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Myofascial Pain Syndromes–

Trigger Points
David G. Simons

Four articles this quarter present major progress in new experimental data.
Hou et al. demonstrated in rabbits that motor endplate potentials [spontaneous
electrical activity] of trigger spots are partially dependent on increased cal-
cium channel permeability. Delaney et al. report an elegant way to measure
the effect of myofascial trigger point [TrP] massage on autonomic nervous
system activity. This opens a new research window through which to explore
the close relation between TrP activity and autonomic nervous system activ-
ity. Esenyel et al. present a randomized, controlled, unblinded comparison of
the results of ultrasound application and injection of TrPs and found that both
were equally and significantly effective. This is one of the very few scientific
papers that address the effectiveness of treating TrPs with ultrasound.
Pongratz reported a noteworthy histological study specifically of TrPs. In ad-
dition, the efficacy of needling TrPs is becoming firmly established, and one
review article presents in detail the importance of considering TrPs in patients
with symptoms of radiculopathy.

CLINICAL STUDIES
Infrared Skin Temperature Measurement Cannot Be Used to Detect
Myofascial Tender Spots: M. Radhakrishna, R. Burnham. Arch Phys
Med Rehabil 82: 902-905, 2001.
Summary
There is great need for an objective test to identifying myofascial trig-
ger points [TrPs] and hot spots of skin overlying TrPs have been recom-
David G. Simons, MD, is Clinical Professor [voluntary], Department of Rehabilitation
Medicine, Emory University, Atlanta, GA.
Address correspondence to: David G. Simons, MD, 3176 Monticello Street, Covington,
GA 30014-3535 [E-mail: loisanddavesimons@earthlink.net].
Journal of Musculoskeletal Pain, Vol. 10(4) 2002
http://www.haworthpressinc.com/store/product.asp?sku=J094
 2002 by The Haworth Press, Inc. All rights reserved. 71
72 JOURNAL OF MUSCULOSKELETAL PAIN

mended as an objective test. In this study, two blinded examiners studied


16 subjects, 11 myofascial pain and five fibromyalgia patients. In each
subject, the examiners marked 36 squares over the back of the shoulders
that included some of the upper trapezius and most of the middle trapezius
muscles. Next, one examiner measured skin temperature at the center of
each square using a hand-held infrared thermometer [area sampled not
identified] and measured the pain pressure threshold at the same location
with an algometer. The second, blinded, examiner located any tender
spots deemed painful by the subject where manual pressure elicited a
jump sign and then noted in which squares tender spots occurred. Findings
within squares were compared. Algometer readings correlated strongly [P
< 0.001] with tender spots. Temperature readings of tender spots and of
contralateral squares were essentially the same [32.0 and 32.1°C]. Ther-
mometry is not a useful tool for diagnosing TrPs.

Comment

The authors are to be commended for distinguishing patients with


fibromyalgia and those with only myofascial pain. They reconfirm that
thermometry is not reliable for identifying TrPs. Swerdlow et al. (1) using
much more rigorous criteria for a TrP [spot tenderness in a taut band, local
twitch response, and jump response] and examining much the same mus-
culature with thermography reached essentially the same conclusion as
this study.
Although the methods section in this study refers to TrPs, the authors’
criteria of only locating tenderness sufficient to elicit a jump sign would
only identify a tender spot. The tenderness could also be caused by
fibromyalgia in the absence of a TrP. When available [as it is in the
trapezius muscle], the presence of a taut band identifies a TrP in either
group of patients. The TrP diagnosis is strongly reinforced by finding a lo-
cal twitch response. Since no significant difference was found between
the two diagnostic groups of patients and since TrPs are very common in
fibromyalgia patients, there is a strong likelihood that most of the tender
spots studied were TrPs. The low average normal threshold [nontender
squares] of 2.1 kg/cm2 is much lower than the published value of 3.7
kg/cm2. The small average threshold difference of only 0.3 kg/cm2 be-
tween tender and nontender squares emphasizes a serious weakness of this
algometer, which is unable to measure below 1.0 kg/cm2. A more sensi-
tive and reliable electronic instrument is needed.
Literature Reviews 73

The Short-Term Effects of Myofascial Trigger Point Massage Therapy


on Cardiac Autonomic Tone in Healthy Subjects: J. Delaney, K.S.
Leong, A. Watkins, D. Brodie. J Adv Nurs 37(4):364-371, 2002.

