Episode 36 - The Art And Science Of Trigger Point Treatments
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Episode Summary
Sometimes imaging doesn’t explain a patient’s pain, and when that is the case, many will feel discouraged if not flat-out alarmed.
Trigger points can offer answers, and it’s the topic of this episode of Back Talk Doc.
Marty Kestin joins the podcast to explain more about trigger points and how they are involved in causing pain. At Ensoma Bodyworks, Marty teaches both patients and students how to restore and improve body functioning by the way of advanced orthopedics like neuromuscular massage therapy and neuroplasticity.
Trigger points typically come into play when MRI imaging and other avenues of identifying pain come up short. Just because the cause of pain can’t be detected through imaging, doesn’t mean the patient is faking it. Quite the opposite. As Dr. Lakhia remarks in this episode: “Your pain is real. We're going to go on the hunt to find where it's coming from.”
Listen to this episode of Back Talk Doc to understand the science behind how trigger points work, their role in causing pain, and how understanding them can lead to better pain management.
Featured Guest
Name: Marty Kestin
What he does: As a Pain Detective, Marty draws on 25-years of pain management experience to not only find what is causing a patient’s pain, but to rid them of it.
Company: Ensoma Bodyworks
Words of wisdom: “My practice has been attracting recalcitrant or just stubborn enigmatic cases for about 10, 15 years now. Fortunately, they've already been to the doctor, or the chiropractor, or the PT, or the acupuncturist. Or the massage therapist. They come to me and go, ‘Nobody could figure it out.’ So they've gone through a lot of diagnostics and assessments, and I ask them, ‘How many people have examined your skeletal muscle in a microscopic way where they're combing over what they think the problematic area could be?’ Almost always, nobody's ever done that for them.”
Connect: LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Don’t overlook trigger point evaluation if you haven’t come up with answers for your pain. Many doctors don’t consider trigger points when it comes to determining the cause of pain; you’ll need to see a specialist. It’s important to know that it is an option, especially if a physician cannot determine what is causing your body pain in a traditional manner.
There are multiple ways to treat trigger points. There is never a one size fits all approach to pain, even when the pain results from trigger points. With a host of different treatment options, it’s important to understand each treatment method and what may be best for you. Dry needling is particularly popular, but “spray and stretch” may be more comfortable for some people.
Other symptoms could be related to trigger points. With trigger points, it’s not uncommon for there to be other symptoms aside from pain. Abdominal trigger points can cause diarrhea or IBS, for example.
Episode Insights
[00:00] Mobile-based solutions for clinical practice: Check out our sponsor, QxMD, which builds mobile solutions that drive evidence-based medicine in clinical practice with over 500 easy-to-use decision support tools.
[01:50] The bodywork savant: Dr. Lakhia introduces Marty, a friend and colleague, and his work with trigger points and massage therapy.
[03:43] What is a trigger point?: Marty defines exactly what a trigger point is by explaining its history and physical representation in a person’s body.
[08:21] When to suspect a trigger point: Dr. Lakhia asks Marty what can indicate a trigger point is the cause of pain and what to look out for, and which doctors to seek out.
[11:09] A short history on imaging studies: Marty talks about imaging studies — especially in relation to trigger points and pain patterns.
[13:18] Treatment options: Dr. Lahkia brings up different options for treatment of trigger points from Travell’s method to injecting trigger points with substance. Marty offers additional suggestions, including self-treatment options.
[17:10] Classic pain patterns: With trigger points, there are classic pain patterns to know and understand, like sciatica. Dr. Lakhia and Marty explain what the most common pain patterns are and how to identify them.
[21:26] When a headache isn’t just a headache: Trigger points can, well, trigger autonomic symptoms such as headaches, vertigo, and dizziness. Marty discusses the autonomic presentations that he has seen.
[24:42] It’s not just about the back: The front of the body and its trigger points often get neglected in favor of back and spinal issues.
[26:52] Self-care in the modern age: Marty offers suggestions for how people can stay out of trouble when it comes to trigger points.
[28:42] How Marty thrives personally and professionally: Marty breaks down what keeps him going, not only as a clinician but as a human being.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Should You Be Concerned About Seeing a Physician Assistant for Spine Care?
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Sometimes imaging doesn’t explain a patient’s pain, and when that is the case, many will feel discouraged if not flat-out alarmed.
Trigger points can offer answers, and it’s the topic of this episode of Back Talk Doc.
Marty Kestin joins the podcast to explain more about trigger points and how they are involved in causing pain. At Ensoma Bodyworks, Marty teaches both patients and students how to restore and improve body functioning by the way of advanced orthopedics like neuromuscular massage therapy and neuroplasticity.
Trigger points typically come into play when MRI imaging and other avenues of identifying pain come up short. Just because the cause of pain can’t be detected through imaging, doesn’t mean the patient is faking it. Quite the opposite. As Dr. Lakhia remarks in this episode: “Your pain is real. We're going to go on the hunt to find where it's coming from.”
Listen to this episode of Back Talk Doc to understand the science behind how trigger points work, their role in causing pain, and how understanding them can lead to better pain management.
Featured Guest
Name: Marty Kestin
What he does: As a Pain Detective, Marty draws on 25-years of pain management experience to not only find what is causing a patient’s pain, but to rid them of it.
Company: Ensoma Bodyworks
Words of wisdom: “My practice has been attracting recalcitrant or just stubborn enigmatic cases for about 10, 15 years now. Fortunately, they've already been to the doctor, or the chiropractor, or the PT, or the acupuncturist. Or the massage therapist. They come to me and go, ‘Nobody could figure it out.’ So they've gone through a lot of diagnostics and assessments, and I ask them, ‘How many people have examined your skeletal muscle in a microscopic way where they're combing over what they think the problematic area could be?’ Almost always, nobody's ever done that for them.”
Connect: LinkedIn
Anchor Points
Top takeaways from this Back Talk Doc episode
Don’t overlook trigger point evaluation if you haven’t come up with answers for your pain. Many doctors don’t consider trigger points when it comes to determining the cause of pain; you’ll need to see a specialist. It’s important to know that it is an option, especially if a physician cannot determine what is causing your body pain in a traditional manner.
There are multiple ways to treat trigger points. There is never a one size fits all approach to pain, even when the pain results from trigger points. With a host of different treatment options, it’s important to understand each treatment method and what may be best for you. Dry needling is particularly popular, but “spray and stretch” may be more comfortable for some people.
Other symptoms could be related to trigger points. With trigger points, it’s not uncommon for there to be other symptoms aside from pain. Abdominal trigger points can cause diarrhea or IBS, for example.
Episode Insights
[00:00] Mobile-based solutions for clinical practice: Check out our sponsor, QxMD, which builds mobile solutions that drive evidence-based medicine in clinical practice with over 500 easy-to-use decision support tools.
[01:50] The bodywork savant: Dr. Lakhia introduces Marty, a friend and colleague, and his work with trigger points and massage therapy.
[03:43] What is a trigger point?: Marty defines exactly what a trigger point is by explaining its history and physical representation in a person’s body.
[08:21] When to suspect a trigger point: Dr. Lakhia asks Marty what can indicate a trigger point is the cause of pain and what to look out for, and which doctors to seek out.
