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Janet G. Travell, MD on Myofascial Pain

Dr. Janet Travell gained national and international attention in 1961 when President Kennedy appointed her White House Physician. That appointment simply confirmed the high professional esteem Dr. Travell had earned as a New York City physician and teacher at Cornell University Medical College for more than 30 years.

It was Dr. Travell's pioneering work in the diagnosis and treatment of myofascial pain that brought her and then-Senator Kennedy together as doctor and patient in 1955. Her therapy literally put the senator on his feet and energized his political career.

Nevertheless, long before she and Senator Kennedy met, Dr. Travell was a Phi Beta Kappa graduate of Wellesley College, distinguished scientist, medical researcher, teacher, clinician, author, wife, and mother.

Her book, Myofascial Pain and Dysfunction: The Trigger Point Manual, co-authored with David G. Simons, MD, has become the text par excellence for the diagnosis and treatment of myofascial pain syndromes of the skeletal musculature for the upper half of the body. A second volume of that text will be published by Williams and Wilkins and will be devoted to the diagnosis and treatment of lower-body myofascial dysfunction.

Senator Barry Goldwater may well have summed up our collective gratitude when he told President Kennedy in a letter that he doubted if the president would ever do anything finer for the American people than bringing this remarkable woman to their attention.

DR. WHITE How did you get interested in myofascial pain? Was there something that happened in your early training?

DR. TRAVELL While I was in medical school and later interning at the New York Hospital, I had a painful shoulder. I was examined and nothing showed up. I couldn't lie comfortably on my right side, and while poking around over the shoulder blade I put my finger on a spot I could just reach. It was very sore and I pressed it and felt it reproduce the pain down my arm. Well, it was a trigger point in the infraspinatus muscle, and we began studying it. It didn't match any known pain pattern of nerve root or segmental distribution or that of any peripheral nerve; it was an independent pattern. We examined patients with shoulder pain and this was the most common source of their pain. Edeiken and Wolferth were internists from the University of Pennsylvania, and they had described trigger zones of pain in relation to heart disease. I got the name from them. Steindler and Luck from the University of lowa had written a couple of papers on procaine tests for allocation of pain to hard or soft tissues. They injected procaine into a tender muscle and if that stopped the pain, they concluded that the pain came from that muscle; and the next day they would cut the muscle so that it would atrophy. One of their case reports described a patient who had the procaine test and the pain was relieved; the next day the patient refused the muscle surgery and got better, too.

DR. WHITE Was that your first clue that procaine might relieve pain permanently?

DR. TRAVELL Yes, it was. I was then teaching pharmacology and also working on a general medical service, a cardiovascular service, and a tuberculosis service. If a patient had pain in the shoulder from a trigger point, perhaps in the infraspinatus, which referred pain to the shoulder and arm, we began mapping the patterns. When I asked the staff at the tuberculosis hospital what caused the pain, they would say, "It comes from the infected lung, of course." On the cardiac service, I'd ask the staff what caused the pain in the shoulder and they replied, "It comes from the heart, of course." On the medical service, they said, "It's an emotional, psychogenic pain." All the patients had identical patterns and we mapped these patterns. We began injecting the trigger points with procaine and got good results.

DR. WHITE So your first pain patterns that you drew were based on their symptoms?

DR. TRAVELL Yes. We would map the distribution from the patient's description of the pain. Later we learned that J.H. Kellgren in England injected hypertonic salt solution into muscles, which evoked a pattern of referred pain. It was a local irritant and it set up a predictable pain pattern that lasted maybe 10 or 15 minutes.

DR. WHITE You were able to experimentally produce these pain patterns?

DR. TRAVELL That's right. You could duplicate the pattern. When you inserted the needle into a muscle's trigger point, the patient would say, "Oh, I feel that down here. I couldn't feel it there, could l?" And I would reply, "Here's the picture." I did a study called "Referred Somatic Pain Does Not Follow a Simple Segmental Pattern". I presented it in 1946 to the neurological section of the Federation of the American Societies for Experimental Biology, and I was very concerned. I didn't think they would accept the evidence. I gave the data and showed the patterns and about nine neurologists and neurophysiologists got up and said that they now understood something they didn't understand before. Only one objected. I was amazed.

