Introduction

I first went to massage school in 1989 and learned Swedish Massage. I learned to give a very good general massage, but actually trying to solve a patient’s muscular problems was often frustrating and elusive. I saw a class on “Neuromuscular Therapy” in the Heartwood Institute catalog, and was very intrigued by the description. I attended the class in 1991, taught by Jeanne Aland, and it opened up a whole new world for me. I learned that “trigger points” often are not located in the area in which the patient is actually feeling symptoms, and that working on the area of pain would not necessarily solve the problem. I also learned that trigger points are areas of cells that are locked in a dysfunctional cycle — blood flow has been reduced and metabolic wastes are not being exchanged for oxygen and nutrients, and that these were the “knots” I could feel when I was working on a patient. Suddenly I was able to start solving problems consistently, even in cases where patients had been lead to believe they “would have to live with it.” I bought Dr.’s Janet Travell and David Simon’s first volume “Myofascial Pain and Dysfunction: The Trigger Point Manual,” and then anxiously awaited completion of the second volume, which came out in 1992.

The Neuromuscular Therapy class taught me about trigger point referral patterns and how to search for and work on trigger points, but the books taught me so much more — about other symptoms in addition to pain referral patterns — causative factors, perpetuating factors, and some self-help techniques to teach to patients. In addition, I have since added my own observations and self-help techniques, and I am grateful to the many patients who have shared with me their own experiences of what worked for them.

This Membership Website draws heavily from Dr.’s Travell and Simon’s books, which are written for physicians. It is intended for use by the lay public, massage therapists, physical therapists, and any others who don’t require the in-depth expertise required for trigger point injections, and I have purposely attempted to use lay terms as much as possible rather than medical terminology. The exception to this is medical terminology used to describe conditions that may need to be ruled out or diagnosed by a health care provider, and the names of muscles. Often trigger point referral symptoms mimic other more serious conditions or occur concurrently with them.

Unfortunately, all too often, you may be diagnosed with general terms such as a “rotator cuff injury,” “frozen shoulder,” “carpal tunnel syndrome,” “thoracic outlet syndrome,” “sciatica,” “arthritis,” or “tendinitis,” without the true cause being identified. Often the cause is trigger points in one or more muscles, and the diagnosing practitioner is unfamiliar with trigger points. If you are not able to get relief with the self-help techniques and something other than trigger points is causing or contributing to your symptoms, MRI’s and other tests can specifically identify conditions such as muscle tears, tendon inflammation, anatomical abnormalities, nerve root irritations, and nerve entrapments.

I recommend that you have your trigger points identified by a trained trigger point or neuromuscular therapist, and use the book to supplement their work. In my experience, patients who perform self-help techniques at home in addition to weekly acupuncture or massage treatments improve at least five times faster than those who only receive treatments.

Pain Diagnosis

Often a patient will tell me they have “arthritis,” “tendinitis,” “carpal tunnel,” “bursitis,” a “rotator cuff injury,” “sciatica,” or some similar term all too often used loosely to describe pain in a certain area of the body. I try to find out whether the area was loosely diagnosed by a practitioner based on the affected area (i.e., if its elbow pain, then it’s tendinitis), whether it’s been diagnosed by a blood test (i.e., Rheumatoid arthritis), x-rays, or an MRI, or if the patient has self-diagnosed. Even with a laboratory-confirmed diagnosis, I assume I can most likely help my patient to some degree with trigger point therapy.

Joint pain will often be caused either by trigger point referral to the joint area, or tight muscles crossing the joint and jamming it together, thereby causing pain. With a confirmed diagnosis of a condition such as a herniated disc or carpal tunnel syndrome, trigger point therapy can still offer pain relief, relax the muscles, and possibly even ward off surgery. Any surgery has inherent risks and may not solve the problem, and may even make the condition worse. It is almost always worth it to try alternative methods to see if you can avoid surgery. If surgery is the best option, trigger point therapy, acupuncture, and other “complementary” therapies can help prepare you for surgery and hasten your recovery afterwards.

When pain is more widespread, it is usually given the diagnosis of Fibromyalgia or Myofascial Pain Syndrome. If I see body-wide pain and tender points, I wonder what is going on systemically — that is, what could be affecting the body as a whole? Anemia, hormonal imbalances (including menopause), nutritional deficiencies, hypoglycemia, and allergies are examples of conditions that could cause widespread trigger points. In cases of what I consider “true” fibromyalgia, the tissues feel “spongy” to the touch, an indication that there is fluid in the interstitial space (see the fibromyalgia section of What Are Trigger Points?)

Regardless of your Western diagnosis, my general treatment principle is the same: identify and eliminate all the underlying causes (if possible) and treat the trigger points.

Patients often assume that if a parent had the same type of condition, “it must be genetic and I’ll just have to learn to live with it.” While it may or may not be true that your condition is genetic, I never operate on the assumption that it is, or that it can’t be improved even if it is genetic. Many things are learned from your parents — eating habits, exercise habits, emotional holding, even posture and gestures. So assume you can change your medical condition, at least until you have exhausted all therapy options.

