A key feature of PainScience.com tutorials is that they I actively update them as new science and information becomes available, and the most recent version is always automatically available to customers. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 93 major and minor updates since I started logging carefully in late 2009 (plus countless more minor tweaks and touch-ups).
Correction (Aug 9 '16, section #2.4) — Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates. See section #2.4, Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.
Safety update (Jul 6 '16, section #5.32) — Updated for consistency with new CDC guidelines. Thorough editing of the section. See section #5.32, The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.
New section (Jun 24 '16, section #5.34) — No notes. Just a new section. See section #5.34, Lidocaine patches.
Important new related reading (Jun 2 '16) — Although not an update to the book itself, I’ve published some important related articles about the scientific controversy over the explanation for trigger points:
- a heavily referenced review of the evidence that a trigger point is a “tiny cramp”
- a summary of the academic controversy about trigger point science
- the story of my own doubts and how they’ve changed over the years (this is the “main” article on this theme; it was around before but has been revised heavily)
All of this stuff is inside baseball, and not of interest to most readers, but it’s critical to my credibility as an author on this topic — it shows that I’ve really done my homework, and I’m not ignoring the concerns of skeptical experts — so for now I’ve made everything freely available to all site visitors instead of integrating them into the book. Nevertheless, the book has already been heavily influenced by this work, and will continue to be.
Minor update (May 23 '16, section #1.10) — Added a good new example of a trigger point “whisperer” myth. See section #1.10, The myth of the trigger point whisperer.
Minor update (May 7 '16, section #5.17) — Finally added lacrosse ball recommendation. See section #5.17, Massage tools: 7 free (or very cheap) and tools from objects not originally intended for massage.
Science update (Feb 13 '16, section #3) — Beefy tune-up for the “pillars” of trigger point science: several new and carefully written footnotes, linking to many painstakingly summarized papers for readers who really want to delve. It’s a bigger update than it looks like on the surface. See section #3, The science of trigger points: It’s a little half-baked, but at least it’s not boring.
Edited (Nov 18 '15, section #9.2) — Yet more modernization and clarification. See section #9.2, Massage quality control issues (“But I’ve already tried massage therapy …”).
Edited (Nov 17 '15, section #9.7) — Modernization and clarification. See section #9.7, Pain in three flavours: the good, the bad, and the ugly.
Edited (Nov 17 '15, section #9.6) — Modernization and clarification. See section #9.6, The Pressure Question: how much is too much?
Edited (Nov 17 '15, section #3.4) — Modernization and clarification. See section #3.4, Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven).
Edited (Nov 9 '15, section #9.3) — Tuned for consistency with my current views. See section #9.3, Two case studies: highly-trained therapists failing miserably.
Science update (Nov 6 '15, section #1.8) — Added a footnote about trigger points being associated with jaw pain. See section #1.8, Trigger points may explain many severe and strange aches and pains.
Revised (Oct 16 '15, section #9.5) — Just modernizing and clarifying. See section #9.5, How to find good trigger point therapy .
Science update (Sep 15 '15, section #3.12) — Some referencing about central sensitization, especially this “fun” fact: muscle pain may be especially good at causing CS. See section #3.12, Referred pain science (advanced).
New Section (Sep 11 '15, section #3.1) — Better late than never, I’ve added a summary of the expanded integrated hypothesis from Gerwin et al. (2004). See section #3.1, The dominant theory of trigger points spelled out in a little more technical detail.
New section (Sep 5 '15, section #9.21) — No notes. Just a new section. See section #9.21, Acupressure: what if we pressed those points instead of puncturing?
Science update (Feb 28 '15, section #2.10) — Added three good references and a diagram about how much “wiggle” room nerve roots have. See section #2.10, Nerve pain is overdiagnosed.
Science update (Feb 22 '15, section #9.17) — Two new science reviews considered and cited. See section #9.17, How about Botox injection therapy?
Rewritten (Jan 4 '15, section #5.1) — Completely revised for the 3rd edition of the Workbook: I no longer recommend it. See section #5.1, A brief detour: why not The Trigger Point Therapy Workbook?
New citation (Dec 30 '14, section #1.4) — Added an important new reference to a scientific paper critical of conventional wisdom. See section #1.4, How can you trust this information about muscle pain?
Minor update (Jul 8 '14, section #9.20) — New footnotes about the theory of acupuncture/trigger point overlap. See section #9.20, How about acupuncture?
Science update (Jul 7 '14, section #9.19) — And, so sorry, it’s bad news. See section #9.19, Maybe stabbing will help! How about Dry Needling, AKA Intramuscular Stimulation (IMS) therapy?
Science update (Mar 19 '14, section #6.5) — Added evidence about the effect of massage on fibromyalgia. See section #6.5, The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia.
