Pain, TRIGGER POINTS AND ACUPUNCTURE POINTS FOR PAIN .

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Pain, 3 (1977) 3 - - 2 3 Elsevier/North-Holland Biomedical PressReview ArticleT R I G G E R POINTS A N D A C U P U N C T U R EC O R R E L A T I O N S A N D IMPLICATIONSPOINTS F O R PAIN:RONALD MELZACK *, DOROTHY M. STILLWELL and ELISABETH J. FOXDepartment of Psychology, McGill University, andDepartment of Medicine, Royal Victoria Hospital, Montreal, Que. (Canada)(Accepted July 21st, 1976)SUMMARYTrigger points associated with myofascial and visceral pains often tie within the areas of referred pain but many are located at a distance from them.Furthermore, brief, intense stimulation of trigger points frequently producesprolonged relief of pain. These properties of trigger p o i n t s - their widespread distribution and the pain relief produced by stimulating t h e m resemble those of acupuncture points for the relief of pain. The purpose ofthis study was to determine the correlation between trfLgger points ar.d acupuncture points for pain on the basis of two criteria: spatial distribution andthe associated pain pattern. A remarkably high degree (71%) of correspondence was found. This close con'elation suggests that trigger points a ad acupuncture pointsfor pain, though discovered independently and labeled differently, represent the same phenomenon and can be explained in terms ofthe same underlying neural mechanisms. The mechanisms that play a role inthe genesis of trigger points and possible underlying neural processes are discussed.INTRODUCTIONIt is well known that short-acting, local anesthetic blocks of trigger pointsoften produce prolonged, sometimes permanent relief of some forms ofmyofascial or visceral pain [5,16,35]. Astonishingly, brief, intense stimulation of trigger points by dry needling [35], intense cold [35], injection ofReprint requests to Prof. R. Melzaek, Department of Psychology, Ste,aart BiologyBuilding, McGill Ur.iversity, Montreal, Que., Canada.

normal saline [33,34], or transcutaneous electrical stimulation [24] mayalso iminish or abolish these pains for days, weeks, and sometimes permanently. These effects of intense stimulation, which have been labeled ashyp,;rstimulation a algesia[22], resemble the effects of acupunture -- inwhi, h brief, intense pain is produced by rota :ing the needles manually orpas ing electri -d i z e n t s through t h e m - on a :' hritic, neuralgic, and otherform0 of chronic pain [5,12 .20]. Well-contro!]c d stu'dies [3,10,12,24] showthat these procedures produce significantly gr - ater pain relief than placebocontributions. It is apparenL, therefore, that ntense stimulation of eithertrigger points or acupuncture points can produce prolonged relief of pain.Indeed, Fox and Melzack [9] have found that acupuna- ure and transcutaneous electrical stimulation are equally effective n relieving chronic low-backpain.There is yet another simila Aty between trigger points and acupuncturepoints for pain: they often lie within the areas of refel red pain, but many arelocated at a distance from them. Furthermore, some ;rigger points appear tocoincide spatially with acupuncture points, and both kinds may be associated with the same pain patterns. 1he purpose of this study, therefore, wasto determine the correlation between trigger points described by Travell andRinzler [35], Kennard and Haugen [13], Sola and Kuitert [33], Sola andWilliams [34] mad acupuncture points for pain [11,18,19].DISTRIBUTION OF T R I G G E R POINTSTrigger points have long been used inWestern medical practice for thediagnosis and treatment of pathological pain [15,35]. Application of pressure at a trigger point evokes pain at the point as well as referred pain inmyofascial or visceral structl res. Travell and Rinzler [35], in a classic studyof myofascial pain, describtd a large number of spatial patterns of painassociated with trigger point (Figs. 1--4). Other points have been found bySola and Kuitert [33] ann ola and Williams [34] (Fig. 5A), who examinedmyofascial pain associated , i h the sho ider, arm and neck. Additionalpoints have been descr;ibed by Bonica [5], Livingston [16], Kraus [15] andothers.Trigger points are dso associated with visceral structures. McBumey'spoint is a well known site of tenderness in acute appendicitis, and gentlepressure at the point triggers local pain as well as distant diffuse abdominal ?::in 1]. Similarly, patients with cardiac disease frequently develop referredpain in tha shoulder, chest, and arm [13,35]. Examination of cardiac patients by Kennard and Haugen [13] revealed a common pattern of riggerpoints (Fig. 5B) in the shoulder and chest. Fressure on the trigger pointsgenerally produces intense pain which sometimes persists for several hours. Itis important to note tha subjects who do not have heart disease have an Imost identical distribution of trigger points [13]. The application ofpressure at the trigger points in these subjects 'okes pain which lasts forseveral minutes and may even increase in in:Lens';,ty for a few seconds afterremoval of he pressure.