A frequent phrase I hear patients have been told by practitioners is “you’re just getting older” or “you’ll just have to learn to live with it.” How depressing! I never assume I can’t help someone, or that I can’t think of someone to refer them to, such as a chiropractor, naturopath, or surgeon who can help them. I’ve actually treated several fairly simple cases where the patient had been told their only recourse was to learn to live with it, only because the health care provider didn’t know about trigger points, or was unwilling to refer to an “alternative” modality. Thankfully, I see that changing with new health care providers being exposed to a wider range of alternatives in medical school, and some health care providers who have been out of school for some time getting excited about exploring some other options.

I’ve only had a few cases where I was not able to help someone, but these people had frustration levels so high (understandably so) from seeing professional after professional with little or no help, that they only allowed me to treat them a few times before giving up, even if they had improved. Sometimes a patient will get a little worse before they get better, especially in complex cases, so they will give up easily in the initial stages of treatment. I encourage you to give any treatment you try some amount of time before you decide it is not working, even if it initially gets worse. Most professionals have numerous tools in their bag, and if something isn’t working, they can try something else. Just give them some time to learn your body and get to know how you use it. If they don’t seem to care or have time for you, then by all means find someone else who cares about you getting better.

I kept thinking it would go away!!

So often I get patients in my office who say “I kept thinking it would go away.” Occasionally symptoms will go away in a few days and never return. But more often, the longer you wait to see if it will go away, the more muscles become involved in what I call a “chain reaction.” A muscle hurts and forms trigger points, then the area of referral (where you feel the pain or other symptoms) starts to hurt and tighten up and forms its own trigger points (“satellite” trigger points), and so on down the line, so to speak. Or the pain may improve for a while, but the trigger points are really just lurking, waiting to activate and cause pain or other symptoms once again. The problem gets more complex the longer the trigger points are left untreated, resulting in it being more painful, more debilitating, more frustrating, more time-consuming, and more expensive to treat. Plus the longer you wait the less likely you are to get complete symptom relief, and the more likely that trigger points will be reactivated chronically and periodically.

Breaking the Pain Cycle

Something starts to hurt, then you tense the area up. Then it hurts more, so the muscle tightens up more . . . and the pain cycle ensues. People are often surprised that I support the use of analgesics, such as aspirin and ibuprofen, but whatever will break the pain cycle as soon as possible helps prevent the symptoms from getting worse or spreading to other muscles. (Icing will also numb out the pain). But be aware that just because the pain level has decreased does not mean the trigger points are gone. You still need to seek treatment, preferably as soon as possible. Analgesics will most likely take the edge off the pain, but unless you plan to take them as a long-term solution, you will also need to treat the source of the problem.

Why Trigger Point Therapy Works

Massage and self-help techniques on trigger points helps reverse the dysfunctional metabolic cycle of the muscle cells. It allows them to start exchanging oxygen and nutrients for metabolic wastes again, the proper cell metabolism process. Also, by pressing on the trigger points and making it hurt a little bit more than it’s already hurting, it causes your body to release pain-masking chemicals such as endorphins and enkephalins, thereby breaking the pain cycle.¹

How Long Will Therapy Take?

A common question I get in the beginning of therapy is “how long will it take?” There is no quick-fix when it comes to treating pain. My general rule of thumb is that the longer the condition has been going on and the more medical conditions (of any kind) the patient has, the greater number of muscles will have become involved, and the treatment will be more complex and take longer. If a patient is perfectly healthy and has only a recent minor injury, I may only see them a few times. Patient compliance is a big factor — whether they follow my recommendations and participate in their healing by performing the self-help techniques. I can usually give the patient a pretty good indication of how many treatments they may need by the end of the second or third treatment, based on their medical condition, how their muscles feel to me, their compliance to date, and how much they have improved (or not) within the first few weeks.

A small percentage of patients will get worse before they get better, mostly in complex cases. Or pain may move around, or the patient may have the perception pain moved around only because the most painful areas have improved and now they are noticing the next most painful area more. I encourage you to stick with the treatments and find ways to make the self-help techniques comfortable, such as reducing the frequency or decreasing the amount of pressure. Keeping good records will demonstrate progress, even if you perceive that your symptoms haven’t changed.

There are a very few patients who have what Dr.’s Travell and Simons call “post-traumatic hyper-irritability syndrome.” With this condition the sensory nervous system and trigger points are extremely irritable, and massage and self-help techniques actually will make the patient feel worse. It is usually initiated by a major physical trauma such as an auto accident, a fall, or other major blow to the body, which affects the sensory modulation mechanisms of the spinal cord or brain stem. Pain is constant and easily aggravated by loud noises, vibrations, slight jarring, moderate or greater physical activity, pain from injections, and emotional stress. With even mild aggravation it may take hours for the pain to return to the “normal” levels. With severe aggravation it may take weeks for the patient to recover. Any subsequent traumas will worsen the condition. If practitioners are unfamiliar with this condition, they may find it hard to believe the patient is experiencing these symptoms. Since just about any therapeutic intervention aggravates the symptoms, these patients are very difficult to treat. If you feel these symptoms describe you, you should not receive massage, even if it feels good at the moment.³

I have had three patients that I believe had post-traumatic hyper-irritability syndrome. I performed acupuncture on these patients, but although it did not worsen their symptoms (as other types of treatment had done), due to their frustration levels they did not return for more than a few treatments, and in that short time I was not able to discover if acupuncture would help in the long term. If you have this condition and want to try acupuncture, I would recommend that the practitioner select very few points with a short needle-retention time, and plan on receiving several treatments.

