Myofascial Pain and Dysfunction, The Trigger Point Manual, 2nd Edition. (2 Volumes). David G. Simons, Janet G. Travell, and Lois S. Simons. Williams & Wilkins, Baltimore, MD, 1999, 1664 pp. $189.00.
Book Review by Clifford Gevirtz, MD, MPH, Mount Sinai School of Medicine, New York, New York
“What a pain in the neck” is a phrase often heard, but when we stop to think about its origins, the importance of myofascial pain and dysfunction become clear. In this second edition, Simons, Travell, and Simons have updated and refreshed the “bible” of trigger points. The volume is also a fitting tribute to Dr. Janet Travell, who passed away during the preparation of this revision.
The 1600 pages of this two-volume set mark several transitions: from trigger points as an ill-defined concept to an experimentally established neuromuscular disease, from a solely muscular disease to one that also impacts on articular problems. Where earlier studies could not identify pathology in vitro, biochemical studies of the motor end plate now point to release of excessive amounts of acetylcholine along the length of motor fibers that are maximally contracted in a band. The actual amount of acetylcholine is modulated by the autonomic nervous system. Where facet joints were once just interesting anatomic structures, an appreciation of their rich and complex innervation and pathology lends new impetus to their manipulation.
Successful treatment of trigger points is marked by restoration of full pain-free range of motion of the affected muscle. Towards that end, a systematic approach is taken in each chapter covering an individual muscle, reviewing the anatomy, function, symptoms, activating and perpetuating factors, physical examination, and discussing the suggested technique for release and injection. A new feature in each chapter is the differential diagnosis, which should be entertained before implementing therapy. For example, in considering afflictions involving the trapezius muscle, the possibility of occipital neuralgia, cervicogenic headache, or hypermobility of C4 should be considered before embarking on therapy.
Perpetuating factors, which were long overlooked or dismissed in importance, such as nutritional inadequacies, endocrine abnormalities, psychological factors, sleep deprivation, and chronic infections are covered extensively in an important new chapter. When progress in treatment seems to be failing, the light of remembrance needs to shine on this chapter to assure that something has not been overlooked.
The illustrations by Barbara Cummings are not only crisp and clear, but also aesthetically pleasing, actively assisting the physician to easily understand the topology and the underlying anatomy. The index is thorough and complete.
In sum, this is a text that every physician who works with pain patients should be able to access, either in their personal library or at their hospital. The practitioners of pain management owe much to this trio of experts; where there was hopelessness, there is now hope; where there was mystery, there is now understanding.