SHORT TALKS AND ARTICLES:
– with comments in italics by Janet Travell’s daughter, Virginia Street

Optimal Health and Time
by Janet Travell, M.D.

Janet Travell gave a short talk entitled Optimal Health and Time in Ohio in 1971. She said:

I am privileged to speak to you today. It is an honor which stems, I know, from my years in the White House with President Kennedy and President Johnson.

The topic I have chosen today is Optimal Health.

People put up with average health, all too often, and think it’s normal. Do each of you have the stamina and endurance, the enthusiasm, for the day’s task that you think you should have? Do you wake up fresh and rested every morning with a wonderful feeling of well-being? Have you forgotten the difference between feeling tired and feeling well most of the time?

One of society’s great enemies is not disease but fatigue. This is not a new problem and many of the remedies are not new either.

I will read to you some observations that were published in 1831 by Dr. James Johnson whose title was Physician Extraordinary to the King of England:

“There is a condition, or state, of body and mind intermediate between that of sickness and that of health, which…is daily and hourly felt by tens of thousands of people, but I do not know that it has ever been described. It is the wear and tear of the living machine which results from over-strenuous exertion of the intellectual faculties conducted in a state of anxiety of mind and bad air. The Wear and Tear Syndrome makes much work for the doctor ultimately, if not for the undertaker.”

The physician usually finds it easier to deal with acute illness than with preventive medicine. The medical emergency demands the urgent attention of both the patient and the physician. In the long-range view, the doctor’s hardest job is persuading a person to do what that person knows is best for his health. Everyone has to work at it to obtain optimal health.

The physician of the future who is health-oriented rather than disease-oriented must be a good teacher. His effectiveness in preventive medicine or health maintenance lies in his power to change behavior, a person’s behavior towards himself.

The question is, how do you – listening to me speak here today – arrange your lives to raise the quality of your own health? The secret, of course, is time, and especially the avoidance of what I call “time-pollution” or the poor use of time.

In the White House, I soon discovered the change of the status of time. Time flowed steadily there like a great river in flood, without seasons or academic vacations, without vacations at all, and its passage was marked only by the crests of crises. Every second counted. All things revolved around the understanding and excellent use of time.

In my own family, we had a habit of taking vacations at our Massachusetts summer home without clocks – literally. I confiscated wrist watches and clocks and, since we had no electricity in our old farmhouse, we had no television or radio. To know what time it was, we had to ring up the telephone operator.

Time was, for the moment, endless.

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Basic Principles of Myofascial Pain
A Talk by Janet G. Travell, M.D.
Written November 1, 1984

I shall discuss today the ubiquitous myofascial pain syndromes that depend on trigger points and their feedback loops to the central nervous system. These trigger points are located in the myofascial structures: skeletal muscle and its facia. Trigger points also occur in skin, tendons, joint capsules, and periosteum.

One of the curious things about myofascial trigger points and their pain syndromes is the fact that the symptoms often long outlast the precipitating event of trauma, either gross or microtrauma, due to perserverating reflex patterns in the central nervous system.

In addition, the trigger points are perpetuated by continuing mechanical stresses (not the precipitating strain) on the myofascial structures, which create repetitive or sustained overload of the affected muscles. Such perpetuating stresses include, for example, a short leg and small hemipelvis, short upper arms, poor posture, inefficient body mechanics, immobility or immobilization, and chilling the body – also unphysiological seating design. Chairs can be a serious health hazard (chair pollution).

Systemic perpetuating causes may also be multiple. These include infectious (especially oral herpes simplex), metabolic, nutritional, allergic, vicerosomatic and psychogenic factors. Marginal vitamin deficiencies and hypometabolism (borderline subclinical hypothydroidism) are especially frequest causes.

Problems:

1) One difficulty is in pinpointing the problem, in making the diagnosis.

2) Another difficulty is in managing the myofascial pain syndrome, for this often requires teamwork of the various health professionals. We are partners in the treatment of pain and maintenance of health. Each profession needs the skills and support of the other.