Summary

Myofascial trigger-point massage therapy [TPT] is commonly used in


sports therapy for alleviation of pain and to induce muscle relaxation fol-
lowing injury. This study compares the effect on 30 healthy subjects of re-
ceiving TPT for 20 minutes in group 1 to the effect on control group 2 of
sitting quietly, relaxing.
Trigger points were identified as discrete hyperirritable areas within a
taut band of muscle that are painful on compression and can evoke
referred pain. The specific myofascial trigger point [TrP] massage proce-
dures included effleurage, petrissage, cross-fiber stroking, and tapotement.
Deeper, more focused pressure and circular frictions were applied to Trp
areas in the upper, middle, and lower trapezius and suboccipitalis muscle
regions. In addition, gentle circular frictions and palmar kneading were
applied to frontalis and occipitalis muscle regions, and linear stroking
added for the sternocleidomastoid muscles.
Cardiac autonomic tone was assessed by heart rate variability. Heart
rate was recorded for five minutes before and five minutes after treatment.
Reduced heart rate variability is associated with increased coronary heart
disease, cardiac sudden death, and all-cause mortality. Time domain of
variability was measured as standard deviation of R-R intervals and root
mean square of successive intervals. The frequency domain was measured
in three discrete frequency components: high, low, and very low based on
spectral analysis of R-R intervals. High frequencies reflect parasympa-
thetic activity [calm and relaxation] and low frequencies reflect sympa-
thetic activity [emotional distress].
Following TPT, there was a significant decrease in heart rate [P < 0.01],
systolic blood pressure [P = 0.02], and diastolic blood pressure [P < 0.01],
indicating a significant increase in parasympathetic tone [P < 0.01]. The
TPT effectively increased cardiac parasympathetic activity and improved
measures of relaxation.

Comments

This is an unprecedented, well-designed, carefully documented study


that uses powerful analytic methods to determine autonomic effects of
74 JOURNAL OF MUSCULOSKELETAL PAIN

TPT. The diagnostic criteria make it clear that part of the treatment was di-
rected specifically to TrPs and that part of it concerned less specific
myofascial pain in general. Several lines of evidence indicate that auto-
nomic activity can strongly influence TrPs and that TrPs can influence au-
tonomic activity. This is a groundbreaking contribution to what promises
to be a useful new tool for future TrP research.

ETIOLOGICAL MECHANISMS

Effects of a Calcium Channel Blocker on Electrical Activity in


Myofascial Trigger Spots of Rabbits: C.R. Hou, K.C. Chung, J.T.
Chen, C.Z. Hong. Am J Phys Med Rehabil 81(5):342-349, 2002.

Summary

Previous studies demonstrated that phentolamine, a sympathetic ner-


vous system blocking agent, reduces the spontaneous electrical activity
characteristic of myofascial trigger points (2). This study examined the ef-
fect of a calcium channel blocker, verapamil. The spontaneous electrical
activity of rabbit trigger spots exposed to verapamil by intravenous injec-
tion declined significantly compared to that of trigger spots exposed to in-
jection of normal saline. This applied to individual trigger spots followed
for 80 seconds after injection and to 25 trigger spots sampled three times
during the 20 minutes after injection.

Comments

This decrease in the endplate potentials [endplate noise and endplate


spikes, if present] that were identified as spontaneous activity in this
study, adds a major new consideration to the integrated hypothesis. The
last link in the positive feedback loop of that hypothesis postulates that in-
creased autonomic activity releases a substance or substances that in-
creases the rate of abnormal spontaneous release of acetylcholine by the
nerve terminals of involved motor endplates (3,4). This study suggests a
way that substances released by sympathetic nerve activity could cause
the increased acetylcholine release into the synaptic cleft. They could do
so by increasing the permeability of calcium channels in the interior/exte-
rior cell membrane of the nerve terminal.
Literature Reviews 75

Neuere Ergebnisse zur Pathogenese Myofaszialer Schmerzsyndrome


[New Aspects on Pathogenesis of Myofascial Pain Syndrome]: D.
Pongratz. Nervenheilkunde 21(1):35-37, 2002.

