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Originea terapiei Trigger point Este una dintre cele mai recente terapii adresate musculaturii, fiind in plină
dezvoltare Janet Travell şi Dr. David Simions au lansat denumirea de trigger point therapy (terapia punctelor de
declanşare) implicând şi stretchingul musculaturii afectate si termoterapia. Cei doi au aplicat aceasta tehnică în
tratarea preşedintelui John F. Kennedy. În 1970 Bonnie Prudden a îmbunătăţit tehnica celor doi prin adăugarea
unei proceduri non-invazive aplicate azi in cazul atleţilor si prescrisăşi recomandată de medici. Această tehnică
este înrudită cu cea a masajului prin acupresiune, tehnica de tratament fiind una similară. Este un tratament care
se poate face şi independent. Din cauza situării greu accesibile a multora dintre punctele de stimulare,
autoaplicarea acestui tip de masaj este însă dificil de realizat. Se pot utiliza unelte specifice de masaj pentru a
acţiona asupra acestor puncte. Harta alăturata este prezentată doar pentru vizualizarea informativăşi
aproximativă a punctelor.
Clasificare:
Active: acestea sunt dureroase, sunt cauza durerilor persistente;
Latente: puncte care dor numai când sunt supuse presiunii. Uneori punctele active pot avea puncte satelit, cum
ar fi o durere la nivelul spatelui se poate reflecta la nivelul umărului, iar tratarea punctului din zona umărului nu
are efect de durata fără tratarea punctului din zona spatelui.
Obiectivele majore ale acestei tehnici sunt: - eliminarea tensiunii protective a musculaturii - eliminarea
hipersensibilităţii receptorilor periferici, în special cei ai durerii - producerea de vasodilataţie reflexă- eliminarea
ischemiei locale.
Protocolul acestei tehnici este la fel de eficient pentru puncte motorii cât şi pentru alte categorii de puncte.
Presiunea aplicată nu este niciodată suficientă pentru a depăşi pragul de durere al pacientului, provocând durere
şi lezarea terminaţiilor nervoase motorii. Vasodilataţia periferica locala readuce pH-ul la normal şi creşte
concentraţia de oxigen din ţesutul afectat ceea ce elimină treptat punctul dureros.
Găsirea adevăratei surse de durere Majoritatea punctelor sunt uşor de depistat, prezentând durere la aplicarea
presiunii. În unele cazuri poate fi vorba de un punct satelit, punctul principal fiind la distanţă de cel satelit. In
1
acest caz este necesară tratarea ambelor. Tratamentele au un efect cumulativ. Uneori efectele de durata apar
imediat, dar de cele mai multe ori durează. Fiecare activare a răspunsului de vindecare va duce la însănătoşirea
organis-mului. In cazul în care nu se observă rezultate într-un timp scurt, se poate creşte frecvenţa
tratamentului. Creşterea frecvenţei este mai eficientă decât creşterea duratei tratamentului. Tratamentul se poate
face de 3, 4 ori pe zi sau o dată la o oră. Este posibil ca după o şedinţă de tratament durerea să revină.
Tratamentul se va face până la dispariţia durerii. In funcţie de organism şi de diferitele zone ale sale, se aplică o
presiune diferită. Dacă durerea este intensă, se aplică o presiune uşoară. Gambele, faţa şi zonele genitale au o
sensibilitate crescută. Spatele, fesele şi umerii, mai ales dacă musculatura este foarte dezvoltată, necesită o
presiune crescută. Pentru spate şi umeri este recomandată folosirea uneltelor specifice.
