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Trigger Point Grading

There is no standard or published grading system for trigger points. About the only system any one will find is grading from 1 to 4 based on the severity of the SUBJECTIVE response from the patient. The problem with this is that the grade is still SUBJECTIVE. Even with this minimal system who can say what the difference is between a 2 or 3 or between a 3 or 4? What if the patient has a high degree of tolerance for pain and only subjectively gives minimal responses? Is the trigger point there all the time? What about when the patient says they have no pain without your testing? Does that mean there are no trigger points there or are they only below the noticeable pain threshold? Regardless of how you cut it a SUBJECTIVE system is generally worthless where it counts - in a court of law.

The following system takes into account OBJECTIVE test results which are admissible in court as true evidence of the described test results. An OBJECTIVE test result is one which the patient is generally incapable of controlling or creating on a conscious level. A good example is a reflex reaction to the Patellar Tap (hammer strike). If the response is fast enough to be considered a reflex, instead of a patient initiated response, by an informed and trained observer ( a doctor) than this can be duplicated by another trained observer and is considered OBJECTIVE evidence. Another form of OBJECTIVE evidence is measurable changes in uncontrollable autonomic nervous system activity, i.e. increased respiration or heart rates.

The following system takes all the above into account. It deals with patient noticeable and non-noticeable pain, SUBJECTIVE and OBJECTIVE evidence and is admissible in court.

For any test results which do not have detailed and strict result criteria (as opposed to quantified and standardized tests like SLR or Kemp's tests) you can still use the tests, introduce their results into your SOAP notes and reports and have them acceptable to all that would review your records - even a judge. All you have to do is have a written definition of what your results mean in specific detail so that another reviewer (although they may not agree) will have to acknowledge your strictness and detail of application of the test, the specific results and their implications. If reporting OBJECTIVE evidence. List known and widely accepted evidence which is considered OBJECTIVE by the majority of the health care community (examples are listed above). Doing so in your reports and notes "objectifies" your findings.

Know these definitions:

Trigger Point Found on Examination

Moderate or firm pressure held for approximately 1 second which would usually not cause pain in the given spot of application may cause pain. The perception of pain MUST be communicated by the patient (ask the patient). The ability for the examiner to feel or find trigger points on his or her own has been shown by controlled clinical research to be fallible and unreliable. For it to be classified as a trigger point the primary criteria must be a change in the patient's perception of the pain (again, ask the patient) within approximately 10 to 45 seconds (generally reduced pain or centralization or from sharp to dull). If it doesn't, the pressure is either not directly on top of the trigger point or it is not a trigger point. A secondary criteria is the referred pattern of pain. This is not always present but the primary change is ALWAYS present. The referred pain may be distal, following specific patterns of referral or may be a halo (surrounding area by an inch or two) pain which reduces to a central point of pain.

Latent Trigger Points

Trigger points found on examination which are generally not consciously felt or perceived by the patient as anything more than a discomfort or tension or stiffness for a majority of the time under question unless exacerbated (aggravated) by some physical activity or what would be considered mild trauma (generally described as "at rest"). These are considered to be there all the time ready to be exacerbated but are below the level of pain perception.

Active Trigger Points

Trigger points found on examination which are consciously perceived by the patient as a pain even at rest even without activity or exacerbating trauma during a significant (generally 30% or more) amount of time during the time in question.

OBJECTIVE Signs of Trigger Points

There are two basic perceivable signs of OBJECTIVE evidence to the examiner. The first is the Jump Sign. The Jump Sign is any physical response in muscle tissue which occurs at the speed of a reflex. Even the slightest delay from reflex speed negates this sign. The second OBJECTIVE sign is a change in the autonomic nervous system activity. This is best observed as an increased respiration and/or increased pulse rate. Both will be found to slow as the trigger point dissipates (changes).

SUBJECTIVE Signs of Trigger Points

This is any physical reaction not at the speed of a reflex. This, also, includes the patient's description of the pain or discomfort felt upon the exerted pressure on the trigger point.

With these definitions in place the grading system is now both descriptive, precise and objective. The first question to be asked is how the patient perceives their condition during the majority of the time in question. This will determine a Latent or Active trigger point. Once that is done the scan and examination of trigger points will define it's specific grading number.