Summary

Myofascial pain caused by trigger points [TrPs] is the cause of most


chronic low back pain. Trigger points are caused by microtrauma,
macrotrauma, and nerve root compression. Two figures illustrate histo-
logical findings from human active TrPs. A light microscopic longitudinal
section illustrates a series of so-called contraction discs, and an electron
microscopic longitudinal section shows an example of the transition be-
tween regions of shortened and lengthened sarcomeres. This sample was
taken from a region of recurring segments of abnormally shortened
sarcomeres. Under light microscopy, this part of the TrP showed what ap-
pear to be repeated abnormal segmental contractions.

Comments

This is a pioneering histological study of human TrPs that were located


by palpation and confirmed electrophysiologically. It shows sarcomere
contraction phenomena that would increase the tension of that muscle fi-
ber and contribute to a taut band, but the nature of these changes and how
they develop is unknown.

TREATMENT

Comparison of Superficial and Deep Acupuncture in the Treatment


of Lumbar Myofascial Pain: A Double-Blind Randomized Controlled
Study: F. Ceccherelli, M.T. Rigoni, G. Gagliardi, L. Ruzzante. Clin J
Pain 18:149-153, 2002.

Summary

The relative value of superficial and deep dry needling of myofascial


trigger points [TrPs] needs clarification. Forty-two patients with chronic
lumbosacral myofascial pain [one or more active TrPs in lumbar or limb
muscles] were randomly divided into one group that receiving superficial
[2 mm] insertion and another group receiving deep [1.5 cm] intramuscular
insertion of acupuncture needles. The needles were inserted into four pre-
76 JOURNAL OF MUSCULOSKELETAL PAIN

selected acupuncture sites and over, or into, four TrPs or into the four most
painful muscle tender points and stimulated four times in 15 minutes by
rotation. [Criteria used for identifying active TrPs were not stated.] Pre-
treatment compared to post-treatment McGill Pain Questionnaire re-
sponses were not statistically significantly improved, and only deep
insertions resulted in statistically significant improvement three months
after treatment. Immediately following eight treatment sessions, the su-
perficial group improved 36 percent and the deep group 59 percent. At
three months, the deep group progressed to 79 percent improvement,
which was significantly more improvement [P < 0.05] than seen in the su-
perficial group at that time. The statistically nonsignificant improvements
immediately following treatment were considered of considerable clinical
importance in this well-controlled study.

Comment

I agree. Too often we throw the baby out with the bath water. This
well-conducted study combined two different concepts of treatment that
leaves unanswered the question of whether combined therapy is more ef-
fective than either approach alone would be for inactivating TrPs. A num-
ber of clinicians find that combining acupuncture methods with specific
TrP treatment is more effective than either alone. From a TrP point of
view the study would have been strengthened if a specific measure of TrP
activity [such as algometry] had been included pre- and posttreatment.

Treatment of Myofascial Pain: M. Esenyel, N. Caglar, T. Aldemir.


Am J Phys Med Rehabil 79(1):48-52, 2000.

Summary

In order to compare the effectiveness of ultrasound and injection as


treatments of myofascial trigger points [TrPs], the authors selected 102
patients who had pain for at least six months and TrPs in one side of the
upper trapezius muscle. They divided the patients into three treatment
groups: ultrasound, injection, and control. All three groups performed the
same neck-stretching exercises. Trigger points were identified by a tender
spot in a palpable band, typical referred pain pattern, visible or palpable
local twitch response, and restricted lateral side bending to the opposite
side. Treatment groups showed no significant differences in outcome, but
compared with controls they showed significant reduction in pain inten-
Literature Reviews 77

sity [P < 0.001], increase in pain pressure thresholds [P < 0.001], and in-
creased range of motion [P < 0.05] at two weeks and at three months after
treatment. Controls showed no improvement at two weeks. Psychological
testing showed depression in 23 percent and high anxiety scores in 90 per-
cent of patients and showed no correlation with the three measures de-
scribed above. Psychological test results did correlate with the duration of
symptoms. Ultrasound and injection were found to be equally effective
and significantly better than just neck stretching exercises and to be inde-
pendent of the severity or duration of pain. Improvement lasted for at least
three months. Anxiety or depression did not limit the effectiveness of
these two treatments.
Comments
More detail as to the treatments administered would be desirable. The
authors found that psychological distress increased as the cause of the pain
remained unsuccessfully treated–maybe the pain and unsuccessful pain
treatments were driving the patient crazy. The favorable response to TrP
treatment in the presence of psychological distress is compatible with the
distress being the result of and not the cause of the persistent TrP pain.
This emphasizes the importance of prompt recognition and effective treat-
ment of the cause of the pain.

