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Perpetuating Factors (Excerpt)

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This section will outline some general causes of trigger point activation and how to address the factors, and each muscle section will specifically address issues particularly pertinent to that muscle. Although you can click on the section listing below to go directly to a section, I recommend you read all the perpetuating factors, since you likely have more than one factor that you may not have recognized up to this point.

Perpetuating Factors Excerpt Sections:  (This is NOT the full chapter!)

What Causes and Keeps Trigger Points Going: Perpetuating Factors

"If we treat myofascial pain syndromes without . . . correcting the multiple perpetuating factors, the patient is doomed to endless cycles of treatment and relapse. [Perpetuating factors are] the most neglected part of the management of myofascial pain syndromes . . . The answer to the question, 'How long will the beneficial results of specific myofascial therapy last?', depends largely on what perpetuating factors remain unresolved . . . One may view perpetuating factors also as predisposing factors, since their presence tends to make the muscles more susceptible to the activation of [trigger points] . . . Usually, one stress activates the [trigger point], then other factors perpetuate it. In some patients, these perpetuating factors are so important that their elimination results in complete relief of the pain without any local treatment."

~~ Doctors Janet Travell and David G. Simons1

Many practitioners who practice "Neuromuscular Therapy" or "Trigger Point Therapy" are only familiar with referral patterns and how to search for trigger points, and have not been taught to identify and figure out with the patient what is causing and perpetuating their symptoms. I have my patients fill out a complete medical history and give them a list of known perpetuating factors so that together we can do the detective work and get to the source of the problem. Trigger points are a symptom, not a cause. Needling or applying pressure to the trigger points treats the acute part of the problem, but does not solve the underlying factors. If you get temporary relief from trigger point therapy but symptoms quickly recur, then trigger points are definitely a factor, but perpetuating factors need to be addressed in order to gain more lasting relief. Be sure to check muscles listed in the muscle chapters that can cause "satellite trigger points," since this is one perpetuating cause. For example, if you find trigger points in the gluteus minimus but trigger points quickly recur, check the quadratus lumborum also, because it can refer to the gluteus minimus and cause trigger points to be reactivated there.

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Acute or Chronic Viral, Bacterial, or Parasitic Infections

Acute infections, such as colds, flu, strep throat, and bronchitis will aggravate trigger points,2 particularly in a person with fibromyalgia or chronic fatigue. It is important to head off illness at the first sign in order to avoid perpetuating trigger points. When you start to get sick, take… This is particularly important if you have fibromyalgia, sinusitis, asthma, or other recurrent infections, since your trigger points will be activated by illness, and getting sick can set you back by months in your treatment and healing.3

Outbreaks of chronic infections, such as herpes simplex (cold sores, genital herpes, herpes zoster) will also aggravate trigger points, and may need to be managed if recurrence is frequent.4

Other chronic infections such as sinus infections, an abscessed or impacted tooth, or urinary tract infections will perpetuate trigger points….

The fish tapeworm, giardia, and occasionally amoeba are the most likely parasites to perpetuate trigger points...

Allergies and other Environmental Stressors

Both inhaled and ingested allergens perpetuate trigger points and make them harder to treat due to the subsequent histamine release...

Environmental allergies must be controlled as much as possible, and if you see a specialist for a skin test to identify allergens, they will make specific suggestions based on the allergen...


In Chinese Medicine, certain types of pain will be aggravated by certain types of food and drink, and helped by others:
Pain that is sharp and stabbing, worse with stress, and better with activity will be aggravated by coffee and black tea (even decaf!), alcohol, deep fried/greasy/fatty foods, heavy red meats, food preservatives, spicy foods, caffeine, sugar, and marijuana.

Pain that is achy and worse with damp weather will be aggravated by...

Pain that is stabbing and worse with cold weather will be aggravated by...

If you feel hot, have a pulse faster than 80 beats per minute, have a red tongue, and burning pain that feels worse with the application of heat or in hot weather, the pain will be aggravated by...

Pain that is dull and achy, worse with activity, and better with rest will be aggravated by ...
Of course, you should avoid any of the listed foods that cause you to have allergic reactions.