DR. WHITE At that time the common understanding of pain was that it had to follow a segmental pattern.

DR. TRAVELL That's correct. And these trigger point pains do not.

DR. WHITE Why do so many TMJ patients have multiple muscle pains?

DR. TRAVELL Trigger points multiply either in muscles that function together or as satellites in pain reference zones. Satellite trigger points develop when muscles in the pain reference zone go into spasm and hypercontract. For instance, most people don't think of the sternocleidomastoid muscle as a masticatory muscle, but it is. Green, DeGroot, and Sutin (published in 1957) studied the sternocleidomastoid electromyographically and discovered that every time the mandible moved, in speaking, swallowing, or chewing, the sternocleidomastoid contracted; the sternocleidomastoid checked any movement of the head. If it didn't, every time you chewed, spoke, or swallowed, and the center of gravity changed, your head would bob like a chicken's. So a sore masseter muscle with trigger points might cause the sternocleidomastoid to contract and form secondary functional-unit trigger points. This could then enlist the parallel line scalene muscles, which would also develop trigger points. Each of these muscles have specific pain reference zones, and when these overlap, they can confuse you.

DR. WHITE Is it a splinting effect?

DR. TRAVELL You have two things happening. First, the primary muscle initiates pain, and then others of the functional unit guard and protect the primary muscle by dividing the load.

DR. WHITE Are trigger points simply dense areas of muscle tissue, or are there metabolites there that cause muscles to tighten up?

DR. TRAVELL Both. When I did direct temperature recordings from trigger points, the temperature was higher than the surrounding tissue. If you put the needle electrode directly into the trigger point, it causes a pain initially and then as the pain subsides, the temperature drops back down, too. Thermography shows trigger points as hot spots, areas of higher temperature. The trigger point is a very tender spot in a palpable band of the muscle; it feels firm and, undoubtedly, has an increased metabolic rate and restricted vascular circulation; so you would have an accumulation of lactic acid, kinins, and a whole variety of locally irritating substances that produce pain. The palpable band is under a lot of tension, and if you snap it transversely at the trigger point, the muscle band contracts, causing a local twitch response. David Simons has done electromyographic studies on this.

DR. WHITE How did you and David meet?

DR. TRAVELL Well, I was asked to give a lecture in San Antonio, Texas, at the School of Aerospace Medicine at Brooks Air Force Base, and he was stationed there. He was doing electrodiagnosis and didn't really deal with the care of patients. They were referred to him and he would do the testing, and then they would go back to their different departments. I got him more interested in what was going on with the patient. He was working also with the central committee of the Veterans Administration here in Washington, DC. He was supervising research in VA hospitals and came to Washington nearly every month. He would come and stay with us for a night or two and we would sit up and talk all night. We were always exchanging ideas. Then he decided to go back to the patient. He took a three-year residency in physical medicine and rehabilitation in Seattle. And then he returned to the VA in California after that. You know about his work with NASA in space, don't you?

DR. WHITE No, I've never talked to him about it.

DR. TRAVELL Oh, my! He was the first man in space. NASA gave him the job of determining whether man could live in outer space. He worked on it for about five years, and he published 15 or 20 papers, all kinds of physiological studies; and he said, "Yes, man can live in outer space." And they said, "How would you like to be the first man?" He said, "Fine"; and they sent him up 100,000 feet in a helium balloon in August 1957--before Sputnik. He was featured on the cover of Life magazine Sept. 2, 1957. He was the first man to go beyond the earth's atmosphere.

DR. WHITE Did you and David ever have any disagreements about the book?

DR. TRAVELL There was never any personal disagreement. Sometimes we'd argue and argue about ideas, but he is really an extraordinary person with a wonderful sense of humor. We have a wonderful time working together. David has always said it isn't who is right, but what is right that counts.

DR. WHITE How can clinicians distinguish whether they are injecting the primary trigger point, or they are injecting some of these satellite or secondary trigger points?

DR. TRAVELL Sometimes it's difficult to know, so I make drawings of pain patterns (Fig. 1).

