Trisoma® - Trigger Point Therapy

Trigger Point Therapy Some Mapped Trigger Point Locations on a Back Trigger Points are defined as discrete, focal, hyperirritable spots located in muscle, which are painful on compression and can produce local and referred pain which can perplex medical professionals not familiar with trigger points. These symptoms can include: tenderness, burning, numbness, weakness, reduced range of motion, motor dysfunction, and various autonomic phenomena, including temperature, sweating, dryness, dizziness, vision problems and others.[1] Repetitive strain injuries (RSIs)[4] are sometimes actually referred from trigger points. Such maladies are common in athletes, dancers, musicians, as well as in the typical slumped-over office worker.

Do you have trigger points? Check the boxes:
  Muscles are sensitive to pressure
  Stiff, tight, spasmic feeling, especially in the neck or lower back
  Headache
  Dull, aching, or burning pain in muscles
  Pain going down the arm or leg
  Numbness
  Muscle imbalances
  Unpredictable, erratic symptoms
  Heat eases the pain

If you checked off many of these, then you probably have active trigger points. Only a medical professional can provide a diagnosis, but a qualified massage therapist may provide relief of myofascial pain. If relief is not found, then you may be referred to other modalities, such as chiropractic. A Back at Ellwood

Have you ever had a headache, clonus or twitching muscles, after a massage? The massage might have felt great, but most probably your therapist activated trigger points on your body.

Most trigger points can be reduced or extirpated by direct pressure, needling, medical acupuncture, electric stimulation,[7] injections or prolotherapy. In trigger point needling, not to be confused with acupuncture, the physician may use a pressure algometer instrument to find the source of the pain (trigger point), and inject carbon dioxide or a solution, which may include dextrose, phenol, analgesic (e.g. lidocaine), corticosteroid (e.g. prednisone), Botox™ or MyoX™, directly into the site. Just like acupuncture is becoming more accepted by Western medical insurance, there are clinical trials for trigger point needling due to be released, and some insurance is covering trigger point injections. Paul has met one doctor (in Europe) who is talented in treating trigger points with injections, but generally injecting chemicals seems to be analogous to dunking your head into the toilet to wash your face.

Trisoma does not use injections, but the simplest and least invasive methods of direct pincer palpation (locating manually and pressing or holding firmly using thumb and finger), elbows and feet, as in Barefoot Deep Tissue Therapy. After release of trigger points in a muscle, several seconds of stretching will help "reset" the muscle, however stretching of affected muscles is recommended only if there is no pain, since muscle strands containing trigger points may be strained before the surrounding fibers "feel" a good stretch. If 1-3 therapy visits do not produce relief, then referral is recommended. Paul also can teach clients how to work manually on themselves for many cases. Paul studied under John Harris, an Olympic Massage Therapist who has written books, videos and also teaches Trigger Point Therapy at the Santa Barbara Body Therapy Institute.

Trigger points arise from several causes, such as acute or chronic muscular overload, direct trauma, poor posture, chilling of a muscle and even emotional stress. Once a trigger point has occurred, due to metabolic stasis in the area of the TP, waste products begin to accumulate. These waste products are nerve irritants (bradykinin, serotonin, hyaluronic acid, etc.) which, in turn, produce and perpetuate pain. Due to the accumulation of waste products, the blood supply to the area is decreased, resulting in a contracture (tight band) of muscle fibers and ischemia and resultant pain are felt by the patient.[5]

Active trigger points frequently refer pain to other areas, sometimes causing an imbroglio of misdiagnoses (such as sciatica and carpal tunnel syndrome and gynecological opinions,) and failure of convention medical treatments (surgery and drugs) to relieve symptoms. An example is a trigger point in the piriformis muscle causing sciatic pain, which some doctors may misdiagnose as spine trouble; or arm and neck trigger points which mimic carpal tunnel syndrome. Why does the pain occur away from the trigger point? In very simple terms, it is analogous to peripheral neuropathy, where nerves for the toe wired to the "toe" area of your brain. No matter where the 3 foot long "toe" nerve is damaged along its length, when it fires you feel pain in your toe. Myofascial pain should not be confused with Myofascial Release.

