A famous critique of the "trigger point phenomenon"
Eighteen articles on PainSci cite Quintner 2015: 1. When to Worry About Low Back Pain 2. The Complete Guide to Trigger Points & Myofascial Pain 3. Quite a Stretch 4. The Complete Guide to Low Back Pain 5. The Complete Guide to Chronic Tension Headaches 6. The Complete Guide to Neck Pain & Cricks 7. Tennis Ball Massage for Myofascial Trigger Points 8. Basic Self-Massage Tips for Myofascial Trigger Points 9. Review of The Trigger Point Therapy Workbook 10. A Historical Perspective On Aches ‘n’ Pains 11. Can Massage Damage Nerves? 12. Toxic Muscle Knots 13. Therapy Babble 14. Trigger Point Doubts 15. The Trigger Point Identity Crisis 16. Trigger Points on Trial 17. The 3 Basic Types of Pain 18. Neurodynamic Stretching
PainSci commentary on Quintner 2015: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.
Quintner, Cohen, and Bove argue that the common picture of trigger points as lesions in muscle and soft tissue, spelled out most formally in Gerwin 2004, is “flawed both in reasoning and in science,” and that treatments (e.g. massage, needling) based on that idea produces results “indistinguishable from the placebo effect.” They believe that all of the biological evidence put forward over the years (like Shah 2008) is critically flawed in one way or another, while other evidence leads elsewhere, and so the old picture of trigger points “remains conjecture in the face of conflicting data.” They also point out that the theory is inappropriately treated like an established fact by a great many people.
Not even these fierce critics of trigger points deny that people have pain that seems to come from their muscles. But if it’s not coming from the muscle, where is it coming from? They briefly discuss two other ideas of their own: inflamed nerve fibres, and referred pain and tenderness from deeper structures. They do not thoroughly explore or defend either idea.
Neuritis is undoubtedly worth investigating, but it requires us to believe that nerve axons are routinely inflamed for no apparent reason, which doesn’t seem much different than the theory it is supposed to replace. The evidence cited to support it is just as limited as the evidence for trigger points, if not more so (just a few papers, all from the authors themselves, or their research colleagues).
The proposal of “referred pain and tenderness” from deeper tissues with unspecified troubles and/or “altered central nociceptive mechanisms” is imprecise. We know that these mechanisms probably exist, but there is not a jot of evidence that they have anything to do with the subjective experience of “muscle pain.” This is just a proposal to look somewhere other than the integrated hypothesis.
This paper is an abridged version of a much more detailed argument laid out in a chapter of an extremely expensive textbook: see Quintner.
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (FM syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.
related content
- “An expansion of Simons' integrated hypothesis of trigger point formation,” Gerwin et al, Curr Pain Headache Rep, 2004.
- “Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct,” Quintner et al, The Clinical Journal of Pain, 1994.
- “Myofascial pain: a bogus construct,” a chapter in the book Myofascial pain, by John L Quintner and Milton L Cohen.
Specifically regarding Quintner 2015:
- “A Critical Evaluation of Quintner et al: Missing the Point,” Dommerholt et al, Journal of Bodywork & Movement Therapies, 2015.
- “The Decline and Fall of the Trigger Point Empire,” John L Quintner, Geoffrey M Bove, and Milton L Cohen, FMperplex.com.
- “A critical evaluation of the trigger point phenomenon,” Lorimer Moseley and John L Quintner, BodyInMind.org.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Inciting events associated with lumbar disc herniation. Suri 2010 Spine J.
- Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Pople 1994 Spine (Phila Pa 1976).
- Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. Konstantinou 2015 BMC Musculoskelet Disord.
- Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. Kuyken 2022 Evid Based Ment Health.
- No long-term effects after a three-week open-label placebo treatment for chronic low back pain: a three-year follow-up of a randomized controlled trial. Kleine-Borgmann 2022 Pain.