DISTRIBUTION OF ACUPUNCTURE POINTSPerhaps the most baffling feature of acupuncture maps, on first encounter,is the profusion of points. Some degre e of clarification is achiew. d if a particular book on acupuncture is examined only for points relevant to pain.We have done this for Kao and Kao's [11] book, Acupuncture Therapeutics.When the acupuncture points are organized on the basis of pain syndromesor discrete spatial locations of pain, the number of relevant acupuncturepoints is relatively small. An examination of Figs. 6 and 7, derived from Kaoand Kao's [11] book, reveals that each major pain syndrome or painfulregion is associated with (a} acupuncture points that are at or near the a c t u a lsite of pain, as well as (b} more distant points that are seemingly unrelated.A similar analysis has been carried out with the maps and book preparedby Mann [18,19]. Although a multitude of points are designated specificallyfor the relief of particular pain syndromes, only a relatively small numberof points is generally used in the actual day-to-day practice of acupuncturefor the relief of pain (Figs. 8 and 9). As in Figs. 6 and 7, it is evident thatthere are points which lie within or near the painful area (Fig. 8 , and othersthat lie at a distance from it (Fig. 9).C O R R E S P O N D E N C E B E T W E E N A C U P U N C T U R E POINTS A N D T R I G G E R POINTSIn order to determine the degree of correspondence between trigger pointsand acupuncture points, each trigger point on thc maps of Travell and Rinzler [35], Sola and Kuitert [33], Sola and Williams [34] and Kennard andHaugen [13] (Figs. 1--5) was numbered and acupuncture m ps were examined to see whether there was a nearby acupuncture point. Because Kaoand Kao [ 11 ] used only selected points for their exposition of acupuncture,the more complete maps prepared by Mann [18] were used. D e to obviousdifferences in drawings, or even anatomical variation from person to person,the proximity of the points to particular muscle groups or other anatomicallandmarks was sought. A difference of 3 cm between the two sites seemed tobe a reasonable allowance for variation based on drawings or a(tual anatomical variability. If the points showed good correspondence (wil hin the 3 cmcriterion}, the site was labeled "plus" ( ). Acupuncture points outside the3 cm criterion were labeled " m i n u s " (--). The next step was to find the clinical syndromes, listed in Mann's [19] and Kao and Kao's [ l l J books, associated with the acupuncture points. If the clinical syndrome correspondedreasonably to that associated with the trigger point, a "plu.,," ( ) was recorded. Lack of correspondence was labeled "minus" (--).The results of this analysis (Table I), using Travell and Rinzler's points,indicate that every trigger point has a corresponding acupuncture point.Furthermore, there is a close correspGndence (64%} betweer the pain syndromes associated with the two kinds of points. A similar procedure wascarried out using the trigger points described by Sola and his , olleagues, andby Kennard and Haugen (Table II). The degree of correspondence, in terms

HEAD A N DNECKSPLENIUSSTERNOMASTOID.:.-." 'TEMPORALIS., ATOR : CAPUCERVICAL.p.P#. N PATTERN lTPIGGIER AREA XFig. 1. Trigger point ; associated with myofascial pain syndromes of the head and neck.Reprinted :torn Travell and Ri zler [35]. Each trigger point is numbered and the majornerve inner cation is, described i . Table I.

SHOULDER AND :ARMSUPRASPINATUSI NFRASPINATUSDELTO,DSCALENm. ".:.-Ii-.!/ RS14,15,1613ADDUGTOF POLLICUSFIRST INTEROSSEO' JS 817PAIN PATTERN E , ;.:.:. .TRIGGER AREA XFig. 2. Trigger points t ssociated with myofascial pair syndromes vf the shoulder and ar .Reprinted from Travell and Rinzler [35]. Each trigger point is Immbered and the majornerve innervation is described in Table I.

CHEST A N DBACKPECTORPECTORALIS MAJOR119SERRATUS EUSMEDIUSIL IOCOSTALIS. /\2324,25/LONGiSSIMU iMULTiFIDUSh /I ,./j26,27PAiN PATTERN i. JTRIGGER AREA XFit.:. 3. Trigger points associated v i t h myofascial pain syndromes of the chest and back. [eprinted from Travell and Rinz er [35]. Each trigger point is numbered and the majornerve innervation is described in 2 able I.

