Cold Laser: Major Change in the Way I Practice Myofascial Trigger Point Therapy!

I'm very excited to announce that I have started using LLLT - Low Level Light Therapy - also known as Cold Laser Therapy.  

I LOVE it, and I think you will, too.  

Cold laser technology has been around since the 1970s, it's very well tested, and it works.  I was dubious at first (as I am of anything that sounds too good to be true) but after much googling, personally both observing and experiencing cold laser treatment from a leader in this field, grilling the CEO of the laser manufacturer, and trying it out for the last few weeks on my own patients, I can confirm that it works.   It. Really. Works.  

The best part is, it works just as well as manual myofascial trigger point therapy but it doesn't hurt.

For 25 years I have somewhat apologetically explained to my patients that getting rid of trigger points requires that I press enough to cause a small amount of pain, and then I must hold it until the trigger point begins to release, marked by a diminishment of the compression pain.  Back in the 1970s and 80s, myotherapists believed we had to use a pretty substantial amount of pressure - 35 pounds per square inch! - and that treatment was necessarily a painful thing. By the 1990s we had observed enough variations in treatments and results to realize that a considerably lesser amount of pressure would do the trick, but it often still hurt a little, and on some people still a lot.  I have noticed that patient sensitivity has more to do with the pain level than amount of pressure, which I have always been careful to keep at a tolerable level.  A patient should be able to stay relaxed, talk and breathe during treatment. But now, after 25 years, it just got even easier!

Cold laser therapy does not require painful compression at all, only the contact of the laser apparatus (it looks like a big fat pen on a cord) against the skin.  Pressing it against the trigger point does not add anything to its ability to work.  It deactivates trigger points with light just as effectively as compression, and perhaps more so, if the muscles are hyper-reactive and prone to rebound spasm when insulted by compression.  The absence of strong compression also results in the absence of post-treatment soreness.  This is fantastic news for anyone with sensitivity or anxiety issues, post-treatment soreness issues, and especially fibromyalgia.  It can not burn or cut like surgical lasers, and short of pointing it directly at your eye, it is completely safe.

Now you can find out how it feels to just. stop. hurting.

One Man's Story

One of my patients kept a pain diary for seven years to document his ordeal.  Doctor after doctor failed to diagnose or explain his pain to him, much less find him an effective treatment.  His persistence paid off in the end, finding therapies that helped lower his pain and keep him sane until he ultimately stumbled upon The Trigger Point Therapy Workbook by Claire and Amber Davies, which led him to understand what his pain really was and then to search me out.

Excerpted from Myofascial Pain and Treatment: My Story

by S.S.

I am approaching the eighth anniversary of My Ordeal as I call this experience, which began as a feeling of slight numbness and tingling, and became progressively worse, and developed increasing, constant pain.

In the beginning, the many doctors I went to could not diagnose the pain, which I now know is myofascial, caused by a muscle knot. I had never had anything like this before in my life. I sought out both physical and non-physical alternative treatments. It is my desire that what you read is both informative and inspiring.

I experienced vertigo at work in February of 2009 that sent me to the George Washington Hospital Emergency Room. The diagnosis was benign positional vertigo, and there was no recurrence.

However, I soon after developed a burning sensation in my entire left leg, left hip area, and left rib cage area just under my arm pit. I was referred to a neurologist and had an MRI of my brain and neck with contrast. She was not able to find a cause for the burning or vertigo, and prescribed the drug Neurontin (used for seizures) which I did not fill right away. There was a breakdown of communication as I was not assertive enough to press about the cause of my condition when the Neurologist did not seem to have an explanation. My neurologist then ordered a pelvic and lumbar MRI and a motor nerve conduction test, which indicated that I had about 50 percent of sensation in my left leg versus my normal right leg. Additional blood tests were normal except for a lower level of B12. I stopped seeing the neurologist after that.

With the burning sensation being constant 24 hours per day, with the only relief being during sleep, I decided to try acupuncture. I has 11 visits from May 2 to August 22 that did not solve the issue either.

My discomfort level during between March and October 2009 varied from 5 to 8.

I couldn't do anything to decrease the burning sensation other than to avoid strenuous physical exercise - my jogging workout - which I continued to perform during the first 6 to 7 months of this ordeal. The discomfort level stayed near constant during the first seven months. It became a nearly unbearable 7 to 8 by that August. I called my neurologist to see if she had any diagnosis yet. The only thing she mentioned was that there was a slight disk hernia in the L5 area of my spine. I then tried taking the Neurontin for about a week, but I did not see any results or lessening of the discomfort so I discontinued use.

