Save Yourself From Trigger Point & Myofascial Pain Syndrome

Trigger Point Tutorial (Advanced)

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AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Are you mus by Paul Ingraham, Vancouver, Canada MORE

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. 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 This guide offers troubleshooting ideas for even the toughest cases — much more than the popular but out-of-date Trigger Point Therapy Workbook.1 Many people suffer from trigger point pain and myofascial pain — muscle knots.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!

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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. Good trigger point therapy can be hard to find, and it doesn’t always work. 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 won’t respond to anything else.

Physicians & therapists need to learn about trigger points too This 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. Footnotes add an optional layer of detail. Trigger points are much more clinically important than most health professionals realize.3 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 dicovery that their chronic pain could be treated easily. 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. 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.

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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 cramp5). That small patch of knotted 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 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,6 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,78 neck pain and low back pain,910 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.11 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).12 There are dozens of examples like that. 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

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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

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, I do not claim to know the one true cause of anything, and I am not selling a treatment system or my own services. I say “I don’t know” when I don’t know and I say “I’m guessing” when I’m guessing. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 190 footnotes here), and I link to the original sources so you can check them yourself. I hang out with doctors. I study harder than I ever did in school. Much harder.

What would Ada Jamie do? You kn they were docto

Some of my favourite sources

I spend a lot of time on PubMed, and I cite from the best sources whenever possible, like The Cochrane Collaboration and The New England Journal of Medicine and PLoS Medicine.

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.13 However, keep reading to learn how to identify TrPs. take photomicrographs of TrPs,14 measure their electrical activity,15 take samples of their acidic and toxic tissue chemistry,16 and a new MRI-like technology can now show them as well.17 Trigger points rest on a bedrock of thousands of scientific papers published in mainstream, peer-reviewed medical scientific journals.18 Detailed charts of the patterns of spreading pain that they cause are widely available.19

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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 specialistss and scientists like Janet Travell20, David Simons, and Siegfried Mense. The existence and importance of trigger points is just not controversial. The problem is educating health professionals — getting the word out. 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? Drs. Janet Travell & David Simons devoted their careers to trying to understand the science of muscle knots, and sharing what they learned with other health professionals. Dr. Travell died in 1997. Dr. Simons is still publishing actively.

Why are trigger points so neglected? “Muscle is an orphan organ. No medical speciality claims it,”21 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.”22 Family doctors are particularly uninformed about muscle tissue health23 — it simply isn’t on their radar. What about medical specialists? They may be the best option for serious cases. Doctors in pain clinics to know about trigger points. But they often limit their treatment methods exclusively to injection therapies — a bazooka to kill a mouse — and most trigger point pain won’t qualify you for a pain clinic

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anyway. 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,24 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,25 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

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 Manual26 — and “the blue book, Muscle Pain: Understanding Its Nature, Diagnosis and Treatment27 These are not easy reading!28 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.

The Big Red Boo

Must-have text books therapist treatin trigger points.

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A brief note about the relationship between fibromyalgia and myofascial pain syndrome Please note that fibromyalgia (FM) and myofascial pain syndrome are not the same thing. However, they do have much in common, routinely coexist, and they are often confused.29 Fibromyalgia is a disease, a significant failure of the entire pain system. Because FM patients usually have lots of trigger points as well, some trigger point therapy is often useful for them.30 By contrast, myofascial pain syndrome is a common dysfunction — no more a “disease” than acne — which is usually limited to an area of the body. More about connections between myofascial pain syndrome and fibromyalgia below. Fibromyalgic Tender Points

The “tender points” of fibromyaliga are not the same phenomenon as myofascial trigger points. Tender points occur in specific locations, and they do not tend to “release” like trigger points.

Trigger points also explain many odd 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).31 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:32 Sciatica (shooting pain in the buttocks and legs) is more often caused by MPS in the piriformis or other gluteal muscles, and not by irritation of the sciatic nerve. Many other trigger points are mistaken for “some kind of nerve problem.” Earaches, sinusitis, toothaches, ringing in the ears (tinnitus), and dizziness are often symptoms of trigger points in the muscles around the jaw, face, head and neck.33 A sore throat or a lump in the throat is often caused or aggravated by trigger points anywhere around the throat. “Appendicitis pain” often turns out, sometimes after surgery, to be caused by a trigger point in the abdominal muscles. Severe MPS is often mistaken for fibromyalgia (and other diseases that cause hypersensitivity to pain throughout the body). And many more!

