SaveYourself.ca helps you solve pain problems

last updated 11 days ago, Aug 23rd, 2010

[Editorial illustration of a back full of painful-looking red spots, with the caption: Are you plagued by muscle knots?]

Are you plagued by muscle knots?

Save Yourself from Trigger Points & Myofascial Pain Syndrome!

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Trigger points (also known as muscle knots) & myofascial pain syndrome, explained and discussed in great detail, including every imaginable self-treatment and therapy option for difficult cases

by Paul Ingraham MORE
close

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

 &  Tim Taylor, MD, www.PainReliefHome.net
illustrations by Paul Ingraham, Shayne Letain, Alexia Tryfon

Welcome to the most detailed and current guide to muscle pain available. This is not just a web page: it’s book-length. What are the controversies and myths about muscle pain? What works, what doesn’t, and why? This guide offers troubleshooting ideas for even the toughest cases — much more than the popular (but out-of-date) Trigger Point Therapy Workbook.1

Many people suffer from trigger point pain and myofascial pain — muscle knots. And yet advanced trigger point therapy is not rocket science!2 You just need a good selection of rational options — a bunch of creative tips, tricks, insights and perspectives, based on recent science and years of clinical experience.

Learning even a little about trigger points can solve more pain problems more easily than anything else I know of. If you have any problems with chronic muscle pain, if you have unexplained aching and stiffness … please keep reading!

About footnotes. There are many footnotes in this document. If you click on them, more information will “pop up” right in front of you. Try this one!3 The page will not reload, and you will not lose your place.

Trigger point therapy is not a miracle cure for chronic pain — but it’s close

Trigger point therapy isn’t “too good to be true” — it’s just ordinary good. It’s not miraculous or a cure for all pain.4 Good trigger point therapy can be hard to find, and it doesn’t always work.5 But it’s also an amazingly under-rated therapy and self-treatment has good potential to quickly, cheaply and safely help many common pain problems that don’t respond well — or at all — to anything else.

pro Physicians & therapists need to learn about trigger points too

This massive tutorial is written for both patients and professionals. It includes analysis of recent research that you won’t find in any text, crafted to suit any skill level.6 Footnotes add a optional layer of detail, and the pro badge marks advanced content.

Trigger points are much more clinically important than most health professionals realize,7 and body pain seems to be a growing problem.8 It is hard to imagine a more rewarding topic, with science showing a clear new path to helping people you probably couldn’t help before. Even if you already know myofascial pain syndrome, you will get new ideas here.

For beginners with average muscle pain — a typical case of nagging hip pain or back pain or neck pain — the advice given here may well seem almost miraculously useful. I get avalanches of email from readers thanking me for pointing out simple treatment options for such irritating problems. Many are stunned by the discovery that their chronic pain could have been treated easily all along.

For veterans who have already tried — and failed — to treat trigger points, this document is especially made for you. You need more advanced methods before giving up. There are more ideas and tips here than anywhere else I know of. This will get you as close to a cure as you can get; I can give you a fighting chance of at least reducing your pain more than ever before. And maybe that is a bit of a miracle.

Does your body feel like a toxic waste dump?

It may be more literally true than you realized! A muscle knot is a patch of polluted tissue: a nasty little cesspool of waste metabolites. No wonder they hurt, and no wonder they cause so many strange sensations: it’s more like being poisoned than being injured. Garden variety back pain is the best known symptom of the common muscle knot. However, knots also cause an astonishing array of other aches and pains, and misdiagnosis is common.


What exactly are muscle knots?

When you say that you have “muscle knots,” you are talking about myofascial trigger points.

There are no actual knots involved, of course. A trigger point (TrP) is a small patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp10). That small patch of knotted muscle cuts off its own blood supply, which irritates it even more — a vicious cycle called “metabolic crisis.” The swampy metabolic situation is why I sometimes also call it “sick muscle syndrome.”

A “muscle knot” is a trigger point: a small patch of muscle tissue in spasm.

A collection of too many nasty trigger points is called myofascial pain syndrome (MPS).

Individual TrPs and MPS can cause a truly spectacular amount of discomfort — far more than most people believe is possible — as well as some surprising side effects. It’s bark is much louder than its bite, but the bark can be extremely loud. More about worst case scenarios below.


Why muscle knots matter so much

Trigger points matter. Aches and pains are an extremely common medical problem,11 and trigger points and myofascial pain syndrome are the most common undiagnosed source. They are a key factor in headaches, probably including migraine and cluster headaches as well,1213 neck pain and low back pain,1415 and (much) more. What makes trigger points clinically important — and fascinating — is their triple threat. They can:

  1. cause pain problems,
  2. complicate pain problems, and
  3. mimic other pain problems.

Trigger points can cause pain directly. Trigger points are a “natural” part of muscle tissue.16 Just as almost everyone gets some pimples, sooner or later almost everyone gets muscle knots — and you have pain with no other explanation.

Trigger points complicate injuries. Trigger points show up in most painful situations like party crashers. Almost no matter what happens to you, you can count on trigger points to make it worse. They can form in response to virtually any other kind of problem. In many cases they actually begin to overshadow the original problem.

Trigger points mimic other problems. Many trigger points feel like something else. It is easy for an unsuspecting health professional to mistake trigger point pain for practically anything but a trigger point. For instance, trigger points are a much more common cause of pain than repetitive strain injuries (RSIs).17 There are dozens of examples like that.

Trigger points routinely complicate most injuries and often begin to overshadow the original problem.

