Why clinical trial results are misleading

To understand why clinical results are misleading it is necessary to look at the typical trigger point development cycle, then what the clinical trials actually demonstrate.

What most clinical trials actually demonstrate

The goal of most clinical trails is to deactivate the trigger points (1–5)⁠. Deactivate simply means to revert the trigger point to how it was before it was activated, ie. to stop it shooting pain. Because of this researchers choose to only measure symptomatic and temporary factors such as:

• pain (eg using a visual analogue scale or a questionnaire)
• tenderness (eg. the amount of pressure needed to produce pain)
• Range of motion

Typically only temporary improvements are measured

These measurements are often made shortly after treatment, with occasional follow ups of a week or rarely a month.

Proof that these courses of treatment do not eliminate trigger points

We were able to find four trials that checked for the presence of trigger points post treatment (6–9)⁠. These conclusively show that even after courses of 12 extensive therapy sessions the majority of trigger points are still there, where of course they continue to develop and are eventually re-activated.

Strategies to effectively eliminate trigger points rather than just give temporary relief

Unfortunately those conducting trials on trigger point therapies have spent a massive amount of time and effort producing studies on short term symptomatic relief rather than long term elimination of the problem. To work out an effective long term strategy we need to piece together information from these and other studies relating to trigger points. Let us look at these.

The relative effectiveness of treatments

While the clinical trials give no evidence about the ability to the various therapies to eliminate trigger points they do give clues about their relative effectiveness (1-4,8,15–42)⁠. As a general observation:

• there is little difference between the effectiveness of the commonly tested therapies that directly target the trigger points (eg. laser, dry needling and the various massage and pressure techniques)
• the techniques that are claimed to use specialised neurological principles are less effective.

Trigger points can be eliminated

While the four trials that checked for the presence of trigger points after treatment found that most were still there a percentage were eliminated and the others had diminished. This indicates that further treatment will likely continue to diminish and eliminate trigger points.

An estimation of what is needed

Of the four trials that did check whether trigger points were still present after treatment the trial in example one above gives the best data (7)⁠. To summarise this patients received 12 weekly sessions. At each session multiple therapies were used under the supervision of world class trigger point researchers. Approximately 1/3 of the trigger points were eliminated.

It is only an indication, but at that rate 36 sessions would have been needed to eliminate all the trigger points. When considering that the sessions used in the trials were very extensive involving multiple therapies (more extensive than a typical professional visit) it likely that more than 36 typical professional visits would be needed. This would require the patient to attend a very expensive course of treatments that would extend way beyond when they felt better: something that very few would actually do. Therefore, to eliminate trigger points patients need to have a safe, easy to do effective self trigger point therapy so they can do at least some of the therapy themselves.

Effective trigger point treatments

When assessing what is needed to effectively treat trigger points the clinical trials are not much help. They test a variety of treatments, each being roughly equal in relation to the temporary symptomatic measures tested. To work out the best treatment we need to look at the structure, pathology, physiology and neurology of trigger points to get an idea of how treatments may be effective, then chose an appropriate remedy.

Why trigger points continue to develop

The nature of positive feedback loops is the while elements remain they will continue to develop and continue to grow. The only way to eliminate trigger points completely is to completely eliminate the trigger points and address any issues that may be causing them to develop.

Why there are so many therapies

This model explains why there are so many different therapies shown to help. Any therapy will help if it reduces any part of the positive feedback loop. For example massage helps relax muscles, increase circulation and mechanically pump out waste products.

What causes trigger points in the first place

There are a host of potential causes and contributing factors for trigger points. We will cover these below, however the two main issues are overuse/repetitive injuries and muscle tightness. Muscle tightness may have a host of courses ranging from postural issues (eg sitting at a desk) and occupational issues (eg overuse) through to emotional stress.

Note: this in not percussion massage (massage guns)

As shown in the diagrams below percussion massagers are designed to give physical penetration rather than send in vibrations. While they do give some vibrations those are a lot less than a genuine vibration massager and not at the optimum therapeutic frequencies. They give much reduced amounts of therapeutic vibrations while increasing the risk of physical injury or damage. In summary they are a marketing gimmick that is far less effective and less safe than a genuine vibration massager. For more info please see: Massage guns explained .

Summary of trigger point elimination strategy

The simple strategy to eliminate trigger points is to:

• use an effective therapy for long enough to eliminate the trigger points,
• take steps to reduce or eliminate the things that cause trigger points, while doing things that help improve muscular health.

Effective long term therapy

Regular therapy needs to be applied for long after the symptoms subside, and until examination shows that the trigger points have been eliminated. Following that, regular (but less frequent) therapy needs to be applied to prevent further trigger points from developing.

The only practical way for most people to have this is by using at least some self therapy. The only such therapy that is safe, easy to do and highly effective is using vibration massage. All a person needs to do is sit the head/pad of a vibration massager over the trigger points and allow the vibrations to penetrate and have their therapeutic effects. For details please see our Trigger point therapy guide .

As mentioned above massage guns are designed to drive their heads in like jackhammer rather than send in vibrations so they are not suitable. The other commonly prescribed self therapy is pressure using balls or rollers. This is painful, hard to do, and confirmed by clinical trial results not very effective. For more information please see our guide Do foam rollers work . Further, because they are painful and hard to so patients are unlikely to continue with these long term if asymptomatic.

How to prevent trigger points

There are a number of things that to help prevent trigger points. Most involve minimising or eliminating the two main underlying causes: overuse and tightened muscles. Let’s look at some examples.

Treat existing trigger points

As we have seen existing trigger points cause muscles to tighten and restrict blood flow. Because of the positive feedback this cause more trigger points to develop and the existing ones to worsen. Therefore, effectively treating trigger points helps prevent further development.

Sitting at a computer

1. Set up your work station to minimise postural and other stresses. An excellent resource that shows you how to do this is our Victorian Government Worksafe guidelines
2. Take regular exercise breaks to help reduce muscle tightening and help get blood pumping though your muscles.

Other jobs and activities

1. Minimise repetitive stresses and prolonged tightening of your muscles. our Victorian Government Worksafe guidelines give specific advice for a large range of jobs and activities.
2. Take regular exercise breaks to help reduce muscle tightening and help get blood pumping though your muscles.

Emotional tension and stress

Emotional tension and stress and be a significant cause of muscle knots, especially in the head and neck muscles. As an example, during the exam period in Chiropractic College fellow students sought regular treatments. This is not our area of expertise, so if this is a concern we advise that you seek appropriate advice.

Spinal and postural abnormalities

Issues with your spine and posture are a very common cause of muscles to be abnormally tight. For more information about this and what to do please see this article

Regular muscle care

Causes of muscle knots can easily be minimised, but it is practically impossible top eliminate them altogether. Therefore it is great to do some ongoing muscle care to keep them from tightening and to keep an excellent blood flow. To do this we recommend:

1. regular exercise and stretching
2. regular massages (Later in this article we will show you the best do self massage so you can do this without the expense and inconvenience)

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