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is the feeling common to such experiences as stubbing a toe, burning a finger, putting iodine on a cut, or bumping the funny bone. I do not like to classify my sensation as pain, but more as discomfort. I guess that they are one and the same, but I prefer to think of it as discomfort.

The main area the discomfort was in was my entire left leg from toes to hip, with the main concentration in the left hamstring and thigh area. I describe it as a burning sensation since it was constant: 24 hours a day, and very steady. I kept a daily pain diary about this during my visits to various doctors during that calendar year. The sensations included burning, hitting the nerve in your funny bone, and that feeling you get when you sleep on a body part for a while and lose sensation, and then get tingling while the sensation returns. They could also be described as as having a muscle rub such as Ben Gay all over the leg and then having a heating pad on top of that, or a small ball of fire inside my left thigh/hamstring area.

I observed that the intensity seemed to spike when I performed vigorous physical exercise such as jogging or swimming. It was like having an electronic ankle bracelet that increased the pain, as though punishing me for exercising. It wasn't life-threatening, but it was lifestyle-hindering.

By September I was feeling desperate. The possible disk herniation sent me in search of a rehabilitation clinic, hoping that physical therapy and traction might help.

The physical therapist evaluated me with range of motion and reflex tests. Everything was fine. She looked at MRI films suggested traction for the slight bulge of the L5 disk. I had some relief but after two more weeks nothing much changed and the PT decided the pain was caused by a pinched nerve and not a herniated disk.

I then began my visits to the Virginia Spine Institute where I was also prescribed Naproxen and Neurontin and had further MRIs ordered. After staying on the two drugs for a month and then returning to the Rehabilitation Clinic for six more weeks of physical therapy the burning sensation did not go away, but was more tolerable at a 2.5 to 3, the best since the previous March. During that six weeks at the PT Clinic, I did lumbar stabilization exercises, received ice, heat, TENS, ultrasound and massage. Although this seemed like a good approach, it did not solve the problem.

The doctor at VSI performed a spinal injection in October 2009, thinking perhaps the nerve bundle around the tailbone was inflamed and that a steroid injection might work. Unfortunately this did not provide any relief and finally the doctor at VSI told me after several visits somewhere in mid-November 2009 that he did not know the cause and had no diagnosis.

The final doctor I saw in 2009 was a neurologist recommended by the VSI. I told gave him the entire story including all paperwork MRI films. He prescribed the drug Lyrica and ordered another extensive blood test (five or six more vials of blood and I will state here that I do not like needles). Again they were normal except for a slightly lower level of B12; I pressed him for a diagnosis and some answers as to what I had. He said that he did not know and was doing all he could, and tried prescribing the drug Nortriptyline. I took this for about a month until mid-January 2010 and then stopped. I was very disappointed canceled further appointments.

I was out of leave and did not want to take off more work in attempts to figure this out.

Over the next several months, my doctors tried me on Cyclobenzaprine, Tramadol, and Tylenol w/Codeine,, with very limited results, nothing lasting.

In July of 2010, my mother found a Reiki healer, a spiritual approach I was willing to try since Western medicine had been unable to find a source for the problem or provide any measure of relief. After receiving a Reiki treatment that did a lot of good, I decided to become a student and learn more about Reiki as a self-healing practice. Over the subsequent six years I continued to both study and receive Reiki, and my pain level gradually dropped from 7 and 8 down to 1 and 2 by the summer of 2016.

I then began to learn more about myofascial pain and its causes from two books purchased on line, “Trigger Point Therapy for Myofascial Pain” and “The Trigger Point Therapy Workbook.”

It turned out that I what I had been experiencing was myofascial pain caused by a muscle knot called a trigger point, which is a very contracted part of the muscle that causes spikes in my level of pain. Pain gets the flare-ups when you further contract a muscle that is already tight.

