Philip A.M. Rogers MRCVS

AP in Pain and Painful Conditions


Brossman_RE1 (1996) Jones' Tender Points and Travell's TPs. RE Brossman AB DDS MS, 3 Crossings Mall, Wheeling, West Virginia 26003 USA; Adapted from WWW ( Janet Travell referred to "myofascial TPs", because they occurred mainly in muscles and fasciae, and their stimulation by deep palpation or needling elicited referred pain at other specific sites. The TPs could be effectively deactivated as sources of referred pain if she treated them with vapocoolants, or injection of local anaesthetics. LH Jones DO, in a paper "Spontaneous Release by Positioning", and in his later manual "Strain and Counterstrain", concisely explains the differences and similarities between his "tender points" and Travell's earlier description of TPs. Jones also describes how tender points and TPs often are intimately and closely related to the AP points of TCM, while at the same time still managing to be somewhat different. Chapman, cited decades later in a book "An Endocrine Interpretation of Chapman's Reflexes", also studied tenderness at local sites. Obviously, Chapman knew of these points before Travell's first publication in 1947, but I have not managed to locate the original text. Owens noted that Chapman related his sore spots to "visceral function", but anyone is entitled to call his work anything he wants, and visceral function must have had some relevance in 1937. The work of Korr is recommended also, as it goes into important detail on somatic joint dysfunction and gives what is probably the best scientific description of the process of dysfunction and spontaneous release.

Serious students of pain-point literature must find a major difference between Jones' tender points and the AP points of TCM: AP points are generally located close to the body surface, whereas tender points generally are in the deeper layers of the body, and in the fasciae, tendons, muscles and periosteum. AP points are needled by precisely placing the AP needle through the skin and into the underlying AP point, whereupon the needle is rotated several times between the operator's finger tips. The needles are left in-situ for some time and may be twisted several times during the session. Jones's tender points are of similar size, but are located within muscles, at the periosteal layers of bones, or within the tissue mass of tendons and fascial structures. Generally speaking, tender points are usually circa 1 cm across but the most tender (highly reactive) points may only be circa 3 mm.

All 3 techniques (TP therapy, AP and unblockage of tender-points), and probably a few others, are based on a common observation that the AP point, the TP, and the tender point are all manifestations of an organ, muscle, tendon, or joint dysfunction, and that the point where the dysfunction can be monitored by the clinician does not have to have a direct local relationship to the area where the patient perceives the complaint to be. The mechanism by which all 3 systems exist, first as a sign of dysfunction (AP point, TP, or tender point), or the physiologic process by which the therapeutic effect is obtained is not entirely clear. Korr comes closest to explaining counterstrain therapy from a rational scientific basis, and he relieves us of the necessity of learning to think in terms of TCM philosophy and culture, as would be needed to understand and use classical AP. Western culture demands the scientific approach, and the associated need for hard scientific fact. Oriental culture accepts philosophical approximation and the inscrutable.

The anatomy and physiology of the system
The function of much neural tissue in the spinal cord, for example, is to control and monitor normal physiologic processes. As well as their efferent nerve supply, muscles also have afferent nerve endings that allow the muscle to signal its state of contraction to the CNS. This muscular feedback is integrated within the CNS along with information arriving from the tendons, ligaments, and joint capsules to provide an awareness of both positions and rates of movement to the various parts of the body. Proprioception takes up a large portion of this neural function and many of the nerve endings of the sensory portions arise in neuromuscular spindles and Golgi tendon organs. Apart from these structures and their functions, which provide information to the CNS, many other types of free nerve endings exist in fasciae and tendons.

Neuromuscular Spindles
Neuromuscular spindles are basically length registering receptors. Structurally, they vary in length between 3-5 mm, are circa 0.1-0.2 mm in diameter, and are enclosed in a loose and extendible connective tissue capsule. Generally, circa 2-12 very narrow modified muscle fibres are enclosed within the capsule. Because of their structural incorporation within muscle tissue, they stretch when the muscle is stretched, and in doing this they form the basis of a neuromuscular servomechanism that is critical to purposeful and controlled muscular activity. Without some form of information feedback to the individual, a purposeful movement of a finger or an arm would be impossible. Visually observing a movement would even constitute a minimal form of information feedback, but even that control would be impossible in the dark. A sophisticated mechanism for generating information about rate of movement, extent of movement, strength of movement, etc is critical to any meaningful movement. Without that critical information, all movement would cease to have any meaning to the organism and there would not be much sense in having any structure larger than a small bundle of cells.