The daily clinical experience of thousands of massage therapists, physical therapists, and physicians strongly indicates that most of our common aches and pains — and many other puzzling physical complaints — are actually caused by trigger points, or small contraction knots, in the muscles of the body.

The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies, p2

What would Adam & Jamie do? You know, if they were doctors?

How can you trust this information about trigger points?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of trigger points. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 230 footnotes here), and I always link to the original sources.

Trigger points are good, hard science

Trigger points are not a flaky diagnosis. This isn’t hippie health care! You can:

No, none of these procedures are available as diagnostic tests for patients.18 However, keep reading to learn how to identify TrPs.

Trigger points rest on a bedrock of thousands of scientific papers published in mainstream, peer-reviewed medical scientific journals. There is so much science, in fact, that it is a full-time job keeping this book up-to-date!23 Detailed charts and databases of the patterns of spreading pain that they cause are widely available24 (the best online example is The Trigger Point Symptom Checker).

Trigger point charts

Many trigger point charts are on the market. How are they made? Believe it or not, pain-causing solution is injected into human subjects. The injection causes such strong pain that it spreads in a clear pattern which the subject can report accurately. These pain patterns are often strange, but they are so consistent from one person to the next that they can be mapped. I sure hope the subjects get paid well!


The pioneers of trigger point research still are and always have been primarily medical specialists and scientists like Janet Travell,25 David Simons, and Siegfried Mense. Most doctors specializing in chronic pain care are well aware of the role of MPS, including Dr. Tim Taylor, co-author of this book, who wrote and maintains an entire section about medical factors that can make trigger points stubborn.

The existence and medical importance of trigger points is just not controversial. The only problem is with getting the word out — educating front-line health care professionals.

Although mild and moderate muscle knots are easily treated, myofascial pain syndrome is simply unknown to many medical professionals, and unfamiliar to nearly all of them. Why?

[Photos of Drs. Janet Travell and David Simons.]

Drs. Janet Travell and David Simons devoted their careers — their entire lives — to trying to understand the science of muscle knots, and sharing what they learned with other health professionals. Dr. Travell died in 1997, and Dr. Simons in 2010.


Why are trigger points so neglected?

“Muscle is an orphan organ. No medical speciality claims it,”26 Muscle tissue is the largest organ in the body, complex and vulnerable to dysfunction, and the “primary target of the wear and tear of daily activities,” nevertheless “it is the bones, joints, bursae and nerves on which physicians usually concentrate their attention.”27 Family doctors are particularly uninformed about muscle tissue health28 — it simply isn’t on their radar.

What about medical specialists? They may be the best option for serious cases. Doctors in pain clinics tend to know about trigger points. But they also often limit their treatment methods exclusively to injection therapies — a bazooka to kill a mouse? — and anything less than serious trigger point pain won’t qualify you for admittance to a pain clinic anyway. This option is only available to patients for whom trigger points are an extraordinary primary problem, or a major complication. Medical specialists may know quite a bit about muscle pain, but aren’t all that helpful to the average patient.

An appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points.

The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies, p2

Physiotherapists and chiropractors are generally preoccupied with joint function, biomechanics,29 and exercise therapy. These approaches have their place, but muscle tissue is routinely underestimated. A lot of patient time gets wasted trying to “straighten” patients, when all along just a little pressure on a key muscle knot might have provided relief.

Massage therapists have a lot of hands-on experience of muscle tissue, but know surprisingly little about myofascial pain syndrome. Their training standards vary wildly. Even in my three years of training as an RMT (the longest in the world), I learned only the basics — barely more than this introduction! The right hands can give you a lot of relief, but it’s hard to find — or be — the right hands.

No professionals of any kind are commonly skilled in the treatment of trigger points. Muscle tissue simply has not gotten the clinical attention it deserves,30 and so misdiagnosis and wrong treatment is like death and taxes — inevitable! And that is why this tutorial exists: to help you “save yourself,” and to educate professionals.

Those clinicians who have become skilled at diagnosing and managing myofascial trigger points frequently see patients who were referred to them by other practitioners as a last resort. These patients commonly arrive with a long list of diagnostic procedures, none of which satisfactorily explained the cause of, or relieved, the patient’s pain.

Myofascial Pain and Dysfunction, by David Simons, Janet Travell and Lois Simons, p36

zoom
The Big Red Books

Must-have text books for any therapist treating trigger points.

Does your trigger point therapist have the big red books?

In addition to dozens of scientific papers, this tutorial is based on medical textbooks like the massive two-volume set, “the big red books” — Myofascial Pain and Dysfunction: The Trigger Point Manual31 — and “the blue book, Muscle Pain: Understanding Its Nature, Diagnosis and Treatment32 These are not easy reading!33

Every therapist who claims to treat trigger points should have the big red books books in their office. If you don’t see dog-eared copies, ask about them — it’s a fair, effective and polite way to check a therapist’s competence.

Muscle Pain (the blue one) is just as important. I highly recommend it to any professional who works with muscle (or should). It’s more recent, and it covers a much wider range of soft tissue pain issues, putting trigger points in context.

A brief note about the relationship between fibromyalgia and myofascial pain syndrome

Fibromyalgia (FM) and myofascial pain syndrome are not the same thing, but they do have a lot in common, routinely coexist, and they are often confused.34 Fibromyalgia is a painful neurological disease, while MPS is no more a disease than acne. Trigger point therapy is useful for many FM patients,35 and therefore so is this book. Dr. Taylor’s advice about medical causes of pain are especially helpful; his wife is also a doctor and has fibromyalgia and has gotten considerable relief from the recommendations shared here.

