The trigger point strikes … out!

John Quintner and colleagues recently published a controversial review in Rheumatology. We asked him to present their position in blog form. I expect it to stir some intriguing emotions in many of you and we welcome comments and alternative perspectives. In anticipation, and with tongue almost completely in cheek – remember to avoid the ad hominem mistake and the straw man mistake. Here is the post from Dr Quintner et al.

“The study of fallacies … should attune the student to the omnipresent dangers to which we are exposed as a consequence of imprecise expressions – vague, ambiguous, or misdefined terms – or of unarticulated assumptions and presuppositions [1].

The 1980s was a watershed decade for me. I had a long-standing interest in what was then called Physical Medicine, and my most valued textbooks were those written by James Cyriax, Allen Stoddard and John Bourdillon. At that time the Australian epidemic of repetitive strain injury (“RSI”) – a diagnosis applied to primarily upper limb (forearm and wrist) symptoms, the cause of which was attributed to keyboard and other occupational overuse – was raging. I was forced to admit that my training and subsequent experience as a rheumatologist did not help me to understand the clinical phenomena associated with “RSI” that I encountered daily. By chance I came upon the first edition of The Trigger Point Manual by Janet Travell and David Simons [2]. Could their theory of “myofascial pain” arising from “trigger points” fill the large gap in my understanding of these complex clinical problems? These authors expanded upon an earlier publication by Travell and Rinzler [3] in which patterns of “pain referral” from specific muscles were illustrated. However, as they did not publish the evidence upon which they based their patterns, it appeared to me that the illustrations were based on little more than inspired guesswork. Nonetheless, taken at face value, the hypothesis for Myofascial Pain Syndrome (MPS) advanced by Travell and Simons seemed quite convincing: myofascial trigger points (MTrPs) were the sites of tissue damage, and resided within taut bands located in the culprit muscles. In hindsight, this is an excellent example of circular reasoning! Many of the MTrPs (marked with an X), together with their respective patterns of pain “referral”, were impressively displayed. Treatments such as cold spray administered to the skin followed by gentle stretching of the involved muscle was said to be helpful, if not curative (page 63). In addition, insertion of “dry” needles into the MTrPs followed by stretch of the involved muscle was recommended, as were ischaemic compression (page 86) and massage (page 87). But when I met the late Bob Elvey, he completely changed my way of thinking about these clinical problems. Bob’s mantra was that “muscles protect nerves.” He introduced me to the dynamics of the nervous system and I came to understand that peripheral nerves of the upper limb had evolved to be able to adapt to the various changes in limb position and length and that they were vulnerable at certain anatomical points along their course. His pioneering work on methods of assessing the mechanosensitivity of peripheral nerve trunks has greatly enhanced the clinical examination of the upper limb. In addition to these important clinical insights, I became aware of the large mechanical forces that could potentially be generated within the cervical spinal canal by the maintenance of fixed head/neck postures being adopted by those who performed repetitive manual work. On a closer reading of The Trigger Point Manual, I discovered that the authors had made at least three fundamental epistemological errors that cast considerable doubt upon their theory of MPS. These three errors are not directly related to MTrPs, which are in any event yet to be validated, but rather to poor diagnostic reasoning. Firstly, they implied that pain of peripheral nerve origin could be diagnosed only with accompanying clinical evidence of neurological deficit (page 22), as defined by loss of muscle power and wasting, loss of myotatic reflexes, and diminished sensibility in the distribution of the relevant peripheral nerve, thus enabling the clinician to distinguish such pain from that said to arise from MTrPs. Travell and Simons did not appear to appreciate that pain of peripheral nerve origin could be present without such clinical evidence. Secondly, they believed that a normal conventional electrodiagnostic examination effectively ruled out the possibility of peripheral nerve pain (page 22). Such an examination does not provide any information as to the state either of the small diameter nerve fibres responsible for nociceptive input or that of the nerve interstitium. Thirdly, they announced in Table 3.2 (page 63) that taut bands within muscles that contained MTrPs could entrap peripheral nerves in the vicinity. The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility. But at least any of a myriad of factors could be drawn upon to exempt from blame those well-meaning therapists who were finding that the recommended treatment regimen was ineffective. Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence). Meanwhile there were important developments on the “RSI” front. Taken together, our work and that of Milton Cohen’s group in Sydney provided scientifically credible and testable hypotheses for “RSI” [4,5]. But that is for the next installment. Early in the 1990s, Milton and I decided to challenge myofascial pain theory. At the time, another concern of ours was that the fibromyalgia construct was also logically and epistemologically flawed. In our 1994 paper we deconstructed the MPS hypothesis of Travell and Simons, found it wanting, and offered scientifically credible explanations for the observed clinical phenomena [6]. The pioneering studies of nerve inflammation conducted by Geoffrey Bove and the publication by Geoff, together with Alan Light, of the “nervi nervorum” hypothesis [7] attracted our interest and culminated in an alliance with Geoff that has continued. In brief, Geoff’s studies have had two major impacts on how we think about pain felt in muscles or other deep structures. Firstly, he confirmed the presence of nociceptors with multiple receptive fields that branch within the nerve sheaths and extend to other deep tissues (nervi nervorum) [7]. The implication of this finding is that activity in a receptor in one structure such as the nerve sheath, could be perceived in another, such as the muscle. Secondly, he showed that inflammation of nerves has profound effects on these same axons, the nociceptors to deep structures. These effects include ongoing activity and abnormal mechanical sensitivity [8, and others]. The implication of this finding is that this activity will be perceived by the brain in the area of the receptive fields mapped for the deep structure nociceptors, not in the area of the problem. Both of these mechanisms are critical to the concepts being discussed, because they encourage consideration of a number of plausible neurobiological explanationsfor ‘muscular’ pain. (see Figure 1).

trigger point

Figure 1. Proposed hypothesis for the development of focal muscle sensitivity and possible alteration in muscle texture with a proximal neural cause. Inflammation affecting a peripheral nerve (red spot) results in spontaneous and mechanically evoked afferent and efferent action potentials in small caliber sensory neurons innervating non-cutaneous structures, and decreased sympathetic discharge (-). These processes may cause reflex motor discharge sufficient to cause a palpable contraction (?), which combined with clinical phenomena associated with neurogenic inflammation (+), could explain the clinical phenomenon that has become known as a “trigger point.”

However our challenge to the MPS theorists failed to evoke a response, which we thought surprising, given that we raised serious doubts about their construct. Not only was the MPS/MTrP literature expanding in volume but also the editors of journals that published papers based on MPS theory appeared reluctant to countenance any criticism of the authors. But this subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture. Early in 2013, Milton, Geoff and I joined forces and decided that another paper was needed to refute the MTrP dogma. The three most prominent North American pain journals did not accept our offerings. Eventually our paper was published online, with open access, in Rheumatology [9]. Now we are left with a major challenge – how to explain the pain previously attributed in error to MTrPs. We hope that in our latest paper we have pointed the way towards a theoretical model that will explain the clinical phenomena by incorporating our knowledge of the mechanisms of referred pain and tenderness, along with the well-documented clinical findings of nerve trunk allodynia, and the experimental evidence derived from studies of nerve inflammation. I gratefully acknowledge the assistance of Geoff Bove and Milton Cohen when preparing this article.

About John Quintner

John QuintnerJohn Quintner is a retired physician in Rheumatology and Pain Medicine who is currently a volunteer with Arthritis and Osteoporosis WA. He is now interested in contributing to pain education for health professionals and consumers. John has long been active as an iconoclast in the field of pain theory and practice. The prime targets have been myofascial pain theory and the North American fibromyalgia construct. His skeptical approach has been well balanced by Milton Cohen’s critical analytical skills. Most of John’s useful ideas have come to him whilst “in the zone” atop his long-cherished bicycle.


[1] Toulmin S, Rieke R, Janik A. An Introduction to Reasoning, 2nd ed. New York: Macmillan Publishing Co., 1979. [2] Travell JG, Simons DG. The Trigger Point Manual. Baltimore: Williams and Wilkins, 1983. [3] Travell J, Rinzler SH. The myofascial genesis of pain. Post-Grad Med 1952; 11: 425-434. [4] Elvey RL, Quintner JL, Thomas AN. A clinical study of RSI. Aust Fam Physician 1986; 15: 1314-1312. [5] Cohen ML, Arroyo JF, Champion GD, Browne CD. In search of the pathogenesis of refractory cervicobrachial pain. A deconstruction of the RSI phenomenon. Med J Aust 1992; 156: 432-436. [6] Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251. [7] Bove GM, Light AR. The nervi nervorum. Missing link for neuropathic pain? Pain Forum 1997; 6: 181-190. [8] Bove GM, Ransil BJ, Lin HC, & Leem JG. Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues. Journal of Neurophysiology 2003; 90: 1949-1955. [9] Quintner JL, Bove GM, & Cohen ML (2014). A critical evaluation of the trigger point phenomenon. Rheumatology PMID: 25477053


  1. Geoffrey Bove says

    Posting for this blog is being closed. I would like to thank each and every one of you who made the effort to follow along, and more so, to all who read our paper and read the in-press article by Dommerholt and Gerwin. Please look for our response to that paper, which should follow by a month or so. Many of the issues were already covered in our paper but seem to have been overlooked. Others have been covered here. We assume that Mr. Chaitow will publish our letter in the spirit of fair play.

    Please keep learning, and questioning.


  2. Geoffrey Bove says

    Todd, I was just being silly, not being condescending. Pain gating refers to the gate theory.
    EG, that is a good paper, but is not about pain gating, rather, it is a classic about spinal cord plasticity.

  3. Btw my last thoughts on the matter are that the nervous system relies on a body and an environment. To simply focus on one element at the cost of marginalizing, or over-simplifying, the others is to metaphorically lose the forest for the trees. Regardless, thank you for sharing your work and taking the time to answer questions.

    John Quintner Reply:

    Todd, we are in agreement on this. I enjoyed reading your Popper quote.

    In summary, in relation to their concept of trigger points the principal argument of our opponents fails because of the two fallacies in it that we have detected: firstly petitio principe (begging the question as to their underlying pathoanatomical status) and secondly reification (making them into concrete entities only to then seek to eliminate them). If we are correct, this means they are now trapped in a circular argument.

  4. Geoffrey & John,

    To use an earlier figure of speech made by Geoffrey, there is a 3rd possibility: an agnostic Jew that is an element of ethnicity, not religion. To ground this metaphor in the current conversation, my practice remains relatively unchanged (i.e. ethnicity), but I do not focus on trigger points (i.e. there is no belief in God, Jesus, etc.). More specifically, while I am personally well-read, credentialed, and have quite a few years of experience under my belt; I am still a proponent of using foam rolling and gentle hands on work.

    To be sure, I know a muscle at rest is completely at relaxed (EMG silent) and there are no muscle imbalances (difference in agonist-antagonist strength ratio), but something is happening that you haven’t been able to clearly elucidate. The external pressure from foam rolling/hands on work isn’t “molding” soft tissue and/or releasing trigger points, but it still makes an immediate difference that lasts longer than any proposed temporary counter-irritation from DNIC down-regulation. Is this simply an example of an immediate shift in centralization that, at times, is long-lasting instead of being a temporary alteration? Can you offer an opinion?

    Basically, I am asking you to speculate on what is happening in the peripheral nerves (trunk, nociceptors, etc.) from foam rolling, hands on manipulation, etc. – what is occurring in the local neural tissue that can be explained without the need to rely on myofascial trigger points? For instance, is it possible that the bio-tensegrity structure (continuous low-level tension) is being directly affected in way that temporarily decompresses the local nerve trunk; is pressure on the taut bands and/or tender soft tissue altering nociceptive gain; is SOMETHING happening in the local tissue that is beyond centralization?

    If you suggest it is “just” a placebo response, then you’re relying on something that presents a host of other problems. The meta-contextual sociocultural memes are always-already in play, so to rely on the context-specific placebo gets us nowhere fast. It simply becomes the defacto answer to the lack of an answer. This explanatory gap is precisely why so many people make the leap of faith that you are contesting.

    If you can offer possibilities beyond myofascial trigger points, then this will go a long way in helping a lot of people turn your hypothesis into practical reality. It will let practitioners – not only academics – participate in discovering ways to utilize the information you’ve presented. If not, then the matter is conceptual fodder that will be difficult to fully embrace when it is seemingly contradicts what many people experience.

    EG Reply:

    Excuse me coming in here:

    Todd you say “but it still makes an immediate difference that lasts longer than any proposed temporary counter-irritation from DNIC down-regulation”

    Pain gating is the mechanism here, not placebo. The way most physical therapies work. And the effect is short lived, maybe 30 minutes. To make large/permanent changes, the Placebo gods need to be invoked, imo.

    todd Reply:

    Your thoughts on the matter are more than welcome.

    Yes, pain gating is the mechanism for the short-lived or temporary effect. Yet, I’d assert to “passively” rely on the placebo effect for longer-lasting changes runs dangerously close to automatically ruling out other possibilities. To put it differently, every experience is influenced by overarching sociocultural memes and the power of immediate context; so, to use contextual meaning to fill in all the blanks doesn’t get us anywhere. Maybe, placebo is the answer, but we don’t know this for “certain.” It makes sense to look at any and all plausible scenarios that don’t require a leap of faith. I’m not trying to be inflammatory, but to simply use placebo as the defacto answer reminds me, to a certain degree, of how very religious individuals often turn random observations into evidence for God. Maybe, they are right too, but the inherent problem for skeptics is that you can’t prove a negative.

    Geoffrey Bove Reply:

    Is this Todd Hargrove? If so, feel free to write me.

    In any case, Todd and EG — the “Gate Theory” is more outdated than trigger point ideas. The fundamental tenet of the theory, which was that there was no specific neuron tuned for noxious stimuli (you have heard of nociceptors?) was proven not true shortly after publication. Still, just about 50 years later, it crops up regularly. Also well marketed. There is no gate! Long live the nociceptor! (And, spinal cord modulation.)

    John Quintner Reply:

    Todd, I am reminded that the profession of physiotherapy was initially formed in the UK as a result of the efforts of nurse-masseuses, who established the Society of Trained Masseuses, which became the Chartered Society of Massage and Medical Gymnastics and this later again the Chartered Society of Physiotherapy (in 1943).

    I am in no position to argue for or against “foam rolling and gentle hands on work” as this is your heritage.

    And we cannot speculate upon any form of treatment that may emerge as a result of scientific endeavours. The only converts we seek are to the cause of medical science.

    Karl Popper, one of my heroes in the philosophy of science, reminded us “It is not his possession of knowledge, of irrefutable truth, that makes the man of science, but his persistent and recklessly critical quest for truth.” [from Ch 10 in The Logic of Scientific Discovery]

    todd Reply:


    I appreciate your thoughts.

    BTW Karl Popper also wrote, “Science may be described as the art of systematic over-simplification — the art of discerning what we may with advantage omit.” [The Open Universe : An Argument for Indeterminism (1992), p. 44]

    I’m not attached to any dogmatic belief, per se, but at the same time have difficulty in ruling out possibilities that haven’t been explored. While I agree with your position on trigger points, there might be a lot more to the “story” that hasn’t been revealed.

    todd Reply:

    I didn’t bring up the gate theory. Yet, my understanding is that gating is an element of spinal cord modulation. If not, then I stand corrected.
    Have I heard of nociceptors? Come on, man. A better question is why would you be condescending for no apparent reason? I’m sure you realize that ad hominin attacks are usually the weapon of choice for people who don’t have a legitimate argument.

    EG Reply:

    Is there something wrong with this paper on pain gating? It looks fairly definite to me. Of course there are other influences in any clinical situation, but pain gating itself, as a mechanism, seems sound here.

  5. Geoffrey Bove says

    What a riot! Special consideration for special interests. Of course. I think we’re done! Thanks everyone for participating.


  6. Elsevier have decided that the article (in proof format) by Dommerholt and Gerwin is now available available as an open access document – as long as it is accessed from the Journal of Bodywork and Movement Therapies website.
    Open Access will be maintained for 6 months.

    If accessed on ScienceDirect it is still charged for, unless you have access via your institution.

    Please read it, and if you agree with the arguments it contains, please disseminate the link to the website.

    John Quintner Reply:

    And should you happen to disagree with the arguments, please at least put away your needles.

  7. John Quintner says

    Peter, can you please answer this simple question? Do you think that the evidence reviewed by Dommerholt and Gerwin justifies the delivery of noxious stimuli (e.g. “dry needling”) to tender muscles?

    As you may have noted from reading our paper, we strongly disapprove of this practice on the ground that it lacks scientific credibility.

    When asked why he robbed banks, the notorious Willie Sutton replied “because that’s where the money is.”

    Following Willie’s logic, brings us to admit that “there is gold in them thar trigger points, boys,” which would explain the proliferation of expensive courses offering to teach this barbaric practice to gullible therapists.

  8. Peter Halloway says


    the review by Dommerholt and Gerwin points out several mis-quotations. I agree with their assessment.

    Geoffrey Bove Reply:

    We are still awaiting your specifics, perhaps you missed my query, above. After you respond, I (perhaps we) will be leaving this conversation to focus on other things.

    Thank you once more BIM for facilitating this discussion!


    John Quintner Reply:

    Unless the real opposition turns up soon, I will also be leaving this discussion. Committing the “straw man fallacy” is proving to be a great temptation.

  9. Geoffrey Bove says

    Hi Kieran,
    I am assuming that this is you on BIM? If so thanks for your comments. I do Kieran, I barely have the time to keep up with this conversation; you have access to PubMed, you can look up things. I was not talking about early imaging for everyone, if you thought so you were mistaken. I was talking about one case.

    There is a balance where spinal discal problems become a problem, and where damage is irreversible. This is perhaps the greatest challenge in these patients. My main point was that if one is working on their “trigger points,” one may miss this window of opportunity.

  10. Peter Halloway says

    I have no right to make the statements I made? Are you kidding me? Geoffrey, for your information, I have read all the articles cited by both parties.

    Geoffrey Bove Reply:

    You have not indicated that, and your comments seem contrary. If you have read them, please give a couple examples of where we have inappropriately cited the literature. I wold like to know, so I can correct. After all, this is what I do for a living.

  11. I urge those who have read the Quintner, Bove, Cohen paper in Rheumatology to access – via ScienceDirect – a critical rebuttal of that paper by Dommerholt & Gerwin. This is currently – in its accepted proof form i.e. NOT in its final corrected form which will include “statements of interest” by the authors.
    This will be published in The Journal of Bodywork and Movement Therapies (which I edit), in April 2015 (issue 19(2) ).
    The authors of the Rheumatology paper were invited to respond in the same issue, with a guarantee that they would have the same amount of space (i.e. number of words, as the rebuttal paper. This offer was declined. They can of course respond if they wish via a Letter to the Editor, although I note that Dr. Quintner has already signalled (in this venue) that they will not do so – which man will see as a lost opportunity.
    A reading of the original papers (i.e. the one in Rheumatology) and the JBMT rebuttal, provides readers with the chance to weigh the relative evidence as presented.

    There are clearly passionate positions held by those with contrasting views. However I hope that the central issues associated with the contrasting pain/dysfunction models can be the focus of attention in this debate – rather than personalities.

    Leon Chaitow Reply:

    I note in a comment by Dr Quintner above that he states: “remember that we have both read what appears to be the unedited and non-refereed version of the Dommerhalt/Gerwin paper.”
    Closer inspection of the paper currently IN PRESS on ScienceDirect will show that it is an accepted paper – therefore by definition, refereed.
    This process is true for all Elsevier’s 2500+ academic journals.
    The proofs remain to be edited by the authors, a process that allows minor corrections and additions to be made. It is however, virtually in its final form.

    John Quintner Reply:

    Thanks for clarifying this matter, Leon.

    Geoffrey Bove Reply:

    The problem remains, and this is a shame, that the rebuttal authors cannot see beyond their beliefs. We will respond appropriately. However, like there is no way to convince a Jewish person that Jesus was the savior (or the other way around), we have no hope to open some people’s minds. This is not “two sides of a coin.” This is belief-driven action versus science. And, as in other similar venues like evolution, for many people, science will lose.

    Peter Halloway Reply:


    can you give a few examples of where you think that D&G cannot seen beyond their beliefs? I have a hard time with your analogies to religion and find it hard to imagine that you really believe that the work of many very prominent researchers who are recognized by organizations like the IASP etc. is all based on a major flaw in their thought process. D&G cite the work of researchers at the US National Institutes of Health, Arendt-Nielsen, Mense, Hong, and several others.

    Do you really believe that for example Siegfried Mense is totally off base when he publishes papers on active and latent TrPs (see for example Mense, S 2010 How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculokeletal Pain, 18, 348-353).

    John Quintner Reply:

    Peter, you are obviously an avid follower of this literature. We do not disagree that voluntary muscle can be a potential source of nociception and central hypersensitivity. A recent paper by Gregory and Sluka (2014) argues this case extremely well.

    But these same authors have also fallen into the trap of “begging the question,” which is in some way to assume in your argument precisely what you are trying to prove by it:

    “The two primary diseases associated with chronic muscle pain are myofascial pain syndrome (MPS) and fibromyalgia (FM). Myofascial pain syndrome is characterized by regional muscle pain with areas of focal tenderness to mechanical pressure. These trigger points are palpable, taut masses typically found within the muscle belly. Affected muscles are stiff and contracted, which can put stresses on adjacent or antagonist muscles that lead to the development of secondary trigger points.”

    They have taken the MPS/TrP construct on board as if it was well established knowledge. However, in our paper, we have argued that this is still a matter of contention. Furthermore, we have argued that there are other credible scientific explanations for very same the clinical phenomena.

    Let me quote an extract from our Letter to the Editor of Pain Medicine (which is currently “in press”):

    “We would ask those who still adhere to MTP theory either to explain the pathogenesis of the associated pain or to make it quite clear to their readers that their assertions are still in the realm of speculation.”

    I cannot speak for Dr Siegfried Mense, but it would certainly surprise me if he condoned the practice of “dry needling” of tender muscles. I am aware that others, such as Hong, Arendt-Nielsen, still espouse the failed construct.


    Gregory NS, Sluka KA. Anatomic and physiological factors contributing to chronic pain. Curr Top Behav Neurosci 2014; 20: 327-348.

    Quintner J, Cohen M. Myofascial trigger points in patients with whiplash-associated disorders and mechanical neck pain. Pain Med 2015; (in press).

    Geoffrey Bove Reply:

    Peter, the entire paper is the example, as are the majority of the published papers. We have clearly pointed this out in our paper, as have John and Milton in previous papers.

    Dr. Mense wrote me and stated among other things that he was in general agreement with what we wrote in our paper. I will not speak for him otherwise, nor copy his email to me here.

    Peter, you have not provided an example of how we did not cite the literature properly (saying you agree with the rebuttal paper is insufficient).

    Geoffrey Bove Reply:

    Peter — RE: “…very prominent researchers who are recognized by organizations like the IASP etc. is all based on a major flaw in their thought process. D&G cite the work of researchers at the US National Institutes of Health, Arendt-Nielsen, Mense, Hong, and several others.”