At the centre of the spindle you can find a few larger fibres that are literally packed with cell nuclei. This area is made up of non-contractile fibres and is called the nuclear bag because of the many nuclei. The other fibres are usually much thinner and are referred to as nuclear chain fibres as their nuclei are lined up like a chain. There may be up to 10 of the nuclear chain fibres within the spindle.

Spindles are enervated by both efferent and afferent nerve fibres. Each nuclear bag fibre receives a large myelinated afferent nerve fibre from 2 sources, one spirals around the nuclear area and is called an annulospiral ending, or primary ending. Another secondary ending attaches outside of the nuclear bag area and are called secondary afferent endings.

Nuclear chain fibres receive afferent enervation from the same primary myelinated fibre supplying the nuclear bag. Secondary nerve fibres terminate in what are termed flower spray endings on each side of the primary afferent endings. Functionally, primary efferent nerve endings (annulospirals) respond with information on degree and rate of muscle stretch, while secondary efferent endings only respond to degree of stretch.

Efferent nerve fibres ending at both static and dynamic efferent plates on the smaller intrarafusal muscle fibres together with those supplying the nuclear bag fibres effectively set up a system that can receive adjustment information from the CNS.

Brossman_RE2 (1996) Jones' Tender Points and Travell's TPs.
Spindles are most numerous in muscles which must have very precise discrimination of position. The masseter is obviously one place where we would expect many spindles, and it has very many. All the masticatory muscles usually have many neuromuscular spindles.

Confused feedback information to, or from, the spindles of the servomechanism is related to the onset and continuance of muscle spasm pain. Relief of muscle spasm pain by the mechanism of spontaneous release through counterstrain positioning is intimately tied into the neuromuscular spindle system. A finite time factor (circa 90 sec) is involved in the manipulative re-setting, or re-balancing of the spindle neural output message to the CNS, although these structures normally generate and receive nerve impulses at much higher rates of information exchange during normal function. The same process occurs in the following structures.

Tendon Organs
Also, referred to as golgi tendon organs, or neurotendinous organs, these structures are found at the junction area between muscles, their associated tendons, and in the aponeuroses on which the muscles attach. They are also encapsulated structures and are generally slightly smaller than neuromuscular spindles. They are usually enervated by a large myelinated afferent fibre that ends in small non-myelinated branches among small tendon fibres. The end fibres are probably stimulated by being compressed and twisted between the collagenous tendon fibres. Functionally, impulses from these organs tends to inhibit the lower motor neurons in the spinal cord. This action may provide a protective inhibition of muscular forces to prevent excessive stress damages to a muscle and its functional attachments.

Joint Receptors
Several types of sensory receptors are associated with synovial joints. Internal and external joint ligaments are supplied with receptor organs that closely resemble the Golgi Tendon Organs. The fibrous connective tissue capsules of joints are also supplied with many free nerve endings intertwined with the collagen fibres. Paciniform corpuscles (mechanoreceptors) and Ruffini type corpuscles are also numerous. Mechanoreceptors are thought to respond to compressive forces associated with joint movement. A lot of similar structures are seen in the periodontal ligament structure suspending the teeth in the alveolar processes, so the sensory information supplied to the CNS via this network must be superlative.

Proprioception is a critical function that allows fine control of all voluntary muscle activity by providing feedback information concerning rate of movement, amount of movement, and strength of movement. The process must first derive information from sensory units within the muscular unit, feed that information to the CNS at various levels, and return the process information from the CNS to the muscle unit in order to achieve any control at all. A motor nerve impulse to a muscle unit would be of little value if the response from the muscle unit was an all-or-none response of simple contraction. Everyone would be moving in uncontrolled jerks, or would all be suited up inside of a single cell membrane so that we could only accomplish the most rudimentary actions. In any organism, increasing complexity implies increasing complexity of process control. However, increased complexity implies increased risk of error in the program for relatively minor control processes.

