Your Wondrous Nervous System

GB Publishing

Including Excursions into Evolution and Epigenetics

Gunnar Backstrom, PhD

(Front figure by Persian)

Copyright 2010 by Gunnar Backstrom GB Publishing, Sweden ISBN 978-91-975553-9-5

Preface

This book was written in order to provide facts and ideas about essential aspects of life. The number of pages was reduced to a minimum, and instead there are references to articles on the web, traceable by means of Google key words. I wish to thank Wikipedia Commons for their generous copyright policy as regards illustrations. In particular, thanks go to the artists who in turn have ceded their legal rights to Wikipedia for general use. New Harbinger Publications have kindly permitted me to include figures and case histories from Clair and Amber Davies: The Trigger Point Therapy Workbook. The television company MEZZO that provides us with operas, ballets, and concerts around the clock, have contributed two snapshots of their screens. As a reader, I have found that books generally contain much unnecessary numbering, which not only is redundant but also makes the text tiresome to read. This made me choose a minimalist system for internal references. Strictly speaking, the page number is the only coordinate required. In this book, p.62 means the figure on page 62. Only rarely are there more than one figure on a page, and anyway the risk of ambiguity is exceedingly small. For such cases, p.62 2 would point to the second figure on page 62. Another simplification is that figures are discussed in the current text, just before of after the figure.

I finally wish to thank Olof Zettervall, MD, my old friend from our Alma Mater, for his help in avoiding embarrassing medical mistakes. Gunnar Backstrom professor emeritus of physics

Contents

Introduction
The Peripheral Nervous System

1 3

The Autonomic Nervous System

Nervous Control in the Intestinal Channel

8 9

The Five Basic Senses

The Sense of Sight The Sense of Hearing The Sense of Taste The Sense of Smell The Sense of Touch

11 11 14 15 15 16

Receptors Limit Free Will

Superorganisms Mankind as a Superorganism

18 18 19

Amazing Accord between Senses

Piano Virtuosity Violin Virtuosity Theatrical Virtuosity

22 22 27 31

Ambiguous Pains
Pains Transferred to Leg and Foot Appendicitis Chest Pain Gall Stones

33 34 35 35 36

Curious Muscular Pains

What is a Trigger Point? A Short, Practical Handbook Massage Techniques Tender Trigger Points Neck Problems Front Side of the Neck Shoulder Blade Trigger Points Surprising Forearm Pains Confusing Abdominal Muscles Various Back Pains Could it be Hip or Knee? From Lower Leg to Foot Calf Muscles Cause Foot Pain Summary of Trigger Point Properties

38 39 42 43 46 47 48 49 50 52 53 55 56 57 59

How Does Referred Pain Arise?

Sternocleidomastoideus Muscle The Scalenus Conundrum Infraspinatus Pain Distribution Brachialis Muscle Extensor Carpi Radialis Brevis, Extensor Digitorum Adductor Longus and Brevis Muscles Extensors Digitorum Longus, Hallusis Longus Gastrocnemius and Soleus Muscles Summary of Referred Pain in Terms of Sensors

61 62 62 63 64 64 65 65 66 66

Strength Training
Electro-Stimulation

68 69

Energy Medicine
The Placebo Effect Tests of Medicines Tests of Surgical Interventions

72 75 76 77

Behavioral Therapies
Cognitive Behavioural Therapy Energy Psychology The Practice of Energy Psychology Physicists Reservations about Mumbo-Jumbo Musical Addressing Instead of Tapping? Preventive Medicine before Invasive Medicine

79 79 80 83 90 91 92

Biological Evolution
The Age of the Earth The Origin of Life Primitive Life The Core of Heritage

94 95 96 97 99

Evolution by Natural Selection

Natural Selection among Humans Cell Modified for a Purpose Stem Cells to Cure Serious Illnesses

103 105 108 109

Epigenetics
Epigenetic Effects in Humans

110 111

Consequences of Epigenetics
Far-Fetched Ideas Beliefs and Epigenetics Epigenetic Medicine The Importance of Nurturing Role of the Nervous System in Epigenetics Anatomy in Elementary School

113 113 114 115 117 118 121

Last Chapter
Why Are We Waiting? Having Had Enough

123 124 125

Sources Index

127

128

Introduction

Our body manages without much effort on our part. The most essential processes that keep us alive are automatic and cannot even be controlled by our conscious mind. After chewing the food we do not have to worry about transporting it through the intestinal canal. When we need rest, we generally feel sleepy. When the body requires food, we get hungry. Lack of water makes us thirsty, and so on. The skeletal muscles, on the other hand, are mostly governed by the will, which permits us to move around. The will originates in the brain (cerebral cortex, p.2 , Nat. Inst. for Aging), which sends orders to some 200 muscles on each side of the body. The brain is also the seat of our inner character, or personality. Much has been written about the structure of the brain. The functioning of this organ is at the center of current medical research, carried out by the use of advanced electromagnetic and radioactive techniques. There are frequent reports about the location of various emotions and capabilities. These deep insights are the results of daring projects, where our brain is used to understand the workings of other brains of similar design. Although the facts uncovered by this kind of research are of immense importance for surgery, the individual concerned has little control of specific parts of his brain. We only exploit its power to experience the surrounding world and to give instructions to our limbs. The tool for this activity is the peripheral nervous system, which is the main subject of this work.

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The image on the front cover shows the brain and the spinal cord, the latter being well protected by the vertebral column. The spine is shown from the side in p.3 (vsion), including the formal numbering of the vertebrae. The various parts of the brain and the spinal cord form the central nervous system (CNS).

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The Peripheral Nervous System

The schematic below (p.4 , Beckley Chiropractic) depicts the brain components and the spinal cord, situated inside the vertebral column. This central nervous system radiates nerve stems and fibres to various organs. The latter, secondary network constitutes the peripheral nervous system. The lines drawn to the right in the figure indicate, in a simplified scheme, the nervous connections to various organs. The eye, which has to transfer a rich stream of information, connects directly to the middle brain. The brain stem communicates with other organs inside the head. Organs below the uppermost rib, from the heart and lungs downwards, are controlled directly by nerves from the spinal cord.

-3-

-4-

Figure p.5 1 (Debivort) below is a cross section half-way up the spinal column, showing more details of the vertebra and the spinal cord, containing white and gray matter.

The picture beside (p.5 2, Grays) illustrates how the spinal cord radiates nerve stems to the left (similarly to the and right). The back (posterior) horn of the spinal cord receives ingoing (sensory) nerves. These nerves report on the state of the body and the outside world. Outgoing (motor) nerves leave the spinal

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cord towards the front (anterior) side. They send orders to muscles and other organs. As shown in figure p.5 1 the spinal cord contains a central core of gray matter, surrounded by white matter. The gray matter is responsible for the communication with the peripheral units. It resembles an H-shaped beam, which connects to the roots of the radiating nerves. The white matter consists of fine nerve fibers that send information up to the brain and also receive motor orders to peripheral organs. The number of nerve fibres contained in the white part of the spinal cord has been estimated to be as large as 10 million. The two nerve stems leave the spinal column through channels between the vertebrae as illustrated by figure p.6 (Debivort). Each of these stems serves its own half of the body, and both eventually branch out into fine nervous fibers.