My Special Interest:

My special interest has dealt with the role of the skeletal muscles and their fascial components in the pathogenesis of these stubborn painful states, the myofascial pain syndromes. I am not talking today about the diseases of collagen nor of muscle, such as rheumatoid arthritis, polymyalgia rheumatica, or polymyostitis, nor about organic neurologic diseases, the dystonias, etc., nor even intervertebral discogenic pathology.

Trauma:

What I will discuss is the chronic, disabling myofascial pain due to trauma. Trauma has been called ‘the neglected disease of modern society’ — true. In the United States and around the world, millions of people have disabling injuries each year.

Two phases:

These myofascial pain syndromes are:

1) initiated by trauma, and

2) if they last for a period of time, they are maintained by continuing trauma.

Two Kinds of Trauma:

Trauma may be of two kinds:

1) gross trauma, due to obvious sudden external force, with tearing of some fascial structures and overstretching, followed by protective reflex contraction of muscles (the guarding reflex); and

2) obscure microtrauma due to overuse of muscles, especially during fatigue, chilling, alcohol ingestion, infectious illness or hypothyroidism. Such microtrauma is an important perpetuating cause of chronic myofascial pain, if not the most important cause of these protracted syndromes.

Skeletal Muscles:

The largest organ in the body is the skeletal musculature, and the myofascial pain syndrome may well be the commonest affliction of the human race.

Myofascial pain and dysfunction can lead to serious disability, and yet they are also the most responsive to specific treatments when these clinical disorders are recognized early and treated in the acute pathophysiological phase.

The myofascial syndromes become increasingly complex with chronicity, and the development of non-specific dystrophic pathological changes. The Tincture of Time does not bring about recovery.

Muscles Learn:

Muscles are different from other tissues. When injured, bones knit; if the skin is cut or a joint capsule is torn, it heals; but when a muscle is injured, something else happens — it learns. It learns to protect that part, and it develops habits of guarding and splinting which limit motion, restrict circulation, and cause pain, stiffness and muscular dysfunction, especially weakness. The muscles have long memories, and these symptoms may persist for years. Then, they are often said to be psychosomatic, or psychogenic, in origin.

Nature of a Trigger Point:

What is a trigger point? It is not something subjective, not something of which the patient complains. It is an objective physical sign in that it is disclosed by physical examination of the patient. Then, the trigger point is identified as a localized area, a spot of deep tenderness in a firm band of muscle that can be readily felt. Usually the palpable band parallels the muscle fibers; occasionally it feels like a button, or a nodule. At the spot of maximum tenderness (the trigger point), if the band is snapped briskly (transversely), and is thus mechanically stimulated, it contracts; this we have called a ‘local twitch response.’ The examiner can feel and see the line of contraction of the band, and can judge which muscle harbors it. An observer can see it, and if that part of the body is free to move, the contraction of the band often jerks the part, the head, or finger, or arm, for example. The patient says ‘Ouch’ and also jumps, which has been designated a ‘jump sign.’ So we speak of the ‘local twitch response of the muscle,’ and the ‘jump sign of the patient.’

Active Trigger Point Re: Pain:

When firm deep pressure is sustained directly on an active trigger point in the palpable band, the patient reports that pain is felt elsewhere; the pain is projected to a distance as referred pain, in a predictable pattern for that site in the muscle. The referred pain pattern is the important clue. Referred pain does not follow simple segmental distribution.

On palpation of a trigger point in the infraspinatus muscle on the back of the scapula, the patient with shoulder pain is surprised and says: ‘Oh, that’s very sore. That’s my pain in the front of my shoulder and arm. Where have you got your finger?’ The reproduction of the pain is reassuring to the patient, and to the doctor, in that a demonstrable source of his or her complaint has been found.

