Questions & Answers
Clinical Definition of a Myofascial Trigger Point: A hyper-irritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. This spot is painful upon compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.
Travell & Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual; 1999, pg.5
They are defined by Drs. Travell & Simons, is a collection of muscle cells that are in a continuous state of full contraction. They are commonly referred to as a “muscle knot”.
They may be responsible for a large variety of physical symptoms that include, but are not limited to pain.
Simply speaking, there are two types of trigger points
Latent trigger points can cause tension, fatigue and weakness to the involved muscle(s); however, they do not produce pain or other symptoms.
Active trigger points will also cause fatigue and weakness to the involved muscle(s) AND will always produce symptoms. Symptoms such as dizziness, numbness, vertigo, sinus issues, toothache, chronic dry cough, tinnitus, excess lacrimation, cardiac arrhythmia, muscle weakness, sciatic pain, migraine, TMJD, heartburn, knee issues, back and shoulder pain, irritable bowel syndrome (IBS), hip pain, bladder control issues, painful intercourse, painful menstruation, and carpal tunnel syndrome are very often caused by trigger points.
Every day I receive many questions from my clients.
My job is to answer them as honestly and accurately as possible, sighting facts from trusted sources… and advising my client when I include my personal opinions/beliefs in an answer.
One question that stands out from the usual –
“Is this a proven therapy?”
My personal belief/opinion is that it IS a proven therapy.
I’ve studied the Travell & Simons Trigger Point Therapy Manuals (for more than 10 years) and have applied their seminal work into my practice; the results are virtually identical to what Travell and Simons found in their studies.
So what does this mean?
- It means that referral patterns are predictable.
- MTrPs and the taut bands they cause can be palpated (not all, but many of them).
- Removing the MTrPs allows the involved muscle to return to a normal (relaxed) state and will give the client relief from their symptoms (not always, but most of the time).
- Perpetuating factors ARE relevant and certainly interfere with the effectiveness of the therapy.
- Identifying and removing perpetuating factors will very often improve the success of treatment.
I believe the real ‘problem’ with Trigger Point Therapy (and whether it’s proven or not) lies with the vast majority of people (you know who you are) who don’t actually study the books nor practice it to any significant degree.
Simply looking at a trigger point illustration in a book and then ‘poking’ a couple TrPs, is NOT Trigger Point Therapy!
And sadly, many who dabble with this therapy (after flipping through a TPT book) are the ones who often imply that it’s ineffective and question whether it’s a ‘proven’ therapy.
Real (i.e. comprehensive) Trigger Point Therapy takes an immense amount of study, clinical practice and dedication to be proficient with it (just like all other therapies). There is NO shortcut.
Those who have dedicated their time to it will tell you it certainly IS a proven (and highly effective) therapy.
They can be tiny like a poppy seed or as big as a pea… sometimes even larger.
They can be active or latent.
Active Myofascial Trigger Point: A myofascial trigger point that causes a clinical pain complaint. It is always tender, prevents full lengthening of the muscle, weakens the muscle, refers a patient-recognized pain on direct compression, mediates a local twitch response of muscle fibers when adequately stimulated, and, when compressed within the patient’s pain tolerance, produces referred motor phenomena and often autonomic phenomena, generally in its pain reference zone, and causes tenderness in the pain reference zone. (To be distinguished
from a latent myofascial trigger point.)
T&S Manual Volume 1, pg. 1
Latent Myofascial Trigger Point: A myofascial trigger point that is clinically quiescent with respect to spontaneous pain; it is painful only when palpated. A latent trigger point may have all the other clinical characteristics of an active trigger point and always has a taut band that increases muscle tension and restricts range of motion.
T&S Manual Volume 1, pg. 4
The actual trigger points (nodules) do not hurt unless you compress them. They do however, when active, cause pain/symptoms that may be difficult for someone who is not well trained in this therapy to figure out.
