A third edition is soon to be published by Simons and his wife, both of whom have survived Travell.
In her later years Travell collaborated extensively with her colleague David Simons. She published more than 40 papers between 19 and in 1983 the first volume of The Trigger Point Manual appeared this was followed by the second volume in 1992. Kennedy's back pain was so successful that she was asked to be the first female Personal Physician to the President. Travell, who was responsible for the most detailed and important work. It was, however, an American physician, Janet G. Today, much treatment of trigger points and their pain complexes are handled by massage therapists, physical therapists, osteopaths, occupational therapists, myotherapists, some naturopaths, chiropractors and acupuncturists, and other hands-on somatic practitioners who have had experience or training in the field of neuromuscular therapy (NMT). Kellgren conducted experiments in which he injected saline into healthy volunteers and showed that this gave rise to zones of referred extremity pain. Kellgren at University College Hospital, London, in the 1930s and, independently, by Michael Gutstein in Berlin and Michael Kelly in Australia (the latter two workers continued to publish into the 1950s and 1960s). However, there was little agreement about what they meant. The existence of tender areas and zones of induration in muscles has been recognized in medicine for many years and was described as muscular rheumatism or fibrositis in English German terms included myogelose and myalgie. Trigger points have been a subject of study by a small number of doctors for several decades although this has not become part of mainstream medicine. Since an involved muscle is weakened by this theorised sustained shortening, surrounding muscles themselves may develop trigger points in a compensatory fashion. This "energy crisis" (as it is termed in the seminal work on trigger points) causes the release of chemicals that augment pain activity. This leads to a compression of capillaries and results in an increased local energy demand and local ischemia (loss of blood circulation) to the area. The hypothesis is that usually an event of muscular overload causes a prolonged release of Ca 2+ ion from the sarcoplasmic reticulum (storage unit for the muscle cell) which results in a sticking of the untrained or overloaded cells. Compression of a trigger point may elicit local tenderness, referred pain, or local twitch response.
The palpable nodules are said to be small contraction knots and a common cause of pain.
Trigger points are described as hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.
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