Trigger Points were first mapped by Dr. Janet G. Travell, President Kennedy's physician, who found that many sufferers of myofascial pain had active points in predictable locations, and by treating these points, the pain would not only cease, but the cessation of the pain reflex would restore muscle function. When Senator Kennedy first consulted Dr. Travell in the spring of 1955, for muscle spasms in his left lower back that radiated to his left leg and made walking prohibitive, he was questioning his ability to continue his political career. Dr. Travell's “trigger point” therapy proved effective.[10] Since then Trigger Point Therapy has been used successfully by doctors and massage therapists on many clients who have suffered under the depredation of chronic myofascial pain with no relief from surgery or drugs. [More TrP History] Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture,[1b] but Trigger Point Therapy is used for myofascial pain syndromes, which may include headache (tension and migraine), neck, jaw, shoulder, arm, back, leg and various other local or referred symptoms.

Despite the overwhelming evidence of its effectiveness in 60 years of medical journals,[2] trigger point therapy finds few allies in the mainstream medical community, who find it difficult to admit that a skilled massage therapist may remove myofascial pain as well as a highly trained, and highly paid, physician. A variety of drugs from diverse pharmacological classes are in use for migraine prevention. Traditionally, they have been discovered by serendipity.[28] Current trends in migraine prophylaxis include inhibition of cortical hyperexcitability, nociceptive dysmodulation and surgical closure of patent foramen ovale.

Manual therapy can't be administered with a lucrative tablet, is difficult to patent, and massage therapists do not have powerful political lobbyists, nor the advertising money of pharmaceutical corporations. Since 2002 however, the rising costs of medications and surgery has begun forcing many mainstream universities and hospitals to research Trigger Point Therapy further[8], and since 2005, trigger point injections have been covered by USA medical insurance.

Research on theories about trigger points is continuing. Previous theories include abnormality at the neuromuscular junction or muscle scarring. Janet Travell and David Simons hypothesized that local ischemia limits energy replacement and consumes more adenosine triphosphate (ATP), leaving insufficient ATP for adequate return of calcium from the contractile elements to the sarcoplasmic reticulum by the calcium pump. Stretching the muscle reduces the overlap between actin and myosin, thereby reducing energy demand and breaking the cycle. Another theory, promoted by David R. Hubbard, MD. in San Diego, is that trigger points are muscle spindle cells or intrafusal muscle fibers, encapsulated structures about 1 cm in length, that are made over-active by adrenalin stimulation via the sympathetic nervous system, which also controls heart rate, blood pressure and other internal regulatory functions. Without ascribing it to a single cause, Paul Svacina believes that both of the latter theories support the idea that increase of psychological stress, repetitive tasks and decrease of moderate physical activity in modern lives has increased the occurence of myofascial pain and trigger points.

New Research:
  • "Nociceptive inputs in active TrPs could lead to muscle atrophy of the involved muscles." (Association of Cross-Sectional Area of the Rectus Capitis Posterior Minor Muscle with Active Trigger Points in Chronic Tension-Type Headache: A Pilot Study. American Journal of Physical Medicine & Rehabilitation. 87(3):197-203, March 2008.)
  • The National Institutes of Health Clinical Center is sponsoring new research to investigate the biochemistry of trigger points in the trapezius, a large muscle lying between the neck and shoulder. According to the NIH, trigger points in the muscle are typically caused by emotional stress, postures such as hunching shoulders, certain activities like using a telephone receiver without elbow support, or by wearing certain articles such as a heavy coat or heavy purse. (Protocol Number: 02-CC-0245)
  • The Journal of the American Medical Association reported that frequent migraine sufferers felt better after acupuncture (which sometimes may relax trigger points.) Trigger points are not the same as acupuncture points, but research is being begun by mainstream organizations on the anatomic morphology and histology of acupuncture and trigger points.
For more myofascial pain information, visit:
More Trigger Point History:

In the 1930's, Dr. Travell noticed that most patients at her hospital had life-threatening pulmonary disease, but some of them complained more about devastating pain in their shoulders and arms than about their major illness. "When I examined them by systematic palpation of the scapula and chest muscles, I easily uncovered the presence of trigger areas.”[1] It was during this time that Janet read that these tender spots that had been so unresponsive to treatment could be eliminated by procaine injection if the clinician hit precisely the right spot, in an article by J.H. Kellgren in the British Medical Journal titled, “A Preliminary Account of Referred Pains Arising from Muscle,” [11] which strongly influenced her thinking. Unknown to Janet Travell, two other clinicians, Michael Gutstein[12] in Germany, and Michael Kelly[13] in Australia, independently published a series of papers about myofascial pain. They all emphasized “four cardinal features [of the condition]: a palpable nodular or band-like hardness in the muscle, a highly localized spot of extreme tenderness in the band, reproduction of the patient's distant pain complaint by digital pressure on that spot [referred pain], and relief of the pain by massage or injection of the tender spot."[1]