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I recently 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. Another client once spent three days in hospital for severe abdominal pain that doctors couldn’t diagnose — we relieved her pain 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. 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!

A couple of typical trigger point pain stories 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. 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.34 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

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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 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! 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.

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What am I buying? Is there a physical book? No, there is no actual book. I sell online access to pages on SaveYourself.ca, just as scientific journals sell access to their articles — this is known as a “document-access” business model. You buy the right to visit the tutorial online for 90 days. Until you pay, it’s impossible to get to.

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While you have access, you can read the tutorial online. To preserve your purchase, you can print the tutorial, or save it as a webarchive file (instructions available to customers).

I’d rather read a book. Will you be publishing a book? Almost certainly, but not for a while yet. For now I prefer to sell access to webpages. They are simply a better product: cheaper to produce, update, and deliver.

Do I have to download anything? Is there a PDF? No, there is no file to download and store. There are several issues with PDFs: they are hard to update, glitchy and unreliable, difficult for some beginners to use, and more. Tutorials in the form of webpages are the superior product. You can also print it, or save it. The full trigger points tutorial is about 85,000 words in 129 sections — about as long as a novel. Major sections include: trigger point science, both basic and advanced self-treatment, stretching, and all about getting professional help. Buy more and save 50%! Buy an “eBoxed set” of all eight SaveYourself.ca eBooks for great savings.DETAILS

What is the “eBoxed” set, and how does it save you 50%? An eBoxed set is a bundle of all eight eBooks about pain problems for sale on this website, ideal for professionals, keen patients and anyone who wants more for less. Purchased individually, they would run you about $160, but the set is only $79.50 — a savings of $80.

Benefits include the savings, a full-year subscription, and inexpensive renewal forever. Want only 5 tutorials? No problem. Just let me know which ones you’d like. More information about eBoxed sets

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To get access to all 129 sections, purchase the tutorial for $19.95. You’ll receive the full version right away.

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Testimonials

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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

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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

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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.

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Why not The Trigger Point Therapy Workbook? 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. 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.

Clair Davies’ book is goo not quite good enough f of people.

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 A: The Perfect Spots As explained early in the tutorial that trigger point reference materials can be useful, but they also confuse patients as often as they help, maybe more often. Therefore, descriptions and diagrams of trigger point locations are deliberately left out of this tutorial! That said … there is trigger point reference material on SaveYourself.ca. Here are the “perfect spots”: several of the most satisfying and therapeutically significant places on the human body to apply pressure. What makes a spot perfect? A common trigger point, reasonably easy to find and treat, good therapeutic “bang for buck”! All of these articles are completely free.

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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.

What’s New In the Trigger Points Tutorial? Most links to sections mentioned in the updates will work only for customers. To get access to all sections, purchase the tutorial for $19.95. You’ll receive the full version right away.

Saturday, February 13, 2010 — A tiny-but-interestingupdate: 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 (The all-powerful acne analogy), and a completely new one logically following from it: The evolution of muscle pain: does muscle “burn out”? Tuesday, January 12, 2010 — Two heavily revised sections: “What are the worst case scenarios for myofascial pain syndrome?” and “Rare but extremely severe cases of myofascial pain syndrome.” Thursday, January 7, 2010 — A small but significant update on nutritition, based on Bischoff-

