Trigger-point therapy (Travell, Simons)

1. Introduction

Version followed: the manual trigger-point approach of Janet Travell and David Simons as set out in Myofascial Pain and Dysfunction: The Trigger Point Manual (Vol. 1, 1983; 2nd ed. 1999 by Simons, Travell & Simons; 3rd ed. 2019, edited by Joseph M. Donnelly), described here through accounts that quote the manual and through current certification and practitioner material. The 3rd edition's front matter states that detailed stretch-and-spray instructions were dropped in favour of dry needling, that perpetuating factors (its chapter 4) should be addressed from the start of treatment rather than only at the end, and that its treatment section has separate chapters on injection and dry needling, manual therapy, therapeutic exercise, physical-therapy modalities, posture and footwear. [source: Trigger Point Manual 3rd ed., Italian edition front matter, Piccin 2020] The detailed content of those treatment chapters, and of the 2nd edition's, is not summarised here [uncertain].

Trigger-point therapy is a manual (hands-on) soft-tissue method delivered by massage therapists, physiotherapists, physicians and other licensed or registered practitioners, not by a psychotherapist acting as a psychotherapist. Travell, a physician who practised from the 1930s to the 1990s, and Simons, whom she met in 1963, developed a model of "myofascial pain": painful, hyperirritable spots (myofascial trigger points) in taut bands of muscle are said to produce local tenderness and characteristic patterns of pain referred to other areas. Change, in the developers' account, happens when sustained pressure, stretching (with or without a coolant spray) and correction of "perpetuating factors" inactivate those points, so the referred pain and restricted movement settle. [source: Street, A History of Manual Trigger Point Therapy; AUT library record of the 3rd ed.]

The model is contested. Quintner and Cohen (1994) proposed that the phenomena are better explained as referred pain of peripheral-nerve origin, and Quintner, Bove and Cohen (Rheumatology, 2015, published online 2014) call the trigger-point hypothesis circular, with referral maps that rest on little published evidence. Systematic reviews of diagnosis find that agreement between examiners locating trigger points by palpation is limited: Myburgh et al. (2008) judged most reliability studies of poor quality, and Rathbone et al. (2017) pooled agreement at a moderate level (kappa about 0.45), with localised tenderness and the patient recognising their own pain the most reliable signs; those authors called palpation alone "unreliable". [source: IASP RELIEF article by Quintner; PainScience summaries of Quintner & Cohen 1994, Myburgh 2008, Rathbone 2017] This guide does not take a side. It describes the method so a psychotherapist can refer, prepare and support clients, and it treats the client's pain as real whatever its mechanism. Evidence for treatment effects was [uncertain: not verified] against a systematic review of manual trigger-point therapy; no claim of effectiveness is made here. The method is not a treatment for cancer or other physical disease.

Separate procedures, named only: dry needling and trigger-point injection are separate medical or physiotherapy procedures under their own regulation. They are not described here and are not within a psychotherapist's or massage therapist's role unless their own licence allows it.

2. Framework

Who delivers it and how they are regulated or credentialed [source: FSMTB/NCBTMB statement; CBMTPT Handbook; MassageMag/NAMTPT; CNHC]

United States: massage therapists are licensed by state boards; many boards use the MBLEx, the entry-level licensing examination run by the Federation of State Massage Therapy Boards (FSMTB). NCBTMB Board Certification is voluntary and separate from licensure (NCBTMB stopped offering licensing exams in 2015). For this method specifically, the Certification Board for Myofascial Trigger Point Therapists (CBMTPT) offers the voluntary CMTPT credential by examination, renewed every five years. Eligibility runs through a 500-hour trigger-point programme, a 500-hour massage programme, or licensure as an allied health professional. The National Association of Myofascial Trigger Point Therapists (NAMTPT, founded 1986) is the professional association and keeps a directory.
United Kingdom: the Complementary and Natural Healthcare Council (CNHC) keeps a register that includes Massage Therapy and Sports Massage and investigates written complaints about registrants. Physiotherapists who use the method are regulated as physiotherapists [uncertain: the regulator is not named in the cited sources].
Canada and Australia: in Canada, five provinces regulate massage therapy through a college that licenses therapists, sets standards and publicly reports discipline (Ontario, British Columbia, New Brunswick, Newfoundland and Labrador, Prince Edward Island); elsewhere the profession is not government-regulated and therapists join associations [source: HHR-RHS Canada; CBC 2021]. In Australia, there is no national registration; massage therapists fall under the National Code of Conduct for health care workers not registered under the national scheme, applied by state health complaints entities (in WA the implementing bill was still before parliament in September 2022), and AMT members can be reported to AMT's Discipline Committee [source: HaDSCO WA 2022; AMT].
Physicians and physiotherapists use the method within their own scope; needling and injection belong to their regulated scope only.