All three had identified myofascial TrPs [trigger points], however, each had used different diagnostic terms and was apparently unaware of the others' work. In 1940, she had the opportunity to do a study of this phenomenon and its treatment by injecting the MTrPs with 1% procaine, and in 1942, Janet Travell, Seymour H. Rinzler, and Myron Herman published “Pain and Disability of the Shoulder and Arm."[16], which was published in the Journal of the American Medical Association in 1942, and described complete relief in 62% of 58 (13 cardiac and 45 noncardiac) patients and moderate-to-considerable improvement in 37%, following procaine injection. This approach of procaine injection of MTrPs in patients suffering from the pain of myocardial infarction convinced her and her colleagues that the treatment could stop both noncardiac pain of muscle origin and true cardiac pain of coronary insufficiency.[15] These findings were first reported in preliminary form in “Relief of Cardiac Pain by Local Block of Somatic Trigger Areas,”[17] and then definitively in 1948 as “Therapy Directed at the Somatic Component of Cardiac Pain.”[18]

Half a century later, clinical recognition of this common source of cardiac-type pain had largely disappeared, and is only now, being again researched. Continuing research with cardiac pain, where Ethyl chloride spray was applied to the region that was rendered painful by ergonovine induced angina, stopped the pain in that area almost at once— faster than nitroglycerin did. Monitoring the effect with electrocardiography (ECG), they established that some of the pain that they were relieving with ethyl chloride did originate in the heart. Spraying the pain reference zones before the use of ergonovine prevented the pain from appearing or delayed its onset for several minutes, but did not affect the ECG changes of cardiac ischemia. They published these results in 1954, “Blocking Effect of Ethyl Chloride Spray on Cardiac Pain Induced by Ergonovine.”[19] However the pharmacologic effect of ergonovine on coronary arteries was thought to be constriction, and the indirect experimental evidence indicated that it caused coronary artery dilation, not constriction, so it occurred to Drs. Travell and Rinzler that possibly ergonovine increased circulation only in normal hearts and decreased it in atherosclerotic hearts. This was a heretical concept because all drug testing of this type had been done on normal animals. After much effort, using rabbits that had become atherosclerotic for another study, Janet and her colleagues confirmed the suspected difference in responses[20] and left no doubt that the spray could relieve pain of cardiac origin, as well as of MTrP origin, and also saw evidence that the spray could suppress cardiac arrhythmias.

Janet Travell continued to relieve pain for patients, including John F. Kennedy, who later became president and surprisingly made her his physician. After retiring from the Johnson administration, she continued to lecture and teach at universities and hospitals, and one of her lines was, “the magic never fails.”

In the mid-1990s, others built on the foundation laid by Janet. Exploring the mechanism by which pain is referred from an MTrP to the reference zone, a study in the Heidelberg research laboratory of the neurophysiologist, Siegfried Mense, demonstrated 1 such referral mechanism.[21] The awakening of sleeping dorsal horn nociceptive connections by pain from the same muscle or another muscle activates new receptive fields for pain. This observation fits the now-extensive literature on the reconfiguration of spinal cord activity in response to sustained pain input and is described in a book that summarizes these mechanisms and their clinical application to muscle.[22] In addressing ourselves to the key issue of causation, my colleague (John Hong, MD), my physical therapist wife (Lois), and I conducted electrodiagnostic studies on both rabbits[23] and patients.[24] These showed that electromyographic endplate noise is significantly related to MTrPs. Others reached this same conclusion.[25] The evidence that any endplate noise corresponds to greatly increased numbers of miniature endplate potentials[26] indicates that a core feature of MTrPs appears to be the release of greatly increased numbers of acetylcholine vesicles of the motor nerve terminal. A detailed description of the current understanding of MTrP etiology can be found in either of 2 recent books.[1],[22]

To identify and treat the MTrPs of pectoral muscles that so commonly contribute to, or cause, pain that is assumed erroneously to be of cardiac origin, or pain that becomes enigmatic when all cardiac tests are normal, one must learn how to find which muscle or muscles need to be palpated, learn what to palpate for, and either develop the skill to treat the pain or find a therapist with that skill. Any muscle with a painfully restricted range of motion and a tender spot that reproduces the patient's pain when compressed likely has a myofascial trigger point.[15] When it is imagined that this phenomenon may hold true for other organ syndromes, the limits of Trigger Point Therapy may be far reaching.

