Thanks to the work of Dr Janet Travell, we have a growing body of evidence that many pain conditions are actually caused by trigger points or small contraction knots in the muscles. Rachel Fairweather, massage therapist and co-founder of Jing Advanced Massage, explains the effects of trigger points and how to treat patients through trigger point therapy in advanced massage.

Sally, 36, came to me complaining of chronic low back pain and a nagging persistent pain between her shoulder blades. The pain made it difficult to sleep and Sally had seen a chiropractor, osteopath, and received epidural injections. None of these treatments had any lasting results. She told me she felt helpless and resigned to a life of constant pain.

John, 40, came into my clinic complaining of a sharp pain in his low back which was worse with movement. The pain had arisen the day before when he had suddenly turned quickly in his chair at work. He was desparate for my help as he was due to play in a big golf tournament that weekend.
Christine, 36, complained of a searing pain down her neck and arm which “made her feel sick” and unable to eat due to the pain.

Samantha, 23, had suffered from chronic migraine headaches since childhood; since the age of 4 she had been having at least one migraine a week causing her to have time off work and spend countless days in bed.

Do you know people like those above? Chances are that you do – they are members of your family, neighbours, work colleagues or perhaps you yourself. Maybe as a massage therapist, these people have come into your clinic and your heart has sank at the expectation to “cure”, to move them out of pain – you really want to help but you just don’t know how. Your qualifying course just taught you to be afraid of people in pain, to stay away from herniated discs and mysterious aches. So you just give these clients a general relaxation massage avoiding the area of pain, refer them on to your local osteopath or send them back to their GP for X-rays, MRIs and usuallly no answers.

Yet all of the clients at the beginning of this article are real and came into my massage clinic seeking help. Using a combination of trigger point therapy, fascial work and advanced stretching techniques, all of these clients experienced a decrease in their pain after just one treatment and were all 90% or more pain free within 6 weekly treatments. They now all come to me for regular maintenance sessions and between them have referred approximately 30 more clients.

Do I have any special magical powers as a massage therapist? The answer is no; just a knowledge of advanced bodywork techniques – in particular the amazing power of precise trigger point therapy. The good news is that as a bodyworker you can learn to bring all of the above clients out of pain quickly, effectively and permanantly, within 1-6 weekly treatments using trigger point skills.

Trigger point therapy is a highly effective technique that can be easily incorporated into your existing massage work and will astound you and your clients with the power of the results. As one of our students said “ I don’t know who was more surprised – me or my clients – when they came back the next week reporting dramatic relief from long standing problems”

Excitingly, the students who have learned these techniques with us have also reported:

• Increased clientele (and therefore more money!) without the need for formal marketing due to the new effectiveness of their treatments.
• Increased confidence in their ability to treat pain conditions.
• Less need to refer clients on to osteopaths or other professionals.
• A renewed enthusiasm and zest for their work.

Dr Janet Travell – the founder of trigger point techniques

Favourite sayings of Janet Travell, quoted on the memorial website set up by her daughters (www.janettravellmd.com):

“Concerning your professional goals, the basic objective is: BE YOURSELF. Do not compare yourself with anyone else. No two people in the world have the same thumb print, not even identical twins. You are unique”
“It’s better to wear out than to rust out,”
“Take care of your muscles and they will take care of you.”

Thanks to the work of Dr Janet Travell, we have a growing body of evidence that many pain conditions are actually caused by trigger points or small contraction knots in the msucles. Studies suggest that trigger points are a component of up to 93% of the pain seen in pain clinics and the sole cause of such pain as much as 85% of the time. (Gershwin; Fishbain quoted in Travell and Simons: Myofascial Pain and Dysfunction: The trigger point manual Volume 1). Trigger points are known to cause or contribute to low back pain, carpal tunnel symptoms, tennnis elbow, neck pain, migraines, jaw pain, and many kinds of joint pain mistakenly attributed to arthritis. They can cause sinus pain and congestion, nausea, chronic dry cough and are thought to contribute to fibromyalgia.

Trigger point theory is really ALL about Janet Travell. Seriously it really is – much of what has been theorized or written about trigger points can be directly traced back to her insights and most of the books that have been written on the subject are condensed or simplified versions of the famous trigger point volumes co-authored with David Simons. As Clair Davis, massage therapist and author of the successful trigger point therapy workbook puts it:

“Among those who recognize the reality and importance of myofascial pain, Janet Travell is generally recognized as the leading pioneer in diagnosis and treatment. Few would deny that she single-handedly created this branch of medicine. . . . Her revolutionary concepts about pain have improved the lives of millions of people.”