Course of care as practitioners describe it (no fixed session count from the manual is given here [uncertain]):

Phase	Goal	Who	Move on when
A. Suggestion and screening	Decide whether a referral fits; medical clearance where needed	Psychotherapist, physician	Red flags excluded; client wants to try it; consent plan in place [synthesis]
B. Intake	History, medications, sleep, diet, work posture and ergonomics, other illness; body chart of pain areas and pain quality	Practitioner	Contraindications screened [source: MassageMag/NAMTPT]
C. Examination	Palpate for taut bands, spot tenderness, referred pain and the client's recognition of their pain; check posture, gait, movement	Practitioner	A working map agreed with the client [source: CBMTPT Handbook; Hodgson 2004]
D. Treatment sessions	Manual release, stretching with or without coolant spray, massage strokes, passive range of motion	Practitioner	Pain and movement change, judged with client feedback [source: Street; CBMTPT Handbook]
E. Perpetuating factors and self-care	Address mechanical, systemic, nutritional and psychological factors; teach self-pressure, stretching, ergonomics	Practitioner, physician, psychotherapist	Client can manage between sessions [source: CBMTPT Handbook; Street]
F. Integration and review	Process body experiences, track adverse effects, decide to continue or stop	Psychotherapist with practitioner	Gains held, or no change after a fair trial → review with physician [synthesis]

Format: one-to-one, client usually on a treatment table, clothed or draped, with the practitioner checking pressure and referred sensations aloud. Typical session number and length: [uncertain: no primary-source figure]. This guide gives no pressure levels or hold times as instructions.

3. Guiding principles

Principles from developers and practitioners are cited; those for the psychotherapist's role are [synthesis] unless cited.

Pressure is graded, never forced. The manual, as quoted, warns that pressure too hard at the start causes pain, autonomic reactions and involuntary tensing, and that release fails if pressure is dropped rather than built gradually. Meaning: the client's ability to stay relaxed sets the limit. [source: Street, quoting Travell & Simons]
The client stays able to relax and breathe. NAMTPT's president advises pressure "only hard enough for the client to be able to relax into". Meaning: "no pain, no gain" is not the method. [source: MassageMag/NAMTPT]
Continuous verbal feedback. Practitioners ask during treatment whether pressure is tolerable and where pain refers. Meaning: the client speaks and is listened to all through the session. [source: MassageMag/NAMTPT]
Look for perpetuating factors. The manual and the CBMTPT exam outline list mechanical, systemic, nutritional and psychological factors that keep pain going. Meaning: stress, sleep, mood and work posture are part of the picture, and the psychotherapist has a real role here. The 3rd edition asks for these factors to be addressed from the start of treatment, not only when progress stalls [source: Trigger Point Manual 3rd ed., front matter]. Critics note the list can also be used to explain away failure. [source: CBMTPT Handbook; Street; IASP/Quintner]
Medical clearance and screening first. Clients should be cleared by their physician; clots, bleeding disorders, blood thinners, low platelets, fragile skin, wounds, pregnancy, recent radiotherapy and tumour sites need a doctor's view before massage. Meaning: no referral without screening. [source: MassageMag/NAMTPT; Healing Works pocket guide]
Consent before and during touch; the right to stop. Meaning: consent covers each body area and can be withdrawn by a word or agreed signal at any time, with no explanation needed. Touch is never sexual, and genital or intimate areas are not part of this work. [synthesis]
Role separation. A psychotherapist does not add hands-on trigger-point work to psychotherapy unless their own profession's code allows it and they hold the training and credential; mainstream codes (BACP, UKCP, BPS, HCPC, APA, AAMFT) contain no explicit touch provision but require competence and prohibit sexual contact, and body-psychotherapy codes (USABP, EABP) regulate touch directly [source: BACP 2018; UKCP 2019; BPS 2009; HCPC 2023; APA; AAMFT 2015; USABP Code VIII; EABP 2020]. Meaning: refer and collaborate, do not treat with your hands. [synthesis]
Hold the model lightly. Diagnostic agreement is limited and the mechanism is disputed. Meaning: talk about "what your therapist calls trigger points", avoid fear-raising tissue-damage language, and judge the work by how the client functions and feels. [source: IASP/Quintner; PainScience reviews; synthesis]
Trauma-informed adaptation. Meaning: predictability, choice of position and clothing, a chaperone or support person when wanted, and pacing set by the client. [synthesis]
Self-management is part of the method. Travell taught self-applied pressure (including with a ball) and stretching. Meaning: the aim is a client who can help themselves, not dependence on the practitioner. [source: Street; MassageMag/NAMTPT]