Masajul Trigger point pentru gât şi umeri Se poate face prin simpla căutare a punctelor cu degetele. Prin
palpare căutăm zonele cele mai sensibile si cele mai tensionate. Poziţia corpului trebuie să fie comodă,
confortabilă, întins sau cu spatele sprijinit. Se începe prin exerciţii de respiraţie, iar cu policele se palpează ferm
muşchii cu inserţii la baza craniului. Prima dată în spatele urechilor, coborând apoi pe coloana vertebrală. În
urma palpării musculaturii şi găsirii zonelor sensibile sau dureroase se revine si se aplică presiune până când
muşchiul se relaxează sau dispare/scade durerea. Apoi se insistă asupra celui mai dureros punct în timp ce se
menţine o respiraţie adâncă şi controlată. Căutarea şi masarea punctelor se face pe partea stângă şi apoi pe
dreapta.
Aplicarea metodei la mase musculare mari Se foloseşte fixarea muşchiului cu degetele si palma si se aplica o
presiune fermă cu policele. Se presează fără alte mişcări timp de câteva minute. Un minut de presiune aplicată
treptat asupra unui punct dureros calmează şi relaxează sistemul nervos, accelerând procesul de vindecarea.
Pentru a stimula o zona se aplică presiune timp de 4-5 secunde. Se frământă uşor muşchiul afectat cu o mişcare
lentă. Se aplica si un tapotament rapid cu degetele în zonele sensibile sau neprotejate cum ar fi fata. Pentru
suprafeţe mai mari, cum ar fi spatele, se foloseşte pumnul relaxat. Se poate folosi gheaţă pentru a reduce
răspunsul nervos in zonă, permiţând astfel o presiune eficientă. In urma presiunii aplicate se recomandă
stretching pe musculatura afectată.
Examination Limitations of stretch range of motion and records of referred pain patterns help to identify which
muscles to examine for active TrPs; palpation and observation of TrP phenomena confirm which muscles are
responsible for the myofascial pain.
How to examine a muscle for TrPs: To confirm its location, with one hand the examiner resists a voluntary
movement by the patient that contracts the muscle, and with the other hand palpates for muscle contraction.
While the muscles are being examined for TrPs, the patient should be comfortable and warm. The muscle must
be relaxed; otherwise, the distinction between tense bands and adjacent slack muscle fibers is diminished or
lost.
Before the examiner attempts to palpate a muscle for TrPs, the examining digits must have the fingernails
trimmed very short. This is especially critical during pincer palpation and when attempting to elicit digital
LTRs. The skin pain caused by long fingernails is readily misinterpreted as TrP tenderness. The skin pain from
the fingernail prevents application of sufficient pressure to elicit the LTR, and the fingernail mechanically
interferes with use of the tip of the finger to apply the pressure.
For those who have difficulty in recognizing TrPs by palpation, a dermometer, orsimilar device to measure skin
conductance or skin resistance, is sometimes used to explore the skin surface for points of high conductance
(low skin resistance), which apparently often overlie active TrPs. This device may be helpful, but has not been
shown to be highly reliable.
Palpating TrPs can severely exacerbate the patient's referred pain activity for a day or two. For this reason, it is
critically important to examine a muscle for TrPs only if the examiner then applies specific myofascial therapy
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such as spray and stretch followed by moist hot packs to muscles with TrPs. The clinical rule is: palpate for
TrPs in only those muscles that can be treated during the same visit.
It now appears that the most reliable diagnostic criterion of TrPs on examination of the muscle is the presence
of exquisite tenderness at a nodule in a palpable tautband. If, in addition, the patient recognizes pain that is
elicited by digital pressure on (or needle penetration of) the TrP as his or her clinical pain complaint, the TrP is
clinically active, not just latent. Associated phenomena, such as a characteristic pattern of referred pain or an
LTR, are strongly supportive evidence. Other features, not critically evaluated but strongly characteristic of
TrPs, are limited stretch range of motion and increased tension of the muscle observed during the patient
examination.
In this manual, flat palpation refers to the use of a fingertip that employs the mobility of the subcutaneous tissue
to slide the patient's skin across the muscle fibers. This movement permits detection of changes in the
underlying structures (Fig. 3.7). First,the skin is pushed to one side of the area to be palpated (Fig. 3.7A) and the
finger slides across the fibers to be examined (Fig. 3.7B), allowing the skin to bunch on the other side (Fig.
