This is my current baby. I have always been interested in personal health, and I am currently working on becoming NASM CPT certified (I've passed practice tests, I just need to set aside a few weeks to actually take the real thing). TrP are a topic of health that has always been an interest of mine, and when training people, or looking after my own health, I would like to incorporate clinical Myofascial dysfunction treatment in my and others workouts. I decided to go straight to the golden source, and I have slowly but surely been going over the Travell Trigger Point Manual over the previous few months, painstakingly notating all information I consider to be important. I plan on finishing this project in particular by mid-2018, and hope that I can help others identify any myofascial pain and stay healthy in their own personal lives :)

1. Myofascial Pain and Dysfunction
II-XII  Glossary of Terms

2. Terminology
• Abduction-Movement from the body
• Active Range of Motion-How much somebody can move a
particular limb
• Active Myofascial Trigger Point-Causes a clinical pain complaint. It is
always tender, prevents full lengthening of the muscle, weakens the
muscle, refers a patient-recognized pain on direct compression,
mediates a local twitch response of muscle fibers when adequately
stimulated, and, when compressed within the patient's pain
tolerance, produces referred motor phenomena and often auto-
nomic phenomena, generally in its pain reference zone, and causes
tenderness in the pain reference zone.
• Acute-Of recent onset; hours or days
• Adduction-Movement towards the body

3. Terminology
• Agonist-Muscle who directly contributes to movement
• Allodynia-Pain due to stimulus that doesn’t ordinarily
cause pain
• Analgesia-Stimulus that ordinarily causes pain doesn’t
cause pain
• Anatomical Position-posterior (Back), anterior (Front),
lateral (Sides), medial (Middle), superior (Above),
inferior (Below)
• Antagonist-Muscle who directly inhibits movement;
opposite of agonist (e.g. Biceps/Triceps)

4. Terminology
• Bruxism-Clenching and grinding of teeth
• Caudad-Inferior
• Cephalad-Superior
• Chronic-Long standing; months, years
• Composite Pain Pattern-Pain Pattern of two or more
adjacent muscles, such that no distinction is made of the
individual muscles
• Contraction-Muscle becomes shorter and tighter by firing
action potentials
• Contracture-Muscle becomes shorter and tighter without
firing action potentials; condition of hardening of muscles

5. Terminology
• Coordinated Respiration-Expansion of chest and
contraction of diaphragm which increases intraabdominal
pressure
• Coronal Plane-Imaginary line that divides body into anterior
and posterior, perpendicular to Sagittal Plane
• Deep-Far from surface
• Distal-Far from point of origin
• Dysestesia-Any unpleasant, abnormal sensation
• Enthesitis-Inflammation at tendons and ligaments
• Enthesopathy-Any general disorder of bone attachment
(tendons, ligaments, etc…) May develop into Enthesitis

6. Terminology
• Erector Spinae-Lower Back Muscles, worked during
deadlifts, back extensions, etc…
• Essential Pain Zone-Pain that is present in every patient
when a particular trigger point is active
• Extension-Straightening of hinge joints
• Flat Palpation-Examination of trigger points by finger
pressure
• Flexion-Bending of hinge joints
• Function-Actions of a muscle
• Functional Unit-Agonist/Antagonist groups which
function together; Myotatic Unit

7. Terminology
• Hyperesthesia-Increased sensitivity to stimulation
• Hyperpathia-Abnormally painful reaction to a stimulus, in
particular a repetitive stimulus
• Hyperalgesia-Abnormally painful reaction to a stimulus that
is normally painful
• Hypoalgesia-Diminished painful reaction to a stimulus that
is normally painful
• Involved Muscle-Muscle with an active or latent trigger
point
• Jump Sign-Pain response of a patient in regards to trigger
point stimulation
• Key Myofascial Trigger Point-Trigger point that activates
satellite trigger points

