Why I am No Longer Using the Term “Trigger Point”

Posted by on Jul 1, 2015 in Brain, Conditions, Fibromyalgia, Myofascial Pain Syndrome, Pain, Research, Trigger Points | Comments Off on Why I am No Longer Using the Term “Trigger Point”

What is Trigger Point Therapy?

Myofascial trigger points have been described as bands of taut, sensitive fascia (connective tissue that wraps and interlaces everything in the body), that when pressed on can radiate pain to another part of the body. Trigger points have been cited as possible causal factors in numerous ailments, including myofascial pain syndrome, fibromyalgia, chronic pain and much more.

Trigger Point Therapy was coined by Dr. Janet Travell (John F. Kennedy’s personal physician) and Dr. David Simons, who together developed the trigger point model and authored two volumes of Myofascial Pain and Dysfunction: The Trigger Point Manual, originally published in the 1990s.

This set of techniques has become a primary go-to treatment by many physical therapists, massage therapists, osteopaths, physicians, etc. I’m a clinical massage therapist and 95% of my clients first come to me for pain and mobility issues. I have offered Trigger Point Therapy since learning the technique through my Orthopedic Massage training in 2009, followed by further study.

Trigger Point Anatomy

Newer Understanding Challenges this Model

My use of this terminology is coming to an end. The explanatory model behind trigger points has been debunked in Oxford’s Rheumatology Journal paper, A critical evaluation of the trigger point phenomenon, by John L. Quintner, Geoffrey M. Bove and Milton L. Cohen. The paper essentially states that myofascial pain syndrome caused by trigger points is a pure invention not based on or supported by actual science. It’s a bit technical for the layperson, but here’s the abstract (feel free to skip):

“The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception [nerves that sense threat to the body and trigger pain sensations]. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (FM syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.”

While this topic remains hotly contested by trigger point devotees and evangelists, I have become convinced Quintner, et al. are correct in their assessment. Understanding of medicine and science changes over time. As a non-scientist and non-doctor, I am somewhat at the mercy of trained pain scientists and researchers to inform me, but it does make sense to me that Travell and Simons made some assumptions to explain their model, rather than doing rigorous studies themselves.

In another article on this topic, Travell, Simons and Cargo Cult Science by Fred Wolfe at The Fibromyalgia Perplex says:

“The book represented opinion, not science. None of the trigger points or their treatments were validated; none were tested for reliability. There were almost no studies in the Travell-Simons book, just testaments. Most of the perpetuating factors were plain wrong, and represented outdated, overthrown junk science.”

… and (with my emphasis):

“In 1992, we performed a study of trigger points. A group of four myofascial pain experts, selected by Simons and including Simons, blindly examined four patients with MFP. The examiners were allowed to take as much time as they needed; they could examine but not interview the patients. As we had mixed MFP patients with those who had fibromyalgia, it was a blinded experiment. These MFP experts were no ordinary examiners. They were the best. They wrote the book, they did the lectures. But, in the end, they could not find or agree on the trigger points. It was a disaster.”

How Do We Explain Trigger Point-Type Pain?

By way of explanation, in a comment on one article, Canadian physiotherapist Diane Jacobs (see Afterthought below) offered,

“I have yet to find any better proposal for what ‘they’ are, than Quintner and Cohen’s paper suggesting peripheral nerve pain, plain and simple. WAY higher plausibility.
Referred Pain of Peripheral Nerve Origin: An Alternative to the “Myofascial Pain” Construct

For the sake of making sure everyone’s noticed what I just quoted …

The hypothetical roots of trigger point-type pain is more likely to be PERIPHERAL NERVE PAIN. This needs further examination and testing of course. This is not the only hypothesis, but it is promising.

In the conclusion to the article, the authors write,

“The construct of MPS [myofascial pain syndrome], as proposed to explain chronic, deep, aching, poorly localized pain, not only lacks internal and external validity but also is epistemologically unsound. The emphasis on the primacy of theTrP phenomenon has directed attention away from other possible explanations. By contrast, there are anatomical and physiological grounds to suggest that the phenomenon of the TrP, on which depends the theory of MPS, is better understood as a region of secondary hyperalgesia [pain sensitivity that occurs in surrounding undamaged tissues] of peripheral nerve origin. This proposition is testable to achieve external validity for the described clinical phenomena.”

