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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Trigger Points & Myofascial Pain Syndrome


Aguidetotheunfinishedscienceofmusclepain,withreviewsofeverytheoryandselftreatmentandtherapyoption
updatedJanuary32017(firstpublished2001)
byPaulIngraham & TimTaylor,MD

Thisisanonlineebook:adetailed,current(2017),andpracticaltourofthescienceandtreatmentofmusclepainandtriggerpoints(muscleknots),forboth
patientsandprofessionals.
Whatarethecontroversiesandmythsaboutmusclepain?Whatworksformusclepain,whatdoesnt,andwhy?Getmanytroubleshootingideasforeventhetoughestcases
morethanthepopularTriggerPointTherapyWorkbook, 1 morereadable(andmodern)thanthefamousTravelltexts,andmorerealisticandhonestthananyothersource.
Manypeoplesuerfromsensitivespotsinmuscle,knownastriggerpoints.Andyettriggerpointtherapyisnotrocketscience. 2 Youjustneedagoodselectionofrational
options:creativetips,tricks,insightsandperspectives,basedonrecentscienceandyearsofclinicalexperience.

https://www.painscience.com/tutorials/triggerpoints.php

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Triggerpointtherapyisexperimentalandabitofacrapshoot,andyetlearningevenalittleabouttriggerpointscansolvemanypainproblemseasily.Ifyoufeellikeyouhave
problemswithstubbornandunexplainedachingandstinessandwhodoesnt,really?pleasekeepreading!

Doesyourbodyfeellikeatoxicwastedump?
Itmaybemoreliterallytruethanyourealized!Someevidenceshowsthata
knotmaybeapatchofpollutedtissue:anastylittlecesspoolofwaste
metabolites.Ifso,itsnowondertheyhurt,andnowondertheycauseso
manystrangesensations:itsmorelikebeingpoisonedthanbeinginjured.
Backpainisthebestknownsymptomofthecommonmuscleknot,butthey
cancauseanastonishingarrayofotherachesandpains.Misdiagnosisis
muchmorecommonthandiagnosis.

Triggerpointtherapyisnotamiraclecureforchronicpainbutithelps
Triggerpointtherapyisnttoogoodtobetrueitsjustordinarygood.Itsdenitelynotmiraculous. 3 Itsexperimentalanditoftenfails. 4 Goodtriggerpointtherapyishard
tond(orevendene).
Butitsalsounderrated,andselftreatmenthasthepotentialtoquickly,cheaply,andsafelyhelpwithmanycommonpainproblemsthatdontrespondwelloratallto
anythingelse. 5
Forbeginnerswithaveragemusclepainatypicalcaseofnagginghippainorlowbackpainorneckpain
theadvicegivenheremaywellseemalmostmiraculouslyuseful.Igetavalanchesofemailfromreaders
thankingmeforpointingoutsimpletreatmentoptionsforsuchirritatingproblems.Manyarestunnedbythe
discoverythattheirchronicpaincouldhavebeentreatedeasilyallalong.

Attentionphysicians&therapists: Thismassivetutorialiswrittenfor
bothpatientsandprofessionals.Itincludesanalysisofrecentresearchthat
youwontndinanytext,craftedtosuitanyskilllevel. 6 Footnotesadda
optionallayerofadvanceddetailthatyoucantakeorleave.
Triggerpointsaremoreclinicallyimportantthanmosthealth
professionalsrealize,andbodypainseemstobeagrowingproblem. 7 Itsa

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Forveteranswhohavealreadytriedandfailedtotreattriggerpoints,thisdocumentisespeciallymade
foryou.Youshouldlearnmoreandtrymorebeforegivingup.Thiswillgetyouasclosetoacureasyoucan
get;Icangiveyouaghtingchanceofatleasttakingtheedgeoyourpain.Andmaybethatisabitofa
miracle.

rewardingtopicfordoctorsandtherapists,thatmakesclearpathtohelping
quiteafewpeopleyouprobablycouldnthelpbefore.Evenifyoualready
knowaboutmyofascialpainsyndrome,youwillgetnewideashere.

Whatexactlyaremuscleknots?
Whenyousaythatyouhavemuscleknots,youaretalkingaboutmyofascialtriggerpoints.[Wikipedia]
Therearenoactualknotsinvolved,ofcourseitjustfeelslikeit.Althoughtheirtruenatureisuncertain,themaintheoryisthatatriggerpoint(TrP)isasmallpatchoftightly
contractedmuscle,anisolatedspasmaectingjustatinypatchofmuscletissue(notawholemusclespasmlikeacharliehorse 9 ).Intheory,thatsmallpatchofmusclechokes
oitsownbloodsupply,whichirritatesitevenmoreaviciouscyclecalledametaboliccrisis.TheswampymetabolicsituationiswhyIliketothinkofitassickmuscle
syndrome.
Afewtriggerpointshereandthereisusuallyjustanannoyance.Manybadonesisasyndrome:
myofascialpainsyndrome(MPS).
TrPscanbevicious.Theycancausefarmorediscomfortthanmostpeoplebelieveispossible.Its
barkismuchlouderthanitsbite,butthebarkcanbeextremelyloud.Itcanalsobeasurprisingly
weirdbark(triggerpointscangeneratesomeoddsensations).

https://www.painscience.com/tutorials/triggerpoints.php

Amuscleknotisatriggerpoint:asmallpatchofmuscle
tissueinspasm.

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Whymusclepainmatterssomuch
Musclepainmatters:itsanimportantproblem.Achesandpainsareanextremelycommonmedicalcomplaint, 10 andtriggerpointsseemtobeafactorinmanyofthem. 11 12
Theyareakeyfactorinheadaches(possiblyincludingmigraineandclusterheadachesaswell 13 14 ),neckpainandlowbackpain,and(much)more.Whatmakestriggerpoints
clinicallyimportantandfascinatingistheirtriplethreat.Theycan:
1. causepainproblems,
2. complicatepainproblems,and
3. mimicotherpainproblems.
Musclejusthurtssometimes.Triggerpointscancausepaindirectly.Triggerpointsareanaturalpartofmuscletissue. 15 Justasalmosteveryonegetssomepimples,sooner
orlateralmosteveryonegetsmuscleknotsandyougetpainwithnootherexplanationorissue.
Itscomplicated.Triggerpointscomplicateinjuriesandotherpainfulproblems.Theyshowuplikepartycrashers.Whateverswrong,youcancountonthemtomakeitworse,
andinmanycasestheyactuallybegintoovershadowtheoriginalproblem.
Itfeltlikeatoothache.Triggerpointsmimicotherproblems.Manytriggerpointsfeellikesomethingelse.Itiseasyforanunsuspectinghealthprofessionaltomistake
triggerpointpainforpracticallyanythingbutatriggerpoint.Forinstance,musclepainisprobablymorecommonthanrepetitivestraininjuries(RSIs),becausemanysocalled
RSIsmayactuallybemusclepain. 16 Aperfectexample:shinsplints. 17
Thedailyclinicalexperienceofthousandsofmassagetherapists,physicaltherapists,andphysiciansstronglyindicatesthatmostofourcommonachesandpainsandmanyother
puzzlingphysicalcomplaintsareactuallycausedbytriggerpoints,orsmallcontractionknots,inthemusclesofthebody.
Thetriggerpointtherapyworkbook,byClairDavies,p.2

thisinformationaboutmusclepain?

Howcanyoutrust

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

IapplyaMythBustersapproachtohealthcare(withoutexplosives):Ihavefunquestioningeverything.IdontclaimtohaveTheAnswerfortriggerpoints.WhenIdontknow,I
admitit.Ireadscienticjournals,Iexplainthesciencebehindkeypoints(therearemorethan340footnoteshere,drawnfromahugebibliography),andIalwayslinktomy
sources.
Forinstance,theresgoodevidencethateducationaltutorialsareactuallyeectivemedicineforpain.Goodinformationisgoodmedicine!
Unfortunately,goodinformationisachallengewithtriggerpoints.Thescienceisabit
shabby. 18 Theyareunderexplained.Theyareoverhyped.Theyarentaakydiagnosis, 19 but
theyrenotexactlyonasolidfoundationeither,andsomecriticshavedismissedtheentire
concept. 20

Thescienceoftriggerpointsisabitshabby.Theyareunderexplained.

Noneofthatisadealbreaker,though:musclepainisstillanimportanttopic,triggerpointsisa
usefulworkinprogresslabelforwhateverisgoingon,andeveryoneagreesthatsomething
painfulisgoingon.Soallthemorereasontohavearationaltourguidetotakeyouthrougha
murkysubject.Whatsusefulinthetheoryoftriggerpoints?Whatshalfbakedandobsolete?Whodisagreesandwhy?

Halfbakedideascanturnoutokayaslongastheystayintheoven.Triggerpointsciencemaybeabitofahotmess,butitalsoisntover.

Whyaretriggerpointssoneglectedbymedicine?
Muscleisanorphanorgan.Nomedicalspecialityclaimsit. 21 Muscletissueisthelargestorganinthebody,complexandvulnerabletodysfunction,andtheprimarytargetof
thewearandtearofdailyactivities,neverthelessitisthebones,joints,bursaeandnervesonwhichphysiciansusuallyconcentratetheirattention. 22 Familydoctorsare
particularlyuninformedaboutthecausesofmusculoskeletalachesandpains 23 itsimplyisntontheirradar.Theyarebusywithalotofotherthings,manyofthemquitedire.
Asseriousasmusclepaincanbe,itsminorcomparedto,say,diabetesorheartdisease.Anditsalsoahardertopicthanitseemstobeonthesurface.Soitsnotreallysurprising
thatdoctorsarentexactlymusclepaintreatmentJedi.
Whataboutmedicalspecialists?Theymaybethebestoptionforseriouscases.Doctorsinpainclinicstendtoknowabouttriggerpoints.Buttheyalsooftenlimittheir
treatmentmethodsexclusivelytoinjectiontherapiesabazookatokillamouse?andanythinglessthanreallyepicchronicpainwontqualifyyouforadmittancetoapain
clinicintherstplace.Thisoptionisonlyavailabletopatientsforwhomtriggerpointsareatrulyhorridprimaryproblem,oramajorcomplication.Medicalspecialistsmayknow
quiteabitaboutmusclepain,butarentallthathelpfultotheaveragepatient.

Anappallinglyhighpercentageofdoctorsandotherpractitionersarestillprettymuchoutoftheloop
regardingtriggerpoints.
https://www.painscience.com/tutorials/triggerpoints.php

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Thetriggerpointtherapyworkbook,byClairDavies,p.2

Physicaltherapistsandchiropractorsareoftenpreoccupiedtoafaultwithjointfunction,biomechanics, 24 andexercisetherapy.Theseapproacheshavetheirplace,but
theyareoftenemphasizedattheexpenseofunderstandingmusclepainasasensorydisorderwhichcaneasilyaictpeoplewithapparentlyperfectbodies,postureandtness.A
lotofpatienttimegetswastedtryingtostraightenpatients,whenallalongjustalittlepressureonakeymuscleknotmighthaveprovidedrelief.
Massagetherapistshavealotofhandsonexperienceofmuscletissue,butknowsurprisinglylittleaboutmyofascialpainsyndrome.Theirtrainingstandardsvarywildly.Even
inmythreeyearsoftrainingasanRMT(thelongestsuchprogramintheworld 25 ),Ilearnedonlythebasicsbarelymorethanthisintroduction!Likephysicaltherapistsand
chiropractors,massagetherapistsareoftenalmostabsurdlypreoccupiedwithsymmetryandstructure.Therighthandscangiveyoualotofrelief,butitshardtondorbe
therighthands.
Noprofessionalsofanykindarecommonlyskilledinthetreatmentoftriggerpoints.Muscletissuesimplyhasnotgottentheclinicalattentionitdeserves, 26 andsomisdiagnosis
andwrongtreatmentislikedeathandtaxesinevitable!Andthatiswhythistutorialexists:tohelpyousaveyourself,andtoeducateprofessionals.
Thoseclinicianswhohavebecomeskilledatdiagnosingandmanagingmyofascialtriggerpointsfrequentlyseepatientswhowerereferredtothembyotherpractitionersasalast
resort.Thesepatientscommonlyarrivewithalonglistofdiagnosticprocedures,noneofwhichsatisfactorilyexplainedthecauseof,orrelieved,thepatientspain.
MyofascialPainandDysfunction,byJanetTravell,DavidSimons,andLoisSimons,p.36

Doesyourtriggerpointtherapisthavethebigredbooks?
Inadditiontomanyscienticpapers,thistutorialisbasedonmedicaltextbookslikethemassivetwovolumeset,thebigredbooks
MyofascialPainandDysfunction 27 andthebluebook,MusclePain 28 Thesearenoteasyreading! 29
Theydontcontainalltheanswers,butanyonewhoclaimstotreatmusclepainshouldstillhavethebigredbooksbooksintheiroce
theyarejusttoohistoricallyimportantnottohave.Ifyoudontseedogearedcopies,askaboutthemitsafair,eectiveand
politewaytocheckatherapistscompetence.MusclePain(theblueone)isjustasimportant.Ihighlyrecommendittoanyprofessional
whoworkswithmuscle(orshould).Itsmorerecent,anditcoversamuchwiderrangeofsofttissuepainissues,puttingtriggerpoints
incontext.