8. Terminology
• Latent Myofascial Trigger Point-A trigger point which
does not cause pain at the moment
• Local Twitch Response-Twitch response of a trigger
point to stimulation
• Lumbago-Lower back pain
• Muscular Rheumatism-Muscle pain attributed to
inflammation in joints or soft tissue
• Myalgia-Pain in muscles due either to infection or
trigger points
• Myofascial Pain Syndrome-Symptoms attributed to
trigger points

9. Terminology
• Myofascial Trigger Point-A hyperirritable spot in skeletal
muscle that is associated with a hypersensitive palpable
nodule in a taut band. The spot is painful on compression
and can give rise to characteristic referred pain, referred
tenderness, motor dysfunction, and autonomic
phenomena; a “knot” in the soft tissue or muscle
• Paradoxical Respiration-Simultaneous expansion of the
chest and contraction of abdomen that pulls abdomen
inwards
• Passive Range of Motion-Range of motion of a limb when
moved by someone or something else
• Pincer Palpitation-Examination of trigger point by using a
pincer grip with thumb and forefingers

10. Terminology
• Primary Myofascial Trigger Point-Trigger Point activated by
overload or repetitive use of muscle, and not activated by
another trigger point
• Prone-Facedown
• Referred Autonomic Phenomena-Vasoconstriction,
coldness, sweating, ptosis, hypersecretion, and/or
pilomotor response (hair standing up) in an area separate
from the trigger point causing the symptoms
• Referred Pain-Pain caused by a trigger point that occurs
elsewhere
• Release-Anything which reduces muscle stiffness
• Sagittal Plane-Imaginary line which divides the body into
left and right portions

11. Terminology
• Satellite Myofascial Trigger Point-A trigger point caused by another
trigger point
• Scoliosis-Lateral curvature of the spine (Spine bends to sides)
• Shortening Activation-Activation of latent trigger point due to
shortening of antagonist when stretching agonist (hurting your back
because you are stretching your chest)
• Spasm-Sudden, involuntary firing of action potentials resulting in
muscle contraction
• Spillover Pain Zone-Region where some patients with particular
trigger points feel referred pain, but others do not
• Strain-Tissue and psychological response to sustained stress
• Stretch-Anything which elongates muscles
• Stress-Resistance force; physical or psychological overload
• Superficial-Close to the surface

12. Terminology
• Supine-Face upwards
• Synergistic Muscles-Muscles which complement
each other (Chest and Biceps, etc…)
• Taut Band-Group of tense muscle fibers
extending from the trigger points to the muscle
attachments
• Trigger Area-Synonymous with Trigger Points
• Zone of Reference-Area of the body where
symptoms of trigger points occur

13. Background
• Trigger Points are an exceedingly common source of
pain amongst patients
Trigger Points found in~ 50% of Shoulder-Girdle Muscles,
with 25% showing referred pain
Other muscle groups show similarly high
prevalence of Trigger Points
• In a sample of 96 patients, 93% of patients had pain
partially attributed to Trigger Points, and in 74% Trigger
Points were the primary source of pain
• People are most likely to suffer Active Trigger Points
when they’re in their mature years (Approx. 31-50)

14. Importance
• Skeletal Muscle is the largest organ in the human body,
accounting for nearly 50% of a person’s bodyweight
• Amount of muscles varies by muscles, but there are
approximately 200 pairs and 400 individual muscles in
the body
Any muscle can develop Trigger Points
• Trigger Point pain can range from debilitating,
incapacitating pain to painless restriction of movement
and distortion of posture
While not life-threatening, Trigger Points can impact
quality of life
Can lead to chronic injuries

15. Definition
• Many advancements in understanding myalgia (Muscle
Pain) and fascia came about starting from the turn of
the 20th century.
By 1990, there was a concrete definition for fibromyalgia,
or widespread muscle pain
Although the cause in not yet fully known, it is
firmly established that a Central Nervous System
Dysfunction is primarily responsible for the increased
pain sensitivity of fibromyalgia
• Studies implicate a dysfunctional endplate region,
which depolarizes skeletal muscle following an action
potential, and the prime site of Trigger Points

