Review of The Trigger Point Therapy Workbook

I am a hopelessly biased reviewer in this case — I am the author of another book about trigger points — a very different sort of book, and less popular, 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.

Davies C, Davies A. The trigger point therapy workbook: your self-treatment guide for pain relief. 3rd ed. New Harbinger Publications; 2013.

Science is a moving target

The 3^rd 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 2^nd 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. We must balance experience against evidence — experience tends to get far too much credit, and there are a great many reasons to question the conventional wisdom…

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 over the last several years … and almost everyone selling treatment is (predictably) ignoring that. This is why I have a great many doubts about trigger point therapy.

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 in 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 3^rd 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 1^st 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 1^st edition of the Workbook was published.8) Claiming that acupuncture works is particularly outrageous.9

The 1^st edition of the Workbook. Notice the tagline: “the PROVEN method for overcoming soft-tissue pain.” It wasn’t anywhere close to proven then, and it isn’t now. But the claim is still on the cover of the 3^rd 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 repetitive 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 in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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Notes

1. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999.

   The “big red books” by Drs. Janet Travell and David Simons are a two-volume set of texts about so-called trigger points and myofascial pain syndrome. Early versions and editions were extremely influential in world of massage and physical therapy starting in the 1980s and continuing well into the 21st Century. Arguably the are the most influential texts in that field.

   The introductory chapters present a good overview of the subject, if somewhat technical and now quite dated. The books are brilliantly illustrated, for what it’s worth, and those drawings will probably influence the field for decades to come, the compelling iconography of a clinical paradigm.

   Although a landmark work, more recent information has been published in Muscle Pain: Understanding its nature, diagnosis and treatment by Siegfried Mense and David Simons, and there are many reasonable questions and doubts about almost everything Travell and Simons thought and wrote about this topic “back in the day.”

2. 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.
3. LA LA LA LA, I can’t hear you!
4. Ironically, this directly undermined one of the main stated goals of the book — outreach to physicians! I think that’s a bit tragic.
5. 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.’”
6. 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 ❐
7. 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.)

8. 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 ❐
9. The science is far more settled and negative in that case. See Does Acupuncture Work for Pain?
10. 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.
11. BodyInMind.org [Internet]. Moseley L, O’Connor N, Harvie DS. Effectiveness of Dry Needling for Myofascial Pain; 2015 Jan 3 [cited 25 Feb 21]. PainSci Bibliography 53829 ❐
12. FMperplex.com [Internet]. Wolfe F. Travell, Simons and Cargo Cult Science; 2013 Feb 19 [cited 17 Oct 27]. PainSci Bibliography 54768 ❐
13. 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!
14. Moseley L. Teaching people about pain — why do we keep beating around the bush? Pain Management. 2012;2(1):2–3. PubMed 24654610 ❐ PainSci Bibliography 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 [2]. A very large amount of research has explored the multifactorial nature of pain (see [3] for a clinic-friendly review).”
15. 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 Bibliography 55668 ❐