Could This All Be Due To Adverse Effects in Software?
In the presence of a joint dysfunction one of the contributing factors to the chronicity of the dysfunction is a disturbed, or altered proprioceptive picture. A common finding in muscle units affected by TP pain is a "switched muscle", in which the functional origin and insertion of the muscle are thought to be reversed. The physiologic effect of this switching is first, an abnormal performance as an effector when under normal neurologic motor control; second, an equally abnormal performance as an antagonistic unit while operating under inaccurate proprioceptive influence. TP pain can exist in both muscle units simultaneously, and most often, does.

To the individual suffering from myofascial pain and dysfunction problems it is not enough to inform them that they may have their pain and dysfunction for no other reason than that they have a somewhat screwed up neuromuscular feedback loop. For all practical purposes, their pain does not ever exist to them as a slight error in the control process. They hurt, and they want someone to help them get relief from their symptoms of pain and altered function.

The Fundamental Concept of Strain and Counterstrain Therapy.
Jones offers 2 definitions for strain and counterstrain therapy. 1. Strain and counterstrain: relieving spinal or other joint pain by passively putting the joint into its position of greatest comfort; or 2. strain and counterstrain: relieving pain by reduction and arrest of the continuing inappropriate proprioceptor activity. He said this was accomplished by markedly shortening the muscle that contains the malfunctioning muscle spindle by applying mild strain to its antagonists. In other words, the inappropriate strain reflex is inhibited by application of counterstrain. Jones also stresses one key factor that must be observed during any active therapy: The return from any position of comfort MUST be done very slowly, especially through the first few degrees of arc. Without careful attention to this clinical detail, release of the myofascial spasm may fail to occur.

Muscle Spasm
Muscle makes up a very large portion of the body and generally, musculoskeletal dysfunction is often revealed by the presence of areas of tension and discomfort within muscles and limitation of motion at the articulations. Mechanical restriction of the associated joints (bracing, guarding), causing a reduced range of motion, is an early sign of muscular dysfunction. In the classic view of the dysfunction, the muscle may be thought of as trying to overcome the restraint supplied by the dysfunctional articulation. In the newer viewpoint, the muscle is viewed as the primary cause of the articular dysfunction. What comes first? The articular dysfunction, or the muscle dysfunction?.

In the normal, homeostatic articulation, the musculature is not painful in any normal position. In a situation where the articulation is painful, there may be one muscle unit that is hyperextended (longer than normal) and the opposing, or antagonistic muscle hypershortened. As regards proprioceptive feedback to the CNS, the hyperextended muscle may send greatly increased information back to the CNS, while the hypershortened muscle sends little or no proprioceptive information of value to the process. The net result is proprioceptive confusion, and that alone may cause the onset of pain in the spastic muscles.

Brossman_RE3 (1996) Jones' Tender Points and Travell's TPs.
You may have begun to realize that counterstrain therapy is fairly easy to apply to the muscles, ligaments and fascia of an anatomic part such as an arm, elbow, or shoulder. These parts have a system of muscle relations that make application of the cardinal principle of therapy, shortening of the painful muscle unit, relatively easy. While the principle should equally applicable to a muscle like the masseter, or temporalis, the anatomy of the functional unit, the mandible itself, is harder to fit into any relationship that can shorten these muscles effectively much more that they are already. Short of extracting all the teeth, it is not mechanically possible to shorten the masseter and temporalis much beyond occlusal contact of the teeth.

Microanatomic studies of muscle usually find that muscle spindles are most numerous in the belly of a muscle, while TPs often are mainly associated with the ends of muscle, where the spindles are absent, or much less numerous.

The masseter has a higher numbers of muscle spindles/unit volume than any other muscle, so the masseter is much more sensitive to anything that disturbs proprioception. It is also the main indicator of problems with the dental apparatus.

It is possible to release a spasm in these muscles by firm digital pressure applied from the insertions toward the origins. You don't get much visible shortening, but the underlying muscle mass does get some effective shortening by means of digital pressure when the fingers of both hands are pushing toward the central mass of the muscle.