Editing (Jan 16 '14, section #3.3) — General revision for quality. Added the cheek-bite analogy story for colour. See section #3.3, One: The vicious cycle (why trigger points are stubborn).
Editing (Jan 16 '14, section #3.2) — General revision for quality. See section #3.2, The dance of the sarcomeres.
Minor update (Jan 5 '14, section #3.11) — Added a story about phantom limb pain. See section #3.11, Referred Pain Science (basic) .
Minor update (Dec 21 '13, section #5.33) — Minor but fascinating new item about the myth of anaesthetic paralysis and the dominance of the CNS over muscle tone — the kind of nifty item I just love to add to the book! See section #5.33, The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.
New section (Dec 13 '13, section #3.14) — An introduction to one of the most important theoretical challengers to the traditional explanation for trigger points. See section #3.14, Quintner: “It’s the nerves, stupid”.
Science update (May 29 '13, section #7.5) — Good news update: new study shows a clear reduction in nonspecific musculoskeletal pain after vitamin D supplementation. See section #7.5, Vitamin D deficiency.
Minor update (Mar 29 '13, section #5.31) — Upgraded risk and safety information about Voltaren Gel. See section #5.31, Voltaren® Gel, an intriguing new option.
Major update (Mar 1 '13, section #8) — Almost all of the stretching sections have been edited, revised, and modernized. See section #8, Stretching: Stretching is generally over-rated … but it might be good for trigger points.
Minor update (Mar 1 '13, section #1.7) — Modernized and expanded a bit, a couple new references, and a generally much better explanation of what fibromyalgia is. See section #1.7, A brief note about the relationship between fibromyalgia and myofascial pain syndrome.
Science update (Dec 14 '12, section #7.15) — Some more evidence showing the role of smoking in chronic pain. See section #7.15, Smoking.
Science update (Dec 7 '12, section #7.15) — Added references showing connections between smoking and chronic pain. See section #7.15, Smoking.
Minor update (Dec 7 '12, section #5.7) — Added a funny sidebar about bad anatomy. See section #5.7, Don’t get hung up on anatomy, and be persistent .
Minor update (Oct 25 '12, section #3) — A minor case study and some science to help establish that muscle can indeed be the source of pain. See section #3, The science of trigger points: It’s a little half-baked, but at least it’s not boring.
New section (Oct 24 '12, section #8.9) — No notes. Just a new section. See section #8.9, What about stretching the antagonist muscle?
Minor update (Oct 24 '12, section #2.5) — Added an item about “mobile” bumps that people often mistake for trigger points. See section #2.5, Negative checklist: symptoms that are probably not caused by trigger points.
Edited (Aug 27 '12, section #2.16) — Now more accurate and clearer. Edits in preparation for audiobook version. See section #2.16, Predictably unpredictable: trigger point symptoms are erratic by nature.
Major update (Jul 23 '12, section #5.38) — New evidence that massage can cause “rhabdomyolysis” makes it quite a lot easier to understand a lot of negative reactions to trigger point therapy. This is valuable perspective, and the section has been heavily revised to exploit it. See section #5.38, Troubleshooting negative reactions to treatment.
Minor update (Jun 9 '12, section #3) — This introduction now does a better (and more honest) job of mentioning some trigger point controversies, and links to an important companion article about them, for keener readers, Trigger Point Doubts. See section #3, The science of trigger points: It’s a little half-baked, but at least it’s not boring.
Minor update (May 2 '12, section #2.8) — A minor but good: clearer, better language. Editing continues as I work on the audiobook version. See section #2.8, “Out of nowhere”: a signature symptom of trigger points.
Minor update (Apr 25 '12, section #2.4) — More editing for clarity and thoroughness. This also happens to be one of the first edits I’m doing to prepare for audiobook production. See section #2.4, Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.
Science update (Mar 28 '12, section #6.7) — I revised the warning away from hydration, and included some fun new myth-busting evidence about hydration and cramping. See section #6.7, Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope).
New section (Mar 8 '12, section #5.28) — No notes. Just a new section. See section #5.28, Neutral positioning: find a comfortable muscle length and rest there.
Minor update (Mar 8 '12, section #2.5) — Added an item about non-pain symptoms, like itching. See section #2.5, Negative checklist: symptoms that are probably not caused by trigger points.
Minor update (Mar 7 '12, section #5.32) — Important new, skeptical footnote about the dangers of the powerful narcotic drugs. See section #5.32, The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.
Modest expansion (again). And the sassy new “muscle stabbing” section name. (Jan 12 '12, section #9.19) — See section #9.19, Maybe stabbing will help! How about Dry Needling, AKA Intramuscular Stimulation (IMS) therapy?