In 1963 David G. Simons, MD, a staff flight surgeon at the United States Air Force's School of Aerospace Medicine, attended a 2-day lecture demonstration on myofascial trigger points (MTrPs) by Janet G. Travell. He knew that years earlier his chief at the Space Medicine Laboratory in Alamogordo, New Mexico, had identified a trigger point as the cause of an enigmatic shoulder pain in a staff member of the laboratory. Janet's lectures were a revelation to Dr. Simons and he stated, "So this was the cause of most of my muscular aches and pains and those of my friends, family, and colleagues!" The cause of this myogenic pain was clearly overlooked in medical training and practice, but diagnosable and treatable by an expert. On later occasions, Dr. Simons saw the conversion of atrial fibrillation to normal rhythm when vapocoolant spray was applied over the arrhythmia MTrP on the lower-right anterior chest wall; the same effect could be achieved by trigger point pressure release applied to that MTrP, as described in The Trigger Point Manual,[1] and it appeared likely that many such unexpected influences, to and from MTrPs, depend on modulation of the autonomic nervous system, in addition to modulation of the sensory nervous system (referred pain). The Trigger Point Manual,[1] describes how the pain patterns of the pectoralis major and pectoralis minor muscles mimic the pain referral patterns of cardiac ischemia. The early studies by Dr. Travell and colleagues provided convincing experimental evidence that the referred pain of cardiac ischemia and the referred pain of active myofascial MTrPs can be eliminated, or decreased remarkably, by application of vapocoolant spray to the skin over the painful area.

Clinical studies showed that the 2 sources of pain are easily mistaken for one another and that persistence of pain for some time after the ischemia of a myocardial infarction should have resolved is likely to be caused by MTrPs. Symptoms of angina in the absence of demonstrable cardiac disease should be considered as likely due to MTrPs. In the light of recent research, the effectiveness of the application of vapocoolant spray to the skin in the referred pain zone indicates that the spray's afferent input to the dorsal horn blocks transmission of nociceptive stimuli or inhibits awakened dorsal horn nociceptor pathways responsible for the referred pain.

Janet's discussions and mentoring inspired Dr. Simons to try to understand what causes trigger points and to become certified as a physiatrist and clinician who treats patients with myofascial trigger points. In 1970, he began examining all his patients for MTrPs as a VA-paid physician in the physical medicine and rehabilitation residency program at the University of Washington in Seattle, but realized only modest success at that time. Then in 1974 Dr. Simons was assigned a ward of the rehabilitation medical service in the VA Hospital at Long Beach, California. The hospital's education committee supported a 1-month instructional visit by Janet. She spent every Friday afternoon giving a lecture-demonstration to the hospital staff, and the rest of the week demonstrating to the diagnosis and treatment of MTrPs on his 23 rehabilitation ward patients. Then she would describe the subjects' problems, her analysis of what caused the MTrPs, how she then demonstrated what was wrong, and the results of her treatment. As soon as she returned to Washington, doctors at the VA Hospital realized that they needed written reminders of what she had taught. From this grew the 1st volume of the Trigger Point Manual,[1] which had its basis partly in Dr. Simons' weekly Friday evening telephone calls to Washington. During these calls, Janet regularly included exciting descriptions of what she had learned that week from patients. During Janet's periodic visits to the VA myofascial pain clinic in Long Beach, California, Dr. Simons tape-recorded her train of thought and continued to write Volume 1 of The Trigger Point Manual. Janet looked under every physical and medical stone imaginable until she found innovative and likely solutions that patient had failed to respond to treatment as expected. The answers ranged from relatively short upper arms or leg-length discrepancies to inadequate vitamin intake. Her writings in the Travell Collection (“Six Ways to Make Housework Lighter” is a good example) are full of advice on how not to develop MTrPs; this advice arose from her observations of what her patients had done to activate their MTrPs.