The Immediate Effects of Lidocaine Iontophoresis on Trigger-Point


Pain: T.A. Evans, J.R. Kunkle, K.M. Zinz, J.L. Walter, C.R. Denegar.
J Sport Rehabil 10(4):287-297, 2001.
Summary
This randomized, double blind, placebo-controlled study compared
pressure sensitivity of active or latent trigger points [TrPs] in the upper
trapezius muscles of 23 young adult volunteer subjects following three
procedures. They were iontophoresis of one percent lidocaine treatment
over the TrP, control treatment of distilled water, and placebo treatment
without current or lidocaine. Trigger points were identified as the most
sensitive spot in a palpable taut band and sensitivity measured with a pres-
sure algometer. A small but statistically significant pretreatment–
posttreatment decrease in TrP sensitivity to lidocaine treatment compared
to control and placebo treatments was not considered clinically significant
because the improvement did not compare favorably with reported effec-
tiveness of dry needling.
78 JOURNAL OF MUSCULOSKELETAL PAIN

Comments
Since lidocaine is an effective local anesthetic, reduction in local ten-
derness immediately following treatment is not surprising. An effect ob-
served several hours later would have told more about its effect on the
TrPs. Reporting change in the clinical pain coming from active TrPs
would be more relevant to clinical practice. Since dry needling of TrPs
without evoking twitch responses is ineffective (5) and injection of anes-
thetics is no more effective than dry needling (6), it is not surprising that
lidocaine iontophoresis would be ineffective for treatment of TrPs.

Myofascial Pain Syndrome Induced by Malpositioning During Sur-


gery–A Case Report: S.T. Hsin, Y.C. Yin, C.H. Juan, J.S. Hu, M.Y.
Tsou, S.K. Tsai. Acta Anaesthesiologica Sinica. 40(1): 37-41, 2002.
Summary
The patient awoke following cholecystectomy for gallstones with in-
tense pain in, other sensory changes in, and motor weakness of the left
arm. Examination revealed an active myofascial trigger point [TrP] in the
left pectoralis minor muscle. Electromyographic and nerve conduction
studies diagnosed a left musculocutaneous nerve lesion. Passive stretch
and dry needling of the pectoralis minor TrP every three days for three
times produced complete recovery.
Comment
This is another typical case of thoracic outlet syndrome due to a pecto-
ralis minor TrP.

Water-Diluted Local Anesthetic for Trigger-Point Injection in Chronic


Myofascial Pain Syndrome: Evaluation of Types of Local Anesthetic and
Concentrations in Water: H. Iwama, S. Ohmori, T. Kaneko, K.
Watanabe. Regional Anesthesia & Pain Med 26(4): 333-336, 2001.
Summary
This extends a previous study that demonstrated the improved effec-
tiveness of diluting one percent lidocaine 1:3 with water for myofascial
trigger point [TrP] injections. Various dilutions of lidocaine or mepi-
vacaine diluted with water or saline were injected into the upper trapezius
muscle of 20 adult healthy volunteers to test injection pain, and different
Literature Reviews 79

dilutions of lidocaine into active trapezius TrPs of pain patients, to test


pain relief. No difference in painfulness of the injection was noted be-
tween lidocaine and mepivacaine. Water dilutions were significantly less
painful than saline dilutions. Dilutions of 0.2 percent or 0.25 percent
lidocaine were equally effective in relieving patients’ TrP pain.

Comment

This finding is reminiscent of Dr. Travell’s experimental determination


that injection of 0.5 percent rather than one percent procaine was more ef-
fective. Since the main advantage of injecting an anesthetic agent is to re-
duce postinjection soreness the next day or two (5) and since TrP pain
relief is similar with dry needling (6), a more pertinent question would
have been the degree of postinjection soreness experienced by these pa-
tients.