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Sensory nerves radiate from the spine to various points on the skin. Such a sensor can send signals to the brain about the mechanical, chemical, and temperature status at the endpoint. The nervous sensors are organized into distinct superficial areas (dermatomes), one for each vertebra (Google: dermatome anatomy wiki). Figure p.7 below (Ralf Stephan) indicates the mapping of sensors on the skin. Numbness on a particular dermatome bears witness of damage to the corresponding part of the spine.

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The Autonomic Nervous System

The brain unloads some of its decisions to local sites that handle frequently occurring processes. An important example of this is digestion. When we are hungry the brain makes us produce saliva, which the tongue mixes with the food to achieve the first chemical breakdown. The resulting lump is swallowed and then transferred automatically to the stomach via the esophagus tube (p.8 1, Arcadian). During this process a flap (epiglottis) prevents food from diverting into the windpipe (larynx). The stomach contains an acid that is kept at the optimal temperature and pH-value for activating the enzymes used to break down proteins. The acidity also kills many undesirable micro organisms. Already at this stage of partial digestion some substances are absorbed by the wall of the stomach to enter the blood stream. When the processing in the stomach has come to an end, the food stuff is transferred to the -8-

duodenum (p.8 2, US Gov.), where it is mixed with juices from the gall bladder and the pancreas. At this stage, the acidity of the contents is decreased to neutral for optimal efficiency of the newly added enzymes. This stage of the process takes care of the fats. The absorption of remaining food nutrients continues in the small intestine, which is narrow but very long. The substances absorbed here are taken by the blood stream into the liver for removal of toxins and for further treatment. In the next, wider duct (colon) (p.9 , Dflock) water is absorbed and leaves waste substances, which are later expelled from the rectum.

Nervous Control in the Intestinal Channel

The above digestive mechanism illustrates that many processes take place automatically and in the right order. After leaving the mouth by the closing flap, a lump of food is driven through the esophagus tube without conscious effort on our part. The tube contains layers of ring-shaped and longitudinal muscles that are periodically contracted to move the material down into the stomach. There the acidity and temperature are measured and adjusted to assure optimal working conditions for the digestive juices. When the processing in the stomach is finished, the ring muscle at the lower end opens to move the almost liquid foodstuff to the -9-

duodenum, where acidity is again adjusted to favour the function of the various enzymes. During the remaining absorption, rhythmic muscular contraction of the guts serves to mix the contents and transport them along the nine meter long digestive canal. In summary, the digestive process constitutes a sophisticated chemical factory. In the above paragraphs we have seen examples of regulatory action in the human body. The blood stream is normally kept at a constant temperature of 36-37 C during sleep and 37-38 C when awake. Bacterial or viral infections may increase the body temperature by 2-3 C, which is commonly named fever. There are indications that fever is a symptom, rather than a disease, and that it helps conquering invading microbes. It also promotes production of white blood cells for the same purpose. Bacterial bone infections (osteomyelitis) are known not to involve fever and become chronic, taking an extremely long time to heal. A little-known fact is that cholesterol is produced in the liver and in several other organs of the body and that it is essential to the proper function of cell membranes. Although there are several internal sources of production, the body maintains the concentration of cholesterol in the blood at a constant level. It is virtually impossible to modify this concentration by dietary changes.

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The Five Basic Senses

By tradition we count five senses, viz. sight, hearing, smell, taste, and touch. A sixth sense is that of balance, which originates from a special organ in the inner ear. We also detect an imbalance, however, by sensing the gravitational forces on the body.

The Sense of Sight

The eye is the organ that transmits a picture into the central nervous system. Figure p.12 (Rhcastilhos) shows the components of the eye. Light passes through the transparent cornea into the pupil and then into the lens, which displays an image onto the retina, the crucial light-sensitive organ. The pupil is the opening corresponding to the aperture of a camera. The size of this aperture is governed by the iris, which contains both radial and ring-shaped muscular fibers. The diameter of this aperture is regulated by these fibers according to the light intensity reaching the retina. All the information about brightness and color is transmitted to the brain via the thick optic nerve, containing a million nerve fibers. The lens only yields a sharp image of objects that are at a certain distance from the eye. A young person normally sees things sharply if they are at a large distance, but the eye automatically adapts to a closer distance, more suitable for reading.

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The lens (partly hidden behind the iris in the following figure) (p.13 , Grays) is suspended by a number of fibers that connect it to a ring-shaped ciliary muscle, which contracts when we wish to read. The radial fibers then slacken and permit the lens to contract into a thicker shape that refracts the light to produce a sharp image on the retina. As we get older, the lens gradually turns stiffer, restricting such accommodation. Most of the time, the annular ciliary muscle remains in its relaxed state, which means that the lens is under persistent radial stress and grows thinner with age. This is probably the main cause of far-sightedness in old people, a problem which of course can be corrected by appropriate eyeglasses. - 12 -

The tension in the ciliary muscle is controlled via the peripheral nervous system. The impulse to read arises in the brain, and we do not have to think of the lens and its radial muscles in order to obtain a sharp image of a book page. The ccommodation is automatic, within certain limits. The size of the aperture in the iris screen is controlled by the amount of light that falls on the retina. The optic nerve reports this status to the brain, and the peripheral nervous system commands the muscles of the iris to increase or decrease the aperture accordingly. When we enter from the sunlight into a dark room everything looks dark at first, but the automatic process restores vision after a few minutes.

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The Sense of Hearing

Hearing depends on a specific organ, the ear, which converts sound waves to information that can be transmitted to the brain through the auditory nerve. Figure p.14 (Brockmann) shows the auditory canal and the eardrum (membrane), which detects the pressure vibrations of the air and makes them available to the auditory nerve by means of several mechanical devices, i.e. hammer, anvil, and stapes (stirrup).

On the nerve side there are very sophisticated acoustical canals. These semicircular canals detect rotary motion of the head, which helps us keep the balance. The ear is simpler than the eye in the sense that there is not much scope for adaptation, except that extreme outbreaks of sound (at a disco, for example) are automatically moderated by dedicated muscles behind the eardrum. - 14 -

Sound has intensity and frequency, and both of these properties can vary with time. The result may constitute a meaningful message that we call music. Since the two ears generally are exposed to different sound images, we can sense the direction from which the sound comes. This is termed stereo reception.

The Sense of Taste

The organs for sight and hearing register the physical properties of light and pressure, but taste is a reaction to the chemical environment in the mouth (p.8 1). The receptors of the basic tastes (sweet, salty, sour, and bitter) reside mostly on the tongue but are also present on other surfaces of the mouth. There have been suggestions that the burning sensation of alcohol is also a taste, and in Eastern countries strong spices merit this special mention. The mouth cavity also detects the texture (crispy, soft, etc.) of the food. These properties should rightly be classified under touch.