[11:09] A short history on imaging studies: Marty talks about imaging studies — especially in relation to trigger points and pain patterns.
[13:18] Treatment options: Dr. Lahkia brings up different options for treatment of trigger points from Travell’s method to injecting trigger points with substance. Marty offers additional suggestions, including self-treatment options.
[17:10] Classic pain patterns: With trigger points, there are classic pain patterns to know and understand, like sciatica. Dr. Lakhia and Marty explain what the most common pain patterns are and how to identify them.
[21:26] When a headache isn’t just a headache: Trigger points can, well, trigger autonomic symptoms such as headaches, vertigo, and dizziness. Marty discusses the autonomic presentations that he has seen.
[24:42] It’s not just about the back: The front of the body and its trigger points often get neglected in favor of back and spinal issues.
[26:52] Self-care in the modern age: Marty offers suggestions for how people can stay out of trouble when it comes to trigger points.
[28:42] How Marty thrives personally and professionally: Marty breaks down what keeps him going, not only as a clinician but as a human being.
Subscribe & Contact
If you enjoyed this episode of Back Talk Doc, check out our recent episode Should You Be Concerned About Seeing a Physician Assistant for Spine Care?
For more information on Dr. Sanjiv Lakhia and the podcast visit BackTalkDoc.com.
Subscribe in your favorite podcast app.
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
QXMD Ad: 00:00
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you, and Calculate for over 500 easy-to-use decision support tools. Try them today at QXMD.com/apps. Again, that is QXMD.com/apps.
Intro: 00:30
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:04
In the world of spine care, we often deal with the concept of pinched nerves and back MRIs. As you guys who follow me on this podcast know, we've done deep dives into MRI imaging and the workup for lumbar radiculopathies and the like. Today, I want to make a bit of a left turn and I'm very delighted to be interviewing my friend and colleague, Marty Kestin, to talk about the concept of trigger point treatments. We've touched before on trigger points versus acupuncture points, but today we're really going to get into more of the clinical side of things. So Marty, thanks for taking time and welcome to the show.
Marty Kestin: 01:46
Thank you, Sanjiv. I'm excited to be here and share some information.
Sanjiv Lakhia: 01:50
I really got to know Marty, for those of you listening, you've followed me for a while and know that I actually off and on suffer with my own back issues that flare and I had a pretty bad flare up last winter. That's where I connected with Marty, and he was a big part of my team to help me get back on track. Marty is a well-established licensed massage therapist in the Charlotte, North Carolina area. He obtained his BS in rehabilitation from Springfield College in 1991. He's got a master's degree in clinical social Work. Marty's trained in zen body therapy. He's done work with the Egoscue training method, and graduated the Chicago School of Massage Therapy in 2001. In short, he's had a 25 to 30 year career of really just helping people in our community and providing an outside the box perspective at times, and really is known as a bit of a wizard with his hands and his mindset. I think you're a bit of a savant when it comes to body work and trigger point treatment, Marty. So thanks for taking time. I think this is going to be fun.
Marty Kestin: 02:52
Thanks, Sanjiv.
Sanjiv Lakhia: 02:53
Yeah, all right. So let's get right into it. People who are listening, if you're suffering out there and you're getting pain going down your arm or going down your leg, sometimes you'll run into the roadblock of meeting a physiatrist, like myself, or a neurosurgeon, or other spine provider who will look at your MRI and just say, "It doesn't make sense." I know when I talk to patients in that context, I'm very careful because I know it can be a bit alarming to hear that, and on some level, dismissive. But I think by the end of this podcast, those of you that are listening, you might feel some hope and be able to go down another pathway. Let's get right into the idea of musculoskeletal trigger points. Explain to listeners, Marty, what exactly a trigger point is and then let's start from there.
Marty Kestin: 03:43
Trigger points are endogenous microscopic contractures in the actin and myosin filaments, units of contracture, caused by either acute overload in a fall or a sporting accident, or chronic overload, as in a cumulative trauma disorder. If the rounded shoulders of somebody is going on for 15 years, they're going to develop these trigger points, which feel like little tiny grains of rice and sometimes larger ones in the anterior deltoid which does medial rotation, it's adaptively shortened, and then the rhomboids as well, which retract the shoulder blade. They're going to be stretched and weakened and they're trying to do their jobs and it can't because they're out of position and we get an energy crisis.
Marty Kestin: 04:32
Metabolically, calcium is not [inaudible 00:04:38]. ATP is involved as well. What Dr. Jay Shaw found at the NIH, by inserting a needle with saline being pushed in and pulling out what is inside of the trigger point, up to 11 noxious waste products in active trigger points. The active ones are the ones that you feel. It could be a deep ache, a throb, a shooting pain, even burning sensations. A latent trigger point is formed in the skeletal muscle, but you don't actually feel the pain. That's because the latent trigger point, with it's up to 11 noxious waste system byproducts, is agitating nearby nociceptors which then in turn, bombards the dorsal horn in the spine, the spinal cords, and then it goes up into the brain, and the brain sends back, "Okay. Something's wrong down there. I'm going to send out [inaudible 00:05:43]."
Marty Kestin: 05:43
Unfortunately, we're calling these things trigger points because the points trigger pain, but often not in the same spot, and that's why they're called trigger points. Why this is happening, Dr. Shaw also brushed at in another paper, is that the signal going up the dorsal horn is not traveling on the same pathway when it comes back down. As neuroscientists say, "What's wired together fires together." Dr. John Kelvin in the 1930s injected healthy skeletal muscle with saline to see what would happen. What he found in the major muscles that he injected, four out of five patients, every time, they got the same pain pattern, but not the fifth patients and that's because muscle is messy. Let's talk about latent trigger points too. Dr. Shaw's work has shown that they only have three to four or five immune system waste products stored up in the hypoxic tissue, thereby not aggravating with nearby nociceptors from [inaudible 00:06:54] dorsal horn.
Sanjiv Lakhia: 06:54
That's why I feel like this is your wheelhouse because I think that was an amazing description of what a trigger point is and some of the research and science behind it. Now, let's just clarify. If I come up behind you and I pushed my thumb on your upper trap and it hurts under my thumb, but does not hurt down your arm or in your head or neck, is that a trigger point?
Marty Kestin: 07:18
That's probably a latent trigger point. The pain pattern for the upper trap is literally a question mark going up behind the ear into the front of the temple. It could be part of that pattern, a third of it, a quarter of it or all of it.
Sanjiv Lakhia: 07:34
Okay. Very good. So my audience is mixed. I think I have probably more lay people than science minded guests or listeners for the show. If you go to see a massage therapist in the community, are all massage therapists going to have their radar up for finding and manually deactivating trigger points?
Marty Kestin: 07:57
Unfortunately, Sanjiv, the answer is definitely no, and it's the same in the physical therapy world and the physician world as well. There's just too few of us clinicians, regardless what our background is and our credentials is, that have stumbled across it or had a mentor that said, "You need to study this. It's the missing link in the pain world."
Sanjiv Lakhia: 08:21
When do you, as a clinician, suspect that a client or a patient may be dealing with a pain pattern from untreated trigger points?