You may have more than one type of pain, and something that is good for one type of pain may be bad for another. If it is worse for one type of pain, you should eliminate the item from your diet, even if it helps another type of pain. Eliminating the foods alone may not be enough, if the underlying condition that was caused by the food is still present. For example, if you have been eating damp-producing foods which has lead to dampness in the muscles (as in fibromyalgia), even if you stop ingesting the food you still have dampness in the muscles that must be eliminated. Plan on avoiding the necessary foods for two months minimum in conjunction with acupuncture and/or herbs and other supplements, in order to determine whether eliminating the food is helpful. Many people will stop ingesting a food or drink for one week, decide it hasn't made a difference, and then re-start their regular diet. Or the food or beverage is so important to them that they'd rather have pain and other medical conditions, than give the substance up. Reaching a conclusion after one week is one way to justify continuing to ingest the substance.15

Excess caffeine increases muscle tension and trigger point irritability, leading to increased pain...16

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Emotional Factors

While it is important to recognize the role of stress and emotional factors in creating and perpetuating illness, unfortunately all too often patients are dismissed (or medicated) by their doctors as "just being under stress." They depart the doctor's office with their physical symptoms not being assessed or addressed, particularly when it comes to the symptoms of pain and depression. This seems to happen more frequently to women, but I've had male patients who have also had this happen to them. Antidepressants may be prescribed, which may possibly help with the acute symptoms, but the side-effects can add to the underlying condition causing the symptoms, and a vicious cycle ensues. If someone is in pain long enough, of course they will begin to get fatigued and depressed. If you are depressed long enough, you will probably develop pain. Anything that has gone on long enough will have both components. One of the things I like most about Oriental Medicine and homeopathy is that both modalities assume you cannot separate the physical body from the emotions, and symptoms of both are used to develop a diagnosis, and are treated simultaneously. Also with acupuncture there are no side-effects, and response is usually rapid. With both homeopathy and herbs (Chinese or American) the wrong prescription or dosage can have side-effects, just as with Western prescription drugs, so it is important to consult with a trained professional.21

"Good Sport Syndrome"

Many people believe in pushing through the pain -- that it will make them stronger and is beneficial. Wrong! This just aggravates existing problems and makes them harder to treat.25


A healthy muscle is pliable to the touch when it is not being used, but will feel firm if called upon for action. If a muscle feels firm at rest, it is tight in an unhealthy way (even if you work-out). I like to use an analogy of a rubber band or stick. Imagine that a sudden, unexpected force is applied to the "stick," or tight muscle (such as a fall). Like a stick, the muscle will be damaged. If a sudden force is applied to a pliable muscle, or "rubberband," it will stretch with the force instead, and will be much less likely to be injured. Since latent trigger points restrict range-of-motion to some degree, and almost everyone has some latent trigger points, a muscle may be tight and restricted without you being aware of it, and can be easily injured if a sudden force is applied.

Injuries are one of the most common initiators of trigger points. If you have an injury, begin treatment as soon as possible...

Mechanical Stresses

Chronic mechanical stresses are one of the most common causes of trigger point activation and perpetuation, and are nearly always correctable...

Misfitting furniture is a major cause of muscular pain, particularly in the work place.32

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Nutritional Problems

Doctors Travell and Simons found that almost half of their patients required treatment for vitamin inadequacies to obtain lasting relief from the pain and dysfunction of trigger points, and thought it was one of the most important perpetuating factors to address. They found the most important were the water-soluble vitamins B-1, B-6, B-12, folic acid, vitamin C, and the minerals calcium, magnesium, iron and potassium. The more deficient in nutrients you are, the more symptoms you will have, and your trigger points and nervous system will be more hyper-irritable. Even if a blood test determines you are at the low end of the normal range, you may still need more of a nutrient, since your body will pull nutrients from the tissues before it will allow a decrease in the blood levels.42

Several factors may lead to nutrient insufficiency:

  • An inadequate intake of a nutrient
  • Impaired nutrient absorption
  • Inadequate nutrient utilization
  • An increased need by the body
  • A nutrient leaving the body too quickly
  • A nutrient being destroyed within the body too quickly