Trigger points also explain many severe and strange aches and pains

This is where trigger points really get interesting. In addition to minor aches and pains, MPS often causes unusual symptoms in strange locations. For instance, many people diagnosed with carpal tunnel syndrome are actually experiencing pain caused by a muscle in their armpit (subscapularis).36 Seriously. I’m not making that up!

This odd phenomenon of pain spreading from a trigger point to another location is called “referred pain.” The neurology will be explained in detail below. Here are some other examples of referred pain leading to misdiagnosis:37

Sometimes trigger points cause such severe symptoms that they are mistaken for medical emergencies. I treated a man for chest and arm pain — he had been in the hospital for several hours being checked out for signs of heart failure, but when he got to my office his symptoms were relieved by a few minutes of rubbing a pectoralis major muscle trigger point. The same trigger point sometimes raises fears of a tumor. Here’s a particularly excellent example sent to me by a physician who had this experience:

I narrowly escaped a breast biopsy because of trigger points in the pectoralis major. I’d had bad chest pain for a month. I was on the table, permit signed, draped. The doctor wasn’t sure: she said she wanted another mammogram. I left confused, relieved … but still hurting.

Then I lucked out: my regular internist was puzzled, but thought it might be “soft tissue.” That made me go to a physical therapist. The physical therapist pulled out the big red books on trigger points, and we read together. Treatment was a complete success. A month-old severe pain that I had been treating with ice packs in my bra and Lortab — gone!

Janice Kregor, competitive swimmer, retired pediatrician and medical school instructor

Another client once spent three days in hospital for severe abdominal pain that doctors couldn’t diagnose — her pain was mostly relieved immediately by massaging a trigger point in her psoas major muscle.

I myself once suffered a dramatic case of a “toothache” that was completely relieved by a massage therapist the day before an emergency appointment with the dentist.

That toothache might not be a cavity — it might be myofascial pain syndrome!

However, the vast majority of symptoms caused by myofascial pain syndrome are simply the familiar aches and pains of humanity — millions of sore backs, shoulders and necks. And some of those can become quite serious.

Is this like you?

Muscle knot pain can be savage. Over the years I have met many people who were in so much pain from muscle dysfunction that they could hardly think straight. Is muscle pain “trivial”? Not if you have it!


Two typical tales of trigger point treatment

The relationship between trigger points and mild-to-moderate pain is often so straightforward that therapy is virtually effortless. One of the nice things about working with trigger points is that sometimes they do make me seem like a miracle worker, because they are such a clinical “slam dunk” for garden variety persistent muscle pain — pains that have gone unexplained by other health professionals.

One of the nice things about working with trigger points is that sometimes they do make me look like a miracle worker!

For instance, Lois McConnell of Vancouver came to see me complaining that she’d had moderate, chronic back pain for several years. She’d received some common misdiagnoses, particularly sacroiliac joint dysfunction.39 But she had a prominent gluteus maximus trigger point (this one) that, when stimulated, felt exactly like her symptoms — a deep ache in the region of the low back and upper gluteals. In just three appointments, her pain was completely relieved. She was quite pleased, I can tell you!

Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help.

Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years

Or consider Jan Campbell. Jan is a moderately active and healthy retired French teacher, but she developed a hip pain sometime in early 2004 during a period of intense exercising. The pain quickly grew to the point of interfering with walking, and was medically diagnosed as either a bursitis or a piriformis strain. I did not believe that either of these could be the case, and treated a trigger point in her piriformis muscle once on June 12, 2004. Her symptom was 100% relieved for about eight months, before it slowly began to reassert itself (as trigger points often do, despite our best efforts — more about that to come).

One trigger point therapy treatment completely relieved a nasty stubborn hip pain that I'd had for five months!

Jan Campbell, retired French language teacher, Palm Springs, recovered easily from several months of hip pain

Jan’s symptom was 100% relieved for about eight months.

Every trigger point therapist has a seemingly endless list of such treatment success stories. Although most such cases involve relatively minor symptoms, this is not to say that they were minor problems. In almost every such case, the pain was relatively mild but extremely frustrating and persistent for many years, then relieved almost effortlessly by a handful of treatments — an incredible thing, when you think about it. So much unnecessary suffering!

How can you tell if trigger points are the cause of your problem?

Trigger points have many strange “features” and behaviours, and can easily be confused with many other problems. Because of their medical obscurity, they are often the last thing to be considered in spite of their clinical importance and many distinctive characteristics. There are several things you can look for that will help you to feel more confident that, yes, trigger points are the problem instead of something else. The next several sections will discuss all of them in detail.

Whether you knew it or not, you were probably already familiar with trigger points even if you’d never heard of them before starting this tutorial.

Almost everyone has a head start in self-diagnosing trigger points, because almost everyone already more or less knows what it’s like to have a muscle knot. If you have ever had muscle stiffness, wrenched your neck around trying to stretch and wiggle your way free of discomfort, or gotten a friend or partner to dig into that annoying spot in your back, then you already have some experience with this — you probably have trigger points!

Almost everyone already pretty much knows what it’s like to have a muscle knot.

But there may be many things you don’t yet know about how trigger points behave and feel …

End of free introduction to this tutorial

Full access to the rest of this tutorial is available immediately for USD$1995. Click the “Buy Now” button to purchase access, and then continue reading this document immediately.

zoom

secure, instant digital delivery
money-back guarantee
call 778-968-0930 for assistance

CompanyRegeneration Training
OwnerPaul Ingraham
Location888 Pacific Street
Vancouver, Canada V6Z2S6
Service 778-968-0930
support@SaveYourself.ca
Guarantee100% money-back
Read Morecompany policies

webstore by eSellerate
security by GeoTrust
 
TABLE OF CONTENTS — PREVIEW
To get access to all 213 chapters, purchase the e-book for $19.95. You’ll receive the full version instantly.