TheBigRedBooks
Must-havetextbooksforanytherapisttreating
triggerpoints.
https://www.painscience.com/tutorials/triggerpoints.php

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Abriefnoteabouttherelationshipbetweenfibromyalgiaandmyofascialpainsyndrome
Fibromyalgia(FM)causesyoutohurtalloverwidespreadchronicpain,anddecreasedpainthreshold.Itisalsoassociatedwithfatigue,sleepdisturbance,andbrofog
(mentalconfusion).Itisdenedbyitssymptoms, 30 becausewedontknowwhatactuallycausesitsopeoplehavepain,butnoonehasFMuntilitisdiagnosed. 31 Heresa
good1minuteprimeronbromyalgiafromOneMinuteMedicalSchool:

FibromyalgiaSyndrome

1:00

Althoughunexplained,FMmaybeamoreclearlyneurologicaldisease,whileMPSmaybemoreofadysfunctionofmuscletissueanditwouldbeniceifsuchacleardierence
wereprovensomeday.FMandMPSsyndromearebothimperfectandimprecisedescriptionsof
closelyrelatedsetsofunexplainedsymptoms,whichmakesthemhardertotellapartthan
mischievoustwinswhodeliberatelyimpersonateeachother.Theymaybetwosidesofthesame
painfulcoin,ordierentpartsofaspectrumofsensorymalfunction.Theymaysimplybe
describingdierentpartsorstagesofthesameprocess,andsomecasesareprobablynearly
impossibletotellapartandthentheychange.Addtothatthefactthatbothconditionsare
controversialtothepointwheresomepeopledenytheyevenexist,anditsunderstandablethat
theygetconfused.

Fibromyalgia&myofascialpainsyndromearehardertotell
apartthanmischievoustwinswhodeliberatelyimpersonate
eachother.

Fibromyalgiasfamoustenderpointsarethemostconfusingpartofall,buttheyareaverydierentideathantriggerpoints.Triggerpointsdescribelocalizedpaininalmostany
location,whichcancomeandgoliketheweather,buttherearejustafew(18)ocial,specictenderpointsthatarepersistentfeaturesofFMliterallybydenition.Ifyoudont
havethetenderpoints,youdonthavethediagnosis!
Whateverthecausesorlabels,therapyforMPSseemstobehelpfulforsomeFMpatientsaswell, 32 althoughpureFMcasesseemtobemostlyimmunetomassage. 33 Butthis
bookisstillusefulformanyFMpatients,insofarasitoverlapswithourmaintopic.Dr.Taylorsadviceaboutmedicalcausesofpainareespeciallyhelpful;hiswifeisalsoadoctor
andhasbromyalgiaandhasgottenconsiderablerelieffromtherecommendationssharedhere.Sothisisnotabromyalgiabook,persebutIcertainlyhopeitsofinterestto
bromyalgiapatients.

https://www.painscience.com/tutorials/triggerpoints.php

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Triggerpointsmayexplainmanysevereandstrangeachesandpains
Thisiswheretriggerpointsreallygetinteresting.Inadditiontominorachesandpains,musclepainoftencausesunusualsymptomsinstrangelocations.Forinstance,many
peoplediagnosedwithcarpaltunnelsyndromeareactuallyexperiencingpaincausedbyamuscleintheirarmpit(subscapularis). 34 Seriously.Imnotmakingthatup!
Thisoddphenomenonofpainspreadingfromatriggerpointtoanotherlocationiscalledreferredpain.Theneurologywillbeexplainedindetailbelow.Herearesomeother
examplesofinterestingreferredpainleadingtomisdiagnosis: 35
Sciatica(shootingpaininthebuttocksandlegs)isoftencausedbypaininthepiriformisorotherglutealmuscles,andnotbyirritationofthesciaticnerve.Manyother
triggerpointsaremistakenforsomekindofnerveproblem.
Chronicjawpain,toothaches,earaches,sinusitis,ringingintheears(tinnitus),anddizzinessmaybesymptomsoftriggerpointsinthemusclesaround
thejaw,face,headandneck. 36 37
Asorethroatoralumpinthethroatisoftencausedoraggravatedbytriggerpointsanywherearoundthethroat. 38
Appendicitispainoftenturnsout,sometimesaftersurgery,tobecausedbyatriggerpointintheabdominalmuscles.Wow.
SevereMPSisoftenmistakenforbromyalgia(andothercausesofpainhypersensitivity).

https://www.painscience.com/tutorials/triggerpoints.php

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Sometimestriggerpointscausesuchseveresymptomsthattheyaremistakenformedicalemergencies.Itreatedamanforchestandarmpainhehadbeeninthehospitalfor
severalhoursbeingcheckedoutforsignsofheartfailure,butwhenhegottomyocehissymptomswererelievedbyafewminutesofrubbingapectoralismajormuscletrigger
point.Thesametriggerpointsometimesraisesfearsofatumor.Heresaparticularlyexcellentexamplesenttomebyaphysicianwhohadthisexperience:
Inarrowlyescapedabreastbiopsybecauseoftriggerpointsinthepectoralismajor.Idhadbadchestpainforamonth.Iwasonthetable,permitsigned,draped.Thedoctorwasnt
sure:shesaidshewantedanothermammogram.Ileftconfused,relievedbutstillhurting.
ThenIluckedout:myregularinternistwaspuzzled,butthoughtitmightbesofttissue.Thatmademegotoaphysicaltherapist.Thephysicaltherapistpulledoutthebigredbooks
ontriggerpoints,andwereadtogether.Treatmentwasacompletesuccess.AmontholdseverepainthatIhadbeentreatingwithicepacksinmybraandpainkillersgone!
JaniceKregor,competitiveswimmer,retiredpediatricianandmedicalschoolinstructor

Anotherclientoncespentthreedaysinhospitalforsevereabdominalpainthatdoctorscouldntdiagnoseherpainwasmostlyandquicklyrelievedbymassagingatriggerpoint
inherpsoasmajormuscle. 39
Ioncesueredadramaticcaseofatoothachethatwascompletelyrelievedbyamassagetherapistthedaybeforeanemergencyappointmentwiththedentist:aparticularlyvivid
experience.
However,thevastmajorityofsymptomscausedbymyofascialpainsyndromearesimplythefamiliarachesandpainsofhumanitymillionsofsorebacks,shouldersandnecks.
Someofwhichcanbecomequiteserious.

Isthislikeyou?
Muscleknotpaincanbesavage.OvertheyearsIhavemetmany
peoplewhowereinsomuchpainfrommuscledysfunctionthatthey
couldhardlythinkstraight.Ismusclepaintrivial?Notifyouhave
it!

https://www.painscience.com/tutorials/triggerpoints.php

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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Twotypicaltalesoftriggerpointtreatment
Therelationshipbetweentriggerpointsandmildtomoderatepainisoftensostraightforwardthattherapyisnearlyeortless.Oneofthenicethingsaboutworkingwithtrigger
pointsisthatsometimestheydomakemeseemlikeamiracleworker,becausetheyaresuchaclinicalslamdunkforgardenvarietypersistentpainpainundiagnosedand
untreatedbyastringofotherhealthprofessionals.
Forinstance,LoisMcConnellofVancouvercametoseemecomplainingthatshedhadmoderate,chronicbackpainforseveralyears.Shedreceivedsomecommonmisdiagnoses,
particularlysacroiliacjointdysfunction. 40 Butshehadaprominentgluteusmaximustriggerpoint 41 that,whenstimulated,feltexactlylikehersymptomsadeepacheinthe
regionofthelowbackanduppergluteals.Injustthreeappointments,herpainwascompletelyrelieved.Shewasquitepleased,Icantellyou!
Justwantedtogiveyouaquickupdate mybackhasbeenabsolutelyne. Unbelievableorperhapsnot,consideringwhatIvelearnedfromyou!Abigthankyouforallyourhelp.
LoisMcConnell,retiredairlineexecutive,sueredchroniclowbackandhippainforafewyears

OrconsiderJanCampbell.Jandevelopedahippainsometimeinearly2004duringaperiodofintenseexercising.Thepainquicklygrewtothepointofinterferingwith
walking,andwasmedicallydiagnosedaseitherabursitisorapiriformisstrain.Ididnotbelievethateitherofthesecouldbethecase,andtreatedatriggerpointinherpiriformis
muscleonceonJune12,2004.Hersymptomwas100%relievedforabouteightmonths,beforeitslowlybegantoreassertitself(astriggerpointsoftendo,despiteourbesteorts
moreaboutthattocome).
OnetriggerpointtherapytreatmentcompletelyrelievedanastystubbornhippainthatI'dhadforvemonths!
JanCampbell,retiredFrenchlanguageteacher,PalmSprings,recoveredeasilyfromseveralmonthsofhippain

Everytriggerpointtherapisthasaseeminglyendlesslistofsuchtreatmentsuccessstories.Althoughmostsuchcasesinvolverelativelyminorsymptoms,thisisnottosaythatthey
wereminorproblems.Inalmosteverysuchcase,thepainwasrelativelymildbutextremelyfrustratingandpersistentformanyyears,thenrelievedeasilybyahandfulof
treatmentsanincrediblething,whenyouthinkaboutit.Somuchunnecessarysuering!

Themythofthetriggerpointwhisperer
Canagoodenoughmassagetherapistremovealltriggerpointsinasession?Istheresuchathingasatriggerpointwhisperer?
Igotthisquestionbyemail,anditshowsacommontheme:theoptimistic/desperatequestforthemystiqueofthemagicsupertherapistwhocanxanythingintwoorthree
sessions.Orevenless. 42 Theideaisanannoyancetoallhonest,humbleprofessionalswhoknowbetterandmoreorlessimpossibletobelieveifyouknowthebasicsabout
painandmuscleknots.Theskillofatherapistisonlyonerelativelyminorfactoramongmanythataectthesuccessofmassagetherapyfortriggerpointsoranytherapy,for
anypainproblem.

https://www.painscience.com/tutorials/triggerpoints.php

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Triggerpointsarenotlittleswitchesthatcanbeickedo(released)byanyonewhohas
sucientlyadvancedtechniquetheyareamysterious,cantankerous,complexphenomenon.
Eventhebesttherapistscanbedefeatedbyanowinsituation. 43 Andnearlyanytherapistcan
luckoutandgetgreatresultswiththeoccasionalpatientwhenalltheplanetsarealigned:
sometimestriggerpointsrespondwelltovirtuallyanyintervention.Itreallydepends.
Forcomparison,canagoodenoughdogtrainertrainanydoginahour?EvenCesarDog
WhispererMillansayshecantifthedogistraumatized,sick,and/orinjured,andrequireshours
ofsmart,gradualconditioning.Itdependsonthesituation.

Eventhebesttherapistscanbedefeatedbyano-win
situation&nearlyanytherapistcanluckout&getgreat
resultswiththeoccasionalpatientwhenalltheplanetsare
aligned.