DR. WHITE Draw maps?

DR. TRAVELL Maps of the patient's pain on a body form. The patient has pain, perhaps in the neck and the head and the arm and the back. I try to date these regions and find out which was the first pain that they had. And that's usually the primary one. Now if you take away the secondary and satellite trigger points, the pain pattern will shrink; certain parts of it will drop out, and at the next visit this is gone and that is gone and you are left with parts of the pattern. And you compare it. You may get the primary one early, or you may attack it later.

There are also mechanical factors, perpetuating factors; and there are causal systemic factors, such as infections and endocrine disturbances and anemia, etc. If these are not controlled, even if the local treatment is perfect, the trigger points tend to reactivate. And this is the difficulty that dentists have in dealing with medical problems: they need physicians to work with them as a team.

DR. WHITE And this brings up a problem . . .

DR. TRAVELL Even if the dentist did the trigger point injection perfectly, the patient might not get better unless these systemic factors were corrected also. More and more, physicians are becoming skilled in the management of myofascial pain syndromes. For instance, the First International Symposium on Myofascial Pain and Fibromyalgia was held May 8-10 in Minneapolis and was sponsored by the University of Minnesota.

DR. WHITE Where can health professionals learn more about the diagnosis and treatment of myofascial pain?

DR. TRAVELL The Academy of Physical Medicine and Rehabilitation and the American Congress of Rehabilitation Medicine work together. The American Congress is broad-based and has as members many different health professionals, such as dentists, physicians, and physical therapists, who are interested in pain management.

I would also recommend a relatively new publication by the National Academy Press, Pain and Disability. This was published in May 1987, and it is the result of a lengthy study by the Institute of Medicine and the Social Security Administration. It is the bible on causes of disability and the anatomy and physiology of pain. Lawrence A. Funt, DDS, and I have taught courses to physicians and dentists for several years. Larry is chairman and director of the Cranio-Facial Pain Center in Bethesda, MD. These are a few sources for information about myofascial pain.

DR. WHITE How can you distinguish the myofascial pain syndrome from fibrositis or fibromyalgia? They seem so similar.

DR. TRAVELL No, the myofascial trigger point is a tender spot in a palpable band in the muscle. If that tender spot is pressed and snapped, the band of muscle contracts. That's a local twitch response. And if the sustained pressure is exerted on the trigger point, you can induce the predictable referred pain pattern.

DR. WHITE And you can't do that with fibromyalgia?

DR. TRAVELL The tender points of fibromyalgia probably don't refer pain, but this is usually not tested or reported.

DR. WHITE How do you differentiate between active and latent trigger points?

DR. TRAVELL The active trigger point causes a clinical complaint of referred pain and referred tenderness and also shows related restriction of motion (Fig. 2). The muscle won't lengthen to its full length, and when it contracts and shortens, this also sets up pain. And the muscle is weak, without neurological changes. It does not atrophy; it's chronically fatigued because it is working too hard all the time. And there are referred patterns not only of pain, but autonomic concomitants. There is sweating or flushing and other autonomic changes that you can see and often record by thermography.

All of these--the restriction of motion and the local twitch response of the palpable band--are there even if the trigger point is latent. It is latent only with respect to pain and it does not cause a pain complaint that brings a person to the doctor. And it's also hard to induce the referred pain from the latent trigger point. An active trigger point with a lot of pain often quiets down spontaneously, and the patient is left with a latent trigger point that is readily reactivated by minor strains and stresses.

DR. WHITE So you could think of a latent trigger point as a pain just waiting to happen?

DR. TRAVELL That's right, just waiting to happen.

DR. WHITE How common is myofascial pain in the population?

DR. TRAVELL It's very hard to find anybody who doesn't have these trigger points.

DR. WHITE Almost 100%, then?

DR. TRAVELL In my experience I would say at least 90%. Once in a great while I can find somebody without trigger points and they are usually nonathletic; they don't use their muscles. The more athletic a person is, and the better the muscles are conditioned and coordinated, the more likely it is that these muscles learn to go on guarding and splinting for years after an injury.

DR. WHITE Have you ever wondered why such a common, serious, painful, expensive problemlike myofascial pain has been so overlooked?