4. Intervention inventory

Part A covers what the credentialed practitioner does, described generally so you can explain it, prepare the client and recognise problems. These are not instructions for a psychotherapist to perform. Part B covers the psychotherapist's own interventions. All example wording is illustrative.

Part A. Practitioner techniques

A1. Intake and perpetuating-factor review

Purpose: gather the history that shapes treatment and screen for contraindications. [source: MassageMag/NAMTPT; CBMTPT Handbook]
Steps (as practitioners describe them): ask about health problems, medications, sleep, diet, work posture and ergonomics, and lifestyle. The client or practitioner marks pain areas and pain quality on a body chart. Review the factors the manual tradition groups as mechanical, systemic, nutritional and psychological. Obtain or check medical clearance.
Example language (practitioner, illustrative): "Before I touch anything, show me on this chart where it hurts and what the pain feels like, and tell me about any medicines you take, especially blood thinners."
Example language (psychotherapist preparing the client, illustrative): "They'll ask about stress and sleep as well as your muscles. You can say as much or as little about our work as you want."
Watch for: an intake that skips medications or medical history; the client feeling interrogated about emotional matters by someone who is not their therapist; red flags (unexplained weight loss, night pain, new neurological symptoms, fever) that need medical assessment first [synthesis].

A2. Palpation examination

Purpose: locate what the method calls trigger points. [source: Hodgson 2004; CBMTPT Handbook; PainScience reviews]
Steps (general): with consent for each area, the practitioner uses flat palpation (fingertip or thumb pressing across the muscle) or pincer palpation [uncertain: pincer palpation is not described in the cited sources] to feel for a taut band or nodule, spot tenderness, and pain referred to another area. The client is asked whether the pressure reproduces their familiar pain ("pain recognition"). A brief visible twitch of the band (the "local twitch response") is part of the tradition, though some researchers left it out because examiners agree on it poorly. Posture, gait and movement may also be checked.
Example language (practitioner, illustrative): "I'm going to press along this muscle. Tell me if you feel it anywhere else, and whether it feels like your usual pain."
Example language (psychotherapist, illustrative): "Their search for sore spots depends on what you tell them, so your honest feedback is the most useful thing you can bring."
Watch for: reviews find limited agreement between examiners, so a client told they have "dozens of knots" or tissue damage may become more frightened than the evidence supports [source: Myburgh 2008; Rathbone 2017; synthesis].