During Janet's visits to California late in the 1970s, Dr. Simons began to formulate a hypothesis on what causes formation of MTrPs, and in 1981, they published their hypothesis which explained how the taut band muscle fibers contracted in the absence of propagated electrical activity, and why stretching the muscle could produce rapid resolution of the tenderness of the nodule and the tautness of the band.[27] The hypothesis focused on excessive calcium release from the sarcoplasmic reticulum as a cause of local muscle fiber contracture. The contracture, in turn, causes local ischemia that limits energy replacement and consumes more adenosine triphosphate (ATP), depleting the energy source. These events leave insufficient ATP for adequate return of calcium from the contractile elements to the sarcoplasmic reticulum by the calcium pump. Stretching the muscle reduces the overlap between actin and myosin, thereby reducing energy demand and breaking the cycle.

Dr. Raymond L. Nimmo, D.C. (1904-86), who was the definitive chiropractic pioneer of soft tissue and trigger point therapy, coined the "noxious generative point" in the late 1940's and evolved neurophysiological explanations in the 1950's for the trigger point phenomenon, formulations that are still regarded as highly sophisticated half a century later.[9] Nimmo developed his Receptor-Tonus Method after he found that malposition of bones which sends a barrage of noxious impulses into an area producing vasoconstriction, ischemia, and trigger points in muscles. Since tonus is controlled by the sympathetic nervous system, and is not under conscious control, we can not correct our own distortions. Nimmo discovered that pressure applied in proper degree, at proper intervals, will release both trigger points and hypermyotonia. In Nimmo's view, the initiating insult to a muscle - such as overuse or frank injury, a cold draft, or even emotional problems - causes an abnormal increase in afferent input to the spinal cord. In turn, this may cause an abnormal stream of efferent impulses back to the muscle, resulting in hypermyotonia (hypertonus), a vicious cycle sometimes called the pain-spasm-pain cycle. These abnormal reflex arcs have tremendous staying power, and often require external intervention to break the loop. In addition to the reflex hypertonus of the muscle related to the trigger points, there may be production of satellite or secondary trigger points, and visceral dysfunction in the organs innervated by the internuncial neuronal pool stimulated by the trigger point.[14] (Return to text) Trigger Points

References

1. Simons, David G.; Travell, Janet G.; Simons, Lois S. (1999) Travell & Simons' Myofascial Pain and Dysfunction: the Trigger Point Manual. 2d ed. (pp. 5). Baltimore: Williams & Wilkins. (Return to Reference 1 in text) (Return to Reference 1b in text)

Trigger Points 2. Davies, Claire. (2001). The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief
(There has been an explosion of Trigger Point Therapy books in recent years! This one is an economical vade mecum.) (Return to Reference 2 in text)

3. 47th Annual Scientific Meeting. (2005). American Headache Society (Return to Reference 3 in text)

4. Office Place RSIs Decreased in 1994, InteriorsAndSources.com, September 1996. (Return to Reference 4 in text)

5. Sheila Laws, D.C., NIMMO-Receptor Tonus Technique, The American Chiropractor, Volume 24, Issue 02 Published 10/30/2005 (Return to Reference 5 in text)

6. Wick, Franziska MD; Wick, Nikolaus MD; Wick, Marius C. MD Morphological Analysis of Human Acupuncture Points Through Immunohistochemistry. Research Article, American Journal of Physical Medicine & Rehabilitation. 86(1):7-11, January 2007. (Return to Reference 6 in text)

7. The Immediate Effectiveness of Electrical Nerve Stimulation and Electrical Muscle Stimulation on Myofascial Trigger Points, American Journal of Physical Medicine & Rehabilitation. 76(6):471-476, November/December 1997. Hsueh, Tse-Chieh MD, MS 2; Cheng, Pao-Tsai MD, MS; Kuan, Ta-Shen MD, MS; Hong, Chang-Zern MD (Return to Reference 7 in text)

8. National Institutes of Health (NIH), http://www.nih.gov/ (Return to Reference 8 in text)

9. Cohen JH, Gibbons RW.; Raymond L Nimmo and the evolution of trigger point therapy, 1929-1986. Journal of Manipulative and Physiological Therapeutics. 1998 Mar-Apr;21(3):167-72. (Return to Reference 9 in text)