Itdepends,itdepends,itdepends.Thisisamajorthemeinthisdocument,anditiswhyIam
dedicatedtoteachingconceptsandprinciples,nottreatmentrecipesandformulaeandthatswhyitsanimportantthingtocoverintheintroduction.

DIAGNOSIS
Howcanyoutelliftriggerpointsarethecauseof

yourproblem?

Triggerpointshavemanystrangefeaturesandbehaviours,andcaneasilybeconfusedwithmanyotherproblems.Becauseoftheirmedicalobscurityandthehalf
bakedscience,theyareoftenthelastthingtobeconsideredinspiteoftheirclinicalimportanceandmanydistinctivecharacteristics.Thereareseveralthingsyoucanlookforthat
willhelpyoutofeelmorecondentthat,yes,musclepainistheprobleminsteadofsomethingelse.Thenextseveralsectionswilldiscussallofthemindetail.
Whetheryouknewitornot,youwereprobablyalreadyfamiliarwithtriggerpointsevenifyoudneverheardofthembeforestartingthistutorial.
Almosteveryonehasaheadstartinselfdiagnosingtriggerpoints,becausealmosteveryonealreadymoreorlessknowswhatitsliketohaveamuscleknot.Ifyouhaveeverhad
musclestiness,wrenchedyourneckaroundtryingtostretchandwiggleyourwayfreeofdiscomfort,orgottenafriendorpartnertodigintothatannoyingspotinyourback,
thenyoualreadyhavesomeexperiencewiththisyouhavetriggerpoints.Youhavepainandstinessthatfeelslikeitsinyourmuscles.
Buttheremaybemanythingsyoudontyetknowabouthowtriggerpointsbehaveandfeel

ENDOFFREEINTRODUCTION

https://www.painscience.com/tutorials/triggerpoints.php

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TABLE OF CONTENTS PR EVIEW

Introduction
1.1
1.2

Triggerpointtherapyisnotamiraclecureforchronicpainbutithelps
Whatexactlyaremuscleknots?
Whymusclepainmatterssomuch

https://www.painscience.com/tutorials/triggerpoints.php

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1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10

TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Whymusclepainmatterssomuch
Howcanyoutrustthisinformationaboutmusclepain?
Whyaretriggerpointssoneglectedbymedicine?
Doesyourtriggerpointtherapisthavethebigredbooks?
Abriefnoteabouttherelationshipbetweenbromyalgiaandmyofascialpainsyndrome
Triggerpointsmayexplainmanysevereandstrangeachesandpains
Twotypicaltalesoftriggerpointtreatment
Themythofthetriggerpointwhisperer

Diagnosis
Howcanyoutelliftriggerpointsarethecauseofyourproblem?
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21

Triggerpointdiagnosisisnotreliablebutitalsomaynotmatterthatmuch
Wherearethechartsanddiagramsoftriggerpointlocationsinthistutorial?
Quickchecklist:classictriggerpointsymptoms
Slowchecklist:amoredetaileddiagnosticchecklistformyofascialpainsyndrome
Negativechecklist:symptomsthatareprobablynotcausedbytriggerpoints
Ifyouhavetriggerpoints,willyourmusclesbetight?
Identifyingyourtriggerpointsbyfeel
Outofnowhere:asignaturesymptomoftriggerpoints
Chasingpain:hurtinginallthewrongplaces
Nervepainisoverdiagnosed
Casestudy:astoryaboutnervepainthatwasntreallynervepain
Morningsymptoms:anuncomfortabledailymysteryformanypeople
Fromthefryingpanofinjurypaintothereoftriggerpointpain
Coulditbe__________?Severalspecicproblemsthattriggerpointsgetconfusedwith
Casestudy:Bursitisstrikesagain!
Predictablyunpredictable:triggerpointsymptomsareerraticbynature
Allthenoise!Triggerpoints,jointpopping,andcrepitus
Whataretheworstcasescenariosformyofascialpainsyndrome?
WorstCaseScenario1:Beingtriggery
WorstCaseScenario2:Rarebutextremelyseverecasesofmyofascialpainsyndrome
WorstCaseScenario3:Quickstarttriggerpoints

Thescienceoftriggerpoints
Itsalittlehalf-baked,butatleastitsnotboring
3.1
3.2
3.3
3.4
3.5
3.6
3.7

Thedominanttheoryoftriggerpointsspelledoutinalittlemoretechnicaldetail
Micromusclesandthedanceofthesarcomeres
One:Theviciouscycle(whytriggerpointsarestubborn)
Two:Goodpain(whypressingontriggerpointshurtslikehellbutfeelslikeheaven)
Three:Tightness(whystretchingisappealingbutunderwhelming)
Four:Weakness(whymuscleswithtriggerpointsareweakandshouldnotbechallengedwithstrengthtraining)
Everythingwejustdiscussedinafewbulletpoints
Triggersfortriggerpoints:whatmakespatchesofsarcomeresgohaywire?

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3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Triggersfortriggerpoints:whatmakespatchesofsarcomeresgohaywire?
Theallpowerfulacneanalogy
Theevolutionofmusclepain:doesmuscleburnout?
ReferredPainScience(basic)
Referredpainscience(advanced)
Othertriggerpointtheories
Quintner:Itsthenerves,stupid
Thebamboocagewhatimmobilizationtorturecantellusaboutthenatureofmusclepainandmassage
Casestudy:anexampleofgettingunstuckandfeelinggiddywithjoy
Muscleknotsarenotinammatory:themythoftheinamedmyofascialtriggerpoint
Adhesionsandcontracture:whentriggerpointsfreezeinplace
Thescienceofadhesions:atomssticktoeachother
Thescartissueissueareyouscarredforlife?

BasicTriggerPointSelfTreatment
Whatcanyoudoaboutgardenvarietytriggerpoints?
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11

Downloadablequickreferenceguide
Basicselfmassageinstructions
Howdoyouknowitsworking?Gettingatriggerpointtorelease
Basictipsandtricksforbetter,longerlastingtriggerpointrelease
Top5mistakesbeginnersmake
Whataboutmassagetools?
Canyoudamageyournerveswhenselfmassaging?
Donthesitatetorecruitamateurhelp
Alittlemoreperspectiveonamateurassistance
Howtogetadequateprofessionalhelp
Commonmedicationsthatmightmakeadierence(andmightnot)

AdvancedTriggerPointTroubleshooting
Whatcanyoudoaboutsevereandpersistenttriggerpoints?
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12

Abriefdetour:whynotTheTriggerPointTherapyWorkbook?
Fundamentallimitationsoftriggerpointtherapy,andhowtotakeadvantageofthem
Severalmoretreatmentmistakesandproblems(thatyoucanx)
Moreseriousbarrierstosuccess
Newevidencethatsquishingtriggerpointsworksatleastalittle
Upgradeyourselfmassagetechnique
Dontgethunguponanatomy,andbepersistent
Focussingononetroublespotversusalittlebitofeverythingwhichisthebetterstrategy?
Moreinformationaboutexactlyhowtorub(movingstrokes)
Yetmoreinformationaboutexactlyhowtorub(pressingandholding)
Usingpressandholdtoidentifyatriggerpointreleaseinprogress
Identifyingyourtriggerpointsbyfeel(onceagain,asitpertainstotreatment)
Referredpainisnotadiagnosticfeatureoftriggerpoints!

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5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
5.21
5.22
5.23
5.24
5.25
5.26
5.27
5.28
5.29
5.30
5.31
5.32
5.33
5.34
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TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Referredpainisnotadiagnosticfeatureoftriggerpoints!
Dontbefooledbyreversereferral
Beyondthetennisball:commercialmassagetools
Commercialmassagetoolstoavoid
Massagetools:7free(orverycheap)andtoolsfromobjectsnotoriginallyintendedformassage
Thesocktrick
Thebathtrick
Introductiontononmassageselftreatmentsfortriggerpoints
Stretching(executivesummary)
Mobilizations:massagingwithmovementandtheGoldilockszone
Casestudy:mobilizationsprovetobecrucialfactorinrecoveryfromneckpainthatstartedinthe1970s
Tryingtosquirmyourwayoutoftriggerpointpain?Dontdoit!Consideralittlemoremethodinyourmadness
Howtotakeyourtriggerpointstothegym(ifyoumust)
Thermotherapy
Breathingdeeplyisfree,safe,andpossiblyamazingtherapyfortriggerpoints
Neutralpositioning:ndacomfortablemusclelengthandrestthere
Anintroductiontomedicatingmusclepain(hint:notagreatoption)
AntiinammatoriesandTylenol
VoltarenGel,anintriguingnewoption
Thenuclearoption:Hillbillyheroin(Oxycontin),codeineandotheropioids
ThesurprisingfutilityofmusclerelaxantssuchasRobaxwhatever,Valiumandotherbenzodiazepines
Lidocainepatches
Combinationtreatments:whyandhowtothroweverythingatitbutthekitchensink
Troubleshootingreferredpain:thereferredpaineldguide
Casestudy:referredpaincausesaheartattackandcompletelyfoolsdozensofprofessionals
Troubleshootingnegativereactionstotreatment

PerpetuatingFactors
Whatmakestriggerpointsstubborn?
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8

Troubleshootingstucktriggerpointsadhesionsandcontracture
Troubleshootingstress(withoutmeditationoryoga,unlessyoulikethatsortofthing)
Troubleshootingposture,ergonomics,andmuscleimbalance
Troubleshootingmysteriousperpetuatingfactors
Therelationshipbetweentriggerpointsandotherphysiologicaldisordersanddiseases,especiallybromyalgia
Waybeyondstubborn:troubleshootingextremecases
Realitychecks:someselftreatmentsthatdontworkatall(ornotnearlyaswellasyouwouldhope)
Whatiftriggerpointsonlypartlyexplainyourchronicpain?Severalothercausesofchronic,undiagnosedpain

MedicalFactorsThatPerpetuatePain
Theeffectofstatindrugs,nutritionalandhormonaldeficiencies,infections,andinflammatorydiseases
7.1
7.2

Someusual,unusual,anduniquemedicaldisclaimers
Gettingtestedandtreated:thehardway,theeasyway,andtherightway
Paincausingdrugsideeects:statins(cholesterolreducingdrugs)andbisphosphonates(forosteoporosis)

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7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16

TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Paincausingdrugsideeects:statins(cholesterolreducingdrugs)andbisphosphonates(forosteoporosis)
Nutritionalandhormonedeciencies
VitaminDdeciency
Thyroidhormonedeciency
Irondeciency(andexcess)
VitaminCdeciency
VitaminB12deciency
VitaminB1,B2,folate,andmagnesiumdeciencies
Testosteronedeciency
Estrogendeciency
Infections
Inammation
Smoking
Overalltreatmentstrategy

Stretching
Stretchingisgenerallyover-ratedbutitmightbegoodfortriggerpoints
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10

Theanecdotalevidenceforstretching(isjusthuge)
Casestudy:Acautionarytaleofstretching:thattimeIalmostrippedmyownheado
Winningatugofwar:howstretchingmighthelptriggerpointsinprinciple
Thebadnewsaboutstretchingfortriggerpoints
Likeaknotinabungiecord
Thesprayandstretchmethod,ifitworks,impliesthatstretchalonemaynotwork
Otherpracticallimitationsofstretchingfortriggerpoints
Whataboutneurology?Stretchtolerance
Whataboutstretchingtheantagonistmuscle?
Stretchingconclusions

GettingHelp
Howdoyoufindgoodtherapyforyourtriggerpoints?
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12

Typesoftherapistsanddoctorsandtheirrelationshiptotriggerpointtherapy
Massagequalitycontrolissues(ButIvealreadytriedmassagetherapy)
Twocasestudies:highlytrainedtherapistsfailingmiserably
Worstpracticesinmassagetherapy
Howtondgoodtriggerpointtherapy
ThePressureQuestion:howmuchistoomuch?
Paininthreeavours:thegood,thebad,andtheugly
Trainingyourtherapist
Otherkindsoftherapies
Howaboutsprayandstretchtherapy?
HowaboutthePaulSt.JohnMethodofNeuromuscularTherapy?
Howabouttranscutaneouselectricalnervestimulationtherapy?(TENSorENS)
Howaboutultrasoundtherapy?(ESWTandSonicRelief)