There is a physiological process that causes the formation. And those who are prone to them forming may develop them as a result of sedentary lifestyle, injury/trauma (e.g. whiplash, concussion, bone fracture), repetitive strain, or diet deficiencies. As well, over-exercising, skeletal abnormalities and day-to-day emotional stress will provide an environment suitable for trigger points to form!
For more precise details click this link.
They can also be very stubborn and difficult to remove. They definitely cannot be stretched out in the traditional way we think of stretching. If this is attempted whilst the TrPs are still present in the involved muscle(s), it will typically make symptoms worse or at the very least, perpetuate the symptoms.
No, virtually never. Only if there is swelling or inflammation, will we consider applying ice.
Do not ice trigger points (or the muscles that have trigger points) unless we specifically tell you to do so!
If your therapist is advising ice for your trigger points, (when there is no indication present) then they know very little, if anything, about Trigger Point therapy.
Only if there is swelling or inflammation, and heat exacerbates the symptoms, will we apply ice.
Trigger points are most effectively treated when the involved muscle is kept warm (i.e. vasodialation). Those suffering from the symptoms of active TrPs, say that heat (especially moist heat) makes the symptoms more bearable. Icing these muscles will only serve to make things worse by causing the muscle tissue to contract and consequently the trigger points re-forming.
Keep in mind that any type of chilling to the skin (e.g. cool air, or swimming) may possibly penetrate into underlying muscle tissue; this chilling of the involved muscles will likely allow trigger points to re-establish in the muscles we are treating.
Short answer – NO. (although mild activity is okay). I advise my clients that the involved muscle should be considered an injured/dysfunctional organ. Since TrPs prohibit development of the involved muscle (i.e. building muscle mass) – exercising the involved muscle(s) will very likely make the problem worse as other muscles that do a similar function as the involved muscle, (Functional Unit) will start to compensate for the involved muscle… this extra burden to these compensating muscles will likely cause them to develop trigger points, thereby compounding the problem.
Trigger Point Therapy has been extensively researched, (over 5 decades by Drs. Travell and Simons) and I enthusiastically subscribe to their protocol.
Here’s what Travell and Simons (authors of ‘Myofascial Pain and Dysfunction. The Trigger Point Manual’) say about exercise –
“Disturbances of motor functions caused by trigger points include spasm of other muscles, weakness of the involved muscle function, loss of coordination by the involved muscle, and decreased work tolerance of the involved muscle. The weakness and loss of work tolerance are often interpreted as the indication for increased exercise, but if this is attempted without inactivating the responsible trigger points, the exercise is likely to encourage and further ingrain substitution by other muscles with further weakening and de-conditioning of the involved muscle.”
Travell & Simons; Myofascial Pain and Dysfunction, The Trigger Point Manual
Travell and Simons’ seminal work was compiled after decades of study and research.
Yes and no. Did your therapist indicate to you why your muscles were weak? (see question/answer directly above).
Did they check the involved shoulder muscles for TrPs (especially the SITS)?
If trigger points are involved, (and they almost always are) it likely would explain this mysterious and sudden weakness.
To answer your question – if there are NO TrPs involved, then exercise may be indicated.
However, if TrPs ARE involved, then exercising the involved muscles is contraindicated until the involved muscle(s) is TrP-free!
You must always check for trigger points, first.
Once TrPs are removed by a knowledgeable therapist, (who will advise you of the proper recovery protocol) the involved muscle will return to a state of normalcy. Once the involved muscle normalized, you may start back to exercising – gently at first!
*** Keep in mind that the involved muscles should remain mildly active during the course of treatment.
We understand that sometime it’s simply not feasible to stop training, or to stop working. If this is the case, then we will attempt to provide symptomatic relief. This means that the trigger points are being treated, the symptoms have diminished, but the muscle has not healed (returned to normal function). It’s sort of like when you tape an injured joint; the joint is still compromised but the symptoms are more bearable. However, it’s strongly recommended that you consider having the trigger points properly dealt with (protocol that allows the involved muscles to heal) at some future time.
