Trigger Point Chapter One

This chapter originally appeared in the first and second editions of The Trigger Point Therapy Workbook by Clair Davies.

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Excerpt from The Trigger Point Therapy Workbook; Your Self-Treatment
Guide for Pain Relief, 3rd edition

Chapter 1- Why Try Trigger Point Therapy?

Jennifer, twenty-eight, loved to run for her health every day in the fresh morning air, but she’s stopped running and hesitates to walk even a short distance because of relentless pain in her knees and heels.

Larry, fifty-two, can think of little else but the constant pain in his back. He struggles to get in and out of bed. His back hurts whether he’s sitting, standing, or lying down. The pain makes him hate his job and has ruined his love life.

Melanie, thirty-six, spends her days at a computer keyboard and her nights worrying about her future, because of the unremitting pain and numbness in her arms and hands. As a single mother, she has to keep working no matter what.

Jack, forty-five, has shoulder pain that wakes him up at night. He can’t raise his arm to comb his hair. Reaching up to scratch his back is impossible. A sudden movement brings a jolt of pain that feels like an electric shock and doubles him over, grimacing and breathless. Is this the start of the inevitable decline into old age and disability?

Howard, twenty-three, is a gifted violin student. After years of hard work under some of the best teachers in the country, he now fears a professional career is out of reach because of constant pain and an unexplained, increasing stiffness in his fingers.

Do you know anyone like Jennifer, Larry, Melanie, Jack, or Howard? They’re everywhere—on every job, in every office, in every town. The thing all these people have in common, other than chronic pain, is that they aren’t getting the help they need. It’s not that they haven’t looked. They’ve gone the rounds. They’ve seen doctors, had tests, done physical therapy, and filled out insurance forms or—sick at heart—have paid the exorbitant bills themselves.

They’ve tried chiropractic, acupuncture, magnets, pain diets, and herbal therapy. They take their pain medicine and dutifully do their stretching exercises. Sometimes they feel better for a while, but the pain always comes back. Nothing really seems to get to the bottom of the problem. They fear surgery may be the only solution, despite being told there are no guarantees of success. They’re beginning to wonder if anybody really knows anything about pain.

If this describes your own situation or that of someone you care about, this book may provide the help you’ve been seeking. In it, I propose to give you a sensible explanation of what’s wrong and to help you find the real cause of your pain. Even better, I’ll show you a hands-on way to get rid of the pain yourself: No pills. No bills. No appointments.

No pills. No bills. No appointments.

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. Pain clinic doctors skilled at detecting and treating trigger points have found that they’re the primary cause of pain roughly 75 percent of the time and they play at least a part in virtually every pain problem. Even fibromyalgia, which is known to afflict millions of people, is thought in many instances to have its beginning with myofascial pain and trigger points. Myo means muscle and fascia is the connective tissue that both covers the muscle and is present within the muscle tissue. Myofascial pain is pain arising from trigger points in the muscles. Most people who have been diagnosed with fibromyalgia also have myofascial pain syndrome and trigger points, and in some cases have been misdiagnosed. It is not uncommon for myofascial pain to be mistaken for fibromyalgia (Simons, Travell, and Simons 1999; Gerwin 1995; Fishbain et al. 1986).

Trigger points are known to cause headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome, and many kinds of joint pain mistakenly ascribed to arthritis, tendinitis, tendinosis, bursitis, or ligament injury. Trigger points cause problems as diverse as earaches, dizziness, nausea, heartburn, false heart pain, heart arrhythmia, tennis elbow, and genital pain. Trigger points can also cause colic in babies and bed-wetting in older children, and may be a contributing cause of scoliosis. They are a cause of sinus pain and congestion. They may play a part in chronic fatigue and lowered resistance to infection. And because trigger points can be responsible for long-term pain and disability that seem to have no means of relief, they can contribute to depression.