16. Related Diagnostic Terms
• The cause of musculoskeletal pain has perplexed the
medical community
• Anatomically Oriented Terms
Pain Syndromes “Discovered” before the identification of
Trigger Points
• Fibromyalgia
A different condition than trigger points with similar
symptoms
Abnormality in how pain signals are processed in the Central
Nervous System, leading to deep tissue tenderness
• Muskleharten/Myogelosen
Palpable firmness of trigger points responsible for pain

17. Related Diagnostic Terms
• Myofascial Pain Syndrome
Two meanings; any pain in soft tissue, or any pain
attributed to myofascial trigger points
• Nonarticular Rheumatism
General term for any soft tissue pain not associated
with a specific joint dysfunction or disease
• Osteochondrosis
Term that refers to interaction of neural and
muscular conditions

18. Symptoms
• Active Trigger Points can produce spontaneous pain, muscle shortening,
and motor dysfunction
Active Trigger Points can produce satellite trigger points throughout the body
• Latent Trigger Points can produce many symptoms of Active ones, but will
not produce spontaneous pain
• Trigger points are often caused by abuse of the muscle, usually in the form
of muscular overload, whether acute, sustained, or repetitive
Leaving a trigger point untreated can cause the trigger point to progressively
get worse
• Nerve compression can cause trigger points in paraspinal muscles
• Oftentimes, the most recently activated trigger point is the most painful
When deactivated, the pain pattern may shift to an earlier trigger point
Intensity of referred pain is based on intensity of trigger point, not size of
muscle
• Active trigger points may spontaneously revert to latent trigger points

19. Symptoms
• Trigger points often cause regional pain in soft
tissue
• People with sedentary lifestyles are more
likely to develop trigger point pain
• Trigger Points are most commonly found in
postural muscles of the neck, shoulders, and
pelvic girdles, and in the jaw muscles
• Sleep positioning can be critical to the relief of
trigger points

20. Physical Findings
• Muscles harboring Trigger Points are prevented from reaching full stretch
range of motion, and are also restricted in strength and endurance
The Trigger Point is identified as a localized spot of tenderness in a nodule in a
palpable taut band of muscle fibers
A taut band is a group of tense muscle fibers extending from the
trigger point to the muscle attachments
• A tender nodule is the highly localized tender spot of a trigger point
Movement of application of pressure by a millimeter can result in a markedly
different pain response
• Pressure on an Active Trigger Point can cause a twitch response in the
muscle
• A trigger point can impede range of motion; attempts to passively stretch
beyond the range of motion can result in pain
• Muscles with an active trigger point start out fatigued, fatigue more
quickly, and become exhausted more quickly than unaffected muscles
• When a trigger point is strongly contracted against, it causes pain

21. Testing
• While there is no laboratory testing of Trigger Points,
there are three measurable methods to detect trigger
points.
• Needle Electromyography
There is a specific EMG for finding Trigger Points, as well
as motor endplate activity that, while not confirming a
trigger point, is characteristic of a trigger point
• Ultrasound Imaging
• Surface Electromyography
Measuring effects of Trigger Points on muscle activity,
and their influence on motor functions in both the
muscle where they occur, and other muscles

22. Testing
• Muscles with Trigger Points tend to exhibit three issues
Increased Responsiveness
Some muscles may become inhibited, while others
may become excited and tend to “overreact,” depending on
the muscle; these muscles become more sensitive to pressure
Accelerated Fatigability
Muscles with trigger points fatigue more quickly than
normal, unaffected muscles
Delayed Relaxation
Common when muscle is overworked
Testing shows low levels of EMG activity when muscle
should be relaxed, which contributes to fatigue

23. Testing
• Oftentimes, spasm occurs in muscles with TrP,
particularly the upper trapezius, masseter (upper jaw
responsible for chewing), posterior cervicals, and
lumbar paraspinal muscle
• Spasm doesn’t necessarily indicate pain referral,
particularly with lumbar paraspinal muscles
• TrP in a muscle oftentimes causes inhibition in other
muscles, which affects normal muscle function.
Oftentimes, this inhibits an antagonist muscle
See: My hip surgery, tight psoas and quads leads to
underactive gluteal muscles
Fixing TrP returns normal muscle function