Now that I knew more about my condition, and wanting to get rid of the residual pain, I found a myofascial trigger point specialist named Michele Macomber who operates Myofascial Trigger Point Therapy of Maryland from her home office. I began treatment with her in June of 2016. She studied my posture and the condition of my upper left leg muscles and began to work on releasing all the residual trigger points or knots in the area. She also prescribed several therapeutic leg stretches and introduced me to some helpful self-treatment tools that I began to use and will continue to use.  After my first treatment my pain level became a 0.5.  Within a couple of weeks I was describing it as 0.1. As of the writing of this paper the pain level CONTINUES TO GET LOWER AND LOWER.  I know the discomfort is there, however it does not limit my movement or exercise in any way.  I am not sure if the pain will completely disappear however I do think that it will continue to diminish over time as I continue to use the tools, do the stretches and get treatment from Michele.

Does Your Car Fit You, or... Does This Bucket Seat Make My Butt Look Big?

Poor ergonomics in the driver's seat can lead to headaches, neck, back and hip pain, even pain or numbness in your hands! 

Do you have an ill-fitting car? Those bucket seats look comfy at the dealer, and feel pretty good to sit in long enough for the test drive. But over time with countless hours of commuting, or long road trips, what happens?  Those seats can be too short to support your whole thigh, forcing the edge of the seat into fatiguing hamstrings, especially if you have to stomp frequently and forcefully on the clutch in city driving.

Ill-designed arm and head-rests can lead to driving-related chronic pain and rotator cuff issues.

Missing or ill-placed armrests make you rest your elbow somewhere that forces your shoulder out of anatomical neutral and holds it that way for hours. Missing or ill-positioned lumbar support throws your head forward and loads up your neck muscles, and the biggest culprit, forward-jutting headrests, keeps your head from sitting atop your cervical spine, even if you add the correct lumbar support. Arms, lumbar spine and thighs all must be adequately supported, sitting up straight should feel restful, and steering wheel must be comfortably and safely held, all while your feet reach the pedals! That's quite an ergonomic juggling act, and some cars simply can not be adjusted to fit some people. When treating myofascial head, neck, back or hip pain, check your car fit for perpetuating factors that can be re-activating trigger points, and see if they can be corrected.

When purchasing a car, always be sure to try it on for an ergonomic fit that will keep you comfortable for the long haul!

Why I Will Never Sell You Supplements

It all started when I had terrible TMJD...

I discovered myofascial trigger point therapy in the late 1980s in the same way many of us do: by stumbling upon an MTPT by happy accident when looking for pain treatment. I had terrible TMJD, and I lucked into a dentist who made me a splint and referred me to the first myofascial trigger point therapist I ever met.

As it happened, she also represented a not-available-in-stores brand of liquid potassium supplement, and right in the initial office consultation persuaded me to purchase this product from her. I obediently bought some and used it for a few weeks. It seemed to live up to its energy-boosting claims, but it was too expensive for me as I was a public school teachers' aide at the time, and I soon gave it up in favor of buying groceries. I noticed I didn't seem significantly worse off without it.

My therapist recommended a supplement now banned by the FDA

A few months later I was back in the office of the same MTPT for a tune-up - supplement salesperson or not, she was a fantastic therapist! - and now she was promoting a very expensive powdered ephedra tea mix for weight loss. I gave that one a miss because I dislike stimulants, and thank goodness I did! It later turned out to be one of those herbal supplements linked to adverse health effects - including death! - that was ultimately banned by the FDA.

In the subsequent years, I have met many myofascial trigger point therapists as well as other doctors and therapists who promote and sell various supplements and products. Some of these products have a degree of merit, most of them are more expensive than similar products found in retail stores. Something about this always bothered me.

I felt like a cash cow, not a patient.

One day a health consultant I was trying on the strong recommendation of a friend - at $100/hour plus $50/monthly supply of a supplement she'd convinced me I needed - tried to sell me two additional products plus the one I already used, plus the session, and I found myself being asked for a check for over $300. Over $300. in a single afternoon for products and services I'd never heard of before with no visible or immediate results, that might help me over time... maybe... and... snap! I suddenly didn't trust her anymore. I still liked her personally, and thought she gave at least the impression that she knew an awful lot.  But I also thought I smelled a sales pitch and my gut told me to back away. Suddenly I felt like a cash cow, not a patient. I never went back.

I decided that for me, promoting a product to my patients undermines my integrity because it presents a conflict of interest. 

I certainly want my patients to be informed if they may have a particular vitamin deficiency related their back pain or migraines, but if I am personally selling those supplements, I appear to be profiting, not to mention using up valuable treatment time to do so. I would also be representing myself as having training that I do not. If my patients are anything like me, they may be politely smiling, and even buying the product, but inwardly they may be feeling put upon, hustled, uncomfortable, resentful, and possibly even in doubt of my motives or ethics.