The Sense of Smell

Smell (olfaction) is similar to taste, in the sense that it detects chemical substances, in particular fumes and gases. The sensors for smell reside in the upper cavities of the nose (p.16 , US Fed. Gov.). Its surface consists of receptor cells sensitive to various kinds of chemical substances. Different cells detect a range of different molecules, and the brain receives a combined signal from all of these cells, which is transmitted to the brain stem (p.4 ) and analyzed by the cerebral cortex (p.2 ). It is this combination of signals that constitutes an odor or smell. There are thousands of variations in this combined property, which is an essential - 15 -

component in food quality.

Eating is accompanied by experiences of taste, texture and smell of the food. On the basis of this information we judge whether it is poisonous or safe to swallow. We also assess a more subjective quality, i.e. whether this nourishment is pleasant to consume. This evaluation expands into the vast subject of gastronomy.

The Sense of Touch

This sense is more complex and more general than the previous ones. By touching we usually mean putting a part of our body in contact with an object, either fluid or solid, sensing its position and surface structure. In medicine one now speaks of the somatic sense as whatever is reported by sensory receptors. Such receptors reside on the skin and on mucus membranes, in skeletal muscles, in bones and joints, as well as in internal organs and blood vessels. Information passes via nerves to the spinal cord (p.4 ) and from there to the brain. - 16 -

Each somatic sensor reacts to a specific state in the body. Thermo-receptors report the temperature at a specific point of the body. Mechanoreceptors are sensitive to forces on, and tensions in, the muscles. There are also chemo-receptors that transmit information about the chemical state in a region, such as acidity. Somatic sensing is usually almost instantaneous, but there are exceptions. If you stub a toe against a piece of furniture, for example, the painful signal is felt several seconds later. It has been proposed that there are special nerves that signal pain (nociception) to the central nervous system. This does not seem to be a necessary hypothesis. A thermo-receptor, for example, could report temperature on a wide scale, involving sensations of coldlukewarm-warm-hot-burning. A sensation of heat above a certain threshold would be interpreted by the brain as painful and potentially harmful. A similar scale may be proposed for mechanical and chemical sensations. The latter may involve traces of broken cells, which signal serious damage.

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Receptors Limit Free Will

Most people assume that we can decide what to do in the next moment, but are we really that free? Our senses report about the environment, which includes other living organisms, both plants and animals. We notice their existence by our senses: we can see, hear, smell, and touch them. Animals have nervous systems that are similar to those of humans; they notice that we exist and react to our presence. They may even taste us. Plants do not have nervous systems similar to those of animals, but some of them have devices to detect insects and to capture them by a snap. If attacked by animal predators trees secrete chemical substances that ward off the aggressor. Such effects are focused by a new field of research named plant neurobiology. We humans share space with all living organisms, and we interact more or less with all species. Each individual claims a minimum territory where it feels free to collect food, or simply avoids being threatened by others. To observe and being observed (and being reacted to) definitely puts restrictions on our will to move and to act.

Superorganisms
In the animal world there are creatures of an unusual kind. They may seem to be individual insects, but they are in fact socially - 18 -

organised to form colonies. The foremost example of these is provided by termites. Already in the tender age of larvae the termites are prepared to become workers (p.19 1, Stock), which will provide food (cellulose) for all the members of the colony. Others have especially forceful build that makes them soldiers, adequate for defending the nest from attacks by invaders, mostly ants. A third caste carries wings and could mature into reproductive insects. Normally the queen is the only member of the family that lays eggs, often thousands a day. The workers take care of the newborn larvae in a special nursery. The different castes in this society thus have dedicated tasks, required for the survival of the colony. Termite nests are partly subterranean but may rise to mounds several meters above ground, housing thousands of insects (p.19 2, Stock). Such a building created by the inhabitants may be regarded as part of the colony, since it is essential to the survival of the species.

Mankind as a Superorganism
The termite mound above may remind us of a Manhattan skyscraper, but this is only a superficial likeness. Man is not confined in a single building but connects with human life on a global scale. - 19 -

Wherever there is life, the effects of it are now noticed on a grand scale. It once began with overseas transports, involving robbery, but also fair trade. Seamen brought home china, spices and tea. The next step was the building of roads that connected cities and nations. Trucks, automobiles and coaches set this network in motion. Airplanes added speedy and long haul transportation. Foodstuff can now be sent to other continents the same day. All this are achievements of mankind. On a local scale man has created extensive pipe networks for the distribution of water and for the elimination of waste. Electric energy is made available in every building by a network of cables. Other cables connect people by telephone to facilitate trade. More recent innovations have established high-speed computer communication by optical fibres, radio, and satellites. The World Wide Web now makes information available over the entire globe. Photos regularly taken from cruising satellites keep a global record of environmental problems, such as floods, hurricanes, forest fires, and possible attacks by nuclear weapons. The sophisticated communications of today constitute a peripheral nervous system, created by mankind, for the service of the human organism. The latter may be regarded as consisting of man himself, including his domesticated animals, his machines, and devices for trade and communications (Stock, 1993, Metaman). This is now a world-wide system, analogous to a living organism. It digests raw materials and uses its arteries for circulating the resulting utilities, (metals, plastics, and foodstuff) to where they are most needed. Waste is finally excreted and partially reused. The various kinds of machines produced by man are essential parts of the superorganism, which is subject to evolution in much the same way as we observe among biological species. All products are tried and evaluated by individual users, but only a fraction of - 20 -

them survive several years on the market. Competing companies soon introduce improvements in some detail or other, and an Eastern country may suddenly offer a better model at a lower price. Successful products spread by individual decisions over all continents and virtually all countries. On the way, a product may specialise according to the needs and customs of the end users. The production of a complicated machine may require collaborative efforts between factories that have optimised a particular component, which can serve numerous end producers. The manufacture of a Toyota car, for example, actually requires contributions from a hundred associated companies. Individuals who are to build and maintain Metaman must be highly specialised by education and training. It would not do to establish a caste for a special position in society, which has been the tradition in India. That system does not take individual capabilities into account and hence fails to fully capitalise on intellectual resources. The Western alternative has been to make young people compete for jobs that are attractive on account of working conditions and income. The wealth of data collected daily by Metamans electronic activities is continuously interpreted by the central nervous system, which in this case is distributed over the entire globe. The response is generated by an enormous number of individuals in a more or less democratic order. They express their preferences mostly by innumerable individual acts of buying and selling. Longer-term decisions are reached by governments sensing the preferences of the national populations.

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Amazing Accord between Senses

A virtuoso musical rendering is truly admirable, if you become aware of the many roles played by the nervous system. In this process there is an intricate cooperation between various parts of the brain and peripheral nerves, ingoing as well as outgoing.