Science update (Dec 21 '11, section #2.6) — Added quite an interesting citation about the correlation (or lack thereof) between tissue hardness and sensitivity. See section #2.6, If you have trigger points, will your muscles be “tight”?
Trivial update (Dec 14 '11, section #2) — Added minor but odd note about “sensory annoyances” and hats. Yes, hats. See section #2, Diagnosis: How can you tell if trigger points are the cause of your problem?
Products added (Nov 11 '11, section #5.15) — Three new product reviews, and some miscellaneous revision of the section. See section #5.15, Beyond the tennis ball: commercial massage tools.
Updated (Oct 16 '11, section #9.15) — Added new references to fascia science about the toughness and contractility of fascia, and some interpretation. This is also supported by a substantial new free article, Does Fascia Matter? See section #9.15, How about myofascial release and fascial stretching?
New section (Aug 26 '11, section #7.15) — No notes. Just a new section. See section #7.15, Smoking.
Minor update (Aug 26 '11, section #7.10) — Added a paragraph about magnesium. See section #7.10, Vitamin B1, B2, folate, and magnesium deficiencies.
New section (Aug 26 '11, section #1.10) — No notes. Just a new section. See section #1.10, The myth of the trigger point whisperer.
New section (Jul 13 '11, section #8.8) — Some new thoughts about how stretching for trigger points might work — quite different from the mainstream theory — inspired some new stretching science. See section #8.8, What about neurology? Stretch tolerance.
Major rewrite (Jul 13 '11, section #3.15) — This might as well be a new section — not only did I re-write it, I gave it a completely new purpose. Previously the “bamboo cage” was a minor metaphor used to illustrate a possible mechanism for sensitization of muscle tissue. Now it is the basis of an extended and (I think) interesting exploration of how the concept of trigger points might actually be debunked. Pretty weighty stuff, but delivered with a major effort to make it interesting to any reader. Hope you enjoy it! See section #3.15, “The bamboo cage” — what immobilization torture can tell us about the nature of muscle pain and massage.
Minor update (Jul 12 '11, section #7.5) — Added an interesting observation about how Vitamin D supplementation might work. See section #7.5, Vitamin D deficiency.
Minor update (Jul 12 '11, section #2.4) — Miscellaneous editing and improvements, plus a couple new items. See section #2.4, Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.
Minor update (May 30 '11, section #9.7) — Added some basic information about the damage that “ugly pain” can actually do, inspired by a recent anecdote received from a reader. See section #9.7, Pain in three flavours: the good, the bad, and the ugly.
Science update (May 7 '11, section #7.5) — The Vitamin D advice provided to readers has not changed, but the science supporting it has been dramatically beefed up — more science, new science, better summarized — to confirm that D supplementation is a safe and sensible option for patients. See also the separate article, Vitamin D Safety for Pain Patients. See section #7.5, Vitamin D deficiency.
Major update (Apr 20 '11) — Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.
Minor update (Apr 10 '11, section #5.32) — Edited to distinguish more clearly between “dependence” and “addiction,” to reduce alarmism about addiction or contributing to the excessive stigma against opioids. (Thanks to reader Evelyn D. for pointing out the issue to me — a good example of how readers contribute to the improvement of this tutorial.) See section #5.32, The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.
Minor update (Mar 22 '11, section #9) — Updated the disclaimer (sidebar) about my “conflict of interest.” I no longer have it, since I am retired from my massage therapy practice. See section #9, Getting Help: How do you find good therapy for your trigger points?
Minor update (Feb 3 '11, section #5.5) — Added evidence showing that trigger point therapy improved ankle range of motion. See section #5.5, New evidence that squishing trigger points works at least a little.
Minor update (Feb 3 '11, section #2.5) — Added a checklist item about muscle wasting. See section #2.5, Negative checklist: symptoms that are probably not caused by trigger points.
Major update (Dec 30 '10, section #9.13) — Previously this section discussed ultrasound rather generally, without much discussion of the science; it is now beefed up with a thorough, fun discussion of the somewhat squishy evidence. See section #9.13, How about ultrasound therapy? (ESWT and “Sonic Relief™”).
Minor update (Dec 30 '10, section #1) — Added an interesting footnote about the Google Book Ngram for “trigger points.” See section #1, Introduction.
Many minor repairs (Dec 1 '10) — A large batch of minor errors and glitches were corrected today, thanks to the sharp eyes of readers Effie and Doris.
Modest expansion (Nov 25 '10, section #9.19) — See section #9.19, Maybe stabbing will help! How about Dry Needling, AKA Intramuscular Stimulation (IMS) therapy?
New section (Oct 6 '10, section #8.2) — Not just for customers: this particular section is a short version of a new free article. See section #8.2, Case study: A cautionary tale of stretching: that time I almost ripped my own head off.
