Davies C, Davies A. The trigger point therapy workbook: your self-treatment guide for pain relief. 3rd ed. New Harbinger Publications; 2013.
I am a hopelessly biased reviewer in this case — I am the author of another (less!) popular book about trigger points — a very different sort of book, but definitely a competing one.
It wasn’t always like this: I was less critical of the Workbook for many years, and so there was less of a conflict of interest. I never knew Clair while he was alive, but I have corresponded amiably with Amber Davies occasionally. I was content to recommend the Workbook as more of a primer and practical guide, while mine was a more advanced troubleshooting guide for tough cases and professionals.
Unfortunately, I can no longer recommend the Workbook.
Science is a moving target
The 3rd Edition of the Workbook has fallen behind the times: it fails to even acknowledge important new scientific information and controversies (never mind explain them). Arguably, this was overdue in 2004, when the 2nd edition was published. In 2013, their absence is more troubling. It’s too important a topic for such neglect!
There’s nothing terribly wrong with reporting the conventional wisdom. But there’s a big problem with not even mentioning its problems.
What is the conventional myofascial pain syndrome wisdom?
People routinely suffer from pain that seems to be coming from soft tissues, and can be provoked by pushing on sensitive spots. No one doubts that this problem exists, but cause and cure are both still unknown. Travell and Simons pioneered the dominant modern theory, which is that the pain is caused by small patches of muscle stuck in a vicious cycle of dysfunction. These putative spots are called “trigger points” and the constellation of symptoms they cause are called “myofascial pain syndrome.”
The TrPs/MPS explanatory model is a runaway success as a “product” in the therapy marketplace. Everyone who sells trigger point therapy has a wonderfully persuasive and seemingly scientific story to tell. The problem is that it’s just a theory with many problems that have come into focus of the last several years … and almost everyone selling treatment is (predictably) ignoring that.
Trigger point therapy is almost entirely about applying pressure to muscles. But after decades of research, it’s still not clear that it works, or that the cause of the pain can even be found muscles.
A good translation … of the conventional trigger point wisdom only
The Workbook started out well. The original edition had a clear and reasonable tone that made me feel like cheering the first time I read it — finally, I thought, a popular but credible guide to trigger points and myofascial pain syndrome! It was well written, and it still is. It has had the benefit of skilled and dedicated editing. The 3rd edition is illustrated simply but well and thoroughly.
Basically it’s a good quality, user-friendly translation of the classic but very weighty texts by Dr. Janet Travell and Dr. David Simons — the “big red books.”1 If that’s what you want, then the Workbook is a good book! If that’s all you want …
It’s a good book if you don’t want to hear who disagrees and why.2 If you don’t know what’s gone wrong with trigger point science in the last twenty years. If you don’t want to hear3 that many of the claims made in the book are now directly challenged by recent evidence.
Promising (much) too much
Like every True Believer, Davies promised too much. In the 1st edition, he tried to convince readers that trigger points are responsible for practically everything that ever hurt you or ever will, and that simple massage will rarely fail. This kind of over-the-top enthusiasm is exactly the kind of thing that undermines medical acceptance, and makes doctors put a book down after the first chapter.4
Clair’s enthusiasm more than a decade ago was more forgivable (to me, anyway) than it is today. I always saw it as a flaw, but I never condemned the book for it. Sadly, the most recent edition gives exactly the same impression, and I find that much harder to overlook today. The new Workbook still makes clear, bold claims that fly in the face of current evidence, like this one:
It is known that needling trigger points and ah shi points is an effective way of relieving pain.
It is known? Really? An unfortunate choice of words!5 There is good evidence of exactly the opposite.67 (And there has been since 2001 — when the 1st edition of the Workbook was published.8) Claiming that acupuncture works is particularly outrageous.9
The 1st edition of the Workbook. Notice the tagline: “the PROVEN method for overcoming soft-tissue pain.” It wasn’t anywhere close to proven then & it isn’t now. But the claim is still on the cover of the 3rd edition!
Much later on in the book, there’s a chapter written for therapists that includes a brief discussion of “When Massage Is Unsuccessful.” It concedes that massage can even cause some problems.10 However, rather than conceding any fault or limitation in trigger point science or therapy, the Workbook doubles down:
It’s very important to keep in mind that the main reason for a failure of trigger point massage is that you’ve simply treated the wrong spots or have missed a primary trigger point somewhere.
Here’s another possibility:
When massage seems to have failed, it may not be your fault: The client may be engaged in an ongoing activity that is unusually taxing or requires reptitive motion.