Piano Virtuosity
An accomplished pianist (p.22 , SVT1) keeps the entire musical score (p.25 ) in her mind while executing the piano part of a

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concert. There is no time for turning over the note papers, even if they were available during the concert. Nor would there be time for reading and interpreting all notes, usually thousands of them, when so many other details need attention. Several notes have to be played simultaneously, which often makes the piano a quartet or even a sextet. Piano music is executed by means of the keyboard (p.23 , Wikipedia), by striking the white and black keys as given by the symbolic stave shown just below. By tradition this is a system of five parallel lines. As a first step, the concert pianist must thus translate the notes into black and white piano keys. The main characteristic of a musical sound is its pitch (frequency, or vibrations per second), its duration, and loudness. The pitch of a note is indicated by its position on a stave. The above figure shows only a small part of the piano keyboard, comprising one octave, which starts with C and ends with the upper C1, which vibrates at twice the frequency of the first one. The basic pitch step in Western music is a half-tone, having a frequency (pitch) about 5.9 % higher than the preceding one. As we see from the lower part of the figure, there is no place on the stave for the black piano keys. For this reason a special sign ( ) has been introduced to shift a note a half-tone higher (sharp), as demonstrated by figure p.24 1 (Jono) below. For a piano score, only the modifier is necessary in order to indicate all tones on the scale. In spite of this, a special sign for a half-tone lower (flat) than a given white one has been used. There is also a sign for restoring a sharp or flat to a natural (white key). - 23 -

The following score (p.25 , Chopin) is a typical one for the piano, where there are no less than five flat signs at the beginning, valid for the entire stave. The number of flags on each note stem indicates the duration of the tone. An additional flag shortens the duration by one half. The pianist may control the loudness by the force he uses when striking the key, but there are also pedals (Ped. in p.25 ) to damp the sound or to make it last longer. The piano amateur is of course initially confused by all the symbols that modify tones on the five-line stave. From figure p.24 2 it is evident that a stave of seven lines and their interspaces could hold all the notes of the octave (Backstrom, 1981). Obviously, certain pairs of notes now fall on the same height on the stave, being identical on the piano. The following example (p.24 3) illustrates this principle, applied to a theme by Prokofieff, with C at the bottom line of the 5-line stave.

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- 25 -

The bottom line of the seven-line stave (p.24 3) is chosen to represent an A and the top one A1, one octave higher, but that is an entirely arbitrary decision. This alternative stave describes a melody in an intuitive way, because the vertical position directly indicates the pitch. After some training a person would be able to sing directly from such a score. Shifting the pattern of notes of a musical piece vertically on a seven-line stave changes each tone by the same number of halftones, which means that most of us still would hear the same melody. Some rare individuals have absolute (perfect) pitch, and hence they should notice a difference in expression. In order to enjoy music one must at least have a sense (and memory) of relative pitch, since the emotional effect of music is created mostly by changes in pitch and duration. The rational arguments for the seven-line stave seem compelling, but every new generation of musicians learns the traditional system and then has no desire to part with it. Furthermore, the entire Western musical literature is written in the old way, and the conversion to a new system might seem appalling. This, however, would be an easy task for a computer. A professional pianist could play directly from a score like p.25 , but in the case of an opus that must be executed at high speed it would probably be preferable to learn it by heart. In fact, this seems to be the standard procedure. Then the piece first becomes stored in memory as an aural musical image (sounds), and the brain just orders the hands and the fingers to execute it accordingly. Playing the piano on the basis of an aural image involves extensive use of the nervous system. Motor nerves transmit the stimulus from the brain to the muscles responsible for moving the arms, hands and fingers. This is by no means a simple process, because it involves large-scale motion of the hands and smaller but highly accurate displacement of the fingers, alternating between - 26 -

white and black keys. The signals from sight, hearing, and touch receptors are essential to ensure the proper execution. A piano concert involving half an hour of rapid finger work is an unbelievable demonstration of the achievements of the human nervous system. This kind of virtuosity is of course only possessed by a minute part of the population, and it requires daily training starting from childhood. An extremely demanding task is to play a piece for two grand pianos, where the musicians have to execute a score while synchronizing accurately with the other pianist (p.27 ).

A pianist must always rely on an accomplished piano tuner, who arranges for each key to yield accurately the specified tone. After proper tuning by such a specialist the musician must trust his instrument, since he cannot correct a false tone.

Violin Virtuosity
A violinist may have to face a complicated score (p.30 , Paganini), but he mostly produces one tone at a time, occasionally two but more rarely three. On the other hand, he is entirely responsible for the tuning of his instrument, which he may even have to improve - 27 -

during a concert in response to local temperature change. The violin (p.28 , Sotakeit) has four strings (G, D, A, E). The violinist usually starts by making the A string sound in agreement with the other instruments in the orchestra. The E string can next be tuned by ear, and further adjustment may be made by sounding the A and E strings together, listening for the pleasant accord resulting from a pitch ratio of 3/2. A similar fine adjustment may be applied to the pairs D-A and G-D. Once the tension in the violin strings has been adjusted by pegs and fine tuners, it becomes possible to play the basic four tones, but all the others must be produced by fingering the strings on the board. To do so requires an extremely precise interaction between the finger muscles, which control the free length of the string, and the ear, which senses the pitch compared to the basic tones. The accomplished violinist can achieve this without exposing the listeners to a single false note. To play the violin, one can either draw the bow across the string (arco) or pluck it by a finger (pizzicato). One can use a variety of ways to modify the tone in the arco mode, foremost by the standard vibrato. This is a pulsating effect obtained by oscillating the fingertip that stops the string against the board. By lightly touching a string at half-length it is also possible to increase the pitch by one octave, changing the quality of the tone as well. - 28 -

The motion of the bow controls the duration of a tone as well as the modes legato, staccato, and spiccato, et cetera. The violinist employs several procedures to obtain the desired musical impression. Having his ear practically on top of the violin he may correct a small mistake in intonation before it becomes noticeable to the audience.

The violinists task (p.29 , Mezzo) may seem simpler than that of the pianist, if one only watches the execution. None of them can take the time to read the score (p.30 , Paganini) during the performance, but the difficulties are of a different kind. The pianist has to handle a larger number of notes, but the violinist must work continuously to obtain the correct pitch, which exacts extremely precise fingering. Both thus make the most remarkable use of their nervous systems.

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Theatrical Virtuosity
Mankind has always wished to communicate its social situation for the benefit of later generations. At an early stage of development this took the form of imitation, or simple reflection of the behaviour of others. The properties that could easily be imitated were facial expressions, voices and general body language. Although all this no doubt originated from the brain, it could only be made visible as effects of motor nerves.