The roller has its benefits; so does a ball, or a therapy cane. Although keep in mind that if you continue to exercise the involved muscles, these tools, will at best, only provide symptomatic relief. Simply using a ball or roller is NOT (and should not be referred to as) Trigger Point Therapy. Muscle is an organ, and when trigger points are involved, needs an environment that’s conducive to healing… and exercising the involved muscle does NOT create this healing atmosphere!
When this therapy is employed in a comprehensive manner it is usually about *90% effective in eliminating migraine and chronic headaches. As well, migraines that are linked to the menstrual cycle can often be effectively eliminated. You can expect to see positive results usually within 4 – 6 treatments if protocol is followed.
* If it is determined that the symptoms source is from active trigger points then the treatment success rate can be (and often is) this high.
For some unknown reason it is simply not included in their curriculum to any practical extent.
Here’s a quote from Dr. David Simons, regarding Trigger Point Therapy –
“Muscle is an orphan organ. No medical specialty claims it.
As a consequence, no medical specialty is concerned with promoting funded research into muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points”.
Dr. David G. Simons, M.D.Co-author:
Travell and Simons’ Myofascial Pain and Dysfunction, The Trigger Point Manual
Did you know that bone goes where muscle pulls it?
Now you do!
We tend to think of trigger points as enigmatic nodules that are capable of referring pain/symptoms to another area of the body; and this is often very true.
However, they can also cause muscle shortening, and this will always affect (and pull) the involved bones.
Excessive, and constant muscle tension (caused by trigger points), and the resulting stress to involved bones, can manifest as:
* displaced ribs,
* vertebral subluxation,
* joint irritation (arthritis),
* scoliosis, lordosis, kyphosis,
* tilting pelvis,
* lower limb length inequality (LLLI),
* TMJ symptoms (including clicking/snapping of the TMJ)
* rounding of the shoulders
* “locked-up” SI joint
* clicking, grinding, or clunking joints
Did you know that this therapy (when employed by a knowledgable therapist) may help these involved muscles to heal, and thereby return to a normal, “relaxed” state?
Now you do!
Yes, often this is the case. Be sure to find a knowledgable therapist with extensive practice in TPT.
Everyone is unique regarding the healing process.
Generally, you should expect to have 2 or 3 sessions before you feel a real difference. How quickly you feel an improvement will vary depending on your active role with the therapy (following protocol), the skill of the therapist, your physical and emotional state, medications that you may be taking, skeletal abnormalities, alcohol/drug or tobacco use, how active or inactive you are and how long you have had the condition that we are treating.
Yes. I’ve travelled and treated clients across North America and Europe. This is however, an expensive way to receive treatments so most distant clients usually arrange to travel to me here on the Canadian West Coast, for treatments.
I receive this question often.
Trigger Point Therapy is not really massage therapy, so really there is no requirement to be a massage therapist to be a good TP therapist. Although, I will state that a massage therapist with good understanding of muscle locations, function, etc. can become a great Trigger Point Bodyworker if they commit to extensive study and applied practice. As well, a kinesiologist, physiotherapist or knowledgable personal trainer could, with dedicated practice/study, be a great TP Therapist.
I was a licensed paramedic and although my medical knowledge was above average, I still had much to learn about muscles and trigger points and Trigger Point protocols. I utilized my established professional skills such as taking patient history and listening to what they say, and following established protocols, to develop a Trigger Point Therapy method that has proven to be very effective toward successful treatment of symptoms.
It’s is a myofascial therapy that employs specific treatment methods and protocols, and the Travell and Simons Trigger Point Manuals do not include very much about using massage techniques to treat TrPs.