    Yes, I fully believe this is the case to an extent. Their research hedges on translation. They understand our position quite well, and mostly respect it, as they understand the limitations of the translation of the hypotheses into clinical practice, as does anyone with an understanding of science and any depth of knowledge in this area.

    BTW, I am at the same level / prominence as the researchers you mention. To me it is not a relevant metric.

    EG Reply:

    I often come back and look at religious beliefs because many of them are rooted in fear, particularly Islam. Religious fears relate to judgment and retributive style karma. Therapy-linked beliefs are also rooted in fear….fear of loss of prestige, loss of income and so on. These are not small fears we are dealing with.

    So I wonder how wise it is to expect people to be open to such confrontations. If someone was to force me to confront one of my fears, I can’t imagine I would be at all receptive. I think I’d probably fight and argue and bite back. Maybe I would become irrational and angry… I don’t know!

    John Quintner Reply:

    EG, these are indeed important issues to consider. But science would never advance if all of us were so fearful of being wrong in our views that we closed our minds to advances in scientific knowledge.

    Milton, Geoff and I have been trying very hard over the last few decades to bring these important matters to the attention of the relevant health professionals. There has been and still is great resistance by some to even considering that our ideas might be useful.

    As you know, I am fond of reviving what I perceive as apt quotations from those whose wisdom is far greater than that which I shall ever attain:

    “The acquisition of any knowledge whatever is always useful to the intellect, because it will be able to banish the useless things and retain those which are good. For nothing can be either loved or hated unless it is first known.” from Codice Atlantico, 226 (tr. by Edward McCurdy in The Notebooks of Leonardo da Vinci, Vol I, Ch II).

    You might also find solace in these words of Rene J Dubos [1901-1982], a great scientist who lived closer to the present time:

    “Like other men, scientists become deaf and blind to any argument or evidence that does not fit into the thought pattern which circumstances have led them to follow.” from Louis Pasteur, Free Lance of Science, Ch VII.

    EG Reply:

    Thanks John, but I can’t gain much solace there because I am both an ‘ordinary man’ and a ‘scientist’. How can I ever be sure I’m not making the same errors?

    The search for an objective truth presupposes that there *is* an objective truth which lies beyond our inescapable subjective viewpoint. Could it be possible that there is no objective truth out there? Could it be that something becomes real when we believe it? I’m sure there are philosophy forums debating this endlessly!

    What makes me consider this angle is the following, a passage from Alice in Wonderland. I use it to remind me of what I’m supposed to be doing when I use suggestion to remove a patient’s pain. I find it really useful… but it certainly clashes with the idea of an objective truth in any field of study.

    “I can’t believe that!” said Alice.

    “Can’t you?” the queen said in a pitying tone. “Try again, draw a long breath, and shut your eyes.”

    Alice laughed. “There’s no use trying,” she said. “One can’t believe impossible things.”

    “I dare say you haven’t had much practice,” said the queen. “When I was your age, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

    *Turn the dial down, down, down and you’ll find that the pain disappears…gone completely*

    When the words are believed they become truth in “reality”, whatever that is!

    Geoffrey Bove Reply:

    Hi EG. I think that the main fear is of saying “I don’t know.” I like your approach, by the way. Pain is very complex and subjective, and people are far more so. People are highly open to suggestion, this could not be more clear.

    Your observations are open to scientific inquiry, in terms of outcomes. However, if you showed great outcomes with suggestion, we would celebrate that finding. However, if your made a hypothesis that it was secondary to your summoning a saint, who materialized and moved the red parts of the patient’s aura, we would not be so celebratory. And, it would discredit your observations.

    This happens all the time in our manual therapy world. With trigger points, it all started out pretty well. David Simons reached out to major physiologists and convinced them to design appropriate studies to develop an animal model. Overall, the research has not supported the hypotheses. The field is stagnant because of this. So it is time to move on. This was our main message.

    John Quintner Reply:

    Leon, I share your hope.

    But we have already clearly stated our views on Body in Mind, as well as in the journals Pain Medicine and, most recently, in Rheumatology. In fact they were first presented in our 1994 paper and were not challenged then by the proponents of the MTrP construct, one that harks back to the conjectures of Travell and Simons. That is now history.

    We are grateful to Dommerhalt and Gerwin for reviewing our recent paper, which was shortened to meet the requirements of the journal.

    Our response to criticisms of the paper will soon appear in the correspondence section of Rheumatology.

  12. Peter Halloway says


    thank you for alerting us that the paper by Dommerholt and Gerwin is now available. I just read their paper and must admit that I find your comments rather inaccurate and strongly suggestive. I checked a few of the points Dommerholt and Gerwin made and there is no doubt that you and your colleagues are guilty of misquoting several references and not including others in support of your point of view. To dismiss their paper with references to religion and a lack of science is inaccurate and just silly and I would have expected a much more sophisticated response from you. The authors make many excellent points. Your comment that you did not include “some of the missing references mentioned by Dommerholt and Gerwin” because of space restraints is a very weak argument. It is like you are saying that you would have made a better argument if you had been given more space. This seems like a lame excuse. Why did you not write your article with consideration of the space restraints? When Dommerholt and Gerwin point out that you missed pertinent references, you cannot excuse yourself by suggesting that you would have if you could have. They could easily make the same argument. Maybe they left out some pertinent issues because of space restraints, so who are you for criticising them for not including all their pertinent points. After reading their article, I must agree that you did a pretty poor job in making your point. You accuse the trigger point folks as adhering to a religion with many holes, but after reading both articles, you seem to be guilty of the same.

    John Quintner Reply:

    Peter, only time (and good science) will tell if we are on the wrong track. For your information, the article we originally submitted for publication contained over 5,000 words and 128 references.

    Geoffrey Bove Reply:

    Peter: Unless you have read the papers cited by both parties, and found inaccuracies, you have no right to make the statements you have made.

    John Quintner Reply:

    Peter, please remember that we have both read what appears to be the unedited and non-refereed version of the Dommerhalt/Gerwin paper.

    I specifically mentioned the paper by Jafri because not only has it been published but also because Dommerhalt and Gerwin are holding it up as a good example of original work that supports their argument. Of course it does, but only if you accept the premise that Jafri endorsed in the Introduction to his paper.

  13. Hello, John,

    I am grateful for your work and your patience in responding to comments here.

    I am a massage therapist who was steeped in “trigger point therapy” for almost 20 years, assisted at teaching it for 10. Even then, I saw flaws in the explanation but had to accept it, I thought, as the best explanation we had. I never knew there were alternative explanations and when I found your 1994 paper a few years ago, it made more sense to me. It offered a potential explanation that Travell did not – for instance, the apparent existence of TPs in non-muscular tissue.

    I do have a couple of questions:

    In Figure 1 you’re showing inflammation of muscle fibers as initiating a response (is that correct?). But what would cause inflammation in the first place? And how would this relate to “trigger points” that are in non-muscular tissue? Could other factors, like compression, be responsible?

    Changing the thinking around “trigger points” is slow going. A lot of people have a lot invested in perpetuating the current model. That plus fascia comprise a huge portion of what is taught to massage therapists in regards to pain management. There is a small but growing number of us who are trying to inform our colleagues that what we were taught was hypothesis, not fact, that the hypothesis we were taught has some serious flaws, and that there are other hypotheses that may offer a better explanation.

    Your paper has changed my working model and I’m now aware that it *is* a model that may become subject to more change over time. Thinking differently has shifted how I work with clients in pain. Since I no longer see myself as “destroying” TPs, I don’t have to push hard on already irritated tissue and cause more pain and soreness. I still seem to get at least as good outcomes as before. My clients probably thank you for that.

    John Quintner Reply:

    Alice, I find your comment most encouraging.

    Geoff would be in a better position to answer your question but I think he is away at the moment.

    My understanding is that peripheral nerve trunks can become inflamed when their immediate environment is perceived as constituting a threat to their integrity. Schwann cells (amongst others) might act as “sentinel” cells in the peripheral nervous system. [Goethals et al. 2010]

    As you mention, compression (with entrapment) is one such possibility, as are mechanical traumata (particularly if repetitive), invasion by tumour, and exposure to toxins or infective agents.

    “Trigger points” in non-muscular tissue are, in my opinion, most likely to represent referred pain phenomena (i.e. what was once known as “secondary hyperalgesia”). In addition, nerve trunks themselves can become hypersensitive to mechanical forces, however they may be generated.

    Goethals S, Ydens E, Timmerman V, Janssens S. Toll-like receptor expression in the peripheral nerve. Glia 2010; 58: 1701-1709.

  14. Diane Jacobs says

    To me, needling trigger points (i.e., sore spots) (or, frankly, trying to change *any* sort of mesodermal derivative with just manual therapy) makes the same kind of sense as believing with all your heart that it’s has to be the pretty painted plaster ponies going up and down that drive the merry-go-round, not a machine hidden well out of sight.

    John Quintner Reply:

    Diane, I do admit to a certain bias but heartily endorse your comment on the lack of rationale for needling trigger points.

    But what is at issue here is one of epistemology (“the investigation of what distinguishes justified belief from opinion”).

    Let me once again bring this debate into focus by quoting from the introduction of a recent paper by Jafri (2014):

    “While myofascial pain syndrome is complex in its presentation, the onset and persistence of myofascial pain syndrome are known to be caused by myofascial trigger points.”

    This reference provided by Jafri is authored by the late David Simons (2004).

    Of course, it follows that Jafri’s postulated mechanisms are based upon his uncritical acceptance of the premise stated in the Introduction to his paper.

    Those who espouse the MTrP hypothesis (which we still maintain is based upon conjecture) have fallen into the trap of not considering alternative explanations for the observed clinical phenomena (which are not in dispute).

    Yes, it is difficult to decide in this particular case what the true explanation might be. But “one is very unlikely to have hit upon the right answer if one has failed to countenance credible alternative explanations.” (Baggini & Fosl, 2010)

    This is precisely the reason why the MTrP theorists have fallen into the big hole which they dug for themselves. I do hope that they can climb out of it.


    Baggini J, Fosl PS. The Philosopher’s Toolkit. 2nd ed. Chichester: Blackwell Publishing Limited, 2010: 72.

    Jafri MS. Mechanisms of myofascial pain. International Scholarly Research Notice 2014; article ID 523924. Available at

    Simons DG. Review of enigmatic MTrPs as a common cause
    of enigmatic musculoskeletal pain and dysfunction. Journal
    of Electromyography and Kinesiology 2004; 14: 95–107.

  15. John Quintner says

    Heidi, a remarkable response from Jan Dommerholt and Robert Gerwin has just appeared as an “Article in Press” in the JBMT. You will get some idea of the flavour and content of their response from the Summary, which is now in the public domain:

    “The objective of this article is to critically analyze a recent publication by Quintner, Bove and Cohen, published in Rheumatology, about myofascial pain syndrome and trigger points (Quintner et al 2014). The authors concluded that the leading trigger point hypothesis is flawed in reasoning and in science. They claimed to have refuted the trigger point hypothesis. The current paper demonstrates that the Quintner et al paper is a biased review of the literature replete with unsupported opinions and accusations. In summary, Quintner et al have not presented any convincing evidence to believe that the Integrated TrP Hypothesis should be laid to rest.”

    We do have a copy of the article in its unedited form and now must await its publication. However, by way of comment, let me reassure readers that our original article did contain some of the missing references mentioned by Dommerholt and Gerwin, but we were severely constrained by the space requirements of Rheumatology and were forced to cut some 2,000 words from our paper.

    We do not intend to respond in the journal JBMT, as we have already done so to the two letters sent to the Editor of Rheumatology. There may be more in the pipeline.

    As Geoff has wryly observed: “We could make the point in analogy that we were not comparing different interpretations of the Bible, but rather we were pointing out its myth.”

    I am guilty of goading the other side of the debate to respond, either in Rheumatology (as is the proper forum) or on Body in Mind, which has graciously allowed a free-flowing discussion to take place.

    As we see the situation, the disputed theoretical and practical issues strike at the very heart of physical therapy practice around the world.

    Let me conclude with these appropriate words of Leonardo da Vinci [1452-1519]: “Those who are enamoured of practice without science are like a pilot who goes into a ship without rudder or compass and never has any certainty where he is going. Practice should always be based upon a sound knowledge of theory.”

  16. Geoffrey Bove says

    What’s important is anatomy. I see little place for models, which are just that, models, not necessarily realities, in directing clinical practice. Access to the peripheral nervous system is pretty straightforward. One has access through transducers. Words like “neurosignature” are to me, gobbledegook. Nice idea maybe, but not definable, and so not manipulable.

    Imaging is overused for sure, and correlations to symptoms are often inappropriate. Delays in obtaining imaging with spinal conditions is known to lead to worse outcomes in many cases due to progressive scarring and nerve damage. Imaging and other tests are supposed to be used to confirm or refute clinical suspicion. The overuse is when they are used in the absence of clinical reasoning.

    The Samueli Institute has been investigating “Optimal Healing Environments” for quite a long while.

    With pain, as a sense that is integrating many peripheral inputs, it is all about changing the gains.

    Kieran Reply:

    Thanks Geoffrey. some very interesting points thoroughout your posts. The OHE link is very interesting.
    But I intrigued by the line “Delays in obtaining imaging with spinal conditions is known to lead to worse outcomes in many cases due to progressive scarring and nerve damage” – have you any refs to show that delays in spinal imaging lead to (or are asscoiated with) poorer clinical outcomes, as pretty much every study i can think of which has looked at this shows either (i) no benefit, or (ii) actual harm, with early imaging. I accept your point that using imaging in the absence of clinical reasoning is a major problem in that they are poorly interpreted. However the sending of someone for early imaging (in the absence of signs/symptoms of serious pathology) in itself could be seen as poor clinical reasoning?

    Geoffrey Bove Reply:

    Kieran, yes, there are many studies that support my statements.

    Kieran Reply:

    Hi Geoffrey
    Could you mention 1-2 key references – would be interested in reading them as most of the data i have read has been underwhelming on the role of early imaging. thanks.

  17. John Quintner says

    Stu, I hope that we are all looking for further insight. But the burning issue for me is just where to look.

    In answer to this question, I am excited by the research which explores the peripersonal space and its social modulation. There seems to be great potential here for devising therapeutic strategies to help our patients. Lorimer and his colleagues are leading the way.

    I accept that this comment is outside the subject under discussion. But the trigger point dry needling brigade appear to have little if any new evidence to offer in support of their cause.

    todd Reply:

    I have a question in regards to “peripersonal space and its social modulation.” How can peripersonal space be accurately used to devise therapeutic strategies, when its precise ontology isn’t clear? In other words, is peripersonal space an element of the implicit sensorimotor body schema and/or the acquired body image?

    The body schema is anchored by somatic proprioception, which is the very basis for immunity to error through misidentification. The sense of self isn’t limited to your body-proper, but rather your personal “reach space.” If not, there is no way to explain how performing a forward bend that displaces your COG outside your physical body is possible without adding another “deeper level” of self-awareness to avoid infinite regress. A little cutting with Occam’s razor suggests the body schema and somatic proprioception is the end of the road.

    The body image is your “held space” that provides an egocentric point of view on the world – it is an element of co-perception with the environment – that relies on the implicit intra-bodily spatial ordering of the body schema. You perceive objects matted in space and time “over there” that, in turn, are self-referenced to your vantage point “over here.” The space of action possibilities, or affordances, cannot be one in the same with the space of the body schema. The former is a relation between oneself and the world and the latter is a communing with the environment. Again, which one is peripersonal space?

    We’re left with the question of how a “living body” integrates with the subjective experience of a “lived body” as one’s own body. My understanding is that Dr. Moseley, and his colleagues, utilize Melzack’s Neuromatrix model in regards to the aporia of pain. This indirectly leads back to the problem of spatiality. Jacque Paillard wrote, “The field of validation of the [Neuromatrix] model covers mostly if not exclusively the neurological disorders associated with the higher cognitive processing of the perceived and memorized representation of a body image without considering the potential role of implicit low level sensorimotor processes [body schema].”

    Mindbody dualism was replaced with a body-body dualism. If the underlying spatiality inherent to different modes of body awareness isn’t clear, then it would seem to limit any therapeutic strategies based on peripersonal space. I’m just thinking out loud through a little creative writing, so please don’t take my ramblings as inflammatory.

    John Quintner Reply:

    Todd, these are important issues that are well worth pondering upon. Creative thinking and writing are great tools to have at our disposal.

    The peripersonal space is said to be a dynamic one and not solely dependent upon our brain receiving visual or auditory input.

    This raises the important question as to what if any sensory information is being utilised by our brain in order for it to maintain a representation of such a space.

    But unless “trigger points” have been shown to inhabit this space, our discussion falls well outside the context of the debate.

  18. Geoff,
    Thanks for this. Appreciate your insight. I am not sure how you inferred that I do lots of modalities – I used to do some 10 – 15 – 20 years ago – ultrasound, IFC, acupuncture – not now – however, I do do functional electrical stimulation with stroke patients (check the evidence – level 1A – best we’ve got). I used to do electrical stimulation with wound patients – if you look at evidence for SMART E-pants, you might gain some insight. I agreed with most of the points of the paper and other papers that John Quintner and Milton Cohen and Pamela Lyon have written (what I could understand).
    My initial question to John, was, just like shock wave therapy having an effect on spasticity, was there potential for accessing the peripheral nervous system to assist in writing a new neurosignature (may not have worded it this way).
    I do like gathering evidence but I get frustrated when the back-up plan, or the first plan, is to look at a picture – to confirm the clinical evidence makes sense perhaps. Our diagnostic imaging in public system is blocked up because this is prevalent. I am assuming you have read recent papers by Neil O’Connell on March 29, 2011 – ‘Of Shiny Pictures and poorer outcomes: Spinal MRI and back pain -insightful – the ones who received ‘advanced’ imaging had a significant reduction in return to work – once in sight, in nervous system – we are a visually dominated species. Thoughts?
    I have ongoing discussions with one of my colleagues who does IMS – the explanatory model is very important. I am always looking for further insight.

  19. John, thanks for this. I can repeat back ‘the explanatory model for the more complex neurophenomenology of emergent pain states’ but in the moment, I get lost with the patient’s emotions, experiences, efforts to deal with life and can’t even spell a word with more than a few syllables. What emerges is me.
    I work with colleagues who stick needles in people – I sometimes consult them to assist. When a patient has had a brachial plexopathy, neuritis or thoracic inlet or outlet issue with swelling in supraclavicular space, I avoid consultation from dry needlers but listen to advice. I try to ‘optimize’ the environment through coming to understanding, adequate sleep, aerobic exercise (if possible), stress management, maintenance of individual joint integrity and awareness of neurodynamics but also try to be comfortable with the wait. I also try to be aware that the arm has a weight to it. I hear comments on platelet rich plasma, protein, peripheral nerve blocks and I ponder. I really appreciate your insight and others.
    Geoff, when you mentioned that you went to the MRI to look for the ’cause’, what did you mean? The maintenance of space is important – I am taking a deep breath and waiting. Please provide further insight. Thanks.

    John Quintner Reply:

    Stu, if I am reading you correctly, you are in a state of great confusion over the number of irrational treatment modalities currently being offered to patients in pain presenting with complex and poorly understood medical problems.

    This is quite understandable and “dry needling” is but the tip of the iceberg.

    The MTrP research is now being focused on finding the offending “lesions” in muscles by using increasingly sophisticated technology. If they are ever found to be culpable, are they then to be obliterated by the enthusiastic therapist?

    I would hazard a guess that in most if not all private physical and physiotherapy practices in my country and in North America “dry needling” is in vogue.

    Courses that teach it are being accredited and advertised by its professional associations, whose Codes of Conduct most probably enjoins members to be aware of contemporary research evidence and to integrate such evidence into their practice. They would then be able to make the claim that the services that are on offer are clinically justifiable. Are these merely empty words?

    I mentioned above some of the other modalities of treatment where supporting scientific in their favour is lacking and where their efficacy appears to rely solely upon contextual factors.

    Quo vadis? Are there any answers out there?

    Geoffrey Bove Reply:

    1. “explanatory model” — you must be confident in every premiss of the argument.
    2. You do loads of modalities, that’s great, most do. Many then blame effects on trigger point therapy; hence in part, our paper.
    3. In the case I gave, I suspected a disc herniation in the fist place, so after what I considered failure of conservative care I looked for it on MRI. No insight there. Although I guess MRIs provide “in-sight.”

  20. John, thanks for the clarity. Sorry, I was trying to reference Paul Hodges’ paper ‘moving differently in pain’ and speculating. I often get stuck in myths. I was reading Dr. Haim Moshe Adahan’s work and noticed that, in one study, there was a significant reduction in pain with patients with long-standing ‘frozen shoulder’ with suprascapular nerve block. No changes in range of motion but…could you comment on this?

    John Quintner Reply:

    Stu, suprascapular nerve blockade is a well-recognised procedure used for the relief of intractable shoulder pain. I would not have expected any change in the restricted range of movement in this context. But please do not stop speculating upon these matters.

  21. John, I was hesitant to respond to this post as I agree with many of the ‘points’ of your paper and did not want to provide input if it is not going to help with my understanding. Having said that, I am interested in your thoughts and others on the ability to access the peripheral nervous system and neuroplasticity even with pain that has persisted for > 3 – 6 months. In stroke, there are studies (Gonkova 2013) in which shock wave therapy is helpful with reductions in spasticity with kids with CP. I am not fully sure of the reasons for this but I would welcome insight. The Physiatrists, and others I work with use injections (wet needling) with botox, anaesthetic and cortisone – there is often a ‘dose-dependency’ to this when done in isolation that is considered critical for effects (from my understanding). Drugs that dampen the nervous system are not usually helpful in these cases. As therapists, we use FES (functional electrical stimulation) to try to access the peripheral nervous system to provide afferent feedback (proprioceptive and somatosensory) and also guide movement patterns in presence of spasticity. We try to access the peripheral nervous system via motor points and having an understanding of the branches of the peripheral nervous system is important to try to select specific movement patterns. We also constrain movement in different ways to guide movement patterns and use. I realize it is an integrated system / an emergent system (from my understanding). My question is, when movements are protective / not coordinated, would accessing the peripheral nervous system to provide afferent input and guide movement patterns (even if it is by counter-irritation analgesia) be helpful?
    I look forward to your insight. Thanks.

    John Quintner Reply:

    Stu, my short answer is NO. Your question Just does not make sense to me. Disordered movement patterns do not appear to be a significant component of the clinical features under discussion. As for the possible benefits of accessing the peripheral nervous system, the dismal failure of generations of “dry needlers” to produce positive outcomes is a sufficiently strong argument against this proposition.

  22. John Quintner says

    Peter, a good start would be for you to read our references 18-22, and reference 69.

    In my opinion, my use of the word “arcane” (i.e. shrouded in mystery) was quite appropriate when referring to the practices being advertised on Myopain Seminars. Are they evidence-based?

    If, as we have proposed, sensitised neural tissue explains in whole or in part the clinical phenomena erroneously attributed to MTrPs, the techniques of treatment based upon the Travell/Simons conjectures are in fact contra-indicated.

    Finally, why would anyone want to attend courses that only serve to perpetuate discredited theory?