.'.:LowER EXTREMITYGLUTEUS MINIMUS1 : ADDUCTOR LONGUSi 32,3;30,31BICEPS FEMOIRISVASTUS MEDIALIS3s34SOLEIISGASTROCNEMIUSABDUCTOR HALLUCIS38 i ::L :IANTICUS./39,40PAtN PI TTERNEXTENSORSl SHORTEXTENSORSPE R()'NIEUSLONGUS.:- TRIGGER AREA XFig. 4. Trigger points e, sociated with myofasciaI pain syndro:nes of the lower extremi:Ly.Reprinted 'r0m Travel] and Rinzter [35]. Each trigger point h numbered and L'., emaio :nerve innervation is described in Table I.

10Trigger Zones for:Shoulder Pain Shoulder andArm PainNeck PainATrigger Zones in Cardiac PatientsB'11Fig. 5. Trigger points associated with (A) myofascial pain syndromes and (B) cardiac painsyndromes. The oints in A are de'ived from Sola and Kuitert [33] and Sola and Williams[34]. The points a B are reprintefl from Kennard and Haugen [13]. Each trigger point isnumbered and the major nerve and muscle innervation is described in Table II.TABLE ILeft: the number of the trigger points described by Travell and Rinzler in Fig. 1, thenerve innervation of the points, and the associated clinical syndrome(s}. Right: the acupuncture point that coincides wittl the trigger point and the associated clinical pain syndrome(s) designated for the acupuncture point by Mann [19] a n d K a o andKao [11]. Theplus signs ( ) indicating correspondence are shown under the Clinical Syndrome columnat the right. Tke first plus sign indicates coincident or adjacent trigger and acupuncturepoints; the second indicates correspondence of clinical syndromes. A minus ( - - ) signdenotes lack of correspondence. Abbreviations of the acupuncture points: see Fig. 6.PointTrigger pointsAcupuncture pointsrio.Nerve innervationof trigger pointClinical syndromeNearestacup. pnt.Clinical syndrome1.Accessory N. (XI)Li 18Orbital neuralgia;hip pain. ( )2.Dorsal Brs. C2--8:: '3!1i ;myalgiaof neck muscles;head and facial pains.Cervical disc disease;degenerative arthritisof cervical spine;kaeadaches.T] 6Headache; eye pain;shoulder, back andarm pain; stiff neck. ,L( )

11TABLE I. (continued.)PointTrigger pointsA upuncture pointsrio.Nerve innervationof trigger pointClinical syndromeNearestClinical syndromeacup. ' t.Trigeminal N.Migraine; myalgia.X H3Facial myalgia;toothache; headache;temporo-mandibularjoint pain.Shoulder, arm andneck pain; headache;stiff neck.S7Accessory N. (XI)and branches ofC3--4C3--5Shoulder, arm and neckpain; headache; intrascapular pain.Myalgia in shoulderregion.B37.CI--TIDegenerativediseases of cervicalspine.310.Suprascapular N.Musculoskeletal diseasesof the shoulder.i i1310. Suprascapular N.Musculoskeletal diseasesof shoulder.r15Pain in neck and shoulder.Shoulder pain.Lil73.(V, Br. 3)4.Trigeminal N.( V , Br. 3 ).7.Accessory N. (XI)and branches ofC3--4G21 lil4Headache; trigemina![ neuralgia; toothache; eye pain ( )Facial neuralgia orspasm; headache;orbital neuralgia;eye pain. ( )Stiff neck; shoulderand back pain;rheumatism; armpain. ( )Acute pain ofshoulders. ( )Muscular pain;neuralgia and spasmof shoulder and arm;spasm of neckmuscles. ( )Brachial neuralg a;neck spasm; torticollis; writer'scramp. ( )Neuralgia andnumbv, ess of theshoulder and arm.( )11.14.C4--8 (via cervicalplexus)C 5 " 6 : ( v i a brachialplexus); Axillary N.Subseapular N.(C5--6 via brachialplexus)Radial N.15.Radial N.16,Radial N.12.13.L2Musculoskeletal diseasesof in.Extensorforearm;pain.tendonitis oftennis elbowT9tendonitis oftennis elbowT9tendonitis oftennis elbowLi11Pain of shoulder;back, arm, elbGw,neck, clavicie;stiff neck. ( )Throat pain. ( --)Neuralgia ot shealder; chest paiP. ( )Pain ia che. t andribs; cardiac pain.( -)Pain ill forearma td elbow joint;tc othache. ( )[ in in forearmaud elbow joint;toothache. ( )Brachial or intercostal neuralgia;torticol!is; elbowpains; pain in frontof ear. ( )