A Special Note to Therapists Teaching Self-Help Techniques

Have your patients color in a body chart every time. Some will be resistant to doing this, saying “it’s just the same.” Since many patients will improve slowly, their perception may be that it is the same, but in fact the area is smaller, and the pain is less intense and/or less frequent. And if indeed it hasn’t changed, then you know that either you are missing the trigger points, the patient is missing the points with the self-help techniques, and/or there are perpetuating factors that need to be addressed. Also, patients will even come in and announce they “have a new problem,” when in fact it is an old problem they have just forgotten about. It is important to have a historical record.

Be sure to explain to your patient what trigger points are and about referral patterns. Tell them why you are working on an area that is different from where they have indicated they feel symptoms. Explain that if they want treatment for a specific problem, there will not also be time to do a full-body massage in an hour, and they will have to pick a few areas to work on each time if they have pain in many areas. You may need to educate them about the need for you to ask them questions during their treatment, getting feedback on invoked referral patterns, pressure-pain levels, gathering information about potential perpetuating factors, and other information critical to giving them the best treatment possible.

I keep a master check list of muscles for each patient so I can easily refer to it while I am working on them, circling the involved muscles and writing short comments. I look at the trigger point referral charts and think in terms of “trigger points in which muscles can possibly be causing their pain?”.

While you are working on your patient, ask them questions like “does this feel familiar, like you are getting it with the ball?”, “is this less tender than last time?”, and “are you feeling better or the same, or worse?”. Sometimes they will mark the same area and the same intensity and frequency, but in fact report feeling much better, so you can’t go strictly by the numbers.

Ask them if they want to learn self-help techniques, and explain that you will need to save five to ten minutes at the end of the treatment to do so (and longer the first time). Tell them that patients who do the self-help get better much faster. At the beginning of the first self-help session, verbally go briefly over the basic self-help guidelines and ask them to read them again before they do the self-help for the first time. Tell them to start the next day, so it will still be fresh in their mind. Give them pictures of the muscles, and highlight important things to remember.

Patients are far more likely to start doing the self-help if they can leave your office with the necessary equipment. Keep a supply of tennis balls, golf balls, racquetballs, and baseballs in your office for patients to purchase.

Be sure to have your patients practice the assigned self-help before they leave your office. Demonstrate what you want them to do, and then watch them do it. They will understand the self-help much better, and will be much more likely to comply since even a few moments of practicing it will help them realize that this is something that will really help them, and they will look forward to doing it. Only teach two new self-help techniques per visit, and prioritize what needs to be taught. Any more than that is too much for patients to remember.

On subsequent visits, find out if they are doing the self-help, how they are doing it, how often, was it too hard or soft, were there any problems, etc. You may need to review it with them again. It’s a lot of information, and new concepts. Check the muscle tissues to see if they are improving. If the tissues haven’t softened, then it is likely they are missing the needed areas, even if they think they are getting them. Walk them through it again, or figure out a way they can get to the area if what they are doing is not working. If they aren’t doing the self-help techniques, find out why. Often they are not doing it because they tried it and it was too painful. Reiterate that they need to figure out how to make the self-help less painful, such as starting on the bed, a pillow, or a folded-up blanket. If they just don’t want to do self-help techniques, I just work on them and stop teaching them something they’re not going to do. If they occasionally ask what they can do to make it better, I just reiterate that addressing the perpetuating factors and doing the ball work are the best things they can do to resolve the problem.

If they are having problems locating the areas they need to work, mark it on them with a permanent marker (which lasts three to four days), or give them a landmark. For example, for the gluteus minimus anterior, they need to get at least to the seam of their pants. For the tensor fascia latae, they need to get all the way to their front pants pocket.

Above all, be patient with your patients. It is a lot of unfamiliar information for them, they are not familiar with anatomy, and they may have to be walked-through the self-help techniques and reminded more than once. Some people will expect you to “fix” them and won’t do anything to help themselves. For those people I do the best I can and “let go” of them getting better as fast as I think they could. And the rewards of working with patients who are willing to help themselves are tremendous.

© Copyright Valerie DeLaune, LAc, 2004

1. Neuromuscular Therapy Training, Fall 1991, Heartwood Institute, Jeanne Aland, instructor.
2. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities vol. 2 (Baltimore: Williams & Wilkins, 1992), pp. 548-549.
3. Janet G. Travell , M.D., David G. Simons, M.D., and Lois S. Simons, P.T., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, Upper Half of Body, 2nd ed. (Baltimore: Williams & Wilkins, 1999), pp. 44-45.