The problems that trigger points cause can be surprisingly easy to fix; in fact, most people can do it themselves, if they have the right information. That’s good, because the time has come for ordinary people to take things into their own hands. Why? Because an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical journals for over seventy years. Why has the medical profession not embraced the idea of trigger points? Partly because they can’t be seen by MRI, X-ray, or CT scan. They can’t be observed in the cadaver lab either. However, there is an even more basic reason. There are not doctors of muscle backed by large learning and research institutions doing the studies into the muscular causes of pain. You can’t go to school to be a doctor of muscle. The largest organ in the body is an orphan. As physician and researcher, Dr. David Simons, writes in the forward to this book, “Muscle is an orphan organ. No medical specialty 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.”

Muscle is an orphan organ. No medical specialty 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.

In fact, there are many things yet to be learned about muscles, fascia, nerves, trigger points, and referred pain. But there are many things we do know: Trigger points are real. They can be felt with the fingers. They emit distinctive electrical signals that can be measured by sensitive electronic equipment. Trigger points have been photographed in live muscle tissue with the aid of the electron microscope (Simons, Travell, and Simons 1999). Trigger points can also be seen by 2D or grayscale ultrasound, vibration sonoelastography, and Doppler ultrasound (Sikdar et al. 2009). The biochemical environment of active and latent trigger points has been sampled with novel microdialysis needles. The levels of biochemicals known to be involved with pain, sensation, intracellular communication, and inflammation have been measured to identify the characteristics of trigger points versus normal tissue. (Shah and Gilliams 2008).

Much of what is known about trigger points is very well documented in the two-volume medical text Myofascial Pain and Dysfunction: The Trigger Point Manual by Janet Travell, MD and David Simons, MD. Most of the information in this foundational text is couched in difficult scientific terms, but basic trigger point science isn’t hard to grasp if it’s put into everyday language.

Travell and Simons describe a trigger point as simply a small contracture knot in muscle tissue. It often feels denser or tighter than the surrounding muscle tissue. Often you can only feel a taut guitar-like string in the muscle fiber harboring the trigger point. The constant tension in the fibers of the trigger point itself restricts circulation of blood in its immediate area. The resulting accumulation of the by-products of metabolism, as well as deprivation of the oxygen and nutrients needed for metabolism, can perpetuate trigger points for months or even years unless some intervention occurs. It’s this self-sustaining vicious cycle that needs to be broken (Simons, Travell, and Simons 1999; McParland and Simons 2011).

The difficulty in treating trigger points is that they typically send pain to some other site. Most pain treatment is based on the assumption that the cause of pain will be found at the site of the pain. However, trigger points almost always send their pain elsewhere. This referred pain is what has always thrown everybody off. According to Travell and Simons, conventional treatments for pain so often fail because they focus on the pain itself, treating the site of the pain while overlooking and failing to treat the cause, which may be some distance away.

Even worse than routinely treating the site of the pain is the pharmaceutical treatment of the whole body for what is usually a local problem. Pain-killing drugs, the increasingly expensive treatment of choice these days, give us the illusion that something good is happening, when in reality they only mask the problem. Most common pain, like headaches, muscle aches, and joint pain, is a warning—a protective response to muscle overuse or trauma. Pain tells you that something is wrong and needs attention. It’s not good medicine to kill the messenger and ignore the message. When pain is seen in its true role as the messenger and not the affliction itself, treatment can be directed to the cause of pain.

When pain is seen in its true role as the messenger and not the affliction itself, treatment can be directed to the cause of pain.

The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies, but physicians rarely get any education in the pathology and dysfunction of muscle. Doctors Travell and Simons believed that most of common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain (Simons, Travell, and Simons 1999).

Luckily, referred pain is now known to occur in predictable patterns. The valuable medical advance made by Travell and Simons and their brilliant illustrator, Barbara Cummings, has been in delineating these very patterns. Once you know where to look, trigger points are easily located by touch and deactivated by any of several methods.

Unfortunately, the two clinically oriented methods—spray, and stretch and injection—put forth in Myofascial Pain and Dysfunction, do not lend themselves to self-treatment. The goal of this book is to build on the work of Travell and Simons and provide a more practical and cost-effective approach to pain therapy: a classic do-it-yourself approach rather than a reliance on multiple professional office visits. This new approach is a system of self-applied massage directed specifically at trigger points. Significant relief of symptoms often comes in just minutes.