The imitation of existing personalities evolved into narration of fictional interactions between persons, often based on real situations that some author had experienced. This resulted in a script corresponding closely to the score that a musician has to interpret. - 31 -

The resulting theatrical performance would be based on a printed account to be executed on the stage or in front of a camera. The presentation of a drama by a film is superior in the sense that each scene can be brought to perfection, and that all viewers come equally close to the leading actor (p.31 , Hedebyborna, SVT1). Pursuing the analogy between the actor and the musician we may note that the basic script, be it a novel or a theatrical drama, can hardly be consulted during the performance. The actor thus has to store all the details of expression in memory and concentrate entirely on the presentation. The instrument available to the actor is his whole body, with its two hundred skeleton muscles on each side. Of course, the facial muscles and the voice are of primary importance for expressing emotions, but the limbs also contribute significantly to the body language. The other actors on the stage complete the orchestra.

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Ambiguous Pains

Although there are many examples of unbelievable accuracy of our senses, there are also situations where the nervous system cannot be trusted. One of these occurs as illustrated by the following crosssections of the lower end of the spinal column (p.33 , Debivort). The left part shows the normal state of a vertebra, where the spinal cord and the nerve roots are exposed by a cut through the protective membrane. The disc separating the vertebrae has a strong annulus around the pulpous matter inside. As a result of excessive load on the spine this annulus may break (figure to the right), leading to the extrusion of the soft interior of the disc. The resulting pressure disturbs the somatic nerve and causes severe pain.

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Pains Transferred to Leg and Foot

The following picture (p.34 , Edave) shows a scan by magnetic resonance imaging (MRI), where a disc clearly protrudes to deform the passing nerve stem. This irritates a close-by nerve root and may cause violent pain, (sciatica), in the lower part of the spine. This is, however, not the only consequence of the defect. In most cases a dislocated disc also sends pain along the leg (on the same side) all the way down to the foot. This occurs because the injured nerve stem contains a bunch of sensory fibers that continue downwards to the lower end of the body. Even if the nerve stem is pinched in the lower part of the vertebral column, the brain interprets the signal as arising from the distant ends of the nerve fibers located in the leg or the foot. This is the best-known example of referred pain. The sciatic nerve stem can also be irritated by events at lower sites of the body. On its way through the region of the hip the stem passes close-by horizontal muscles, and in some individuals it may even penetrate the piriformis muscle. In this region it may hence be exposed to forces that would be registered by the brain as a sciatic ailment. Carrying a thick wallet in the back pocket is another classical cause of such pain.

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Appendicitis
Appendicitis is an inflammation of the appendix (p.35 1, US Publ. Dom.), a minute organ attached to the beginning of the colon. It is the most common cause of severe bowel pain. In the initial stage of the inflammation, the pain is not centered on the appendix, but is felt in the region of the navel. This is another example of the occasional inaccuracy of the central nervous system in interpreting somatic sensor signals. As the inflammation progresses there will be persistent pain in appendix region as well.

Chest Pain
There is a particular form of pain (angina pectoris) that signals lack of oxygen in the heart muscles, a gentle forerunner of a heart attack. It is recognised as a burning or strangling sensation across most of the upper part of the chest. In the picture to the left (p.35 2, JHeuser) the most intense pain has been indicated by a darker hue and this part obviously starts above the heart and extends over a much larger area. In many cases it may even reach out into the region of the jaw and

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into the left arm. This is additional evidence of pain transferred from an injured organ to a distant location.

Gall Stones
The gallbladder is lodged in the liver, as shown in p.36 (Wikipedia). The liver produces bile, which neutralises the partly digested food entering the duodenum (p.8 2) and prepares fatty substances for further chemical treatment. Bile enters the intestinal tube directly from the liver but also from the gallbladder, which stores bile for situations when a large quantity must be urgently injected. If the gall bladder has not been frequently emptied, the bile eventually stalls and begins to crystallize into blocks similar to amber. These objects are constantly pushed by newly formed bile, and a large stone may happen to get stuck at the end of the common bile duct. This event is signalled by acute pain and may often cause nausea and vomiting. One could expect that the pain from a trapped gall stone would be sensed as coming from the exit of the bile duct, but that is not always the case. The pain may also radiate towards the right shoulder, and the author has visited three emergency rooms with these symptoms (in three different cities, including Mountain View, CA), and the physicians were unable to recognize this ailment. - 36 -

My symptoms may not have been the most typical ones, but they are nevertheless fully described on the web. The doctors were content, however, to diagnose it as a possible heart problem. All of these facts indicate that the brain locates pain at the sensor end of a nerve fiber, even if the stimulation occurs at a different point along the line. The human body has millions of nerve fibers, and the distribution of them may be somewhat unique to each individual. Hence it is not easy to find detailed evidence of how this happens. As we shall see in the next chapter, however, there are numerous reports of referred pain that everyone may experience first-hand.

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Curious Muscular Pains

Much has been written over the last century about muscular pain, which is estimated to be responsible for most of the suffering of human beings. The numerous medical reports on this subject have been summarised and analysed in two impressive volumes (Simons, Travell, and Simons 1999), comprising nearly 2000 pages (p.38 ). This careful work was pioneered and mostly completed by Janet Travell, MD, who was the White House physician during the Kennedy and Johnson administrations. This admirable treatise is clear and very well written, but it is mainly addressed to the medical profession. In spite of this, these basic books have not been seriously discussed by physicians. The reason could be that doctors in general do not believe in trigger points, which is the central object discussed. In fact, this term may not have been wisely chosen, since it makes you think about the Wild West and the associated weapon romanticism. In addition, physicians prefer to prescribe pills and use high-tech apparatus, rather than their hands, to remove pain centres. The handiwork is left to the therapist caste. Possibly much of the information on trigger points is also too recent to have made its way into the curricula of medical education. - 38 -

What is a Trigger Point?

A trigger point (TrP) can occur in any of our 400 skeleton muscles. It can be overstrained by occasional or repetitive load, with the result that a small region of the muscle fails to relax after being used. This nodule or contraction knot may be as large as a pea but often much smaller. An observable knot is the combined effect of local contraction and swelling of individual muscle fibers, as indicated in p.39 , (Davies). The main signature of a trigger point is that it is very tender to the pressure of a knuckle. The swelling may occasionally be large enough to be detected by the touch. An indirect effect of a TrP is stiffness in the whole muscle, or at least in a taut band along the muscle. Such a large-scale defect is easily felt when palpating the muscle. The patient is also aware of the ensuing reduced range of motion. This state may last for months or years, with stiffness as the only symptom clearly noticed. This is referred to as a latent TrP. An active trigger point not only brings stiffness, but also referred pain, often very intense, to an area close to the nodule or at some distance from it. The examples of referred pain discussed in the preceding section give some clues about how this transported pain may come about. We shall return to this question later. The patient himself easily recognises a trigger point by the intense pain he feels when it is pressed. The necessary force may be exerted by a physician, but the pain remains subjective. Thus it could just be a product of imagination. There are, however, objective observations that confirm the existence of a TrP. - 39 -