Latent trigger points are always rated as 1 or 2 regardless of the severity described by the patient upon compression of the trigger point. Active trigger points are always rated as 3 or 4 regardless of the severity described by the patient upon compression of the trigger point. Therefore, a rating of 2 describes trigger points which are not generally perceived by the patient as pain at rest but still exist below the conscious level of pain. A rating of 3 describes trigger points which cause perceptible pain and/or discomfort in the patient even at rest during a significant (30% or more) amount of the time in question.

A Latent Trigger Point which elicits an OBJECTIVE sign is classified as a 2 (describe it in your notes). However, a subjective scale described by the patient as a 5 or 6 or more on a scale from 0 to 10, with 10 being severe pain, can also be classified as a 2 for it's severity. Any description by the patient as 4 or less should be classified as 1. This now describes trigger points which are not generally perceived but which do occasionally flare up and do cause mild to severe pain upon examination. How long these trigger points have been there is subject to patient history and determines chronicity not grading.

An Active Trigger Point which elicits an OBJECTIVE sign is classified as a 4. Any trigger point without this OBJECTIVE evidence is classified as a 3 regardless of the severity described by the patient. By specifying this difference on OBJECTIVE signs this system now renders OBJECTIVE evidence upon testing, grading and where it counts - in court.

Some examples will be helpful.

The same pain is felt upon some activity every few months but usually doesn't hurt. Upon examination objective signs are found. Grade 2 because these are Latent Trigger Points not generally perceived during the time in question.

A dull ache has lingered for some time and causes discomfort or pain upon activity. Upon examination the patients states the pain is a "16" on the 0 to 10 scale but no objective signs are found. Grade 3 because the perception of pain or discomfort is there for a significant amount of the time in question but objective signs are not found.

A pain or ache is there 3 or 4 days a week for the past few months. Upon examination there is a reflex speed muscle contraction and the patient says it hurts at a 4 on the 0 to 10 scale. Grade 4 because it is perceived during a significant amount of the time in question and there is OBJECTIVE evidence present.

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Sample Trigger Point Grading

Patient worked in yard yesterday for 45 minutes. No trauma. Felt tight. Sat in hot tub for 30 minutes and relaxed the rest of the day. No pain all day. Next morning in your office with moderate back pain that started upon arising. You find no jump sign but notice faster breathing on a sore spot in the low back. - Grade 2 - No traumatic incident. More than 30% of time since yesterday but less than 3 days total time. Prior history suggest recurring response to minimal activity. Therefore, latent trigger point with objective sign.

  1. Same patient but waits 4 days before coming in. - Grade 4 - Total time of pain is more than 3 days. Therefore, considered an active trigger point.

  2. Same patient but felt snap while lifting a box. Stopped immediately then same rest of day as #1. Same pain and exam findings next day. - Grade 4 - Specific traumatic incident that could have caused injury. Rest of exam and history is the same. Considered latent TP currently increased to active status due to specific incident.

  3. Patient has history of recurring headaches 1 to 3 times per month. Recent job move has increased these to 2 to 3 times per week at the end of the day that last for 1 to 2 hours before they fade away with rest. No objective signs on examination. - Grade 1 - History shows less than 30% of total recent history (time per week) and no traumatic incident. No Objectives.

  4. Same patient waits a few months before coming in. Now headaches are 3 to 4 days a week but still only at the end of the work day. Patient takes NSAIDs and headache is gone within 45 minutes. Jump sign is found on cervical scanning. - Grade 4 - less than 1 hour per day times 3 or 4 days a week is less than 30% of the time. There is no traumatic incident. However, it is considered active because of the pharmaceutical intervention. Without that and if the stress of the job were every day, the pain would be there every day and for most of the time after it starts until the end of the day. Therefore more than 30% of the time.

  5. Same patient after 2 weeks of care. Pain is still there in the afternoon and NSAIDs are taken. However, there is on objective sign during scanning or treatment. - Grade 3 - Still active for timing but no objective signs indicates improvement. Therefore reduction in the number.

  6. Six weeks later the headaches are only 1 day a week and there are no objectives. - Grade 1 - Now latent trigger point history applies. Continues to show improvement.

  7. Patient can't move without pain. History is as patient #1 above. When TPs are scanned and tested the patient screams and states they can't stand the pain. On a scales of 0 to 10 the patients says it's at least a 16! No objectives are found on the scan or exam. - Grade 1 - The subjective complaint of pain by the patient has no bearing on the history or lack of objective evidence.

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