Books:

Myofascial Pain and Dysfunction The Trigger Point Manual-Upper
David G. Simons, Travell, Janet G., and Lois S. Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual; Vol. 1. The Upper Half of Body. 2nd ed. Lippincott Williams & Wilkins, November 1999. Print.

Myofascial Pain and Dysfunction The Trigger Point Manual-Lower
Travell, Janet G. and David G. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual; Vol. 2., The Lower Extremities. 1st ed. Lippincott Williams & Wilkins, October 1992. Print.

Clinical Trial Abstracts:


Abstract: Effect of topical aerosol skin refrigerant (Spray and Stretch technique) on passive and active stretching.

Journal of Bodywork and Movement Therapies - April 2008 (Vol. 12, Issue 2, Pages 96-104, DOI: 10.1016/j.jbmt.2007.11.005) Effect of topical aerosol skin refrigerant (Spray and Stretch technique) on passive and active stretching. Kostopoulos, D., Rizopoulos, K. Objectives: The purpose of this study was to examine the effects of the use of a vapocoolant blend of pentafluoropropane and tetrafluoroethane (Gebauer's Spray and Stretch) on hip flexion stretching. Methods: Thirty volunteers were randomly assigned to spray and stretch treatment and stretch only control groups. Each group was assessed pre- and posttest on passive and active hip flexion range of motion (ROM). Results: Findings indicated greater posttest hip flexion gains for the spray and stretch group over the stretch only group for both active and passive ROM. Additionally, females achieved greater pre- and posttest differences on active ROM compared to males. Conclusions: Study findings suggest that spray and stretch techniques can be an effective treatment in increasing hip flexion ROM.
<click here to purchase entire article>


Abstract: Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia.

Arch Phys Med Rehabil. 1981 Mar;62(3):100-6. Identification of myofascial trigger point syndromes: a case of atypical facial neuralgia. Travell J. Myofascial trigger points (TPs) in a muscle are usually activated by acute or chronic overload of the muscle. They are identified by objective and subjective findings. Objective signs include a palpably firm, tense band in the muscle, production of a local twitch response, restricted stretch range-of-motion, weakness without atrophy, and no neurologic deficit. Subjectively, the patient reports stiffness and easy fatigability, spontaneous pain in a distribution predictable for that TP, an exquisite deep tenderness specifically at the TP. Sustained pressure on the TP induces referred pain in the predicted pattern. Some muscles are likely to produce additional objective and subjective autonomic concomitants. Laboratory and radiographic findings are negative. The affected muscle is treated by passive stretch while a jet stream of vapocoolant spray is applied over it, or by injection of the TP with a local anesthetic. A case report describes in detail the treatment of a patient who, for 13 years, had suffered from a medically enigmatic, intense right facial pain with severe dysfunction and who is now pain-free, with a full schedule of unrestricted activities 23 years later.
<click here to purchase entire article>


Abstract: Otolaryngic myofascial pain syndromes.

Curr Pain Headache Rep. 2004 Dec;8(6):457-62. Otolaryngic myofascial pain syndromes. Teachey WS. Haygood Medical Center, 1020 Independence Blvd., Suite 313, Virginia Beach, VA 23455, USA. It has been long recognized in the otolaryngic community that despite great effort dedicated to the physiology and pathology of the ear, nose, throat/head and neck, there are a number of symptoms, including pain in various locations about the head and neck, which cannot be explained by traditional otolaryngic principles. The tenets of myofascial dysfunction, however, as elucidated by Dr. Janet Travell, explain most of these previously unexplained symptoms; furthermore, treatment based on Dr. Travell's teachings is effective in relieving these symptoms.
<click here to purchase entire article>


Abstract: Myofascial origins of low back pain. 1. Principles of diagnosis and treatment.