  23. Geoffrey Bove says

    When I teach, I take cases, and using information as presented, develop a mechanistic hypothesis, like I did in the previous post. Indeed, EVERY CASE should have the benefit of a scientifically informed thought process, don’t you agree? The problem is that for trigger points, the thought process has major holes in it, which have been ignored for decades. And that’s the main point.

    I wish Dr. Mense would get in on this sort of discussion. I cannot speak for him.

    I don’t think that there are any outcome studies of fascial manipulation. While someone could write a similar article at this point, at least they are working on it. Some progress as well. The hyaluron stuff seems awesome, for instance. BTW they have to pay for it themselves, which is the way it is.

    Remember there are precious few studies on treating people with any form of manual therapy.

    So no, no more new information. You hopefully have the literature, and everyone can find a way to get what you need. Thanks for chiming in!

  24. Peter Halloway says


    while all that is interesting, if Mense agrees with you, than why would he continue publishing papers on active and latent trigger points? Why does his book Muscle Pain have lots of information about trigger points? I guess you are going to tell me to ask him, but I do not have your connections. Bringing up one case of misdiagnosis is not very persuasive. Where are the outcome studies of fascial manipulation? You say you have great respect for the Stecco’s but could one not write the same kind of article about fascial manipulation as you just published about trigger points? John seems to think that their work is “arcane”….. Is this not a matter of opinion and bias? I am not convinced that you have managed to refute the trigger point story no matter how many times John repeats that mantra in this discussion. I am signing off unless there is any new information. Thanks for you replies. Much appreciated.

    John Quintner Reply:

    Peter, what would it take to convince you? The religion I referred to above seeks to gain its converts on the point of a needle. This is of course a biased view but I can see precious little else on offer from the MTrP theorists.

    Let me leave you with a quote from Claude Bernard [1813-1878]: Our ideas are only intellectual instruments which we use to break into phenomena; we must change them when they have served their purpose, as we change a blunt lancet that we have used long enough. From: An Introduction to the Study of Experimental Medicine, part I, Ch. 2, Sect iv (tr. by HC Greene.

  25. Peter Halloway says

    Thanks Geoffrey, I certainly appreciate your work! I do not think that referring to John’s seniority has any place in this discussion. From the looks of it, it seems that Dr. Gerwin has more years of clinical practice and based on your assessment, that did not get him very far. I hope you are not suggesting that the Fascial Manipulation courses, Myopain Seminars offers are not based on science. Carla Stecco, for example, has a long list of research kind of along the lines of your research. Forget about Myopain Seminars for a minute. Some very prominent scientists are studying myofascial pain and trigger points and it remains hard to imagine that all those scientists are dead wrong and that the three of you can wipe of their research agenda with one article. I just did a quick Pubmed search and come across reputable names, including Lars Arendt Nielsen, Thomas Graven Nielsen, S. Mense, etc. Do you really believe that they are not as smart as you are and that they are taking leaps of faith, which brings us back to religion?

    Geoffrey Bove Reply:

    Hi Peter,
    Thank you for your comments. I’ll have to plead the 5th on this one to some extent, I’m in enough trouble. I know Dr. Mense and his position on this topic; he agrees with us. I also know the Stecco family, I respect them loads, especially since I had a most wonderful (translated) discussion with Louigi Stecco, where I raised a concern, pointing out their “Achilles heel” in their logic having to do with muscle spindles. He agreed with me, but this remains a leap of faith in their story. And it is probably not so hard to address experimentally. But again, does it matter to outcomes? Not a whit.

    I told one scientist that his work was great, but he should take out the words “trigger point,” as it did not seem to have much to do with it, and thus promulgating myth.

    We would posit that studies in humans of “trigger points” should simply stop using that terminology. Why not say “X or Y treatment for persistent muscle pain?” Describe it without the trigger point verbiage? It has for decades carried a load of baggage.

    I learned trigger point therapy, I have the big red bible, etc. (Isn’t it interesting that everyone seems to pick up this method easily, but that the agreement when controlled is so horrible?) In practice, I tried hard. I had a chart, ethyl spray stuff, acupuncture needles. I took people to get trigger point injections, meaning I drove them and observed. I was told by one doctor that it did not matter if he put anything in the syringe or not. Hmmm.

    One patient I took had a classic piriformis TP, perfect chart-compliant radiation, reproducible…. he had fallen on his left bum and this was the symptom for which he sought care. My manual work didn’t help for long, and the TP injection followed by manual work didn’t either. I got a MRI looking for the cause, and he had a little central disc herniation. His symptoms fully cleared after a relatively minor surgery. Not a fan of that of course, but how many treatments might he have had to someone else (I treated him 2-3 times, and he had one injection)?

    My point here is when stuck in the myth we can lose our objectivity, and miss things.

    Mechanistically, I can make up a great story. Central disc herniation contained — more ventral root, so does that change firing properties of the muscle efferent neurons? We do not know yet! (I should do THAT experiments, right?) But if so, there we have a easy mechanism. If not, we have to dig. How about if that herniation was more lateral, affecting the spinal nerve? Now our paper can be used to give a mechanism for persistent symptoms, including the tenderness and radiating symptoms, AND the failure to respond!

    Anyway, I can’t remember what I did with the spray stuff. I would however like some for the “Shelf of Woo-Woo,” in my lab.

  26. John Quintner says

    Heidi, it would be timely to focus the debate onto the key issues.

    We believe that the MTrP proponents have fallen into the trap of circular argument: because muscles contain them, “myofascial pain” must arise from “myofascial trigger points”.

    In our paper, we have argued strongly against this proposition and suggested that there are other possibilities, for which there is at least some good scientific evidence.

    We have just heard from Leon Chaitow, Editor–in-Chief of the Journal of Bodywork and Movement Therapy, that two of the MTrP gurus, Dr Robert Gerwin and Mr Jan Dommerholt, will be publishing a detailed and wordy (9,000 words?) critique of our paper in his journal. Of course, we think that the journal RHEUMATOLOGY would have been a more appropriate choice. Perhaps they will offer a summary to Body in Mind?

    Both of these learned gentlemen studied and worked with Drs Travell and Simons. It therefore seems unlikely that they now will throw away their needles and recant their outdated beliefs.

    They are also Directors of Myopain Seminars, a commercial enterprise that markets educational programmes dealing with “trigger point therapy,” “fascial manipulation,” “craniomandibular management” and other arcane practices.

    As Milton Cohen has just reminded me, we are dealing with religion: no matter what we say, the true believers (in TrPs) will find a way to rationalise it. Logic is so cold and hard!

    Carel Bron Reply:

    Just curious, is this an clear example of what they call an “ad hominem mistake”.
    Thanks for sharing this non-argument!

    John Quintner Reply:

    Carel, you would be quite correct if those on the “other side” were in fact arguing their case on Body in Mind.

    However, I do admit to making insensitive comments from time to time whenever the subject of MPS/TrP comes up. For this I apologise to Heidi and Lorimer.

    Peter Halloway Reply:

    John, I did read your paper that started this discussion. Frankly, I do not see where the myofascial proponents argue that muscles contain trigger points and therefore myofascial pain must come from trigger points. Can you provide a few references in support of this argument?

    Earlier it was mentioned that you declined to partake in a debate in the Journal of Bodywork etc. What was your rationale? Would that not have been a good opportunity to make your points directly to these “learned gentlemen” and others who disagree with your assessment?

    I looked at the Myopain Seminars website. I don’t think that Gerwin is a director, although he does seem to teach courses for this group. You make some very strong statements and seem to suggest that when you teach courses you cannot be objective anymore. What is wrong with courses on trigger point therapy, fascial manipulation and craniomandibular management? I don’t mean to start an entirely different discussion, but I do not understand where you are coming from when you are discarding apparently everything they offer. I understand fro your paper that you are not necessarily questioning the presence of trigger points but are refutuing the theoretical model. In other words, if there were any support for your proposed hypothesis, would teaching trigger point therapy based on your hypothesis still be arcane?

    I have enjoyed articles by your co-author Geoffrey Bove about visceral massage and manipulation in the same journal. The fascial manipulation courses Myopain offer are from the Stecco family and they include visceral manipulation. Do you suggest that the research by the Stecco family and many others is arcane, which by default would make the research of your co-author arcane?

    I am considering attending the next fascia congress in the fall in Washington Dc and noted that Dr. Bove will be teaching a workshop that covers “Palpation methods to distinguish normal from abnormal tissue and Treatment approaches for adhesions”, which sounds like the kind of stuff the folks at Myopain Seminars are offering. What am I missing?

    Do you really believe that all they should be characterized as religion? Just because they apparently worked with Travell and Simons? You seem to be doing what you accuse them of! Are you not representing your own religion? Did the editor share their article with you? If so, maybe you have a point, but if not, it seems that you have some preconceived notions that whatever they write won’t be worth your while. That is a pretty scary thought and not very logical.

    Maybe it is time to leave this discussion. You are becoming rather unreasonable, judgmental and not very objective.

    Geoffrey Bove Reply:

    Hi Peter,
    I tell people that as a scientist, I am judgmental for a living… John tells it like it is, sure, in his view, but it might not be he who is being not very objective. Milton said the “R” word, but it is the correct one in a lot of ways. We are trying only to refute with myth / dogma, established without facts.

    John is a little harsher than I am regarding what he would “discard,” for sure, but this is based in no small measure on his 45 years (more?) of clinical practice seeing everything that one could possibly see. And, all the while, keeping up with the science.

    Bottom line for me is this: for everyone who treats discrete entities in muscle (which there piss-poor evidence for interexaminar reliability, and for which there has never been shown any pathophysiology, and for which there is no animal model), using methods that don’t seem to have a specific effect when tested in clean outcome trials (like needles), I suggest the following. Don’t take our word for this! Please do everything ELSE you are doing for that person, including whatever other manual therapy at which you excel, and leave the lumps alone. See what your outcomes are then.

    We chose not to write anything more about this topic for JBMT for a number of reasons, primarily because we just did! There is nothing that they “other side” can present that we did not cover, or that flies in the face of what we did cover.

    Regarding my research, here’s the difference. I am actually DOING the research! Just this morning, I am just cleaned from characterizing postoperative adhesions in a novel model, upon which we will characterize the effects of manual therapy, in a clinical outcomes manner as well as a mechanistic manner. When we teach, we teach from our own data, and from the literature. We are exceptionally careful to not fabricate mechanisms of action, we do not “reify”, and we do not take leaps of faith. We are more comfortable saying “we don’t know.”

    As should all of us be.

    John Quintner Reply:

    Peter, the references you require are contained within our paper. There are others!

    As for our decision not to accept Leon’s kind invitation, we decided that the terms on offer were not acceptable. We publish a paper in journal A to which his school objects. They publish a response in their own journal (B) – hardly objective – “invite” us to rebut their argument, and then criticise us publicly for declining to do so. They should have written to journal A, as other have, to which we respond. In cricketing parlance, we are on the front foot: we propose, other oppose, we respond.

    I apologise for stating that Dr Gerwin is a Director of Myopain Seminars. In 2014, I understand that he stepped down as co-owner and director of that organisation.

    On its website, Myopain Seminars tells intending applicants that “Drs Gerwin and Dommerholt have published more books, book chapters, peer-reviewed studies and articles, case reports and literature reviews than course instructors of all other US course programs combined! Did you know that course instructors from some other course programs have never even published a chapter or article?”

    In other words, they are being promoted as the “high priests” of the Cult of the Trigger Point. No doubt they are great teachers, but unless there is new data to which only they have access, the content of their teaching is now under serious challenge.

    No, Leon Chaitow has not shared their response with us, nor would we expect him to do so.

    But Body in Mind is an open forum and, to date, they have not contributed anything to the discussion (which I hesitate to call a “debate”). I hope that they will rise to the occasion but will not hold my breath until they do so.

    Peter Halloway Reply:


    thank you for explaining your reluctance to participate in the discussion in Chaitow’s journal. He has set up this kind of “debates” in the past and they can be very enlightening. Too bad you did not think that you would have a fair playing ground.

    You are a master at not answering direct questions. I told you I read your paper and asked you specifically which papers you are referring to when you make the circular argument. Referring me back to the paper is not helping me very much.

    I also asked you “What is wrong with courses on trigger point therapy, fascial manipulation and craniomandibular management? I don’t mean to start an entirely different discussion, but I do not understand where you are coming from when you are discarding apparently everything they offer. I understand from your paper that you are not necessarily questioning the presence of trigger points but are refutuing the theoretical model. In other words, if there were any support for your proposed hypothesis, would teaching trigger point therapy based on your hypothesis still be arcane? You did not answer that question. Based on your replies so far, it seems you are not against TrPs, but you are challenging the hypothetical thought process. Would that mean that TrP courses could be OK if they would be based on your hypothesis? Same for fascial manipulation? Should the Stecco’s stop teaching because there are major holes in their ideas? Should Geoffrey stop teaching because he has not figured out all the details in his work?

  27. Yep, no problem John. It certainly looks like a hip stress test of some sort.

    Peter, good point about the patting/cuddling… unless the patting was done to soothe the dog only *whilst* he was being needled and not prior. As always, lots of variables. I’d be prepared to remove number 2) from the list.


    John Quintner Reply:

    Peter, it seems to me that our refutation of the MTrP construct in humans will surely mean that veterinarians who have based their treatment of animals on that construct will no longer be able to justify performing such practices as dry needling.

    Peter Halloway Reply:

    I think I am missing something here. I understand that dry needling can be quite painful. Why would a dog respond favorably to a painful stimulus? Looking at the video, it seems obvious that the dog was not able to support the left hind hip before needling and did fine before needling.

    Peter Halloway Reply:

    I meant “did fine after needling”….. my typo…..

    John Quintner Reply:

    Peter, the phenomenon is known as “counter-irritation analgesia”. It is referenced in our paper. The content of the video did not allude to the differential diagnosis of the dog’s ailment. Could this be what you are missing?

  28. Peter Halloway says

    Thanks for the providing the links about placebo in animals. Very enlightening!

  29. Peter Halloway says

    I came across this video about dry needling of a dog. do you really think that there is a placebo factor?

    John Quintner Reply:

    Thanks Peter. There does seem to be quite a lot of leg pulling going on! No doubt both the dog and its owner went home feeling quite relieved.

    EG Reply:

    Peter there seems to be a good difference pre- and post needling. I don’t know the test he is using on the dog, but the WB (left) leg definitely copes better after needling.

    What it shows is an immediate effect, and I’d be fairly sure needling in humans would have a similarly positive short term effect through pain gating or DNIC. After an hour it could be a different picture. That’s the first thing.

    The second thing we don’t know is whether the dog has been conditioned with previous vet visits. Words are not completely meaningless to animals (eg. “walk!”). Also, patting and cuddling and pleasant interactions are healing for humans, so I think this would apply to animals as well.

    The third thing is that positive expectation can be transmitted without words. This is well known amongst horse and dog trainers. Try walking up to a horse with a timid attitude and he will quickly move away. Change your attitude and the horse remains still and allows you to touch him.

    So there! 3 good reasons, and my money is on the last of these. So much so that this is the only area I train myself in nowadays, and it has enormous depth. The days of studying physical techniques has long been abandoned.


    Peter Halloway Reply:


    thanks for your input. Re 1. we really don’t know based on the video. Re. 2 and 3, if patting and cuddling and pleasant interactions can do the job, would you not expect to see the positive change before the needling?

    John, are you suggesting that the leg pulling explains the difference? That is hard to believe.

    John Quintner Reply:

    EG, I was not being serious. Sorry about that. But I was rather amused by the legend listing the various phantom “trigger points” that the veterinary surgeon had allegedly “discovered” and then treated.

    We are not told whether this particular animal was in fact presenting with a painful hip joint.

    Geoffrey Bove Reply:

    I see at least three placebo effects going on: the strongest one in the provider, second in the dog, and the third one in the viewer.

    Geoffrey Bove Reply:

    I was being serious. The video is reminiscent of the tests performed for “applied kinesiology,” for instance. Besides us not knowing which side was affected, the provider is clearly not doing the same on the two sides, nor is he doing the same things before and after to the same sides. Although this would be clearly fraudulent, my extensive experience with these situations is that the providers are 100% earnest. Thus, my stating that they are influenced by placebo.

  30. Aaron James says

    A very interesting discussion and I look forward to reading John’s paper. I am a physio who is in your generation, John. To be honest the appeal of Travell and Simons at the time had a lot to do with selling a concept product rather than science. The two volume manuals were so beautifully illustrated and presented, giving a sense of assurance about symptoms.

    I was trained in the Maitland/Grieve approach as well as being exposed to other “schools” of manual therapy and I perceived Travell’s approach as just another school. The concepts of adverse neural tension were not documented back then; upper limb tension teste and slump had not been formulated. It was common for practitioners to take an eclectic and pragmatic approach: identify a comparitive sign, apply a techque of regardless of the school of thought and reassess the comparitive sign. If it seemed to be relieving symptoms and signs then stick with it. We used massage and “Ischaemic pressure” rather than vapocoolant sprays and stretches on often got results in the clinic which we didn’t with other techniques.

    Another aspect of TPs is that from a clinical viewpoint they tended to correlate with postural problems and movement impairments, creating a good clinical bridge between the bioemechanical/motor control schools sucha as (Janda and Sahrmann) and directly treating pain. For example, muscle pain was often seen in muscles that were either shortened or “over-recruited” in activities.

    I was, back then, oblivious to the role placebo, patients wishing to please their therapists, regression to the mean and so forth. So when a patient actually reported decreased symptoms after a treatment I believed they were actually better!

    As for the theory behind myofascial pain, plausability was always less of a priority than and physical medicine was flaky science.

    As the concept of adverse neural tension developed I found a close clinical relationship between positive neuro-dynamic signs and myofascial pain. In treatment in the clinic if I work on triggerpoints often neurodynamic signs improve and if I mobilise the peripheral nervous system triggerpoints improve. Rather than being guided by which is the more plausible theory I would tend to use techniques aimed at the muscle first – seemed less likely to exacerbate an irritable nerve than using a neural mobilisation technique, but then follow through with neural mobilisations. But perhaps that says less about the validity (or lack) of myofascial theory vs adverse neural tension theory and more about there being a variety of ways of influencing pain pathways.

    John Quintner Reply:

    Aaron, you have reminded me that I was working in London in 1967 when James Cyriax was in his prime and Geoff Maitland dropped in to demonstrate his then revolutionary techniques of spinal mobilisation. Since then manual therapy has advanced in leaps and bounds. But unfortunately the MPS/TrP therapists have remained stuck in a 1980s time warp espousing a simplistic hypothesis that has now been comprehensively refuted. I too am feeling my age!

  31. Geoffrey Bove says

    Dear Bas,
    Thank you for your comments. Is there a named fallacy about “well, it is so complicated it cannot be measured?” As you point out, we can measure pretty much everything that is claimed regarding mechanical perturbation of structures.

    Dear Peter,
    First, let’s get rid of the 4-letter word “placebo;” see above. That said, what do you get when you remove higher though processes, perhaps a “super-ego” — you get an organism perhaps with heightened “instincts” and other senses, like a dog. I know from years of scientific experimentation with animals (the lowly rat even!) that they have perhaps a stronger susceptibility to non-specific effects. We must control for this in every experiment.

    Dear Zim,
    Thank you for your comments. Trigger points and a focus on adhesive or fibrotic tissue are only related in that a focus on the former has in our opinion limited research in the latter. Thus, abandoning the trigger point myths and dogma will only enhance research into the areas consistent with what you are stating in your comment. Indeed, I am preparing a manuscript describing what might be the first documentation of manual therapy preventing fibrosis as the mechanism behind preventing functional declines in an animal model.

    All: Keep up the good work and fight the good fight.

    John Quintner Reply:

    Geoff, I don’t think there is such a fallacy but I am happy to be corrected on this point.

    However, in “The Philosopher’s Toolkit (2010)”, Baggini and Fosl formulate a rough principle that seems quite applicable to this debate: “the stronger the case for an opposing new theory, the stronger must the explanation be for why one ever held beliefs to the contrary.” (p. 95)

  32. Sebastian Asselbergs says

    CD suggests: “whilst I am of the belief that MTrPs definitely exist (though as a result of physiological disturbances rather than ‘muscle damage’) being able to “truly and accurately” prove a different, pathological level of tension or change in muscle length is virtually impossible.”
    Two things here jump out: first, the word “belief”. If a “belief” trumps the research that has tried so hard to prove the existence of TrPs and failed, then I do not know what more can be done. This is like saying: “green men on Mars exist, I know it! Even though research can not prove their existence”. When belief is rolled out to trump science in medicine, I worry.

    Then there is mention of “pathological level of tension” that somehow cannot be measured?!? How can you say something is “pathological” if it can not be tested for? How is it that we can research and find the gentlest of forces, for instance those needed to cause neural anoxia (7 grams sustained tension), but fail to find those
    taut bands” and TrPs found by fingers? So, how would we tell if there is “pathological” abnormal tension or length?

    Lastly: please check the research on cognitive errors produced by our own brain. That same brain that makes us “feel” things that aren’t there (rubber hand experiements), that makes us “feel” a very light arm after an isometric effort, that makes us “see” a wide variety of realities when we look at the same car accident……Our perceptions, created by our brain and based on peripheral input and contextual factors, should make us extra leery believing them over scientific evidence.

  33. Zim PT, DPT, CLT says

    I take a myofacial hands on approach as well as an exercise approach to chronic pain. I am more generic though and focus less on trigger points and more on tissue adhesions. I work with people post lymph node dissection frequently and I have been intrigued by how different people heal from such injury. It seems, though I have not reviewed the literature, that those with inflammatory diseases such as fibromyalgia have significant adhesions/ scar tissue formation. the contribution of the fascia to the scar can visually observe a string down the arm of a person with a double mastectomy specifically on the side with lymph nodes removed as opposed to the side with no nodes removed. This makes me very curious about the lymphatic system’s involvement in chronic pain. Nodes after all are throughout the body particularly at the joints. I know there is something to myofacial adhesions because I can take a person from 90 degrees flexion in the shoulder to 130 in one session with focus only at the scar as well as decrease pain, swelling and improve function. I have never done that with the passive range of motion/ exercise approach and had it translate into active motion. I do hope this article has a positive effect on learning more about myofacial pain and does not result in an abandonment of the approach altogether. I agree that we seem to be traveling down an unscientific path which will not allow us a more specific expedited and successful approach to treatment of chronic pain.

    John Quintner Reply:

    Zim, I cannot agree with you that fibromyalgia merits being awarded the status of a distinct disease, unless of course one accepts the proposition that “chronic pain” can be a disease in its own right. But the proponents of this view have not as yet offered a name for their “new” disease. However it seems to me that despite it being a tautology, “fibromyalgia” would be a prime candidate.

    Your assertion that fibromyalgia can be categorised as an “inflammatory” condition associated with “significant adhesions/scar tissue formation” does not accord with the extensive research into this condition that has been published to date.

    As for predicting the future of the concept of myofascial pain arising from “trigger points,” I would like to borrow a phrase from French writer Andre Gide, who quoted an Arab proverb to Truman Capote: “The dogs bark but the caravan moves on.”