Latent Trigger Point Re: Pain:

A source of confusion is that trigger points have varying thresholds of hyperirritability: they may be clinically active, or clinically silent, (latent), with respect to pain. When the patient actually comes to the doctor with a clinical complaint of pain, you are dealing with active trigger points, and pressure on a trigger point should readily evoke the pattern of referred pain specific for that muscle. After a period of time, the focal hyperirritability often subsides somewhat; the trigger point becomes latent, and the patient no longer complains of spontaneous pain. There is not the intensity of pain that brings the person to a physician. However, he or she becomes used to a low level of pain, and the patient may deny having pain, when, in fact, it is there.

From such clinically latent trigger points the typical pattern of referred pain usually is not evoked by sustained pressure. However, a needle inserted directly into a latent trigger point may elicit the predictable pattern of referred pain.

Other Effects:

Both active and latent trigger points have other profound effects besides pain.

1) They have referred tenderness in pain reference zones even during painfree periods.

2) They inhibit muscle lengthening and limit motion at the joint, or joints, which the muscle traverses. The tense muscle is shortened; it will not stretch to its full normal length. So, whether the trigger point is active or latent with respect to pain, on examination the associated restriction of movement can usually be found.

3) There is also demonstrable weakness (without atrophy) of the muscle that contains the trigger point, whether it be active or latent. The barrage of different impulses from the trigger point apparently inhibits maximal contraction of that muscle; it is not strong. When the patient with latent trigger points in the hand extensor muscles tries to pour milk out of a carton, he may unexpectedly drop the carton; his grip is weak. This weakness may be present for years, due to latent trigger points.

4) There are also a variety of referred autonomic effects, both sensory and motor.

Why Overlooked?

Recognition of this extremely common type of myofascial disorder is made difficult because the myofascial structures are soft tissues and are not visualized on X-ray examination, and because no specific test on blood or urine is available to pinpoint the problem. There is no neurological deficit unless entrapment of a peripheral nerve by a taut muscle occurs.

The Diagnosis:

The diagnosis is established by objective signs elicited on palpation of the affected muscles and by observation of specific associated restriction of motion. The pattern or distribution of referred pain elicited by palpation of an active trigger point is described by the patient, not observed, and is therefore a subjective phenomenon. However, the pattern of referred pain for a given site is constant from person to person and therefore predictable. When the patient’s description of the induced referred pain matches the known pattern for that muscle, the accuracy of the patient’s reporting is verified.

A major difficulty in the treatment of myofascial pain is that after it has been initiated by one traumatic event, the multiple factors which usually act together to perpetuate the pain syndrome must all be dealt with, and this requires much detective work and time on the part of the physician.

References:

Travell, Janet G., M.D. and Simons, David G., M.D. Myofascial Pain and Dysfunction. The Trigger Point Manual, Volume One and Volume Two, Williams & Wilkins, Baltimore, 1983 & 1992.

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Life Is Like a Bicycle…, Two Minds Play Ball… and Point of View

Janet Travell often began her talks or lectures with a statement attributed to Democratic Florida Congressman Claude Pepper: “‘Life is like a bicycle,” she would say. ‘”You don’t fall off unless you stop pedalling.’ So here we go, all of us, pedalling, pedalling, pedalling.”

Then she would recite a poem that was published in her autobiography called “Two Minds Play Ball.” She had written the poem while thinking about the old days in the late 1920s and early 1930s when she had worked at Cornell’s inadequately heated, ramshackle Loomis Laboratory on 26th Street. At Loomis, she and other members of the faculty had been “exposed inevitably to each other’s research in progress.” In 1932 the Department of Pharmacology moved uptown to the new towering white buildings of the New York Hospital at 1300 York Avenue. There the doors of the “individual laboratories…had self-closing devices…and they stayed shut most of the time.” My mother propped her door to the long hall corridors open. She missed the back and forth of ideas with Dr. Harry Gold and her other former professors, and the “scientific arguments” with colleagues that “clarified her thinking.”

