninjured.) When you've done a number on the QL, you can finish off with a nice stretch -- with the person you're working with still prone -- by picking up both feet and pulling the whole lower half of the body, legs, pelvis, and all, to one side and then the other.

As Pamela Sundin-Hart, one of my favorite teachers at East-West, always insisted, "any muscle that attaches to the ribs is a breathing muscle." The QL has a crucial role in keeping the ribs stable so that when the diaphragm pulls, the rib cage doesn't simply fold in and follow it. When the QL is knotted up we favor it by breathing shallowly. Shallow breathing means less oxygen, and less oxygen means less energy: a jacked up QL will make you tired, and not just because you're in pain.

April 5, 2011

Fat and Massage

“What do you do with a client who's really fat? I mean, like 300 pounds? How can you do them any good?”

It was a fellow student in massage school asking the question, a few years ago. I looked at him in surprise. He was a big guy, heavier than me, probably only 60 pounds shy of the 300 mark himself. The question struck me as bizarre. He went on, “How do you even get to the muscle?”

I don't remember what the teacher answered. She seemed as perplexed as I was. How do you get to it? You go around the adipose tissue or through it, just like with anyone else. If there's a lot, going through it can be poky, so you use a blunter “point” – the heel of the hand instead of fingertips or thumbs, say. But we all already did that. Even a skinny person, anyone who's not downright emaciated, has patches of adipose tissue. We'd been working with it for a year. What was the big deal?

But this student was plainly distressed, and I could see that we had left the realm of the rational. He was a good guy, not a jerk. But some people are a little nuts about obesity. We had left the realm of facts and were floating in the anxiety zone.

I find it slightly easier to work on fat people than to work on skinny people. Skinny people are easy to hurt: the muscle tissue lies smack against the bone without any padding and working it without pinching it takes some delicacy. Fat people often have a few places where I change techniques so as not to poke – upper arms and inner thighs, for example. Trigger point can be a little trickier. But actually the way the body lays in fat leaves almost all of the sweet spots completely accessible. It's just not a problem. And if you work glutes and abdominals at all, you already know how to work through fat.

Every body – every body, no exceptions – presents challenges and requires some improvisations and adaptations. There's no such thing as a normal body. They all have injuries and unexpectedly tender places; joints with limited range or hyperextensible ones. If you can't modify your routine to fit the body at hand, you simply can't do massage. The clients I find most challenging are heavily muscled men, weight lifters, for instance, who are simply damned heavy to move around, and present a lot of dense muscle acreage to get through. But I don't mind that. It's my job, working with different bodies. That's what I do. I got into this profession partly because I like bodies. I'm curious about all the shapes they can take. I don't want them all to be the same.

Over and over people – especially women – apologize to me for their fat, as if they were offending me. I'll be working on what seem to me like perfectly lovely calves, and suddenly my client will be explaining to me how she has always had thick ankles and the weight just seems to settle in there, and she's been trying to diet and . . .

There's always a moment of disorientation, while I try to figure out what on earth they're talking about. But when I do, it makes me unhappy. I want to say, “Look, there's nothing wrong with your ankles, or anything else about you! Your body's lovely! I'm enjoying it! If I wanted to do massage only on bony fourteen year old models, I would have mentioned it in my ads!” But that would not quite be professional either. I don't really know what I do. Murmur something reassuring and neutral, I suppose. It's all the odder because the people who do this are often leaner than I am. If apologies are in order, shouldn't I be apologizing to them?

I have worked on some very obese people, and their obesity has never been the main thing I have been coping with, during the massage. It's the regular challenges – what's the root of this tension? How do I work with this injured shoulder? What's the best positioning for this leg? – that occupy my attention. It simply doesn't make that much difference.

A couple years ago I had an email inquiry about massage, in which the writer said something to the effect of, “I'm very big, so please tell me up front if you have issues about fat.” I was glad she felt she could ask, but I was mortified, on behalf of my profession, that she felt she had to. No one should have to ask that. We're therapists, for God's sake. We have no business “having issues about fat,” any more than we should be having issues about shin splints or headaches.

I understand that many people – erroneously, I believe, but that's a different subject – think that obesity is a self-inflicted condition. But so what? We're surrounded by injuries and conditions that are more or less self-inflicted. I see lots of people who have run on concrete until their knees or ankles are a mess. I see long-time smokers who have an eerie, system-wide dessication of tissue. I see desk workers who have so abused their neck muscles, by staring motionless at a screen for twenty hours a day, that they can no longer turn their heads. Do I suddenly get on my moral high horse and refuse to treat them? Turn them away in disgust? I do not.