90 days access
print or save
sharing encouraged
100% guaranteed

heavily researched
constantly updated
reader Qs answered

105,000 words
213 chapters
221 footnotes

all myths & controversies
all diagnostic issues
all treatment options

A little Q & A about the book …

Q Does your book include diagrams showing common trigger points?

A Yes, thirteen classic trigger points are explored, the “Perfect Spots” for massage, accounting for about 75% of common pain problems. Other reference material is reviewed and recommended, especially the best free online option, The Trigger Point Symptom Checker.

Q Will the book solve my problem? What if it doesn’t?

A Maybe! But, naturally, I can’t guarantee “results” … and I don’t want to. I don’t believe in giving false hope, and trigger point therapy is far from perfect. My goal is to give you the best chance of success, and help you avoid wasting your time and money on bollocksy therapies. If that’s not worth $20, I should get out of the publishing business.

Q Does the book include information on [insert your pain problem]?

A Probably not! Many specific pain problems are mentioned, but the book doesn’t go into detail about any of them. Once you understand the nature of trigger points, you don’t really need me to spell out their relationship to every common injury. Trigger points cause and complicate all injuries in quite predictable ways — that’s why they are clinically interesting!

Testimonials

Here are some of the nicest things that readers have said about my trigger points tutorial over the years. Thanks everyone!

I have been suffering from lower back pain for the last 5 weeks and found your page to be very informative and interesting. I really can’t thank you enough actually because for the first time I’m really starting to feel like I’m on the right track here.

Glenn Hill, Canterbury, Australia


Thanks to your website, I pretty much got rid of my back problems almost overnight. It’s also fun and thought provoking to read!

Amsterdam Jeroen Strompf, MFA, Screenwriting, Chapman University


I’m really enjoying your work!

Janice Kregor, competitive swimmer, retired pediatrician, medical school instructor


Your tutorial is great! It has humor and factual information presented in a clear “layman” mode. Your writing has given me much mental clarity and power about a subject that has been so confusing for so long. I am now in a much better position when I see the muscle doctors, and it also made me look much smarter in dealing with the health insurance people.

Melissa Rizio, a “classic trigger sufferer” suffering chronic pain since 1991


My husband had been suffering from shoulder and neck pain for years. He had tried numerous medications, physical therapies, deep tissue massage, Bowen technique, acupuncture and trigger point injection — none of which provided anything more than minor, temporary relief. Then I bought your tutorial on trigger points. I read it, carried out your instructions to the detail, and … after 5 sessions of the technique you provided, the trigger points were ‘gone’! He has never felt better in years. Thank God I was able to stumble upon your website by chance. I want to thank you for sharing your expertise over the net.

June Lim, MD, Diplomate, Philippine Society of Anesthesiologists


First, THANK YOU for this information. You’ve done all the heavy lifting: reading the literature, the studies, et cetera. And you’ve presented all the information in a concise, useful and entertaining format. I have learned a lot from reading these two tutorials, including the miscellaneous articles you have referenced along the way.

Jan Nelson, pharmacist and power yoga practitioner


I am blown away by your trigger point eBook. It is fantastic! I wish I would have come across your site sooner as I do serious research on just about any purchase I make, and that goes double now that I have hand pain issues. I purchased Claire Davies’ Trigger Point Therapy Workbook back in mid Dec, which has been great, but it was lacking. By comparison, I’m in awe of how well you illustrate and explain what’s going on with trigger points. Your analogies are superb and reading your book helps give so much better an understanding of what’s going on that I don’t feel like I’m shooting in the dark as much. I’m just surprised that I didn’t find your site sooner. I’ve done lots of research online and could only find short one-page write ups on trigger points. From your copyright, you’ve been up for 9-10 years and your content is superb. Thank you for such a great book, well worth the $20.

Kevin Janisch

Thanks, Kevin — I’ve been coughing up good analogies even longer than that! Since the early 1990s! — Paul

Read 15 more testimonials


One more special testimonial. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

Dr. Jonathon Tomlinson, MBBS, DRCOG,MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.




Q Why not The Trigger Point Therapy Workbook?

A One of the better books out there about trigger points is Clair Davies’ mostly excellent The Trigger Point Therapy Workbook. There is one thing in particular that The Trigger Point Therapy Workbook offers that this tutorial deliberately lacks: detailed, muscle-by-muscle reference material. His book is a better reference book than this document is.

zoom

Davies’ book is excellent in many ways, but it doesn’t teach principles and it makes too many promises.


Instead of reference material, this tutorial offers many advanced troubleshooting concepts that can’t be found in Davies’ book at all, not even between the lines. Challenging cases of myofascial pain require good understanding of the nature of the problem and clear guiding principles … not one-size-fits-all treatment recipes.

I have met many patients who got a lot of benefit from The Trigger Point Therapy Workbook, got them started on the path to self-treating muscle pain … but then they couldn’t take it all the way. The book particularly does not help people successfully troubleshoot difficult cases.

My main beef with Davies is that he promises too much, giving the impression that self-massage is an infallible cure — trigger point therapy is great stuff, but it isn’t that good. His over-the-top enthusiasm is a serious flaw. It sets patients up for disappointment, and it alienates sensible doctors.

Davies’ over-the-top enthusiasm sets patients up for disappointment.

This tutorial has a more realistic tone, and is the superior resource — in my completely biased opinion! — for people who are struggling with more serious trigger point pain.