A3. Sustained pressure release (ischemic compression; trigger-point pressure release; manual pressure release)

Purpose: the core manual technique in the tradition, intended to inactivate a trigger point. [source: Street, quoting Travell & Simons; Hodgson 2004, citing Simons 2002]
Steps (general): the 1983 manual described sustained pressure on the point, built up gradually until the tenderness eases. Skin blanching followed by reddening was mentioned as an expected sign. Later descriptions (Simons 2002, as cited by Hodgson) call it trigger-point pressure release: persistent pressure with a thumb or fingertip against the first point of tissue resistance, held until the practitioner feels the tissue give, then taken further. Some practitioners use the client's pain rating to adjust pressure. For chronic, highly irritable points the manual described a gentler approach spread over several days. The pressure tools in use include finger, knuckle, elbow or a hand tool. [source: MassageMag/NAMTPT]
Example language (practitioner, illustrative): "I'll lean in slowly. If you can't breathe easily or you start to brace, say so and I'll ease off straight away."
Example language (psychotherapist, illustrative): "It can feel intense in a 'good ache' way, but it shouldn't make you hold your breath or grit your teeth. You can say stop at any point."
Watch for: the manual's own failure points as quoted: point too irritable, pressure released instead of built up, pressure too hard too soon (causing pain, autonomic responses and tensing), and unaddressed perpetuating factors. A client who endures rather than reports pain is a warning sign. A compound fracture is treated as a contraindication in CBMTPT exam material. Bruising and soreness can follow. Working: tenderness eases and the client reports better movement or less referred pain afterwards. [source: Street; CBMTPT Handbook; Healing Works pocket guide]

A4. Progressive pressure across sessions ("myotherapy")

Purpose: for chronic or hyperirritable points the manual, as quoted, described progressive work over days rather than full inactivation in one session. Travell and Simons noted that this is essentially what Bonnie Prudden called myotherapy (Pain Erasure, 1980). [source: Street]
Steps (general): lighter, repeated pressure release over several sessions, re-checking response each time.
Example language (psychotherapist, illustrative): "Your therapist may go gently over a few visits rather than all at once. That's a plan, not a sign it isn't working."
Watch for: session counts growing without measurable change; a practitioner attributing lack of progress only to the client [synthesis].

A5. Stretch and spray

Purpose: Travell's method of passive stretching of the affected muscle combined with a skin coolant (vapocoolant) spray, to make stretching more comfortable and release the point. [source: Street; CBMTPT Handbook] The 3rd edition of the manual dropped its detailed stretch-and-spray instructions in favour of dry needling, so the method now has a smaller place in the manual itself. [source: Trigger Point Manual 3rd ed., front matter]
Steps (general): the practitioner positions the client supported and relaxed, applies the coolant over the muscle and its referral area, and takes the muscle gently into stretch, followed by movement through range. Spray products, distances and timings are left to the practitioner's training and are not given here.
Example language (practitioner, illustrative): "You'll feel a cold spray on the skin, then I'll move your arm slowly. Tell me if the stretch is too much."
Example language (psychotherapist, illustrative): "The cold spray can be a surprise. If unexpected sensations unsettle you, it's fine to ask for each step to be announced first."
Watch for: startle or panic at sudden cold; skin reactions; over-stretching. [synthesis]

A6. Stretching without spray and passive range of motion

Purpose: restore muscle length and movement after release. [source: Street; MassageMag/NAMTPT; CBMTPT Handbook]
Steps (general): the practitioner moves the limb or trunk slowly through its range, or guides a gentle stretch, after pressure work.
Example language (practitioner, illustrative): "I'm going to move your shoulder through its range now. Let me do the work and tell me where it catches."
Watch for: guarding, pain at end of range, joint symptoms. Travell's family manipulation methods were an adjunct, with fracture, osteoporosis, infection and tumour to be ruled out first. [source: Street]

A7. Massage strokes used around trigger-point work

Purpose: warm tissue, find taut bands and support release. [source: MassageMag/NAMTPT]
Steps (general): basic Swedish strokes (kneading, stripping), broad compression with the whole hand, light cross-fibre friction, strumming across the fibres, and stripping along the muscle toward the heart, followed by focused pressure.
Example language (practitioner, illustrative): "I'll start with broad strokes to warm the area before I look for anything specific."
Watch for: pressure or areas beyond what was consented to; bruising in clients with bleeding risk. [synthesis; Healing Works pocket guide]