Geloid Masses in a Patient with Fibromyalgia and Chronic Myo-


fascial Pain: D.J. Starlanyl, J.L. Jeffrey. Phys Therapy Case Reports
4(1):22-31, 2001.

Summary

This case report presents detailed accounts of many treatments received


over the years and their effectiveness. A myofascial trigger point [TrP]
was identified by exquisite spot tenderness and a tender nodule in a palpa-
ble taut band, patient recognition of pain elicited by pressure on the tender
spot, and painful limitation of full stretch range of motion. In addition
there were firm, clearly definable masses indicative of interstitial swelling
that occurred in tissues in the vicinity of multiple TrPs and sometimes
were as large as 44.5 cm in diameter. The masses felt like tense indurated
tissue but not fibrotic or calcified and are described in detail.
Finding the optimal dose for manual therapy was difficult because of
the fine line [that could shift from day to day] between sufficient therapy
to be effective and too much therapy that exacerbated symptoms. Experi-
ence indicated that strengthening exercises should not be started until the
patient is free of continuous pain and normal range of motion has been re-
stored. Apparently geloid masses are a complication that can appear in
some patients with severe fibromyalgia and many active TrPs.
80 JOURNAL OF MUSCULOSKELETAL PAIN

Comment

Apparently geloid masses are a complication that can appear in some


patients with severe fibromyalgia and many active TrPs. Their relation to
impaired thyroid metabolism is being investigated.

REVIEWS AND COMMENTS

Trigger Points: Diagnosis and Management: D.J. Alvarez, P.G.


Rockwell. Am Family Physician 65(4):653-660, 2002.

Diagnosis of myofascial trigger points is based on finding a hard hyper-


sensitive bundle or nodule of muscle fibers, eliciting a twitch response and
eliciting characteristic referred pain. Treatment emphasized elimination
of perpetuating factors, spray and stretch with Fluori-Methane
spray–which [contrary to author’s note] is still commercially avail-
able–and injection.

Three Clinical Sports Massage Approaches for Treating Injured Ath-


letes: P.A. Archer. Athletic Therapy Today 6(3):14-20, 2001.

Summary

This review of massage techniques of value for treating the results of


muscular over activity discusses myofascial release, site-specific friction,
and lymphatic massage. The section on neuromuscular/trigger-point tech-
niques presents a five-step technique that starts with gentle myofascial
trigger point release then positions the muscle in a position of ease and
ends with muscle stretch.

Comment

The proposed rationale presented for why the combination of these two
release techniques works is not convincing to this reviewer, but a number
of skilled clinicians find this combination of treatments very effective.
Literature Reviews 81

Management of Myofascial Trigger Point Pain: P. Baldry. Acupunc-


ture in Medicine 20(1):2-10, 2002.

Summary

The objective is to treat the cause of the pain, not just the symptom.
First one locates myofascial trigger point [TrP] tenderness by palpating its
taut band. Digital pressure elicits a ‘jump’ or ‘shout’ reaction and repro-
duces the patient’s pain. A scholarly historical review and detailed de-
scription compares superficial [subcutaneous penetration only] and deep
[intramuscular penetration] dry needling techniques. The review con-
cludes with a hypothesis of pathophysiology to explain the effectiveness
of superficial dry needling and the importance of identifying strong, aver-
age, and weak responders to superficial needling.

Comment

This use of superficial dry needling for treatment of TrPs has been pre-
sented in this journal (7) and in a book (8). Clinically, this technique ap-
parently is frequently effective, but the neurophysiological mechanism by
which it inactivates an TrP remains obscure and deserves serious experi-
mental study. Modulation of sympathetic nervous system activity by the
procedure would be a likely place to start. The effect of this procedure on
the autonomic nervous system could be tested using heart rate variability
as the indicator (see Delaney et al., reviewed above). The results of
Ceccherelli et al., reviewed above, are relevant and indicate that deep dry
needling is clinically clearly more effective than superficial dry needling
of acupuncture points and trigger points.

Myofascial Pain: J. Borg-Stein, D.G. Simons. Arch Phys Med Rehabil


83(Sup.1):S40-S47, 2002.