Marty Kestin: 08:33
My practice has been attracting recalcitrant or just stubborn enigmatic cases for about 10, 15 years now. Fortunately, they've already been to the doctor, or the chiropractor, or the PT, or the acupuncturist. Or the massage therapist, and they come to me and go, "Nobody could figure it out." So they've gone through a lot of diagnostics and assessments, and I ask them, "How many people have examined your skeletal muscle in a microscopic way where they're combing over what they think the problematic area could be?" Almost always, it's nobody's ever done that for them.
Sanjiv Lakhia: 09:14
Yeah. No, I would agree with that. I think you have to be on the lookout for them. For me, I'm very suspicious because I live in a world, Marty, where we have a lot of imaging where MRI imaging, plain film studies are, on some level, standard of care and also on some level, they're an expectation of people coming into the office, even if I don't necessarily feel like the imaging always adds value. But when I pull up imaging studies for patients that literally just do not explain the symptoms, I feel like I have an added tool in the toolbox that I can give someone hope because of my understanding of trigger points that I can say, "Look, you do not have a ruptured disc. This is good news. Your pain is real. We're going to go on the hunt to find where it's coming from."
Sanjiv Lakhia: 10:02
Then I love pulling up diagrams on the computer from Travell's book, or you literally can go on Google and just type in, "gluteus medius trigger point referral pattern," and up pops the classic image. I can't tell you how many aha looks I get from people saying, "That's exactly it. That's exactly where my pain is." So I think it's a real addition to the clinical toolbox to have this sort of knowledge and the ability to take a look at things. For me, I suspect also, in addition to imaging studies that are benign, when I have someone come in with an asymmetric gait or asymmetric posture, I know at least from my osteopathic training, that whenever there's asymmetry, there's going to be tight muscle bands in some areas and loose and overstretched in the other. So it's very easy to see some, like you mentioned, the rounded shoulder. Now in the days, with tech-neck and 24 hours on a computer, it's very easy to just palpate and find them in the chest wall, in the rhomboid, the shoulders, everywhere. So those are some clues for me as well.
Marty Kestin: 11:03
Can I share some imaging studies now since we're on the subject matter?
Sanjiv Lakhia: 11:09
Yeah.
Marty Kestin: 11:09
Back in 1989, a doctor by the name of [inaudible 00:11:13] wrote a pain management journal, took 283 patients, he and his two colleagues, and [inaudible 00:11:23] skeletal muscle palpations, enigmatic back pain patients and 96% of them had two to four active trigger points that found that would recreate the patient's pain patterns. [inaudible 00:11:38] 2006 in the archives of physical medicine, he asked, "Is spinal stenosis causing the pain from the left?" In about 150 patients [inaudible 00:11:49] and some had stenosis and some did not, but all the patients with stenosis also had active trigger points. So he concluded those with stenosis [inaudible 00:12:00] and do these trigger points aggravate the pain? Yes. [inaudible 00:12:05] needs to be really up on not having a strong information bias [inaudible 00:12:11] stenosis [inaudible 00:12:19].
Marty Kestin: 12:19
Muscles have four things that they don't like. Length issues, too short, too long, [inaudible 00:12:28]. Looseness, if you have a [inaudible 00:12:32] front of your shoulder blade, if that's [inaudible 00:12:38] that signal's going to get sent up to your brain [inaudible 00:12:42] and the pain's going to send back pain. That's an interesting concept that stability and mobility [inaudible 00:12:50]. So you might have [inaudible 00:12:51] the brain turning on the pain in your shoulder, so we don't use it as much. Muscle has two other complaints. Chemical irritation if you have the flu, or a cold, or a fever, you feel all achy all over. Then finally, trigger points, the most misunderstood full body, metastatic [inaudible 00:13:18].
Sanjiv Lakhia: 13:18
Very complex musculoskeletal system that we deal with on a daily basis. I think if you know where to look, the body will give you the clues to help figure out what's going on. Let's talk a little bit about kind of treatment options. Now, when you suspect trigger points contributing to an individual's pain syndrome, there are a whole host of kind of evolving options. Number one, you certainly can work with someone who's got your qualifications to kind of hunt them down and do manual techniques to release them. Number two, the emerging field of dry needling, which is extremely popular now particularly amongst physical therapists and patients literally coming in asking for it. Number three, the classic Travell technique of spray and stretch, use a vapor coolant spray on the muscle and then therapeutic stretching.
Sanjiv Lakhia: 14:13
Then the more aggressive medical option of literally injecting the trigger points with some substance, whether it's lidocaine. Some will actually use corticosteroid, which I don't recommend, Sarapin. There's been other agents that have been utilized. What's kind of your thoughts? Obviously, you may have a bias because what you do for a living, but how do you conceptualize which tool to use to address and eliminate and correct the trigger point?
Marty Kestin: 14:40
Right now, Travell basically and Dr. Simons, his colleague, basically said. "You do whatever works," and then they're wheelhouse of spray and stretch and [inaudible 00:14:51] injections, but it doesn't matter if they're an acupuncturist, [inaudible 00:14:55], an MD, an osteopath, [inaudible 00:14:57] a massage therapist [inaudible 00:15:01] get just as deep as [inaudible 00:15:08] injection needle without actually [inaudible 00:15:11] into the body. That could deactivate trigger points very fast, very effectively. I think more importantly than which methodology you're using to treat the trigger point, it's identifying the perpetuating factors. That's part of treatment. What's causing it in the first place? Then making sure [inaudible 00:15:35].
Marty Kestin: 15:37
For me, it's all these teachers people had to self treat first. [inaudible 00:15:44] First, by warming up [inaudible 00:15:45] specific treatments on the trigger point with a [inaudible 00:15:53]. I think that's the most important thing is that the power or persons with the knowledge of why they're in pain and explaining to them that it's not another physician's fault that they missed it, the trigger points. It's just not part of their background and training, and just move forward with the right [inaudible 00:16:14].
Sanjiv Lakhia: 16:15
Yeah. No, I like that because we all look at things through a different lens and a bit of a different bias based upon our experience. I'll tell you that tennis ball, I don't leave my house without the tennis ball. I know when I was having the pain down the leg, activating those trigger points, using that tennis ball, it's just amazing, simple, effective, immediate tool that you can use if you're in a rough situation. Teaching patients how to prevent it, I like how you mentioned find and eliminate the factors that are triggering it and contributing to it, and I think that's where sitting posture, ergonomics, breathing, stress, diet, all these things play a role, and a comprehensive approach to that is warranted beyond just someone coming in and asking me to stick a needle in it and then going home and then they'd come back in a week and it's back. That's a very good point that you made.
Sanjiv Lakhia: 17:10
Let's get into educate people here. There are some classic pain patterns. So let's talk about sciatica. I just had a patient come in the other day and we had literally, about to walk out the room, finished our eval and he asked me, "Hey, document. Do you think this wallet I sit on is contributing to my problem?" and pulls out this huge wallet. So then we stopped a little bit talked about the piriformis muscle, the glute muscles, and how this can contribute. So I thought about that when you mentioned the factors that can trigger symptoms. But what are some common muscles that you see, and maybe some uncommon ones that people wouldn't even be aware of can reproduce a ton of pain going down the leg minimus?