    Zimm Reply:

    John, Thank you for your reply though I am saddened that with all I said you focused on a minor statement. My intentions were not to categorize anything as a distinct disease but to offer an observation of treatment experience for further thought.

    John Quintner Reply:

    Zim, I apologise for not finding your statement to be a “minor” one. Can I please direct your attention to the quotation with which I opened this discussion? In other words, we all must pay close attention to the language that we use. I did not mean to impugn your observations.

  34. John Quintner says

    Post-script: I would like to thank Lorimer, Heidi, and Carolyn for allowing this debate to take place on Body in Mind. However, I found it disappointing that the “other side” did not participate. Leon Chaitow, Editor-in-Chief of the journal JBMT was quick to see that our paper was a “major attack on the concepts surrounding myofascial pain – and the link between this common pain syndrome and trigger point activity.”

    He graciously offered to host the debate within the confines of his journal, an offer that we eventually declined. However, he and his followers were made aware that we hoped that the debate would take place in another forum, such as BiM.

    As Geoff has indicated, the MPS/TrP advocates will duly respond in a Letter to the Editor of RHEUMATOLOGY. No doubt responses will also appear in JBMT and our paper will be critically discussed elsewhere.

    Be that as it may, our paper is now in the public domain and the “dry needlers” and others who chase the will-o’-the-wisp cannot pretend otherwise.

  35. Geoffrey Bove says

    “He or she who best takes advantage of non-specific effects, wins.”
    Bove, 199?

    Matt, keep going! Read for instance (now that you mention ego):
    Davis, M. A., & Bove, G. M. (2008). The chiropractic healer. J.Manipulative Physiol Ther., 31(4), 323-327.
    (You can take out “chiropractic,” we were writing for an audience.)

    Moreman’s papers are foundational, this one has all the others referenced:
    Moerman, D. E. (2013). Against the “placebo effect”: a personal point of view. Complement Ther Med, 21(2), 125-130. doi: 10.1016/j.ctim.2013.01.005

  36. Geoffrey Bove says

    “Have I not made it abundantly clear that I don’t believe it is possible to formulate a study based on the real world application of these techniques.”

    Absolutely untrue.

    “Have I not made it abundantly clear that I don’t believe it is possible to formulate a study based on the real world application of these techniques. That there is a disconnect between the research community and what we are doing in the massage profession. That we in my circle are no longer discussing causality. I don’t understand how I can make myself any more clear. I believe this is a perfect example of the disconnect between what is happening in research facilities vs application in the real world.”

    There is no disconnect: there is a “never-connected.” The massage therapy world is just recently making any effort. A concerted effort by the AMTA could, in the next 10-20 years, make a difference for manual therapy. The future is in your hands. No pun intended.

  37. I have to admit that much of this debate causes me to glaze over and it feels at times that it’s simply an ego circus. I have been resisting my own opinionating as I read the thread, but now can’t help myself giving over to the ego’s strong and universal urges to say something important and to be “right” :). It seems to me that the spirit of healing is often lost in the consciousness (and limitations) of the scientific model – it can only take us so far, and in looking at it’s success at healing, especially chronic illness, there remains an enormous gap. I am all for evidence-based and evidence-informed/extrapolated treatment, but also feel within such confines, the true spirit of healing is lost.
    However, what I am most inclined to comment on is what appears to me to be a lack of understanding, (as well as a surprising negative tone here and there throughout the thread), around the neurobiological mechanisms of placebo. This always seems to be the elephant in the room. I cringe when I hear, “Oh, it’s JUST placebo…” To me, that IS the most powerful medicine, so much so that drug trials have to go out of their way to rule it out. Now that is an irony – ruling out good medicine. No doubt there lies an ethical debate around supporting a treatment that the patient believes strongly in, that does not have an existing “evidence-basis” for. But is this not “evidence-informed” since there is a wealth of science supporting the mechanism of placebo and is it not at least partially the responsibility of a caregiver to reinforce the mechanism?
    In a talk I gave recently, I prepared a analysis of different definitions of placebo.
    Here is the first (insert, personal opinion: disaster) definition: Google dictionary: “a harmless pill, medicine, or procedure prescribed more for the psychological benefit to the patient than for any physiological effect” (Note the mind-body dichotomy here, distinguishing “psychological” from “physiological” – part of the problem that is so deeply reinforced in Western thought…psychological IS physiological)
    Here’s one rooted in the dominance of pharmaceuticals in medicine: The Free Dictionary: “A substance containing no medication and prescribed or given to reinforce a patient’s expectation to get well”.
    How about Merriam Webster Dictionary: “a pill or substance that is given to a patient like a drug but that has no physical effect on the patient” (Seriously, “a pill or substance that is given to a patient like a drug but that has no physical effect on the patient” ?) (Again, a tragic example of the lack of understanding of the neurophysiological basis of all things “mind”).
    Now to get perhaps slightly more interesting:
    Psychospiritual definitions based on shamanic practices in indigenous cultures…
    “The [determination of the] power base of the patient, and the enemy; an examination of motives and belief systems, and an interpretation [of the trauma] in the cultural context.” (Jeanne Achterberg, PhD)
    “[Any effectiveness of shamanic healing is] a function of heightened expectancy on the part of the sick and injured, and that the true benefit of the [primitive] techniques is to provide emotional relief and a sense of community.” (Jerome Frank) *
    Here is a decent one, from Fabrizio Benedetti, and I encourage people to review his work:
    “The placebo effect is a psychobiological phenomenon that can be attributable to different mechanisms, including expectation of clinical improvement and Pavlovian conditioning.”
    Benedetti F, Mayberg HS, Wager TD, Stohler CS, Jon-Kar Zubieta J (2005) Neurobiological Mechanisms of the Placebo Effect. The Journal of Neuroscience, 25, 10390-10402.
    Here is a possible synthesis:
    Placebo: “any substance, treatment or modality that brings about physiological healing that is based on either conscious or unconscious individual or collective beliefs; the power base of the patient (and the enemy (nocebo)), rooted in motives and belief systems, including interpretation in the cultural context; and based on the desire to bring about relief of suffering”.
    Let’s stop trying so darn hard to rule out the placebo and work to harness it, consciously and unconsciously, in ourselves (as well as the patients we work if, that is if you are a healthcare provider). And likewise, to assist in undoing the effects of nocebo – let’s work with the biology of belief?

    John Quintner Reply:

    Matt, you make some excellent points.

    Indeed WE proposed that most if not all of the “therapeutic response” in MPS is due to placebo effect. According to my colleague Milton Cohen, it is not the elephant in the room, it is the MASTODON in the room.

    Milton has commented to me that most of the “definitions” that you cite do not describe the phenomenon but move as quickly as they can to a putative mechanism and/or a teleological interpretation.

    Even the “decent” one, from Fabrizio Benedetti, is a non-definition, as it does not say what the placebo effect actually is, but rather jumps directly to putative mechanisms: “The placebo effect is a psychobiological phenomenon that can be attributable to different mechanisms, including expectation of clinical improvement and Pavlovian conditioning.”

    The most accurate definitions that Milton has come across are taken from the article by Stewart-Williams S & Podd J. The placebo effect: dissolving the expectancy versus conditioning debate. Psychological Bulletin 2004; 130: 324-340:

    “A placebo is a substance or procedure that has no inherent power to produce an effect that is sought or expected.”

    “A placebo effect is a genuine psychological or physiological effect that is attributable to receiving a substance or undergoing a procedure but which is not due to the inherent powers of the substance or procedure”

    Milton argues that as such effects are attributable to the sociocultural context in which a treatment is delivered, to avoid confusion it may be preferable to use the term “contextual effects” rather than “placebo/nocebo effects.”

    We agree with you when you say: “Let’s stop trying so darn hard to rule out the placebo and work to harness it, consciously and unconsciously, in ourselves (as well as the patients we work if, that is if you are a healthcare provider). And likewise, to assist in undoing the effects of nocebo – let’s work with the biology of belief?”

    But first, the air of obfuscation has to be cleared. Milton’s relayed comments on this blog have been made with this intention.

  38. Geoffrey Bove says

    Aaron and John Q., please do not confuse “opinion leaders” with authorities, these are often disparate.

    John Quintner Reply:

    Thanks Geoff. I will in future avoid doing so.

    Aaron, should you visit the website of Myopain Seminars – “the premier post-graduate medical and physical therapy continuing education company in the US with a focus on myofascial pain syndrome, manual trigger point therapy, dry needling …” – you will see that intending students are being invited to study under two key opinion leaders – Dr Robert Gerwin and Jan Dommerholt. They, in turn, studied and worked with Drs Travell and Simons. Students are asked “Why not study with the source?”

    By the way, this same company also offers a “Canine Trigger Point Therapy Program”!

    Please draw your own conclusions.

    Peter Halloway Reply:

    what would be wrong with a canine trigger point program? Would that not be a great way to see whether trigger point remedies are placebo-driven assuming dogs are not influenced by placebo?

    Geoffrey Bove Reply:

    Peter, in case you don’t look below, here is my response (correcting a typo!).

    First, let’s get rid of the 4-letter word “placebo;” see above. That said, what do you get when you remove higher thought processes, perhaps a “super-ego” — you get an organism perhaps with heightened “instincts” and other senses, like a dog. Assuming that dogs are not placebo responsive is a bad assumption, actually proven not to be true. I know from years of scientific experimentation with animals (the lowly rat even!) that they have perhaps a stronger susceptibility to non-specific effects. We must control for this in every experiment.

    John Quintner Reply:

    Peter, why exclude the rest of animal kingdom from receiving the benefits of this wondrous modality of treatment? Surely there is scope for Myopain Seminars to offer programmes in TrP Therapy applicable to ailing felines, ursines, pachyderms and even piscines. Reductio ad absurdum? Please pardon my scepticism.

    EG Reply:


    Nice idea to test on animals, however animals do respond to conditioning expectation, as per the Pavlov experiments. They probably also respond to love and attention, which may be another aspect to placebo.

    Here’s some studies:


    EG Reply:


    Nice idea to test on animals, however animals do respond to conditioning expectation, as per the Pavlov experiments. They probably also respond to love and attention, which may be another aspect to placebo.

    Here’s some articles:


  39. Geoffrey Bove says

    And John Ware, kudos on the apple cart metaphor!

  40. Geoffrey Bove says

    I feel like I am writing to myself. The threads above are now really hard to follow; might we consider using replies in a thread rather than a cobweb?

    Another point: what is peer review for many of the papers that appear in the manual therapy field? There is almost no such thing, so few of us have appropriate expertise; I have coined the phrase “authority review.” But if the review process is hit-or-miss, and our therapists have never had any training in critical evaluation of literature (which includes most schools, including all the medical schools where I have taught…) what are we supposed to do? We must rely on authorities. What I have often seen in the manual therapy field is the fallacy “Appeal to Authority.” This is when the person being considered an authority is not really an authority on that particular topic. For instance, are Drs. Quintner, Bove, and Cohen “authorities” on the topic at hand? We think so, but others obviously do not. Again, what to do?

    Reminds me of the phrase “trust me, I’m a doctor.”

    Aaron Allen LMT Reply:

    You’re hitting the nail on the head.

  41. Geoffrey Bove says

    In an attempt to bring this discussion back on track, let me reiterate that the manuscript had little if anything to do with manual treatments, or really any treatments at all. It is more about maintaining a dogmatic rather than informed approach to treatment, and how it can inhibit progress.

    I will also repeat that there is a paucity of studies using manual treatments for treating pain that seems to be arising from muscles, or pain that seems to be arising from perhaps palpable lumps in muscles. Of course, as we have pointed out, every study based on the latter idea is flawed from the beginning, since identification has been shown to be unreliable. One might comment that because those studies were done with PTs, MDs, and DCs, that they are flawed. This might be. My extensive experience with non-medical therapists supports that they often have much sharper palpatory skills, and perhaps are feeling something different than I was taught to feel (or hallucinate?). For instance, many describe a gritty feeling in a muscle, and try to make that dissipate (that of course would not be a “trigger point”). I would love to know what that is, or if it is “real.”

    Why are there are so few studies using manual methods as practiced by non-medical practitioners? This is simple: who is going to do them? The type of person who goes into massage therapy school (and most who go into PT or DC training) are not interested in research, meaning actually doing what it takes to get trained to actually do the research. And that’s the only way it will happen. Moreover, the training programs of even the best massage therapy schools is minimal, as since they are privatized, there is a strong dis-incentive to change that (check you AMTA facts, or reports from the Teacher’s Summits).

    I have tried to get a PhD student from the massage therapy field. Indeed, I even had substantial funding to support one, from a professional organization. We could not find an interested person who qualified. Not the first time: for years ago I sought a chiropractor to enter my basic science research lab, and in latter years fellowships paying up to $75K/yr were available. Again, no interest.

    So until the other professions buck up and make the effort to do the research, or pay people like me to do the research, it simply will not get done.

    Aaron Allen LMT Reply:

    “Why are there are so few studies using manual methods as practiced by non-medical practitioners? This is simple: who is going to do them? The type of person who goes into massage therapy school (and most who go into PT or DC training) are not interested in research, meaning actually doing what it takes to get trained to actually do the research. And that’s the only way it will happen. Moreover, the training programs of even the best massage therapy schools is minimal, as since they are privatized, there is a strong dis-incentive to change that (check you AMTA facts, or reports from the Teacher’s Summits).

    I have tried to get a PhD student from the massage therapy field. Indeed, I even had substantial funding to support one, from a professional organization. We could not find an interested person who qualified. Not the first time: for years ago I sought a chiropractor to enter my basic science research lab, and in latter years fellowships paying up to $75K/yr were available. Again, no interest.”

    I agree with this statement 99%, except, I take issue with your assumption that interest is the only factor limiting participation.

    I may be an intelligent enough massage therapist to keep abreast of modern research and participate in discussions such as this one, but that doesn’t mean that I come from a socio-economic background which would have allowed me to participate. I simply didn’t have the time or money in life to become educated enough to participate. I rely on the research community as that is something I will never get to do in life. It does not mean that the process does not interest me, in fact I feel much frustration. Other than that your point is dead on the money. Thank you for expressing it.

    John Ware, PT Reply:

    I could certainly live on $75k while doing a research fellowship. My goodness, how much are LMTs making these days?!

    I’m not sure what socioeconomic background has to do with the ability to acquire a terminal degree these days. If it did, I wouldn’t stand a snowball’s chance in Hades.

    John Quintner Reply:

    Critical reviews of such popular modalities of treatment as “myofascial release therapy,” “fascial manipulation,” and “craniosacral therapy” can be performed without the passionate and intelligent researcher receiving any external funding. The obvious question to pursue is whether or not they are underpinned by scientifically credible theory. If not, they fall into the category of “cargo cult science,” a term first used by physicist Richard Feynman in 1974.

    Andrew McMullan Reply:

    I agree John – it is quite a chunk of change.


  42. John Quintner says

    Aaron, you will find some of their names in the list of references that accompany our paper.

    But you might also look at the current (January 2015) issue of the Journal of Bodywork and Movement Therapies, where you will find “An evidence-informed review of the current myofascial pain literature” by Dommerholt et al. Incidentally, we do not agree that the contents of the article properly reflect its title.

    Finally, if you do a search on “Massage Today” you will also discover articles written by some of the key opinion leaders.

    Aaron, it may interest you to know that you are in much the same position as I was in when I embarked upon this particular journey of discovery in 1985. Best wishes, John

    Aaron Allen LMT Reply:

    Have I not made it abundantly clear that I don’t believe it is possible to formulate a study based on the real world application of these techniques. That there is a disconnect between the research community and what we are doing in the massage profession. That we in my circle are no longer discussing causality. I don’t understand how I can make myself any more clear. I believe this is a perfect example of the disconnect between what is happening in research facilities vs application in the real world. None of my colleagues are discussing causality. We more often have conversations around helping the client to form new/positive relationships around sensations in their body. We’re employing active listening, and far from the blissed out relaxation session which is many peoples concept of massage we are in active communication with clients throughout a session, eliciting feedback as to the sensations experienced throughout any applied technique. But as a massage therapist, being able to “skillfully rub” “the knot” is the name of the game, and would seem to provide the perfect direct access point to the clients CNS. It is as close empathetically as a human being can be to experiencing the lived experience of another. We move through a process of first finding and then palpating the knots which clients report feel most relevant to their pain in order to guide the client through recognizing where and how they have been holding tension and then show them that it is possible to release it, through breath and visualization and a gentle coach to guide them through the process of finding a more parasympathetic state. This is the way we, in my locality discuss our work. It bares no resemblance to the reductionist models being applied in the studies you quote.

  43. John Quintner says

    Aaron, to date, from my reading of the MPS/TrP literature, it has not reflected such “wide variation in receptiveness to/integration of new ideas.” The fact that the various authors, who are key opinion leaders, have so far been “missing in action,” lends support to my opinion.

    Having said that, I am aware of the legal constraints under which you practice as a massage therapist. But if there is a groundswell amongst your colleagues to develop a language (including a taxonomy) that better reflects what you have to offer your patients, your voices need to be raised and heard by those who are responsible for your training and continuing education.

    Of course, this gratuitous advice also applies to many other health professions whose members engage with people in pain, not the least important being my own specialty – that of pain medicine.

    I hope that we are now “on the same page”.

    Aaron Allen LMT Reply:

    I get it John. I am not asking you to accept extraordinary claims without extraordinary evidence, but at the same time I’m at a loss as to how to devise studies which would reflect the real world practice of TPx. I have considered submitting case studies for all the help they might provide, but my abilities as an independent practitioner and the limits of my education, at times exclude me from participation.

    What you have been left with are those who DO feel capable of producing such research, and I cannot answer for their conclusions, nor can I agree that they are opinion leaders, as your descriptions of their position bares little resemblance to my understanding of, or the current state of training and/or continuing education here in Oregon for TPx practice. Perhaps you could finally name these opinion leaders and I could provide greater insight.

  44. Geoffrey Bove says

    I consider “placebo” a dirty word, since it is something used to deceive. No one is trying to deceive their patients/clients. I prefer the phrases “contextual effect” or “meaning response.”

    Aaron Allen LMT Reply:

    Not to mention the known ways placebos are being manipulated in modern research, knowingly and not, skewing outcomes. Like many of these topics, we are not all on the same page regarding supposed universally established concepts.

    I like both of your alternatives, thank you.

    John Quintner Reply:

    Aaron, to ensure that we are all on the same page, would you please provide relevant examples of these “supposed universally established concepts”?

    Aaron Allen LMT Reply:

    @John Quintner

    I was seeking to reinforce Geoffreys point above mine, that he felt placebo could be taken as a “dirty word” with negative connotations.

    I only sought to reinforce that idea, that even with a word as ubiquitous as placebo we as a scientific community do not hold universal agreement on its definition when it comes to research.

    This would relate to the arguments you’ve been presenting that would make it seem that “we” TP therapists (or at least the “authorities” in the field) are in universal agreement regarding the models which govern our practices, when in fact there would seem to be wide variation in receptiveness to/integration of new ideas.

  45. I am the anomalous gynecologist who registered my first comment earlier in the week. I just now had a chance to read through the entire “stream” and I have a few observations to share.
    1. Not sure I see any other physicians joining in discussion (Maybe I missed one or two)
    2. As a physician, I do have license to “tools” that manual therapists simply do not.
    3. I can prescribe drugs, inject drugs, use a scalpel, and order all sorts of expensive and invasive tests and referrals to other physicians and to a huge variety of manual, spiritual, emotional and psychological “specialists”
    4. I am licensed to talk and to touch patients in pain as well, which the vast majority of my fellow physicians have either no time or training to do anymore.
    5. Interestingly my anxiety level grew as I read through the stream – why? Because it hits so close to home of my 50 years since graduating med school and hearing endless battles of what is the “gold standard” one day and being told the next that the gold had turned to “s—“.
    6. Bio-psychosocial model is what I practiced unknowingly for decades and finally someone named it – and now even that appears to be politically incorrect.
    7. Estimated 13 trillion cells in the human body and as practitioners we are trained, educated and expected to help others find a balance among millions to billions of variables – ? impossible to do with current research tools – but just as there must be a place for science at the edges of outer space and deep oceans, we must continue to take care of our fellow complex humans to the best of our abilities.
    8. Reductionism vs. current ethically sound care based on knowledge, experience, intuitive understanding and compassionate communication. Even in the arena of chronic pelvic and genital pain, those conflicts and battles go on. We all need each other but it becomes difficult to not talk around each other.
    9. Educated patients like Soula, living in the world of pain need some assurance that all practitioners are striving to learn even the basics of pain science – and in the physician world – it just is not happening.
    10. Incidentally, my greatest model of pain management stems largely from BIM and NOI – but my last comment is that my “wet needling” of muscular tender spots and peripheral nerves is a large reason my patients stop “needing” surgery, emergency rooms and the psych wards. Manual therapists should be trained and licensed to use local anesthetics in a variety of safe and easy to learn techniques, just as physicians need to practice listening, teaching, and actually touching.
    11. Lastly, 100% of pelvic pain patients benefit from pelvic floor PT.

    Soula Reply:

    Yes, thank you Dr Echenberg, it’s exactly what patients expect. And that’s what has always drawn me to the wonderful John Quintner and his associates, they question. But for this process to get us all anywhere, we need more physicians commenting, agreed there.

    I wish we weren’t living so far apart, I’d be happy to put my pelvic pain to the test with your approaches! Just reading your response calms me, there’s so much more to treating chronic pain as we all know of course.

    Aaron Allen LMT Reply:

    “7. Estimated 13 trillion cells in the human body and as practitioners we are trained, educated and expected to help others find a balance among millions to billions of variables – ? impossible to do with current research tools – but just as there must be a place for science at the edges of outer space and deep oceans, we must continue to take care of our fellow complex humans to the best of our abilities.
    8. Reductionism vs. current ethically sound care based on knowledge, experience, intuitive understanding and compassionate communication. Even in the arena of chronic pelvic and genital pain, those conflicts and battles go on. We all need each other but it becomes difficult to not talk around each other.
    9. Educated patients like Soula, living in the world of pain need some assurance that all practitioners are striving to learn even the basics of pain science – and in the physician world – it just is not happening.”

    Thank you for articulating this.

    John Quintner Reply:

    Robert, you are correct in noticing that there are few of us from the medical fraternity participating in this discussion. I do find this surprising given the large number of pain clinics where physicians offer “trigger point” injections to their patients. I suspect that this practice is entrenched, which is why the North American pain journals rejected our paper. No doubt we were seen as trying to “rock the boat”. Well, that particular boat is sinking fast and none of the key opinion leaders seems prepared to mount a rescue operation.

    John Ware, PT Reply:

    If I may adjust your metaphor a bit…
    Rather than avoiding “rocking the boat”, I think many interventionalists are more concerned about “upsetting the apple cart”, which last I checked each “apple” was going for about $300 a piece.

    Them’s some sweet apples.

    Sarah Haag Reply:

    I think 100% of pelvic pain patients should TRY pelvic PT. Unfortunately, there are situations we can’t help in pelvic pain. Another issue is the medical profession itself. Unfortunately a good part of the caseload at our clinic are patients who’ve been not helped (or made worse) by ‘pelvic pain Physios’.