Summary

This prevalent trigger point [TrP] cause of musculoskeletal pain is di-


agnosed only by history and physical exam. There are many other condi-
tions that present with confusingly similar symptoms. The most likely
explanation of its cause is the integrated hypothesis that postulates a
5-step positive feedback loop starting with excessive acetylcholine re-
lease at involved motor endplates. There is also important spinal,
82 JOURNAL OF MUSCULOSKELETAL PAIN

supraspinal, and autonomic nervous system involvement. Recommended


treatments include manual release techniques, acupuncture, postural and
ergonomic corrections, modalities, dry needling, and injection of TrPs.

Comment

This succinct focused review was written by and for physiatrists. It crit-
ically examines the state of the art and knowledge of myofascial pain
caused by Trps.

Myofascial Pain and Fibromyalgia: Trigger Point Management, Ed.


2: E.S. Rachlin, I.S. Rachlin. Mosby, St. Louis, 2002.

This second edition is coauthored by Ed’s daughter, Isabel Rachlin, PT,


whose chapter, and two other chapters by physical therapists, has added a
much-needed appreciation of the importance of manual therapy in addi-
tion to injection techniques that were the bulk of the book. Isabel empha-
sizes the importance of treating the trigger points of fibromyalgia patients
with utmost gentleness. The manual therapy chapter by Beth Paris reflects
the fact that she is also a massage therapist and was trained by an outstand-
ingly competent disciple of Dr. Janet Travell.

Interventional Approaches to the Management of Myofascial Pain


Syndrome: C.M. Criscuolo. Current Pain & Headache Reports 5(5):
407-411, 2001.

The introduction notes that myofascial pain characterized by myo-


fascial trigger points accounts for at least half of patient encounters at a
busy university anesthesiology pain clinic. Injection therapy is described in
detail and acupuncture mentioned.

Radicular and Myofascial Pain Syndromes: Evaluation and Manage-


ment: P.K. Richardson. Trauma 43(1):71-95, 2001.

Summary

After an extensive review of pertinent anatomy and the pathogenesis of


both conditions, the neurologist author summarized their clinical features.
Myofascial trigger points [TrPs] were identified by the location of the pain
Literature Reviews 83

symptoms, the presence of tenderness in muscles that characteristically


refer pain to that location, and by elicited pain that was familiar to the pa-
tient. No mention was made of palpating for a taut band. Radicular syn-
dromes at various spinal levels were described in detail and the muscles
likely to have TrPs that could produce a confusingly similar pain distribu-
tion were well listed. Treatment of TrPs was described only for patients
free of radiculopathy. Treatment of perpetuating factors was appropriately
strongly emphasized. The thorough listing of treatment options included
manual therapy and injection methods. The author appropriately noted
that no compelling evidence supports traditional physical modalities for
treatment of TrPs as usually administered [emphasis mine].

Comment

Several articles have reported significantly greater prevalence of TrPs


in muscles supplied by nerves suffering radicular compression (9-12).
Sometimes, especially after a month or more, much of the pain complaint
by these patients is coming from treatable TrPs that have developed a life
of their own. As the difference between pain originating from
radiculopathy and TrPs becomes more difficult to distinguish, the identifi-
cation of palpable taut bands and local twitch responses helps consider-
ably to reliably distinguish by physical exam the presence of TrPs, but
identifying these TrPs may require considerable specialized skill (13).

Understanding Effective Treatments of Myofascial Trigger Points:


D.G. Simons. J Bodywork Movement Therapies 6(2):81-88, 2002.

The effectiveness of manual therapy techniques including trigger point


pressure release, contract-relax [or contract-release], reciprocal inhibi-
tion, and trigger point massage are explained and illustrated based on the
principles of the integrated hypothesis (3,4).

Do Cerebral Potentials to Magnetic Stimulation of Paraspinal Muscles


Reflect Changes in Palpable Muscle Spasm, Low Back Pain, and Ac-
84 JOURNAL OF MUSCULOSKELETAL PAIN

tivity Scores?: D.G. Simons. J Manip Physiol Ther 25(1): 77-78, 2002
[letter].