Any brief examination of the life and character of Janet shows clearly that she was a “tour de force”; a woman of determination and will and moreover an excellent physician and healer. Balancing an intensive career with marriage and children in a pre-enlightened era, she is famous for being the first woman ever to hold the post of White House physician and Kennedy described her as a “medical genius”. Authors of the book “Trigger point therapy for myofascial pain” Steven and Donna Finando worked directly with Janet Travell on several occasions in the nineties, declaring the experience to be “the opportunity to observe a master practitioner”:

“Watching Dr. Travell treat patients was a joy. She understood what to do, where to touch, how to move, how to feel and she ultimately helped her patients. She understood what was of benefit and hypothesised about why. The concepts and approaches that she utilized simply work; they help change lives and alleviate suffering”

As massage therapists we owe a great debt to Janet Travell – as the quote above simply states – her approaches “simply work” and I have found this true thousands of times over in my bodywork career dealing with chronic musculo-skeletal pain.

What exactly is a trigger point?

Although the term trigger point has passed into more common usage since the publication of Travell and Simons seminal works in the 80s there is still a surprising amount of mis- information about what trigger points actually are (and aren’t), not to mention the best way to treat them.

Let’s start with the universally known classic definition from Travell and Simons themselves – you will be hard pressed to read an article or book on trigger point therapy without encountering the classic soundbite below: According to the “the source”, a trigger point is:

“A hyper irritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia. The spot is painful on compression and can evoke characteristic referred and autonomic phenomena”

As this definition tends to make a large percentage of the population glaze over, most of your clients are likely to understand trigger points as “muscle knots” ie: lumps and bumps in their muscles that are responsible for their pain. Although the muscle has definitely not tied itself into a knot, clearly the average massage therapist is well aware that clients will be seeking help for relief from these pesky “muscle knots” .

Clearly the knot analogy is a pervasive image and we all instinctively feel the urge to poke around our own bodies when we are in pain to try and find these “hot spots”.

So if trigger points are not actually knots what are they? The key points about trigger points as drawn out from this definition are:

• They “feel” like knots in muscle but are in fact small areas of tightly contracted muscle (NOT the same as a whole muscle spasm)
• They are usually found within a taut band of skeletal muscle which can be palpated
• If you press on the trigger point it hurts
• This is the most exciting point to therapists – the pain has a characteristic referred pain pattern. This means that the pain from trigger points often causes pain in other parts of the body distant from the trigger point itself. A good example is trigger points in the SCM muscle which can commonly cause headaches or jaw pain. Or trigger points in the piriformis muscle that can cause a pain down the leg commonly confused with sciatica. Or trigger points in the quadratus lumborum that cause pain around the sacrum that can feel like sacro-iliac pain.
• There is also a lesser known mysterious part to the definition– trigger points can also cause “autonomic referred phenomenen”. In other words trigger points can also cause symptoms you would never guess were coming from your muscles – for example ringing in the ears or dizziness can be caused by trigger points in the SCM

The concept of referred pain is an important one as it means that the source of the pain can often be in a different location than where the client is feeling their discomfort. This is critical to what we do as massage therapists, as the theory of trigger point therapy suggests that if we are only treating the area of pain we are unlikely to achieve lasting results. It is likely that if the cause is myofascial trigger points and you are only in the area of pain, you will be wrong 75% of the time!

What are the effects of trigger points?

Pain

The bad boys of the body, trigger points are always up to no good. Travell and Simons go so far as to describe them as the “scourge of mankind”. Many researchers have corroborated the notion that trigger points are responsible for a large percentage of musculo skeletal pain, with some studies suggesting that trigger points are a component of up to 93 percent of the pain seen in pain clinics and the sole cause of such pain as much as 85 % of the time
The pain from trigger points can manifest in many different ways – it can feel dragging, stabbing, dull, tingling, burning, superficial or deep in the joint. Trigger points can also known to cause weakness in the affected muscles. Because there is a lack of awareness as to the concept of trigger points, the pain is often misdiagnosed as having a more serious or unknown cause leading to unnecessary medical tests or fear and hopelessness on the part of the client.