You may be in a high risk group if you are..:.43

  • Vitamin C reduces post-exercise soreness and corrects the capillary fragility which leads to easy bruising. (Hint: if you don't remember how you got a bruise, you are likely bruising too easily.) It is essential for collagen formation (connective tissue) and forming bones. Vitamin C is required for synthesis of the neurotransmitters norepinephrine and serotonin, is needed for your body's response to stress, is important for immune system function, and decreases the irritability of trigger points caused by infection. Too much Vitamin C can lead to watery diarrhea or non-specific urethritis. However, Vitamin C helps terminate diarrhea due to food allergies. Vitamin C is likely to be deficient in smokers, alcoholics, older people (the presence of Vitamin C in the tissues decreases with age), infants fed primarily on cows' milk (usually between the ages of 6-12 months), people with chronic diarrhea, psychiatric patients, and fad dieters. Initial symptoms of deficiency include weakness, lethargy, irritability, vague aching pains in the joints and muscles, easy bruising, and possibly weight loss. Severe cases of Vitamin C deficiency (scurvy) are rare in this country, but the gums become red, swollen, bleed easily, and the teeth may become loose and fall out. Food sources include citrus fruits and fresh juices, raw broccoli, raw Brussels sprouts, collard, kale, turnip greens, guava, raw sweet peppers, cabbage, and potatoes. It is currently known that Vitamin C daily doses above 400mg are not used by the body, and that 1000mg/day increases the risk of kidney stone formation, so mega-dosing with Vitamin C is not necessary nor recommended. Women taking estrogen or oral contraceptives may need 500mg/day. Do not take Vitamin C with antacids. Since Vitamin C is ascorbic acid, and the purpose of an antacid is to neutralize acid, antacids will neutralize Vitamin C and make it ineffective.51
  • Taking too many vitamins A, D, and E, and folic acid can cause symptoms similar to deficiencies….52
  • Thiamine (Vitamin B-1) is essential for normal nerve function and energy production within muscle cells...53
  • Pyridoxine (Vitamin B-6) is important for nerve function, energy metabolism, amino acid metabolism, and synthesis of neurotransmitters including norepinephrine and serotonin, which strongly influence pain perception….54
  • Cobalamin (Vitamin B-12) and Folic Acid need to be taken together to form erythrocytes (a type of red blood cell)…55
  • A folic acid deficiency can cause you to be fatigued easily, sleep poorly, and feel discouraged and depressed. It can cause "restless legs," diffuse muscular pain, diarrhea, a loss of sensation in the extremities, and you may feel cold frequently….56
  • Calcium, magnesium, potassium, and iron are needed for proper muscle function….
  • Magnesium deficiency is less likely to occur as a result of an inadequate dietary intake in a healthy diet as it is to malabsorption, malnutrition, kidney disease, or fluid and electrolyte loss...76
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Organ Dysfunction and Disease

Both thyroid inadequacy (also known as hypometabolism or subclinical hypothyroidism) and hypothyroidism will cause and perpetuate trigger points...

Both postprandial (reactive) and fasting hypoglycemia cause and perpetuate trigger points, and make trigger points more difficult to treat...

Gout will aggravate trigger points and make them difficult to treat....8

Sleep Problems

Pain can interrupt sleep, and interrupted sleep can perpetuate trigger points. It is useful to know whether the sleep was interrupted before the pain pattern started, or whether sleep was sound and restful before the pain started...

Spinal Mis-alignments and Other Problems

Vertebrae may be out-of-alignment, and need to be adjusted…

Herniated and bulging disks may be very successfully treated with acupuncture (especially Plum Blossom technique), but if you don't get some relief fairly quickly, you may want to consider surgery if you have insurance....

Bone spurs and narrowed disc spaces can cause pain. But in a random sample of the population you will find many people with bone spurs and narrowed disc spaces with no pain, and many people with pain and no bone spurs or narrowed disc spaces, so don't assume these are causing your problems, even if a practitioner has made this assumption.

Laboratory Tests

Laboratory tests may be necessary to help diagnose some of the systemic perpetuating factors...