There are very few Massage Therapists who have extensively studied the Travell & Simons manuals, and employ comprehensive Trigger Point Therapy techniques. Yes, massage therapy seems a ‘natural fit’, but it really isn’t requisite… and being a Massage Therapist, (or physiotherapist or doctor) does not and should not imply efficacy as a Trigger Point Therapist.
Note: massage therapists, and physiotherapists, receive only minimal exposure to Trigger Point Therapy during their training, whilst some receive no exposure to it (e.g. many doctors receive no training in myofascial sourced pain).
A Trigger Point Therapist should have amongst other skills, a reasonably good understanding of human anatomy/physiology. A comprehensive therapist should also know virtually all the muscles, their locations and function, TrP referral patterns, and most importantly, understand the protocol for healing the involved muscles… in other words have extensive studies with the T&S manuals.
Note:your TP Therapist/Bodyworker should spend at least 30-45 minutes at the beginning of your first treatment to establish your chief complaint, contraindications, medical history, lifestyle (including emotional stress), physical activities, nutrition, and other pertinent TPT questions, before you receive the treatment. If they don’t then you should surmise that they are NOT employing comprehensive Trigger Point methods.
I don’t list other therapies/techniques/skills, because I do not employ other therapies/techniques/skills with my treatments (except for some light effleurage to help the client relax, and it assists in removing metabolic waste from involved tissues).
I’m not implying that TP therapy is the ultimate therapy, as many therapies can offer some benefits to the client if employed correctly. However, I have chosen to exclusively study Trigger Point Therapy. To be proficient at it requires my full attention!
I consider it a therapy unto itself (NOT an adjunct to massage or other therapies), and the Trigger Point Manuals require extensive study for one to become proficient.
Of course, incorporating other methods (as long as they are not contraindicated) can compliment TP therapy, and I will recommend these other therapies (and the good people who employ them) to my clients if I feel they’re required to facilitate healing.
Trigger Point Therapy has many approaches to applied practice, and there are countless people who claim to offer TPT to their clients/patients. Unfortunately, most are dabblers with little training, practice, or commitment to the therapy. Simply poking trigger points is NOT Trigger Point Therapy.
There are very few (globally) who practice comprehensive TPT and this makes it very difficult to find one!
It’s your pain, your time, and your money. Call ahead to a potential therapist and ask the questions that need to be asked.
Here’s what we’d look for when searching for a knowledgable TP therapist/bodyworker.
If you don’t get the answers you like, call another Trigger Point Therapist/Bodyworker.
A knowledgable TP therapist/bodyworker
- has studied, in-depth, Travell & Simons, Myofascial Pain and Dysfunction, The Trigger Point Manual (hundreds of hours) and understands the perpetuating factors and protocols that are paramount towards successful treatment.
- is often is considered nerdy (they’re almost always studying and talking about what they do)
- has years of experience employing Trigger Point Therapy as their PRIMARY treatment method. I.e. it’s not just adjunct to other therapies they offer.
- will spend at least 30 minutes (usually longer) during your first appointment to determine your medical history and lots of other pertinent, trigger point related information before you have your first treatment.
- will advise you about what you should and should not be doing during your treatment schedule.
- will advise you regarding exercise and stretching. I.e. not too much exercise to the involved muscles and do not overstretch the involved muscles.
- will almost never advise ice as part of your treatment.
- will rarely (if ever) tell you that your case is too complex (e.g. multiple symptoms).
- will explain to you what muscles are likely involved and what you should be doing to encourage/facilitate the healing process.
- will not consider you as a permanent client (even if they really like you)… the objective is to remedy your symptoms and send you on your way, making room for another client who’s suffering.
- will see you as often as you like for maintenance/tuneups as part of your regular health and/or fitness routine.
Disturbances of autonomic functions caused by TrPs include abnormal sweating, persistent lacrimation, persistent coryza, excessive salivation, and pilomotor activities. Related proprioceptive disturbances caused by TrPs include imbalance, dizziness, tinnitus, and distorted weight perceptions of lifted objects.