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Ferrari et al , which basically boils down to a recommendation to take vitamin D — it might help. Thursday, December 31, 2009 — Minor update: just added a couple of references, Calandre et al and Fernández-de-Las-Peñas et al , to substantiate the relationship between migraines and trigger points. Tuesday, December 22, 2009 — A substantial new section makes the case for self-treatment: Fundamental limitations of trigger point therapy, and how to take advantage of them Wednesday, November 25, 2009 — Upgraded the quality of the writing in an important section, Trigger point diagnosis is not reliable … but it may not matter that much. Tuesday, November 17, 2009 — A little smorg of updates today: (1) A lovely new illustration by Shayne Letain for the introduction! Look for the man with toxic waste signs sticking into his back. And (2) a new case study section with a fascinating success story, demonstrating “a terribly important basic piece of wisdom to ‘get’ for anyone who is prone to muscle pain.” And (3) just a bit of updating of the tools sections with the idea of a “bucket of balls.” Friday, October 23, 2009 — As promised last week, there are now four new advanced sections about the use of medications to treat trigger point pain. These are major new sections with a whole bunch of useful information for patients and pros. This is the kind of content update that I particularly hope motivates past customers to pay a for a subscription renewal — at a low renewal price, which available to all past customers forever. 1. Meds: Anti-inflammatories and Tylenol 2. Meds: Voltaren® Gel, an intriguing new option (or see the less detailed but free article Voltaren® Gel) 3. Meds: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids 4. Meds: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazapenes Also, all discussion of Botox (especially the Botox section) was updated with new scientific evidence that it’s not as effective a therapy for trigger point pain as we all hoped. Friday, October 16, 2009 — Two new sections: “Muscle knots are not inflammatory: the myth of the inflamed myofascial trigger point” and “Common medications that might make a difference (and might not).” More advanced medication information to follow soon: this is just a summary of the basics so far. Wednesday, September 30, 2009 — A substantial new section today: Trigger point diagnosis is not reliable … but it may not matter that much. I wrote about this a while back on the front page and it will be there and free for a while longer, but I’ve also added more information here and included some references to other studies. Wednesday, September 16, 2009 — Several minor updates and refinements, not in any particular section. Saturday, August 15, 2009 — It’s come to my attention that the trigger point treatment method of dry needling doesn’t have as much going for it as I used to think. I discuss the (lack of) evidence and problems in an overhaul of the section How about dry Needling and Intramuscular Stimulation (IMS) therapy? Since Dr. Chan Gunn is the doctor behind one of the most popular methods of dry needling (IMS), I also revised a section which was inspired by his ideas, “The bamboo cage” theory of muscle

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pain. Thursday, August 13, 2009 — Completely re-wrote the section How about myofascial release and fascial stretching? which is accompanied by a new (free) general review of myofascial release therapy (MFR), as promoted by John Barnes. Friday, July 24, 2009 — Rewrote the section How about chiropractic joint adjustment and popping? It’s been condensed into more finely tuned summary, and links out to a new “special supplement” to the tutorial: a separate article covering the topic in much greater detail, accessible to tutorial customers only. As the SaveYourself.ca inventory of tutorials expands, such special supplements will be a useful new way of providing detailed information without repeating it in multiple tutorials. Please think of the special supplement as a part of the tutorial, that just happens to be on another page. Thursday, July 16, 2009 — Physiatrists and rheumatologists added to “Types of therapists and doctors and their relationship to trigger point therapy.” Wednesday, July 1, 2009 — Major bibliography update. The SaveYourself.ca bibliography has long been the largest of its kind. It contains an incredible amount of surprisingly readable information about musculoskeletal health science, and it is now possible for visitors to search and sort the bibliography with powerful new features. For instance, every source about trigger points referenced in this tutorial can now easily be displayed in a single search, with a variety of options. See the front page for the announcement of the new features, or visit the bibliography itself. Friday, June 12, 2009 — New section: “Quick-start trigger points” (access for customers only) describing the clinical characteristics and significance of extremely fast-activating and severe trigger points. Monday, May 18, 2009 — Added an important point to the section, “From the frying pan of injury pain to the fire of trigger point pain,” about injuries that are so severely complicated and overshadowed by trigger point pain that the victims literally don’t even know that there is a physical trauma at the heart of the problem. This is also discussed in the recent article Widespread Chronic Pelvic Pain In a Runner With a Surprising Cause. Wednesday, April 1, 2009 — The visual design of the site was upgraded over the past several days. Although this is not an update to the content of this tutorial, it is nevertheless a significant upgrade for all of them — like publishing new editions of books with better typesetting and layout. The new design is even cleaner and reader-friendly; it now looks that good in most web browsers; and pages load as much as 50% faster. Many under-the-hood improvements will make it much easier for me to improve tutorial content. The tutorials are now well-oiled machines of digital publishing goodness, vastly superior to the low-production values of most eBooks. More information about the upgrade is published on the front page. Monday, March 16, 2009 — Minor update. Added information about a massage tool product, the ShiatsuBag, an 18" round satin-Lycra bag of massage balls. You can read the full review or buy one now for USD $39.95 at ShiatsuBag.com, because it’s a bag of massage balls and you simply must have one. Sunday, February 15, 2009 — Another new advanced tip section today: “Don’t be fooled by reverse referral.” This one’s a head trip. It’s so confusing, I left it out of earlier versions of the tutorial simply because I still didn’t know how to explain it. But I decided it was time to tackle it, and here you go — I