24. Testing
• Algometry
Way of testing pain from TrP by applying direct pressure
Three Levels of Pain
Localized Pain
Referred Pain
Intolerable Pain
Three things to keep in mind when testing
Test reveals nothing about source or cause of pain
Thinner muscules will yield pain more easily than thicker
muscles
Specific testing is very skilled. I cannot do this personally, but I
can use this testing to get an idea of my own TrP so I know what to
focus on

25. Testing
• Algometry
Referred pain can be extracted from all active TrP in a
clinical setting, but only about half of Latent TrP
Pain threshold for Active TrP is significantly lower than for
Latent TrP
• Thermography
TrP correlates with areas of higher temperature
A hot spot does not necessarily indicate the presence of a
TrP
When referred pain is caused by pressure in a TrP, the TrP
region becomes hyperthermic

26. Treatment
• To treat TrP we must consider and deal with the cause
that activated the TrPs, to identify and correct any
perpetuating factors (which often are different than
what activated the TrPs), and to help the patient to
restore and maintain normal muscle function.
• Treatment options that are of interest to me include
the use of simple muscle stretch, augmented muscle
stretch, post-isometric relaxation, reciprocal inhibition,
slow exhalation, TrP pressure release, massage, range
of motion, heat

27. Diagnostic Criteria

28. Diagnostic Criteria

29. Diagnostic Criteria
• Jump Test/Spot Tenderness
Easy, but test is very ambiguous as to cause of pain.
For reliable clinical results, must be tested with quantifiable
methods
• Pain Recognition
Luckily, I know what a TrP feels like. With experience, you will
too
• Palpable Taut Band
Ambiguous as Taut Band can be observed without pain
The presence of spot tenderness combined with a palpable
band and nodule is highly reliable
Detecting a palpable nodule in a taut band increases reliability

30. Diagnostic Criteria
• Twitch Response
The single highest correlation with TrP
Very difficult to elict, sometimes cannot be elicted,
especially near areas with Enthesopathy
TrP tend to be in the belly of muscle rather than
where muscles are attached
Needle penetration of TrP will easily elict trigger
response
• Range of Motion
Fundamental characteristic of TrP

31. Diagnostic Criteria

32. Diagnostic Confusions
• Musculoskeletal pain is often attributed to
myofascial TrPs, fibromyalgia, and articular
dysfunction that requires manual mobilization
• All three need significantly different
treatments, and different diagnostic exams
• Refer to page 37 of Vol. 1 for a chart of
common conditions, and their common TrP
culprits

33. Diagnostic Confusions

34. Diagnostic Confusions
• Non-myofascial TrP
Can occur in skin, etc…
Scar TrP (in skin or mucous membranes) refer burning,
prick- ling, or lightning-like jabs of pain, can have alcohol
injected to fix
• Acupuncture
Pain relief experienced from classical acupuncture points
is associated with an endorphin response in the central
nervous system
Frequently the acupuncture point selected for the
treatment of pain is actually a TrP. Sometimes, it is not a
TrP.

35. Muscle Structure and Function
• Striated Skeletal Muscle
Composed of fascicles, bundles of muscle fibers
Muscle fibers cover roughly 1,000 myofibrils, composed of
chains of sarcomeres
Sarcomere’s are the basic unit of the muscle cell
• Sarcomere
Connected to each other by bands, in a chain-like fashion
Consists of actin and myosin molecules which interconnect to produce
force to contract
Myosin heads are a form of ATP that interacts with Actin to produce
contractile force
Ionized Calcium triggers interaction, and ATP provides energy
Sarcomere produces maximum force in the midrange, but expends
energy at either extreme to prevent further shortening or lengthening

36. Muscle Structure and Function
• The Motor Unit
The Central Nervous System controls voluntary
muscle activity through motor-neurons
Motor Neurons controls hundreds of muscle fibres
The fewer muscle fibres a neuron controls,
the finer the movement control of that neuron is
• Motor Point
Area where visible twitch could be elicited using
electro-stimulation