This is a letter-to-the-editor that responded to the original paper by the


same title (14). The original article described cerebral evoked responses to
magnetic stimulation of paraspinal muscles at muscle locations that
showed myofascial trigger point [TrP] characteristics in low back pain pa-
tients. The letter questioned the authors’ avoidance of TrP terminology
and suggested that the responses that they observed were apparently spe-
cific to TrPs. If so, this testing could serve as a TrP research tool and might
provide an objective diagnostic test or confirmatory finding for TrPs. The
prime author of the original article responded that current terminology for
TrPs was too confusing for him to use that term, but raised no objection to
the likely relation of the response to TrPs.

Handbuch der Muskel-Triggerpunkte [Handbook of Muscular Trigger


Points]: J.G. Travell, D.G. Simons, 2. Auflage [Ed. 2]. Urban &
Fischer, München [Munich], 2002.

This is a German translation of the 1999, second edition of volume 1 of


The Trigger Point Manual (3) that has an erroneous version of the author-
ship carried over from the first edition. As usual with foreign translations
of this book [there are now seven], I had no contact with the translator.

Travell y Simons Dolor y Disfunción Miofascial; El Manual de los


Puntos Gatillo [Travell and Simons Myofascial Pain and Dysfunc-
tion: The Trigger Point Manual], Volumen 1, Segunda edición [V.1,
Ed 2]. D.G. Simons, J.G. Travell, L.S. Simons. Editorial Medica
Panamericana, Madrid, 2002.

This Spanish Edition (3) was meticulously and conscientiously trans-


lated by a Spanish physical therapist who understood what he was trans-
lating, refined by considerable Email correspondence with me during the
years of translation.

REFERENCES
1. Swerdlow B, Dieter JNI: An evaluation of the sensitivity and specificity of medi-
cal thermography for the documentation of myofascial trigger points. Pain 48:205-213,
1992.
Literature Reviews 85

2. Chen J-T, Chen S-U, Kuan T-S, Chung K-C, Hong C-Z: Phentolamine effect on
spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal
muscle. Arch Phys Med Rehabil 79:790-794, 1998.
3. Simons DG, Travell JG, Simons LS: Travell & Simons’ Myofascial Pain and Dys-
function: The Trigger Point Manual, Vol.1, Ed. 2. Williams & Wilkins, Baltimore, 1999,
pp. 57-82.
4. Mense S, Simons DG: Muscle Pain Understanding its Nature, Diagnosis, and
Treatment: Lippincott Williams & Wilkins, Baltimore, 2001, pp. 240-259.
5. Hong C-Z: Lidocaine injection versus dry needling to myofascial trigger point: the
importance of the local twitch response. Am J Phys Med Rehabil 73:256-263, 1994.
6. Cummings TM, White AR: Needling therapies in the management of myofascial
trigger point pain: A systematic review. Arch Phys Med Rehabil 82:986-992, July 2001.
7. Baldry P: Superficial dry needling at myofascial trigger point sites. J Musculoske
Pain 3(3):117-126, 1995.
8. Baldry PE, Yunus MB, Inanici F: Myofascial Pain and Fibromyalgia Syndromes.
Churchill Livingstone, Edinburgh, 2001.
9. Wu C-M, Chen H-H, Hong C-Z: Inactivation of myofascial trigger points associ-
ated with lumbar radiculopathy: surgery versus physical therapy. Arch Phys Med Rehabil
78:1040-1041, 1997 (Abstr).
10. Wu C-M, Chen H-H, Hong C-Z: Myofascial trigger points in patients with lumbar
radiculopathy due to disc herniation before and after surgery. J Surgical Association Re-
public of China 30(3):175-185, 1997.
11. Hsueh T-C, Yu S, Kuan T-S, Hong C-Z: Association of active myofascial trigger
points and cervical disc lesions. J Formos Med Assoc 97:174-180, 1998.
12. Chu J: Twitch-obtaining intramuscular stimulation: observations in the manage-
ment of radiculopathic chronic low back pain. J Musculoske Pain 7(4):131-146, 1999.
13. Gerwin RD, Shannon S, Hong C-Z, Hubbard D, Gevirtz R: Interrater reliability in
myofascial trigger point examination. Pain 69:65-73, 1997.
14. Zhu Y, Haldeman S, Hsieh C-Y J, Pingjia W, Starr A: Do cerebral potentials to
magnetic stimulation of paraspinal muscles reflect changes in palpable muscle spasm,
low back pain, and activity scores? J Manip Physiol Ther 23 (7): 458-464, 2000.