Postgrad Med. 1983 Feb;73(2):66, 68-70, 73 passim. Myofascial origins of low back pain. 1. Principles of diagnosis and treatment. Simons DG, Travell JG. Myofascial trigger points (TPs) are frequently overlooked sources of acute and chronic low back pain. An active myofascial TP is suspected by its focal tenderness to palpation and by restricted stretch range of motion. The restricted lengthening of the muscle is due to the tense band of muscle fibers in which the TP is located. The presence of a TP is confirmed by a local twitch response and by reproduction of its known pattern of referred pain, which matches the distribution of the patient's pain. Only an active TP causes a clinical pain complaint; a latent TP does not. The pain can be relieved by the stretch-and-spray procedure, ischemic compression, or precise injection of the TP with procaine solution. Relief is usually long lasting only if mechanical and systemic perpetuating factors are corrected.
<click here to purchase entire article>


Abstract: Myofascial trigger point syndromes: an approach to management.

Arch Phys Med Rehabil. 1981 Mar;62(3):107-10. Myofascial trigger point syndromes: an approach to management. Rubin D. Department of Physical Medicine and Rehabilitation, University of Southern California-Los Angeles County General Hospital, Los Angeles, California. The treatment of myofascial trigger point (TP) pain syndromes is not difficult once the source of the problem has been determined. Whereas many modalities may be used, two of the most effective are spray-and-stretch and TP injection. These can be followed by deep massage, specific, manual resistive exercises, and an exercise program which the patient can follow at home. The goal of management is to inactivate the TPs and to restore shortened and stretch resistant muscles to their full range of motion. A number of such syndromes are discussed in terms of recognition and management.
<click here to purchase entire article>


Abstract: Myofascial pain syndrome. Primary care strategies for early intervention.

Postgrad Med. 1994 Aug;96(2):56-9, 63-6, 69-70 passim. Myofascial pain syndrome. Primary care strategies for early intervention. McClaflin RR. Department of Family Medicine, Sioux Falls Family Practice Residency, University of South Dakota School of Medicine. Diagnosis of myofascial pain syndrome may become less challenging as clinical criteria become better defined. The mechanisms are not well known, and the syndrome occurs in a wide variety of settings. Trigger points with referred pain are the most common feature. Treatment consists of physical modalities (spray-and-stretch techniques and trigger point block) combined with a program of graded muscle stretching and strengthening. Early, aggressive treatment yields an improved prognosis.
<click here to purchase entire article>


Abstract: Myofascial pain syndromes and their effect on the lower extremities.

J Foot Surg. 1982 Spring;21(1):74-9. Myofascial pain syndromes and their effect on the lower extremities. Mandel LM, Berlin SJ. Podiatric Section, University of Missouri, School of Medicine, Kansas City, Missouri. Myofascial pain syndrome is an entity with which every podiatrist should be familiar. These disorders are usually the result of acute or chronic injury and are characterized by the presence of trigger areas and symptom complexes that have definite patterns. Once these patterns have been learned, the sources of pain can be readily predicted. Most of these conditions can be effectively treated in the podiatrist's office by local block techniques and/Or by application of Fluori-Methane spray. It is important to consult the appropriate medical specialist for diagnostic confirmation or for aid in treatment if uncertainty exists. Treatment regimens in this group of syndromes are based on the notion that in these disorders there is a self-sustaining cycle of pain-spasm-pain persisting after the precipitating cause has disappeared, which may be permanently abolished by interruption of the reflex mechanisms. In order to produce optimal results, the trigger area must be accurately located and treatment directed toward its elimination. Physical therapy and active exercise are necessary adjuncts to local blocks. Not all patients respond, and in many the response is slow, incomplete, and/or only temporary, but there are those in whom these simple measures provide relief of pain and disability in a manner as dramatic as one is likely to encounter in practice.
<click here to purchase entire article>


Abstract: Pseudo-dental pain and sensitivity to percussion.

