vortrag kristiansand_1

© Kosub/Thieme 2004

Trigger Point rESWT

Kristiansand 25-27 august 2006


Soft Shockwave Therapy

Dr. med. Martin Kosub

MD, Orthopaedistchiropractice, naturopathy, out-patient surgery, sports medicine, rehabilitation, acupuncture, paediatric chiropractice


MechanicalTrigger Point Therapy

• musculature: – largest single organ

• 50% of body weight


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


Case Report

• MRI 16.04.2004


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


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!


TP Shockwave

aus Travell + Simons „Handbuch der Muskeltriggerpunkte


Trigger Points

Dr. Janet G. Travell (1901-1997)


Trigger Point



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



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



Referred Pain



Satellite Trigger Point



“Taut Bands” and Trigger Points

Taut BandLocal Twitch


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


Concerning Innervation

• Trochanter-tendinosis


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


Trochanter-Tendinosis


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


Therapy

• Treating releasing factors

– joint disorders (Greenman)

– causes of nerve irritation

(structural damage)


Spray and Stretch


Trigger Shockwave


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


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


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


Smoothing

Smooth out the muscle

frequency 15 Hzrate of impulses

total 1000-2000pessure 1.2 – 2.2

bar


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)


M. rectus abdominis

from Travell + Simons „Handbuch der Muskeltriggerpunkte


M. rectus abdominis

vortrag kristiansand_1

Documents

rectusabdominis fromtravell

orthopaedist chiropractice

activetriggerpoint b

spindlecells golgitendon

medialisandintermediusl4

comeaux v

martin kosub md

gluteus maximus