Marty Kestin: 17:56
[inaudible 00:17:56] will actually put pain down the side of the legs and the calf, but it won't extend in [inaudible 00:18:05]. Now, if it's going into the toes and feet, we definitely have [inaudible 00:18:11]. If it's not, the pain is achy, it's not super sharp, electrifying tight feeling, it's probably muscular. The piriformis could entrap the sciatic nerve. That's going to put down the side of the leg, but bypass the knee. It won't go through the knee [inaudible 00:18:30] syndrome rather than lumbar [inaudible 00:18:33]. For me, it's always trial and error. Even if they come in with an official diagnosis of X, Y, or Z, I'm going to do a thorough sciatic muscle palpation examination of every muscle in the area of their [inaudible 00:18:48] probably elsewhere to look for dysfunction [inaudible 00:18:52] that might be lending to the [inaudible 00:19:03] smaller than the other. I don't see that too often, but I see it maybe four or five times.
Marty Kestin: 19:08
A common muscle dysfunction in the shoulder blade... Travell and Simon say the most common trigger point in the body, the upper trapezius. Based on the past 25 years, I'd have to say it's probably the infraspinatus. That's a muscle on the back of the shoulder blade and it's referral pain [inaudible 00:19:31] front of the shoulder, it's deep in the shoulder and down the arm. If I had a dollar for each time somebody came in with a radiculopathy or a pinched nerve [inaudible 00:19:44] diagnosis turned out to be that [inaudible 00:19:45].
Sanjiv Lakhia: 19:45
Uh-huh (affirmative). You've talked to me before. What about carpal tunnel center?
Marty Kestin: 19:50
Carpal tunnel syndrome... Let's talk about carpal tunnel syndrome. I'm not a doctor. I diagnose it, but I can't tell my patients, "The diagnosis is the end result of a bunch of things that you've been doing and not doing." So even if it is maybe a nerve entrapped in some scar tissue and pressure, there's going to be multiple other factors involved in why that's happening, the poor posture, the repetitive strain around the shoulders, the not knowing how to go home and do ice bath after work or how to massage your arms properly. You can have multiple trigger points in the forearms, muscles of the extensor group, the flexor group [inaudible 00:20:38].
Marty Kestin: 20:40
There's the first dorsal [inaudible 00:20:45] muscle [inaudible 00:20:47] the numbness on the top of the hand and bottom of your hand, just that [inaudible 00:20:53]massage therapists. So if we learn how to massage to give a full body [inaudible 00:21:10] or trigger points, some of that, [inaudible 00:21:18] over and over again, and by the right manual [inaudible 00:21:24].
Sanjiv Lakhia: 21:26
One of the things that I find fascinating about the field of trigger points is the idea that some of these can almost trigger autonomic symptoms. So for example, I think the key area there, at least that I've seen, would be kind of headaches, head stuff, dizziness, vertigo, headaches. What are some of the kind of autonomic presentations that you've seen in your clinical career of hunting for and searching and treating trigger points?
Marty Kestin: 21:58
The textbooks make it very clear that trigger points can cause autonomic phenomena. The exact mechanism of action is fully understood by some and argued by others, but at the end of the day, it doesn't matter. You just need to identify the offending muscle that's telling the brain something's wrong and the brain sends out automatic phenomena. One of the best case histories is a doctor by the name of Jeff, who's now a good friend of mine. He came to me because his neighbor, who was 51 facing retirement because of disability as a nephrologist, or [inaudible 00:22:41] doctor, he comes in the office like a deer in the headlights going, "I'm here because a friend recommended it and I'm desperate." He was having tingling in his hands and his feet and slight vertigo, was having trouble driving himself to work, and he presented with one of the most extreme forward head postures I've ever seen. I showed him my red Travell books and we talked, and I showed him the sternocleidomastoid muscle, that big muscle that attaches the back of your head to your collarbone.
Marty Kestin: 23:17
Dr. Travell and Simons identified it as [inaudible 00:23:21] organ, that is it's telling your brain where the head is in space in relation to the body. If someone presents with an extreme forward head posture, that sternocleidomastoid or SCM muscle is adaptively shortened and his neck was harboring, I counted eight active trigger points in his SCMs, and also his scalenes, those are small little muscles of inspiration on the front of your neck, were also adaptively shortened, and his suboccipitales, which attach the base of your skull to the first two vertebrae, were adaptably shortened. If you stick your head forward, the back of your skull comes down. It took about three weeks and he said, "I'm 25% to 50% improved." It took about six weeks for him to go, "The tingling's gone." His homework was to reverse forward head posture. I gave him postural care exercises, corrected the perpetuating factors. He was sitting at a desk dictating after work. I said, "Stand up. Get a walking treadmill desk," and he did. Today, he's pain free and still seeing all his patients.
Sanjiv Lakhia: 24:42
Yeah, that's amazing. That's amazing. It makes me think about in the osteopathic world, we focus a lot on tender points and dysfunction in the front of the body. I think the front of the body gets neglected quite a bit. So for example, abdominal trigger points with irritable bowel syndrome, even abdominal lower abdominal trigger points with low back pain. So dysfunction, shortened muscles, irritated muscles in the front of the body contribute to pains on the back of the body or elsewhere. Do you encounter a lot of that in terms of working on the front versus just looking at the backside of the body?
Marty Kestin: 25:17
I've worked on several Pilates instructors over the years and they're taught when they get trained to be teachers to pull in the belly, and that was because several of the original students of Joseph Pilates were ballet dancers and they always pulled in their belly. Several of them developed IBS as a result, and they would harbor massive trigger points in the upper rectus, which is attaching to the lower ribs and the lower rectus, which attaches to the top of the pubic bone and the oblique muscles as well, even the transverse abdominis. When we would release those trigger points, one woman reported, "My diarrhea is going down."
Sanjiv Lakhia: 26:03
Yeah, and it makes sense. It kind of all ties together because if I put on my Eastern medicine hat, with acupuncture, a lot of those are the points that you use to treat these functional GI as a services. What I've learned through the years is I have an evolving definition of fitness. I don't think you necessarily have to look like the guy on the front cover of Men's Health magazine. I think it's key to be able to breathe deeply, and anything that impairs your diaphragmatic motion and that creates the muscle tension that blocks that is going to put you down a pathway that you don't necessarily want to be on. Now, kind of to wrap it up here. If people are listening to this, I'm sure an obvious question is, Marty, how do I prevent some of this stuff from happening? So can you share maybe two or three tips, self-care tips that you use and recommend with your clients about how people can kind of stay out of trouble?
Marty Kestin: 26:52
If we're living in the modern age, I don't think we could really stay out of trouble because we're always stuck in a four by four box, whether we're seated at the desk, or in the car, or in front of the TV, or at the computer. One of the things that people can do is go buy any self-care book on treating trigger points. There's several out there. Just look up, "self-treating trigger points," and pick the one that resonates with you. Moving more, micro breaking at work. Micro breaking means pushing away from your computer and doing spinal flexes or cat and cow seated, that yoga exercise.
Marty Kestin: 27:33
If you're working at home or at the office, walk upstairs to go to the bathroom or walk downstairs. Stay moving as much as you can. If you think you got a trigger point or just a pain in your back or your neck, you're probably first going to go run for ice. If you run for moist heat instead and it gives you relief, you've probably got a trigger point. Break out your self-care book, identify the muscle and treat it. Self-treating these little pot bands is the most overlooked, obvious way to do self-care and that's because trigger points don't respond too much to stretching. They don't like ice. We don't even know that we have them until you go to someone like Sanjiv or me.