  46. John Ware, PT says

    You present a stark inconsistency in your argument. You claim 75-80% efficacy for your treatment approach targeting trigger points, but then you assert that “objective quantification of what I do is impossible.” This is an illogical and untenable position. It’s a case of wanting your cake and eating it, too- or invoking science when it confirms your bias. This is in fact, not a scientific position.

    I agree with you, however, that positivist approaches to explain the effects of manual therapy are limited. The intersubjectivty inherent in manual techniques makes it impossible to distinguish specific from “non-specific” (e.g. placebo) effects. You can’t design a double-blind trial of manual therapy.

    It might interest you that there’s a growing body of qualitative research in manual and physical therapy, but the results do not appear promising for approaches that promote a causal link between peripheral “dysfunctions”, such as joint or soft tissue abnormalities on manual examination, and the lived pain experience (see Snelgove and Liossi, 2009 and Richardson and Daykin, 2004). What appears to be emerging form these qualitative studies is that the biomedical model permeates the explanations of pain provided to patients, whether explicitly or implicitly. This places patients in a difficult moral position because invariably patients who have these things (trigger points, mal-positioned joints, muscle imbalances, take your pick), don’t respond to treatment. What’s wrong with these people? Are they lying, feigning their pain? Malingerers? Or are they just “difficult”?

    What do you tell the 20-25% of patients in whom you’ve treated trigger points but don’t respond? Why don’t their trigger points respond to your treatment?

    John Quintner Reply:

    John, I agree that it is difficult, if well-nigh impossible, for us to escape from the reductionist way of thinking that characterises biomedicine.

    However, the “trigger point” concept seems to be a particular example of the fallacy known as reification (identified by Alfred North Whitehead), which is an attempt to make an intangible experience such as pain into a “thing” that apparently can take up residence within the muscles and cause mischief in this location. Then, in the mind of the therapist, the metaphorical “trigger point” takes on a life of its own and has to be “attacked” and “defeated” by using whatever means are at hand.

    This logical error is repeated whenever pain itself is asserted to be a causative agent responsible for physiological or pathological change. It is not at all uncommon to detect this fallacy in the peer-reviewed pain medicine literature.

    Of course in our society we often use “military” metaphors in our day to day discussions of known diseases. Patients fight against cancer etc. But at least we do not mistake the reality of the disease for its metaphorical counterpart.

    Aaron Allen LMT Reply:

    @John Ware, I had previously bowed out of this conversation, but decided to respond as I appreciated your insightful comments.

    I can’t be certain, but I believe you may have conflated two separate statements I made. I do believe we can objectively measure client outcomes, and I regularly do for both oral pain scale and frequency of acute episodes, although admittedly I was throwing around numbers in my post which have not been revisited recently (I am not involved in research, simply tracking client progress). What I stated could NOT be objectively quantifiable is palpatory findings/application of TPx, or in other words you can not devise an objectively measurable experiment without destroying any possible efficacy of the treatment.

    The 75-80% efficacy I believe I was referring to was the number of clients who reported lasting relief (a month or longer between treatments while maintaining an OPS of 4 or more points lower than their initial assessment, and/or a reduction in frequency of 25% or greater) Many clients report much greater and longer lasting relief than these thresholds. Of the 20-25% of clients who do not receive such lasting results it may be for myriad reasons, not the least of which is that no one I have ever met in the TP community believes that TPs are the “cause” of clients pain, or that they are the only factor in clients pain, and we know that many clients present with much more complex conditions (degenerative changes or congenital defects for example) than what massage therapy/TPx can effect. What we tell them is that their condition is not advancing at the pace we would expect and that we may have to reconsider whether these therapies are sufficient to address their condition, or provide them the relief they crave. We most often refer them out to other types of therapy if we think there may be a chance of efficacy. And we let them know that if they choose to continue treatment with us they will have to make a decision whether the financial outlay is worth the quality of life increases they are receiving.

    Please understand that the models most discussed in TPx circles which I am aware of are the exact ones the author put forward in his paper in the section titled “Towards explaining the clinical phenomena”, a claim I have already made here and that the author seems unwilling to answer for. He seems intent on lumping together anyone who would dare use the term trigger point into one uneducated group of charlatans uninterested in research literacy, a point easily refuted by anyone who would check my social media pages where I regularly advance contrarian positions when there are advances in research, as well as research literacy. He also seems intent to ignore or distort the fact that I contribute to this forum because the advances in understanding presented here by Lorimer Moseley et al both advance AND reflect the current understanding in the TP community as I know it, and as was presented during my education at the second oldest school for massage in the united states. Whoever these authorities/boogeymen are that he keeps trotting out, did not and do not exist in my circle of therapists in the state of Oregon, and I work/network/continue my education with therapists who are putting these forms into practice daily.

    “It might interest you that there’s a growing body of qualitative research in manual and physical therapy, but the results do not appear promising for approaches that promote a causal link between peripheral “dysfunctions”, such as joint or soft tissue abnormalities on manual examination, and the lived pain experience”

    In case it is not obvious from my answers above I know of noone who professes a causal link between peripheral dysfunctions (TPs) and lived pain experience. We simply are ages beyond that type of thinking in large part due to the research and publication of scientists such as at the ones participating here at bodyinmind.

    John Quintner Reply:

    Aaron, beware of the “straw man” fallacy. In our paper, we do not dispute the existence of the clinical phenomena known as “trigger points”. It is the explanation provided by Travell, Simons, and their followers, that we have refuted. I know I have said this many times before in this discussion.

    I have no way of knowing the educational content of the discourse that takes place between you and your colleagues in Oregon. Perhaps you could enlighten me?

    Aaron Allen LMT Reply:

    Which part of my comment you are referencing as a strawman fallacy? I have never said you dispute the existence of the clinical phenomena.

    You would seem to be the one offering a strawman as I have never voiced support for the explanations provided by Travell Simons. Only disagreed that it was to time to discard their entire body of work due to errors in the approach and findings.

    I’ve also stated repeatedly that the models you put forth in your paper regarding neuritis and allodynia were part and parcel to my training. It would seem we are on the same page with regards to the need to update our models as the science progresses. Why do you keep insisting otherwise?

    I’m working daily with clinical phenomena which most closely resembles what Travell Simons wrote about. I do not have to accept their 75 year old answer for why it is happening to continue to practice and explore the work. I am a massage therapist. It is my job to rub on peoples knots to bring them relief. I feel taught bands, I feel twitch response, I feel reduction in hypertonicity, my clients report reduced pain. I do not possess the educational or financial resources to further the research needed in this field, but I do have a profitable career offering a highly safe and conservative therapy, with an exceptional track record as evidenced by thousands of happy customers who swear I’ve helped them achieve decreased pain and greater quality of life in a cost competitive manor.

    I disagree with the conclusion in your paper and the general tone of your comments here because I fear that it suppresses discussion of my experience which so closely resembles what Travell Simons described. Say that Travell did shoddy research. Shout from the mountain tops that TPs are not causative of MPS and I will agree with you and support you.

    What texts would you provide a young massage therapist who is curious to learn how to effectively rub on a knot? I would prefer to hand them Travell Simons with the caveat that much of their theory as to “why” has been discredited and that we are still searching for answers as to the “why”. I would point them to Lorimer Moseley lectures and Mindinbody to read up on the latest in research. The reason I would do this is because this is exactly how the information was presented in my education. I believe that this approach helps impress upon the initiate the importance of research literacy (which was also taught in my school). What texts/resources would you provide as alternatives for massage professionals? Or is it your position that massage therapists should not be allowed this scope of practice due to lack of efficacy voiced in the research?

    John Ware, PT Reply:

    I could use some enlightenment as well because it sounds like whatever it is you’re doing in Oregon is not what Travell, Simons and their current acolytes have described in the published literature. Of the criteria for diagnosis of myofascial trigger points (presence of a hypersensitive taut band, reproduction of referred pain, and palpable or visible local twitch response [from Llamas-Ramos et al, JOSPT, November 2014]), two of them imply a causal link between the TrP and the patient’s pain experience. As John just clarified, the TrP is an effort to “reify” the pain experience as some discrete entity within the tissue. Rid the tissues of this thing, and pain will at least improve. The trigger point construct, as I’ve understood it based on reading much of the literature, clearly proposes that these things cause pain.

    Having said that, I have to qualify that the criteria I just provided have a rather checkered history. Taut bands have been reliably found within muscles, but the interrater precision of location is on the order of several centimeters. Pain referral patterns are highly variable and, as I put it in my letter to JOSPT coming out next month, there’s an incoherence of distinction between “reproduction of familiar pain” and “referred pain” in the TrP literature. And finally, the widely referenced reliability study by Gerwin et al (1997) found that the latent twitch response on average demonstrated poor to fair reliability (except in the extensor digitorum muscle where it was found to be “almost perfect agreement”, for some reason). The 4 examiners were all physicians who were experienced in diagnosis and treatment of myofascial pain syndrome.

    If you want a name, I’ll provide one: Cesar Fernandez-de-las-Penas leads a clinical research group out of Spain, who have published several recent clinical trials investigating both needling and manual therapy techniques to treat TrPs in patients with myofascial pain syndrome. The Llamas-Ramos et al trial is their most recent effort, and it found no difference in short-term (2 weeks) pain and disability between needling and manual therapy directed at TrPs. Unfortunately, no control or sham group was included, so we cannot rule out non-specific effects and natural history. Incidentally, pressure-pain thresholds of the spinous process of C7 were significantly higher in the group receiving dry needling than in those receiving manual therapy for 2 weeks following the intervention. Other groups have compared needling to sham and the effects on pain have been slight, which suggests to me that the counter-irritation mechanism would most likely account for any differences.

    Aaron Allen LMT Reply:

    “I could use some enlightenment as well because it sounds like whatever it is you’re doing in Oregon is not what Travell, Simons and their current acolytes have described in the published literature. Of the criteria for diagnosis of myofascial trigger points (presence of a hypersensitive taut band, reproduction of referred pain, and palpable or visible local twitch response [from Llamas-Ramos et al, JOSPT, November 2014]), two of them imply a causal link between the TrP and the patient’s pain experience. As John just clarified, the TrP is an effort to “reify” the pain experience as some discrete entity within the tissue. Rid the tissues of this thing, and pain will at least improve. The trigger point construct, as I’ve understood it based on reading much of the literature, clearly proposes that these things cause pain.”

    I don’t understand how I can make myself any more clear. I believe this is a perfect example of the disconnect between what is happening in research facilities vs application in the real world. None of my colleagues are discussing causality. We more often have conversations around helping the client to form new/positive relationships around sensations in their body. We’re employing active listening, and far from the blissed out relaxation session which is many peoples concept of massage we are in active communication with clients throughout a session, eliciting feedback as to the sensations experienced throughout any applied technique. But as a massage therapist being able to “skillfully rub” “the knot” is the name of the game, and would seem to provide the perfect direct access point to the clients CNS. It is as close empathetically as a human being can be to experiencing the lived experience of another. We move through a process of first finding and then palpating the knots which clients report feel most relevant to their pain in order to guide the client through recognizing where and how they have been holding tension and then show them that it is possible to release it, through breath and visualization and a gentle coach to guide them through the process of finding a more parasympathetic state. This is the way we, in my locality discuss our work.

    I’ll ask you the same question I am asking John quintner. If we are to completely abandon Travell Simons (as is the conclusion in the paper) because of their low quality research and questionable findings, What texts would you provide a young massage therapist who is curious to learn how to effectively rub on a knot? I would prefer to hand them Travell Simons with the caveat that much of their theory as to “why” has been discredited and that we are still searching for answers as to the “why”. I would point them to Lorimer Moseley lectures and Mindinbody to read up on the latest in research. The reason I would do this is because this is exactly how the information was presented in my education. I believe that this approach helps impress upon the initiate the importance of research literacy (which was also taught in my school). What texts/resources would you provide as alternatives for massage professionals? Or is it your position that massage therapists should not be allowed this scope of practice due to lack of efficacy voiced in the research?

  47. EG I agree placebo is alway there and important, but I think it a fallure to explain thereby every positve effect. Not all can be explained from placebo. Why is it that some patient very surprised the pain and movement restrictions are gone after a treatment or centralizing there symptoms as McKenzie describes. They were not told how to react and had no expectations. Why are my placebo effects so much better and lasting for so much longer, why was the placaebo effect not there when they visisted my collegues and orther doctors in former days? Some patients are cured after 10 to 20 years searching for a solution!

    EG Reply:

    Hi Koen,

    Really good point you make about “surprise”. If placebo is driven entirely by client expectation, then *genuine surprise* would be an excellent measure of something ‘else’ happening, possibly an alteration in peripheral neurological or mechanical processes. Placebo researchers rarely look at this aspect – “what is the client’s genuine expectation?” It’s absolutely critical, so thanks for bringing this up.

    Placebo might not just be a function of client expectation, however. There may be other mechanisms at play. I like to keep up to date with Harvard’s placebo studies – And if you don’t mind skiing ‘off piste’, there’s a guy called Bill Bengston who is worth reading about. He proposes mechanisms of healing where expectation is bypassed.

    Remember that your level of expectation (which related to your strength of belief in your techniques) will come across to your client even without words. It means your positive expectation is quite strong… stronger than your colleagues. You probably also generate rapport more quickly/deeply. It doesn’t *necessarily* mean the technique is working at a peripheral level, but it could be. I definitely acknowledge that.


  48. As a patient, I’d like to know the implications of this theory (from Quintner et al) for the future treatment of what is currently commonly referred to as myofascial pain or trigger point pain.

    John Quintner Reply:

    Leigh, the implications of our refutation of Myofascial Pain Syndrome/Trigger Point theory of Travell, Simons and their successors are in my opinion quite profound. For far too long have chronic pain sufferers been treated as passive recipients of whatever treatment happens to be in fashion at the time. I cannot foretell the future but I would hope that the popularity of passive physical treatment modalities steadily diminishes as word gets out that they have not been shown to produce positive outcomes beyond placebo (i.e. contextual) effects.

  49. John Quintner says

    Aaron, we have been discussing just one model, which has now been completely discredited because of its many flaws. In its place we have offered the rudiments of what we consider to be a scientifically supportable explanatory model for the clinical phenomena under discussion. Why is this important? Our clinical practice is informed by the theoretical models that we bring to bear to assist us in our therapeutic endeavours. When the theoretical basis of our favoured model is highly flawed, the patients who we treat are at risk of being harmed by our treatment. If there is evidence that we have either ignored or dismissed, please provide it so that it can be evaluated. Science is a hard taskmaster!

  50. Interesting to see how dramatic the placebo response can be. This article talks about the effect being up to 70%. The brain is interesting!!

    “Previous research on the potential efficacy of placebo has primarily focused on pain relief. In these studies, patients have been shown to release opioid-like substances that appear to exert an analgesic effect. Overall, the pain-relief response falls in the range of 30-40%. Interestingly, the more aggressive and invasive the intervention, the greater the response tends to be, with patients receiving sham surgery displaying a response of up to 70%[1]. However, as placebo treatments are repeated, analgesic effect seems to dissipate. In trials, placebo response often appears greatest at 3-4 months, but diminishes over a year or so[2].”

  51. It is interesting how folks from all professions and walks of life (physical therapy, massage therapy, osteopathy, chiropractic, medicine, patients, etc) get so up in arms when ‘trigger points’ are discussed. Those supporting the trigger point theory get the opposing side jazzed up. Those refuting the trigger point theory jazzed up the side full of ‘beliefs, I do it because it works, my outcomes are great, the science is behind the times’ people.

    The simplistic reality of trigger points is this:

    -Chronic pain statistics continue to climb in spite of the claims made by some people here.
    -Those making money or their livelihood needling ‘trigger points’ won’t stop, no matter what the science and evidence says. This can be said for all professions in healthcare.
    -The people claiming their outcomes are great would have the same outcomes with homeopathy, meaning you are a great interactor with your patients. Stop giving the needles so much credit and understand you are the reason for good outcomes, not an inert object.
    -The science for the trigger point theory is not good. This means the debate will never stop. There will be more theory and money to take from people with pain.
    -The evidence for trigger point needling therapy is sad. This means its time to place the needles where they belong; next to the ultrasound, diathermy and ice packs in the closet.
    -Anecdote is not evidence

    Aaron Allen LMT Reply:

    I get “up in arms”, though in a markedly reserved manor, because every day I watch clients exit the cycle of chronic pain and wasted human potential, and I only want to see more (learning why it is working would advance that goal and is one part of why I reject this papers conclusion). I do not make claims that TPx can treat all causes of pain, only that a large volume of chronic pain sufferers do suffer from these conditions and benefit from this work (whatever the mechanism). Also, I can’t speak to dry needling as I have no experience there, and engage a more deep tissue massage approach.

    John Quintner Reply:

    Aaron, have the details of the particular approach you favour ever been published? If so, can you please supply me with the relevant references? If you cannot provide this information, I have no way of evaluating the claims you are making for its efficacy.

    I suspect that aficionados of “myofascial release” and related techniques have always seen themselves as a “protected species” when matters of scientific inquiry such as those I have raised on this website are being discussed. Please prove me wrong!

    Aaron Allen LMT Reply:

    “I suspect that aficionados of “myofascial release” and related techniques have always seen themselves as a “protected species” when matters of scientific inquiry such as those I have raised on this website are being discussed.”

    This is the kind of language that belies bias John. Why would I be here using this site if I am uninterested in more truth (I promise you am here with an open mind to learn more about the field I am engaged in) I have openly stated more than once in this discussion that I am not in possession of scientific evidence to refute or champion any model. I have also been clear that I champion the work you are doing in investigating these claims as you have. I simply take issue with your condemning any future discussion of these models as in the conclusion in your paper. I also found in reading of your paper a fair amount if bias in the papers assumptions and dismissive “tone”. These are the things I am challenging. I feel you should be exemplifying an impressive open mind should eventually evidence be presented in any direction, yet you seem dogmatic and intent on pigeonholing, goading and being “right”. I’m dropping out of this discussion.

    Riccardo Reply:

    Matt, I agree with you 90%!

  52. Somehow I am messing up my replies and they are not being attached to the portions of the discussion where I intended. I hope this is not too confusing.

    I also would like to reiterate that I am not refuting the findings of this or any other study. I simply take issue with the authors sensationalist tone regarding TPx being fully and finally disproved simply because contradictory evidence has been found, or that flaws in the original research erode the theory.

    My overarching point is that it may well be impossible to objectively quantify massage for trigger point therapy, as well as many other types of work. Some things simply cannot be objectively studied. That is not to say that objective study should not be pursued, but that an understanding that the gold standard of double blind will never be possible for some aspects of life must be embraced, and that we may possibly need a new standard of evidence for those aspects of life which cannot be isolated objectively.

    For now, my therapies as applied provide results for many/most clients which by far out perform placebo, or medication or physical therapy alone (vs PT combined with TPx) and I will therefore continue to apply them with evidence or without (though I will always seek to understand the why better, thats why I’m on this site), as my clients safety and quality of life are my only concerns as a therapist, and if the therapies I apply worked no better than placebo I would very quickly be out of a job. Luckily for me there is no danger of that happening.

    Geoffrey Bove Reply:

    Aarom, please continue to do what you do! Just lose your dogma.

    Aaron Allen LMT Reply:

    Geoffrey, Can you define the dogma you believe I am operating under? you may not have been reading all of my comments, but I happen to agree with certain points made in this paper/by your community while others sound like leaps of logic which ultimately compromise its conclusion. You may have me confused with some others on here who are defending older models as to the causes of TP phenomenon. One instance where I disagree is:
    “One common factor shared by most therapies is that
    they elicit pain at the site of their application; that is, they
    are noxious stimuli. If they do work, this similarity suggests a common mechanism of action. One possible
    mechanism is counterirritation, or application of a competing noxious stimulus [87, 88]”
    This is exactly wrong about the type of TPx I learned. If you are increasing noxious stimulus the body doubles down on its protective spasm and you achieve nothing, or make the pain worse. The goal of all TPx should be to reduce noxious stimuli to the CNS. Only when you are successful at reducing noxious stimuli do clients experience pain reduction results.
    For an example of where we are in accord lays in the section titled “Towards explaining the clinical
    phenomena”. These explanations were part and parcel with my education on the possible mechanisms behind TP phenomenon. Why the authors believe that TP therapists are unaware or unaccepting of this research is beyond me.
    My conclusion after reading the paper is that while well intentioned and to some degree accurate in its assessment it, as we say, throws the baby out with the bath water, and I wholly disagree that because bad research has been performed in the past and can be refuted is any reason to discard the theory. It simply means we need to revise our model. As for research which refutes the efficacy of the therapies I employ, I have seen none which have reproduced the real world conditions as pertaining to the application of TPx as that would provide too many variables to be considered sound research. We are therefore left with hollow non-therapeutic application which predictably yields no results.

    EG Reply:


    “For now, my therapies as applied provide results for many/most clients which by far out perform placebo, or medication or physical therapy alone (vs PT combined with TPx) and I will therefore continue to apply them with evidence or without”

    How do you know your treatments “far outperform placebo”?

    Here’s how I know that my various Physio techniques do *not* outperform placebo. I do clinical experiments such as:

    – manipulate/mobilize the wrong spinal segment (the non-painful or non-stiff level). The outcomes are as good as when I treat the correct segment.

    – apply ischaemic pressure to a non-tender, non-lumpy muscle. The outcomes are just as good.

    – leave the ultrasound switched off whilst in use. The outcomes are as good as when switched on.

    – Purposefully work on the wrong side of the body. This one always surprises me the most. The outcomes are as good as treating the ‘correct’ side. Even more strange is how few people pull me up and tell me “hey, wrong side!”.

    In terms of getting an immediate pain-gating effect, I suspect it’s probably important to target the right spot with an ‘active’ treatment, but pain-gating is a temporary effect. Anyone can do pain gating on themselves by simply identifying where it hurts, then rubbing it.


    Frédéric Wellens Reply:

    EG, I second your observations!

    Al Reply:

    EG do you work in a setting that only sees acute self limiting/healing conditions, for a patient set with unlimited resources in a town with zero other skilled therapist..?

    Aaron Allen LMT Reply:

    EG, you are correct in that I have not collected evidence personally within my practice, but compared to the outcomes from research which I’ve read we are seeing far greater change in oral pain scale for instance (in both individual sessions and over a course of treatment) compared to not only stated placebo results, but also compared to the non control groups. Our assumption which is not a large assumption is that the constraints of isolation on the experimentation are effecting outcomes negatively. P.S. I would love to be involved with/collaborate on studies which attempt to disprove the efficacy of therapies I perform, yet it would seem I face educational barriers to inclusion. Still, my challenge would be for anyone to study the results we are getting and help us to understand better why.

    EG Reply:

    @Al, Physical aspects of treatment don’t appear to do much, but we can still be of enormous help to those in pain. The great Patrick Wall said “in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome”. That’s out work, to understand placebo on a very deep level. And don’t worry, medicine is in the same boat.