See my full review of The Trigger Point Therapy Workbook for more information.

Appendix B: Trigger Point Therapy Resources

(Where is Appendix A? It is included in the full, paid version of this document. Appendix B is included as a free sample, like the introductory sections.)

This is a list of resources relevant to chronic pain in general, but muscle pain in particular. I avoided publishing this section of the tutorial for many years, because I am generally not impressed by the resources available (to both patients and professionals), especially online resources. I remember a slightly testy conversation with someone from an American organization a couple years ago (that shall rename nameless, but is listed below):

THEM   You say it’s hard for patients to find good trigger point therapy. You shouldn’t say that! We certify good trigger point therapists!
ME   You have about fifty practitioners in your directory, concentrated in a handful of major cities, with a certification no one has ever heard of, for a country of more than 300 million people spread over almost 10 million square kilometres. That’s one certified therapist for about every 60,000 people and 200,000 square miles. If “needle in a haystack” is the new “easy to find,” then sure, I’ll say that your certified therapists are easy to find.
THEM   Well, you still shouldn’t say that it’s hard to find them!
ME   Call me when your organization has grown by at least an order of magnitude and your website doesn’t look like it was built by chimps.

Two years later that organization still has only about 100 certified therapists in its directory, and yet remains one of the largest directories of its kind. If you live in a big city, there’s a fair to middlin’ chance that you can find one of those therapists. But certification of trigger point therapists is still generally a mess, with several businesses and organizations competing to be the standard, and — sorry everyone — no one looking like an obvious leader. Even this document is part of the mess: a sanity-inducing part of the mess, hopefully, but nevertheless a good example of how everyone and their dog is out there trying to provide “the best” information/training/therapy in this field.

For inclusion in this section, an organization or business must be defining the field in some way, and they must have a strong online presence. (In the digital age, it is not good enough to merely be good: you have to look good online and provide real substance to visitors.)

The relevance of each listing to professional readers and/or patients is shown with the pro and patient icons. For instance, although professional associations are rarely of much interest to patients, they do often provide directories of professionals to help patients find practitioners.

With apologies to my international readers, this section is quite American-o-centric. If you are aware of important resources and organizations elsewhere in the world, please let me know.

National Association of Myofascial Trigger Point Therapists (NAMTPT) pro patient

The only organization dedicated to representing professionals specializing in myofascial pain and trigger point therapy. NAMTPT provides resources for both patients and professionals, such as a trigger point therapist directory and a symptom checker.

The International Myopain Society (IMS) pro

A nonprofit health professionals organization dedicated to the promotion of information about soft-tissue pain disorders like myofascial pain. IMS publishes the Journal of Musculoskeletal Pain.

American Society of Pain Educators (ASPE) pro

A nonprofit organization that trains Certified Pain Educators (CPEs). A CPE educates clinical peers, patients, families, and caregivers on ways to relieve pain by the safest means possible. Note that ASPE training is not focussed on muscle pain.

American Academy of Pain Management (AAPM) pro patient

The largest association of pain professionals in the United States with 6000 members. Similar to the ASPE in that members do not focus on muscle pain in particular: they are included here because they are chronic pain experts in general. They provide a directory of members and listings of pain clinics, and The Pain Practitioner and a monthly newsletter, Currents, both good sources of pain management news.

Massage Therapy Foundation (MTF) pro

A nonprofit organization to advance the profession of massage therapy, founded by the American Massage Therapy Association. The MTF website has a strong focus on research and they publish the International Journal of Therapeutic Massage & Bodywork, which routinely publishes papers about myofascial pain syndrome.

The Pressure Positive Company pro patient

The best and oldest American manufacturer of good quality massage tools, Pressure Positive has also been a superb corporate citizen, contributing to the advancement of trigger point therapy in many ways, such as collaborating with writers like myself and supporting and promoting scientific research — admirable qualities in a field so often afflicted with hype. Their website provides many useful resources for both patients and professionals.

National Fibromyalgia Research Foundation (NFRF) pro patient

The source for what’s new in fibromyalgia research and education, such as the newest material regarding the connection between the central nervous system and FM/CFID. They publish many resources for patients and professionals such as diagnostic criteria for fibromyalgia, an informational guide to fibromyalgia, scientific abstracts (including those from NFRA’s scientific research symposium), exercise videos, and listings of patient organizations.

Trigger Point Therapy Workshops

Hands-on workshops, noteworthy because they are presented by Amber Davies, NCTMB, daughter of Clair Davies, author of The Trigger Point Therapy Workbook — a very popular entry-level book for myofascial pain syndrome, which is good but limited and growing obsolete as it ages (see my review).

David G. Simons Academy (DSGA) pro patient

Dr. Simons co-authored the famous big red texts — the seminal text on myofascial pain syndrome — with Dr. Janet Travell. DGSA is named in his honour, and has offered courses in dry needling and manual trigger point therapy worldwide since 1995. They are hardly the only provider of such workshops, but I single them out because I specifically appreciate their attitude towards certification: they offer to teach skills, not certification levels in a branded treatment “system.” I don’t necessarily object to branding of training, but I admire DSGA’s more academic approach. They publish a nice page summarizing and listing recent trigger point research. (See also Seminarios Travell & Simons, offering trigger point courses in Spain led by Orlando Mayoral — there is a regular exchange of experience between DGSA and Orlando Mayoral.)

Pittsburgh School of Pain Management (PSPM) pro

A school specializing in myofascial trigger point therapy training, recognized by the National Association of Myofascial Trigger Point Therapists. PSPM offers a 650-hour entry level program, and graduates are eligible to sit for the certification exam offered by the Certification Board for Myofascial Trigger Point Therapists.