3.7C). Any ropy structure (taut band) within the muscle is felt as it rolls under the finger. A taut band feels like
a cord that can range from 1 mm to 4 mm or more in diameter depending on the severity of theTrP. The
sensation of applying snapping palpation
palpation across the taut band can be compared to what plucking a violin or
guitarstring imbedded in the muscle might feel like. In a muscle that has many TrPs, five or six such bands, or
cords, may lie in such close proximity to one another that they seem to merge. If the examiner tips the palpating
finger up on end to palpate with the end of the terminal phalanx, individual bands may be distinguishable. This
technique requires a very short fingernail. For examination of the abdomen, flatpalpation using "fingertip"
pressure locates spot tenderness in the abdominal wall, while "flathand" pressure using the flat part of the finger
or hand is more likely to elicit tenderness of underlying viscera Static pressure with the finger flat can be
expected to detect little more than underlying tenderness in any muscle.
The technique of pincer palpation is performed by grasping the belly of the muscle between thumb and fingers
(Fig. 3.8A) and pressing the fibers between them with a back-and-forth rolling motion to locate taut bands (Fig.
3.8B). When a taut band is identified, it is explored along its length to locate the nodule and spot of maximum
tenderness, which identifies a TrP. When intervening tissue makes the muscle naccessible to flat or pincer
palpation, the examiner must use deep palpation. This means placing the fingertip over an area of skin that
overlies the motor-point region or attachment of the muscle suspected of harboring TrPs. Localized tenderness
sthat is elicited only when the finger pressure is directed in one specific directionis compatible with the
diagnosis of either a central or attachment TrP if pressure elicits pain recognized by the patient as his or her pain
complaint. Additional evidence, such as restricted stretch range of motion and characteristic referred pattern are
helpful in making a provisional diagnosis when the usual palpable findings are inaccessible. Favorable response
to specific myofascial TrP therapy helps to confirm the diagnosis. Sufficient pressure on an active TrP almost
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always elicits at least withdrawal, wincing, or vocalization by the patient. In the past, if the withdrawal were
sufficiently vigorous the response was identified as a "jump sign." This jerk response was notedby Good5 5 in
1949 with regard to TrP characteristic sthat he called myalgic pain, and by Kraft et ai.9 1 in 1968 with regard to
TrP characteristicst hat they called fibrositis. Kraftlater dubbed this response the "jump sign." This response
served as a rough indicationof the tenderness of the TrP that depended strongly on how much pressure was
applied. Now the tenderness can be measured quantitatively using an algometer. The extreme sensitivity to
applied pressure that elicits the jump sign is not by itself considered to be a sufficient diagnostic criterion ofa
TrP, but it is characteristic of an active TrP.
Generally, central TrPs become less irritable in response to warmth. However, sometimes patients find relief by
application of cold. Attachment TrPs may be more responsiveto cold than to heat, especially when they are very
irritable. Since the attachment TrPs are the result of the tension from the tautbands of the central TrPs,
inactivation of the central TrP is essential; on the other hand, reducing the sensitivity of the attachment TrPs
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may greatly facilitate inactivation of their central TrPs. The optimal therapeutic intervention for central TrPs
compared to that for attachment TrPs is an issue that needs competent experimental investigation. In our
experience, spray and stretch is the single most effective noninvasive method to inactivate acute TrPs. However,
many other noninvasive techniques require no supplies and are better suited to use by the patient at home. When
the simpler approaches fail to give satisfactory results, many times the addition of spray and stretch (often in
combinationwith other techniques) brings success.
STROKING WITH ICE. The stroking movements progress slowly, at the same rate as the spray (1 cm/sec).
This application of the sharp edge of ice simulates the jet stream of vapocoolant spray. The practitioner should
hold a small cloth ready to blot the skin as needed to prevent melting ice from wetting the skin. The skin must
remain dry, because dampness reduces the rate of the change in skin temperature produced by the ice stroking.