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think I more or less got the point across. Monday, February 9, 2009 — This tutorial has always been strong in the “practical tips and tricks” department. Well, play to your strengths! Lately I’ve been in the mood to add even more tips, and here’s another one today, “Focussing on one trouble spot versus ‘a little bit of everything’ — which is the better strategy?” Tuesday, February 3, 2009 — Added new information about Traumeel, a popular but questionable remedy that I often get asked about. See the section, “Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope) ,” or the free article, Does Traumeel Work?. Monday, February 2, 2009 — Improvements to the section, “How about acupuncture?” Some optimism about acupuncture was removed from the section, and an important new reference was added. Recent scientific evidence has continued to hammer away at acupuncture, and optimism about it can no longer be justified. You can read about the most recent acupuncture evidence in, Does Acupuncture Work for Pain?. Tuesday, January 27, 2009 — New section! “Don’t get hung up on anatomy, and be persistent.” Sounds like a bit of a no-brainer, but there’s a couple ideas in there that patients often need to hear. It’s a nice addition in the “tip” category that really should have been there before. Thursday, December 4, 2008 — A new section, “From the frying pan of injury pain to the fire of trigger point pain,” helps readers understand the unholy relationship between injury and trigger points. For readers who have been injured, this is an important addition to the tutorial. Similar information is also available in the form of a story in the article Into the Fire: Trigger point pain as a major injury complication, and how I finally “miraculously” healed from a serious and stubborn shoulder injury by untying the muscle knots. There is some overlap between the new section here and the stand-alone article, but they both offer different information in different ways. If you are injured, read both! Monday, November 17, 2008 — Added some information about some nice self-massage tools built by Allan Saltzman of YogaTools.com in the section, “Beyond the tennis ball: some of the best commercial massage tools,” as well as some self-massage tools and products I don’t like, in the (now independent and expanded) section “Commercial massage tools to avoid.” Saturday, September 20, 2008 — Added some information about the relationship between myofascial pain syndrome and disease that obviously affect the harmony of the musculoskeletal system, using Parkinson’s disease as an example. See the section “Are you a “triggery” person? The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia.” Monday, August 18, 2008 — Corrections and minor improvements have been made by the hundreds since the publication of the last major upgrade, which was three weeks ago. The polishing never really ends! Monday, July 28, 2008 — Massive upgrade published. This is by far the largest single update a SaveYourself.ca tutorial has ever gone through. The trigger points tutorial has more than doubled the amount of information it offers, and is now book-length at around 80,000 words. Every single customer who ever purchased the tutorial received 2 weeks of free access to the upgraded tutorial. Here’s a summary of everything that’s changed:

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There were “only” 50 sections of treatment recommendations before. Most were overhauled and expanded significantly, and then 20 new ones were added. A valuable new feature has been added, a downloadable Quick Reference Guide, which somewhat miraculously summarizes all this information in a single page. Lots of interesting new scientific evidence has now been integrated into the tutorial. There are now around 150 footnotes (up from 60ish), all of them adding value with interesting tangents and/or referencing hard science. An incredible amount of work went into improving the organization and “flow” of the tutorial. A small technological innovation, the addition of a table of contents button that is always available on the left side of the screen, will make it much easier to get around such a large document. I added many new “expanding” sections with extra information for professionals and keen patients — sort of like super footnotes, readers can reveal them or ignore them as they wish. (They appear in parentheses in the table of contents.) Several of the “Perfect Spots” articles were revised and expanded as well — they aren’t technically part of the tutorial, but they are an important free accessory to the tutorial. October 2007 through May, 2008 — Fifteen substantive updates were published over eight months. All of them were made more or less made obsolete by and rolled into the major update of the whole tutorial, published July 28, 2008.

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. 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. 2. Here’s a funny quote: Rocket science isn’t all that difficult. It’s not brain surgery. A rocket scientist 3. 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).” 4. 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

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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. 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 obvious as you learn more about trigger points. 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! 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.” 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.” 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.” 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).” 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. 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

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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.’” 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 … 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. 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. 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. 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.” 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 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! 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. 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” 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

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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.” 22. Travell et al . Myofascial Pain and Dysfunction. 1999. Vol 1, p13. 23. 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.” 24. “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. 25. See I See Muscle and A Historical Perspective On Aches and Pains. 26. Travell et al . Myofascial Pain and Dysfunction. 1999. 27. Mense et al . Muscle Pain. 2000. A dense text, important reading for professionals. 28. 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. 29. 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. 30. 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 ….”

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31. 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. 32. 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”. 33. There’s a large body of research about this, but Rocha is a good recent example. In 2007, these researched 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.” 34. 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.

There are 140 more footnotes in the full version of the trigger points tutorial. See above for details, or click the “buy” button to buy it now.

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