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9.13
9.14
9.15
9.16
9.17
9.18
9.19
9.20
9.21
9.22
9.23

TheCompleteGuidetoTriggerPoints&MyofascialPain(2016)

Howaboutultrasoundtherapy?(ESWTandSonicRelief)
Howaboutchiropracticjointadjustmentandpopping?
Howaboutmyofascialreleaseandfascialstretching?
Howabouttriggerpointinjectiontherapy?
HowaboutBotoxinjectiontherapy?
Howaboutnerveblocks?
Maybestabbingwillhelp!HowaboutDryNeedling,AKAIntramuscularStimulation(IMS)therapy?
Howaboutacupuncture?
Acupressure:whatifwepressedthosepointsinsteadofpuncturing?
HowaboutActiveReleaseTechniques(ART)?
Measuringprogressintriggerpointtherapy

FinalThoughts
Howisalemonlikeatriggerpoint?
Appendices
11.1
11.2
11.3

11.4
11.5
11.6
11.7
11.8

AppendixA:TriggerPointReferenceMaterialsor:Diagrams,Diagrams,Diagrams!
AppendixB:TheTriggerPointSymptomChecker
AppendixC:ThePerfectSpots
Spot#1forpainalmostanywhereinthehead,faceandneck,butespeciallythesideofthehead,behindtheear,thetemplesandforehead
Spot#2forpainanywhereinthelowback,tailbone,lowerbuttock,abdomen,groin,sideofthehip
Spot#3forpainintheshin,topofthefoot,andthebigtoe
Spot#4forpainintheupperback(especiallyinneredgeoftheshoulderblade),neck,sideoftheface,upperchest,shoulder,arm,hand
Spot#5forpainintheelbow,arm,wrist,andhand
Spot#6forpaininthelowback,hip,buttocks(especiallyimmediatelyunderthebuttocks),sideofthethigh,hamstrings
Spot#7forpaininthesideoftheface,jaw,teeth(rarely)
Spot#8forpaininthelowerhalfofthethigh,knee
Spot#9forpainanywhereinthechest,upperarm
Spot#10forpaininthebottomofthefoot
Spot#11forpainanywhereintheupperback,mainlybetweentheshoulderblades
Spot#12forpaininthelowerback,buttocks,hip,hamstrings
Spot#13forpaininthelowback,buttocks,hamstrings
Spot#14forpainanypartoftheshoulder,andupperarm
AppendixD:TriggerPointTherapyResources
Acknowledgements
ReaderComments
Whatsnewinthistutorial?
Notes

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readonanydevice,nopasswords
refundatanytime,inaweekorayear
call778-968-0930forpurchasehelp

Doesyourtutorialincludediagramsshowingcommontriggerpoints?
Yes,thirteenclassictriggerpointsareexplored,thePerfectSpotsformassage,accountingforabout75%ofcommonpainproblems.Otherreferencematerialisreviewedand
recommended,especiallythebestfreeonlineoption,TheTriggerPointSymptomChecker.
Willthetutorialsolvemyproblem?Whatifitdoesnt?
Maybe!But,naturally,IcantguaranteeresultsandIdontwantto.Idontbelieveingivingfalsehope,andtriggerpointtherapyisfarfromperfect.Mygoalistogiveyouthe
bestchanceofsuccess,andhelpyouavoidwastingyourtimeandmoneyonbollocksytherapies.Ifthatsnotworth$20,Ishouldgetoutofthepublishingbusiness.
Doesthetutorialincludeinformationon[insertyourpainproblem]?
Probablynot!Manyspecicpainproblemsarementioned,butthebookdoesntgointodetailaboutanyofthem.Onceyouunderstandthenatureoftriggerpoints,youdont
reallyneedmetospellouttheirrelationshiptoeverycommoninjury.Triggerpointscauseandcomplicateallinjuriesinquitepredictablewaysthatswhytheyareclinically
interesting!
Whynot

TheTriggerPointTherapyWorkbook?

ClairandAmberDaviespopularbookiswellwritten.Itisillustratednicely,andoersdetailedmusclebymusclereferencematerialsomethingthistutorialactually
deliberatelylacks.
(Thisisaveryshortversionofmyfullreview.)
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IusedtowonderwhyIevenbotheredtocreatethistutorial!WhynotjustrecommendtheWorkbook?Becausethistutorialhasgrownto
oeralotthattheWorkbookdoesnt,andprobablyneverwill.
Thestrengthofthistutorialisthedelvingintothenatureofthebeast(thescience),whileWorkbookhasfallenbehindthetimes.The3rd
edition(2013)promisestoomuchandneglectsimportantnewknowledge.Triggerpointtherapyhasbeenchallengedbymanyscientic
disappointmentsandcontroversies,andnewwaysofunderstandingpain,buttheWorkbookdoesntacknowledgeanyofthat.Thistopicis
tooimportantforsuchneglect.
Thegoalofthistutorialistooeramorerealisticandbalancedviewoftriggerpointtherapy,tomeetthechallengeofdicultcaseshead
on,andtoexploreeverypossibletreatmentoptiontheirpotentialandtheirlimitsandrisks.Ibelieveithasbeendoingabetterjobof
thatthantheWorkbookfromthebeginningnowmorethanever.

TheWorkbookpromisestoomuchand
neglectsrelevantscience.

readonanydevice,nopasswords
refundatanytime,inaweekorayear
call778-968-0930forpurchasehelp

APPENDICES

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Acknowledgements
ThisdocumentandallofPainScience.comwas,formanyyears,createdinmysocalledsparetimeandwithalotofassistancefromfamilyandfriends.Undyingthankstomy
wife,Kimberly,forcountlessindulgenceslargeandsmall,andforbeingmyeditorgirlfriend;tomyparentsfor(possiblyblind)faithinme,andmuchcopyediting;andtoMike
Gobbi,buddyanddigitalmentor,formanyoftheniftyfeaturesofthisdocument(hiddenandobvious).Andthankstoalloftheabove,andmanyothers,formany(many)answers
towhatdoyouthinkofthis?emails.
Thanksnallytoeveryreader,client,customer,andbigtipperforyourcuriosity,yourfaith,andyourfeedbackandsuggestionsandstories.Withoutyou,allofthiswouldbe
pointless.
Andafewthankstosomehealthprofessionalswhohavebeenparticularlyinspiringtome:Dr.RobTarzwell,Dr.StevenNovella,Dr.DavidGorski,SamHomola,DC,Dr.Harriet
Hall,SimonSingh,andDr.StephenBarrett.
ThankyounallytoDr.TimTaylor,MD,authorofthisbooksvitalsectionsaboutmedicalfactorsthatperpetuatepain,newasofthesummerof2010.Morethanacollaborator,
Timisanidealisticanddecisivevolunteer,whodidntjustoertocontributetothisbook,butmadeithappenquicklyandwellandallforthesakeofhelpingpeople.Intwenty
yearsofwritingandpublishing,Ihaveneverseenacollaborationgothatsmoothly,andIamextremelygratefulforit.

ReaderComments
Hereiswhatsomereadershavesaidaboutthetriggerpointstutorialovertheyears.Feedbackisalwayswelcome.Ifocusonthepositiveinthissection,butIwanttoacknowledge
thatIcertainlydoreceivesomecriticismsaswell.InmanycasesIrespondbymakingimprovementstothetutorial.However,thevastmajorityoffeedbackisenthusiastic.Thanks,
everyone!

Justwantedtosayhowgreatajobyouvedoneonallthisstu.Peopleclaimtheyknowabouttriggerpoints,butthemajorityreally,reallydont.IfIdidntbecomemyowndoctorIdbe
inareallydarkplacerightnow.Whatyouredoingisreallyimportant.IstillhavetheTriggerPointTherapyWorkbookandTravellandSimonsbigredbooks,butyouoersomereally
importantcommentaryandrealitychecksmissingfrombothofthosesources.
J.M.,chronicpainsuerer

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Ifeverydisorderhadsuchawellwrittenselfdiagnosticandtreatmentguidewe'dbealotclosertomanageablespendingonhealthcare.Thanks.
TimothyTrutna,programmerwithchronicmusclepain,California

Ipurchasedthelowbacktutorialrecentlyandgotthefreetriggerpointonealso.Manythanks.Theyaregreat!Ihadalreadyaccessedtheperfectspotseriesandhavebeenworkingon
mytriggerpoints.Itisverypleasingtohavethefulldiscussiononthechemistryandphysiology,andInowhaveamuchbetterideaaboutthewholeghastlybusiness.
LeahBrannen,Saskatoon,Canada

Ioweyoumanythanks.Yourtutorialhasgivenmegreathope.IwasextremelydiscouragedandfrustratedbytheissuesIwashaving,butIexperiencedmorereliefinmyrstsession
withatriggerpointtherapistthanIdidin12weeksofphysicaltherapy.
RyanLuke,MA,CSCS,DepartmentofKinesiologyandHealth,GeorgiaStateUniversity

FromAllansreviewofmytriggerpointbook:ThethingthatreallyjumpsoutatmeaboutPaul'striggerpointtutorialisthefairlymindbogglingamountofresearchhehasdone.It's
prettyincredible.It'sobviousthathedoeshishomework.It'sobviousthathe'sbeendoingitformanyyears.Andyetit'snotaboringoracademicdocument.Hekeepsitsurprisingly
lightandfunwhilesimultaneouslyexplainingalotofphysiologyandpathology.
AllanSaltzman,ownerofYogaTools.com,makerofsomenehandcraftedtoolsforyogaandselftreatment

Ihavebeensueringfromlowerbackpainforthelast5weeksandfoundyourpagetobeveryinformativeandinteresting.Ireallycantthankyouenoughactuallybecausefortherst
timeImreallystartingtofeellikeImontherighttrackhere.
GlennHill,Canterbury,Australia

Thankstoyourwebsite,Iprettymuchgotridofmybackproblemsalmostovernight.Itsalsofunandthoughtprovokingtoread!
AmsterdamJeroenStrompf,MFA,Screenwriting,ChapmanUniversity

Imreallyenjoyingyourwork!
JaniceKregor,competitiveswimmer,retiredpediatrician,medicalschoolinstructor

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READ19MORECOMMENTS

Onemorespecialcomment.IntheSpringof2009,IreceivedanincredibleendorsementfromJonathonTomlinson,aGPinHackney,EastLondon,praisingthewholewebsite
andeverytutorial:
I'mwritingtocongratulateandthankyouforyourimpressiveongoingreviewofmusculoskeletalresearch.Iteachacourse,MedicineinSociety,atSt.LeonardsHospitalinHoxton.I
originallystumbledacrossyourwebsitewhilstlookingforinformationaboutpainformymedicalstudents,andhaverecommendedyourtutorialstothem.Yourworkdeservesspecial
mentionforitstransparency,evidencebase,clearpresentation,educationalcontent,regulardocumentedupdates,andlackofanycommercialpromotionalmaterial.
Dr.JonathonTomlinson,MBBS,DRCOG,MRCGP,MA,TheLawsonPractice,London

Highpraiseindeed!Thankyou,Dr.Tomlinsontestimonialsjustdontgetmuchbetterthanthat.

Whatsnewinthistutorial?
RegularupdatesareakeyfeatureofPainScience.comtutorials.Asnewscienceandinformationbecomesavailable,Iupgradethem,andthemostrecentversionisalwaysautomaticallyavailableto
customers.Unlikeregularbooks,andevenebooks(whichcanbeobsoletebythetimetheyarepublished,andcangoyearsbetweeneditions)thisdocumentisupdatedatleastonceeverythree
monthsandoftenmuchmore.Ialsologupdates,makingiteasyforreaderstoseewhatschanged.Thistutorialhasgotten101majorandminorupdatessinceIstartedloggingcarefullyinlate2009
(pluscountlessminortweaksandtouchups).
Repairs(Jan3'17,section#11.4)Repairoftheresourcelist,purgingsomethatarenolongeravailableandmakingmany
correctionstothosethatstillare.Seesection#11.4,AppendixD:TriggerPointTherapyResources.
Scienceupdate(Nov21'16,section#7.5)AddedafewnewcitationsabouttheprevalenceofvitaminDdeciencyandits
correlationwithchronicpain.Seesection#7.5,VitaminDdeciency.

