How To Make Percussion Truly Therapeutic

April 10, 2024

The use of therapeutic percussion/vibration to address pain and movement limitation has a long history, from manual percussion in traditional modalities like Thai or Shiatsu to more recent use of “massage guns” by manual therapists.

I began incorporating therapeutic percussion into our Coaching The Body® modality several years ago as an experiment to determine how it could augment our approach to trigger point therapy. While we were impressed with its ability to speed treatment, we were not happy with the tools available at the time, and ended up developing our own, the Muscle Liberator™.

Since that time, extensive clinical experience has convinced us that properly used, vibration tools can powerfully augment trigger point work Since that time, extensive clinical experience has shown us that properly used, vibration tools can powerfully augment trigger point work - but it demands a very different approach than the usual "vibrate where it hurts".

The typical broadly applied, non-specific, “meat tenderizer” use of percussion in areas where the pain is felt  may provide symptomatic relief for a time, but will not create lasting change. Tools aren’t magic – they are only as effective as the underlying understanding of the practitioner allows them to be.

In this article, I'll cover some ways in which you can make therapeutic percussion far more specific and targeted, so that it becomes an effective technique for eliminating pain at the source.

The first key is working the right muscles in the optimal order - easier to describe than it is to do. Proper analysis is one of the more difficult tasks facing trigger point therapists, and this lack of sophisticated analysis has limited the adoption of trigger point therapy in the past. More about this in a bit.

The second major key is understanding how to use vibration to enhance neuroplasticity.

Vibration tools are unrivaled in their ability to provide neurological distraction during movement, allowing taut fibers to normalize without the usual protective guarding that is triggered by techniques that mistakenly attempt to "break up adhesions" and cause too much discomfort.

The CTB Treatment Cycle is an approach that we have developed and use with modifications on each individual muscle. It uses distraction, feedback, compression, vibration and contract/relax and movement to encourage the brain to allow muscles to move again without invoking the protective response. We have found that using vibration within the treatment cycle makes it hugely more effective, and you can see a vivid example of this in the treatment video accompanying this article.

Finding The True Source

Myofascial trigger points, not injury or disease, have been shown to be responsible for the majority of pain complaints in several formal and informal studies. Even in cases in which tissue damage or inflammation is present, trigger points are a useful target for treatment, due to their role in providing peripheral nociceptive input to the central nervous system, fostering upregulation and protective muscle splinting.

Many practitioners make the mistake of identifying hard, taut bands in muscle as “scar tissue” or adhesions. In most cases, these areas are actually taut fibers containing trigger points. This is easy to verify in practice - scar tissue can’t be softened in minutes, but taut fibers can be released quickly via the use of appropriate techniques.

Trigger point theory has shown us that it’s generally a mistake to “rub where it hurts” to have a lasting impact on pain, because the vast majority of muscles with trigger points refer pain to an area well removed from the location of the trigger point.  

For example, pain over  the anterior deltoid is a very common complaint. While it’s tempting use a massage gun in the front of your shoulder where you feel the pain, you will probably find that the benefit is short-lived if that’s where you stop.

There are 13 muscles that refer pain to the front of the shoulder, including local referral from the anterior deltoid itself. However, the deltoid, even in the presence of painful taut bands, is not the most likely origin of this sort of pain, which often occurs without any obvious stress or injury in the deltoid.

The Hidden Referral Network

So why then would the deltoid develop taut fibers and tenderness if it isn’t under unusual stress? To understand this, you have to be familiar with satellite referral.

When a muscle’s fibers sit under the referral zone of another muscle, it can develop dysfunction itself, in a kind of chain reaction. This phenomenon was conceived and explored to an extent by Travell and Simons, but in their decades-long effort to establish the foundation of trigger point ideas they were never able to fully flesh it out. Sadly, in the most current 1-volume revision by other authors, satellite referral has been relegated to the dustbin, lumped in with other “associated muscles”.

In our development of the Coaching The Body® modality, we have found that satellite referral plays a much greater role than its marginal coverage would suggest. Satellite referral chains occur consistently throughout the body, and set up a confusing, hidden network of causality that few practitioners are aware of. We have found satellite referral to be a reliable model that reveals the true source of many common pain patterns.

In the anterior shoulder example, there are several commonly involved muscles that refer over the anterior deltoid and could set it up with taut fibers and tenderness. The scalenes, infraspinatus, clavicular pectoralis major and pectoralis minor are all frequent sources of inbound referral to the deltoid.

In the video accompanying this article, I show how therapeutic percussion powerfully accelerates my ability to release the clavicular branch of the pectoralis major, a major contributor to anterior shoulder pain.

The satellite referral chain often extends beyond a single step. For example, infraspinatus can itself be a target of satellite referral from low trapezius and serratus anterior, both important scapular stabilizers. The intersection of functional and satellite referral relationships is where the secrets lie in understanding the true origins of pain symptoms.