Trigger Point Books

© Copyright Valerie DeLaune, LAc, 2004-2018

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Many of the Common Symptoms, Causes of Trigger Points, Helpful Hints, Stretches, and Exercises are drawn from Travell and Simons Myofascial Pain and Dysfunction: The Trigger Point Manual. Please assume that any text prior to a footnote is attributed to the source noted in the footnote.
  1. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, The Upper Extremities, (Baltimore: Williams & Wilkins, 1983), pg. 103.
  2. Travell & Simons, M.D.s, Vol. I, pg. 151.
  3. Author's experience or education
  4. Travell & Simons, M.D.s, Vol. I, pg 151.
  5. Author's experience or education
  6. Travell & Simons, M.D.s, Vol. I, pg. 152.
  7. Author's experience or education
  8. Travell & Simons, M.D.s, Vol. I, pg. 153.
  9. Author's experience or education
  10. Travell & Simons, M.D.s, Vol. I, pp. 153-154.
  11. James F. Balch, M.D., and Phyllis A. Balch, C.N.C., Prescription for Nutritional Healing: A Practical A-Z Reference to Drug-Free Remedies Using Vitamins, Minerals, Herbs & Food Supplements,(New York: Avery, 1990), 79-87.
  12. Author's experience or education
  13. http:/, search on Seasonal Affective Disorder, 12/03/03.
  14. Author's experience or education
  15. Author's experience or education
  16. Travell & Simons, M.D.s, Vol. I, pg. 90.
  17. Travell & Simons, M.D.s, Vol. I, pg. 78.
  18. Travell & Simons, M.D.s, Vol. I, pg. 92.
  19. Travell & Simons, M.D.s, Vol. I, pg. 92.
  20. Author's experience or education
  21. Author's experience or education
  22. Travell & Simons, M.D.s, Vol. I, pg. 149.
  23. Travell & Simons, M.D.s, Vol. I, pg. 54.
  24. Author's experience or education
  25. Travell & Simons, M.D.s, Vol. I, pg 149-150.
  26. Author's experience or education
  27. Author's experience or education
  28. Author's experience or education
  29. Travell & Simons, M.D.s, Vol. I, pg. 150.
  30. Travell & Simons, M.D.s, Vol. I, pp. 103-156.
  31. Author's experience or education
  32. Travell & Simons, M.D.s, Vol. I, pp. 103-156.
  33. Author's experience or education
  34. Janet G. Travell , M.D., David G. Simons, M.D., and Lois S. Simons, P.T., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, Upper Half of Body, 2nd ed. (Baltimore: Williams & Wilkins, 1999), pp. 266-267.
  35. Travell & Simons, M.D.s, Vol. I, pg. 430.
  36. Author's experience or education
  37. Travell & Simons, M.D.s, Vol. I, pp 112-113.
  38. Author's experience or education
  39. Leslie Bennett, CMT
  40. Travell & Simons, M.D.s, Vol. I, pg 113-114.
  41. Author's experience or education
  42. Travell & Simons, M.D.s, Vol. I, pg 114.
  43. Travell & Simons, M.D.s, Vol. I, pg 115.
  44. Author's experience or education
  45., Research on 6/21/04
  46. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 191.
  47. Author's experience or education
  48. Travell & Simons, M.D.s, Vol. I, pg. 125.
  49. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 201.
  50. Author's experience or education
  51. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 204-207.
  52. Travell & Simons, M.D.s, Vol. I, pg. 116.
  53. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 190-192.
  54. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 192-195.
  55. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 196-202.
  56. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 198.
  57. Travell & Simons, M.D.s, Vol. I, pp. 134-137.
  58. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 208.
  59. Balch, M.D., and Balch, C.N.C., pg. 18.
  60. Author's experience or education
  61. Balch, M.D., and Balch, C.N.C., pg. 18.
  62. Author's experience or education
  63. Balch, M.D., and Balch, C.N.C., pg. 18.
  64. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 75.
  65. Author's experience or education
  66. Travell & Simons, M.D.s, Vol. I, pg. 142.
  67. Author's experience or education
  68. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 211.
  69. Travell & Simons, M.D.s, Vol. I, pg. 142.
  70. Balch, M.D., and Balch, C.N.C., pp. 20, 120.
  71. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 208-210.
  72. Balch, M.D., and Balch, C.N.C., pg. 20, 120.
  73. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 208-210.
  74. Balch, M.D., and Balch, C.N.C., pg. 20.
  75. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 212.
  76. Balch, M.D., and Balch, C.N.C., pg. 20.
  77. Travell & Simons, M.D.s, Vol. I, pg. 144-147.
  78. Author's experience or education
  79. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 215.
  80. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 216.
  81. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 192.
  82. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 211.
  83. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 218.
  84. Travell & Simons, M.D.s, Vol. I, pp. 144-147.
  85. Travell & Simons, M.D.s, Vol. I, pp. 144-147.
  86. Author's experience or education
  87. Travell & Simons, M.D.s, Vol. I, pp. 147-148.
  88. Author's experience or education
  89. Travell & Simons, M.D.s, Vol. I, pg. 148.
  90. Author's experience or education
  91. Author's experience or education
  92. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 227.
  93. Travell & Simons, M.D.s, Vol. I, pp. 155-156.
  94. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 228.
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