What is conspicuously not a possibility discussed in this book is that trigger point therapy probably doesn’t work very well, even though the scientific literature is chock-a-block with reasons to suspect exactly that. It’s also obvious to any humble therapist that they aren’t exactly stopping all pain in its tracks. Even if the MPS/TrPs model is exactly biologically correct, there’s no particular reason to suspect that simply disturbing the TrPs with pressure or needles is going to treat them.
The overconfidence is really a serious problem with the book. Excessive enthusiasm sets patients up for serious (and often expensive) disappointments.
Ignoring the controversy
Not everyone thinks trigger point therapy works, or works anywhere near as well as you might think after reading this book. The rise of trigger point needling in particular — with its relatively high risks and costs, but no good evidence of benefit — has raised many skeptical eyebrows over the last ten years.11 Some professionals are starting to see trigger point therapy as a great wave of snake oily hype … not a plucky underdog bringing new hope to pain patients.
Some qualified critics have pointed out serious problems.1213 Meanwhile, pain science has been moving decisively away from the hunt for specific sources of pain in tissues, because that approach hasn’t helped much with a long list of stubborn body pains of every description.14 In particular, trigger point therapy is characterised by the assumption that trigger points form and are stubborn because of postural stress and biomechanical asymmetries (and indeed a chapter about this is one of the only “new” ideas in the 3rd edition of the Workbook), and that has also been strongly criticized.15
Even if there is something going on in the tissues, it’s pretty clearly not the only thing going on. There are other ideas that clearly need to be a part of the discussion.
The critics may be right. Or they could be wrong. Regardless, any modern book on this topic should at least acknowledge the debate. The Workbook does not. That’s a deal-breaker for me.
About Paul Ingraham
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
- Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. The ultimate myofascial pain syndrome reference, the product of decades of extraordinary dedication by two doctors famously devoted to the subject of soft tissue pain. The two-volume set is also brilliantly illustrated. The introductory chapters constitute an excellent overview of the subject, albeit a dauntingly technical one. Note: although a landmark and important text, more recent information has been published in Muscle Pain: Understanding its nature, diagnosis and treatment by Siegfried Mense and David Simons. BACK TO TEXT
- Dr. Harriet Hall of Science-Based Medicine has often expressed this as an axiom of critical thinking: always ask, “Who disagrees, and why?” It’s a pillar of rationality. Its absence from the book is serious, not a peccadillo. BACK TO TEXT
- LA LA LA LA, I can’t hear you! BACK TO TEXT
- Ironically, this directly undermined one of the main stated goals of the book — outreach to physicians! I think that’s a bit tragic. BACK TO TEXT
- UrbanDictionary.com: “an expression indicating that a given idea is based more on superstition or outright bullshit than on fact, derived from dialogue in TV series ‘Game of Thrones.’” BACK TO TEXT
- Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009 Jan;13(1):3–10. PubMed #18395479. ❐ BACK TO TEXT
- Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of Dry Needling for Upper Quarter Myofascial Pain: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2013 Jun. PubMed #23756457. ❐
It seems like a positive review, but it’s not: it’s a classic case of disappointing evidence that the authors disingenuously spin as a “positive” result. See critical analysis by Moseley.
(See more detailed commentary on this paper.)BACK TO TEXT
- Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001 Jul;82(7):986–92. PubMed #11441390. ❐ BACK TO TEXT
- The science is far more settled and negative in that case. See Does Acupuncture Work for Pain?
BACK TO TEXT
- Indeed it can, and trigger point therapy tends to encourage massage therapists to “dig” deep into tissues in search of points — which is riskier. See Poisoned by Massage. BACK TO TEXT
- BodyInMind.org [Internet]. Moseley L, O’Connor N, Harvie DS. Effectiveness of Dry Needling for Myofascial Pain; 2015 Jan 3 [cited 17 Feb 27]. BACK TO TEXT
- FMperplex.com [Internet]. Wolfe F. Travell, Simons and Cargo Cult Science; 2013 Feb 19 [cited 17 Oct 27]. BACK TO TEXT
- Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392–9. PubMed #25477053. ❐ This is a new paper, but it’s essentially an update to a paper they published in 1994 — their concerns are not new! BACK TO TEXT
- Moseley L. Teaching people about pain — why do we keep beating around the bush? Pain Management. 2012;2(1):2–3. PubMed #24654610. ❐ PainSci #54762. ❐ “This issue was actually settled a couple of decades ago — there is not an isomorphic relationship between pain and nociception, nor between pain and tissue damage . A very large amount of research has explored the multifactorial nature of pain (see  for a clinic-friendly review).” BACK TO TEXT
- Lederman E. The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131–8. PubMed #21419349. ❐ PainSci #55668. ❐ BACK TO TEXT