Myopain Seminars pro patient

A post-graduate continuing education company focussing on myofascial trigger points, manual trigger point therapy, intramuscular manual therapy (a form of dry needling) and trigger point injections. Their primary flagship training product is the Travell Seminar Series. Like DSGA (above), Myopain Seminars is focussed on teaching skills and knowledge and not a branded certification program. They publish a list of graduates, including quite a few in the Netherlands.

Acknowledgements

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stores. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Thank you finally to Dr. Tim Taylor, MD (www.PainReliefHome.net), author of this book’s vital sections about medical factors that perpetuate pain, new as of the summer of 2010. More than a collaborator, Tim is an idealistic and decisive volunteer, who didn’t just offer to contribute to this book, but made it happen quickly and well and all for the sake of helping people. In twenty years of writing and publishing, I have never seen anything quite like it, and I am extremely grateful for it.

What’s New In the Trigger Points Tutorial?

Monday, August 23, 2010 — Numerous repairs and upgrades to the new chapter, especially links to the clinics Dr. Taylor recommends, and some new charts, and a colorful anecdote about drinking blood (seriously).

Thanks to several readers, and especially Elaine M., for their assistance with this. It’s quite amazing how the new chapter is driving immediate refinements. People read it and write to ask questions, and that spurs little email debates between me and Dr. Taylor, a trip to PubMed for more evidence or detail, or a clarification wrangle with the language ... and the results get put into the book within hours or even minutes … so cool! As reader Bill C. put it, “Your books are alive!” It does kind of feel like that.

Friday, August 20, 2010 — Major upgrade! An important new chapter by Dr. Tim Taylor, Medical factors that perpetuate pain. This is the first major collaborative effort on SaveYourself.ca, and I’m extremely proud of it, and pleased with how well it went. For more about how it came to be, and a taste of some of the science, see the official announcement.

zoom

This is the most important single upgrade the book has ever gotten. Dr. Taylor adds vital medical information that I simply did not have the expertise to produce myself. Demonstrating the power of electronic publishing, this update is available now to all current subscribers, and with a very cheap renewal for past customers — much better than buying a whole new edition of a book at full price.


Tuesday, July 20, 2010 — Fixed some wrong science about hydrogen bonding and tissue adhesions. Hat tip to reader and chemist K.D. for the good catch.

Wednesday, July 7, 2010 — Updated the with a summary of a bizarre experiment with muscle relaxants that had quite surprising results.

June 28, 2010 — At last! This e-book finally has a “cover.” [show]

Friday, June 25, 2010 — Added to the introduction about a trigger point that was almost mistaken for a possible tumor.

Wednesday, May 26, 2010 — A weakness of this e-book has finally been eliminated: reference material! Where are the trigger points? Although this is still not an encyclopedia of trigger points, and it never will be (by design), the book now helps readers find specific trigger point information in three new ways:

Monday, May 17, 2010 — Nothing specific: just a particularly large dose of editing love, with my thanks to reader Elaine M. for pointing out several errors that got me started. Elaine received some free product for her assistance, of course, and so can you if you send me any more than a few error reports.

Saturday, April 17, 2010 — Minor update to description of physiatrists (a medical speciality). See: .

Saturday, April 3, 2010 — Added a long-missing (free) appendix of online resources related to trigger point therapy. Better late than never?

Saturday, February 13, 2010 — Tiny-but-interesting update: added some pretty good evidence that a muscle relaxant was no better for injured neck muscles than ibuprofen.

Tuesday, January 19, 2010 — One refreshed section (), and a completely new one logically following from it:

Tuesday, January 12, 2010 — Two heavily revised sections: “” and “.”

Thursday, January 7, 2010 — A small but significant update on nutritition, based on Bischoff-Ferrari et al, which basically boils down to a recommendation to — it might help.

October 2007 through December 2009 — Forty-five additional updates are listed in a separate document, for anyone who cares to take a look.

Notes

  1. The most popular trigger point book for patients is still the Trigger Point Therapy Workbook, by Clair Davies. It has some qualities, but it’s also simplistic and out of date. It was never more than an introduction to the subject, and five long years of new scientific research have left it in the dust. And it will never be updated again: Mr. Davies died in 2006.

    zoom

    Many people have written to me over the years to tell me how the Workbook did not really do the trick for them, but this tutorial did. The Workbook’s qualities and limitations are reviewed more thoroughly below.

    Return to text.
  2. Here’s a funny quote:
    Rocket science isn’t all that difficult. It’s not brain surgery.