Major update (Sep 23 '10, section #7) — Numerous repairs and upgrades to all of Dr. Taylor’s sections of the book, especially links to the clinics that Dr. Taylor recommends, some new charts, and a colorful anecdote about drinking blood (seriously). Thanks to several readers, and especially Elaine M., for their assistance with this. It’s quite amazing how the new chapter is driving immediate refinements. People read it and write to ask questions, and that spurs little email debates between me and Dr. Taylor, a trip to PubMed for more evidence or detail, or a clarification wrangle with the language ... and the results get put into the book within hours or even minutes … so cool! As reader Bill C. put it, “Your books are alive!” It does kind of feel like that. See section #7, Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.
Many new sections (Sep 20 '10, section #7) — An important new chapter (with several sections) by Dr. Tim Taylor. This is the first major collaborative effort on PainScience.com, and I’m extremely proud of it, and pleased with how well it went. See section #7, Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.
New section (Sep 15 '10, section #5.5) — I’m delighted to add a whole small new section about evidence of the efficacy of trigger point therapy. See section #5.5, New evidence that squishing trigger points works at least a little.
Minor update (Sep 15 '10) — I’ve done a bunch of work to continue integrating Dr. Taylor’s new chapter into the book: discussing perpetuating factors wherever they are relevant, and linking to the chapter. Thus there are many more spots in the book now where the importance and relevance of Dr. Taylor’s contribution is emphasized.
New cover (Aug 6 '10) — At last! This e-book finally has a “cover.”
Corrected (Jul 20 '10, section #3.19) — Fixed some wrong science about hydrogen bonding and tissue adhesions. Hat tip to reader and chemist K.D. for the good catch. See section #3.19, The science of adhesions: atoms stick to each other.
Minor update (Jul 7 '10, section #5.33) — Updated the muscle relaxant section with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. See section #5.33, The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.
Minor update (Jun 25 '10, section #1.8) — Added a nice anecdote from a doctor about a trigger point that was almost mistaken for a possible tumor. See section #1.8, Trigger points may explain many severe and strange aches and pains.
New section (May 26 '10, section #11.3) — This is a major upgrade to the presentation of PainScience.com’s own Perfect Spots series of articles. They have always been here, but perhaps not presented in as useful a way as they could have been. I’ve also made many upgrades to the articles themselves over the last 2 months. See section #11.3, Appendix C: The Perfect Spots.
New section (May 26 '10, section #11.2) — Describes a new partnership with the publishers of the best online reference available. See section #11.2, Appendix B: The Trigger Point Symptom Checker.
New section (May 26 '10, section #11.1) — Reviews and recommendations of other sources. See section #11.1, Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!
Major update (May 25 '10) — A weakness of this tutorial has finally been eliminated: reference material! Where are the trigger points? Although this is still not an encyclopedia of trigger points, and it never will be (by design), the book now helps readers find specific trigger point information in three new ways, in three new sections.
Many minor repairs (May 17 '10) — No specific update today, but a particularly large dose of editing love, with my thanks to reader Elaine M. for pointing out several errors that got me started. Elaine received some free product for her assistance, of course, and so can you if you send me any more than a few error reports.
Minor update (Apr 17 '10, section #9.1) — Improved description of physiatrists (a medical speciality). See section #9.1, Types of therapists and doctors and their relationship to trigger point therapy.
New section (Apr 3 '10, section #11.4) — Finally, I’ve added a (free) appendix of online resources related to trigger point therapy. Better late than never? See section #11.4, Appendix D: Trigger Point Therapy Resources.
Tiny update (Feb 13 '10, section #5.33) — Tiny-but-interesting: I added some pretty good evidence that a muscle relaxant was no better for injured neck muscles than ibuprofen. See section #5.33, The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.
New section (Jan 19 '10, section #3.10) — No notes. Just a new section. See section #3.10, The evolution of muscle pain: does muscle “burn out”?
Minor update (Jan 19 '10, section #3.9) — A little revision, slight expansion. See section #3.9, The all-powerful acne analogy.
Major update (Jan 12 '10, section #2.20) — Section heavily revised, improved, and expanded. See section #2.20, Worst Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome.
Major update (Jan 12 '10, section #2.19) — Section heavily revised, improved, and expanded. See section #2.19, Worst Case Scenario 1: Being triggery.
Minor update (Jan 7 '10, section #5.38) — A small but significant update on nutrition, based on Bischoff-Ferrari et al, which basically boils down to a recommendation to take vitamin D — it might help. See section #5.38, Troubleshooting negative reactions to treatment.
Older updates — Listed in a separate document, for anyone who cares to take a look.