Mostlinkstosectionsshownhereworkforcustomersonly.For
accesstoallsections,buythetutorialfor$19.95.Youllgetthefull
versionrightaway.

Rewrite(Nov15'16,section#8.5)Anewwayoflookingathowtriggerpointscausethesensationofstinessandwhathappenswhenwetrytostretchthemout.Seesection#8.5,Likea
knotinabungiecord.
Modestrevision(Nov15'16,section#8.4)Reorganizedpresentationofthepracticalandtheoreticalchallengeswithstretchingtriggerpoints.Seesection#8.4,Thebadnewsabout
stretchingfortriggerpoints.
Minorediting(Nov12'16,section#8.6)Madethepointofthesectionmoreclearly.Seesection#8.6,Thesprayandstretchmethod,ifitworks,impliesthatstretchalonemaynotwork.
Edited(Oct20'16,section#2.4)Thoroughrevisionandmodernization.AlthoughIrevisedthissectionjustveyearsago,itneededitagain!Seesection#2.4,Slowchecklist:amoredetailed
diagnosticchecklistformyofascialpainsyndrome.

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Simplified(Sep12'16,section#5.32)Thissectionhasbeensimplied,andnowonlycoverskeypointsaboutopioidsandtherelevanceofopioidstoMPSspecically.Detailedinformation
aboutopioidshasbeenmovedtoaseparatearticle,OpioidsforChronicAches&Pains.Seesection#5.32,Thenuclearoption:Hillbillyheroin(Oxycontin),codeineandotheropioids.
Majorrewrite(Sep2'16,section#3.2)Thoroughrevisionoftheintroductiontosarcomeres,inspiredbythebookLifesRatchet,aboutmolecularmachines.Seesection#3.2,Micromuscles
andthedanceofthesarcomeres.
Correction(Aug9'16,section#2.4)Removedovercondentstatementsabouttheclinicalsignicanceoftheeectsofpsychoactivedrugs,plusrelatedminorupdates.Seesection#2.4,Slow
checklist:amoredetaileddiagnosticchecklistformyofascialpainsyndrome.
Safetyupdate(Jul6'16,section#5.32)UpdatedforconsistencywithnewCDCguidelines.Thorougheditingofthesection.Seesection#5.32,Thenuclearoption:Hillbillyheroin
(Oxycontin),codeineandotheropioids.
Newsection(Jun24'16,section#5.34)Nonotes.Justanewsection.Seesection#5.34,Lidocainepatches.
Importantnewrelatedreading(Jun2'16)Althoughnotanupdatetothebookitself,Ivepublishedsomeimportantrelatedarticlesaboutthescienticcontroversyovertheexplanation
fortriggerpoints:

1. aheavilyreferencedreviewoftheevidencethatatriggerpointisatinycramp
2. asummaryoftheacademiccontroversyabouttriggerpointscience
3. thestoryofmyowndoubtsandhowtheyvechangedovertheyears(thisisthemainarticleonthistheme;itwasaroundbeforebuthasbeenrevisedheavily)
Allofthisstuisinsidebaseball,andnotofinteresttomostreaders,butitscriticaltomycredibilityasanauthoronthistopicitshowsthatIvereallydonemyhomework,and
ImnotignoringtheconcernsofskepticalexpertssofornowIvemadeeverythingfreelyavailabletoallsitevisitorsinsteadofintegratingthemintothebook.Nevertheless,the
bookhasalreadybeenheavilyinuencedbythiswork,andwillcontinuetobe.
Minorupdate(May23'16,section#1.10)Addedagoodnewexampleofatriggerpointwhisperermyth.Seesection#1.10,Themythofthetriggerpointwhisperer.
Minorupdate(May7'16,section#5.17)Finallyaddedlacrosseballrecommendation.Seesection#5.17,Massagetools:7free(orverycheap)andtoolsfromobjectsnotoriginallyintendedfor
massage.
Scienceupdate(Feb13'16,section#3)Beefytuneupforthepillarsoftriggerpointscience:severalnewandcarefullywrittenfootnotes,linkingtomanypainstakinglysummarized
papersforreaderswhoreallywanttodelve.Itsabiggerupdatethanitlookslikeonthesurface.Seesection#3,Thescienceoftriggerpoints:Itsalittlehalfbaked,butatleastitsnotboring.
Edited(Nov18'15,section#9.2)Yetmoremodernizationandclarication.Seesection#9.2,Massagequalitycontrolissues(ButIvealreadytriedmassagetherapy).
Edited(Nov17'15,section#9.7)Modernizationandclarication.Seesection#9.7,Paininthreeavours:thegood,thebad,andtheugly.
Edited(Nov17'15,section#9.6)Modernizationandclarication.Seesection#9.6,ThePressureQuestion:howmuchistoomuch?
Edited(Nov17'15,section#3.4)Modernizationandclarication.Seesection#3.4,Two:Goodpain(whypressingontriggerpointshurtslikehellbutfeelslikeheaven).
Edited(Nov9'15,section#9.3)Tunedforconsistencywithmycurrentviews.Seesection#9.3,Twocasestudies:highlytrainedtherapistsfailingmiserably.

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Scienceupdate(Nov6'15,section#1.8)Addedafootnoteabouttriggerpointsbeingassociatedwithjawpain.Seesection#1.8,Triggerpointsmayexplainmanysevereandstrangeaches
andpains.
Revised(Oct16'15,section#9.5)Justmodernizingandclarifying.Seesection#9.5,Howtondgoodtriggerpointtherapy.
Scienceupdate(Sep15'15,section#3.12)Somereferencingaboutcentralsensitization,especiallythisfunfact:musclepainmaybeespeciallygoodatcausingCS.Seesection#3.12,
Referredpainscience(advanced).
NewSection(Sep11'15,section#3.1)Betterlatethannever,IveaddedasummaryoftheexpandedintegratedhypothesisfromGerwinetal.(2004).Seesection#3.1,Thedominanttheory
oftriggerpointsspelledoutinalittlemoretechnicaldetail.
Newsection(Sep5'15,section#9.21)Nonotes.Justanewsection.Seesection#9.21,Acupressure:whatifwepressedthosepointsinsteadofpuncturing?
Scienceupdate(Feb28'15,section#2.10)Addedthreegoodreferencesandadiagramabouthowmuchwiggleroomnerverootshave.Seesection#2.10,Nervepainisoverdiagnosed.
Scienceupdate(Feb22'15,section#9.17)Twonewsciencereviewsconsideredandcited.Seesection#9.17,HowaboutBotoxinjectiontherapy?
Rewritten(Jan4'15,section#5.1)Completelyrevisedforthe3rdeditionoftheWorkbook:Inolongerrecommendit.Seesection#5.1,Abriefdetour:whynotTheTriggerPointTherapy
Workbook?
Newcitation(Dec30'14,section#1.4)Addedanimportantnewreferencetoascienticpapercriticalofconventionalwisdom.Seesection#1.4,Howcanyoutrustthisinformationabout
musclepain?
Minorupdate(Jul8'14,section#9.20)Newfootnotesaboutthetheoryofacupuncture/triggerpointoverlap.Seesection#9.20,Howaboutacupuncture?
Scienceupdate(Jul7'14,section#9.19)And,sosorry,itsbadnews.Seesection#9.19,Maybestabbingwillhelp!HowaboutDryNeedling,AKAIntramuscularStimulation(IMS)therapy?
Scienceupdate(Mar19'14,section#6.5)Addedevidenceabouttheeectofmassageonbromyalgia.Seesection#6.5,Therelationshipbetweentriggerpointsandotherphysiological
disordersanddiseases,especiallybromyalgia.
Editing(Jan16'14,section#3.3)Generalrevisionforquality.Addedthecheekbiteanalogystoryforcolour.Seesection#3.3,One:Theviciouscycle(whytriggerpointsarestubborn).
Editing(Jan16'14,section#3.2)Generalrevisionforquality.Seesection#3.2,Micromusclesandthedanceofthesarcomeres.
Minorupdate(Jan5'14,section#3.11)Addedastoryaboutphantomlimbpain.Seesection#3.11,ReferredPainScience(basic).
Minorupdate(Dec21'13,section#5.33)MinorbutfascinatingnewitemaboutthemythofanaestheticparalysisandthedominanceoftheCNSovermuscletonethekindofniftyitem
Ijustlovetoaddtothebook!Seesection#5.33,ThesurprisingfutilityofmusclerelaxantssuchasRobaxwhatever,Valiumandotherbenzodiazepines.
Newsection(Dec13'13,section#3.14)Anintroductiontooneofthemostimportanttheoreticalchallengerstothetraditionalexplanationfortriggerpoints.Seesection#3.14,Quintner:
Itsthenerves,stupid.
Scienceupdate(May29'13,section#7.5)Goodnewsupdate:newstudyshowsaclearreductioninnonspecicmusculoskeletalpainaftervitaminDsupplementation.Seesection#7.5,
VitaminDdeciency.
Minorupdate(Mar29'13,section#5.31)UpgradedriskandsafetyinformationaboutVoltarenGel.Seesection#5.31,VoltarenGel,anintriguingnewoption.