12TABLE I (continued)PointTrigger pointsAcupuncture pointsno.Nerve innervationof trigger pointClinical syndromeNearestacup. pnt.Clinical syndrome17.Ulnar N. (C8, vi brachial plexus)Tendinous strain inhand.Li418.Ulnar N. (C8, viabrachial plexus)Sprain of thumb.Li419.Anterior thoracic N.(C5--T1, via brachialplexus)Sternoclaviculararthritis. 15Headache; migraine;neuralgia of scapula,back and renalareas; toothache;sore throat ( --)Headache; migraine;neuralgia of scapula,back and renalareas; toothache;sore throat. ( --)Chest, ribs andlimbs "heavy";intercostal neuralgia.20.Anterior thoracic N.(C5--6, via brachialplexus)Strain of pectoralismajor.Sp1921.Long thoracic N.(C5--7, via brachialplexus)Costal vertebralsprain; scapularfractures.Spl722.C3--4 (?)Chest pain; shoulderand arm pain.C 1923.L1Low back pain;myalgia of the longextensors of the back.B4424.Superior gluteal N.Lumbosacral strain.B48Low back pain;myalgia of long extensors of back.Low back yain;myalgia of long extensors of back.Dorso-lumbar pain.B47( )Chest, ribs andlimbs "heavy";difficulty in lyingdown or turning.( )Chest, ribs andlimbs "heavy";diaphragmaticpain. ( )Chest and breastpain; cardiac pain.( )(L --Sl)2r .L126.T8--T9 (dorsal brs.)27.TS--T9 (dorsal brs.)),8.C3--5 (dorsal krs.)Myalgia of long e: .tensors of back; paraumbilicai pain.B2529.C3--5 (dorsal hrs.)Myalgia of long extensors c,f back; paraumbilical pain.B22Rheumatism; intercostal neuralgia;abdominal discomfort. ( --)Pain and stiffnessin back and renalarea;, pain in lowerabdomen. ( )Pain and stiffnessof back. ( )B19Pain in lower ribs;eye pain. ( --)B18Intercostal neuralgia;eye pain. ( --)I. umbar musclespasm; pain aroundumbilicus; intestinalpain. ( )Stiff vertebralcolumn; tighteningin back and shoulder;pain in loins. ( )

13TABLE I (continued)PointTrigger pointsAc apuncture pointsno.Nerve innervationof trigger pointClinical syndromeNearestacvp. pnt.Clinical syndrome30.Superior gluteal N.(L4--S1 via lumbosacral plexus).B49Lumbar and sacralpain; sciatica. ( )31.Superior gluteal N.(L4--S1 via lumbosacral plexus).Diseases of the hipjoint; degenerativeconditions of lumbarspine.Diseases of the hipjoint; degenerativeconditions of lumbarspine.G3O32.Obdurator N.( L 2 , 3 , via lumbosacral plexus).Obdurator N.(L2--3, via lumbosacralplexUs)::Femoral N, (L2--4via lUmbosacralplexus) :Tibial N. (L5-- 2 vialumbosacral plexus)Strain of adductormuscles; degenerativc,diseases of the hip.Strain of adductormuscles; degenerative diseases of the hip.Diseases of the kneejoint; injury to quadriceps.Diseases of the kneejoint; myalgia of theposterior thigh.Tendon and musclestrains of the lower leg;periostitis of the calcaneus.Tendon and musclestrains of the lower leg;periostitis of calcaneus.Li 11Pain in buttocks;sciatica; pain inloins, spine andthighs; rheumatism;pain in knee, painin hip joint. ( )No pain syndromes.33.34.35.36.Tibial N. (L5-- 2 vialumbosacral plexus)37.Tibial N. (81--2, vialumbosacral plexus)38.Tibial N. ( 1--2, vialumbosacral plexus)39.Anterior tibial N.(L4 5: via !umbosacral plexus)Common peroneal N.(L4--S1, via lumbosacral plexus)Common peroneal N.(L4-- 1, via lumbosacral plexus)40.41.42.Common peroneal N.(L4--S1, via lumbosacral plexus)( -)Livl0No painsyndromes. ( --)Sp 10Pain along thigh.( )B51Pain in back andloin; sciatica. ( --)K5Pain in loins andback. ( --)K: 0Knee and thighpain; genital painduring micturition;abdominal pain. ( --)Chest pain; sharpstomach pain; legand foot pain. ( )Weak limbs; abdominal pain. ( --)Disease of metatarsophalangeal joint of thebig toe.Strain of dorsiflexorsof foot; ankle sprain.K'2Strain of toe extensors.S37Foot strain.G40 Strain of foot evertors;ankle sprain.C34S ;6Arthritis of knee;pain on dorsifiexionof foot. ( --)Pain in heels; painin lower limbs;pain in chest andribs; pain in buttocks.pain in lower abdomen; sciatica; muscular spasms. ( )Knee pain; pain inribs; lumbago;sciatica. ( --)