I will never suggest a supplement that can not be purchased in a brick-and-mortar store.

I like to make a point of telling my patients that I am not a physician, nor am I a nutritionist, and I can neither prescribe nor diagnose. I can tell them what the studies say about the relationship between muscle pain and nutrition, and make some recommendations about which supplements they might want to discuss with their physician or a licensed nutritionist. I will also never suggest a product that can not be purchased in an ordinary grocery or health food store or pharmacy. It is my belief that a good, known, tested product at a fair price will be available at a retail store, and should not come with a hard sell on why you must buy this product even though it is much more expensive than its competitors, or why this product has no competitors and therefore must be purchased only through this seller.

I am aware and respectful of the fact that some people see their health care professionals in an authoritative light. I know that I certainly like to think that my doctors and therapists always know what they are talking about! This can make it easy to persuade people that they Really Need Something if a doctor or therapist says so. No one should ever take advantage of that to make a profit. In my experience, a supplement side-line subtracts integrity from my practice, which means it can never add value, no matter what the profit.

Patient Stories: Car Accident

Physical therapy, massage, and chiropractic didn't help...

I was cleaning out my inbox the other day and found this testimonial gem from 2012. Apologies to Ms Thomas; she wrote me this wonderful review and I set it aside until I got my blog set up, then forgot to post! Still every bit as relevant today though:

I was experiencing a lot of pain in my back, hips, and neck.

I had a car accident five months ago. I was fortunate to have no signs of any broken bones, but I was experiencing a lot of pain in my back, hips, and neck. After getting physical therapy, massages and chiropractic treatment, I had no relief. It was just getting worse. I hurt everywhere. I couldn’t sleep at night, I struggled to get out of my car, up from a chair after sitting and definitely had a hard time walking any short distance. My chiropractor actually suggested I get a massage. It did feel better…for a day. In addition to my new found pains, I also was suffering from plantar fasciitis pain in my feet. I have had several steroid injections over the years to address this pain. I was at the point where just getting out of bed and keeping my head up all day was extremely difficult. Living with constant pain while you are just doing your normal routine can get to be exhausting and depressing. I was starting to believe and accept this was a normal state for me; that I was just getting older!

The payoff for me is when I sleep through the night comfortably...

 I was desperate for help so I decided to search for a massage therapist on the internet. To my now pleasant surprise, I found the Pain Free Maryland website. I have had several treatments now and feel like a different person. I can actually get through the day without thinking about how bad it feels to sit, walk, or sleep. Today, I actually feel lighter! As days pass, I just feel relieved and grateful! The payoff for me is when I sleep through the night comfortably and get up in the morning and place my feet on the floor, there is no pain. The rest of the day will follow suit! I am so pleased with my improvement, I am taking my teenage daughter to deal with her headaches and chronic neck pains as a result of a fall.

If you’ve tried various treatments that are not giving you relief, I highly recommend that you give myofascial trigger point therapy a try. 

This is not your grandmother’s massage! You won’t get the candles, floral scents and background music with ambiance (but there is a very friendly cat!). It is very focused, stress-relieving pressure on trigger points and stretching. If you’ve tried various treatments that are not giving you relief, I highly recommend that you give myofascial trigger point therapy a try. Don’t get caught up on the long phrase. You can always use it later to impress your friends at a party!

J. Thomas Silver Spring, Maryland

Muscles That Mimic

Easily-treatable Myofascial Pain Can Scare the Pants Off You

Ow! I think I have sciatica!

It is important to note that myofascial pain patterns commonly mimic those of other conditions and illnesses. High on the list of muscles that mimic other problems is the gluteus minimus, in the hip. Sitting for a long time in a chair or car seat with inadequate thigh support, or taking a fall can create trigger points in this muscle. These refer pain into the buttocks, and down through the thigh and calf, as in illustration A. When this particular pain occurs, lay people and healthcare professionals alike often reasonably presume this pattern to be a symptom of sciatica.

OMG!  I'm having chest pain!

Trigger points in the pectoralis major will cause pain in the chest and down into the arm, as in illustration B, mimicking a heart attack. Of course, a patient should immediately have this checked out by a physician, but when the appropriate tests for heart problems come back negative, the doctor may next refer the patient for myofascial trigger point therapy, having ruled out a more serious diagnosis.

Oh no, pelvic pain!  That has to be bad, right?!