Gen Dent. 2001 Mar-Apr;49(2):156-8. Pseudo-dental pain and sensitivity to percussion. Konzelman JL Jr, Herman WW, Comer RW. Department of Oral Diagnosis and Patient Services, School of Dentistry, Medical College of Georgia. Two case reports examine a little-known cause of dental pain and sensitivity to percussion. Contrary to the traditional assumption that pain and sensitivity to percussion almost always are diagnostic of pulpal inflammation and/or necrosis, these symptoms actually may be referred to the sensitive tooth from trigger points in the masticatory muscles. Therefore, myofascial pain syndrome must be ruled out in patients who have dental pain and display sensitivity to percussion.
<click here to purchase entire article>


Abstract: Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.

Arch Phys Med Rehabil. 2002 Oct;83(10):1406-14. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Institute of Biomedical Engineering, National Cheng Kung University, Taina, Taiwan. hcr@speech114.csie.ncku.edu.tw OBJECTIVE: To investigate the immediate effect of physical therapeutic modalities on myofascial pain in the upper trapezius muscle. DESIGN: Randomized controlled trial. SETTING: Institutional practice. PATIENTS: One hundred nineteen subjects with palpably active myofascial trigger points (MTrPs). INTERVENTION: Stage 1 evaluated the immediate effect of ischemic compression, including 2 treatment pressures (P1, pain threshold; P2, averaged pain threshold and tolerance) and 3 durations (T1, 30s; T2, 60s; T3, 90s). Stage 2 evaluated 6 therapeutics combinations, including groups B1 (hot pack plus active range of motion [ROM]), B2 (B1 plus ischemic compression), B3 (B2 plus transcutaneous electric nerve stimulation [TENS]), B4 (B1 plus stretch with spray), B5 (B4 plus TENS), and B6 (B1 plus interferential current and myofascial release). MAIN OUTCOME MEASURES: The indexes of changes in pain threshold (IThC), pain tolerance (IToC), visual analog scale (IVC), and ROM (IRC) were evaluated for treatment effect. RESULTS: In stage 1, the IThC, IToC, IVC, and IRC were significantly improved in the groups P1T3, P2T2, and P2T3 compared with the P1T1 and P1T2 treatments (P<.05). In stage 2, groups B3, B5, and B6 showed significant improvement in IThC, ItoC, and IVC compared with the B1 group; groups B4, B5, and B6 showed significant improvement in IRC compared with group B1 (P<.05). CONCLUSIONS: Ischemic compression therapy provides alternative treatments using either low pressure (pain threshold) and a long duration (90s) or high pressure (the average of pain threshold and pain tolerance) and short duration (30s) for immediate pain relief and MTrP sensitivity suppression. Results suggest that therapeutic combinations such as hot pack plus active ROM and stretch with spray, hot pack plus active ROM and stretch with spray as well as TENS, and hot pack plus active ROM and interferential current as well as myofascial release technique, are most effective for easing MTrP pain and increasing cervical ROM. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
<click here to purchase entire article>


Abstract: Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers.

Clin J Pain. 2000 Mar;16(1):64-72. Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers. Harden RN, Bruehl SP, Gass S, Niemiec C, Barbick B. Center for Pain Studies, Rehabilitation Institute of Chicago, Illinois 60611, USA. nharden@rehabchicago.org OBJECTIVE: The goal of this study was to assess clinical consensus regarding whether myofascial pain syndrome (MPS) is a legitimate and distinct diagnosis as well as the signs and symptoms characterizing MPS. DESIGN: A standardized mailed survey with return postage provided. SUBJECTS: A total of 1,663 American Pain Society members in medically related disciplines listed in the 1996/1997 directory. OUTCOME MEASURES: A standardized survey assessing clinical opinion regarding whether MPS is a legitimate diagnosis, whether MPS is a clinical entity distinct from fibromyalgia, and the signs and symptoms believed to be "essential to," "associated with," or "irrelevant to" to the diagnosis of MPS. RESULTS: Of the 403 surveys returned, 88.5% respondents reported that MPS was a legitimate diagnosis, with 81% describing MPS as distinct from fibromyalgia. The only signs and symptoms described as essential to the diagnosis of MPS by greater than 50% of the sample were regional location, presence of trigger points, and a normal neurologic examination. Regarding the signs and symptoms considered to be essential or associated with MPS, more than 80% of respondents agreed on regional location, trigger points, normal neurologic examination, reduced pain with local anesthetic or "spray and stretch," taut bands, tender points, palpable nodules, muscle ropiness, decreased range of motion, pain exacerbated by stress, and regional pain described as "dull," "achy," or "deep." Sensory or reflex abnormalities, scar tissue, and most test results were considered to be irrelevant to the diagnosis of MPS by a large proportion of the respondents. CONCLUSIONS: There was general agreement across specialties that MPS is a legitimate diagnosis distinct from fibromyalgia. There was a high level of agreement regarding the signs and symptoms essential or associated with a diagnosis of MPS. Differences across specialties are discussed. This survey provides a first step toward the development of consensus-based diagnostic criteria for MPS, which can then be validated empirically.
<click here to purchase entire article>


