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© Kosub/Thieme 2004
Trigger Point rESWT
Kristiansand 25-27 august 2006
© Kosub/Thieme 2004
Soft Shockwave Therapy
Dr. med. Martin Kosub
MD, Orthopaedistchiropractice, naturopathy, out-patient surgery, sports medicine, rehabilitation, acupuncture, paediatric chiropractice
© Kosub/Thieme 2004
MechanicalTrigger Point Therapy
• musculature: – largest single organ
• 50% of body weight
© Kosub/Thieme 2004
Case Report
• Patient I.L. ♀ – Date of birth: 26.09.1942– Disc operation (Nucleotomia,
Hemilaminectomia 10/2001)– For the last 18 months aches and pains in the
left leg again, in the L5 segment, with paraesthesia, no reduction in muscular strength
– Sitting for long periods was painful
© Kosub/Thieme 2004
Case Report
• MRI 16.04.2004
© Kosub/Thieme 2004
Case Report
• Therapy– segmental injections– anti-inflammatory infusions– chiropractice– physiotherapy (pelvic torsion)– CT controlled blockades root L5/S1 left., – facette joint L5/S1
• ►worsening of symptoms
– hospitalisation
© Kosub/Thieme 2004
Case Report
• hospitalisation: 6.-16.04.2004
– Diagnosis: Postdiscectomiesyndrome I°
• minimal invasive spinal therapy• lumbar root blockades twice daily• lumbar epidural anaesthetic• facette injections• physiotherapy• back training• electrotherapeutics
►no recovery!
© Kosub/Thieme 2004
TP Shockwave
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
Trigger Points
Dr. Janet G. Travell (1901-1997)
© Kosub/Thieme 2004
Trigger Point
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
Trigger Point• Neuromuscular Disease
– approx. 100 maximal contracted Sarkomers (equal to one motor end-plate)
– Permanent recurring contractions because of depolarisation of the postsynaptic membrane
• (end-plate noise)– Endurance contraction –
increasing demand of metabolism– Constriction of the capillary
network, lack of blood supply• (contraction of more than 30-50%
of the maximum power disrupts the vessel flow in a muscle)
– Energy crisis—production of vasoactive agents that irritate the nociceptors
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
Trigger Point
• latent trigger points (no identification of the pain, no spontaneous pain)
• active trigger points (identification of the pain, rest pain)
• satellite trigger point
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
Referred Pain
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
Satellite Trigger Point
aus Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
“Taut Bands” and Trigger Points
Taut BandLocal Twitch
© Kosub/Thieme 2004
Findings
1.) pressure provocation, taut banda.) pressure pain on knot (disappears after treatment)b.) local and referred pain
2.) identification of activated paina.) yes: active trigger pointb.) no: latent trigger point
3.) referred sensory phenomena4.) local twitch during strong palpation or tweaking of the muscle
(spinal reflex)5.) reduced range of motion, reduced tensibility (Screening)6.) pain provocation by extension of the muscle 7.) painful contraction8.) muscular weakness
© Kosub/Thieme 2004
Concerning Innervation
• Trochanter-tendinosis
© Kosub/Thieme 2004
Concerning Innervation• L5
– M. gluteus medius, M. gluteus maximus, M. gluteus minimus
– M. tensor fasciae latae
– M. piriformis– M. biceps femoris– M. iliocostalis lumborum– M. obturatorius internus– Mm. intertransversarii lat. +
med. lumborum– Mm. multifidi lumborum– Various other thigh and lower
leg muscles– not M. vastus lateralis,
medialis and intermedius (L4)
N. glutaeus superior
© Kosub/Thieme 2004
Trochanter-Tendinosis
© Kosub/Thieme 2004
Vertebral Reflex Syndrome(Goodheart, 1987 , Walther 2000, Leaf, 1996)
• Vertebral Dysfunction– soft tissue dysfunction:
• hypertonia• myotendinoses• lymphatic congestion• circulatory dysfunction• imbalance of the
acupuncture pathways
© Kosub/Thieme 2004
Therapy
• Treating releasing factors
– joint disorders (Greenman)
– causes of nerve irritation
(structural damage)
© Kosub/Thieme 2004
Spray and Stretch
© Kosub/Thieme 2004
Trigger Shockwave
© Kosub/Thieme 2004
Soft Shockwave Therapy
– experience report: Lohse-Busch, Bad Krozingen– percussion-technique by R. Fulham / Goodheart– 2002: development of the Facilitated Oscillatory
Release (FOR) (Zachary J. Comeaux)– V.T. Nazarov: application of vibrations to stimulate
the muscular fibres
© Kosub/Thieme 2004
Effect of TST Hypothesis
mechanical: spindle-cells golgi-tendon-organ
transient denervation of nerve endings
acute pain treatment
chemical: First increase, after 6 weeks
release of substance P and endorphines
Anti-inflammatory and analgetic effect
Blocking of the enzyme COX II
reactive: hyperaemia increased metabolism neoplasm of vessels
© Kosub/Thieme 2004
Technique
palpation for locating the trigger-point (TP)
treatment of tigger-points:
frequency 15 Hz rate of impulses 400-
600pressure 1.2 – 2.8 bar
© Kosub/Thieme 2004
Smoothing
Smooth out the muscle
frequency 15 Hzrate of impulses
total 1000-2000pessure 1.2 – 2.2
bar
© Kosub/Thieme 2004
Treating Key LesionsAlgorithm of Lumbalgia
• M. rectus abdominis• M. quadratus lumborum• M. glutaeus minimus bds.• M. glutaeus medius bds.• M. iliopsoas• M. piriformis (nach Buchmann)
© Kosub/Thieme 2004
M. rectus abdominis
from Travell + Simons „Handbuch der Muskeltriggerpunkte
© Kosub/Thieme 2004
M. rectus abdominis