37. Muscle Structure and Function

38. Integrated Trigger Point Hypothesis
• Energy Crisis Component
Calcium intake by muscle is created and sustained;
recall this tells muscle to contract
Sustained contractions use energy and prevent flow
of oxygen into region
Circulation in a muscle fails at 30-50% effort
Because of the energy shortage, due to sustained
contraction, the Ca pump that returns calcium to
tell muscle to stop doesn’t have necessary ATP

39. Integrated Trigger Point Hypothesis

40. Integrated Trigger Point Hypothesis
• Taut Band
Forms because trigger point contracts at nodule, and then pulls on rest of
muscle fiber, increasing tension
• Palpable Nodule
These feel swollen because sarcomeres must maintain a constant volume
Therefore, they broaden as they shorten
• Spot Tenderness
Caused by sensitized pain receptors, caused by energy crisis in region
• Enthesopathy
Caused by tendons being unable to withstand tension of taut band
• Response to Massage
TrP myoglobin response to massage differs from normal muscle
Massage ruptures cell and relieves the myofascial impingement
Response for TrP fades dramatically with repeated interests

41. Integrated Trigger Point Hypothesis

42. Integrated Trigger Point Hypothesis
• Histopathological Complications
Adjacent TrP can cause shear forces with other
muscle, causing more TrPs
If a taut band goes untreated for too long, it can
cause sarcolemma (tube that envelops muscle
fibers) to have regions of emptiness (no fibres)
This is where condition becomes chronic

43. Local Twitch Response
• Mechanical stimulation of TrP can cause twitch in taut
band, primarily through needles
• Very useful for confirmatory purposes
• For needle stimulation, if LTR is activated, that signals
• LTR can be prohibitively painful
• Difficult to elicit from manual stimulation like massage
because of surrounding muscle and fat
• Requires meticulous accuracy to stimulate LTR from
taut band/TrP
• Can also occur in regions of Enthesopathy or bursitis

44. Referred Pain and Tenderness
• Pattern of referred pain is vital to identifying cause of
myofascial dysfunction
• Referred pain is usually felt at the muscle attachments of
the taut band
• TrP referred pain is usually steady, deep, or aching,
occasionally sharp
• TrP pain patterns are predictable and reproducible
• Trigger points may refer pain in three directions
Peripheral, away from center of body
Central, in center of body
Local, immediate vicinity
• Peripheral is most common (85% of patterns)

45. Referred Pain and Tenderness

46. Referred Pain and Tenderness

47. Referred Pain and Tenderness
• Referred pain can come from overlapping TrP
pain patterns, and may require inactivation of
multiple TrP to resolve
• Keep in mind, pain can return to TrP, and in
the event it does, it may be required to treat
underlying causes AS WELL AS TrP (Such as
poor muscle movement)

48. Anatomy
• In this text, descriptions of muscle attachments assume anatomical
position
Above implies Cephalad, superior, or proximal
Below implies Caudad, inferior, or distal
• Fiber Length
Cross-Sectional Area is proportional to relative strength of a muscle
Force producing muscles such as the quadriceps have a low fiber
length:muscle length ratio
Muscles with low ratio have endplate zones that run along the
muscle
High Velocity movements muscles such as the hamstrings have high
fiber length:muscle length ratio
Muscles with high ratio have endplate zones that ran
transverse to the muscle

49. Anatomy
• A functional unit includes muscles that reinforce
and counter the movements of a given muscle, as
well as joints that the muscle crosses
A TrP in a muscle in a functional unit usually leads
to TrP in other muscles in the functional unit
Dysfunction of a given muscle leads to
overload of muscles in the same functional unit
• Myotatic Unit
Composed of agonist, synergists, and antagonists