A8. Self-treatment and self-care

Purpose: continue the work between sessions. [source: Street; MassageMag/NAMTPT]
Steps (general): self-applied finger pressure, or lying or leaning on a ball for hard-to-reach upper-back muscles, as Travell taught; gentle stretching; posture and workstation changes. The practitioner sets the details.
Example language (psychotherapist, illustrative): "What did your therapist suggest for between sessions? Let's see how it fits into your week."
Watch for: over-use (bruising, flare-ups), compulsive checking of sore spots, self-treatment used to avoid feelings or other care. [synthesis]

A9. Procedures named only

Dry needling and trigger-point injection are separate medical or physiotherapy procedures with their own training and regulation. Name them if clients ask, and direct questions to the treating clinician.
Example language (psychotherapist, illustrative): "That's a medical procedure. Your doctor or physio is the right person to explain whether it's suitable for you."
Watch for: anyone offering needling outside a regulated scope. [synthesis]

Part B. The psychotherapist's interventions

The trigger-point literature cited here does not describe a psychotherapist's role, so Part B is [synthesis] built on the safety, regulatory and consent sources cited.

B1. Deciding when to suggest it, and screening

Purpose: offer a referral when muscular pain, tension or restricted movement is part of the client's difficulty and the client is interested, without implying that the pain is "psychological".
Steps: (1) Ask what the pain is like, where it is, what has been tried and whether a doctor has assessed it. (2) Screen for issues that need a doctor's view before massage: blood clots or a history of deep vein thrombosis, bleeding disorders, low platelets, blood thinners, bruises, open wounds or fragile skin, pregnancy, cancer (with recent radiotherapy or tumour sites avoided), fractures and osteoporosis [source: Healing Works pocket guide; CBMTPT Handbook; Street]. (3) Ask about red flags (unexplained weight loss, fever, night pain, new numbness or weakness, bladder or bowel change) and refer to medical care first. (4) Check the client's touch history and preferences (see B3). (5) Agree that medical clearance comes before booking [source: MassageMag/NAMTPT].
Example language (illustrative): "Some people find hands-on work for muscle pain helpful alongside what we do here. Before you look into it, it's worth checking with your doctor, especially as you take a blood thinner."
Watch for: pain framed as only emotional or only physical; clients hoping manual work will remove the need to address distress; health anxiety that a "knots" explanation could feed.

B2. Referral and collaboration

Purpose: connect the client with a properly credentialed practitioner and set up safe communication.
Steps: (1) Help the client check credentials: a state massage licence (US), NCBTMB Board Certification or the CMTPT credential where relevant, CNHC registration (UK), or a physiotherapy or medical licence [source: FSMTB/NCBTMB; CBMTPT Handbook; CNHC]. (2) Get written client consent before sharing any information, and limit it to what is needed (e.g. "startles with unannounced touch to the neck"). (3) Agree how adverse effects or concerns will be passed on. (4) Keep roles clear: the practitioner treats tissue; you hold the psychological work.
Example language (illustrative): "Would it help if, with your permission, I let the practitioner know you'd like each step explained before they start? I won't share anything else."
Watch for: practitioners who claim to treat trauma, emotions or disease by releasing points; pressure to over-share clinical details; unregistered practitioners where registration exists.

B3. Preparing clients with trauma histories for touch

Purpose: make a predictable, client-controlled experience more likely.
Steps: (1) Explore what touch means for the client and which areas, positions, pressures or sensations (cold spray, pressure on the neck, lying face down) could trigger them. (2) Write a consent plan together: areas that are off-limits, clothing or draping, preferred position, whether the door is open, whether a chaperone or support person attends, and a stop word or hand signal. (3) Rehearse saying "stop", "lighter" and "not there" aloud in session. (4) Remind the client that consent is given before and during touch and can be withdrawn at any time with no reason given. (5) Plan grounding steps for after the appointment. (6) State plainly that touch is never sexual and that genital or other intimate areas are not part of trigger-point work; any intimate-area concern belongs with regulated clinicians, such as a pelvic-health physiotherapist or physician, referred separately.
Example language (illustrative): "Let's practise the words now: 'Can you stop, please.' You don't need to explain, and a good practitioner will stop immediately."
Watch for: fawning or freezing (the client consents to what they do not want); dissociation; the client planning to "push through". If these appear, slow the referral down or postpone it.

