vortrag kristiansand_1

© 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

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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

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Case Report

• MRI 16.04.2004

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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

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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!

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TP Shockwave

aus Travell + Simons „Handbuch der Muskeltriggerpunkte

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Trigger Points

Dr. Janet G. Travell (1901-1997)

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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

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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

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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)

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Spray and Stretch

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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

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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