50. Anatomy
• Posture is very important, and it is important to
be aware of this
Common issues: Leaning forward, not maintaining
normal lumbar-spine curve, not engaging
core/slumping in chair, feet not touching floor,
elbows not touching armrests
• It is also essential to be aware of pain and
dysfunction in the body
“Doesn’t everybody’s feet hurt?” This is a problem
that should be solved and acknowledged

51. Patient History
• Every patient has unique dietary needs
Even if on surface they are reaching those needs, they
may not be
E.g. reheating food or keeping under warming light
may cause vitamins to leach out of food, specific methods
of preparation may change nutritional value of food
• Sleep is a big issue for people
If someone is cold, muscles often contract to keep warm,
which can cause activation of TrP and pain
• TrP may flare up when hungry, because energy crisis
becomes worse with less available energy in body

52. Myofascial Pain Onset
• Abrupt Onset
Due to a singular event or action
• Gradual Onset
Due to chronic overload of muscle
• Other
Can be caused due to psychological stress, viral
infection, illness

53. Myofascial Pain Onset
• Aggrevating Causes
Strenuous use of muscle, especially when shortened
Passive stretching of muscle
Pressure
Being placed in shortened position for extended time
period
Usually worst after long period of sitting or after
waking up
In cold environments
When ill

54. Myofascial Pain Onset
• What decreases pain
Short period of rest
Slow, long passive stretches
Moist heat directly over the TrP
Short period of light activity with plenty of
movement, which causes blood to pump
Myofascial Therapy

55. Myofascial Pain Onset
• TrP can lead to limited range of motion, as muscle
limits full stretch with TrP
• Weakness can be caused by TrP inhibiting muscle
contraction
Additionally, body can learn to limit contraction to stay
below pain threshold
• Chronic pain and depression go hand in hand, and TrP
can help further depression and visa-versa
• TrP can cause sleep disturbances
• If TrP is progressively getting worse, then perpetrating
factors must be eliminated before treating myofascial
condition

56. Activation and Perpetration
• One time trauma can activate a TrP, but will not
necessarily perpetrate them
• Any repeated or chronic muscle overload can lead to
TrP
• Sudden onset
Mechanical stresses that tend to lead to TrP are
wrenching movements, automobile accidents, falls,
fractures, joint sprains, impact, or dislocations
TrP from one time traumatic issues are easily
treated
Latent TrP in a fatigued muscle can be activated by direct
cooling

57. Patient Examination
• Note the spontaneous movement of a patient in a clinical setting
Patients with painfully active TrP tend to move slowly and protectively, and
avoid movements that will lead to activation of TrP pain
Key observations
Does body turn, or body and head turn
Are shoulders level while sitting
Is spine rounded in resting position
Does patient stretch passively
• Neuromuscular Functions
Different populations inherently behave differently and develop different
problems
Some people are jerky, some people misuse their muscles
Athletes tend to avoid movements that cause discomfort, which leads to the
development of weakness

58. Patient Examination
• Relevant TrP
Can be done by performing range of motion stretches
Taking slack to point of tension
Ask patient where tension occurs
Palpate area to look for a taut band
These TrP can cause dysfunction with or without pain
• Compression Test
When a patient complains of TrP pain only during movement,
compressing the agonist muscle of the movement can
sometimes temporarily relieve pain
Can convince patient of nature of issue, especially if patient
has tried many times to have issue fixed to no avail

59. TrP Examination
• One way to confirm location is to resist movement of
patient to contract muscle with one hand manually,
and palpate muscle with second hand
Patient must be warm and muscle must be relaxed,
otherwise distinction between tense bands and adjacent
slack muscles is lost
• Fingernails must be properly trimmed to avoid
distracting pain
• Examining muscle for TrP can lead to pain for a day or
two, so examination should be followed by specific
myofascial therapy, such as spray and stretch or moist
hot packs

60. TrP Examination
• “A taut band feels like a palpable cord of tense
muscle fibers among the normally pliable
fibers. Such palpable tense muscle fibers were
described as "matted together" by Wilson.
The examiner should palpate along the taut
band to locate the nodule that corresponds to
a circumscribed slightly enlarged region of
decreased compliance. This nodular region is
also the location of maximum tenderness “