The most direct detection of a nodule is to probe it with the needle of a syringe. It then appears to be an object that is small and so hard that it tends to bounce off the needle. This observation is frequent when trying to inject TrPs with an anaesthetic prior to treatment by cooling or stretching. A therapist having some experience in this field can often identify a TrP by the swelling associated with it. This assumes, however, that the nodule is not deep inside the muscle. He may also notice a stiff band along that particular muscle. An electron microscope was employed to investigate the gracilis muscle from a dog, having exhibited signs of tender knots. In the picture beside (p.40 , Davies) one can clearly see a TrP between the

white arrows. The detailed structure of the surrounding muscle is also visible. Trigger points have also been detected using an ordinary optical (light) microscope. The samples were then stained by certain chemical substances that help to increase the contrast between parts of - 40 -

different structure or composition. One group of researchers applied these techniques to recently diseased patients that had palpable nodules in the gluteus medius muscle and found clearly visible knots under the microscope. There have been extensive works to detect muscle knots by needle electro-myography. This technique involves measuring the electrical voltage by needles introduced into the muscle. Nodules confirmed from the outside were shown to emit signals in the micro-volts range. Disturbing the muscle by a needle, however, does not seem to be a satisfactory diagnostic method. The same may be said of high-resolution ultrasound imaging, which irritates the muscle. It is well known that muscle knots are associated with an elevated temperature on the surface of the skin (hot spots). Thermography by infrared radiation proved to be the most successful procedure, but the results are still not entirely convincing signatures of a TrP. Magnetic resonance imaging (MRI) would seem to be eminently suited for diagnosing muscle knots. High-resolution versions of this method are now available and have been utilised in many scientific works, but so far no studies of muscle nodules have been reported. In summary, the most satisfactory confirmation of TrPs so far is by microscopic examination of slices taken from organisms recently diseased. In living patients one can observe a nodule by probing with a needle. Other methods for confirming the existence of such objects are less convincing. The extreme tenderness of a nodule may, however, be confirmed repeatedly by the physician by observing the reaction of the patient. Another convincing fact is that the TrP with its associated pain and dysfunction may be removed by direct treatment of the knot, as we shall see later.

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A Short, Practical Handbook

Anyone who has seen the standard work by Simons et al. (1999) will be looking for a popular and down-to-earth guide. Fortunately there is such an alternative (p.42 ). Clair Davies was a successful piano tuner, who found that his profession left him with an extremely sore back, so painful that he had to abandon his vocation for good, while his services were still in high demand. Climbing under and over grand pianos is an exhausting occupation. He consulted a massage therapist that put him on the right track, but she moved from his region before he was completely cured. He had occasion, however, to notice her impressive reference literature, viz. the two volumes by Travell and Simons. His only option was to start studying these books himself, and he later joined the Utah College of Massage Therapy to acquire formal education. During the classes he had occasion to relieve some of his fellow students from pains they had suffered for a long time. He soon expanded his consulting services to previous colleagues in the piano tuning business. During the last years of his life he wrote the book shown beside. Apart from explaining the nature of trigger points in everyday language, he added solid advice about treatment. He first pointed out that pain killers only mask the problem and hide the warning signal that something is wrong. One must acknowledge the pain and look for the cause of it. - 42 -

He noted that the treatments suggested by Simon et al. were strictly clinical and could hardly be carried out by the patient on his own. The instinct of the piano tuner made Davies prefer a more practical approach, taking advantage of appropriate tools to facilitate self-applied therapy.

Massage Techniques
Davies introduced a massage procedure that anyone can carry out without access to complicated medical instruments. The principle is to apply a series of short, deep strokes over the tender nodule, in order to move blood and lymph that has been stalling in this area. This type of massage may be carried out using finger tips or knuckles, but this could in turn cause damage to those parts. There are tricks for supporting one hand by the other one to reduce such risks. The best is, however, to employ simple mechanical tools to exert the force necessary. A tennis or hard rubber ball is efficient if supported by the floor or a wall. For work on the back side of the body there is a special, curved tool, called the Thera Cane. The massage should not last more than twenty seconds, but it must be repeated several times a day. The goal is not to remove the trigger point, but just to assist the body in doing its repair. The following two figures (p.44 , p.45 , Mikael Hggstrm) show the major skeleton muscles.

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Tender Trigger Points

The figure below (p.46 , Davies) shows a particularly difficult pair of muscles named sternocleidomastoideus. They both have their origin in the mastoideus, the bony node behind the ear. One branch goes to the collar bone (clavicle), the other to the breast bone (sternum). Skeleton muscles are symmetric, so there is a corresponding group on the other side of the neck. The picture shows possible locations of trigger points in the muscle connected to the breastbone. Such points hurt violently when pressed. If they are active they also send referred pain to the regions shown by the areas shadowed by diagonal lines. Thus referred pain might occur at the top of the scull, over the eye, behind the ear and in some parts of the jaw. The referred pain occurs on the same side of the body as the trigger point. These muscles are frequently overstrained, and the following history (from Davis&Davies) describes how dramatically these trigger points can act. Kate, age fifty-one, was a case that illustrates the unexpected effects that sternocleidomastoid trigger points can have, and the dramatic and swift relief that can occur with appropriate treatment. Shed lived with pain in the jaws since the age of nine, when shed had several teeth removed to compensate for a small jaw. She also had frequent headaches and pain deep in her left ear. - 46 -

One day, while reading an article about myofascial pain that suggested neck muscles as the source of many mysterious symptoms, she began feeling these muscles with her hand. She was startled to find a big knot on the left side of her neck that she had not realized was there she said it felt just like an egg. While she was massaging her muscle, she experienced a relief in her jaw that was so sudden and intense that it frightened her. The side of her neck felt like it was expanding like a balloon. She ran to look at it in the bathroom mirror, but she could not see any swelling or anything else wrong. Then she noticed the pain in her ear and jaws was gone and her bite felt different. Her jaw felt like it had shifted position. Her dentist, after inspecting the change, told Kate that her jaw dysfunction had somehow resolved itself and she now had a proper bite. The astonishing aspect of this case is how long-lived and serious the consequences of trigger point can be.

Neck Problems
The levator scapulae muscles shown below (p.47 ) connect the vertebral column with the shoulder blade (scapulae) and serve to elevate the latter. Tender knots frequently occur in this area, as witnessed by this case history. Tony, age thirty-three, had typical levator scapulae trouble. Hed had constant pain and stiffness in the right side of his neck ever since a fender bender three months earlier and couldnt turn his head to the right at all. His insurance was paying for physical therapy, but the stretching and traction only seemed to be making his pains worse. Electrostimulation helped but it didnt last. - 47 -

Massage to Tonys levator scapulae muscles cut through his pain at once and gave him his first relief. He was shown various ways to do the massage himself, which he was encouraged to do several times a day. Within a week, his pain was gone. In three weeks, he could turn his head again with a full range of motion. Innocent factors may cause problems with these muscles, such as sleeping on your side without proper support for your head, or typing while looking at your original text. Holding your phone clamped between your head and shoulder is also risky, as well as having backpacks and purses suspended by shoulder straps.