Sanjiv Lakhia: 28:22
No, that's a great tip. I like that about moving your body more, micro breaks and the heat. Well, I really appreciate you taking the time to, I think, talk about an area that doesn't get enough attention. Before I do let you go, I always like to close my episodes with picking the brain of my guests, just some health habits that have served you well. Now, in the past, I've had people share their morning routine or one or two things that they love to do that keeps them healthy and happy. So do you have any parting tips about what's helped you stay on top and remain as a thriving, productive professional?
Marty Kestin: 28:56
I think first and foremost is... Well, it's probably several things. There's my faith in my higher power, is that that I'm supported all the time by a entity or supreme being that is loving and kind. I have had a daily meditation practice since I was about 22 years old. That has changed over the years as to what I do, but the one thing that's the same is I work on my deep breathing. I focus my mind on something. That's been very instrumental, especially over the past year with COVID. Probably three, if you own a foam roller, one of the things that you can do with it is a befriend it. Don't hurt yourself with it, go easy, and that ties into my third point about my own self-care.
Marty Kestin: 29:40
Like makeup, less is more. That's what I learned from women over the years, that the ones who put on a lot of makeup don't look as good as the ones that put on less, and I've learned this from them. I don't wear makeup, but I'm just saying less is more. So maybe not run for 45 minutes, run for 30, and then do some stretching afterwards. Finally, frankly, the Wim Hof method. It's a method of cold exposure with cold showers and specific breathing technique, and then mental focus through the first two. That's been a game changer for me. Over the past two years, I've been very healthy, fortunately, and my muscular aches and pains have gone down.
Sanjiv Lakhia: 30:22
That's a fascinating topic that we could spend an hour talking about as well, but thank you for sharing those personal tips. We'll go ahead and put some links in the show notes too. I want to link to the Travell manuals that we talked about. I think if you're a physical therapist listening or a bodywork specialist, you should definitely own the two volume set. We'll link to some personal self-care trigger point workbooks. I did an episode of kind of top 10 gifts over Christmas time, and I had the workbook along with a There Cane. I don't know if you use a Thera Cane, but I really love that. It's a great way to get to tough to reach spots. Then if people are listening in the area and they want to get a hold of you, what's kind of the way that people can find you?
Marty Kestin: 31:05
Well, since it's the age of Zoom, I actually do Zoom therapy sessions with people and I just ask them if we're doing lower body or back stuff, to get a foam roller and a tennis ball, and if we're doing shoulder stuff, to get up Thera Cane just like you mentioned. Probably looking me up at my website, www.ensomabodyworks.com. That's E-N-S-O-M-Abodyworks.com, or send me and email.com at MKestin, K-E-S-T-I-N, @ensomabodyworks.com.
Sanjiv Lakhia: 31:37
Fantastic. All right, my friends. Thank you so much for letting me pick your brain. I think this is a very valuable episode that people are going to learn a lot from. If it helps even one person who's listening discover a solution to their issue, then I'm going to be a happy man. So thanks again and I look forward to speaking with you again soon.
Marty Kestin: 31:55
Thanks, Sanjiv. Take care.
Outro: 31:58
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates. With offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia, and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
This podcast is sponsored by our partner, QXMD. QXMD builds mobile solutions that drive evidence-based medicine in clinical practice. Check out Read for easy access to research personalized for you, and Calculate for over 500 easy-to-use decision support tools. Try them today at QXMD.com/apps. Again, that is QXMD.com/apps.
Intro: 00:30
Welcome. You're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health. Brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now, it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Sanjiv Lakhia: 01:04
In the world of spine care, we often deal with the concept of pinched nerves and back MRIs. As you guys who follow me on this podcast know, we've done deep dives into MRI imaging and the workup for lumbar radiculopathies and the like. Today, I want to make a bit of a left turn and I'm very delighted to be interviewing my friend and colleague, Marty Kestin, to talk about the concept of trigger point treatments. We've touched before on trigger points versus acupuncture points, but today we're really going to get into more of the clinical side of things. So Marty, thanks for taking time and welcome to the show.
Marty Kestin: 01:46
Thank you, Sanjiv. I'm excited to be here and share some information.
Sanjiv Lakhia: 01:50
I really got to know Marty, for those of you listening, you've followed me for a while and know that I actually off and on suffer with my own back issues that flare and I had a pretty bad flare up last winter. That's where I connected with Marty, and he was a big part of my team to help me get back on track. Marty is a well-established licensed massage therapist in the Charlotte, North Carolina area. He obtained his BS in rehabilitation from Springfield College in 1991. He's got a master's degree in clinical social Work. Marty's trained in zen body therapy. He's done work with the Egoscue training method, and graduated the Chicago School of Massage Therapy in 2001. In short, he's had a 25 to 30 year career of really just helping people in our community and providing an outside the box perspective at times, and really is known as a bit of a wizard with his hands and his mindset. I think you're a bit of a savant when it comes to body work and trigger point treatment, Marty. So thanks for taking time. I think this is going to be fun.
Marty Kestin: 02:52
Thanks, Sanjiv.
Sanjiv Lakhia: 02:53
Yeah, all right. So let's get right into it. People who are listening, if you're suffering out there and you're getting pain going down your arm or going down your leg, sometimes you'll run into the roadblock of meeting a physiatrist, like myself, or a neurosurgeon, or other spine provider who will look at your MRI and just say, "It doesn't make sense." I know when I talk to patients in that context, I'm very careful because I know it can be a bit alarming to hear that, and on some level, dismissive. But I think by the end of this podcast, those of you that are listening, you might feel some hope and be able to go down another pathway. Let's get right into the idea of musculoskeletal trigger points. Explain to listeners, Marty, what exactly a trigger point is and then let's start from there.
Marty Kestin: 03:43
Trigger points are endogenous microscopic contractures in the actin and myosin filaments, units of contracture, caused by either acute overload in a fall or a sporting accident, or chronic overload, as in a cumulative trauma disorder. If the rounded shoulders of somebody is going on for 15 years, they're going to develop these trigger points, which feel like little tiny grains of rice and sometimes larger ones in the anterior deltoid which does medial rotation, it's adaptively shortened, and then the rhomboids as well, which retract the shoulder blade. They're going to be stretched and weakened and they're trying to do their jobs and it can't because they're out of position and we get an energy crisis.
Marty Kestin: 04:32
Metabolically, calcium is not [inaudible 00:04:38]. ATP is involved as well. What Dr. Jay Shaw found at the NIH, by inserting a needle with saline being pushed in and pulling out what is inside of the trigger point, up to 11 noxious waste products in active trigger points. The active ones are the ones that you feel. It could be a deep ache, a throb, a shooting pain, even burning sensations. A latent trigger point is formed in the skeletal muscle, but you don't actually feel the pain. That's because the latent trigger point, with it's up to 11 noxious waste system byproducts, is agitating nearby nociceptors which then in turn, bombards the dorsal horn in the spine, the spinal cords, and then it goes up into the brain, and the brain sends back, "Okay. Something's wrong down there. I'm going to send out [inaudible 00:05:43]."