61. TrP Examination
• Can use Flat Palpation, Pincer Palpation, or
Deep Palpation for examination
• Flat Palpation

62. TrP Examination
• Pincer Palpation

63. TrP Examination
• Deep Palpation
Place finger deep in tissue for deep muscle and feel for tenderness
• Sufficient pressure on active TrP will elict response from patient in
most cases
A jump sign means the response is vigorous
• Two types of TrP, Central and Attachment
• Central TrP
The primary central TrP abnormality is associated with individual
dysfunctional endplates in the endplate zone (or motor point). This
dysfunction produces a local energy crisis that results in sensitization
of local nociceptors. This dysfunction can produce contraction knots
which then produce a nodule and a taut band of tense muscle fibers.

64. TrP Examination
• Attachment TrP
The attachment TrPs result from the sustained increased
tension of these muscle fibers at the attachment point. This
sustained tension can produce enthesopathy with swelling
and tenderness where the muscle fibers attach to an
aponeurosis, tendon, or bone. Some muscles have sufficient
separation between the muscle fiber-to-tendon attachment
and tendon-to-bone attachment that one end of the muscle
may have two distinctly different attachment TrPs.
• Some TrP may be related to each other
Key TrP can induce Satellite Trp, which cannot be fixed
without root TrP being fixed first

65. TrP Examination

66. TrP Examination

67. Trigger Point Release
• The Treatment of a TrP depends on the type of TrP
Central TrP
Respond well to stretching
Respond well to warmth
Deactivating Attachment TrP may help fix Attachment
TrP
Respond well to manual release
Respond well to cold, especially if inflamed
Central TrP must be deactivated to prevent reactivation
of Attachment TrP
• TrP recovery often involves relieving pain, deactivating TrP,
then reeducating muscles on proper movement patterns

68. Trigger Point Release
• Spray and Stretch
Stretching is the “action,” and spraying is the “distraction”
Ethyl Chloride Spray
This spray has been shown to work as a surface level anesthesia,
especially regarding myofascial pain
The spray does not relieve any of the underlying issues, but will help
with the pain
This can cause health issues; there are replacements, but none are
fully accepted yet
Spray and Stretch is a very effective non-invasive method, but there are more
effective methods that a patient can use at home
Spray and Stretch works well for children
Advantages
Spray and Stretch does not require finding precise TrP, only region of
taut bands and discomfort

69. Trigger Point Release
Spray and Stretch

70. Trigger Point Release
• Stroking With Ice
Cooling effect of spray can be achieved with ice, but skin must
be kept dry
• When coldness is applied, skin temperature drops which
causes alarm reactions to appear in the region
This input has an inhibitory effect on pain, which can help
patient with stretch when it would normally be painful to
perform the stretch
• Keys to stretching
Any gentle lengthening of muscle is shown to reduce Central
TrP
Push to boundary until muscle relieves tension, then
push further, until lowered slowly, standard stuff

71. Trigger Point Release
• Post isometric Relaxation
Done by supporting muscle to prevent shortening of muscle , client
performs isometric contraction for 3-10 seconds then relaxes and
muscle lengthens
Can be combined with reflex augmentation, such as synchronized
breathing or eye movements, for greater effect
• Reciprocal Inhibition
Contracting the antagonist to the muscle being stretching will allow
the target muscle to stretch more
E.G. contracting hamstring during quad stretch
• Contract-Relax
Gentle, minimally resisted contraction of tight muscle followed by
relaxation

72. Trigger Point Release
• Trigger Point Pressure Release
Here’s a surprising fact; when using pressure release, don’t
need enough pressure to produce ischemia in muscle to be
effective
Lengthen muscle to point of increasing resistance within
comfort zone
Apply gradually increasing pressure until tissue begins to
increase resistance against touch
Continue until tissue relaxes
This is good for central TrP, and should not be brought to pain
It is worth nothing that Shiatzu and Accupuncture,
while conceptually different, have similar treatments to the
treatment of TrP