Two Minds Play Ball

Ideas stall against a wall,
Tangled with facts and figures until
Two minds play ball across the hall.

Fresh concepts emerge then, doubts to still.
Toss, brains, toss the ball to and fro, provoking
Wisdom, words choking, new fitness of mind evoking. (1)

Janet Travell told her audiences that often she was awakened in the middle of the night when a ditty popped into her head and she kept pen and paper on a table next to her bed to record her thoughts. One night, when she had been pondering the effects of body asymmetry and leg-length disparity, she hurriedly wrote down the following lines:

Point of View

Against the sea
The sky
Is slanted.

Or can it be
It’s I
That’s canted. (2)

Yes, she would say, about eighty percent of us are canted.

Footnotes:

(1) OFFICE HOURS: DAY AND NIGHT, The Autobiography of Janet Travell, M.D. by Janet Travell, M.D., NAL/ The World Publishing Company, New York and Cleveland, 1968, pp. 194 & 195.

(2) Ibid. p. 292.

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Doctor, Wife and Mother

Janet Travell planned to be a physician when she grew up because of the great love and respect she had for her father, Willard Travell. “An aura of exitement and mystery surrounded him,” she wrote, “from my earliest memory to the end of his life…” (1)

In an article published in the 1953 Wellesley Alumnae Magazine, she elaborated on the reasons for her decision to study medicine. She also gave her readers some excellent advice on how they could budget their time and accomplish more in their lives. The good advice she gave almost fifty years ago is still useful today.

Doctor, Wife, and Mother
by Dr. Janet Travell Powell, Class of 1922

When I was seven years old, I decided to study medicine because my father was a doctor and a magician and whatever he did was wonderful. Through his eyes, every patient and in fact, every living thing, every piece of machinery, became an exciting mystery. Take it apart, see how it works, and fix it. It seemed as if his magic touch could repair anything. But I must admit there were failures, and boxes still lie around containing separated parts of old watches that could never be put together again. Later, I learned that in medicine, too, the solution to the problem is not always simple and the correct answer often cannot be found.

So I became interested in two different aspects of the healing profession, – first, the immediate care of the patient of today, which yields the most tangible results, and secondly, research and teaching to better the care of the patient of tomorrow. It’s hard to combine these things, even in a 60-hour week, but it never seemed that I could give up any part of them. They have now grown to be members of a single body, and if an arm or a leg were cut off, the rest of the body would bleed to death. That’s why I continue to teach pharmacology, conduct a research program, write scientific papers and practice medicine from my own office.

Sometimes I’ve found time to follow my inclinatation along various side paths. Work on muscular pain led me to Mr. Henry Dreyfuss, who gave me free rein to my ideas on designing more comfortable seats for airplanes, and a new chair for 60,000 switchboard operators of the A.T. and T., and even future models of – you’ll never guess – toilets. All in the cause of preventive medicine!

You want to know how it is possible to do all these things and still have a home, a husband, grandchildren… It’s the problem of any woman who takes her profession seriously. Each person has to solve it for herself, but I’ll tell you some secrets.

1) Give your undivided attention to what goes on at the moment.

2) Don’t wait to start a job until you have enough time for it, because that time will never come. I try to make the most of each five or ten minutes and do many things piecemeal, like knitting. That applies to relaxation as well as work; they are pretty well mixed in together. Gardening and tennis, swimming, horseback riding with the family, and [other] activities are woven all through the weekly pattern.

3) Avoid the SENSE of hurry like the plague. Hurrying and feeling hurried are not the same thing…I find the best preventive against that devastating anxiety over being late is to know my own capabilities and to say NO to many things. And the things I don’t do that fill the average housewife’s day make a long list. I rarely sweep, cook, wash dishes, stand in line at the A & P, sew, taxi the children, attend luncheons (lunch is very sketchy), play bridge, watch television, read the latest novel, sit in a beauty parlor, chat on the telephone or go shopping. But I could do all these things with pleasure if I didn’t choose to live a fuller life, or lives. (2)

Footnotes

(1) OFFICE HOURS: DAY AND NIGHT, The Autobiography of Janet Travell, M.D. by Janet Travell, M.D., NAL/ The World Publishing Company, New York and Cleveland, 1968, p. 75.