10. James E. Bagg, Jr.; The President's Physician, Texas Heart Institute Journal. 2003; 30(1): 1–2. (Note: Paul Svacina volunteered at the Texas Heart® Institute and Emergency Department at St. Luke's Episcopal Hospital in the Texas Medical Center, Houston, in the 1980's) (Return to Reference 10 in text)

11. Kellgren, JH. A preliminary account of referred pains arising from muscle. Br Med J 1938;1:325–7. (Return to Reference 11 in text)

12. Gutstein M. Diagnosis and treatment of muscular rheumatism. Br J Phys Med 1938;1:302–21. (Return to Reference 12 in text)

13. Kelly M. The treatment of fibrositis and allied disorders by local anaesthesia. Med J Aust 1941;1:294–8. (Return to Reference 13 in text)

14. Cooperstein, Robert Twenty-nine years ago in chiropractic Dynamic Chiropractic, Feb 10, 2003 (Return to Reference 14 in text)

15. Simons, David G. Cardiology and Myofascial Trigger Points, Janet G. Travell's Contribution Texas Heart Institute Journal. 2003; 30(1): 3–7. PMCID: PMC152827 by the Texas Heart® Institute, Houston (Article used by Trisoma® with permission of Dr. Simons) (Note: Paul Svacina volunteered at the Texas Heart® Institute and Emergency Department at St. Luke's Episcopal Hospital in the Texas Medical Center, Houston, in the 1980's) (Return to Reference 15 in text)

16. Travell J, Rinzler S, Herman M. Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride. J Am Med Assoc 1942;120: 417–22. (Return to Reference 16 in text)

17. Travell, J.; Rinzler, S.H. Relief of cardiac pain by local block of somatic trigger areas. Proc Soc Exp Biol Med 1946;63:480–2. (Return to Reference 17 in text)

18. Rinzler, S.H.; Travell, J.G. Therapy directed at the somatic component of cardiac pain. Am Heart J 1948;35:248–68. (Return to Reference 18 in text)

19. Rinzler SH, Stein I, Bakst H, Weinstein J, Gittler R, Travell J. Blocking effect of ethyl chloride spray on cardiac pain induced by ergonovine. Proc Soc Exp Biol Med 1954;85:329–33. (Return to Reference 19 in text)

20. Karp D, Penna M, Rinzler SH, Travell JG. Effects of ergonovine on the heart [abstract]. J Pharmacol Exp Ther 1956; 116:34. (Return to Reference 20 in text)

21. Hoheisel U, Mense S, Simons DG, Yu X-M. Appearance of new receptive fields in rat dorsal horn neurons following noxious stimulation of skeletal muscle: a model for referral of muscle pain? Neuroscience Letters 1993;153:9112. (Return to Reference 21 in text)

22. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis, and treatment. Philadelphia: Lippincott Williams & Wilkins; 2001. (Return to Reference 22 in text)

23. Simons DG, Hong C-Z, Simons LS. Prevalence of spontaneous electrical activity at trigger spots and control sites in rabbit muscle. Journal of Musculoskeletal Pain 1995;3(1):35–48. (Return to Reference 23 in text)

24. Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial [sic] trigger points. Am J Phys Med Rehabil 2002;81(3):212–22. http://www.ncbi.nlm.nih.gov/pubmed/11989519 (Return to Reference 24 in text)

25. Couppe C, Midttun A, Hilden J, Jørgensen U, Oxholm P, Fuglsang-Frederiksen A. Spontaneous needle electromyographic activity in myofascial trigger points in the infraspinatus muscle: a blinded assessment. Journal of Musculoskeletal Pain 2001;9(3):7–16. (Return to Reference 25 in text)

26. Simons DG. Do endplate noise and spikes arise from normal motor endplates? American Journal of Physical Medicine and Rehabilitation 2001;80: 134–40. http://www.ncbi.nlm.nih.gov/pubmed/11212014 (Return to Reference 26 in text)

27. Simons DG, Travell JG. Myofascial trigger points, a possible explanation. Pain 1981;10:106–9. (Return to Reference 27 in text)

28. Nabih M. Ramadan, MD. (2007) Current Trends in Migraine Prophylaxis Headache: The Journal of Head and Face Pain 47 (s1) , S52–S57 doi:10.1111/j.1526-4610.2007.00677.x Department of Neurology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA. (Return to Reference 28 in text)


Images

1. Paul Svacina 2008. Modified image of: Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/.

2. Paul Svacina by Delphine Louie, Ellwood, 2008.

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