Abstract: Myofascial pain syndrome and trigger-point management.

Reg Anesth. 1997 Jan-Feb;22(1):89-101. Myofascial pain syndrome and trigger-point management. Han SC, Harrison P. Department of Anesthesiology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA. BACKGROUND AND OBJECTIVES: Myofascial pain syndrome (MPS) is a common condition often resulting in referral to a pain clinic. The epidemiology, pathogenesis, and various diagnostic tools are reviewed, and a variety of treatment methods are discussed. METHODS: Extensive periodical literature and textbooks are reviewed, and selected manuscripts are critically analyzed. RESULTS: The incidence of MPS with associated trigger points appears to vary between 30 and 85% of people presenting to pain clinics, and the condition is more prevalent in women than in men. Patients complain of regional persistent pain, ranging in intensity and most frequently found in the head, neck, shoulders, extremities, and low back. Muscle histologic abnormalities have been described in some studies. Similarly, electromyographic, thermographic, and pressure algometric studies have inconsistently identified abnormalities. A multidisciplinary approach to treatment appears to be most beneficial and may include such modalities as trigger-point injections, dry needling, stretch and spray, and transcutaneous electrical nerve stimulation. CONCLUSIONS: The definitive pathogenesis of MPS is currently unknown, and no single diagnostic method is consistently positive. While trigger-point injection is the most widely employed method of treatment, other modes of therapy have also proved to be effective.
<click here to purchase entire article>


Abstract: Effect of Fluori-Methane spray on passive hip flexion.

Phys Ther. 1981 Feb;61(2):185-9. Effect of Fluori-Methane spray on passive hip flexion. Halkovich LR, Personius WJ, Clamann HP, Newton RA. The purpose of the study was to evaluate the influence of Fluori-Methane spray as a method of affecting passive range of motion measured at the right hip joint. Subjects were 30 normal volunteers randomly divided into an experimental group and a control group. A special table was constructed to position and stabilize each subject for monitoring the right lower extremity's resistance to side-lying straight leg raising. Specific right hip flexion goniometric measurements were compared and analyzed before and after application of Fluori-Methane spray to the soft tissue overlying the posterior part of the right thigh. The results of the study showed that the experimental group, which received application of Fluori-Methane spray and static passive stretch, did significantly (p less than .02) increase the range of passive hip flexion over that of the control group, which received only static passive stretch.
<click here to purchase entire article>


Abstract: A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain.