Wetness also prolongs and diffuses the cooling effect, which delays rewarmingof the skin. The ice block can
becovered with thin plastic as long as the stroking edge of the ice is thin and cold.
Spray and-stretch technique does not require the precise localization of the TrP that is needed for injection; it
requires only identification of where the taut bands are located in the muscle to ensure that those fibers are
released, it is important that the spraybe applied before or concurrently with, but not after, the muscle is
stretched. Much of the shoulder pain in patients with hemiplegia arises in TrPs caused by the overload of
spasticity and strain on the remaining functional musculature. During thefirst few weeks following a stroke,
much temporary relief can be obtained by sprayand stretch of both agonists and antagonists in the shoulder
region, applied twice daily. Liberson described wheeling a drum of vapocoolant equipped with a hose and spray
nozzle through the Physical Medicine and Rehabilitation Ward twice daily to spray and stretch the patients with
hemiplegia in order to reduce their pain and increase their function more rapidly during the early weeks of
recovery. After 4-8 weeks, as the degree of paralysis and spasticity stabilizes, the relief of TrP pain becomes
more lasting. Such relief of pain encourages the patient to strive for function, and influences the results of
rehabilitation by improving the patient's efforts to use marginally functional muscles.
To apply TrP pressure release, the clinician lengthens the muscle to the point of increasing resistance within
the comfort zone and then applies gentle, gradually increasing pressure on the TrP until the finger encounters a
definite increase in tissuere sistance (engages the barrier). 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 (engage) a new barrier (the finger "follows" the releasing tissue). The clinician
again maintains only light pressure until more of the muscle tension releases ("lets go") under the finger. During
this period the clinician may change the direction of pressure to achieve better results. This process of TrP
pressure release can be repeated for each band of taut muscle fibers in that muscle. The virtue of this technique
is that it is painless and imposes no additional strain on any attachment TrPs, and there by avoids aggravating
them. This digital technique is particularly well suited to muscles like the infraspinatus and serratus muscles
that are relatively thin and overlie bone. Release of the TrP may be further enhanced by occasionally
performing a contract-relax maneuver alternated with reciprocal inhibition. The goal is to release the
contraction knots in the TrP and release the tension they cause in the muscle fibers comprising the taut band.
This barrier release approach may fail to afford relief because: (1) the TrP is too irritable to tolerate any
additional mechanical stimulation; (2) the operator misjudged the pressure required to reach the barrier; (3) the
operator pressed too hard, causing pain and autonomic responses with involuntary tensing by the patient; and
(4) the patient has perpetuating factors that make the TrPs hyperirritable and resistant to treatment.
Posttreatment Activity. Hard activities should be avoided for at least the 2-3 day period of muscle soreness,
preferably for 1 week. They must avoid placing their muscles in a fixed, shortened position for a long time.