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Majorupdate(Mar1'13,section#8)Almostallofthestretchingsectionshavebeenedited,revised,andmodernized.Seesection#8,Stretching:Stretchingisgenerallyoverratedbutit
mightbegoodfortriggerpoints.
Minorupdate(Mar1'13,section#1.7)Modernizedandexpandedabit,acouplenewreferences,andagenerallymuchbetterexplanationofwhatbromyalgiais.Seesection#1.7,Abrief
noteabouttherelationshipbetweenbromyalgiaandmyofascialpainsyndrome.
Scienceupdate(Dec14'12,section#7.15)Somemoreevidenceshowingtheroleofsmokinginchronicpain.Seesection#7.15,Smoking.
Scienceupdate(Dec7'12,section#7.15)Addedreferencesshowingconnectionsbetweensmokingandchronicpain.Seesection#7.15,Smoking.
Minorupdate(Dec7'12,section#5.7)Addedafunnysidebaraboutbadanatomy.Seesection#5.7,Dontgethunguponanatomy,andbepersistent.
Minorupdate(Oct25'12,section#3)Aminorcasestudyandsomesciencetohelpestablishthatmusclecanindeedbethesourceofpain.Seesection#3,Thescienceoftriggerpoints:Itsa
littlehalfbaked,butatleastitsnotboring.
Newsection(Oct24'12,section#8.9)Nonotes.Justanewsection.Seesection#8.9,Whataboutstretchingtheantagonistmuscle?
Minorupdate(Oct24'12,section#2.5)Addedanitemaboutmobilebumpsthatpeopleoftenmistakefortriggerpoints.Seesection#2.5,Negativechecklist:symptomsthatareprobably
notcausedbytriggerpoints.
Edited(Aug27'12,section#2.16)Nowmoreaccurateandclearer.Editsinpreparationforaudiobookversion.Seesection#2.16,Predictablyunpredictable:triggerpointsymptomsareerratic
bynature.
Majorupdate(Jul23'12,section#5.38)Newevidencethatmassagecancauserhabdomyolysismakesitquitealoteasiertounderstandalotofnegativereactionstotriggerpointtherapy.
Thisisvaluableperspective,andthesectionhasbeenheavilyrevisedtoexploitit.Seesection#5.38,Troubleshootingnegativereactionstotreatment.
Minorupdate(Jun9'12,section#3)Thisintroductionnowdoesabetter(andmorehonest)jobofmentioningsometriggerpointcontroversies,andlinkstoanimportantcompanion
articleaboutthem,forkeenerreaders,TriggerPointDoubts.Seesection#3,Thescienceoftriggerpoints:Itsalittlehalfbaked,butatleastitsnotboring.
Minorupdate(May2'12,section#2.8)Aminorbutgood:clearer,betterlanguage.EditingcontinuesasIworkontheaudiobookversion.Seesection#2.8,Outofnowhere:asignature
symptomoftriggerpoints.
Minorupdate(Apr25'12,section#2.4)Moreeditingforclarityandthoroughness.ThisalsohappenstobeoneofthersteditsImdoingtoprepareforaudiobookproduction.Seesection
#2.4,Slowchecklist:amoredetaileddiagnosticchecklistformyofascialpainsyndrome.
Scienceupdate(Mar28'12,section#6.7)Irevisedthewarningawayfromhydration,andincludedsomefunnewmythbustingevidenceabouthydrationandcramping.Seesection#6.7,
Realitychecks:someselftreatmentsthatdontworkatall(ornotnearlyaswellasyouwouldhope).
Newsection(Mar8'12,section#5.28)Nonotes.Justanewsection.Seesection#5.28,Neutralpositioning:ndacomfortablemusclelengthandrestthere.
Minorupdate(Mar8'12,section#2.5)Addedanitemaboutnonpainsymptoms,likeitching.Seesection#2.5,Negativechecklist:symptomsthatareprobablynotcausedbytriggerpoints.
Minorupdate(Mar7'12,section#5.32)Importantnew,skepticalfootnoteaboutthedangersofthepowerfulnarcoticdrugs.Seesection#5.32,Thenuclearoption:Hillbillyheroin
(Oxycontin),codeineandotheropioids.
Modestexpansion(again).Andthesassynewmusclestabbingsectionname.(Jan12'12,section#9.19)Seesection#9.19,Maybestabbingwillhelp!HowaboutDryNeedling,
AKAIntramuscularStimulation(IMS)therapy?
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Scienceupdate(Dec21'11,section#2.6)Addedquiteaninterestingcitationaboutthecorrelation(orlackthereof)betweentissuehardnessandsensitivity.Seesection#2.6,Ifyouhave
triggerpoints,willyourmusclesbetight?
Trivialupdate(Dec14'11,section#2)Addedminorbutoddnoteaboutsensoryannoyancesandhats.Yes,hats.Seesection#2,Diagnosis:Howcanyoutelliftriggerpointsarethecauseof
yourproblem?
Productsadded(Nov11'11,section#5.15)Threenewproductreviews,andsomemiscellaneousrevisionofthesection.Seesection#5.15,Beyondthetennisball:commercialmassagetools.
Updated(Oct16'11,section#9.15)Addednewreferencestofasciascienceaboutthetoughnessandcontractilityoffascia,andsomeinterpretation.Thisisalsosupportedbyasubstantial
newfreearticle,DoesFasciaMatter?Seesection#9.15,Howaboutmyofascialreleaseandfascialstretching?
Newsection(Aug26'11,section#7.15)Nonotes.Justanewsection.Seesection#7.15,Smoking.
Minorupdate(Aug26'11,section#7.10)Addedaparagraphaboutmagnesium.Seesection#7.10,VitaminB1,B2,folate,andmagnesiumdeciencies.
Newsection(Aug26'11,section#1.10)Nonotes.Justanewsection.Seesection#1.10,Themythofthetriggerpointwhisperer.
Newsection(Jul13'11,section#8.8)Somenewthoughtsabouthowstretchingfortriggerpointsmightworkquitedierentfromthemainstreamtheoryinspiredsomenew
stretchingscience.Seesection#8.8,Whataboutneurology?Stretchtolerance.
Majorrewrite(Jul13'11,section#3.15)ThismightaswellbeanewsectionnotonlydidIrewriteit,Igaveitacompletelynewpurpose.Previouslythebamboocagewasaminor
metaphorusedtoillustrateapossiblemechanismforsensitizationofmuscletissue.Nowitisthebasisofanextendedand(Ithink)interestingexplorationofhowtheconceptoftriggerpoints
mightactuallybedebunked.Prettyweightystu,butdeliveredwithamajoreorttomakeitinterestingtoanyreader.Hopeyouenjoyit!Seesection#3.15,Thebamboocagewhat
immobilizationtorturecantellusaboutthenatureofmusclepainandmassage.
Minorupdate(Jul12'11,section#7.5)AddedaninterestingobservationabouthowVitaminDsupplementationmightwork.Seesection#7.5,VitaminDdeciency.
Minorupdate(Jul12'11,section#2.4)Miscellaneouseditingandimprovements,plusacouplenewitems.Seesection#2.4,Slowchecklist:amoredetaileddiagnosticchecklistfor
myofascialpainsyndrome.
Minorupdate(May30'11,section#9.7)Addedsomebasicinformationaboutthedamagethatuglypaincanactuallydo,inspiredbyarecentanecdotereceivedfromareader.Seesection
#9.7,Paininthreeavours:thegood,thebad,andtheugly.
Scienceupdate(May7'11,section#7.5)TheVitaminDadviceprovidedtoreadershasnotchanged,butthesciencesupportingithasbeendramaticallybeefedupmorescience,new
science,bettersummarizedtoconrmthatDsupplementationisasafeandsensibleoptionforpatients.Seealsotheseparatearticle,VitaminDforPain.Seesection#7.5,VitaminDdeciency.
Majorupdate(Apr20'11)Majorimprovementstothetableofcontents,andthedisplayofinformationaboutupdateslikethisone.Sectionsnowhavenumbersforeasierreferenceand
bookmarking.Thestructureofthedocumenthasreallybeencleanedupingeneral,makingitsignicantlyeasierformetoupdatethetutorialwhichwilltranslateintomoregoodcontentfor
readers.Careformoredetail?Really?Heresthefullannouncement.
Minorupdate(Apr10'11,section#5.32)Editedtodistinguishmoreclearlybetweendependenceandaddiction,toreducealarmismaboutaddictionorcontributingtotheexcessive
stigmaagainstopioids.(ThankstoreaderEvelynD.forpointingouttheissuetomeagoodexampleofhowreaderscontributetotheimprovementofthistutorial.)Seesection#5.32,Thenuclear
option:Hillbillyheroin(Oxycontin),codeineandotheropioids.
Minorupdate(Mar22'11,section#9)Updatedthedisclaimer(sidebar)aboutmyconictofinterest.Inolongerhaveit,sinceIamretiredfrommymassagetherapypractice.Seesection
#9,GettingHelp:Howdoyoundgoodtherapyforyourtriggerpoints?

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Minorupdate(Feb3'11,section#5.5)Addedevidenceshowingthattriggerpointtherapyimprovedanklerangeofmotion.Seesection#5.5,Newevidencethatsquishingtriggerpoints
worksatleastalittle.
Minorupdate(Feb3'11,section#2.5)Addedachecklistitemaboutmusclewasting.Seesection#2.5,Negativechecklist:symptomsthatareprobablynotcausedbytriggerpoints.
Majorupdate(Dec30'10,section#9.13)Previouslythissectiondiscussedultrasoundrathergenerally,withoutmuchdiscussionofthescience;itisnowbeefedupwithathorough,fun
discussionofthesomewhatsquishyevidence.Seesection#9.13,Howaboutultrasoundtherapy?(ESWTandSonicRelief).
Minorupdate(Dec30'10,section#1)AddedaninterestingfootnoteabouttheGoogleBookNgramfortriggerpoints.Seesection#1,Introduction.
Manyminorrepairs(Dec1'10)Alargebatchofminorerrorsandglitcheswerecorrectedtoday,thankstothesharpeyesofreadersEeandDoris.
Modestexpansion(Nov25'10,section#9.19)Seesection#9.19,Maybestabbingwillhelp!HowaboutDryNeedling,AKAIntramuscularStimulation(IMS)therapy?
Newsection(Oct6'10,section#8.2)Notjustforcustomers:thisparticularsectionisashortversionofanewfreearticle.Seesection#8.2,Casestudy:Acautionarytaleofstretching:that
timeIalmostrippedmyownheado.
Majorupdate(Sep23'10,section#7)NumerousrepairsandupgradestoallofDr.Taylorssectionsofthebook,especiallylinkstotheclinicsthatDr.Taylorrecommends,somenewcharts,
andacolorfulanecdoteaboutdrinkingblood(seriously).Thankstoseveralreaders,andespeciallyElaineM.,fortheirassistancewiththis.Itsquiteamazinghowthenewchapterisdriving
immediaterenements.Peoplereaditandwritetoaskquestions,andthatspurslittleemaildebatesbetweenmeandDr.Taylor,atriptoPubMedformoreevidenceordetail,oraclarication
wranglewiththelanguage...andtheresultsgetputintothebookwithinhoursorevenminutessocool!AsreaderBillC.putit,Yourbooksarealive!Itdoeskindoffeellikethat.Seesection
#7,MedicalFactorsThatPerpetuatePain:Theeectofstatindrugs,nutritionalandhormonaldeciencies,infections,andinammatorydiseases.
Manynewsections(Sep20'10,section#7)Animportantnewchapter(withseveralsections)byDr.TimTaylor.ThisistherstmajorcollaborativeeortonPainScience.com,andIm
extremelyproudofit,andpleasedwithhowwellitwent.Seesection#7,MedicalFactorsThatPerpetuatePain:Theeectofstatindrugs,nutritionalandhormonaldeciencies,infections,and
inammatorydiseases.
Newsection(Sep15'10,section#5.5)Imdelightedtoaddawholesmallnewsectionaboutevidenceoftheecacyoftriggerpointtherapy.Seesection#5.5,Newevidencethatsquishing
triggerpointsworksatleastalittle.
Minorupdate(Sep15'10)IvedoneabunchofworktocontinueintegratingDr.Taylorsnewchapterintothebook:discussingperpetuatingfactorswherevertheyarerelevant,andlinkingto
thechapter.ThustherearemanymorespotsinthebooknowwheretheimportanceandrelevanceofDr.Taylorscontributionisemphasized.
Newcover(Aug6'10)Atlast!Ebooknallyhasacover.
Corrected(Jul20'10,section#3.19)Fixedsomewrongscienceabouthydrogenbondingandtissueadhesions.HattiptoreaderandchemistK.D.forthegoodcatch.Seesection#3.19,The
scienceofadhesions:atomssticktoeachother.
Minorupdate(Jul7'10,section#5.33)Updatedthemusclerelaxantsectionwithasummaryofabizarreexperimentwithmusclerelaxantsthathadquitesurprisingresults.Seesection
#5.33,ThesurprisingfutilityofmusclerelaxantssuchasRobaxwhatever,Valiumandotherbenzodiazepines.
Minorupdate(Jun25'10,section#1.8)Addedaniceanecdotefromadoctoraboutatriggerpointthatwasalmostmistakenforapossibletumor.Seesection#1.8,Triggerpointsmay
explainmanysevereandstrangeachesandpains.
Newsection(May26'10,section#11.3)ThisisamajorupgradetothepresentationofPainScience.comsownPerfectSpotsseriesofarticles.Theyhavealwaysbeenhere,butperhapsnot
presentedinasusefulawayastheycouldhavebeen.Ivealsomademanyupgradestothearticlesthemselvesoverthelast2months.Seesection#11.3,AppendixC:ThePerfectSpots.