There are numerous cases in which appendixes have been removed and found to be disease free. In these cases, the culprit might have been trigger points in the lower rectus abdominis, which, as you can see from the pain pattern in illustration C, cause pain in the lower abdominal area, mimicking appendicitis. These trigger points can be activated when a person is tired, worried or premenstrual. Trigger points in the other lower abdominals can cause diarrhea and symptoms mimicking diverticulitis or gynecological disease.

Ugh, these migraines are ruining my life!

With the ever increasing pace of today’s hectic lifestyle more and more people are suffering from migraine headaches on a monthly, weekly, or daily basis. Trigger points in the posterior cervical muscles (the back of the neck) are nearly always involved in severe headaches such as migraines, tension headaches, and post-traumatic headaches. When trigger points in the upper trapezius are activated, they mimic migraines (illustration D) and cause severe head and neck pain. These muscles can contract strongly, or cramp, compressing and entrapping the greater occipital nerve, causing not only muscle pain, but nerve pain, as well.

These are just a few examples of the tricks muscles can play on us if we are not aware of this common but sneaky type of pain. There are many more of these patterns, but even once correctly recognized, there are also key concepts to be aware of in order to treat this kind of pain effectively.

This is an excerpt of an article I wrote for Pathways, and contains material used with the permission of my excellent colleague, Vicki MacGown.

How Hard Does a Myofascial Trigger Point Therapist Press?

Eliminating Myofascial Pain Should Not Be Painful

How hard does a myofascial trigger point therapist press? This is how John F. Kennedy's White House physician and Trigger Point Manual author Janet G. Travell describes it:

"...clinician applies gentle, gradually increased pressure on the TrP until the fingers encounter a definite increase in the tissue resistance. At that point the patient may feel a degree of discomfort but should not experience pain. This pressure is maintained (but not increased) until the clinician senses relief of tension under the palpating finger. The palpating finger increases pressure enough to take up the tissue slack and to encounter a new barrier... the clinician again maintains only light pressure until more of the muscle tension releases."

Eliminating Muscle Pain Should Actually Be Relaxing

I like to say to my patients: “I'm going to press slowly and you're going to tell me 'when'. It should hurt a little bit, but not a lot. I want that trigger point talking to you, but not screaming at you. You should be able to talk and breathe and stay relaxed.” Just hearing this before I even begin to apply pressure goes a long way to relieving anxiety about anticipated pain, which in turn enhances the patient's total ability to relax. With the patient relaxed and confident of not being hurt, he or she can breathe into the process and aid it, at the same time learning how to do that on his or her own.

Trigger Point Myotherapists started developing their technique in the late 1970's. Different styles have evolved over the years with experience and better understanding from new research.

What About Compression on Fibromyalgia?

In the early years of my practice I used what some now consider a heavy hand - or elbow! - because that is how I was trained. The assumption was, the bigger the muscle, the heavier pressure required. The instructions were: press to the point of pain, and warn the patient what we are going to do, so they don't get a shock. It was understood that this type of treatment what necessarily if temporarily painful in order to be effective.

Then, within my first few months of practice, I got a new patient with severe fibromyalgia and I had to re-learn everything I knew about pressure and touch. I customized a combination of feather-light touch, heat, and gentle stretch that worked well for her and what do you think I discovered? Gentle compression, or if needed on a bad day, no compression at all can still be effective... at least for that patient.

On one hand, light treatment and stretch seemed to be working very well for some, but I still couldn't get stubborn trigger points out of others without some hardcore persuasion. For those people it had to be deep, sustained pressure only; any other technique was either more aggravating or ineffective.

Customizing Myofascial Trigger Point Therapy to Your Body

What I quickly realized is that all patients are different. Bodies all feel different, and people have different perceptions of pressure and different experiences of pain. They are irritated or soothed by different sensory input. Some people's muscles feel as hard as a Dunlop steel-belted radial while others' feel like they are made out mattress grade memory foam, and still others' twice-proofed sourdough. (Guess who hurts more!) Learning to touch and treat each new patient is like learning a unique new language. I get a knowledge and feel for what works best for a person, depending on the condition of their muscles and connective tissue, what feels good to them, and what technique releases their trigger points with minimal reaction and maximum results. I now know that different techniques, amounts of pressure, and even types of rehabilitative stretch are appropriate in different situations, with different patients. The real art is determining the correct match each time.

Travell and Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. 1999 Williams and Wilkins