Most problems can be eliminated within three to ten days. Even long-standing chronic conditions can be cleared up in as little as six weeks. Results may be longer in coming for those who suffer from fibromyalgia, or widespread myofascial pain syndrome, but even they can experience continuing progress and can have genuine hope of significant improvement in their condition.

Trigger point massage works by accomplishing three things: it breaks into the chemical and neurological feedback loop that maintains the muscle contraction; it increases circulation that has been restricted by the contracted tissue; and it directly stretches the trigger point’s knotted muscle fibers. The illustrations in this book show you how to find the trigger points that generate your specific problems as well as the exact hands-on techniques for deactivating them. Special attention has been given to designing methods of massage that do no damage to hands that may already be in trouble from overuse.

Self-applied massage has multiple added benefits. If you treat your own pain you are in control of when, where, and how much treatment you receive. If pain awakens you at night, there you are; you might as well get to work resolving the problem. With self-applied massage, you have control over intensity of the pressure. This is especially important if you can only tolerate a light amount of pressure. Best of all, with self-care, you can benefit from multiple daily treatments wherever you are—without appointments, expensive equipment, or time off from work.

With self-care, you can benefit from multiple daily treatments wherever you are—without appointments, expensive equipment, or time off from work.

This book is primarily designed for use is as a self-instruction manual, but it can also be used as a textbook for classroom use. This simplified and direct approach to treating pain with self-applied massage can constitute a foundational course in trigger point therapy in any professional training curriculum. Students in chiropractic colleges, physical therapy departments, and massage schools will derive particular benefit. Chapter 11, Clinical Trigger Point Massage, is designed to help the professional manual therapist adapt the book’s technical content to the treatment of others. Additionally, if therapists can learn how to interpret their own referred pain and how to find and treat their own trigger points, they will know exactly what to do when they encounter similar problems in their clients or patients

A class in self-applied trigger point massage would be a boon in medical schools for exactly the same reasons. When new doctors can learn how to fix their own pain with self-applied massage, they are in better touch with the realities of pain and with the great potential in the treatment of trigger points. Such an addition to medical education would profoundly improve the treatment of pain and significantly lower its cost.

And it’s not too late for physicians already in practice to learn about trigger points and myofascial pain and put the knowledge to good use. They will find this book a quick and practical introduction to the magnificent work of Travell and Simons and this neglected branch of medicine. Hopefully, many will be encouraged to go to Travell and Simons’s two-volume work, Myofascial Pain and Dysfunction: The Trigger Point Manual (1992, 1999), Jan Dommerholt and Peter Huijbregt’s Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management (2011), and Muscle Pain: Understanding the Mechanism and Muscle Pain: Diagnosis and Treatment (2010), edited by Siegfried Mense and Robert D. Gerwin. Several journals, including the Journal of Bodywork and Movement Therapies, Journal of Manual and Manipulative Therapy, Journal of Musculoskeletal Pain, Pain, and Archives of Physical Medicine and Rehabilitation, publish studies concerning myofascial pain. See the Resources section at the back of this book for a list of course providers for medical and allied health professionals. A large segment of the public needs help and encouragement in learning how to deal with their trigger point–induced pain. No one is better positioned to provide this help than members of the medical community.

The members of the medical profession are not unaware of the deficiencies of current methods of treating pain. Doctors hurt, too. Many of them worry like the rest of us about the relentless popping of pills, and many experience frustration with their inability to offer better solutions to their patients. Trigger point therapy, whether self-applied or administered by a professional, has the potential to truly revolutionize pain treatment throughout the world.

A NEW DAY

A doctor should have written this book. It should’ve been written by a bona fide, credentialed expert in a white coat with years and years of experience and scores of articles published in medical journals. Instead, it took a regular working man—my father, Clair Davies—frustrated by the current medical approach to pain.