Compression of nerves and blood vessels

As nerves and blood vessels perforate the muscles at many places, the shortening of muscles caused by trigger points can lead to their entrapment with consequences of numbness, tingling (nerves) or oedema (blood vessels). I have had many cases of misdiagnosed carpal tunnel syndrome in my clinic that have been easily resolved through appropriate trigger point treatment of the scalenes or pectoralis minor, both of which can trap the brachial plexus (nerve bundle that runs down the arm) when shortened by trigger points.

Restricted movement

The taut bands that arise in connection with trigger points lead to shortening of the muscles – this in turn leads to reduced mobility and potentially joint dysfunction.

Autonomic effects

Autonomic effects can be found both in the area of the trigger point and in the area of referred pain. Autonomic effects include changes to skin temperature, increased sweat secretion, nausea or dizziness. Some other more bizarre cases of autonomic effects cited by Travell and Simons comprise reddening of the eyes, excessive tearing, blurred vision, a droopy eyelid, excessive salivation, persistent nasal secretion and goose bumps.

Adhesions and contractures

Persistent trigger points in muscles can lead to stiff ropy like cords in the muscle – these are caused by fascial adhesions overlying and fixing the trigger point complex. Layers of connective tissue literally stick to each other causing hard, ropy muscles that feel like they are glued together. These are known as adhesions and severe cases can even develop into a form of contracture, similar to that seen in people with paralysis. Adhesions literally “lock in” trigger points making them more difficult to treat and compounding problems of pain and movement. Contractures also affect the overall functioning of the muscle; the contracture is felt as hard, tight and fibrotic whereas the rest of the muscle becomes weak and atrophied.

The great pretenders – Misdiagnosis and myths attributed to trigger points

Because most primary health care providers are not specialists in musculo skeletal pain, the pain from trigger points can be a cause of medical misdiagnosis. Travell and Simons name a list of 23 common diagnoses where overlooked trigger points were the cause of symptoms. Looking down the list is similar to leafing through my client notes over the last 20 years – the conditions mentioned are common occurences in the average massage therapists clinic and can usually be successfully treated through trigger point therapy. Some common examples of misdiagnosis I have encoutered over the last 20 years of clinical practice include:

• Frozen shoulder
• Bursitis
• Suspected herniated cervical or lumbar disc
• Osteoarthritis
• TMJ

Causes of Trigger Points

Trigger points are very common and can develop in any of the 200 muscles in the body. No one escapes them – not even children and babies. Trigger points can be caused by a variety of events including accidents, falls, repetitive motions, poor posture, pychological stresses and inadequate diet.

How to find and treat Trigger Points

For massage therapists the most efficient way to treat trigger points is by direct sustained pressure applied directly to the point for about 8-12 seconds.
Compression of the trigger point should always be followed by stretching of the muscle. In Jing we highly recommend the approach of treating all the muscles around the joint for trigger points – this is a key concept if you really want to successfully get your clients out of pain.
So for example to treat low back pain, the therapist looks for trigger points in the erector spinae, quadratus lumborum, gluteus maximus, gluteus medius, hamstrings and psoas.

Learning Trigger Points skills to integrate into your massage work

Like many bodywork modalities, effective trigger point technique is a subtle blend of art and science. Effective treatment depends on knowing how to accurately locate the muscles involved, confidence in your approach, focussed palpation skills and the opportunity to practice under experienced supervision.
There are many great CPD courses out there in trigger point therapy and we would highly recommend you get further training in these great techniques.
Upcoming articles in Massage World will also give more practical advice on how to incorporate trigger point therapy for effective results
For now – get yourself one of the great books out there on trigger point therapy and get trigger happy! You have nothing to lose and everything to gain!

This article originally appeared in the camclub newsletter - July 2015.

About Rachel Fairweather and Jing Advanced Massage

Rachel Fairweather is co-founder and director of Jing Advanced Massage. An acclaimed teacher and guest lecturer, she has been a massage therapist for 25 years and is co-author with Meghan Mari of an upcoming book “Massage Fusion: the Jing method for the treatment of chronic pain” to be published this year by Handspring Publishing. Based In Brighton, London and Edinburgh, Jing run a variety of courses in advanced techniques to help you build the career you desire including a BTEC level 6 (degree level) in advanced clinical and sports massage – the highest level of massage training in the UK. Our short CPD courses include excellent hands on learning in a variety of techniques including advanced stretching, trigger point therapy, myofascial release, pregnancy and hot stone fusion. For the first time you are now able to learn these techniques at your own time and pace with our revolutionary new online courses and webinars.

Want to find out more? Please contact Jing on 01273 628 942 or email [email protected] or see them at camexpo 2015, stand 1608.