(2) Wellesley Alumnae Magazine Issue of November 1953, pp. 13 & 14.

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The Humble Chair
by Janet Travell, M.D.

Janet Travell gave a talk in 1952 on the subject: the design of chairs and musculoskeletal pain. She said:

The importance of correct posture in body mechanics needs no thesis. Ill effects of the body’s sagging out of shape are well known. During long periods of sitting, as the muscles tire, there is:

1) Overstretching of muscles;

2) Strain on ligaments and joint capsules ordinarily protected by muscle tension;

3) Impaired circulation due to direct pressure on blood vessels at critical points, and

4) Similarly, pressure injury to nerve trunks, or to the voluntary muscles themselves.

Lasting harm can be caused by a bad chair, but the humble chair, now at the mercy of modern furniture designers, has not received proper recognition as the most important and most useful form of external support for the framework of the human body in this era of sedentary living.

When a person is seated and at rest, correct posture should be maintained – insofar as possible – by the chair, and not by work of the muscles. This is obviously important for the patient with arthritis, fibromyositis or some other musculoskeletal disorder, but it is equally important for the healthy person. A bad chair is like a bad diet; in the normal individual its ill effects are not immediately apparent, but if continued it produces cumulative harm.

The principles of seating design are now new. Human anatomy hasn’t changed much in the past thousand years or so, and there are only a limited number of things one can do to the basic design of a chair without ruining it, physiologically speaking.

What methods of investigation have been used to determine what constitutes correct seating design?

1) One method is based on anthrometric data from which the average size of a man, woman, or child is calculated. Some excellent results in industrial seating design have been achieved by this method, especially when mechanical adjustments are provided for variations in body size. The designing of seats for the average-sized man is at times a necessity. But average dimensions should have no place in an individual’s selection of a chair for his home or office use. How many people go into a shoe store and buy an average-sized pair of shoes?

The usual height of a chair at the front is 16 to 18 inches from the floor. I recently saw a woman, 5 feet tall, in whom the length of the leg from the popliteal space to the heel was only 13 inches. She was a bookkeeper and sat at work all day with her feet dangling several inches above the floor. In view of the heavy compression of the femoral vessels which this would produce, is it any wonder that she complained of varicose veins, calf cramps, and pain and swelling of her feet? I have seen many women with a lower leg length of 14 or 15 inches and a variety of circulatory, muscular, and joint disorders in the lower extremities; these patients were greatly benefited by a prescription for a portable folding foot stool which fitted in a briefcase.

2) Because of such obvious deficiencies in anthropometric methods, the pendulum has swung to the opposite extreme. A chair to fit exactly a particular individual may be designed by having the person sit in some plastic material and then making a replica of the mould.

This technique also has drawbacks: first, if the person has any faults of sitting posture, this procedure merely serves to perpetuate them. Secondly, the net effect of this method is like sleeping in sand. At first it feels fine but later on, one can not get comfortable. The material oozes out from under the structural points of the body most in need of support, and as a result, the body sags out of shape.

3) The third method is based on electromyographic studies, as exemplified by the work of Arne Lundervold. Action potentials recorded from muscles of the back and shoulder girdle were related to changes in design of the chair. When these muscles were at rest and no action potentials were present, continuous muscular activity appeared, for example, when the seat of the chair was lowered so that the right angle at the knee became an acute angle or when the chair was unsteady owing to easily movable castors.