    @Aaron, My experiments were informal and easy to conduct. Such experiments can be conducted ethically. If the ‘wrong’ treatment doesn’t work, I always follow up with the ‘correct’ treatment. Also, inadvertent mistakes need to be included in the sample. An example of this would be the inadvertent forgetting of the interferential current whilst chatting to a patient. Coming back 10 minutes later, the machine suction is humming away but ooops, no current. Discovering this, I would re-assess the condition and see what sort of change has occurred. Over the course of a career such mistakes happen enough that you can utilize the results. Once again, if there’s no change then the machine needs to be re-applied with the current switched on. Same thing applies if you inadvertently treat L3 instead of L5, for example.

    Clients pay for pain relief – that’s my motto. Treatments are deemed ethical so long as they are safe and evidence-based. There is an enormous amount of evidence (actually proof) that expectation drives the placebo response. We can use this ethically and with great effect.


    Alice Sanvito Reply:

    EG: That is beautiful.

    I assisted at NMT seminars for many years. In one seminar, the instructor was discussing the importance of treating all the muscles believed to be involved in low back pain that were not in the area where pain was felt, like hamstrings, glutes, psoa, etc. He told how one of the TAs had some nagging low back pain and, as an experiment, he treated everything *except* the area where she felt pain. The result? She got up off the table and had less back pain. It was assumed this validated the idea that treating these other muscles was more important than treating the painful area itself.

    It never occurred to us that maybe it was *invalidating* our assumptions about treatment.

  53. John I have every intention of reading your paper in the next couple of days. My interest in your research comes from my training which not only included objective analysis of research findings, but also a healthy dose of the type of skepticism you seem to feel is lacking from “our” side. When/where I was taught TPx there were no dogmas regarding why our treatments are effective, and much open questioning of the available science surrounding pain/pain management. All this from the second oldest school of massage in the USA. This is why I have a problem with your viewpoint. It is more that you sound exactly like the people you claim to refute (dogmatic) than that I have a problem with contradictory evidence.

    John Quintner Reply:

    Aaron, I look forward to receiving your further responses after you have read our paper.

  54. John Quintner says

    Mathew, “theatrical placebo” refers to the ritual that accompanies the particular treatment we happen to be administering. I picked up on this when I was reading an article on needle acupuncture.

    Aaron, you have every right to disagree with me on this matter, but let me say that those who taught you the manual skills in which you are obviously proficient must have drawn upon the theory and practice as published by the current and past leaders of your profession.

  55. Kieran, I would postulate that the clinical trials you reference are not able to replicate the real world experience as it is far too subjective an experience, and that in the objectification process it loses efficacy. And while your experience/reference materials may say that clients only gain a few minutes/hours/days of relief, many of my clients experience permanent (as much as anything is permanent) lasting relief. As per my example below, this one client was having 4-5 migraine days per week. After her first session she experienced immediate relief which lasted for several weeks, and over the past month (and two treatments) she has only had 2 migraine episodes. How much more lasting do you believe her relief needs to be? I would love to get her to an even better place, but assuming she needs to return twice a month for life in order to maintain these results I believe she would find the expenditure worth every penny compared to the negative quality of life she was experiencing prior to treatment. I also have clients who continue to remain pain free years later.

  56. Beatriz Brandao says

    Its an excellent revision and article!!!!

  57. I disagree so strongly – yet I assure you, not emotionally – on so many levels with this thread, and will therefore excuse myself to a better purpose, such as palpating taut bands of muscle, at my own practice, where we do not just question but freely work against what’s been handed down and what is currently accepted as the norm for our profession, as we refuse to accept anything less than what’s best for our patients. At least in those instances, I know I can do some good. I am apparently not well read enough to debate effectively here.

    I would like to leave you with one thought though, and that is to remember there may be a limit to our current understanding of the human body and the research that can be performed regarding it. While we work toward improving this understanding and capability for research, I hope that we do not go as far as to exclude those phenomena that we currently simply cannot understand in terms of present scientific data, as they will then be lost when the capacity to understand them may finally exist.

    Finally, science and faith do not exclude each other. But I fear the proof of that would likewise be lost on this forum.
    Good evening to all of you.

    John Quintner Reply:

    Tiffany, you may like to know that our paper is now freely available online from Painaustralia, our peak body in Australia.

    We are all in favour of gaining a better understanding of the phenomena to which you refer and which you and others encounter daily in your practice. It just so happens that we have long felt the need to challenge what is currently accepted as the “norm” for your profession.

    Those who have handed down the MPS/TrP theory to you have been noticeably absent from this discussion. To be quite frank they appear to have “left you up the creek without a paddle.”

    I can only echo to you Geoff’s sound advice to Aaron.

    Diane Jacobs Reply:

    Thank you for that link! Hopefully it’s permanent.

  58. sarah sturman says

    Tiffany, I would like to respectfully disagree with you.
    I have read the comments and responses given by the authors of this post and of the original article and have considered them to be patient in their attempts to ask all us therapists to remain open minded and questioning of dogma that has been handed down to us. They just so happen to be very well read and proactive in their attempts to carry out research and therefore are able to quote the appropriate research, I do not feel this is patronising at all. Trying to judge somebody’s thought processes and feelings by reading text is unreliable (apparently as unreliable as palpating a taut band of muscle tissue!). Perhaps we should try not to take these things personally and just enjoy the intellectual debate?

    Soula Reply:

    Agreed. Please keep the conversation going. Tone is difficult to grasp online and the last thing we need here is medical emoticons.

  59. I wish I had the time to follow this discussion thread in depth, read the article in full (since I’m not sure it’s even accessible for free, based on what others are commenting), and fully describe my position in this matter and the clinical findings on which it is based. Alas, I’m actually a practicing therapist, so most of my time is consumed with getting my patients better, which I somehow continue to even while using these apparently outdated and incorrect techniques. (Guess I’m just lucky.)
    However, what I find especially alarming as I skim these recent comments is the condescending tone that is taken, mostly by the author and a few key others here. If you’re so appreciative of the discussion that your article (or at least, the part of it that the general public can access) has generated, why can you not support a more friendly peer-to-peer forum that seeks to find the best for all patients? Talking down to someone you believe to be wrong, regardless of whatever scientific proof you may feel you have on your side, is the “adult” version of school-yard bullying. You’d think our advanced degrees and decades of experience would have taken us beyond that level.
    What I fear is happening in our “evidenced-based-medicine” world today is that too much focus is placed on disproving treatments and not enough on finding those that truly are effective from a scientific AND clinical standpoint. Is the goal not to get our patients better? Can we not learn from each other instead of picking apart a treatment technique from which so many have benefited? Meanwhile, the insurance companies get to search for whatever “proof” they can find to deny coverage for certain conditions and modalities, citing that their “evidence” doesn’t support the efficacy of that intervention.
    Oh well, I’m sure the comments to follow this post should be interesting to say the least, whenever I get a chance to check back and read them… In the meantime, I appreciate the efforts of Aaron to stand by what he has found so helpful to his clients, despite the embarrassingly childish remarks that have resulted.

    John Quintner Reply:

    Tiffany, I apologise for any of my comments that you have found to be “embarrassingly childish”. Irrespective of my personal failings, to which I freely admit, let me state unequivocally that my cause is that of Science. As Rudolf Virchow [1821-1902] correctly observed: “There can be no scientific dispute with respect to faith, for science and faith exclude one another.”

    Al Reply:

    I actually think the authors have been ?helpful in the discussion… search neil o’connell et al on BiM to get a truly depressing sense that as a therapist we really know nothing and do nothing : )

  60. Geoffrey Bove says

    Hi Aaron,
    As John said, we covered these findings; in short, the results are consistent with neurogenic inflammation (not necessarily a local etiology) and also were present in the same patients at remote sites.

    I’m sure you have great results with your clients; but how many other methods do you use? More than likely, you do general massage methods as well as mobilizations, active stretches (maybe muscle energy or PNF?), and help them with postural and other lifestyle issues? Perhaps next time, do all that, and leave out working on the what you find as indurated. See if you have the same results.

    Aaron Allen LMT Reply:

    Geoffrey, as I stated before I absolutely utilize other therapies in conjunction, but when it comes to TPx, I know where to look for the points because they are more or less consistently located from client to client. When palpated the client subjectively reports that the sensation feels familiar or relevant to their pain, and after a few moments of ischemic pressure we elicit the fabled twitch response, after which we often see global relaxation of that muscle and clients typically report immediate reduction in the previously reported pain, as well as exhibiting more dynamic active range of motion. all of this is independent of any other therapy. All the other therapies are applied to maintain the changes elicited during the TPx session.

  61. @Aaron (and anyone else here who provides treatment through TP therapies) can you specify ‘lasting pain relief’? I’ve had 8 years of chronic pelvic pain and yes, there is some relief with massage, acupuncture, I’ve even experienced a ‘switching off of my pain’ with a certain pressure technique but my ‘lasting pain relief’ in the long run ends up as temporary (seconds, minutes, days only). Is there follow up with patients a months/years on to certify this long lasting effect?
    I will continue to have remedial massage but I understand I will be receiving temporary relief after my experience (and reading this paper!).

    Aaron Allen LMT Reply:

    Soula, it is not my assertion that all pain is due to TPs, and it’s hard to know what type of massage you have received or how experienced your therapist. The same is true of any study regarding the efficacy of TPx, as it is a highly subjective art as well as science (hard or impossible to objectively measure).

    In terms of lasting relief it will vary from client to client depending in the history or severity of their condition. An anecdote from a client email from this morning shows a decrease in migraine frequency from 4-5x per week to 2 episodes in the past month, not to mention that there was significant improvement in both oral pain scale and objective measurement of active range of motion immediately following both of only two treatments this client has so far received. This is a very common anecdote in my professional experience. It is a rare client who I cannot provide similar results over varying amounts of time/therapy, not because I have “the special touch”, but because of training I received in repeatable TP protocols many would be capable of learning. TPx is also not the only modality provided, there are retraining/postural exercises etc., but it is the TPx which provides the pain relief which then allows dynamic AROM which allows for further rehabilitative self care.

    Soula Reply:

    Is this relief your patients are reporting impacting the additional layers that have accumulated from the original injury? That’s what I feel my treatments accomplish, they don’t touch the source! I have an incredible pain management team, incredibly skilled and experienced.

    Aaron Allen LMT Reply:

    Soula, while I feel as though I understand your question I’m not sure it is relevant to the discussion. Yes I attempt to work through multiple “layers” which seem to “accumulate” around an original injury, but more to the point of this discussion is that the trigger point therapy as I apply it brings relief to my clients for varying amounts of time for each individual depending on the extent of their injury, condition etc., yet for most the relief is long lasting. For some days, for others weeks, for even others months, for some years. In my experience if I can get a few hours of relief for a client, within a few sessions we can expand that to days, and with more treatment weeks, months, even years of relief are possible.

    John Quintner Reply:

    Aaron, the available scientific evidence does not support your case. As for the Art component of your therapy, I have no doubt that it could be fairly described as a “theatrical placebo”. But you are not alone here. I freely admit that many therapeutic procedures, including medically administered ones, embody the same principle.

    Matthew Reply:

    John, could you define what you mean by “theatrical placebo”.

    Aaron Allen LMT Reply:

    John, I get that the scientific evidence does not support my case. I would argue that objective quantification of what I do is impossible, therefore I’m not sure I trust that any scientific evidence for my case could be found, or that the findings which refute my case are any more valid. I also am not disputing your findings, or championing earlier findings. I simply take issue with your sensational claim that you have slayed TPx as a myth. Also if my therapy were theatrical placebo it would have to be statistically consistent with placebo instead of the 75-80 percent efficacy we are seeing daily.

    Koen Reply:

    I Agree with Aaron that treating tendor points in the musculature, origo´s or insertions through temporarily pain reduction can open an possiblity for further and lasting results. After that You have to trie to get as close as possible to the treat cause. I have recognised there are several common mechanisms. Pirifomis syndrom and or chronic or returning bursitis subtrochnaterica I´ll trie to explain as one example. I Find often assymetric tender points at the m gluteus med or minimus. Because of the nociception this create, they will tend to function less. So less that they won´t hurt untill you press them. The m pirifomis tries to compensate for this regional weakness and becomes due to overuse high toned and painfull. The source of the Gluteus med and minimus soreness may be problems from the hip, the SI jiont or the Low Back. If so, this joint should be adressed too. Only after densentisizing the tender points, muscle strenghtening can follow . The piriformis thereafter will release his high tone and pain himself through normal motion or with a little help. I densentisize the tender points of the medius and minimus by continous pressure and massage directly afterwards. It should be painfull at first, but so that the patient is able to relax and adapt. This I guess is also a central mechanism. I cannot always find palpable triggerpoints. I can live with the idea there is no evidence for there strcuture. I trust to localize solely on what the patient tells me while touching in the deeper layers, Only when the patient can relax the pain will subside. So dossage and therapuetic environment is extrem important. In this example only treating the TP pirifomis will cause nothing but pain. Also treating the TP of the gluteii will lead to no lasting result as there was no muscle strenghtening. Treating a adjacent joint first maybe neccesary too. So that could be a good explanation why studies found trp therapy does not help seems to be in contracdiction to some people´s clinical experiences here. I guess there are a lot of such causative failing compensations mechanism in the Human Body and when bad enough may cause lasting painfull problems. The compensation strategy may differ from person to person, but it is also clear that there never will be one single therapy found to be clearly effective, as the effectiveness depends on the clincial reasoning of the therapist his skills in his technics especially the dossage and the skill in combining his technics and the therapeutic environment and trust he creates. Al things that cannot be meassured by a scientific blinded study. The key for long lasting results is to educate the patient what he can do to stabilize his condition by advices for posture, movement, and perhaps a single simple exercise. At the end the locus of control should be at the patient.

  62. “no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture.”

    I seem to be able to find reputable contemporary research which would support evidence of nociceptive input from myofascial trigger points with just a simple google search.

    I am apparently blocked from pasting links here so I will name one study for those who care to search titled Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis.

    As a successful massage therapist who provides highly predictable and lasting pain relief for my clients in part through trigger point therapy (ischemic compression/stretching/vibration) I am very interested in your research and appreciate your point of view toward questioning “established” hypotheses, but find that the dismissiveness of comments like the one above show an almost willful ignorance of contemporary science which would seem to back Travell, Simons theories.

    John Quintner Reply:

    Aaron, I suggest you carefully read our paper, where you will find that we discuss the findings from the study you mention. In our assessment, and we are prepared to admit that we may have overlooked important evidence to the contrary, contemporary science does not support the conjectures of Travell and Simons. As for our showing “almost willful ignorance” in these matters, you would be better to level this accusation at the key opinion leaders in your profession who continue to teach outdated theory and demonstrably ineffective techniques of practice to their followers.

    Aaron Allen LMT Reply:

    You are correct that I have not read your entire paper, only the article above. While I am in agreement that some may cling to outdated models, it is somewhat excusable considering how effective the therapies based on those models can be at relieving clients pain and improving their quality of life. I am not in a position to refute your findings, or to champion Travell Simons, other than to say that utilizing protocols based on evolving theory whos foundation is their work, I, and thousands of other massage therapists have very successful practices applying these demonstrably effective (at providing lasting pain relief and improved active range of motion) techniques. You may continue to denigrate the efficacy of these techniques and be able to cite some piece of research to back your claims, but the fact remains that protocols based on Travell Simons theories work predictably and reliably for millions of chronic pain sufferers, and members of the scientific community lose credibility with the public who have experienced this relief first hand when they try to convince them that not only is the model wrong, but that their experience of pain relief from these techniques is not real.

    Kieran Reply:

    It’s that word “lasting” that is the problem though Aaron. Pain relief “lasting” how long? Nobody doubts some/many patients can feel better for a few hours/days after a range of therapies. But there seems to be no effect “lasting” beyond that – as seen in pretty much every controlled trial investigating manual therapies including, but not limited to, manual treatment of TrPs.

    John Quintner Reply:

    Aaron, may I again urge you to read our paper? There you will find that we do discuss the phenomenon known as counter-irritation analgesia, along with the well-recognised and important influences of context upon treatment outcome.

  63. Geoffrey Bove says

    Nigel, no one said touching did no good; your approach seems wonderful, and will probably generate a strong meaning response. The key is to not make stuff up (I’m not saying that you are). There’s nothing wrong with answering the question of “why am I sore there” with “I don’t know.”

  64. John Quintner says

    EG, I agree it is impossible for clinicians of all persuasions to distance themselves from the placebo effects of their treatment. This is why we need double-blind randomised controlled clinical trials of medications and interventions. Surgical interventions are not exempt from this requirement. But to hold up homeopathy as an example of an effective form of treatment can only serve to perpetuate a falsehood.

    In the words of Oliver Wendell Holmes [1809-1894]: Homoeopathy [is] … a mingled mass of perverse ingenuity, of tinsel erudition, of imbecile credulity, and of artful misrepresentation, too often mingled in practice … with heartless and shameless imposition. [from Medical Essays, “Homoeopathy and Its Kindred Delusions”.]

    It is tempting to draw a comparison with “dry needling”. However, I will stoutly resist the temptation to do so.

  65. John Ware, PT says

    I’m not convinced that *any* trigger point, according to the hodge-podge of criteria that have been used in the extant literature to define them, is observable. The reliability data just isn’t there. The hypothesis presented here makes sense to me, and would explain why tender spots can be so difficult to reliably characterize and locate. The concept of a “latent” trigger point makes absolutely no sense to me at all.

    Although, an august one, the Mayo Clinic is just another authority to which appeals can be made. I second Geoffrey’s request for references.

  66. John Ware, PT says

    I just want to raise a brief caution flag against what I think is best termed “peripheralism”. Although the hypothesis proposed by John Q and his colleagues appropriately shifts emphasis towards the only tissue in the body that depolarizes and sends rapid signals to the brain for processing, we should be careful to avoid making a simplistic shift to just another potential source of nociceptive input. I think we all agree that nociception is neither sufficient nor necessary for the experience of pain.

    Several clinical trials have shown that the best predictors of recalcitrant pain are psychosocial factors. I don’t fully comprehend the complex neurobiological evidence that might explain these clinical findings, but a 2005 review by Suzuki and Dickenson published in Neurosignals (vol. 14, pp175-181) provides a description of the spinal and supraspinal pathways involved in peripheral neuropathy that makes sense to me. They identify two distinct pathways from lamina I in the dorsal horn: the well-publicized spinothalamic tract, which we know provides sensory-discriminative information about the precise location of the pain, and the spino-parabrachial pathway, which is the predominant pathway from lamina I and projects to areas of the brain responsible for processing aversive emotions. While the former is somatopically organized, the latter is not. Moreover, the parabrachial area possesses broader receptive fields, which suggests a more diffuse and widespread response from noxious input. Might this explain to some extent the rather ill-defined and often far-reaching referral patterns found when pressing on a tender spot? Might it also explain the fact that patients with persistent musculoskeletal conditions rarely have pain in just a single body region? Could this process be mediated by the lack of descending (cortical?) inhibitory control of the parabrachial area, which is known to travel through the PAG and rostral ventral medulla- a key spinal cord descending modulatory pathway? Of course, several of Lorimer’s clinical trials suggest a lack of descending inhibitory control from cortical areas and that this is modifiable with education.

    Just throwing this in lest David Butler shows up and puts us all on the spot with his famous question: “Are you ignoring the brain on purpose?” 😉

    John Quintner Reply:

    John, your input is most welcome and provides much food for thought.

    In relation to the famous “David Butler” question you pose, I am reminded that the late Patrick Wall gave the same response when he was invited to comment upon our 1991 hypothesis.

    Geoffrey Bove Reply:

    John, there should be no question that pain is an integrated function. That said — we do not fully understand the pathophysiology of the peripheral structures, including the nerves. With a couple exceptions (wait for it) all central processes are reactions to the periphery to some measure. And, remember that for the most part, injuries leading to chronic pain seem to be peripheral. We are currently not very good at identifying the peripheral problems. Still, might it be a worse trap to try to understand a system where the main determinant is not understood? Revisions will be necessary, and as we see here, such revisions are difficult pills.

    I’ll give two examples of where peripheral mechanisms are becoming more important to what has previously been considered central. First, Staud et al. are publishing that persistent peripheral input is likely at fault for fibromyalgia pain. Second, in today’s “APS Smart Briefs” there were two interesting articles featured. One was essentially confirming that referred pain depended on primary afferent input, using a wonderful experimental design (a similar phenomenon was shown a long time ago by Gracely).

    This same APS article also referred to a paper by Vincent about fibromyalgia sufferers having flares from “poor sleep, overextending yourself, stress and changes in the weather.”
    And, we know from some elegant studies by Haack that sleep deprivation leads to the same symptoms of fibromyalgia. We are an organism.

    Finally, I would like to plant the seed about the importance of the “proinflammatory state” as possibly involved in may chronic pain conditions. If research in this direction bears more fruit, we may start treating chronic pain by diet.

    So, I agree with you: we cannot become trapped by finger pointing at one structure or phenomenon.

    Geoffrey Bove Reply:

    And lastly, I would like to point out if there is not a peripheral source of pain, and you are treating the periphery… see where I am going? Lots of people out of jobs!

    EG Reply:

    That won’t happen. Treatment of the periphery is what people want and it is effective in a lot of cases. Outcomes are probably placebo-mediated, but so is a lot of medicine. Surgery, for example, has less evidence for its effectiveness than homeopathy, due to the lack of placebo controlled trails.


    Nigel Roff Reply:

    EG, To a point I agree with what your saying. It’s all in how we frame it with the patient, I’m sure there must be some middle ground that satifies the brain centric and the peripheral treaters.There is an awful long way to go to educate patients, it will probably take another generation at least. As someone said “the patients dont care, just fix me”. In very simple terms I explain to the patient that they are perceiving pain in that spot and there are lots of reasons why this is happening and there isnt necessarily anything “wrong”with that spot. I then explain that even though I’m sometimes working on their “periphery, and holding on to muscles ,joints ,ligaments etc” I’m actually tyring to access and effect their nervous system. Even though I am starting to get some “lightbulb”moments with patients and they go “wow, I get it, thats really interesting”, they often then turnaround at the end of the treatment and say “so why am I sore there?”, and we go back to square 1. On the other hand any treatment/consult is essentially a human interaction, so many other variables come into play which effect the outcome. I dont think we should become too robotic and sit and lecture patients on neuroscience and try to refute all their ideas in one sitting and simply say, “well,I’m not touching you because its a complete waste of time and it will do you no good”. It’s certainly an interesting time for physical/manual therapy, all these conversations/investigations need to be had.

    Marta Reply:

    Thanks John Ware. This is precisely why I asked Geoff above to clarify his statement that “So if our spinal cord cannot tell which structure is sending nociceptive messages, how can our brain?”.

    Geoffrey Bove Reply:

    Marta: please refer to Bove and Light J Neurophysiol. 1995. Deep nociceptors branch to various structures. Thus primary afferent input to cord may be non-specific regarding the structure.

  67. Geoffrey Bove says

    I would like to thank all of you who have responded to this post and to our paper, regardless of the “side” you are on. I have been quite anxious about this issue, but see that we have perhaps simply awakened a sleeping giant by revealing the Emperor’s New Clothes. We note that no proponent of trigger point treatment from the scientific side has commented. We expect that there will be a few letters to the editor of Rheumatology (we have replied to one), so please stay tuned. Also, JBMT will be running a response of some sort to our paper in the next few months. We welcome this debate. Thanks again. -Geoff

  68. Patient humour: How many ‘dry needlers’ does it take to change (and locate) a ‘trigger point’?

    Geoffrey Bove Reply:

    ALL OF THEM +1!! (Could not resist.) Thanks Soula.