    A rocket scientist

    Return to text.
  3. Bold, blue notes contain extra commentary and detailed information, so check them wherever you want to know more. Light gray notes usually contain only bibliographic data and shorter summaries of scientific papers. All the footnotes can also be found in a list at the foot (of course) of the document.
    23 23
    boring!
    bibliographic info and simple summaries
    of scientific papers
    (often “boring,” but not always!)    		 interesting!
    more detail, elaborations, asides
    Return to text.
  4. Big promises are common on the internet, and it’s a problem when a treatment method or product is presented as being “good for” nearly any kind of pain problem. There are too many kinds of pain for any one idea to work for all of them. Return to text.
  5. Substantiation later: this is an important and complicated problem for pain patients, and I’ll discuss it much more later on in the book. Return to text.
  6. There is a bit of “neato” in any good research. Making it understable and interesting for all kinds of readers is simply a matter of expressing that. Return to text.
  7. Commenting on two fascinating 2008 research papers (Chen and Shah), Dr. David Simons wrote, “Currently, consideration of the possibility of a myofascial trigger point component of the pain complaint is commonly not effectively included in the differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).” Return to text.
  8. It’s not certain that this is the case, nor why it would be. However, there is certainly plenty of suggestive evidence. Consider a recent Spanish study (Jiménez-Sánchez et al): studying health surveys of the population of Spain, researchers looked for changes in rates of serious musculoskeletal pain since the early 90s, finding that it “increased from 1993 to 2001, but remained stable from the last years (2001 to 2006). Return to text.
  9. Simons writes, “Many authors through the years have ‘discovered’ a ‘new’ muscle pain syndrome ….” The popular Dr. John Sarno is still stubbornly calling it “tension myositis syndrome” to this day, the term he invented when he “discovered” MPS. MPS has been named for the region a particular researchers finds it in. It’s been thoroughly confused with fibromyalgia, it’s been called fibrositis and muskelharten and myofascitis and myelgelosis. It’s been stuck with the labels non articular or soft-tissue, rheumatism, osteochondrosis, and tendomyopathy. Every last one of them is a historical artifact. Return to text.
  10. Other muscle injuries are often confused with trigger points. But a trigger point is not a regular whole-muscle spasm, or a “muscle strain” (torn muscle), which is an actual rip in muscle tissue that occurs suddenly and is instantly very painful. The differences will seem more obvious as you learn more about trigger points. Return to text.
  11. Smith. Journal of Musculoskeletal Pain. 2007. It’s amazingly difficult to find hard data on the prevalence of musculoskeletal problems. However, this Australian study of medical students found that almost 90% of them had some kind of body pain problem, mostly in the neck, lower back and shoulders — and these are young people. It may not be an exaggeration to say that virtually the entire population of planet Earth has musculoskeletal pain! Return to text.
  12. Fernández-de-Las-Peñas et al. Current Pain & Headache Reports. 2007. This important review of the scientific literature on the relationship between trigger points and neck and head pain generally found that there is not much literature to review. Interestingly, the authors do note that there is more evidence “that both tension headache and migraine are associated with referred pain from trigger points.” Return to text.
  13. Calandre et al. Head & Face Medicine. 2008. Although this research was “preliminary and uncontrolled” and is not powerful enough to prove anything, its results were certainly noteworthy — the sort of results that can inspire more research, hopefully. All of 12 patients with chronic cluster headaches (a kind of migraine, nicknamed “suicide headaches”) had myofascial trigger points, and treating them (with injection) produced “significant improvement in 7 of the 8 chronic cluster patients.” The authors speculate that trigger points are not the cause of cluster headaches, but a nasty complicating factor: “chronic pain or repeated acute pain sensitize muscular nociceptors creating active trigger points which, in turn, contribute to potentiate headache pain. This kind of vicious cycle explains why the number of active trigger points has been found to be higher in patients with chronic primary headaches than in healthy subjects or in patients experiencing less frequent headache attacks.” Return to text.
  14. Simons et al. Myofascial Pain and Dysfunction, pxi. Or, as stated more eloquently and authoritatively by Drs. Travell and Simons, “Myofascial trigger points are a frequently overlooked and misunderstood source of the distressingly ubiquitous musculoskeletal aches and pains of mankind.” Return to text.
  15. Much more recently than in the previous footnote, in 2008, Dr. Simons writes: “Currently, consideration of the possibility of an MTP component of the pain complaint is commonly not … included in the differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).” Return to text.
  16. I believe that trigger points are essentially a by-product of the “volatility” of muscle. Muscle tissue is incredibly powerful and complex, and like any finely-tuned machine, it breaks down easily. I suspect that we get trigger points as a relatively small price to pay for having high-functioning muscle tissue, an evolutionary compromise. Higher function would require an escalating risk of dysfunction. Reduced function would probably result in fewer trigger points … but also in weaker and less responsive muscle. Return to text.
  17. Office Place RSIs Decreased in 1994. InteriorsAndSources.com. 1996. Estimates of the incidence of repetitive strain injuries generally range from 3-6% of all cases requiring time away from work. In comparison, MPS is ubiquitous. In my own clinical experience, treating RSIs represent a negligible fraction of my work, whereas MPS is either a cause or complicating factor in nearly every case I treat — including the RSIs! In 1996, Interiors and Sources magazine reported that, “the total number of serious injuries or illnesses attributed to all repetitive motion was just ... four percent of the total number of cases requiring time away from work. Of those, the majority of cases or 53 percent were recorded in the manufacturing sector ... ‘Clearly, most repetitive motion injuries are not occurring in the offices of America,’ said PJ Edington and executive director of the Center for Office Technology (COT). ‘And the so-called epidemic of office-related repetitive motion injuries reported in the media has been a clear case of misdiagnosis.’” Return to text.
  18. I wish I could take a photomicrograph of my own trigger points, or my clients' trigger points. Or sample the tissue fluid. Or use the new MRI technique. Or measure their electrical activity. But, unfortunately, these procedures are not available to anyone, at all: some, like photomicrographs, are advanced and expensive techniques that can be only done for the purposes of research.  (Also, though I'm not sure about this, I think it's possible that photomicrographs can only been done on dead, excised animal muscle! I don't know if it's possible to take photomicrographs of living tissue. If any of my readers knows more about this, please let me know). There’s some hope that the MRI method will become practical for clinical use, but even that is likely to be years off. It’s strange, isn’t it? We can put a man on the moon, but we can’t use high tech to diagnose muscle knots yet … Return to text.
  19. So, wouldn’t it be great if I had such a picture to show you? It sure would! But they are hard to come by, and there are copyright problems. You can see one in “Myofascial Pain Caused by Trigger Points,” a chapter in the book Muscle Pain, by David G Simons, Siegfried Mense and IJ Russell. Return to text.
  20. Measuring trigger point electrical activity is also described in detail in Muscle Pain. That text is one of the main sources for this tutorial, and I won’t put it in a footnote every single time it comes up — just when in matters. Return to text.
  21. Two recent scientific papers, one in 2005 and then more convincingly in 2008, have shown how the tissue fluid in and around a trigger point is painfully poisonous. This will be explored in much greater detail further along in the tutorial. Return to text.
  22. Chen et al. Archives of Physical Medicine & Rehabilitation. 2007. This paper demonstrates the use of a promising new method of imaging the taut bands of muscle associated with myofascial trigger points, using a modification of MRI technology. It is thoroughly analyzed by Simons, who writes that this technology “may open a whole new chapter in the centuries-old search for a convincing demonstration of the cause of MTP symptoms.” Return to text.
  23. The clinical prominence of trigger point therapy is still not what it should be — doctors as a group are still barely aware of it — but the scientific interest in MPS is quite strong, which bodes well for the future. The amount of scientific attention that trigger points are getting can be verified by searching PubMed for “myofascial trigger points,” which is the database of medical scientific information — 5248 papers, and the majority of those are recent. Browsing through the list of titles, you can see an extraordinary array of scientific efforts to understand and explain the phenomenon and the treatment options! Very exciting! Return to text.
  24. Of course, the existence of nice laminated wall charts hardly proves anything. There are laminated charts available for many kinds of ineffective therapies! Any practitioner who hangs a nice chart on their wall looks more credible, whether there is any basis to the chart or not. However, trigger point charts are a by-product of an incredible amount of medical research, and the pain patterns on the chart can easily be demonstrated for patients by any competent therapist. Return to text.
  25. Dr. Travell died in 1997. Her life’s work was remarkable. Her daughter published a lovely article about her in 2003. See “Janet G. Travell, MD: a daughter's recollection” Return to text.
  26. Simons in The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, from the foreword. The full quote reads: “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points. Fortunately, massage therapists, although rarely well-trained medically [BC being one of the obvious exceptions, see Massage Therapy In British Columbia (Canada) — PI], are trained in how to find myofascial trigger points and frequently become skilled in their treatment.” Return to text.
  27. Travell et al. Myofascial Pain and Dysfunction. 1999. Vol 1, p13. Return to text.