Marty Kestin: 05:43
Unfortunately, we're calling these things trigger points because the points trigger pain, but often not in the same spot, and that's why they're called trigger points. Why this is happening, Dr. Shaw also brushed at in another paper, is that the signal going up the dorsal horn is not traveling on the same pathway when it comes back down. As neuroscientists say, "What's wired together fires together." Dr. John Kelvin in the 1930s injected healthy skeletal muscle with saline to see what would happen. What he found in the major muscles that he injected, four out of five patients, every time, they got the same pain pattern, but not the fifth patients and that's because muscle is messy. Let's talk about latent trigger points too. Dr. Shaw's work has shown that they only have three to four or five immune system waste products stored up in the hypoxic tissue, thereby not aggravating with nearby nociceptors from [inaudible 00:06:54] dorsal horn.
Sanjiv Lakhia: 06:54
That's why I feel like this is your wheelhouse because I think that was an amazing description of what a trigger point is and some of the research and science behind it. Now, let's just clarify. If I come up behind you and I pushed my thumb on your upper trap and it hurts under my thumb, but does not hurt down your arm or in your head or neck, is that a trigger point?
Marty Kestin: 07:18
That's probably a latent trigger point. The pain pattern for the upper trap is literally a question mark going up behind the ear into the front of the temple. It could be part of that pattern, a third of it, a quarter of it or all of it.
Sanjiv Lakhia: 07:34
Okay. Very good. So my audience is mixed. I think I have probably more lay people than science minded guests or listeners for the show. If you go to see a massage therapist in the community, are all massage therapists going to have their radar up for finding and manually deactivating trigger points?
Marty Kestin: 07:57
Unfortunately, Sanjiv, the answer is definitely no, and it's the same in the physical therapy world and the physician world as well. There's just too few of us clinicians, regardless what our background is and our credentials is, that have stumbled across it or had a mentor that said, "You need to study this. It's the missing link in the pain world."
Sanjiv Lakhia: 08:21
When do you, as a clinician, suspect that a client or a patient may be dealing with a pain pattern from untreated trigger points?
Marty Kestin: 08:33
My practice has been attracting recalcitrant or just stubborn enigmatic cases for about 10, 15 years now. Fortunately, they've already been to the doctor, or the chiropractor, or the PT, or the acupuncturist. Or the massage therapist, and they come to me and go, "Nobody could figure it out." So they've gone through a lot of diagnostics and assessments, and I ask them, "How many people have examined your skeletal muscle in a microscopic way where they're combing over what they think the problematic area could be?" Almost always, it's nobody's ever done that for them.
Sanjiv Lakhia: 09:14
Yeah. No, I would agree with that. I think you have to be on the lookout for them. For me, I'm very suspicious because I live in a world, Marty, where we have a lot of imaging where MRI imaging, plain film studies are, on some level, standard of care and also on some level, they're an expectation of people coming into the office, even if I don't necessarily feel like the imaging always adds value. But when I pull up imaging studies for patients that literally just do not explain the symptoms, I feel like I have an added tool in the toolbox that I can give someone hope because of my understanding of trigger points that I can say, "Look, you do not have a ruptured disc. This is good news. Your pain is real. We're going to go on the hunt to find where it's coming from."
Sanjiv Lakhia: 10:02
Then I love pulling up diagrams on the computer from Travell's book, or you literally can go on Google and just type in, "gluteus medius trigger point referral pattern," and up pops the classic image. I can't tell you how many aha looks I get from people saying, "That's exactly it. That's exactly where my pain is." So I think it's a real addition to the clinical toolbox to have this sort of knowledge and the ability to take a look at things. For me, I suspect also, in addition to imaging studies that are benign, when I have someone come in with an asymmetric gait or asymmetric posture, I know at least from my osteopathic training, that whenever there's asymmetry, there's going to be tight muscle bands in some areas and loose and overstretched in the other. So it's very easy to see some, like you mentioned, the rounded shoulder. Now in the days, with tech-neck and 24 hours on a computer, it's very easy to just palpate and find them in the chest wall, in the rhomboid, the shoulders, everywhere. So those are some clues for me as well.
Marty Kestin: 11:03
Can I share some imaging studies now since we're on the subject matter?
Sanjiv Lakhia: 11:09
Yeah.
Marty Kestin: 11:09
Back in 1989, a doctor by the name of [inaudible 00:11:13] wrote a pain management journal, took 283 patients, he and his two colleagues, and [inaudible 00:11:23] skeletal muscle palpations, enigmatic back pain patients and 96% of them had two to four active trigger points that found that would recreate the patient's pain patterns. [inaudible 00:11:38] 2006 in the archives of physical medicine, he asked, "Is spinal stenosis causing the pain from the left?" In about 150 patients [inaudible 00:11:49] and some had stenosis and some did not, but all the patients with stenosis also had active trigger points. So he concluded those with stenosis [inaudible 00:12:00] and do these trigger points aggravate the pain? Yes. [inaudible 00:12:05] needs to be really up on not having a strong information bias [inaudible 00:12:11] stenosis [inaudible 00:12:19].
Marty Kestin: 12:19
Muscles have four things that they don't like. Length issues, too short, too long, [inaudible 00:12:28]. Looseness, if you have a [inaudible 00:12:32] front of your shoulder blade, if that's [inaudible 00:12:38] that signal's going to get sent up to your brain [inaudible 00:12:42] and the pain's going to send back pain. That's an interesting concept that stability and mobility [inaudible 00:12:50]. So you might have [inaudible 00:12:51] the brain turning on the pain in your shoulder, so we don't use it as much. Muscle has two other complaints. Chemical irritation if you have the flu, or a cold, or a fever, you feel all achy all over. Then finally, trigger points, the most misunderstood full body, metastatic [inaudible 00:13:18].
Sanjiv Lakhia: 13:18
Very complex musculoskeletal system that we deal with on a daily basis. I think if you know where to look, the body will give you the clues to help figure out what's going on. Let's talk a little bit about kind of treatment options. Now, when you suspect trigger points contributing to an individual's pain syndrome, there are a whole host of kind of evolving options. Number one, you certainly can work with someone who's got your qualifications to kind of hunt them down and do manual techniques to release them. Number two, the emerging field of dry needling, which is extremely popular now particularly amongst physical therapists and patients literally coming in asking for it. Number three, the classic Travell technique of spray and stretch, use a vapor coolant spray on the muscle and then therapeutic stretching.
Sanjiv Lakhia: 14:13
Then the more aggressive medical option of literally injecting the trigger points with some substance, whether it's lidocaine. Some will actually use corticosteroid, which I don't recommend, Sarapin. There's been other agents that have been utilized. What's kind of your thoughts? Obviously, you may have a bias because what you do for a living, but how do you conceptualize which tool to use to address and eliminate and correct the trigger point?
Marty Kestin: 14:40
Right now, Travell basically and Dr. Simons, his colleague, basically said. "You do whatever works," and then they're wheelhouse of spray and stretch and [inaudible 00:14:51] injections, but it doesn't matter if they're an acupuncturist, [inaudible 00:14:55], an MD, an osteopath, [inaudible 00:14:57] a massage therapist [inaudible 00:15:01] get just as deep as [inaudible 00:15:08] injection needle without actually [inaudible 00:15:11] into the body. That could deactivate trigger points very fast, very effectively. I think more importantly than which methodology you're using to treat the trigger point, it's identifying the perpetuating factors. That's part of treatment. What's causing it in the first place? Then making sure [inaudible 00:15:35].