  69. I was happy to get a comment in early expressing my strong support for the spirit of this post, and I’ve been pleasantly surprised at how many others like it there have been since. We obviously have a long way to go before we actually understand this kind of pain, and we can’t very well get there if we don’t critically evaluate every idea.

    So I’m returning now to do a little critical evaluation, because I am not yet convinced there aren’t relevant lesions in muscle tissue. I’m only about 65% convinced. 🙂 I do agree that Travell and Simons made “epistemological errors that cast considerable doubt upon their theory of MPS” but I don’t think those errors and doubts are necessarily fatal to the theory. Homeopathy and astrology are good examples of truly dead horses. The hypothesis of a metabolic crisis in muscle seems merely wounded.

    Some arguments made against the idea of muscular trigger points seem irrelevant to me. Clinical overconfidence is a serious but separate problem that doesn’t really have anything to do with the pathophysiology, and so too with poor outcomes from treatment by pressure and needling. These interventions were never properly “based on” any specific notion of how trigger points work in first place, just “aimed at” them, so their failure just doesn’t say much about mechanism. Stories about why these practices might work were mostly bolted on long after they were established.

    John Quintner Reply:

    Paul, thanks for your input.

    As you know, we have publicly stated that the original conjecture made by Travell and Simons (and the explanatory model arising therefrom) has been refuted. We have thrown down the metaphorical gauntlet to those who continue to believe otherwise.

    Nonetheless, we freely admit that the hypothesis we present above is a tentative one and, like all hypotheses, is open to critical examination and, if possible, refutation.

  70. Reading this opinion piece has been disturbing. Mostly because it’s being presented by a physician who is using very medical terms generating an amount of respect and faith from the uninformed reader and while he tries to systematically disprove “Myofascial Pain Syndrome” (Guess he didn’t realize that the Mayo Clinic has actually imaged what he’s calling “unobserved” and that as we now know what the condition is, how it’s caused and how to cure it… it’s no longer a syndrome and it’s proper name is Chronic Myofascial Pain aka CMP) he is using old information and taking leaps of logic that make no sense at all. You don’t apply pressure to a trigger point because like treats like homeopathy reasoning… you apply it to interrupt the brain’s signals to hold that compression so it can relax. Latent and satellite trigger points are observable, not metaphysical. The former are points that are not actively referring pain but they are still a palpable knot of muscle and satellite trigger points can either be latent or active but they form as a result of the improper way the muscle is now forced to work as a trigger point’s presence weakens the muscle it resides in and causes dysfunction.

    Geoffrey Bove Reply:

    Kirsten, thanks for your comment; however we would love to see the studies you are mentioning (meaning we do not believe that they exist). Could you post the primary literature for your comments? The leaps of faith are 1/2 a century old, which is a primary point of our paper. RE: the authors, I am one on this paper as well, it was a shared three person effort. I am a chiropractor who learned trigger point therapy starting in 1984 (30 years ago!). This experience was incorporated into the paper.

  71. Trigger points have engaged myself and my colleagues in debate numerous times over the years but always we come to the same conclusions. Are they not a product of the CNS response to changes in the body. For example a degenerative joint in the spine evokes a behavioural change, guarding response, a reaction in the peripheral nervous system creating focal changes in the muscles tissue. Is it not our first port of call to try and aid the patient in a return to a more functional/normal behaviour. Whether we use massage, dry needling or whatever method of hands on treatment to alleviate symptoms, a return to a more normal movement pattern is paramount.

    John Quintner Reply:

    Gary, I think you are referring to the phenomenon of referred pain and what was once known as “secondary hyperalgesia”. There may well be accompanying observable behavioural responses but I doubt whether the underlying neurophysiological phenomena are amenable to “hands on” treatment or to “dry needling” of the tissue(s) which are the site of referred pain.

  72. Not to challenge the science behind your findings (who’s to say it couldn’t be a mix?), and not that I expect the clinically-based evidence of 2 PTs’ patient outcomes will be enough to convince you, but my partner and I have found excellent responses to our manual therapy and myofascial release techniques. He actually developed a headache-treatment protocol based almost solely on myofascial pain, trigger points, and their referral patterns, which has been successful in over 90% of patients who complete the treatment protocol (which begins solely with manual therapy from a PT), including patients who have been “diagnosed” with chronic migraine (a supposedly neurological and/or vascular event). We’ve alleviated knee and back pain that has persisted even after surgical interventions.
    One problem in our field is the wide array of techniques that are grouped under “manual therapy,” in addition to the education, skill and experience level of the PT delivering the intervention. Quite honestly, I would not trust many of my peers to deliver the same treatment with the same results as we have found. However, in our clinic with our particular treatments, our (compliant) patients find relief from pain and return to their normal activity level without restrictions.

    John Quintner Reply:

    Thanks Tiffany. You have raised the important questions of validity and reliability. But from what you say in your comment, it appears that your positive therapeutic outcomes are not reproducible by other therapists. Are you intending to publish your techniques and results.

    By the way, I continue to be baffled by the term “myofascial release”. What exactly is being released?

    By the way, the song by Engelbert Humperdinck (“Please release me, let me go” comes to mind whenever I read about it.

    Geoffrey Bove Reply:

    No one has ever looked to see if anything is “released.” We (and others) are working albeit slowly on this issue. It would be wonderful if anything at all changed terms of movement due to manual therapy to muscles, tendons, skin, and primarily their interfaces. I hope something comes out of this soon.

    Andrew McMullan Reply:


    glad to hear that someone is at last actually measuring the tissue at issue in this technique and its ilk. Far too long has it been accepted (or Langevin’s paper on “needle grasp” resorted to as adequate) that what is claimed is what actually happens.

    I look forward with great(!) interest in reading your findings – we need a lot more of that sort of of primary investigation. Should have been done years ago!


    Geoffrey Bove Reply:

    Kirsten, thanks for your comment; however we would love to see the studies you are mentioning (meaning we do not believe that they exist). Could you post the primary literature for your comments? The leaps of faith are 1/2 a century old, which is a primary point of our paper. RE: the authors, I am one on this paper as well, it was a shared three person effort. I am a chiropractor who learned trigger point therapy starting in 1984 (30 years ago!). This experience was incorporated into the paper.

  73. am I understanding this correctly that the proposed mechanism is inflammation in the nerves causing trigger points/tight tender pieces of tissue..? So anti-inflammatories should work a treat then?

    John Quintner Reply:

    Al, if only it was that straight forward a problem! The available anti-inflammatory drugs are singularly ineffective when used in this context.

  74. Derek Griffin says

    Thanks to Drs. Quintner and Bove for a thorough and constructive critical appraisal of the “trigger point” hypothesis as it is currently conceptualised. Clinicians will likely continue to report on the positive outcomes that they see in clinical practice in response to treatment directed at the “trigger point” (manual compression, dry needling etc.). Unfortunately this positivity in the outcomes that they see is not often subject to any reflective reasoning, especially as we know that what we see (or think we see!) clinically is open to various biases. An analgesic response to such treatments in no way validates the notion that the muscle was at fault. Dry needling for example is a treatment with high face validity, it is “invasive”, and is associated with positive expectations (both from the clinician and the patient). All of these factors can enhance the placebo response which could potentially explain the results that clinicians are only too happy to report. Furthermore as highlighted in the paper itself, conditioned pain modulation due to the noxious nature of the treatment is a plausible neurophysiological mechanism. I personally believe that as therapists we need to always consider the mechanism of action of our treatments (or at least be open to mechanisms that contradict our long held beliefs). We need to recognise that confirmation bias is often at play in what we deem to be clinically effective. It is no longer acceptable to justify treatments by saying things like “well it worked for him/her” or “patients don’t care about the mechanisms”. Clinical experience is no substitute for scientific evidence or reasoning.

  75. Hi John

    I have always viewed Trigger Points in the same (Osteopathic) context as their earlier predecessors: Chapman’s Reflexes and Jones’ Tender Points.
    Irwin Korr implies that by an accumulative neurological input, structures innervated by the same segment can be stimulated and sensitised, leading to altered levels of sensation, variation in muscle tone and changes in sympathetic tone too.
    He did not suggest these changes would lead to more conventional clinical neurological findings.
    Most practitioner’s agree to the presence of ‘Trigger Points’ as a finding, but its what causes them that causes controversy.
    Reducing all neurological stimuli into the affected segment centrally and peripherally, including local spinal restrictions – does usually alleviate the pain perceived from them in practice

    Andrew Cunnington

    John Quintner Reply:

    Thanks Andrew. I really do not understand what you are saying. There have been some studies performed on the effects of blockade of all sensory input from regions of referred pain and tenderness. Are you referring to such studies?

  76. John you critisize Travell and Simons, saying it’s all conjecture and no proof. Fair enough. But then you go on to say:

    *[questions in parentheses are mine]

    “But when I met the late Bob Elvey, he completely changed my way of thinking about these clinical problems. Bob’s mantra was that “muscles protect nerves.” *[any proof for this?] He introduced me to the dynamics of the nervous system and I came to understand that peripheral nerves of the upper limb had evolved to be able to adapt to the various changes in limb position and length *[proof?] and that they were vulnerable at certain anatomical points along their course. *[Any proof that such vulnerability is related to pain development?] His pioneering work on methods of assessing the mechanosensitivity of peripheral nerve trunks has greatly enhanced the clinical examination of the upper limb. *[any proof that such assessments are useful in resolving a patient’s pain?].

    In addition to these important clinical insights, I became aware of the large mechanical forces that could potentially be generated within the cervical spinal canal by the maintenance of fixed head/neck postures being adopted by those who performed repetitive manual work. *[any proof that large mechanical forces are a problem for the body, or that they cause pain?]

    Regards, EG.

    John Quintner Reply:

    EG, in the context of the hypothetico-deductive method of investigation, which we follow, I suggest that you might be asking for evidence, rather than for proof. The question then becomes: “does the evidence corroborate or falsify a hypothesis?”

    The late Bob Elvey and I did assemble a large body of the then available evidence supporting our hypothesis, all of which was published in 1991. You can access it by following this link:

    Thanks for raising these important issues.

    EG Reply:

    Good. Thanks for that.


  77. John,
    Great stuff. Your reasoning is eloquent and reflects my practical experience that trigger points are an artifact of the nervous system because they are not reproducible enough to be real, mechanical MSK.
    As a manual therapist I always noted the diminishing returns of a Trigger Point Massage approach to patients and could not rationalise it – then looking at the 80 odd pages of excuses in Travell and Simmons – the maintaining factors – the ‘it is not the treatment – it is the patient factors’ – that transfer treatment failure from therapist to patient so neatly.
    Since taking a cognitive neuroscience approach to pain medicine those diminishing returns seem like diminishing top down effects to me. Less hope, less expectation as the percieved peripheral changes do not take hold after manual therapy.
    I hope your work will do for trigger points what Lederman did for ‘the core stability’ meme. But these zombie ideas are hard to kill and our clinical efforts so often turn to ‘Whack-a-mole’ meme crushing as we live in a society that drips honeyed words from every private healthcare ad hoarding into the ears of those desperately unwilling to accept the human condition.

    I hope that this work of yours becomes the manual therapy water cooler discussion hot topic of 2015.
    Thank you for doing the hard yards,
    Kind thoughts,

  78. Geoffrey Bove says

    Hi John (Ware); the figure has sympathetics represented in blue. They decrease their activity when their axons are inflamed (Bove, G. M. (2009). Focal nerve inflammation induces neuronal signs consistent with symptoms of early complex regional pain syndromes. Exp.Neurol., 219, 223-227.). The rest is covered in the figure legend and the text. It is unknown what effect this will have on muscle afferent activity, if anything, or if it could be palpable.

    todd Reply:


    If I’m not mistaken, you are referring to a decrease in focal sympathetic neuronal activity and not the overall sympathetic tone in the ANS. Isn’t this simply due to the focal nerve inflammation decreasing local sympathetic activity in order to prevent movement (e.g. smudges in the motor maps). If so, is it possible that an injury/nerve inflammation calls for immobilization which itself is part of the process leading to the “trigger point?”


  79. John Ware, PT says

    Hi John,
    Thank you for your dogged determination to bring high quality discussion and debate about trigger point construct in particular and myofascial pain syndrome in general.

    In your illustration, I wonder if you have considered the possibility of localized congestion due to a relatively discrete area of altered autonomics, as opposed to (or possibly in addition to) muscle fiber contraction? Since autonomic fibers are also present in peripheral nerves, couldn’t disruption of efferent signals to small vessels affect smooth muscle tone and create circulatory abnormalities in the area that may be perceived as a muscle knot/taut band?

    As far as I’m concerned, the jury is out: these things are not identifiable entities as they’ve been described from Travell and Simons to the present day. Tender spots certainly exist, but it seems the only purpose for insisting that they exist in a muscle is to justify jabbing, poking, squeezing or otherwise assaulting them with various implement, including needles.

    I was recently notified that my letter to the editor at JOSPT, which challenges recent reports of the reliability data for trigger points in a couple of highly-touted dry needling trials, will be appearing in next month’s issue. The carelessness of reliability statistics reporting by clinical researchers and then being missed by peer reviewers should concern us all. However, given the elusive and cryptic qualities of the diagnostic criteria, it’s hard to blame anyone for getting confused about what exactly these things are. Based on what John Quintner and colleagues have been telling us for over 2 decades, I think it’s safe to say that poking or jabbing things into muscles is probably not a good idea.

    John Quintner Reply:

    John, I look forward to reading your letter in due course. You will be interested to know that Milton Cohen and I have a letter in press critiquing an article that appeared in Pain Medicine last year – Castaldo et al. Myofascial trigger points in whiplash-associated disorders and mechamocal neck pain. Pain Medicine 2014; 15: 842-849.

    I also see that Geoff has responded to your question.

    John Quintner Reply:

    Apology: it should read …. “mechanical neck pain.”

  80. Hi John,
    Generally this discussion is way above my non medical brain box but what does come through loud and clear is the challenge in medicine of facing new theories, treatments and the advancement that is going on continually in all forms of treatment. I personally had to face a practitioner who doggedly went about his practice with no regard for any advances in what ten years ago was a change in the treatment of and understanding of chronic lymphocytic leukemia. As a patient I would not accept his musings and his treatment plan to contain my fairly aggressive disease and I went further afield for second and third opinions and ended up at the Mayo Clinic where the now obligatory Fish, and IGVH showed me just how aggressive my disease was and that in itself pointed to a certain treatment direction. The bottom line I am trying to make is that unless you the medical profession are prepared to maintain open minds and not doggedly follow historic treatment practises then ultimately it is us the patients who may, or may not, suffer as a result. In these modern times a well informed patient advocating on his own behalf is becoming more and more the norm and as an advocate for CLL I encourage all to never walk blindly into a surgery and just say YES to everything but to go in with a list of questions not to challenge you the medical profession but to open a dialogue on something that is the most important thing to most of us…OUR LIVES!!

    John Quintner Reply:

    Hi Derek. Thank you for delivering this most important message. As one who has followed your progress over some years, may I congratulate you publicly for your persistence to find answers to your questions and for your advocacy on behalf of others who are faced with these serious health problems.

  81. Thanks for an informed, thought provoking piece John.
    As you have outlined, the question is not whether people who have local (or widespread pain are tender – that is pretty obvious. The questions are;
    – whether this tenderness represents a specific local tissue diagnosis (very unlikely the evidence suggests)
    – whether squeezing/jabbing these tender points leads to a medium to long term improvement in pain/disability/participation – compared to another active intervention (not a single RCT has shown this as far as i know.

    I would agree with your pessimism that we are about to see a large change in practice however. TrPs have enormous face validity in the eyes of a great many patients and clinicians – they can feel it! (no other validity perhaps, but some people find them irresistible as they fit the lingering peripheral input / tissue damage model of pain.

    Whatever my misgivings about the physical impact of needling/massaging these tender points, i have greater concerns about the language and thought processes that can be passed on by TrP therapists to their patients. Too often i hear patients describe how they have been told they are “covered in” TrPs, as if these were a contagious lesion spreading across their body!

    We have touched on the allure of other novel therapies which are based on the premise of healing “damaged” peripheral tissue in a recent BJSM blog

    John Quintner Reply:

    Kieran, I take your point about the allure of innovative and expensive treatments (e.g. SCT) that are being administered to our patients more on the basis of hope than on solid scientific research.

    One of the important points we make in our paper is that some prominent rheumatologists and other key opinion leaders are asserting that nociceptive inputs from myofascial trigger points are responsible for initiating and maintaining the state of central hypersensitivity that is thought to underly CWP (aka Fibromyalgia). Of course, this is pure conjecture, yet it can be used to endorse the “search and destroy” operations launched by the dry needlers etc.

  82. Geoffrey Bove says

    Thank you Robert for your comment. I’ll add however that the concepts that you have mentioned, which I have heard, remain quite conjectural as well. We need to always understand the facts and keep them separate from the fictions, even though the fictions may guide us to novel treatments and investigations.

  83. Wonderfully challenging discussion. Hoping I am not totally off base as a gynecologist caring for complex pelvic and genital pain disorders. 100% of our patients are referred to specialized pelvic floor physical therapists – who in the US, certainly appear to know a great deal more about pain processing than the vast majority of physicians (still not being taught here in basic medical school curricula).

    I have learned a great deal from many of these manual therapists, but I am also sent a great number of patients who have “plateaued” in their pelvic pain relief and together with advancing experience with a variety of peripheral nerve blocks in the pelvic region (to gradually decrease the peripheral sensitivity), use of a variety of pharmaceuticals to lower the “central dial”, and a great deal of personal education to the patient and their partners about ‘rebooting the reception of a great many visceral and somatic signals in the pelvis, – then is when the manual therapy starts to really benefit,

    In the pelvis, “everything is connected” and central “cross talk” between bladder, bowel, reproductive organs, along with the complex muscle “clenching”, flaring of neuro-inflammatory issues from often lifelong traumas, it becomes even more important to clinically delineate between what can be treated in the periphery while slowly helping the patient “reboot” how those signals are received (in context) by the incredible “protective” neuro-matrix.

    I have learned so much about pain in the pelvic region by personal and persistent curiosity and scouring the literature. There are no fellowships teaching pain to pelvic specialists and I frequently come upon really stimulating discussions by manual therapists, but very difficult to find physician related forums like this where “medical doctrine” is so thoughtfully challenged. It does “take a village” to support the suffering that we see and I appreciate all efforts to find our way there.

    John Quintner Reply:

    Robert, I agree that much in the way of innovative thinking and practice derives from the work of our eminent manual therapists. They are driving much of the research into these perplexing conditions. We do have much to learn from each other but sometimes we need to stop and critically analyse our current theories and practices.

  84. Patient perspective: Thank you John and Geoffrey for asking the questions, continuing pain research and not leaving any stone unturned. If research locks into past learnings, what hope do patients and their practitioners have? This certainly helps me understand my chronic pain experience. I understand my treatments are all providing temporary relief and preventing secondary issues that come from living with chronic pain. Let’s get to the point, let’s be real and face the reality of chronic pain: it doesn’t go away pushing body buttons!

  85. Chris Newman says

    Myofascial Trigger points have proven to be yet another fad and unfortunately physiotherapy is littered with them. Skeptics are in short supply, and it’s encouraging to see the standard dogma challenged and dismissed. I’ve treated many patients using the approach (manually and via needle), with some success, but there has always been other potential explanations for improvement, and far too much inconsistency in response to be satisfied with the proposed explanation. There is still far too much that we cannot measure, but why continue to support an explanation that holds less water than Death Valley in the summer, when the evidence does not exist. Yes – your treatment may be having an effect, but be brave enough to say “I’m not sure why” (and hopefully “I’ll always be looking for a better explanation”)!

    Thank you for the article.

  86. Emanuele, if you are having a problem downloading, others are probably having the problem too. I do not have an account and that link works for me. You can also go to our University website link below, and click “Read the article” at the bottom:
    or go to my website:
    the paper is at the bottom of the page.

    Emanuele Careddu Reply:

    Excellent… that works… I will read it as soon as I get some spare time!

    Koen Reply:

    Thanks Geoffry!

  87. Great discussion. I am tuned into the part about viable treatment options – if we can theorize about the mechanism behind the phenomenon by extrapolating published science (evidence-based), which is what the paper does, we should be able to also apply critical thinking to theorize about potential treatment options (evidence-informed, at this point) beyond pharmacological (which I also largely feel ends up being a Band-Aid itself and creates as many physiological problems as it attempts to correct, which is usually worse than any side effects found in most treatments being offered today) for the clinic. As a therapist with primary interest in central and autonomic dysregulation and the science behind mind-body medicine including the neurobiology of placebo, my mind is contemplating treatment considerations and ethics. If the theory proves correct, we must also theorize, formulate and put into practice treatment options based on the science before we can then effectively study those treatment options. An integrative model that works on addressing biological stress (environmental/epigenetic, ergonomic/physical/postural, nutritional/food as medicine, mental/cognitive/belief, emotional, movement patterns, chemical, etc.) seems of most interest, but exceptionally difficult to study and break down components in a living system.
    Anyway, musings aside, I appreciate these opportunities for self-examination of one’s current practices, opinions, beliefs etc.

  88. sarah sturman says

    great discussion!
    I work in pain management and to be honest I feel both excited and dizzy when reading such discussions. I flip flop between believing the ‘pyschosocial camp’ have got it right, where we pain management physios are encouraged to have a hands off approach (“don’t create dependancy”, “don’t touch the body when the pain is purely an output of the mind”). But then I think of; my own personal experiences of pain, the effects of misusing my body and noticing what occurs within it, my current understanding of the growing interest in fascia (sorry John!), and overall the effects of touch (which we have all experienced) and I start to look more at the work being done by the bio-medical camp and go along with these guys for a while.
    I find it a shame that there seems to be little middle ground between the 2 camps, if our search for solid evidence could be guided by the biopyschosocial model perhaps we would start to really get somewhere? (apologies again John I know you are not keen on the ‘biopyschosocial’ label).
    Finally, I am really keen to continue using a hands on approach (for some patients when I can clinically reason its usefulness). Any evidence as to the bodily mechanisms which underpin/influence complex persistent pain (and trigger points can fall into this category) could provide support for continuing to explore ‘bottom-up approaches’ which I believe leaves us therapists in an exciting position.

    John Quintner Reply:

    Sarah, we are all seeking some firm ground upon which to stand. Yes, we live in exciting times!

  89. “my hope is that more effective pharmacological agents will be developed and soon become available….”
    This sounds very sad…

  90. Geoffrey Bove says

    Emanuele, simply click on the spot “Full Text (PDF)” to the right of the abstract, and the full article downloads or opens, depending on your settings.

    Andrew, a problem is that what you find and treat might be (and through research, usually is) different from what other therapists might feel. I personally have treated hundreds of people with “trigger points” and never felt one change even a little bit. The literature also supports sensory illusions, and groups are susceptible to that as well. It is a conundrum.