A rather unusual approach to releasing masseter and pterygoid spasm involves nothing more than gentle massage of the muscle unit between an intraoral finger of one hand versus an extraoral finger of the other hand. Imagine all of those rays of healing Qi flowing out of those fingertips.

Far Out Stuff
Sooner or later, one meets therapies and therapists that seem to defy scientific facts as we presently know or accept them. I do not understand a lot of these techniques, and I will report only a few of them. Students should approach these ideas with an open mind. One thing that I have learned in 20 yr is that there is little new under the sun: not much is new or unique. Therapy in this whole general area seems to undergo cycles where an older idea is rediscovered and possibly greatly enhanced by the application of newer technology that has only become available the second time around.

I always preferred cranial osteopathy, or cranial manipulation. A Brazilian Physical Therapist, Mariano Rocobado, was expert in this area; he gives continuing education courses around the country. Such operators get right in there and TOUCH their patients. That direct physical contact between clinician and patient is greatly downplayed in traditional therapy; it should not be underestimated as an effective therapeutic tool. Chiropractors enjoy occasional success with jaw manipulation, but only occasional success. A lot of that success is basically due to the placebo effect that comes from just touching the patient and establishing a caring mannerism. When it comes to feeling the movement of the cranial bones in response to the circulation of CSF, I must admit I can't feel a thing and have an equally hard time envisioning any physical motion of matured sutures in the cranium. When it comes to applying pressures to re-align the abnormal relation of cranial bones by digital pressures, I just remember how solid that old skull is and chalk that up to salesmanship.

Applied kinesiology, or dental kinesiology is another fringe area that probably will grow. There is something there. George Eversaul linked applied kinesiology with nutritional factors; there may be some interesting associations between somatic problems in general, and faulty nutrition. The key seems to be the personal interests of the clinician in his patients, and that they all enjoyed the luxury of the laying-on of hands. Maybe patients wanted to believe most of all.

If we (dentists and orthodontists) learn the basics and apply them, we have a lot to offer in the area of head pain. Keep an open mind and study different ideas. You will learn to pick out what you are comfortable with after a period of review and apply what you feel most comfortable with in treating your patients.

Deluze_C; Vischer TL (1993) EAP in Fibromyalgia: Reply. BMJ Feb 6 306(6874):393-393. Hop Cantonal Geneva, Dept Phys Med & Rehab, CH 1211 Geneva 4, Switzerland.

Harman_JC (1994) The Effects of AP on the Performance of Horses. Equine Athlete 1993 Nov-Dec 6(6):22-25. C Harman, Harmanny Equine Clin, POB 193, Orlean, VA 22128. High athletic performance is directly related to optimal musculoskeletal function. For optimal performance, horses must be free from neck and back pain. Saddle-induced pain (from poor fit or improper positioning) is a factor in >90% of cases of back pain. Contraction of the "lower ring of muscles" (R. abdominis, Iloipsoas, T. fasciae latae and Quadriceps (all protractor muscles of the hind limbs) raises the back but only if the L. dorsi can relax. For optimal use of the back, the L. dorsi should be free of pain, otherwise it will not relax and the back will be "splinted" (dorsiflexed). AP (1-4 sessions) successfully restored performance in >85% of horses presented with a history of poor performance.

Ivanichev_GA (1991) [Combined treatment of myodystonic pain syndromes by manual therapy and AP]. Zh Nevropatol Psikhiatr Im S S Korsakova 91(4):37-40. Combination of manual therapy (++post-isometric relaxation) and AP to treat myodystonic syndromes is based from the standpoint of realization of the neurophysiological components of the pathogenesis of myofascicular hypertonus. The controlled afferent flow created by ++post-isometric relaxation and AP exerts a varying effect on the structural and functional levels of the nervous system. The therapeutic effect of manual therapy is realized at the special segmental level, that of AP with participation of the suprasegmental systems.

Lewis_PJ (1993) EAP in Fibromyalgia. BMJ Feb 6;306(6874):393-393. On Pk Med Ctr, Carrara, Qld 4211, Australia.