Marty Kestin: 15:37
For me, it's all these teachers people had to self treat first. [inaudible 00:15:44] First, by warming up [inaudible 00:15:45] specific treatments on the trigger point with a [inaudible 00:15:53]. I think that's the most important thing is that the power or persons with the knowledge of why they're in pain and explaining to them that it's not another physician's fault that they missed it, the trigger points. It's just not part of their background and training, and just move forward with the right [inaudible 00:16:14].
Sanjiv Lakhia: 16:15
Yeah. No, I like that because we all look at things through a different lens and a bit of a different bias based upon our experience. I'll tell you that tennis ball, I don't leave my house without the tennis ball. I know when I was having the pain down the leg, activating those trigger points, using that tennis ball, it's just amazing, simple, effective, immediate tool that you can use if you're in a rough situation. Teaching patients how to prevent it, I like how you mentioned find and eliminate the factors that are triggering it and contributing to it, and I think that's where sitting posture, ergonomics, breathing, stress, diet, all these things play a role, and a comprehensive approach to that is warranted beyond just someone coming in and asking me to stick a needle in it and then going home and then they'd come back in a week and it's back. That's a very good point that you made.
Sanjiv Lakhia: 17:10
Let's get into educate people here. There are some classic pain patterns. So let's talk about sciatica. I just had a patient come in the other day and we had literally, about to walk out the room, finished our eval and he asked me, "Hey, document. Do you think this wallet I sit on is contributing to my problem?" and pulls out this huge wallet. So then we stopped a little bit talked about the piriformis muscle, the glute muscles, and how this can contribute. So I thought about that when you mentioned the factors that can trigger symptoms. But what are some common muscles that you see, and maybe some uncommon ones that people wouldn't even be aware of can reproduce a ton of pain going down the leg minimus?
Marty Kestin: 17:56
[inaudible 00:17:56] will actually put pain down the side of the legs and the calf, but it won't extend in [inaudible 00:18:05]. Now, if it's going into the toes and feet, we definitely have [inaudible 00:18:11]. If it's not, the pain is achy, it's not super sharp, electrifying tight feeling, it's probably muscular. The piriformis could entrap the sciatic nerve. That's going to put down the side of the leg, but bypass the knee. It won't go through the knee [inaudible 00:18:30] syndrome rather than lumbar [inaudible 00:18:33]. For me, it's always trial and error. Even if they come in with an official diagnosis of X, Y, or Z, I'm going to do a thorough sciatic muscle palpation examination of every muscle in the area of their [inaudible 00:18:48] probably elsewhere to look for dysfunction [inaudible 00:18:52] that might be lending to the [inaudible 00:19:03] smaller than the other. I don't see that too often, but I see it maybe four or five times.
Marty Kestin: 19:08
A common muscle dysfunction in the shoulder blade... Travell and Simon say the most common trigger point in the body, the upper trapezius. Based on the past 25 years, I'd have to say it's probably the infraspinatus. That's a muscle on the back of the shoulder blade and it's referral pain [inaudible 00:19:31] front of the shoulder, it's deep in the shoulder and down the arm. If I had a dollar for each time somebody came in with a radiculopathy or a pinched nerve [inaudible 00:19:44] diagnosis turned out to be that [inaudible 00:19:45].
Sanjiv Lakhia: 19:45
Uh-huh (affirmative). You've talked to me before. What about carpal tunnel center?
Marty Kestin: 19:50
Carpal tunnel syndrome... Let's talk about carpal tunnel syndrome. I'm not a doctor. I diagnose it, but I can't tell my patients, "The diagnosis is the end result of a bunch of things that you've been doing and not doing." So even if it is maybe a nerve entrapped in some scar tissue and pressure, there's going to be multiple other factors involved in why that's happening, the poor posture, the repetitive strain around the shoulders, the not knowing how to go home and do ice bath after work or how to massage your arms properly. You can have multiple trigger points in the forearms, muscles of the extensor group, the flexor group [inaudible 00:20:38].
Marty Kestin: 20:40
There's the first dorsal [inaudible 00:20:45] muscle [inaudible 00:20:47] the numbness on the top of the hand and bottom of your hand, just that [inaudible 00:20:53]massage therapists. So if we learn how to massage to give a full body [inaudible 00:21:10] or trigger points, some of that, [inaudible 00:21:18] over and over again, and by the right manual [inaudible 00:21:24].
Sanjiv Lakhia: 21:26
One of the things that I find fascinating about the field of trigger points is the idea that some of these can almost trigger autonomic symptoms. So for example, I think the key area there, at least that I've seen, would be kind of headaches, head stuff, dizziness, vertigo, headaches. What are some of the kind of autonomic presentations that you've seen in your clinical career of hunting for and searching and treating trigger points?
Marty Kestin: 21:58
The textbooks make it very clear that trigger points can cause autonomic phenomena. The exact mechanism of action is fully understood by some and argued by others, but at the end of the day, it doesn't matter. You just need to identify the offending muscle that's telling the brain something's wrong and the brain sends out automatic phenomena. One of the best case histories is a doctor by the name of Jeff, who's now a good friend of mine. He came to me because his neighbor, who was 51 facing retirement because of disability as a nephrologist, or [inaudible 00:22:41] doctor, he comes in the office like a deer in the headlights going, "I'm here because a friend recommended it and I'm desperate." He was having tingling in his hands and his feet and slight vertigo, was having trouble driving himself to work, and he presented with one of the most extreme forward head postures I've ever seen. I showed him my red Travell books and we talked, and I showed him the sternocleidomastoid muscle, that big muscle that attaches the back of your head to your collarbone.
Marty Kestin: 23:17
Dr. Travell and Simons identified it as [inaudible 00:23:21] organ, that is it's telling your brain where the head is in space in relation to the body. If someone presents with an extreme forward head posture, that sternocleidomastoid or SCM muscle is adaptively shortened and his neck was harboring, I counted eight active trigger points in his SCMs, and also his scalenes, those are small little muscles of inspiration on the front of your neck, were also adaptively shortened, and his suboccipitales, which attach the base of your skull to the first two vertebrae, were adaptably shortened. If you stick your head forward, the back of your skull comes down. It took about three weeks and he said, "I'm 25% to 50% improved." It took about six weeks for him to go, "The tingling's gone." His homework was to reverse forward head posture. I gave him postural care exercises, corrected the perpetuating factors. He was sitting at a desk dictating after work. I said, "Stand up. Get a walking treadmill desk," and he did. Today, he's pain free and still seeing all his patients.
Sanjiv Lakhia: 24:42
Yeah, that's amazing. That's amazing. It makes me think about in the osteopathic world, we focus a lot on tender points and dysfunction in the front of the body. I think the front of the body gets neglected quite a bit. So for example, abdominal trigger points with irritable bowel syndrome, even abdominal lower abdominal trigger points with low back pain. So dysfunction, shortened muscles, irritated muscles in the front of the body contribute to pains on the back of the body or elsewhere. Do you encounter a lot of that in terms of working on the front versus just looking at the backside of the body?