    The phenomenon of people pointing to their muscles as where their pain is, needs addressing, and it is unlikely that there will be any one explanation, as there are far more structures that are innervated besides muscles.

    Did you know that the sensory innervation to muscle can also have branches to tendons and the nerve sheaths, proximal to the muscle? This has only been shown in rat, but is likely to explain some pain distributions. And it also supports our trouble locating the main problem. So if our spinal cord cannot tell which structure is sending nociceptive messages, how can our brain? We have a lot to learn.

    I note on the bottom of this page that we are supposed to not suggest and particular treatment approach. Great idea BIM! My experimental research direction, now collaborating with Dr. Mary Barbe, is to look more closely in rat models of the role of fibrosis in pain and dysfunction, specifically in the prevention of the changes using manual therapy.

    Stay tuned. Blog posts like this have changed the face of information dissemination. Thank you BIM!

    Emanuele Careddu Reply:

    Nope… I tried… I also created an account but it does not work… I cannot open it :\

    alex Chisholm Reply:

    I was unable to get the full article to come up. I had to access it via a university account.

    However, I find it refreshing that we are questioning conventional ‘wisdom’ regarding trigger points.

    John Quintner Reply:

    Alex, I prefer to see the article as the culmination of our attempts to remove the shackles of dogma.

    Marta Reply:

    Hallo Geoff,

    Could you please clarify your statement above: “So if our spinal cord cannot tell which structure is sending nociceptive messages, how can our brain?”…What are you saying?

    I am sure Lorimer and BIM has an answer, please, Lorimer and BIM, could you comment?
    Thank you.

  91. Frédéric Wellens, pht says

    Hi John,

    I am very thankfull for your article. I have to admit I am biased toward the position adopted by the article. Regardless, the points that were made are definitely very valid and should prompt any therapist to reconsider his understanding of TrPts. Although the article was about TrPts, much of the logic could be applied to most of the current traditionnal rationnal in manual therapy for pain in general. It is fraught with circular reasonning, post hoc fallacies and a lack of current pain science knowledge.

    Although I profoundly hope your article will stir the masses and encourage a deep change in our way of treating patients, I think that the power of Dogmas and the cognitive dissonances associated with the questionning of one’s cherished beliefs will strongly stand in the way of such a needed change.

    Yet, reading the article felt like a breathe of fresh air.


    John Quintner Reply:

    Frédéric, thanks for your words of encouragement. Until such time as third party payers decide that precious health dollars are better spent elsewhere, I suspect that the deep change you mention will not occur.

  92. Interesting ……it will take a while even longer to have this take off and become main stream …. are there other Studies done or are you the only ones… I own a Small Massage school and yes Trigger Points are talked about via the Text books I however will not teach it…

  93. Hi John

    Nice paper – and I have absolutely no problem with any of the arguments presented there. It does, however, still leave the open question as to what people are doing when they find trigger points? Because both the practitioner and the patient often experience very distinct sensations/textures in specific locations. And what are those distinct textures/sensations caused by? As a general observation, if a tight fibrous lump in the muscle is pushed fairly lightly for 10 or 20 seconds perpendicular to the fiber direction, then it often relaxes with a consequent reduction in pain in many cases, provided that the pressure is neither too great or too small. The fact that these fibrous lumps in muscle tissue can be detected manually (whether they happen to lie on an official trigger point location or not) and relieved directly with no need for systemic medication is imo a great thing.

    Because regardless of how shot full of holes the trigger point theory is, and regardless of how it does not work in a proportion of cases (larger or smaller) – something appears to be happening that is useful in a proportion of cases. And that proportion is not insignificant. The chances of one pressing any random place in the body and achieving a specific mutually recognised “significant” sensation are very low, as equally are the chances of that random pressure in a few discrete locations having any significant effect in any significant proportion of people.

    As you know, it’s easier to disprove something than to formulate a positive hypothesis, and I was wondering if you had any opinions as to what might be going on (i.e. possible fruitful lines of investigation), given that the present trigger point theory is without foundation?

    John Quintner Reply:

    Andrew, in our paper we do raise this issue and offer explanations for what might be going on. Broadly speaking, contextual factors are likely to figure prominently in the situations you describe. You may not have noticed that we are in fact offering a hypothesis for critical review and, if possible, for refutation. We believe that it is consistent with the current scientific knowledge base and can serve as a launching pad for further research.

  94. Emanuele Careddu says

    So the answer of all that would be a “get the magic pill”? A classic “the dashboard is signalling a problem with the engine let’s smash the dashboard” reasoning which will not lead to anywhere if not into a worse dysfunction, in my honest opinion. I have the feeling that, no matter whatever drug will be launched on the market, these problem will persist (if not getting worse and more common), in future if this is going to be the standard/major approach to non specific MSK disorders. Thanks for your reply and thoughts exchange.

    John Quintner Reply:

    Emanuele, beware of the “straw man fallacy” here. Neither of us is at the cutting edge of pharmacological research in this area so it is unfair to attack me for my comment. I agree that the available “anti-neuropathic” drugs do not work all that well and that adverse reactions are not uncommon. But I do not agree that the clinical problem is likely to prove insoluble.

    Emanuele Careddu Reply:

    I wouldn’t say attack, I have just exposed my doubts on what you said above, I don’t think I fell on the straw man fallacy… your comment looked fairly clear and I picked on it. Maybe I got lost in translation, or maybe not fully understood your message? But it sounds like you are saying, and please tell me if I got it wrong, that a stronger/more effective drug is everything is needed to fix common MSK problems and this cannot be the case. Would be a dream (for physicians, and I would say for everyone) to have a pill that can fix anything. But it is not being pessimistic saying that this will never occur, I would say it is just common sense for the simple reason that a pill can work brilliantly on inflammation… but inflammation is not a curse cast from heaven, it must be the result of something else, often a combination of dysfunctional pattern of movement, poor postural habits, de-conditioning, stress in life, diet, trauma all things that are more important predisposing and maintaining factors for pain than just mere inflammation I believe… a better pharmacological agent(s) cannot be the turning-point key to fix MSK problems, it would be so unnatural, drugs can represent just an adjuvant often not needed, at least for common MSK problems, nothing more.

    John Quintner Reply:

    Emanuele, you have lumped together all “MSK problems” as if they shared a common pathophysiology. Clearly this is unlikely to be the case. My speculative comment was made solely in relation to the hypothesis that we have advanced. I am well aware of the NNT/NNH values for each of the currently available medications.

    You would know more than me about “dysfunctional” movement patterns but I do not know whether there is any consensus about their recognition, let alone their possible significance in the clinical context of musculoskeletal pain. Beware of the post hoc propter hoc fallacy!


    Thanks you John and the co authors for putting up an alternative theory for Muscle Pain and MRTPs.I am working with Chronic Pain patients and employ a lot of education using the current pain science theory.

    However,i also do agree with Emanuele Careddu,irrespective of the mechanism ,what treatment option are you suggesting as a plausible and effective management for MSK pain based on the current theory.I am asking this because you are attacking a certain model of treatment which many are using in the management of MSK pain.

    John Quintner Reply:

    Mohamed, my so-called attack on current management is based upon the scientific evidence that shows it does not work. From my personal experience, in the 1990s many of my patients with “RSI” underwent “trigger point” therapy and reported no benefit whatsoever following an often painful therapeutic encounter. Those that submitted to “cold spray and stretch” techniques were made worse! One of the practitioners concerned had been taught the techniques by no less a personage than Dr Janet Travell.

  96. Geoffrey Bove says

    Hi, time I chime in. Some brief points — in writing this paper, we discovered that among the therapies that have been studied, the fewest studies have been manual therapy. Those which have been done have been promising. But they are not specific to “trigger points.” Actually, since we cannot agree on where they are, studies are all pretty much methodologically flawed from the start. However, I would like to see some good outcome studies with manual therapy, just what we do, not focused on and polluted by the concepts of trigger points, with all that baggage. Outcomes are most important to the patients, for sure. But we curious types want to know mechanisms. As we have said in our paper and posts, we hope that a good step back without dogma will lead to more fruitful investigations. Emanuele, the paper is free access:

    Emanuele Careddu Reply:

    Hello Geoffrey, uhm… I clicked the link but only the abstract is free. Cannot access the full paper. However John has already answered my question. To be honest I do not believe any pharmaceutical remedy will ever fix these problems, and if the main issue was a peripheral nerve inflammation leading to the peripheral sensitization of a tissue, well then why so often NSAIDs fail often also short term, to kill pain and fix a “MSK non specific condition “in a patient? What a medication can really fix on a MSK dysfunction?

  97. John Quintner says

    Emanuele, I do not want to speculate on treatment approaches until such time as we better understand the pathophysiology of these conditions. But as you are pressing me for an answer, my hope is that more effective pharmacological agents will be developed and soon become available.

    Emanuele Careddu Reply:

    So the answer of all that would be a “get the magic pill”? A classic “the dashboard is signalling a problem with the engine let’s smash the dashboard” reasoning which will not lead to anywhere if not into a worse dysfunction, in my honest opinion. I have the feeling that, no matter whatever drug will be launched on the market, these problem will persist (if not getting worse and more common), in future if this is going to be the standard/major approach to non specific MSK disorders. Thanks for your reply and thoughts exchange.

    I have just copied and pasted my comment here as in this way there is continuity with your answer above. If you wish to delete the copy below it is fine to me, thanks.

  98. Andrew Claus says

    Thanks for these thoughts and the discussion John,
    Observing clinicians plunge some very large ‘dry needles’ into patients, and a proportion of patients reporting excellent improvements in pain and range of motion, this phenomenon also got me pondering possible mechanisms. Would these patients respond in the same way if a stranger on a park bench plunged the same needle into the same muscle, instead of a qualified therapist in a professional clinic setting? I doubt it.

    Interventions for ‘trigger’ points share a common theme of being locally threatening/provocative sensory inputs. I suspect that patients have the options of hit the therapist, run away from the therapist, or relax. In clinic they mostly relax. This makes me want to climb the nervous system to look for mediators of the presentation and the response.

    Between the extremes of tetanic contraction and denervation, the primary motor cortex is amongst the usual suspect for modulating regional muscle activity down to individual motor units. If a region of the body is perceived to be painful, sensory cortical representation could be quite distorted (along with many other elements from receptor to perception). I wonder if applying a local, threatening/provocative sensory input could perturb the state of sensory and motor cortices, and drive relaxation/pain relief from that level?

    Keep well,

  99. Emanuele Careddu says

    John, I don’t have to convince anyone, whatever trigger points are, they simply are messages of our CNS that something is wrong and what is wrong usually lays on patient’s habit and patients’s way to (mis)use their body. As far I am concerned working purely and passively on these, lets call them neuromyofascial trigger points inflammation driven has a limited sense if we do not address what it is causing them in first place. This is why I asked you whether your provided explanation about these “trigger points” would consider and cover also active/educative approaches or not… if not, then could you just mention your view on the recommended treatment approaches, that would make sense administering according to your theory… still waiting for your view. Thanks.

    John Quintner Reply:

    Emanuele, we have only put together a hypothesis for consideration. The issue of treatment needs to be given a lot of careful thought, given that the MPS/TrP theorists and practitioners have held sway for so long. There may be merit in the educative approaches you suggest but I can not see any rational reason to massage or needle innocent muscles.

    Emanuele Careddu Reply:

    John, it is fair enough, your effort is appreciable and it is good to see you are trying to discover more about the neurophysiology of all this. However you are still eluding my question. What kind of treatment/approach would you consider, according to your understanding, a plausible or more effective approach for “non specific” MSK conditions, since you are looking a bit down to other approaches what is your proposed alternative route that patients and practitioner should seek? Thanks.

    Jennifer Reply:

    Hi – I just wanted to chime in to respond to the query; ” I can not see any rational reason to massage or needle innocent muscles.”…

    As a human who has experienced pain that certainly fits the description of “trigger points”, and also as a massage therapist who has clients come to me for relief, my simple answer to that question is that quite often massage does provide some relief. Sometimes that relief is annoyingly temporary, and sometimes it is more long-term, but either way *any* relief is welcome.

    Of course, I do not tell my clients that I can cure them, though I do say it will hopefully help. I also admit that the science behind it all is a bit fuzzy, and the way I do things is a combination of techniques that really truly would be hard to scientifically study. But fortunately I am just a massage therapist and my rates are not exorbitant, so people do not feel ripped off if they come to me and I cannot “fix” them.

    I would like to know the best techniques to help them (and myself). But with all the conflicting information out there, I have to rely quite a bit on intuition and I suppose faith. I have had good success with massage, and I believe it is a very nice thing to do to innocent muscles (I much prefer it to scraping!). Of course, I do acknowledge that massage can be painful and brutal, but I would argue that that means the therapist is doing it wrong.

    At any rate, I appreciate this information and am hungry for more. I believe the nerves are the key and wish I could magically know all the answers NOW. But in the meantime, I will continue to read and experiment (on myself), and try to give my clients some relief for at least a short time.

    Thanks for all of this!

    John Quintner Reply:

    Jennifer, I admire your honesty and willingness to learn more about the subject.

    In my reading I note that some physical therapists are now fascinated by fascia and are blaming dysfunctions in this structure for causing all manner of painful musculoskeletal conditions. A lucrative industry has sprung up with the aim of teaching therapists about this new fashion in treatment.

    I think there will always be a place for the sceptical clinician.

    EG Reply:

    Excuse me for jumping in here. Jennifer you say:

    “I am just a massage therapist” and
    “I cannot ‘fix’ them”.

    These beliefs get transmitted to your clients, even without words. Huge leaps forward can be made here.


  100. Nigel Roff says

    Great article. I have been in the “therapy” game for over 20 years now. I get the feeling there are 2 sorts of practitioners, those that just keep doing what they are doing with undying belief or those that slowly and continually question what they do. Thankfully I am in the latter. So much could be written here but I’ll keep it brief. Although a very different article this reminds me of David Butler’s waves of professional life blog. With regards to trigger points some years ago I “discovered” dry needling for trigger points and at first thought this stuff is amazing! But as time went on I realised the results were unpredictable,unreliable and unreproduceable. Hence, I don’t use it anymore and this article probably articulates way better than I could why I don’t use it anymore. As a practitioner you really need to stand in the room of mirrors everyday and be critical of what you are doing or think you are doing. This all might be a bit of a segway from the guts of the article but it’s too easy to only remember your success stories in clinic, and forget or ignore the failures and then kid yourself that what your doing must be working.

    EG Reply:

    Hi Nigel,

    I’m interested in what sort of physical techniques you use and why. Genuine question here, not a set up!


  101. The classic mistake you have made Mr Quinner is assuming that if you cannot “evidence” it’s existence, it does not exist. The complexity in diagnosing such a phenomenon is fraught with hazards and whilst I am of the belief that MTrPs definitely exist (though as a result of physiological disturbances rather than ‘muscle damage’) being able to “truly and accurately” prove a different, pathological level of tension or change in muscle length is virtually impossible. The complex anatomy and biomechanics of the shoulder girdle/complex clearly mean that small changes in certain muscles require an astute experienced mind and hand to assess. However, you are right that even then there will be disagreement.
    Evidence base medicine is not about “only” doing what is proven. It is about ensuring that we continue the pursuit of challenge…..and not “dismissal”, of theory in order to progress understanding. MTrPs has a definite, instantaneous, observable effect in the right population. However, in the wrong population it can lead to dependence and should be avoided. That is the role of the manual therapist, to know the “whole person”, and to select appropriate techniques. The real problem is that many manual therapists (much like the majority of doctors) do not understand the potential impact of their actions…..particularly those that are only briefly effective and the way they influence the patients understanding/belief going forward.

    John Quintner Reply:

    CD, I am inclined to agree with your final sentence but I cannot understand your logic when you claim that by knowing the whole person, manual therapists are thereby able to select appropriate techniques of treatment.

    CD Reply:

    Here’s the logic, if I was working with a patient whom I knew/suspected to have psycho-social problems which may lead to dependency on passive, short term interventions, I would steer clear of “hands-on” treatment, and focus on behaviour change, CBT, ACT therapy etc. However, as part of a toolkit of treatments (always along with exercise and education) I may well choose to do minimal amounts of hand-on to encourage adherence, in a patient who does not have those particular personality traits.
    People who work with chronic disease patients seem to believe that because many of the patients they see have had treatments such as dry-needling, which for them may have been inappropriate and unhelpful, that they are inappropriate and unhelpful for every patient….and are as such….voodoo/quackery. Personally, I find it very narrow minded. RCT’s and EBP generally, by it’s very nature, tries to limit variables so as to determine the efficacy of the intervention/variable being measured. However, a good manual therapist does not offer single treatment options but a complex of interventions aim at facilitating improved function. Of course, their are many “therapists” who are self-interested and actually seek to encourage dependency – which I cannot stand.
    Interventions such as dry-needling are not likely to treat the cause, but are an extremely valuable tool in helping manage symptoms, whilst we work on rehabilitating the root cause, such as muscle imbalance.
    I lose faith in the medical community when those that are supposedly trying to push boundaries are actually closing minds and attempting to shut down innovative, creative thought by mocking attempts to shift paradigms.
    In any good debating group, you are taught to focus on your own argument, rather than try and found weaknesses in the other, and are particularly encouraged not to mock or belittle anothers view….leave that to lawyers. Present a theory, allow others to present theirs, encourage all to challenge your own, and to continue to challenge others. Simple

    Guy Reply:

    Right on!

    John Quintner Reply:

    CD, sorry but I missed responding to your comment. If I now ask you to focus on your own argument, as you rightly suggest Is the best way to proceed, can you please let me know what evidence leads you to suspect “muscle imbalance” as being the “root cause” of muscle pain? Could you also enlighten me as to which particular paradigm shift I am allegedly guilty of mocking?

  102. I am the author of a fairly popular book about so-called trigger points, and so I could hardly be more biased or likely to be outraged by this post. But I applaud it! I think it’s bloody great.

    Although medical history is peppered with competing theories and debate about the nature of MPS/TrPs, direct criticism of the modern conventional wisdom is amazingly sparse. Treating triggers points as if the conventional wisdom is fully baked is big business. The clinical cart is much too far ahead of the science horse, and there are many glaring loose ends and awkward questions. Above all, it’s obvious that most trigger point therapy just doesn’t work all that well. Many people just keep right on suffering. I hear from them constantly, from all over the world.

    And therefore the conventional wisdom needs criticizing, badly! Right or wrong, agree or disagree, it’s extremely valuable. As Dr. Harriet Hall has often written on, it is always important to ask of any claim, “Who disagrees, and why?” We need to hear from anyone who believes the emperor has no clothes.

    John Quinner Reply:

    Paul, this is high praise indeed!

    But you have reminded me of two other unexplained anomalies that appeared in the writings of Travell and Simons:

    Firstly, they raised the issue of “non-myofascial trigger points” only to then forgot all about them.

    Secondly, they unilaterally decided to shift the myofascial trigger point to the myo-neural junction, when previously they said it could inhabit any portion of a voluntary muscle.

    To expand upon your metaphor, in the case of MPS/TrP theory and practice, it appears that long ago the clinical cart successfully uncoupled itself from the horse named Science.

  103. Thank you John for this summary of your explanation of these pain phenomena. I am not a neurologist or physio but from my simplistic point of view It seems to me that your suggested explanations are perhaps a further elucidation of what might be going on in what has been referred to as trigger point activity and pain. So there is maybe no need to refute previous theories, but as with all scientific progress we start somewhere and then progress our understandings as we continue to explore and test and observe and build our understanding of phenomena.

    John Quinner Reply:

    Christine, I agree with you. But in this case the MPS/TrP theorists made some fundamental logical and epistemological errors, which took them and their followers, down a wrong path.

  104. Emanuele Careddu says

    Assuming that the proximal neural inflammation theory would be the base for common MSK conditions (which surely is plausible considering the neurophysiological phenomena reported) then what should be, according these authors, a valuable or suitable modality of intervention for a therapist? The clinical phenomenon of a “trigger point” is not denied as they stated on their research, yet clinically we very often see patients improving their symptomathology with approaches, being these active or passive, aiming to “switch off trigger points”… so a part from a possible more sounded technicisms on the nature of MSK dysfunctions, does this theory practically really matter to a manual therapist?

    John Quinner Reply:

    Emanuele, of course it should matter to those manual therapists who claim to be administering theoretically sound, ethical, and evidence-informed treatment. In our paper we offer possible explanations for the observed improvement that might follow the administration of passive treatment modalities, such as are described above.

    Emanuele Careddu Reply:

    Hello John, unluckly I haven’t got access to the full paper so I cannot read about your suggested understanding about the “trigger point” phenomenon and why certain techniques work. Would your explanation cover also active approaches? Wouuld you be so kind to expose briefly also here?However, although could be important for a discussion amongst peers, theory becomes a secondary matter for patients… I think you would agree with me that a patient wouldn’t care less if what we are doing is affecting a possible nerve inflammation rather then a possible taut band or as far as we know, a combination of the 2… so if this theory gives just a new insight about the phenomenon but no new understanding or radical changes about how to clinically work with it… well… as I said above, good for a chat between peers or ally practitioners not that great for patients. Thanks.

    John Quintner Reply:

    Emanuele, I cannot agree with you. The huge problem you and others face in convincing me otherwise is that the various therapeutic approaches and techniques being implemented by physical therapists who claim to be targeting “myofascial trigger points” have not been shown to result in positive outcomes.

    Priscilla Mitchell Reply:

    John, Geoffrey and team
    thank you for your excellent work so far, it’s great to see the quest for greater understanding of these matters being openly challenged and debated. I feel the reference made to placebo in some of the comments represents a misconception around the understanding of the term placebo.
    John I cannot agree with the definitions you cite by Milton as representing a correct understanding of placebo.
    I beleive greater understanding of the ‘positive’ effects of the placebo effect is needed, in particular the understanding of the placebo effect as described by Louis Gifford as ‘top down’ and ‘ central processing’ . I’d recommend that those that wish to understand this area further look at Gifford L. (2014) Aches and Pains, chapters 7 and Wall, P.D. (1992) The Placebo effect: an unpopular topic Pain 51:1-3 and Wall, P.D. (1994) The placebo and the placebo response. Textbook of Pain. P.D.Wall and R. Melzack.

    The authors cited above note

    John Quintner Reply:

    Thanks Priscilla. Milton’s point is when we are attempting to define something (such as “placebo effect”), we should avoid incorporating postulated causes or mechanisms in the definition. If we don’t follow this advice, we can get trapped in our own language.

    The topic of this discussion is a good example, where a phenomenon (“myofascial pain”) is defined by its postulated cause (“the myofascial trigger point”). But other modern day examples include “repetitive stain injury,” “fibromyalgia,” and “whiplash.”

    We need to find a definition that does the right kind of work. My favourite reference – “The Philosopher’s Toolkit” (2010) by Julian Baggini and Peter S Fosl – puts it rather nicely:

    A definition is like a property line; it establishes the limits marking those instances to which it is proper to apply a term and those instances to which it is not. The ideal definition permits application of the term to just those cases to which it should apply – and to no others. (p.33)