4) A fourth method of evaluating seating design, the one we used, might be regarded as a form of biological assay. Like the bioassay of liver fractions in pernicious anemia patients, or the human assay of digitalis materials, suitable subjects who give a clear-cut effect, or endpoint, are employed. We had available a large number of patients with chronic muscular pain in whom pain was immediately brought out by their sitting in certain types of chairs, but no pain was produced by other types of chairs. Thus, the effects of varying the seating construction could be evaluated in these patients who served as sensitized indicators of postural stresses and strains.

Furthermore, in many instances, the clinical pain syndrome often was not permanently relieved until such faults in seating design were corrected.

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A Talk On Medical Misconceptions
by Janet Travell, M.D.

Janet Travell gave this talk in 1984. She said:

At the present time, the myofascial pain syndrome is riding high on the crest of a tidal wave of interest. The increasing numbers of scientific and popular articles have created a great demand for expert treatment. But unfortunately, there is a scarcity of well-trained and knowledgeable experts to handle the multitude of these complex pain problems.

As a result, many misconceptions have arisen. The patient may say:

1) “I’ve had backaches all my life, so I have to live with them.” There is general apathy and lack of confidence in any therapy.

2) “My pain will go away in time,” which also creates apathy. However, muscles have long memories, and when a part of the body is strained or injured, they learn to continue to guard the part indefinitely, unless the muscles are taught differently. The more athletic and well coordinated a person is, the more likely the muscles are to develop this habit of protective splinting. The Tincture of Time does not bring about recovery.

3) “I’ll just ignore the pain and do whatever I want. I’ll grin and bear it.” The “good sport” syndrome (the opposite of hypochondriasis) usually leads to multiple microtraumas to the affected muscles by either repetitive or sustained overload.

4) The patient believes that where it hurts is where the trouble is. It is hard to believe that most myofascial trigger points refer pain to a distance – and not only referred pain, but also referred deep tenderness. So, the painful area is sore to pressure, to rubbing, and to palpation. The misconception is natural that treatment should be applied to the sore and painful region.

5) “I couldn’t have a muscular problem because muscle pain doesn’t hurt that much.” On the contrary, it is a sickening, or a paralysing pain. If a swimmer gets a cramp in his leg, he may drown; he can not move any part of his body, as if he were paralyzed. Patients have told me that the steady deep aching muscular pain is worse than that of a fracture, or a heart attack, or any other kind of pain that they have experienced.

6) “My pain couldn’t be muscular because I was given a muscle relaxant drug and it only made my pain worse.” Yes, that happens in the myofascial pain syndromes because of the protective tension which develops in functional, or myotatic, muscle groups; the normal muscles tighten to divide the load with the parallel-line muscle that contains the trigger points. The muscle relaxant, in the dose that is given, relaxes the normal muscles only, leaving the one that is the source of the pain unprotected and more heavily loaded than before the drug was given.

7) “My pain must be psychological, I am told, because all my tests are normal. Everything is fine.” Yes, everything that one can see in an x-ray is normal, but the muscles are soft tissues that do not show in an x-ray examination – nor on EMG (electromyography) which measures nerve dysfunction, nor in the CAT scan, nor in any available specific test on blood or urine. Some day, NMR (nuclear magnetic resonance) may yield information concerning specific molecular changes occuring in the trigger point, but as yet, this is not available.

How then, does one make a diagnosis of a myofascial pain syndrome? By the history and the physical examination.

8) “I couldn’t have a vitamin deficiency because I eat everything, a normal diet.” This belief does not take into account the low intake of water-soluble vitamins due to their destruction in the processing of food, by heat in cooking, washing out in boiling water, by exposure to florescent lighting, etc.; nor due to malabsorption from the gastrointestinal tract; nor to defects of utilization, or dependency, of genetic origin. Marginal vitamin deficiencies, or inadequacies, are extremely common, and may increase neuromuscular irritability.

The doctor’s management of the myofascial pain syndrome is complicated further by a variety of different misconceptions:

1) When the patient says that he has pain in the shoulder, it is assumed that that is where the pain is felt. But the average patient’s knowledge of anatomical terms is minimal, and “the shoulder” may mean the scapular region, or the upper arm, or angle of the neck. Thus, x-rays and even arthrograms are taken of a non-painful shoulder, and treatment is erroneously applied there. Poor comminication by the patient must be anticipated by having him or her point to the painful region while the doctor maps the distribution of pain on a body form.