Spine. 1989 Sep;14(9):962-4. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Garvey TA, Marks MR, Wiesel SW. Department of Orthopaedic Surgery, George Washington University Medical Center, Washington, D.C. The efficacy of trigger-point injection therapy in treatment of low-back strain was evaluated in a prospective, randomized, double-blind study. The patient population consisted of 63 individuals with low-back strain. Patients with this diagnosis had nonradiating low-back pain, normal neurologic examination, absence of tension signs, and lumbosacral roentgenograms interpreted as being within normal limits. They were treated conservatively for 4 weeks before entering the study. Injection therapy was of four different types: lidocaine, lidocaine combined with a steroid, acupuncture, and vapocoolant spray with acupressure. Results indicated that therapy without injected medication (63% improvement rate) was at least as effective as therapy with drug injection (42% improvement rate), at a P value of 0.09. Trigger-point therapy seems to be a useful adjunct in treatment of low-back strain. The injected substance apparently is not the critical factor, since direct mechanical stimulus to the trigger-point seems to give symptomatic relief equal to that of treatment with various types of injected medication.
<click here to purchase entire article>


Abstract: Clinical care for myofascial pain.

Dent Clin North Am. 1991 Jan;35(1):1-28. Clinical care for myofascial pain. Fricton JR. Department of Diagnostic and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis. Myofascial pain (MFP) is a regional muscle pain disorder characterized by localized tenderness in taut muscle bands and referred pain. Frequently, MFP is overlooked as a common cause of chronic pain because of the frequent association with joint dysfunction and other pain disorders and the multiple behavioral and psychosocial contributing factors that are often present. Nonetheless, studies have reported that MFP is present in a significant number of people. This article describes current concepts for the diagnosis and management of MFP.
<click here to purchase entire article>


Abstract: Guidelines for the treatment of temporomandibular disorders.

J Craniomandib Disord. 1990 Spring;4(2):80-8. Guidelines for the treatment of temporomandibular disorders. Clark GT, Seligman DA, Solberg WK, Pullinger AG. Dental Research Institute, University of California, Los Angeles, School of Dentistry 90024. These guidelines include the usual and customary treatment approaches recommended for each of the diagnostic categories described in a previous article on the examination and diagnosis of temporomandibular disorders. The current article describes when it is appropriate to use initial therapy, behavior modification therapy, pharmacotherapy, occlusal appliances, physical therapy, and surgical treatment for temporomandibular disorders. The physical therapy procedures described include various exercises as well as pain-relief techniques such as vapocoolant spray, massage, electrical stimulation of muscles and nerves, ultrasound, and trigger-point injections. Pharmacotherapy using muscle relaxant, nonsteroidal anti-inflammatory, tricyclic antidepressant, and narcotic pain medications are also discussed. Occlusal stabilization and repositioning appliances are reviewed as well. Finally, the broad indications for arthroscopic surgery, open surgery, and steroid injections are described.
<click here to purchase entire article>


Abstract: Piriformis syndrome: a rational approach to management.

Pain. 1991 Dec;47(3):345-52. Piriformis syndrome: a rational approach to management. Barton PM. Department of Physical Medicine and Rehabilitation, University of Western Ontario, London, Canada. Although rarely recognized, the piriformis syndrome appears to be a common cause of buttock and leg pain as a result of injury to the piriformis muscle. Four cases representing a broad spectrum of presentations are described here. The major findings include buttock tenderness extending from the sacrum to the greater trochanter and piriformis tenderness on rectal or pelvic examination. Symptoms are aggravated by prolonged hip flexion, adduction, and internal rotation, in the absence of low back or hip findings. Minor findings may include leg length discrepancy, weak hip abductors, and pain on resisted hip abduction in the sitting position. Myofascial involvement of related muscles and lumbar facet syndromes may occur concurrently. The diagnosis is primarily clinical as no investigations have proved definitive. The role of MRI of the piriformis muscle is assessed and other investigative tools are discussed. A rational management schema is demonstrated: (1) underlying biomechanical factors and associated conditions should be corrected; (2) the patient is instructed in a home program of prolonged piriformis muscle stretching which may be augmented in physical therapy by preceding ultrasound or Fluori-Methane (dichlorodifluoromethane and trichloromonofluoromethane spray); (3) a trial of up to three steroid injections is attempted; and (4) if all these measures fail, consideration should be given to surgical sciatic nerve exploration and piriformis release.
<click here to purchase entire article>