The infraspinatus can be a satellite referral target of several other muscles, including the iliocostalis, which is sensitive to lateral asymmetry due to a short leg or hemipelvis.

Treating Functional Units

Functionally related muscles tend to become dysfunctional together – both agonists and antagonists. There is a particularly problematic case of this with subscapularis and infraspinatus, which are not only functional antagonists, but subscapularis also refers directly over infraspinatus. Their close functional relationship alone makes them likely to propagate dysfunction in each other, but this is greatly potentiated by satellite referral.  

A complex web of referral and functional relationships exists in the shoulder and other parts of the body, making the task of finding the true source of shoulder pain far more nuanced than the simplistic trigger point idea that “Muscle A causes Pain B”. We want our practitioners to have a high rate of success. So we have developed regional pain protocols for both bodywork and self-care to ensure that you visit all of the muscles that are likely contributors in an optimal order, and you know what decisions you need to make to stay focused on the most important and relevant areas.

The CTB core shoulder protocol first establishes balance between the functionally opposed muscles that stabilize the scapula. Normalizing position at rest, for example eliminating excess protraction and restoring proper scapular rotation, lowers chronic stresses due to abnormal resting lengths on these muscles which tend to cause regional myofascial pain syndromes. When muscles develop extensive trigger points, embedded taut fibers will tend to keep certain muscles in a shortened position. As Leon Chaitow suggested, the central nervous system can actually exploit this property of trigger points to add extra stability in a joint that has chronically disturbed position or range.

Therapeutic Vibration Mechanisms of Action

As opposed to blindly using percussion where pain is felt, therapeutic percussion is an excellent treatment modality for unraveling the neurological protection that develops in these areas.

It’s mistaken to assume that the benefit percussion provides is mechanical disruption of “scar tissue and adhesions”, which are misconceptions about the nature of taut fibers caused by trigger points. There are two different mechanisms by which percussion can reduce taut fibers, dissolve trigger points and restore normal muscle length and range.

The first mechanism is micro-stretch of local fibers. We use custom-designed silicone heads with a narrow but elastic point of contact so that individual fiber bundles can be targeted without excessive discomfort or possibility of damage to delicate bones and tissues. This causes a rapid micro-stretch each time the head contacts compromised muscle fibers, which happens so quickly that it defeats the normal myotatic stretch response that will cause muscle fibers to protectively engage to resist stretch.

Stretching taut fibers at slower speeds will also tend to invoke the muscle’s referred pain patterns, sending the CNS a nociceptive stream and further encouraging a protective resistance to stretch. The lightning speed of each percussive strike when using a tool avoids this barrier.

Secondly, vibration tools are excellent sources of neurological distraction. The vibration causes a flood of regional sensation across groups of muscles, overwhelming the CNS with input and defeating the pain referral mechanism. This causes the CNS to allow muscles to release much more easily.

We often use therapeutic percussion while a muscle is under stretch, usually as part of a contract/relax cycle. The combination of micro- and macro-stretch along with powerful neurological distraction dramatically accelerates progress in comparison to other techniques involving simple stretch or compression.

How To Make Therapeutic Vibration Truly Effective

Even the fanciest tools are only effective if they are supported by an informed analysis and used on the right muscles at the right time.  

Over the last 20 years, we have been developing  Coaching The Body® Clinical Protocols for all the major pain areas. These protocols each represent hundreds of hours of research to discover the key muscles contributing to each pain area, along with their interlocking patterns of satellite referral and functional relationships.

Order of events is very important in designing treatments. It’s of little use to put a lot of time into full treatment of a muscle until some attention has been paid to the upstream muscles that might be feeding referral into it, and we must always ensure that we’re attending to its functional antagonists as well. This is nearly impossible to design on the fly during a session without some kind of framework.

The CTB protocols present a suggested order of treatment based on numerous factors, including the best treatment positions for each muscle and its functional unit and what key muscles should be covered first.

Most importantly,  our protocols include assessments and decision points that facilitate spending your time only in the most relevant areas, eliminating muscles that are less relevant. This allows the protocol to adapt dynamically to each client.

Armed with the right analysis, vibration can completely transform your practice. We offer a range of affordably priced remote study practitioner courses that provide you with a framework for resolving the most common pain conditions that you will see, including specifics on how to use therapeutic vibration for each muscle.

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Most pain is referred by trigger points in muscles, although most medical professionals don’t understand this, and are misled by the “illusion of injury”.

The truth is, most pain can be eliminated fully and efficiently by understanding its true origins using the Coaching The Body principles and techniques.

With my foundations online courses and membership, you’ll learn how to eliminate pain and be supported in our robust CTB Mastermind community.

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