2) Another misconception which the therapist sometimes shares with the patient is that finding a tender spot by palpation, even with a jump sign of the patient, means that a trigger point has been located. No, the tenderness may be referred to the pain reference zone from the active trigger point located at a distance. To be sure that the tender spot is indeed a trigger point, one should be able:

a) to induce a local twitch response by snapping palpation of a palpable band in the
muscle, and

b) to reproduce the predictable known pattern of referred pain specific for that trigger
point.

3) It is also a misconception that when needling the area sets off the expected referred pain pattern, this proves that the needle penetrated the trigger point. Actually, the needle may have been pressing against the trigger point from outside, inducing the pain pattern, just as palpation through the skin can do. To be sure that the needle has punctured the trigger point, one must have the feeling of its penetrating through a tough layer, like a soft rubber ball, and of inducing a localized twitch response of the palpable band.

It may be that puncturing the trigger point releases trapped metabolic end-products, such as lactic acid and kinins, which have accumulated owing to impaired circulation, causing hypertonicity and local irritation with effects similar to those of hypertonic saline injection.

4) The physician may think that if the needle clearly punctures one trigger point and a local anesthetic (procaine) is injected, that will resolve the myofascial trigger point problem. However, a cluster of several trigger points usually exists in the palpable band, or bands, and these require thorough probing with the needle for their inactivation and for relaxation of the muscle.

5) Another mistake is for the operator to think that this needling-injection technique completes the therapeutic procedure. Prompt passive stretching of the affected muscle to full length is essential in order to re-educate the muscle as to its function (not guarding). During stretching, simultaneous application of the vapocoolant spray may help restore full muscle length. Brief active movement through the full range of motion of the muscle should then be directed. If not so instructed, the patient will often make the active movements himself, as nature directs.

6) The importance of applying hot moist packs immediately to all treated areas is often not appreciated. Moist heat has many reflexes from the skin to deeper structures that are not fully understood. It helps greatly in preventing what might be regarded as post-exercise soreness then, and on the following day or two.

7) A frequent misconception is that the vapocoolant spray, passive-stretch procedure is as simple to perform as it looks. It is not. It requires great manual dexterity of the operator in applying the stretch force and a knowledge of muscle anatomy in applying the slow sweeps of the vapocoolant over the muscle. Awareness of the degree of voluntary relaxation achieved by the patient is essential to success. The procedure can not be done in a hurry.

8) The use of immobilization is subject to misconception in relation to the myofascial pain syndromes. While it may be necessary for a period of time in the treatment of fractures or surgery for a ruptured intervertebral disc or joint repair, the shorter the period of immobility, the better for the skeletal muscles. In fact, in experimental knee fractures it has been shown that the articular cartilage heals faster when the joint is passively moved, continuously without weight-bearing, than when it is immobilized. Furthermore, if a muscle which is completely at rest (electrically silent) is held immobile, within 15 – 20 minutes motor unit activity, that is, true spasm, develops; electrical silence (relaxation) is restored at once by a quick isotonic movement (Lundervold 1951). So if a person fidgets, remember that it is probably relaxing to the muscles.

9) The false assumption is sometimes made that the condition could not be a myofascial syndrome because there is no obvious restriction of motion. However, some muscles are long and slack, and cross more than one joint, so that the related limitation of motion is not obvious unless specifically tested, as in the case of the rectus femoris of the quadriceps, sternocleidomastoid, latissimus dorsi, and triceps brachii muscles.

10) The commonest misconception perhaps is that if one or two muscles have responded to specific trigger point therapy, the job is done. The primary trigger point of the functional, or myotatic unit may be overlooked, including both agonists and antagonists.


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