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Newsection(May26'10,section#11.2)Describesanewpartnershipwiththepublishersofthebestonlinereferenceavailable.Seesection#11.2,AppendixB:TheTriggerPointSymptom
Checker.
Newsection(May26'10,section#11.1)Reviewsandrecommendationsofothersources.Seesection#11.1,AppendixA:TriggerPointReferenceMaterialsor:Diagrams,Diagrams,Diagrams!
Majorupdate(May25'10)Aweaknessofthistutorialhasnallybeeneliminated:referencematerial!Wherearethetriggerpoints?Althoughthisisstillnotanencyclopediaoftriggerpoints,
anditneverwillbe(bydesign),thebooknowhelpsreadersndspecictriggerpointinformationinthreenewways,inthreenewsections.
Manyminorrepairs(May17'10)Nospecicupdatetoday,butaparticularlylargedoseofeditinglove,withmythankstoreaderElaineM.forpointingoutseveralerrorsthatgotmestarted.
Elainereceivedsomefreeproductforherassistance,ofcourse,andsocanyouifyousendmeanymorethanafewerrorreports.
Minorupdate(Apr17'10,section#9.1)Improveddescriptionofphysiatrists(amedicalspeciality).Seesection#9.1,Typesoftherapistsanddoctorsandtheirrelationshiptotriggerpoint
therapy.
Newsection(Apr3'10,section#11.4)Finally,Iveaddeda(free)appendixofonlineresourcesrelatedtotriggerpointtherapy.Betterlatethannever.Seesection#11.4,AppendixD:Trigger
PointTherapyResources.
Tinyupdate(Feb13'10,section#5.33)Tinybutinteresting:Iaddedsomeprettygoodevidencethatamusclerelaxantwasnobetterforinjuredneckmusclesthanibuprofen.Seesection
#5.33,ThesurprisingfutilityofmusclerelaxantssuchasRobaxwhatever,Valiumandotherbenzodiazepines.
Newsection(Jan19'10,section#3.10)Nonotes.Justanewsection.Seesection#3.10,Theevolutionofmusclepain:doesmuscleburnout?
Minorupdate(Jan19'10,section#3.9)Alittlerevision,slightexpansion.Seesection#3.9,Theallpowerfulacneanalogy.
Majorupdate(Jan12'10,section#2.20)Sectionheavilyrevised,improved,andexpanded.Seesection#2.20,WorstCaseScenario2:Rarebutextremelyseverecasesofmyofascialpain
syndrome.
Majorupdate(Jan12'10,section#2.19)Sectionheavilyrevised,improved,andexpanded.Seesection#2.19,WorstCaseScenario1:Beingtriggery.
Minorupdate(Jan7'10,section#5.38)Asmallbutsignicantupdateonnutrition,basedonBischoFerrarietal ,whichbasicallyboilsdowntoarecommendationtotakevitaminDit
mighthelp.Seesection#5.38,Troubleshootingnegativereactionstotreatment.
OlderupdatesListedinaseparatedocument,foranyonewhocarestotakealook.

Notes
1. ThemostpopulartriggerpointbookforpatientsisstillTheTriggerPointTherapyWorkbook:Yourselftreatmentguideforpainrelief,byClair&AmberDavies.Unfortunately,it
wasscienticallyweakwhenthersteditionwaspublishedin2001,anditstillisafteraneweditionin2013.Itignoressomeimportantscienticndingsandcontroversiesofthelast20
years,andpromisestoomuch.
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ManypeoplehavewrittentomeovertheyearstotellmehowtheWorkbookdidnotreallydothetrickforthem,butthistutorialdid.TheWorkbooksqualitiesand
limitationsarereviewedmorethoroughlyelsewhere.

2. Heresafunnyquote:

Rocketscienceisntallthatdifficult.Itsnotbrainsurgery.
arocketscientist

3. Bigpromisesarecommonontheinternet,anditsaproblemwhenatreatmentmethodorproductispresentedasbeinggoodfornearlyanykindofpainproblem.Therearetoomany
kindsofpainforanyoneideatoworkforallofthem.

4. Sorrytobethebearerofbadnews.Therealityisharsh,amajordowner.Iwillgetbacktothis:thedicultiespainpatientsfaceingettinggood,eectivecareisanseriousandcomplicated
problem.Illdealwithitinconsiderabledetaillateroninthebook.Inparticular,Illdomybesttosubstantiatetheaccusationthatalotofcareispoorqualitywhichmanyprofessionals
takeexceptionto,ofcourse.

5. Commentingontwofascinating2008researchpapers(ChenandShah),Dr.DavidSimonswrote,Currently,considerationofthepossibilityofamyofascialtriggerpointcomponentofthe
paincomplaintiscommonlynoteectivelyincludedinthedierentialdiagnosisandthereforeismissedcoldturkey,whichcanbeveryexpensiveforthehealthcaresystem(expensive
examinationslookingforaphantomdiagnosis)anddisastroustothepatient(wrongdiagnosis,wrongtreatment).

6. Thereisabitofneatoinanygoodresearch.Makingitunderstandableandinterestingforallkindsofreadersissimplyamatterofexpressingthat.

7. Itsnotcertainthatthisisthecase,norwhyitwouldbe.However,thereiscertainlyplentyofsuggestiveevidence.ConsiderarecentSpanishstudy(JimnezSnchezetal ):studyinghealth
surveysofthepopulationofSpain,researcherslookedforchangesinratesofseriousmusculoskeletalpainsincetheearly90s,ndingthatitincreasedfrom1993to2001,butremained
stablefromthelastyears(2001to2006).

8. Simonswrites,Manyauthorsthroughtheyearshavediscoveredanewmusclepainsyndrome.Forinstance,thepopularDr.JohnSarnoisstillstubbornlycallingittensionmyositis
syndrometothisday,thetermheinventedwhenhediscoveredMPS.SuchdiscoveriesareakintoColumbusdiscoveringAmericamuchtothesurpriseofthenatives.MPShasbeen
namedfortheanatomicalneighbourhoodthataparticularresearchershappenstonditin.Ithasbeenthoroughlyconfusedwithbromyalgia.Ithasbeencalledbrositisand
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muskelhartenandmyofascitisandmyelgelosis.Ithasbeenstuckwiththelabelsnonarticularorsofttissue,rheumatism,osteochondrosis,andtendomyopathy.Everylastoneofthemisa
historicalartifact.

9. Othermuscleinjuriesareoftenconfusedwithtriggerpoints.Butatriggerpointisnotaregularwholemusclespasm,oramusclestrain(tornmuscle),whichisanactualripinmuscle
tissuethatoccurssuddenlyandisinstantlyverypainful.Thedierenceswillseemmoreobviousasyoulearnmoreabouttriggerpoints.

10. SmithDR.PrevalenceandDistributionofMusculoskeletalPainAmongAustralianMedicalStudents.JournalofMusculoskeletalPain.2007Aug29;15(4).
Itsamazinglydiculttondharddataontheprevalenceofmusculoskeletalproblems.However,thisAustralianstudyofmedicalstudentsfoundthatalmost90%ofthemhadsomekind
ofbodypainproblem,mostlyintheneck,lowerbackandshouldersandtheseareyoungpeople.ItmaynotbeanexaggerationtosaythatvirtuallytheentirepopulationofplanetEarth
hasmusculoskeletalpain!

11. TravellJ,SimonsD,SimonsL.MyofascialPainandDysfunction:TheTriggerPointManual.2nded.Lippincott,Williams&Wilkins;1999.p.xi.Or,asstatedmoreeloquentlyand
authoritativelybyDrs.TravellandSimons,Myofascialtriggerpointsareafrequentlyoverlookedandmisunderstoodsourceofthedistressinglyubiquitousmusculoskeletalachesand
painsofmankind.

12. Muchmorerecentlythaninthepreviousfootnote,in2008,Dr.Simonswrites:Currently,considerationofthepossibilityofanMTPcomponentofthepaincomplaintiscommonlynot
includedinthedierentialdiagnosisandthereforeismissedcoldturkey,whichcanbeveryexpensiveforthehealthcaresystem(expensiveexaminationslookingforaphantomdiagnosis)
anddisastroustothepatient(wrongdiagnosis,wrongtreatment).

13. FernndezdeLasPeasC,SimonsD,CuadradoML,ParejaJ.Theroleofmyofascialtriggerpointsinmusculoskeletalpainsyndromesoftheheadandneck.CurrentPain&Headache
Reports.2007Oct;11(5):36572.PubMed#17894927.Thisimportantreviewofthescienticliteratureontherelationshipbetweentriggerpointsandneckandheadpaingenerallyfoundthat
thereisnotmuchliteraturetoreview.Interestingly,theauthorsdonotethatthereismoreevidencethatbothtensionheadacheandmigraineareassociatedwithreferredpainfrom
triggerpoints.

14. CalandreEP,HidalgoJ,GarciaLeivaJM,RicoVillademorosF,DelgadoRodriguezA.Myofascialtriggerpointsinclusterheadachepatients:acaseseries.Head&FaceMedicine.2008Dec
30;4(32):32.PubMed#19116034.PainSci#55349.
Althoughthisresearchwaspreliminaryanduncontrolledandisnotpowerfulenoughtoproveanything,itsresultswerecertainlynoteworthythesortofresultsthatcaninspiremore
research,hopefully.Allof12patientswithchronicclusterheadaches(akindofmigraine,nicknamedsuicideheadaches)hadmyofascialtriggerpoints,andtreatingthem(withinjection)
producedsignicantimprovementin7ofthe8chronicclusterpatients.Theauthorsspeculatethattriggerpointsarenotthecauseofclusterheadaches,butanastycomplicatingfactor:
chronicpainorrepeatedacutepainsensitizemuscularnociceptorscreatingactivetriggerpointswhich,inturn,contributetopotentiateheadachepain.Thiskindofviciouscycleexplains
whythenumberofactivetriggerpointshasbeenfoundtobehigherinpatientswithchronicprimaryheadachesthaninhealthysubjectsorinpatientsexperiencinglessfrequent
headacheattacks.
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15. Ibelievethattriggerpointsmaybeabyproductofthevolatilityofmuscle.Itsatruismofengineeringthatthechanceofabreakdowngoesupwiththenumberofmovingparts.Muscle
tissueismorepowerfulandbiologicallycomplexthanmostpeoplegiveitcreditfor,andlikeanynelytunedmachine,perhapsitbreaksdowneasily.Isuspectthatwegettriggerpointsas
arelativelysmallpricetopayforhavinghighfunctioningmuscletissue,anevolutionarycompromise.Higherfunctionwouldrequireanescalatingriskofdysfunction.Reducedfunction
wouldprobablyresultinfewertriggerpointsbutalsoinweakerandlessresponsivemuscle.

16. InteriorsAndSources.com[Internet].OcePlaceRSIsDecreasedin1994;1996Sep[cited10Nov9].
Estimatesoftheincidenceofrepetitivestraininjuriesgenerallyrangefrom36%ofallcasesrequiringtimeawayfromwork.Incomparison,MPSisubiquitous.Inmyownclinical
experience,treatingRSIsrepresentanegligiblefractionofmywork,whereasMPSiseitheracauseorcomplicatingfactorinnearlyeverycaseItreatincludingtheRSIs!In1996,
InteriorsandSourcesmagazinereportedthat,thetotalnumberofseriousinjuriesorillnessesattributedtoallrepetitivemotionwasjust...fourpercentofthetotalnumberofcases
requiringtimeawayfromwork.Ofthose,themajorityofcasesor53percentwererecordedinthemanufacturingsector...Clearly,mostrepetitivemotioninjuriesarenotoccurringinthe
ocesofAmerica,saidPJEdingtonandexecutivedirectoroftheCenterforOceTechnology(COT).Andthesocalledepidemicofocerelatedrepetitivemotioninjuriesreportedin
themediahasbeenaclearcaseofmisdiagnosis.

17. Thereareseveraltypesofshinsplints,andmostofthemhavenothingtodowithtriggerpoints.However,themeatypartoftheshinthetibialisanteriormuscleisoftentheculprit.
Atleastafewseeminglyunbeatablecasesofshinssplintscanbeeasilytreatedifyouknowwhereandhowtorubthetibialisanteriormuscle.

18. Mostimportantly,therubberhasneverhittheroadintheformofwelldesignedclinicaltrialsofoutcomesforpatients:thatis,dopeopleactuallygettheirpainproblemssolvedbygood
qualitytriggerpointtherapy,wellenoughandoftenenoughtobeworththecosts?Iftreatingtriggerpointsworkswellasatherapy,thenthereshouldhavebeensuchstudiesmoreorless
easilyprovingitmanyyearsagobuttherestillarent.Thatsaconcernatthispointinhistory.

19. Idputthemsomewhereinthemiddleoftherange:triggerpointsarenowherenearasbadasalotofcommonpseudoscienceandquackerygets,buttheycertainlydofallwellshortof
provenandwellunderstood.Atworst,theymayevenbeabadideaalegitimatemisunderstanding,anideathatwasreasonable20yearsagobutwhichnowneedstoberetiredor
heavilyrevised.