  28. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

    Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

    More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

    Return to text.
  29. “Structuralism” is an excessive clinical focus on posture, alignment, and symmetry and other biomechanical factors — crookedness, in other words, or what I call the “biomechanical bogeyman.” Therapists who are into structuralism attribute virtually all pain problems to alleged biomechanical deficiencies that are either entirely imaginary (sometimes absurd), or just relatively unimportant factors in most cases. For much more information, see Your Back Is Not “Out” and Your Leg Length is Fine. Return to text.
  30. See I See Muscle and A Historical Perspective On Aches and Pains. Return to text.
  31. Travell et al. Myofascial Pain and Dysfunction. 1999. Return to text.
  32. Mense et al. Muscle Pain. 2000. A dense text, important reading for professionals. Return to text.
  33. And not impossible reading, either. Over the course of a decade, I have seen several keen patients tackle Travell and Simons’ massive red texts and get good value from them. The diagrams are exceptionally clear, and the writing is generally quite good. It’s not out of the question for patients to try to work with them. But they are expensive reference books, filled with jargon, and intended clinicians who are dealing with every area of the body on a daily basis. Return to text.
  34. Fibromyalgia is common, but (much) less common than myofascial pain syndrome. It causes you to “hurt all over” — widespread chronic pain — and causes many other symptoms, especially the FM “tender points,” which are easily mistaken for trigger points. The main difference between them: trigger points often go away, but tender points defy all treatment. Return to text.
  35. Staud. Curr Pharm Des. 2006. “…interventions aimed at reducing local FM pain seem to be effective but need to focus less on tender points but more on trigger points (TrP) and other body areas of heightened pain ….” Return to text.
  36. Travell et al., op.cit. (Virtually all information in this article is drawn from Travell and Simons, so I won’t cite page references for every instance.) The subscapularis case is a good example of how MPS is probably much more clinically significant than RSIs: not only is MPS a causal or complicating factor in many RSIs, it frequently imitates them and is the correct diagnosis! This is why at least some RSIs do not respond to conventional treatment. Return to text.
  37. It’s possible to richly reference this section with individual scientific papers backing up every single example of trigger points mimicking some other health problem. This kind of information is everywhere in the MPS literature. For now, here’s just one of many, a 1995 paper, “Myofascial pain syndromes — the great mimicker”. Return to text.
  38. There’s a large body of research about this, but Rocha is a good recent example. In 2007, these researchers found that “in 56% of patients with tinnitus and MTPs, the tinnitus could be modulated by applying digital compression of such points, mainly those of the masseter muscle.” And how many people with tinnitus had trigger points? Quite a few. The researchers found “a strong correlation between tinnitus and the presence of MTPs in head, neck and shoulder girdle.” Return to text.
  39. As discussed above, such “structural” misdiagnoses are a common red herring, and almost always wrong. Mistaking a gluteus maximus trigger point for sacroiliac joint pain is a particularly common diagnostic error. See Massage Therapy for Low Back Pain (So Low That It’s Not In the Back) for more about this particular area. Return to text.

There are 182 more footnotes in the full version of the trigger points tutorial. See above for details, or click the “buy” button to buy it now.