Nor do I tell people they should lose weight. If they haven't been living in a particularly remote section of the Carlsbad Caverns for the last fifty years, they already know that, and they've already tried to do it – repeatedly, and at a grievous expense of spirit. The last thing they need is for their massage therapist, the person they go to for comfort, to start harping on the same theme.

April 1, 2011

Why I Don't Stretch

"What have you been doing to make it feel better?' I usually ask.

"I've been stretching it, every day," the client says. "But it doesn't seem to be getting better."

I don't know how stretching came to be, in the popular mind, the panacea for muscle and joint pain. But I have this conversation over and over. Athletes sometimes will surprise and please me by saying they're alternating heat and ice, which really is helpful, for a new injury. But mostly people say they're stretching it. If they admit to babying it and giving it rest, it's only with a certain shame. They know that what they really ought to be doing is exercising and stretching it.

Maybe it comes of a misunderstanding of yoga. To Westerners first meeting yoga practitioners, the striking thing about them was that they were extraordinarily flexible. Which they are. But they're not pain-free because they're flexible: they're flexible because they're pain-free. And they're pain-free because they move mindfully throughout their range of motion and relax thoroughly, not because they stretch.

Or possibly it comes of the mechanistic model of the body. We learned lots of wonderful stuff by thinking of the body as a machine. How the circulatory system works, for instance. It wasn't until someone thought mechanistically about it that anyone really understood what the heart does and how the blood flows.

But the body is not a machine, and you don't repair it like a machine. It's probably true, as your physical therapist will tell you, that you can't turn your head to one side because a neck muscle, maybe the levator scapula, is shortened. But we're not talking about a fan belt here. You don't fix it by stretching it out. A muscle is "shortened" because it's contracted, and it's contracted for a reason. If you try to stretch it you will simply tear it, and make matters worse.

A muscle is not a fan belt in another way, an even more important way: it's replacing itself, all the time. Muscle cells in particular have a short life span. And that means that the neck trouble you've had for years is not the original injury. It's a replicated injury. The muscle is pretty much brand-new: the pain you have now is one that's been recreated in new tissue. Fixing it is not like fixing an object. It's intervening in a system. A long-standing muscle injury is more like a bug in a computer program, causing an infinite loop of contraction, than it is like a fan belt that's too tight. Or like a snag in a current, distorting everything that flows past it. This is why surgery is so seldom effective for chronic pain. When everything heals up, the movement patterns that created the original injury will all still be in place, and they'll simply reproduce themselves. My guess is that much of the relief people get from surgery is the result, not of any changes the surgeon makes, but of the splinting and enforced rest the muscles get after the surgery. It's no simple matter to improve on the mechanical design of the body, and it's usually better not to try.

The four strategies I think are best, for dealing with chronic musculo-skeletal pain, are

1) judicious rest
2) trigger point massage
2) skillful physical therapy
3) skillfully taught yoga

First of all -- get some rest. Let the damn thing get better. I don't mean immobilize yourself. But move lightly and loosely, and stop doing whatever screwed you up, for a while.

I hesitate to recommend physical therapy and yoga, because they're such a crap shoot. It's hard to know how good the physical therapist or yoga teacher will be. Many of them are young people with perfect bodies who don't have the slightest idea what it's like to inhabit a sixty-year-old body, and they'll urge you to do all kinds of appallingly unwise things. There are terrific ones. If you find them, hang on to them! But there's a lot of bad ones too. Be careful.

Trigger point massage is also a crap shoot. You should expect to have to try a couple therapists before you find the right one. But the nice thing is, the bad ones don't usually hurt you. You can afford to try a couple. It's a much lower-stakes game.

A final note about stretching: damaging stretches can become almost addictive. It feels so good, sometimes -- like scratching a maddening itch. But it can be like scratching a rash: no matter how much relief you get in the moment, you're really just going to make it itch more. There's can be a temporary relief, and even a kind of pleasure, in tearing a muscle. But stretching should never hurt. Never. If a stretch starts to hurt, or you start to tremble with it, stop at once. Back off. You're doing too much.

If you must stretch, read Bob Anderson's book and learn to do it right. I don't even like the word "stretching," I do something in the morning that probably most people would call "stretching." But I'm not trying to make my muscles longer. They're a perfectly good length. My body looks after sizing my muscles, and I'm happy with the job it does. I'm exploring my range of motion. The idea is not to extend my range of motion, though that happens, sometimes. The idea is just not to lose it. If you never lift your arm over your head, you will, sooner or later, lose the ability to lift your arm over your head: that's why I move. Or, as some people might call it -- but I don't -- "stretch."