Front Side of the Neck

There is a group of muscles, the scalenes, which connect the vertebral column with the upper ribs. As demonstrated by the following series of figures (p.48 ), knots on these muscles may cause a curious distribution of referred pain. It extends far over the front side of the body, but also reaches the other side. Hence, massage on the aching area would have no effect at all.

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The following case histories are cited from Davies&Davies. Hong Sun, age thirty-one and a ballet dancer, complained of constant ache in his upper back at the inner edge of his left shoulder blade. It felt good to reach over his shoulder and massage the place with his fingers, but it didnt stop the pain. He had had the pain for several years. Amy, age seventeen, had been a serious student of the cello, but shed to quit playing because of weakness and numbness in her shoulders, arms, and hands. Her parents believed the problem might be related to an accident in the swimming pool that had strained her neck. Thousands of dollars of medical tests had turned up nothing. The cure of these ailments was of course simple once the tender nodules had been found.

Shoulder Blade Trigger Points

The infraspinatus (p.49 , below) is perhaps the most afflicted muscle of the human body. Its knots yield referred pain in the most unexpected place on the reverse side of the arm! Kim was a thirty-two-year-old professional tennis coach who had lived with pain in both shoulders ever since she began playing tennis as a child. Diagnosed with rotator cuff tendonitis, Kim had had numerous steroid injections and was going for physical therapy almost weekly. Despite the treatments, pain kept her from playing most of the time. She was very concerned that several of her young players were eveloping shoulder pain very similar to her own. I make them play through the pain just like we were told to do at their age, she - 49 -

said. Im afraid theyll end up as tennis cripples like me, but I do not know what else to do. They want to play so badly. After a massage therapist had shown Kim how to self-treat her shoulder with a tennis ball against the wall, she became free of shoulder pain for the first time since the age of fourteen. She felt that the best part of the new trick was that she could pass it on to her students.

Surprising Forearm Pains

Problems with forearms and hands are very common, since they are often overstrained in everyday toils. We shall see that it is not obvious where to apply massage. Here is another case from Davies&Davies. Libby, age forty, suffered with chronic pain in her shoulders, arms, and hands. In addition, her fingers felt numb, stiff and swollen. When she went out walking on her lunch hour, the swelling in her hands became so uncomfortable that she often held them up in the air for relief. Her doctor had urgently recommended carpal tunnel surgery to arrest the condition before it got worse. He did not know whether it would help her shoulder pain but said it was worth a try. She felt like she was in a corner and didnt know what else to do but to go through with it. On the recommendation of a friend, Libby decided to try triggerpoint therapy before committing to surgery. Massage immediately decreased the pain in her shoulders and the numbness and swelling in her hands. After three massage sessions and some coaching she was able to continue massage herself. In six weeks, most of her symptoms were gone. Some of the pain in her forearms and hands tended to come back after working all day at the computer, but she was able to minimize it with the massage techniques she had learned. Libby was able to determine that although her job with an insurance company had made all her symptoms worse, her problems actually had started with whiplash shed suffered in an auto accident three years earlier. Triggerpoints created in her scalenes (p.48 ) by the accident accounted - 50 -

directly for many of the symptoms and had predisposed muscles in her forearms to trigger points on their own. The brachialis muscle (p.51 1) lies under the better-known biceps, and they actually share the work of bending the elbow. There are two common locations for knots on this muscle, but the referred pain is nowhere near the origin, but occurs mainly in the thumb.

In the case of knots in the extensor digitorum (p.51 2) there may be some pain close to the upper attachment of the muscle, but surprisingly the middle fingers also ache. Neither of the pain areas responds to massage, but the nodules (black dots) do.

The extensor muscles serve to straighten the hand. The extensor carpi radialis brevis (p.52 1) and extensor carpi ulnaris (p.52 2, to the right) have similar functions. For both of them the referred pain is some 25 centimetres away from the trigger point. In neither case - 51 -

would it help to treat the aching area. Applying massage to the nodule (black) is what is required.

Confusing Abdominal Muscles

The psoas and iliacus form a muscle pair (iliopsoas) within the abdomen, connecting the vertebral column to the hip (p.53 ). The presence of trigger points (black dots) may cause unexpected pain in the lower back and also in the groin on the front side. Davies&Davies present the interesting case history below. Dawn, age thirty-nine, was a massage therapist and the owner of her own massage clinic, employing several other therapists. She also taught a daily aerobics class that included vigorous stair-climbing routines. To her great annoyance, the exercise that she depended on to maintain her health usually left her with low back pain. She also had pain and stiffness in her groin when she walked. She told a friend, a fellow therapist, about her concern. I know its classic repetitive strain, but no way am I going to give up aerobics. If I dont keep myself in shape, I balloon up like you

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wouldnt believe. I do lots of stretching, but it doesnt seem to be doing what it should.

During massage, her friend discovered that Dawns iliopsoas muscles, which did so much of the work in the stair-climbing routines, were as hard as rocks and hypersensitive to touch. Pressure on the trigger points actually reproduced her groin pain. The friend showed her a technique for

massaging her own iliopsoas. Within days, the pain in her low back and groin were gone. She was able to help a client with a related problem right away.

Various Back Pains

There are several muscles that could cause extreme pain if only slightly damaged by overload. One of them is the quadratus lumborum (p.54 1, below), which connects the bottom rib with the hip. Eileen, age forty-seven, had suffered spells of excruciating low back pain ever since hit by a car twenty years earlier. The pain extended downward into her left buttock and hip. Her problem was made worse by her job, - 53 -

which entailed standing most of the day on a concrete loading dock. Only an hour of standing made her back hurt so bad she could hardly keep her mind on her work. Sometimes she could not work, stand, or even sit upright. Her only relief came from lying down. I have had lots of chiropractic and physical therapy but, lordy, it just gives me more pain. I take all kinds of pills just too keep going. How else am I going to be able to work? Trigger points were found in Eileens longissimus and quadratus lumborum muscles on her left side, where she felt most of her pain. Three sessions of massage cut her pain by 75 percent. She subdued the rest of the pain with a tennis ball and a Thera Cain. Another muscle that often causes back pain is gluteus medius (p.54 2, below). The area of referred pain depends on where the trigger point is located. It may be as shown here, or it may be centered right on the spinal column. Duane, age thirty-nine, was totally incapacitated with intense low back pain after moving a heavy couch by himself. It was on the curb. I was afraid somebody else would get it if I took time to find help. Now he couldnt sleep because of the pain and he hadnt smiled for two days. The curve was gone from his lower back, his pelvis was locked in a forward thrust, and he could hardly walk. He was sure that hed done horrible damage to - 54 -

his spine. Hed been to the emergency room where hed been given muscle relaxants and a painkiller; hed been to the chiropractor twice. Nothing helped. Three days after deep massage to his buttocks and low back muscles, Duane was walking erect with very little pain. His hips were free and the curve had returned to his back. He was sleeping too. If my back starts hurting in the night, I just reach for the tennis ball and work on it right there under the covers, he said. Why didnt the doctor tell me about that?