B4. Integrating the body experience in psychotherapy

Purpose: make use of what the client noticed: sensation, referred pain, emotion, memories, relief or fear.
Steps: (1) Ask open questions about the session: what they noticed, when, what they did with it. (2) Track the link between felt sense, emotion and meaning without interpreting tissue as "storing" memories, which is not established by the sources here. (3) Note any experiences of saying no and being respected as useful experiences in their own right. (4) Connect perpetuating factors (sleep, stress, posture at work) to goals you can work on together.
Example language (illustrative): "When the pressure reached your shoulder and you felt it in your head, what happened in the rest of you?"
Watch for: strong emotion or flashbacks during or after treatment; shame about crying on the table; the client feeling that their pain is "all in their head" because stress was mentioned.

B5. Recognising adverse effects and boundary violations, and reporting them

Purpose: protect the client and pass on information safely.
Steps: (1) Ask after each early session about bruising, soreness, worsened pain, numbness or skin reactions to oils or creams [source: Healing Works pocket guide]; signs of a clot (calf swelling, heat, pain) or breathing problems need urgent medical care [synthesis]. (2) Ask whether touch went beyond what was agreed, whether requests to stop were honoured, and whether anything felt sexual or secretive. (3) If a boundary was crossed, support the client to report it: to the US state massage board or the licensing board of the practitioner's profession; in the UK to CNHC by written complaints form, where the practitioner is a registrant (CNHC handles fitness-to-practise matters and suggests raising issues with the practitioner first only where that is safe) [source: CNHC; FSMTB/NCBTMB]; to the police for any sexual assault. (4) Follow your own safeguarding and confidentiality duties, and record what was disclosed.
Example language (illustrative): "Was there any moment when you wanted it to stop and it didn't? You can tell me even if you're unsure what it means."
Watch for: clients minimising ("it was probably part of the treatment"); practitioners who discourage the client from speaking to others; repeated soreness treated as normal.

B6. Talking about a contested diagnosis

Purpose: support the client's hope and safety without overselling a disputed model.
Steps: (1) Use the practitioner's terms descriptively ("what your therapist calls a trigger point"). (2) If asked, say that the idea is debated and that examiners often disagree about where points are [source: Rathbone 2017; Myburgh 2008; Quintner et al.]. (3) Focus on what the client can do and how they feel day to day. (4) Avoid language of damage or fragility.
Example language (illustrative): "Experts argue about what these sore spots are. What matters most here is whether the work helps you move and feel better."
Watch for: the client concluding that their pain is fake or that nothing will help; rupture if the client feels you dismiss a treatment they value.

5. Handling problems

Cited points come from the sources named; the rest is [synthesis].