73. Trigger Point Release
• Deep Stroking Massage
Arguably the most effective way to inactivate TrP
Should pay close attention to barriers and release in body
Muscle to be treated should be relaxed to point of no slack,
and lubricated if subcutaneous tissues are tense
Start on TrP, apply pressure, then apply deep massage along
taut band
Pressure applied should be in response to body;
applying too vehemently or quickly can destroy muscle
endplates as functional structure and cause pain or discomfort
Be sure to apply massage in both directions of TrP

74. Trigger Point Release
• Strumming
Similar to deep tissue massage, but motion is directed
perpendicular to the length of the muscle, rather than with
the length of the muscle
Finger runs along muscle belly until it comes into contact with
Nodule, and is strummed
Very useful for thin muscles like the masseter
• Myofascial Release
Therapeutic System for soft tissue recovery
A clinical practice that is often effective for TrP, but the
specific TrPs are not diagnosed, so it is hard to say how much
pain is attributed to TrP from patient to patient with this

75. Trigger Point Release
• Accessory Techniques
Exhalation tends to make most muscles in body relax, so it can be used
with stretching to increase effectiveness
Phased respiration
Eye movement facilitates movement in head and trunk of patient and
inhibits opposing movement
By looking in direction of movement needed to release
muscle, it will be help
Avoid exaggerated movements, as they will inhibit effect and
become distracting
Heat penetrates skin poorly, and works to increase circulation in an
area and relaxation
Cold penetrates skin deeply, and will offer pain relief
Muscle relaxants don’t help

76. Trigger Point Release
• Vitamin C deficiency is often caused by tobacco smoking
Sufficient Vitamin C should be available in body for TrP therapy
• Reactive Cramping
Sometimes, deactivating a TrP will cause cramping in antagonist
This can be avoided by treating both agonist and antagonist at
once
• It didn’t work!?
Many reasons
Patient not fully relaxed
Inadequate Stretch Technique
Not enough ROM for stretch
Poor posttreatment (if cooled, skin should be warmed after)

77. Trigger Point Injection
• This section (P1.C3.S13) is irrelevant for my
purposes, but I welcome you to read and
notate the section.
• I have read it, will not notate because I do not
plan on treating TrP with injection due to lack
of availability of anesthetic, and more
importantly, lack of training and environment
in which to perform injection
• Page 150-166

78. Corrective Actions
• Corrective Actions can be impinged on three factors by patient
Overenthusiasm
These people may abuse their muscles, ignore what their body
tells them, etc…
Misunderstanding
Patient misunderstands what they need to do
Lack of Interest
Patient must learn that Dr/Therapist/Anybody can only give
them the tools to treat their muscle pain THEMSELVES
Sometimes, patient will take a declaration, such as “I have
arthritis of the spine,” as a condemnation and sentence themselves to
a life of pain medicine instead of corrective action

79. Corrective Actions
• Proper muscle mechanics
It is important to keep simple rules in mind
Do not lift with rounded back
Do not apply force with a rotated joint
Do not bend forward and twist when getting up from a
seated position
Jerky, rapid movements are poorly coordinated, and should
be replaced by habitual smooth, controlled movements
Keep in mind height level when sitting down to avoid neck
strain; as a taller person, I should set my chairs lower to the
ground

80. Corrective Actions
• It is usually best to avoid using maximal effort in muscles, in
order to avoid strain
• Posture when laying down should not be contracted for
extended periods (Hello my legs are always up)
• Movement and full ROM stretching will help muscles to
remain limber and healthy
• Mix up housework so as to not perform the same activity
for hours on end
• Cultivate a rhythm of movement
• Take short breaks every hour, especially during activity.
Laying down will relax anti-gravity muscles
• Don’t sit in one place for too long; take short walking
breaks, move neck and shoulder blades, use a rocker, etc

81. Corrective Actions
• Relaxation
Relaxation is an active process that requires
focused attention to accomplish
Muscles relax more fully following a light
contraction
• Heat following exercise will aid in muscle
relaxation and recovery

82. Page 179