Could it be Hip or Knee?

A pair of muscles, the adductor longus and brevis, attach the thighbone to the pubic bone. Taking overly long steps or keeping the legs far apart can create knots on these muscles. The resulting referred pain (shadowed) is often misread as problems in the hip or the knee. Beverly, age fifty-two, had to stop her early morning walks at the mall because of the intense pain she had begun to have deep in the right groin. On an X-ray, the cartilage in her hip appeared to be thin. She was told that, without an operation, her hip would only get worse and shed probably end up in a wheelchair. She was assured that a hip replacement was common now and that her assurance would pay for it.

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As a last resort before scheduling surgery, and at the urging of a friend, Beverly went to a massage therapist. She was sceptical that anything so trivial as massage could help such a serious condition, but her friend pointed out that she had nothing to loose. Horribly painful spots were found in Beverlys inner thighs. Pressure on the trigger points in her right leg sent pain to her hip that was just like the pain she got from walking. The therapist showed her how to massage her own thighs and arranged for two follow-up sessions. In three weeks, the deep pain in her hip was gone and she was able to resume her walking in the mall.

From Lower Leg to Foot

When walking it is essential to raise the foot after each step forward, in order not to drag it and trip over. One important muscle that contributes to this function is the tibialis anterior (p.56 ). Its pattern of referred pain is extraordinary. The pain in the big toe is reminiscent of gout, which is normally caused by deposition of urate crystals in the joints. The treatment is, however, completely different. Andy, age eighty, had chronic pain in his big toe. His toes also tended to catch on steps and on the edge of carpets, causing him to trip unexpectedly. He had almost fallen several times. Falling and breaking his hip was his greatest fear. So for safety he had begun using a cane. The doctor prescribed medicine for gout, though the tests hadnt strictly confirmed that gout was the problem. The medicine didnt seem to help, however, and Andys toe continued to hurt. Trigger points were discovered in the muscles of the front of Andys lower leg. Pressure on one particular spot reproduced the pain in his toe exactly. After the massage the pain was noticeably diminished. He found - 56 -

he was able to massage the spot himself with the rubber tip of his cane. With continued self-applied massage as needed, Andy stopped tripping over his own feet and his gout soon disappeared. A neighbouring muscle on the front side of the lower leg is extensor digitorum longus (p.57 ), which helps to raise the foot. The referred pain from the trigger point, indicated by the dot, occurs at the top of the foot on the same side. Ben, age forty-six, had constant pain in the top of his left foot and the lower part of his shin. His ankle was so weak that he had difficulty raising his foot. Any attempt to do so greatly increased the pain. The immediate problem was that he was unable to pull up with his foot to shift gears on his motorcycle. As a consequence, hed had to drop out early from a long-anticipated weekend tour with his motorcycle club. Triggerpoints were found in the front of Bens left lower leg, in muscles being overused in shifting gears. Tightness in the muscles caused pressure on the nerve that supplied motor impulses to the muscles, leaving them unable to make a strong voluntary contraction. Self-applied massage immediately stopped the pain in the top of his foot and over several weeks brought back the strength in the muscles.

Calf Muscles Cause Foot Pain

Trigger points in a strong pair of calf muscles (p.58 1, below) named gastrocnemius are known to provoke unexpected pain in the sole of the foot.

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April, age twenty-two, was to spend five marvelous weeks travelling around Europe after graduating from college. Unfortunately, during her first two days, she walked everywhere in shoes with two-inch platform heels and developed disabling pain in the arches of her feet. Every night in the hostels and hotels, she soaked her feet in hot water and gave them a good rub, but the next day, after walking only a short distance, the pain came back as bad as ever. She knew the high heels were bad for her feet, but it didnt seem to help much to change to low heels after the pain started. The pain actually seemed to get worse, and it was ruining her vacation. A guidebook suggested massaging her calves to get rid of her foot pain. It made no sense to April, but she tried it anyway out of desperation. Amazingly, it worked. She made time at night and in the morning to massage the backs of her legs and then to carefully stretch them. Her feet, legs and ankles responded by getting stronger with walking and climbing instead of reacting defensibly by developing trigger points. Within a few days, pain ceased to be a problem. The next example concerns the soleus muscle (p.58 2), which is partly covered by the gastrocnemius. A triggerpoint sends pain to the heel on the same side. Jeffrey, age fifty, lived in a pleasant neighbourhood near his job and enjoyed the walk to and from work, but he began to have sharp pain in his heels and had to go back to taking his car. The backs of his heels were extremely sensitive to touch, so much so that he had to hang his feet over the edge of his bed at night. At a medical clinic, he was told that his bone - 58 -

spurs were the cause of his pain and that surgery was the only solution. Massage to Jeffreys soleus muscles in the calves ended his heel pain. A final example of referred pain from afar is the flexor digitorum longus (p.59 ), a muscle that serves to press the foot against the ground. A knot in it creates pain in the forward half of the sole.

Summary of Trigger Point Properties

A contraction knot (nodule or TrP) generally is the result of occasional or repetitive overstraining of a muscle. The knot may be the size of a green pea or smaller, and it does not relax spontaneously. This object is recognised by an extreme tenderness to concentrated pressure, for instance by a knuckle or a finger tip. If the nodule is large enough and close to the skin the swelling may be identified by the touch. A secondary effect of its existence is stiffness in a larger part of the muscle, appearing to the touch as a taut band. This stiffness, and the resulting restricted mobility, is typical of a latent TrP. A triggerpoint may suddenly turn active, which means that it creates persistent referred pain, close to the TrP, or often at a considerable distance from it. In some cases, touching the TrP immediately reproduces the referred pain.

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A physician may easily probe the tender spot by means of a syringe to find a small object, so hard that it becomes difficult to penetrate with the needle. That is the most direct way of confirming the presence of TrP nodule. A muscular nodule is readily recognized by the patient, but doctors have systematically remained sceptical. The subject of triggerpoint therapy has surreptitiously been equalled to acupressure, which is completely wrong. The recently developed technique of high-resolution magnetic resonance imaging (MRI) would be well suited for studies of TrPs, but so far it does not seem to have been used for that purpose. The existence of TrPs has been confirmed by several methods, but the physiology of this object is still hypothetical. Known facts and medical intuition have led to the following model, reduced to its simplest terms. The muscle first contracts strongly to carry out work, but at the maximum tension fibers become damaged, so that a minute part of the muscle remains taut after the rest of the muscle has relaxed. This remaining mechanical tension impedes blood circulation and causes shortage of oxygen inside the nodule. The transport of waste products from the object is similarly impeded, with the result that the system cannot spontaneously unlock itself. Frequent short sessions of deep massage, however, can bring oxygen in and eliminate the waste products. The bodys own defence collaborates with repeated massage to eliminate the TrP completely.

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