In the first two editions of The Trigger Point Therapy Workbook, my father told the story of how he came to be a trigger point enthusiast, massage therapist, and author. In short, he was motivated by pain. He had suffered a frozen shoulder in the mid-1990s that disabled him for eight months. It started as a slightly achy shoulder after shoveling snow. Eventually, he couldn’t raise his arm above shoulder level, reach across his body to put on his seat belt, open a jar, or reach out to catch a closing door. One doctor diagnosed him with bursitis and recommended that he wear his arm in a sling for six months. As a self-employed piano rebuilder, that was not an option. A second doctor diagnosed it as adhesive capsulitis. His prescription was to put Dad under anesthetic then forcibly manipulate the shoulder to break up adhesions in the joint capsule. My father thought both ideas were nutty and opted for physical therapy. After a round of treatment that worsened his condition, he learned that the physical therapist was also suffering from a frozen shoulder. Her treatment couldn’t fix her and it couldn’t fix him. Nonetheless, she expected payment. Needless to say, Dad was a little irritated. Later, he tried massage therapy where he observed the therapist using the medical textbook on trigger points to try to solve his shoulder pain. My father saw an opportunity to take control over his treatment, and leapt at it. He purchased the books by Travell and Simons and got to work.

His story is extraordinary in that he cured his own frozen shoulder with a simple tennis ball, a Thera Cane, and Travell and Simons’s two-volume Myofascial Pain and Dysfunction: The Trigger Point Manual. It took four weeks of diligent study and treatment for all of the trigger points to be released in the twenty-three affected muscles. After the trigger points were gone, another two weeks of stretching assigned to him by the original physical therapist restored his complete range of motion. He was astonished. He had solved his own shoulder pain!

Then he came after me. I had lived with chronic low back pain since a lifting injury during a scene change in a regional theater at age eighteen. For six years, I lived with pain. I couldn’t sit for more than about an hour without having to jam my knuckles into my low back. I couldn’t lift more than twenty-five pounds without paying for it for three days. I couldn’t trust my back to do the normal things young people take for granted. Massage therapy and, more specifically, regular self-treatment changed all of that for me. I looked up one day after sitting making jewelry for four hours and realized that I didn’t have pain anymore. When I should have been at my worst, I wasn’t. My old friend, pain, had vanished; my body was restored. That old pain reappeared one more time a couple months later, and I made a classic self-treatment mistake, I smashed into the trigger points with a vengeance. Luckily, my body was able to accommodate the aggressive self-treatment with nothing more than a couple of bruises. I’ve had many bouts with other pain conditions through the years, and nearly everything has been resolved with self-applied trigger point massage.

My father and I both attended massage school and became massage therapists with a self-taught specialty in myofascial trigger points. After the publication of the first edition of The Trigger Point Therapy Workbook in 2001, we traveled throughout the United States teaching weekend continuing education seminars to massage therapists and any other health care professional who would listen. We reached several hundred therapists in those two and a half years. As I mentioned earlier, my father was a lone wolf in many ways and collaboration was a challenge for him. When I became ready to equal my mentor, the time came for us to break up our “Davies and daughter” enterprise and resume being daddy and daughter. I have continued the seminar business providing workshops for professional therapists and as well as regular folks in pain. You can find more information on my website at www.TriggerPointBook.com.

Many manual therapists now treat trigger points. It is not as difficult to find a capable therapist who can assist you in your quest for pain relief. But you don’t have to wait. You can begin today with self-applied massage. Start with the Pain and Other Symptoms Guides at the beginning of chapters 4 through 10. They will show you where to begin your search for trigger points that cause your pain. Many muscles and trigger points may be involved. Read chapter 3, Treatment Guidelines, to better understand how to most effectively do the massage technique. I encourage you to carefully read about each muscle that may be contributing to your pain. Above all, don’t be afraid to try it. Significant relief can be just around the corner.

The next [second] chapter, All about Trigger Points, describes a little history and science of myofascial trigger points. If you need immediate help without a deeper scientific understanding, skip to chapter 3, Treatment Guidelines.

This excerpt is copyrighted material from:
Davies, Clair and Amber Davies. The Trigger Point Therapy Workbook; Your Self-Treatment Guide for Pain Relief, 3rdedition. 2013. Oakland, CA: New Harbinger Publication.

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