The client asks you to press on the sore spots yourself. Decline, and explain role separation: hands-on work belongs to a credentialed practitioner, and combining it with psychotherapy is only possible where your own code allows it and you hold the training [synthesis; source: UKCP 2019 item 23; BACP 2018 para 13; USABP Code VIII]. Illustrative: "I'm not trained or licensed for that, and keeping it separate protects what we do here. Let's find someone who is."
The client endures pain and says nothing. The manual's own cautions say that pressure too hard too soon causes tensing and autonomic reactions [source: Street]. Rehearse stop language again (B3), consider asking the practitioner, with consent, to check in more often, and explore where "enduring" comes from in the client's history.
Overwhelm, panic or dissociation on the table. The client stops the session or asks for a pause, sits up and uses grounding; the practitioner should stop at once. In psychotherapy, review triggers (position, cold spray, neck pressure, being unable to see the practitioner) and revise the consent plan, or postpone manual work. Raise referral to trauma-focused treatment where needed.
Pain or soreness worsens after treatment. Some soreness and bruising are documented side effects [source: Healing Works pocket guide]; increasing pain, numbness, swelling, or calf heat and pain need medical review, and urgent care if there is chest pain or breathlessness. Pass this on to the practitioner with consent.
No change after several sessions. The manual tradition attributes failure partly to perpetuating factors; critics warn this can explain away an ineffective treatment [source: CBMTPT Handbook; IASP/Quintner]. Agree a review point in advance, judged by the client's function and wellbeing, and return to the physician if there is no change.
Non-adherence to self-care. Explore obstacles (time, pain, low mood, perfectionism), shrink tasks, and link them to the client's goals. Do not set exercise doses yourself; refer questions back to the practitioner.
Over-adherence or compulsive self-treatment. Bruising from balls or tools, constant checking of points, or avoidance of feelings through self-treatment: work with it as you would other compulsive or safety behaviours, and ask the practitioner to review the plan.
Fear or catastrophising about "damaged" muscles. Use B6 language; the evidence on diagnosis is limited and the mechanism debated [source: Rathbone 2017; Quintner et al.]. Avoid reinforcing threat language.
Rupture over the evidence. If the client feels you are dismissing a treatment that helps them, acknowledge it, say that their experience counts, and return to shared goals.
A boundary violation or sexual misconduct by a practitioner. Believe and support the client, follow safeguarding duties, and help with reporting to the licensing board, CNHC for UK registrants, or police (B5) [source: CNHC; FSMTB/NCBTMB].
Medical conditions arising mid-course (pregnancy, new anticoagulant, cancer diagnosis or radiotherapy). Pause and get medical advice before treatment continues [source: Healing Works pocket guide]. Oncology settings need practitioners with specific oncology-massage training [uncertain].
Children and adolescents. Manual work with minors needs parental consent, the young person's own assent, a parent or chaperone present, and a practitioner trained for young people [synthesis].
Needling or injection is proposed. Name it as a separate medical or physiotherapy procedure and direct the client to the treating clinician (A9).

Sources

Web pages:

Books and papers cited (details as given in the pages above):

Travell J, Simons D. 1983. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Upper Extremities, Vol. 1. Baltimore: Williams and Wilkins (as given by Hodgson 2004).
Simons DG, Travell JG, Simons LS. 1999. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed.
Donnelly JM (ed.), with Fernández de las Peñas C, Finnegan M, Freeman JL. 2019. Travell, Simons & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, 3rd ed. Philadelphia: Wolters Kluwer Health.
Geri T, Pellicciari L, Piscitelli D (eds). 2020. Dolore e disfunzione miofasciali: Manuale per i trigger point (Italian edition of the 3rd ed.). Padova: Piccin Nuova Libraria. Publisher front matter only (introduction, preface, contents), as hosted by an Italian bookseller.
Prudden B. 1980. Pain Erasure (as cited by Street).
Simons DG. 2002. Understanding effective treatments of myofascial trigger points. Journal of Bodywork and Movement Therapies 6(2):81–88 (as cited by Hodgson 2004).
Quintner JL, Cohen ML. 1994. Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct. Clinical Journal of Pain 10(3):243–51.
Quintner JL, Bove GM, Cohen ML. 2015 (online 2014). A critical evaluation of the trigger point phenomenon. Rheumatology 54(3):392– [uncertain: end page].
Myburgh C, Larsen AH, Hartvigsen J. 2008. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Archives of Physical Medicine and Rehabilitation 89(6):1169–76.
Lucas N, et al. 2009. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clinical Journal of Pain [uncertain: volume and pages].
Rathbone ATL, Grosman-Rimon L, Kumbhare DA. 2017. Interrater agreement of manual palpation for identification of myofascial trigger points: a systematic review and meta-analysis. Clinical Journal of Pain 33(8):715–29.
Gerwin R, Shannon S, Hong C-Z, Hubbard D, Gevirtz R. 1997. Interrater reliability in myofascial trigger point examination. Pain 69:65–73 (as given by Hodgson 2004).

Professional codes and massage regulators cited above:

← Previous · X-006Hot-stone massage Next · X-008 →Neuromuscular therapy