DR. TRAVELL It's easy to understand. The muscles don't show on x-rays and they don't show on nerve testing or electromyography, unless a tense muscle happens to pinch a nerve causing peripheral nerve entrapment. But a straightforward myofascial trigger point does not cause measurable electrogenic changes. Now, I think some variety of MRI, magnetic resonance imaging, will eventually help us make the soft tissue diagnosis.

DR. WHITE But right now there's not anything better?

DR. TRAVELL Nothing better than the fingers and the eyes.

DR. WHITE So you should try to develop eyes in your fingers?

DR. TRAVELL Eyes in the ends of your fingers. But you also have the pattern of referred pain, you have the restriction of motion, you have other objective criteria. Thermography shows the vasomotor changes in the pain reference zone. It doesn't explain them, but it shows there's something wrong that the patient isn't inventing. But you must examine the patient. This is the way you learn about myofascial pain syndromes, together with the history. This all takes a lot of time.

DR. WHITE Dentists, and I imagine physicians, seem to rely too much on x-rays, lab tests, and everything save touching and carefully examining the patient.

DR. TRAVELL That's the problem. The patient comes in and says he saw a neurosurgeon and an orthopedic surgeon and a psychiatrist. When I ask what the surgeon did, the patient may say, "He watched me walk and he looked at my x-rays and tests." But when I ask, "Did he feel of your muscles?" the patient says, "Oh, no, he never put his hands on me."

DR. WHITE You've got an entire chapter in your book, Myofascial Pain and Dysfunction: The Trigger Point Manual, dedicated to perpetuating factors.

DR. TRAVELL That's Chapter 4, and it's probably the most important chapter in the book because you can make the diagnosis and find the muscle that is making the trouble and treat it correctly. But if you don't correct these contributory causes, the condition is better for a while and then it recurs.

DR. WHITE Could you give us some examples?

DR. TRAVELL Well, there are physical factors like leg length discrepancy with functional scoliosis, also short upper arms, head-forward position, nearsightedness, and the way you drive your car. There are dozens of such physical factors. Systemic contributory factors include borderline anemia and especially borderline low thyroid function; and if you do not correct these, the patient will not get permanently better.

DR. WHITE Do you feel that lack of proper nutrition is an important perpetuating factor?

DR. TRAVELL Oh, tremendous. Deficiencies are often found in B vitamins, such as folic acid and vitamin B-6, since they are so perishable.

DR. WHITE When dentists check for masticatory myospasm--myofascial pain of the masticatory muscles--should they do it in a particular way? Mouth open? Mouth closed?

DR. TRAVELL The first thing is to make a chart on a form of the head and neck and ask the patient to show you with the finger where the pain is felt. I had one patient who had "TMJ pain" that had been treated unsuccessfully and I asked her to show me, don't tell me, show me, where the pain is. And she put her finger just behind the ear on the mastoid bone. She said "right here, right in my TMJ".

DR. WHITE On the mastoid bone?

DR. TRAVELL Yes, not the TMJ. And if you have a patient who comes in complaining of pain in the shoulder and you say, "Well, show me where it hurts, please put your finger on it", the answer may be, "Well, you know, I can't quite reach it", and the person reaches down behind the shoulder blade. The next one says, "Well, it's right here in my shoulder", and points to the angle of the neck. You have to communicate. People just don't know the front or the back from the side; they don't know where the low back is. The first thing that you have to do is to get a picture of where the pain actually is. Have the patient show you, not tell you.

DR. WHITE So you get a good picture of the pain by having the patient point it out?

DR. TRAVELL That is the key. You have to get an accurate picture of the pain distribution.

DR. WHITE Then you can refer to your geographic map?

DR. TRAVELL Yes, and then you ask, "Is this everywhere you hurt?" And the answer is, "That's it." Then you say, "Do your feet hurt?" "Oh, yeah, sure." You say, "Why didn't you tell me?" The patient says, "Doesn't everybody's feet hurt? My feet have hurt all my life." They may neglect to tell you about areas they think are unimportant. You have to keep questioning.

DR. WHITE So a good history is invaluable?