5
I. Muschii Capului
Muschiul Masseter
T – Mandibulă
N - Trigemen
7
Muschiul Temporal
N - Mandibular
8
Muschiul Pterygoid Medial
9
Muschiul Pterygoid Lateral
10
Muschiul Digastric
N – Trigemen si facial
11
Muschiul Orbicularis Oculi / Zygomaticus Major / Platysma
N – Facial
12
Test pentru Platisma cont ->
Muschiul Bucinator
O – procese alveolare ale
maxilei și mandibulei
T – mandibulă, linia milohidiană
A – masticație, fluierat
N - Facial
13
Muschiul Occipitofrontal
A – ridică sprâncene
N – Facial
14
II. Muschii Cap-Gât
Muschiul Sternocleidomastoidian
O - claviculă T – proces mastoid și p. ant. linie nucală superioară
15
Muschiul Trapez
O – linia nucala sup, proc spinoase vert7 și vertTor T – 1/3 lat claviculă post, acromion med, scapul
scapulă med
16
Muschiul Trapez - cont
17
Muschiul Splenius Capului / Splenius Cervical al Gâtului
T – occiput lateral între linii nucale sup-inf / tuberculi posteriori de pe proces transvers C1-3
N - Accesor
18
Muschiul Semispinal,, Longissimus Capitis, Semispinalis Cervicis, Multifidi and Rotatores
O – proc transv
19
Muschi Suboccipitali: Drept Posterior Mare și Mic al capului / Oblic Inferior și Superior
N – Suboccipital
20
Muschiul Ridicătorul Scapulei
21
Muschiul Scalen Ant / Med / Mic / Post
O – proc transv C3-6 / C2-7 / C7 / C4-6 T – coasta1 / coasta1 / membrane suplapleurală / coasta2
22
Muschiul Scalen - cont
23
Muschiul Scalen si Extensor degete (pag 40) - cont
24
Muschiul Rotund Mare (Teres Major)
25
Muschiul Supraspinos
A - Abd N - Suprascapular
26
Muschiul Infraspinos
A – Rext N – Suprascapular
27
Muschiul Dorsal Mare - Latissimus Dorsi
28
Muschiul Subscapular
29
Muschiul Romboid Mare / Mic
O – vert C7-T1 / vert T2-5 T – p med Scapula sub m.Ridic. Scapula / p med Scapula
30
Muschiul Deltoid
31
Mușchiul Coracobrahial
32
Mușchiul Biceps brahial
A – antebraț: Fl + S; braț: Fl + Add (cap sc) + Abd (cal lg) N - Musculocutanat C5-6
33
Muschiul Biceps brahial - cont
Muschiul Brahioradial
34
Muschiul Brahial
35
Muschiul Triceps brahial
36
Muschiul Triceps brachial - cont
37
Muschiul Anconeu
Muschiul Supinator
38
Muschii Extensori Ulnar al carpului / Sc radial al carpului / Lg radial al carpului /
39
Muschii Extensor degete si Extensor index
A - Ext N - Radial
40
Muschiul Palmar lung
41
Muschii Flexori Supeficiali degete / Profunzi degete
42
Muschii Flexor lung Police / Rotund Pronator
43
Muschii Adductor Police / Opozant Police
44
Mușchii Interososi dorsali / Lumbricali / Abductor Degete mic
O – Metacarp 1-5 / Tendoane m.fl profunzi degete / Pisiform T – falange prox / idem / Baza Deg 5
45
Mușchiul Pectoral Mare
46
Mușchiul Pectoral Mic
47
Mușchiul Pectoral Mic - cont.
Mușchiul Subclavicular
O – coasta 1 T - clavicula
48
Mușchiul Sternal
O - Stern T - Stern
A-- N--
O – coaste 1-11 inf / L1-3, coaste 7-12, xifoid T – coaste 2-12 sup / tendon central
TrPs of the diaphragm are not accessible to palpation. The tenderness of attachment TrPs in the costal portion of
the diaphragm is detectable just inside the lower border of the thoracic cage. Tenderness detected in this region
could originate in the diaphragm, the external oblique, internal oblique, or transversus abdominis.
