By Leon Chaitow, ND, DO and Judith DeLany, LMT
Editor’s Note: This article is in response to an article by Gregory T. Lawton, “Truthaches and Trigger Point Therapy,” published in the December 2005 issue of Massage Today.
A variety of grossly inaccurate and unsupported assertions in the article by Mr. Lawton in Massage Today 1 (December 2005) call for rebuttal, and in the limited space available, we will attempt to offer a different, scientifically supported, perspective.
Mr. Lawton asserts that almost as a matter of course, massage therapists treating myofascial trigger points (MTrPs) are simultaneously hurting people, injuring themselves and getting poor results. No evidence for these statements is offered. Where is the research evidence, or mention of a nationwide (or worldwide) survey that documents these purported poor results and/or injuries? The readership of Massage Today deserve more than statements of “fact” with no validating support.
As research evidence emerges, theories change over time. Scientific protocol demands that we formulate theories, then go about proving, improving or abandoning them. Mr. Lawton’s statement that “most established members of the research community” have abandoned the MTrP theory is untrue. Where is the evidence for this assertion? Have researchers worldwide been questioned as to their position on MTrP theories? Again, we have a statement without any supporting evidence.
Mr. Lawton states that Travell and Simons dropped the idea of applying ischemic compression in MTrP deactivation. This is inaccurate, as is the claim that they opted for injections to replace compression. They did indeed abandon the term “ischemic compression,” which was replaced by the term “trigger point pressure release” (i.e., the term was changed, but not the modality). Simons, Travell and Simons,2 and other leading clinicians3 continue to support the use of applied pressure. They also advocate (pages 140 to 145) application of massage therapy, strain-counterstrain, muscle energy technique, myofascial release, and a variety of other manual modalities and objectives, including “spray and stretch,” specific exercises and postural rehabilitation. They do discuss injection materials, including local anesthetics, and the advantages of manual versus injection methods, depending upon the presenting case details, but dedicate more pages to manual applications than to injections.
Regarding the Quinter and Cohen article4 of which Mr. Lawton makes so much, this discussesold theories of MTrP pathophysiology, with its most current citation being 1993. Major research-based advances in the understanding and treatment of MTrPs by Simons, et al., and Mense and Simons5 emerged in 1999, however, none of these developments are discussed in Mr. Lawton’s article or, of course, by Quinter and Cohen in their decade-old paper. Changes included the distinction between central and attachment trigger points, which altered the way tissues housing trigger points are treated, including variations as to where to (and where not to) apply pressure or friction, how much pressure to use (minimal), where to use ice/heat, and so forth.
Regarding references, there are NONE in Mr. Lawton’s article. Casual mention of untitled articles does a disservice to readers who might wish to judge for themselves – if only a citation (or even title) were provided. Where is the support for statements intended to replace all themisinformation that Mr. Lawton claims everyone else is teaching their students? Full citations are needed so readers can follow through and form their own opinions.
Mr. Lawton is correct to say that inappropriate or heavy-handed manual treatment of trigger points can leave the patient in pain with the problem unresolved (and can potentially stress therapists’ hands). However, advances in our understanding of trigger points, and the use of gentle deactivation methods,6 reduces these possibilities significantly.
Mr. Lawton states, “There is, unfortunately, a lack of histological evidence that they [trigger points] actually exist, which led most established members of the research community to abandon that idea all together.” He also says, “Needle biopsy of supposed trigger points identified by trigger point ‘experts’ consistently failed to show any difference between the muscle tissue within borders of an ‘identified’ trigger point and any other normal muscle tissue.” These statements are blatantly inaccurate – and are once again unsubstantiated.
In a 2003 NIH-funded study, Shah, et al.,7,8 using in vivo microdialysis, measured the chemical composition of interstitial fluid surrounding active and latent trigger points in the upper trapezius muscle, by means of a semipermeable membrane at the tip of a probe. “Our microdialysis system, utilizing samples of < 1 µl, is capable of continuous, near real-time, in-vivorecovery of molecules 75 kDa and smaller directly from the soft tissue environment without harmful effects on subjects. Subsequent analysis of the collected samples can distinguish analyte levels before, during and after a local twitch response (LTR). In this preliminary proof of principle investigation, differences have been demonstrated in the level of these analytes between people who have pain and those who do not and between those who have active myofascial trigger points (MTrPs) versus those who have latent or no MTrPs.” (emphasis added) In conclusion, we believe it’s possible that referred pain from trigger points is due to more than one factor. It’s possible a local energy crisis catalyzes endplate chemical changes, inducing the formation of taut bands, creating additional localized ischemia, resulting in enthesopathy and local compression, leading to peripheral nerve pain. It’s also feasible that all of these possibilities fit together in a polymodal model. Thinking we have it figured out ends the learning game. We do not have all the answers – none of us do. In fact, isn’t that what science and medicine are all about?
As editor and associate editor, respectively, of the peer-reviewed Journal of Bodywork & Movement Therapies, we are pleased to offer Dr. Lawton space in the journal to debate these issues, and we sincerely hope he will accept this offer.
- Lawton GT. Truthaches and trigger point therapy. Massage Today, December 2005.www.massagetoday.com/archives/2005/12/13.html.
- Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1: upper half of body, 2nd ed. Baltimore: Williams & Wilkins, 1999.
- Lewit K. Manipulative Therapy in Rehabilitation of the Motor System. London: Butterworth, 1999.
- Quintner JL, Cohen ML. Referred pain of the peripheral nerve origin. Clin J PainSep;10(3):243-51. www.paineducation.com/100137.php.
- Mense S, Simons DG. Muscle Pain: Understanding its Nature, Diagnosis and Treatment. Philadelphia/Baltimore: Lippincott, Williams & Wilkins, 2001.
- Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques, Volume 2: The Lower Body. Edinburgh: Churchill Livingstone, Edinburgh, 2002, p. 197.
- Shah JP. An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol July 25, 2005. Doi:10.1152/japplphysiol.00419.2005.
- Shah JP, Phillips T, Danoff JV, Gerber LH. A novel microanalytical technique for assaying soft tissue demonstrates significant quantitative biochemical differences in three clinically distinct groups: normal, latent and active. Archives of Physical Medicine 2003;84:9.
Judith DeLany serves as director of NMT Center, writes textbooks for Elsevier Health Sciences, and lectures internationally in the field of neuromuscular therapy. For more information regarding her work, visit www.nmtcenter.com or call toll-free at (866) 571-7942.