20. QuintnerJL,BoveGM,CohenML.Acriticalevaluationofthetriggerpointphenomenon.Rheumatology(Oxford).2015Mar;54(3):3929.PubMed#25477053.
Quintner,Cohen,andBovethinkthemostpopulartheoryaboutthenatureoftriggerpoints(muscletissuelesions)isawedbothinreasoningandinscience,andthattreatmentbased
onthatideagetsresultsindistinguishablefromtheplaceboeect.Theyarguethatallbiologicalevidenceputforwardovertheyearsiscriticallyawed,whileotherevidenceleads
elsewhere,andtakethepositionthatthedebateisover.(Theyalsopointoutthatthetheoryistreatedlikeanestablishedfactbyagreatmanypeople,whichisdenitelyproblematic.)
However,theiropinionisextreme,andmostexpertsdonotthinkweshouldthrowoutallthesciencesofar(seeDommerholtetal ).
Thiscontroversialopinionisdiscussedinmoredetaillater.

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21. SimonsD.ForewordofTheTriggerPointTherapyWorkbook.1sted.NewHarbingerPublications;2001.Thefullquotereads:Muscleisanorphanorgan.Nomedicalspecialityclaimsit.
Asaconsequence,nomedicalspecialtyisconcernedwithpromotingfundedresearchintothemuscularcausesofpain,andmedicalstudentsandphysicaltherapistsrarelyreceive
adequateprimarytraininginhowtorecognizeandtreatmyofascialtriggerpoints.Fortunately,massagetherapists,althoughrarelywelltrainedmedically[BCbeingoneoftheobvious
exceptions,seeMassageTherapyInBritishColumbia,CanadaPI],aretrainedinhowtondmyofascialtriggerpointsandfrequentlybecomeskilledintheirtreatment.

22. TravellJ,SimonsD,SimonsL.MyofascialPainandDysfunction:TheTriggerPointManual.2nded.Lippincott,Williams&Wilkins;1999.Vol1,p13.

23. Doctorsareunqualiedtocareproperlyformostcommonpainandinjuryproblems,especiallythestubbornones,andthishasbeenprovenbyotherdoctors:Stockardetal foundthat


82%ofgraduateslackedbasiccompetencyinthisarea.Formoreinformation,seeTheMedicalBlindSpotforAches,Pains&Injuries:Mostphysiciansareunqualiedtocareformany
commonpainandinjuryproblems,especiallythemorestubbornandtrickyones.

24. Structuralismistheexcessivefocusoncrookednessandmechanicalproblemsascausesofpain.Ithasbeenthedominantwayofthinkingabouthowpainworksfordecades,andyetit
issourceofmuchbogusdiagnosis.Structuralismhasbeencriticizedbyseveralexperts,andmanystudiesconrmedtherearenoclearconnectionsbetweenbiomechanicalproblemsand
pain.Manyt,symmetricalpeoplehaveseverepainproblems!Andmanycrookedpeoplehavelittlepain.Certainlytherearesomestructuralfactorsinpain,buttheyaregenerallymuch
lessimportantthanmessyphysiologyandneurology.Structuralismremainsdominantbecauseitoerscomforting,marketablesimplicity.Forinstance,alignmentisthedubiousgoalof
manymajortherapymethods,especiallychiropracticadjustmentandRolng.SeeYourBackIsNotOutofAlignment:Debunkingtheobsessionwithalignment,posture,andother
biomechanicalbogeymenasmajorcausesofpain.

25. Anditcertainlyfeltlikeitattimes.

26. Ingraham.AHistoricalPerspectiveOnAchesnPains:Wearelivinginagoldenageofpainscienceandmusculoskeletalmedicinesorta.

PainScience.com.1804words.

27. TravellJ,SimonsD,SimonsL.MyofascialPainandDysfunction:TheTriggerPointManual.2nded.Lippincott,Williams&Wilkins;1999.

28. MenseS,SimonsDG,RussellIJ.Musclepain:understandingitsnature,diagnosisandtreatment.1sthardcovered.LippincottWilliams&Wilkins;2000.Adensetext,importantreadingfor
professionals.

29. Andnotimpossiblereading,either.Overthecourseofadecade,IhaveseenseveralkeenpatientstackleTravellandSimonsmassiveredtextsandgetgoodvaluefromthem.Thediagrams
areexceptionallyclear,andthewritingisgenerallyquitegood.Itsnotoutofthequestionforpatientstotrytoworkwiththem.Buttheyareexpensivereferencebooks,lledwithjargon,
andintendedforclinicianswhoaredealingwitheveryareaofthebodyonadailybasis.

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30. HeresDr.FredWolfestechnicalbutreadabledenitionofbromyalgia,froma2013blogpost.Dr.Wolfeisarheumatologistwithalonghistoryofexpertiseabouttriggerpointsand
bromyalgia:
Fibromyalgiaisanamegiventoaclinicalsyndromewhosemainfeaturescurrentlyarethepresenceof chronicpainsimultaneouslyinmanyareasofthebody togetherwithmultiplesomatic
symptoms.Inparticular, persistentandsubstantialfatigue , sleepdisturbance and cognitivediculties areamongthemostcommonofthesymptoms.Decreasedpainthresholdisalmost
alwaysfound,andisstronglycorrelatedwiththeextentofbodypain.Becausethesymptomsandtheirintensityarevariable, theboundariesofbromyalgiaaresomewhatindistinct .The
identicationofbromyalgiaisbasedontheoverallseverityofsymptoms.Thegoldstandardfornecessaryseveritywassetbythe1990AmericanCollegeofRheumatology(ACR)criteria:
roughly,itisthelevelofsymptomsfoundinpersonswith11/18tenderpointswhenexaminedbycapableexaminers.Asbromyalgiasymptomsatlessthancriterialevelareoftenfoundbefore
bromyalgiaisdiagnosed,itisuncertainwhenbromyalgiabegins.Therearenoconsistentclinicallaboratoryorimagingabnormalities.

31. EhrlichGE.Painisreal;bromyalgiaisn't.JRheumatol.2003Aug;30(8):16667.PubMed#12913918.PainSci#54771.
Whenonehastuberculosis,onehastuberculosis,whetherornotitisdiagnosed.Thesameistrueforcancer,rheumatoidarthritis,hookworminfestationreally,ofthegamutofdiseases.But
notforbromyalgia(FM). NoonehasFMuntilitisdiagnosed.

32. StaudR.Aretenderpointinjectionsbenecial:theroleoftonicnociceptioninbromyalgia.CurrPharmDes.2006;12(1):2327.interventionsaimedatreducinglocalFMpainseemtobe
eectivebutneedtofocuslessontenderpointsbutmoreontriggerpoints(TrP)andotherbodyareasofheightenedpain.

33. LiYH,WangFY,FengCQ,YangXF,SunYH.Massagetherapyforbromyalgia:asystematicreviewandmetaanalysisofrandomizedcontrolledtrials.PLoSOne.2014;9(2):e89304.
PubMed#24586677.PainSci#53919.

Thisisareviewofmassagetherapyforbromyalgiathatepitomizesthegarbagein,garbageoutproblemwithmetaanalysis:therewasvirtuallynoresearchonthistopicworthanalyzing
tobeginwith,andtryingtopooltheresultsofseveralweakstudiesismeaningless.Totheextentthatthestudyresultsaregenerallyinconclusiveandambiguous,theconclusionsofany
reviewaregoingtohavemoretodowiththeauthorsopinionsandbiasesthanharddata.Inthiscase,theyreportsignicantpositiveresultswithoutmentioningthattheyonlymean
statisticallysignicant,andtheeectsizeisbarelythereclinicallyinsignicant.TheyalsoboastabouttraditionalChinesemassageintheabstract,whichisodd.Andtheyfailtonote
thatamuchofthedatadidnotevenmeasuretheeectonpain,justmood.Soheresmyconclusion:whooptydo.Theresreallynothinghere,exceptmaybemassageforbromyalgiabeing
damnedbyfaint,ambiguouspraise.
IvewrittenseveralmoreparagraphsaboutthispaperinDoesMassageTherapyWork?

34. Travelletal.,op.cit.(VirtuallyallinformationinthisarticleisdrawnfromTravellandSimons,soIwontcitepagereferencesforeveryinstance.)Thesubscapulariscaseisagoodexample
ofhowMPSisprobablymuchmoreclinicallysignicantthanRSIs:notonlyisMPSacausalorcomplicatingfactorinmanyRSIs,itfrequentlyimitatesthemandisthecorrectdiagnosis!
ThisiswhyatleastsomeRSIsdonotrespondtoconventionaltreatment.

35. Itspossibletorichlyreferencethissectionwithindividualscienticpapersbackingupeverysingleexampleoftriggerpointsmimickingsomeotherhealthproblem.Thiskindof
informationiseverywhereintheMPSliterature.Fornow,heresjustoneofmany,a1995paper,Myofascialpainsyndromesthegreatmimicker.
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36. Theresalargebodyofresearchaboutthis,butRochaisagoodrecentexample.In2007,theseresearchersfoundthatin56%ofpatientswithtinnitusandMTPs,thetinnituscouldbe
modulatedbyapplyingdigitalcompressionofsuchpoints,mainlythoseofthemassetermuscle.Andhowmanypeoplewithtinnitushadtriggerpoints?Quiteafew.Theresearchers
foundastrongcorrelationbetweentinnitusandthepresenceofMTPsinhead,neckandshouldergirdle.

37. FernndezdeLasPeasC,GalnDelRoF,AlonsoBlancoC,etal.Referredpainfrommuscletriggerpointsinthemasticatoryandneckshouldermusculatureinwomenwith
temporomandibulardisoders.JPain.2010Dec;11(12):1295304.PubMed#20494623.
Thisstudycompared25healthywomento25otherswithtemporomandibulardisorders(TMD).Trainedexaminerslookedfortriggerpoints(withoutknowingwhichgrouptheywerein),
specicallyintheneckandjawmuscles.Accordingtothecriteriatheyused,theyfoundmoreandworsetriggerpointsinthewomenwithTMD(wherebyworseImeanlargerareasof
referredpain).Thetriggerpointsintheneckproducedmorereferredpainthatthoseinthejawmuscles.

38. ThisisoneIknowwellfrompersonalexperience:acoupleoftimesperyear,Igetadisturbingacheylumpinmythroat,ahitchinmyswallow.Itusedtogetmeworriedandanxiousand
thinkingaboutgoingtothedoctor.ThenIdiscoveredthatitscloselyassociatedwitharecurringpatchofsensitivityinthemusclesundermyjaw,intheupperthroatanditcanbe
massagedawayinaboutaminute.Ihavebeendoingthissuccessfullyforseveralyearsnow.

39. Theiliopsoasmuscle(illyohsoass)isatwoinonehipexingpair,mostlyonlypalpablethroughtheguts.Itsclinicalimportanceisoftencuriouslyexaggerated,butsometimesitdoes
needamassage.Formoreinformation,seePsoas,SoWhat?Massagetherapyforthepsoasmajorandiliacus(iliopsoas)musclesisnotthatbigadeal.Exceptwhenitis.

40. Asdiscussedabove,suchstructuralmisdiagnosesareacommonredherring,andalmostalwayswrong.Mistakingagluteusmaximustriggerpointforsacroiliacjointpainisaparticularly
commondiagnosticerror.SeeMassageTherapyforLowBackPain(SoLowThatItsNotIntheBack)formoreaboutthisparticulararea.

41. Thisisoneoftheperfectspotsformassage:spot#12,specically.Formoreinformation,seeMassageTherapyforLowBackPain(SoLowThatItsNotIntheBack).

42. Perhapsjustacoupleofmagictouches.HeresanotherquestionIreceivedbyemail:Ifamassagetherapisttoldyouthatallhehadtodowastouchatriggerpointwithonenger,then
touchyousomewhereelseonthebodyfarfromthetriggerpointwithhisotherhand,thatthetriggerpointwouldvanishinstantly.Isthattrue?

43. Forinstance,whatiftriggerpointsarepresentmainlyduetoanincurableneurologicaldiseaselikebromyalgia?Therearemanysignicantmedicalfactorsthatmaketreatment
impossibleornearlyso.Amuchmorecommonexampleissmoking,whichmakestreatmentsodicultthatmycoauthor,Dr.TimTaylor,willnotacceptsmokersaspatients.

Thereare287morefootnotesinthefullversionofthisbook.Ilikefootnotes,andItrytohavefunwiththem.
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readonanydevice,nopasswords
refundatanytime,inaweekorayear
call778-968-0930forpurchasehelp

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