49
Mușchiul Dințat anterior (Serratus)
50
Mușchiul Dințat
Din Posterior-Superior / Inferior
51
Mușchiul Erector spinal
52
Mușchiul Multifizi
O - Sacru T - Axis
A - Ext N
53
Mușchiul Drept Abdominal
A – Fl Trunchi N - Intercostali
54
Mușchiul Oblic extern / Oblic intern / Transvers
O – Coaste 4-12 / Creasta iliacă / Creasta iliacă T – Creasta iliacă / Coaste 9-12 / Pubis
55
Mușchiul Piramidal
56
Mușchiul Pătrat Lombar
A – Fl Lat N - Subcostal
57
Mușchiul Psoas mare / Psoas mic / Iliac
O – apofize L1-5 / corpuri T12-L5 / Fosa iliacă T – Trohanter mare /idem / Trohanter mic
58
Mușchiul Obturator Intern, Sphincter Ani, Levator Ani, Coccygeus
A – RE Șold N – Obturator
59
Mușchiul Gluteu Mare
O – sacru, coccis, foșa iliacă ext T – femur linia aspră, fascia lata N - Gluteal
A – șold Ext, RE, Add / cont bilat: bazin retroversie / cont unilat: iliac retrovers, RI, înclin lat
60
Mușchiul Gluteu Mijlociu
O - Foșa iliacă ext T – trohanter mare fața ext N – fesier sup L4-L5
A – femur Abd, Fl cu fibre ant, Ext cu fibre post/ Cont bilat: bazin antevers cu fibre ant, retrovers cu fibre post
/ Cont unilat: bazin înclin lat ext
61
Mușchiul Gluteu Mic
O – Foșa iliacă ext, sub gluteu mijl T – trohanter mare fața ant N – fesier sup L4-S1
A – femur Fl, Abd, RI / Cont bilat: bazin antevers / cont unilat: bazin înclin lat ext, RE
62
Mușchiul Gluteu Mic - cont
Mușchiul Piriform
A - RE N – S1-2
63
Mușchiul Piriform - cont
64
Durere de spate
65
Durere de spate
66
Mușchiul Tensor Fascia Lata
O – spina iliacă ant sup T – fascia lata coapsă și platou tibial N – Gluteal superior L4-S1
A – femur: Fl, RI, Abd / gen: Ext, RE / cont bilat: bazin antevers / cont unilat: iliac antevers, inclin Ext, RE
67
Mușchiul Pectineu
68
Mușchiul Croitor
A - femur: Fl, RE, Abd / tibie: Fl, RI / cont unilat bazin: antevers / cont bilat os iliac: antevers, RI, înclin lat
ext
69
Mușchiul Drept Femural
70
Mușchiul Vast Intern - Medial
O – creasta int din spatele femurului T – tend rotulian pe tuberozit ant tibie
71
Mușchiul Vast Intermedial
72
Mușchiul Vast Lateral - Extern
O – creasta ext din spatele femurului T - tend rotulian pe tuberozit ant tibie
73
Mușchiul Adductor Lung și Mic
74
Mușchiul Adductor Mare
75
Mușchiul Biceps Femural, Semitendinos șii Semimembranos
O – ischion, în spatele os iliac T – tibie cap peroneu / laba de gâscăă / platou tibial
A – Ext femur, Fl gen, retroversia bazin, RE biceps / RI semit+semim N - Sciatic popl ext L5-S2
76
Mușchiul Popliteu
77
Mușchiul Peronieri lung, scurt lateral și al treila
78
Mușchiul
ș Gastocnemian (Gemen) și Solear
79
Mușchiul Plantar și Solear - cont
80
Mușchiul Tibial posterior
O – tibie post și fibulă post T – scafoid si alte oase tarsiene în afară de astragal
O – Fibula int sus (peroneu) / Fibula int mijl T – fal mijl+dist deg 2345 / Haluce falang mijl
81
chii Extensor Scurt Degete și Extensor Scurt Haluce
Mușchii
82
chii Flexor Lung comun Degete șii Flexor Lung Haluce
Mușchii
O – tibie fața post / peroneu fața post T – falanga dist / haluce falanga mijl
83
Mușchii Abductor Degete Mic și Flexor comun Degete
O – calcaneu fața int / calcaneu T – falanga prox partea ext / falanga 2345
A – Abd deg mic, Fl plant deget, boltă plantar / Fl N – plantar ext S1-S2 / plantar med S1-S2
84
Mușchiul Adductor Haluce șii Flexor Scurt Haluce
O – cuboid+art metatarsofalang 345 / cuboid+cuneiforme 2+3 T – falanga prox partea ext / falanga prox int+ext
Mușchiul Pătrat
trat Plantar (Accesor al Flexorului Lung comun al degetelor)
85
Mușchii Interosoși dorsali și plantari
86