Marty Kestin: 25:17
I've worked on several Pilates instructors over the years and they're taught when they get trained to be teachers to pull in the belly, and that was because several of the original students of Joseph Pilates were ballet dancers and they always pulled in their belly. Several of them developed IBS as a result, and they would harbor massive trigger points in the upper rectus, which is attaching to the lower ribs and the lower rectus, which attaches to the top of the pubic bone and the oblique muscles as well, even the transverse abdominis. When we would release those trigger points, one woman reported, "My diarrhea is going down."
Sanjiv Lakhia: 26:03
Yeah, and it makes sense. It kind of all ties together because if I put on my Eastern medicine hat, with acupuncture, a lot of those are the points that you use to treat these functional GI as a services. What I've learned through the years is I have an evolving definition of fitness. I don't think you necessarily have to look like the guy on the front cover of Men's Health magazine. I think it's key to be able to breathe deeply, and anything that impairs your diaphragmatic motion and that creates the muscle tension that blocks that is going to put you down a pathway that you don't necessarily want to be on. Now, kind of to wrap it up here. If people are listening to this, I'm sure an obvious question is, Marty, how do I prevent some of this stuff from happening? So can you share maybe two or three tips, self-care tips that you use and recommend with your clients about how people can kind of stay out of trouble?
Marty Kestin: 26:52
If we're living in the modern age, I don't think we could really stay out of trouble because we're always stuck in a four by four box, whether we're seated at the desk, or in the car, or in front of the TV, or at the computer. One of the things that people can do is go buy any self-care book on treating trigger points. There's several out there. Just look up, "self-treating trigger points," and pick the one that resonates with you. Moving more, micro breaking at work. Micro breaking means pushing away from your computer and doing spinal flexes or cat and cow seated, that yoga exercise.
Marty Kestin: 27:33
If you're working at home or at the office, walk upstairs to go to the bathroom or walk downstairs. Stay moving as much as you can. If you think you got a trigger point or just a pain in your back or your neck, you're probably first going to go run for ice. If you run for moist heat instead and it gives you relief, you've probably got a trigger point. Break out your self-care book, identify the muscle and treat it. Self-treating these little pot bands is the most overlooked, obvious way to do self-care and that's because trigger points don't respond too much to stretching. They don't like ice. We don't even know that we have them until you go to someone like Sanjiv or me.
Sanjiv Lakhia: 28:22
No, that's a great tip. I like that about moving your body more, micro breaks and the heat. Well, I really appreciate you taking the time to, I think, talk about an area that doesn't get enough attention. Before I do let you go, I always like to close my episodes with picking the brain of my guests, just some health habits that have served you well. Now, in the past, I've had people share their morning routine or one or two things that they love to do that keeps them healthy and happy. So do you have any parting tips about what's helped you stay on top and remain as a thriving, productive professional?
Marty Kestin: 28:56
I think first and foremost is... Well, it's probably several things. There's my faith in my higher power, is that that I'm supported all the time by a entity or supreme being that is loving and kind. I have had a daily meditation practice since I was about 22 years old. That has changed over the years as to what I do, but the one thing that's the same is I work on my deep breathing. I focus my mind on something. That's been very instrumental, especially over the past year with COVID. Probably three, if you own a foam roller, one of the things that you can do with it is a befriend it. Don't hurt yourself with it, go easy, and that ties into my third point about my own self-care.
Marty Kestin: 29:40
Like makeup, less is more. That's what I learned from women over the years, that the ones who put on a lot of makeup don't look as good as the ones that put on less, and I've learned this from them. I don't wear makeup, but I'm just saying less is more. So maybe not run for 45 minutes, run for 30, and then do some stretching afterwards. Finally, frankly, the Wim Hof method. It's a method of cold exposure with cold showers and specific breathing technique, and then mental focus through the first two. That's been a game changer for me. Over the past two years, I've been very healthy, fortunately, and my muscular aches and pains have gone down.
Sanjiv Lakhia: 30:22
That's a fascinating topic that we could spend an hour talking about as well, but thank you for sharing those personal tips. We'll go ahead and put some links in the show notes too. I want to link to the Travell manuals that we talked about. I think if you're a physical therapist listening or a bodywork specialist, you should definitely own the two volume set. We'll link to some personal self-care trigger point workbooks. I did an episode of kind of top 10 gifts over Christmas time, and I had the workbook along with a There Cane. I don't know if you use a Thera Cane, but I really love that. It's a great way to get to tough to reach spots. Then if people are listening in the area and they want to get a hold of you, what's kind of the way that people can find you?
Marty Kestin: 31:05
Well, since it's the age of Zoom, I actually do Zoom therapy sessions with people and I just ask them if we're doing lower body or back stuff, to get a foam roller and a tennis ball, and if we're doing shoulder stuff, to get up Thera Cane just like you mentioned. Probably looking me up at my website, www.ensomabodyworks.com. That's E-N-S-O-M-Abodyworks.com, or send me and email.com at MKestin, K-E-S-T-I-N, @ensomabodyworks.com.
Sanjiv Lakhia: 31:37
Fantastic. All right, my friends. Thank you so much for letting me pick your brain. I think this is a very valuable episode that people are going to learn a lot from. If it helps even one person who's listening discover a solution to their issue, then I'm going to be a happy man. So thanks again and I look forward to speaking with you again soon.
Marty Kestin: 31:55
Thanks, Sanjiv. Take care.
Outro: 31:58
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates. With offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia, and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Top quotes from the episode:
Marty Kestin:
[05:43] “Unfortunately, we're calling these things trigger points because the points trigger pain, but often not in the same spot, and that's why they're called trigger points.”
Marty Kestin:
[15:18] “I think more importantly than which methodology you're using to treat the trigger point, it's identifying the perpetuating factors. That's part of treatment. What's causing it in the first place?”
Marty Kestin:
[21:58] “The textbooks make it very clear that trigger points can cause autonomic phenomena. The exact mechanism of action is fully understood by some and argued by others, but at the end of the day, it doesn't matter. You just need to identify the offending muscle that's telling the brain something's wrong and the brain sends out automatic phenomena.”
Marty Kestin:
[27:33] “If you're working at home or at the office, walk upstairs to go to the bathroom or walk downstairs. Stay moving as much as you can. If you think you got a trigger point or just a pain in your back or your neck, you're probably first going to go run for ice. If you run for moist heat instead and it gives you relief, you've probably got a trigger point.”
Marty Kestin:
[05:43] “Unfortunately, we're calling these things trigger points because the points trigger pain, but often not in the same spot, and that's why they're called trigger points.”
Marty Kestin:
[15:18] “I think more importantly than which methodology you're using to treat the trigger point, it's identifying the perpetuating factors. That's part of treatment. What's causing it in the first place?”
Marty Kestin:
[21:58] “The textbooks make it very clear that trigger points can cause autonomic phenomena. The exact mechanism of action is fully understood by some and argued by others, but at the end of the day, it doesn't matter. You just need to identify the offending muscle that's telling the brain something's wrong and the brain sends out automatic phenomena.”
Marty Kestin:
[27:33] “If you're working at home or at the office, walk upstairs to go to the bathroom or walk downstairs. Stay moving as much as you can. If you think you got a trigger point or just a pain in your back or your neck, you're probably first going to go run for ice. If you run for moist heat instead and it gives you relief, you've probably got a trigger point.”