I look forward to those tests!

Does Anyone Disagree?

It is no surprise that there has been a lot of opposition to this news, most notably, A critical evaluation of Quintner et al: Missing the point by Dommerholt and Gerwin.

In a comment Quintner points to his Response to Dommerholt and Gerwin: Did we miss the point?, wherein he notes:

“We invite the reader to examine these statements by Dommerholt and Gerwin, and to identify how these authors disagree with us:

  • “In spite of years of research into the nature of myofascial pain and significant gains especially during the last decade, several aspects remain elusive and are not well understood. A distinct mechanistic understanding of this disorder does not yet exist.”

  • “We acknowledge that there has not been a study to demonstrate the minimal essential features of the TrP needed to identify it for diagnosis and treatment purposes.”

  • “… there has never been a credible anatomic pathology associated with myofascial TrPs.”

  • “We agree that there are few outcome studies of good quality and although some studies showed reduction in pain scores and pressure pain thresholds, the literature has neither convincingly supported or refuted the effectiveness of some invasive and non-invasive modalities beyond placebo.”

  • “We agree with Quintner et al. that studies of the efficacy of TrP interventions have shown such marked statistical heterogeneity that it can be difficult to evaluate outcomes.”

My Experience with Trigger Point Therapy

Since Quintner and colleagues’ paper came out, it has had a ripple effect in some massage forums and communities, and I’ve reflected on the effectiveness of my treatment. I can’t discern if client improvement was because of Trigger Point Therapy or other techniques I used … or simply because they liked me, my touch and found me credible in my professionalism, i.e. the placebo effect.

I can definitely say that Trigger Point Therapy hasn’t worked, in any kind of lasting way, on the majority of my clients who’ve received it, though many had temporary relief and a small minority seemed to be “cured.” Other techniques (such as Orthopedic Massage) have demonstrated more lasting benefit. Client self-care seems to offer the most lasting effect of all, but alas, many don’t want to invest time in improving their own conditions. (Note: If you’re my client and I’ve suggested stretching, strengthening, more or less activity, epsom salt baths, heat [or rarely ice], castor oil packs, etc., it’s likely you’ll really do better if you follow through.)

Over 1500 studies have been done on myofascial trigger point pain and treatment, whether it be dry needling, Trigger Point Therapy, acupuncture or some other technique. However, this meta review of the studies, Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials, published in the European Journal of Pain, found only seven studies with the right criteria and quality to be included. Six of the seven studies revealed a poor correlation of treatment to benefit, showing little difference from placebo effect. (Dry needling is also under fire as a result.)

I believe Fred Wolfe is right when he says the “cause” and model of trigger points are pseudo-pseudo evidence based medicine. I believe Dr. Quintner and colleagues.

I am no longer calling the treatment I offer Trigger Point Therapy.

Afterthought

Myofascial Release (MFR) is also being questioned and is under investigation by Quintner, in relation to fibromyalgia. I do still offer so-called Myofascial Release because I often see benefit to clients in slow, gentle (to firm, but not extra deep) “fascial” treatment, though I don’t buy into some of the explanations of that model either, a la some of what teacher John Barnes espouses. (I didn’t study under Barnes, MFR was one of the three modalities taught in my basic massage school education). For years people like Ida Rolf (the inventor of Rolfing) thought that fascia could be stretched, but that too has been disproven. When it comes to health care, there is still so much we don’t know. But just because an explanatory model gets busted, it doesn’t necessarily mean that treatment techniques aren’t effective. I have definitely seen more clients benefit from MFR than Trigger Point Therapy.

That said, last year (2014) I studied DermoNeuroModulation (DNM, developed by Diane Jacobs) under Jason Erickson (DNM is a technique I now offer to my clients to help reduce their pain. I am increasingly of the belief that the type of MFR I practice may more closely resemble DNM, i.e. the effect of my MFR technique may be to calm the nervous system. (I’m not saying MFR and DNM are the same thing, they’re vastly different in concept and application.) Beyond that, I also follow Dr. Lorimer Moseley’s BodyInMind.org publications on pain science (here’s a further explanation by Quintner published there) and believe in the BioPsychoSocial model of pain as a more well-rounded concept than the old BioMechanical model. So I’m moving on to other techniques and modalities to see if they work better than Trigger Point Therapy.

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