14.TABLE IILeft: the number of the trigger points described by Sola, Kuitert and Williams (A) and byKennard and Haugen (B) in Fig. 2, the muscle (M) and nerve (N) innervation of thepoints, and the associated clinical syndrome(s). Ri ht: the acupuncture point that coin,cides with the trigger point and the associated clit ical pain syndrome(s) designated forthe cupuncture point by Mann [19] and Kao and Kao [11]. The plus signs ( ) indica ;in. correspondence are shown under the Clinical Syndrome column at the right. Thefirst lus sign indicates coincident or adjacent trigger and acupuncture points; the secondin i, ; tes correspondence of clinical syndromes. A m .nus ( -- ) sign denotes lack of correspondence. Abbreviations of the acupuncture points: see Fig. 6.PointAcupuncture pointsTrigger pointsno.Muscle and nerveinnervation of triggerpointClinicalsyndro eNearestacup.pointClinical syndromeM: Upper trapez':.usN: Spinal accessory(XI) and hrs. fromC3--4M: Levator scapulaN: C3--4 and dorsalscapu!arM: Supra. pinatusN: SuprascapularShoulder painG21Shoulder, back, andarm pain; rheumatism;stiff neck. ( )Neck painshoulder pa:nSil4Shoulder painSil0M: Rhomboid majorN: Dorsal scapularShoulder painB40Spasm and muscle painof neck; neuralgia ofshoulder and arm. ( )Muscle pain; arthritisor swelling of shoulderand scapular area. ( )Brachial and intercostalneuralgia; spasm of backA5M: InfraspinatusN: SuprascapularA6M: Teres minorN: AxillaryShoulder painshoulder andarm painShoulder painA1A2A3A4B1B2M: Pector li . ajor(clavicular b.ead)N: Lateral pectoral(C5--7 ,M: Pectorali major(sternal head)N: Medial pectoral( )SillNeuralgia in scapulaor forearm. ( )Si9Arthritis and pain ofupper limb and scapula.( )CardiacsyndromesS13Chest, ribs, limbs"heavy"; spasm of diaphragm. ( )CardiacsyndromesK24Cardiac yndromesK23Pain in chest and diaphragm; effort anginasyndrome; neuralgia offorearm. ( )Angina pectoris. ( )CardiacsyndromesG22Intercostal neuralgia.CardiacsyndromesT15(G2I)Shoulder, back and armpain; rheumatism; stiffneck. ( ),C8--TI )B3B4B5M: Pectoralis major(sternal head)N: Medial pectoral(C8--T1)M: Pectoralis major(both heads)N: Pectoral nerves(C5--T1)M: TrapeziusN: Accessory(cranial XI)( -)

15(Table II continued)PointTrigger pointsAcupuncture pointsrio.Muscle and nerveinnervation of triggerpointB6B7]]8Deeper tissues:M: Levator scapulaeN: C3--4 and dorsalscapular C5M: TrapeziusN: Accessory (XI)Deeper tissues:M: InfraspinatusN: Suprascapular(C5--6)M: TrapeziusN: Accessory (XI)Deeper tissues:M: Rhomboid majorN: Dorsal scapular(C5)M: TrapeziusN: Accessory (XI)Deeper tissues:M: Rhomboid majorN: Dorsal cal syndromeCardiacsyndromesSil0(Sil 1 )Muscular pain in shoulderand scapula; neuralgia inscapula and forearm. ( )Cardiac

TRIGGER POINTS AND ACUPUNCTURE POINTS FOR PAIN: CORRELATIONS AND IMPLICATIONS RONALD MELZACK *, DOROTHY M. STILLWELL and ELISABETH J. FOX Department of Psychology, McGill University, and Department of Medicine, Royal Victoria Hospital, Montreal, Que. (Canada) (Accepted July 21st, 1976) SUMMARY Trigger points associated with myofascial and visceral pains often tie with- in the areas of referred .

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