DR. TRAVELL The history lets you complete the picture. Then you date when these symptoms began and try to relate it to events in their lives. This began when you moved from California to New York and you had everything packed and you did all of this; or this began when you got a new job; or this began after you had a viral infection and you were very sick and had pneumonia.

DR. WHITE What is your next diagnostic step after the history?

DR. TRAVELL Study the restriction of movement and demonstrate it to the patient. After doing this, I can usually reproduce the pain by putting my fingertip on the responsible trigger point.

DR. WHITE Do myofascial syndromes of the masticatory muscles ever refer pain to teeth?

DR. TRAVELL Oh, yes.

DR. WHITE How could the dentist easily differentiate between dental pain and masticatory muscle pain?

DR. TRAVELL The temporalis muscle is often overlooked. And trigger points in it refer pain to the upper teeth. Trigger points in the anterior border of the muscle hit the two upper incisor teeth, and then there's a section low in the back part of the muscle that hits the upper molars. The masseter trigger points refer to both upper and lower molars. And it hurts to bite, and these teeth are hypersensitive to heat and cold, as well as to pressure, which represents referred tenderness.

DR. WHITE How about referring to gums?

DR. TRAVELL The masseter trigger points refer either to the upper or the lower teeth depending on the level of the muscle involvement, and to the gums around them. The anterior division of the digastric refers pain and tenderness to the lower incisor teeth. I once had a patient who had driven with the car window open, and a cold draft blew on his face and he developed a severe toothache. He went to his dentist, and the dentist told him he couldn't find anything wrong. He came to me because I had treated him for other pain problems, and I cleared up the toothache immediately by injecting the myofascial trigger points in the temporalis muscle. The hypersensitive teeth were normal.

DR. WHITE In your own experience, do you find women more susceptible to myofascial pain?

DR. TRAVELL That's an interesting question. There are reports that it's more frequent in women than in men; but at one time I went through a year's list of my patients to see how many were men and how many were women, and it was about 50-50. Women tend to report their symptoms earlier than men do. Men think they can manage it, and they are often less likely to go to a doctor with a complaint of pain than a woman is. I really think that it's just about the same frequency for both sexes.

DR. WHITE We were talking about perpetuating factors for pain generally; what would be someof the perpetuating factors dentists should look for specifically in their patients with masticatory muscular pain?

DR. TRAVELL The premature contact of a tooth can cause chronic muscle contraction and fatigue. Extensive gum chewing may overwork these muscles. Smoking and chewing on the end of a pipe can perpetuate pain in masticatory muscles. One patient who stopped smoking said he still liked to hold the pipe in his teeth. He didn't smoke it any more, but he chewed the pipe constantly.

DR. WHITE Sometimes with facial pain, you'll see an eyelid droop or people have blurred vision or an eyelid twitching, even lacrimation. Why would you have these autonomic responses?

DR. TRAVELL These are complex reflex effects. The trigger points of the sternal division of the sternocleidomastoid muscle are often accompanied by a narrowing of the palpebral fissure of the eyelid.

DR. WHITE If you sprayed and stretched the sternocleidomastoid, you should get rid of that?

DR. TRAVELL That's likely. But you may have a satellite trigger point in the orbicularis oculi, the muscle that encircles the eye and controls the eyelid, which makes this more difficult to treat. This is quite common.

DR. WHITE How can you distinguish myofascial facial symptoms from neurological ones?

DR. TRAVELL With the neurological disorder known as Horner's syndrome, you will see pupillary changes. There may be nystagmus. If the eyeball jerks when the patient looks up, down, or sideways, that's usually a neurological problem. The coordinated twitching of the dystonias is neurological, not myofascial.

DR. WHITE Do you think dentists should be hesitant to inject these myofascial trigger points?

DR. TRAVELL I think dentists need training. I think they need to study the problem before they treat it, and to work with physicians.

DR. WHITE They should not have a cavalier attitude?

DR. TRAVELL Correct. And the trigger point in the palpable band is tough. When you insert the needle, it may press against the trigger point from outside and set off the referred pain just like pressing through the skin; and the operator says, "Oh, I hit the trigger point. I've set off the referred pain." That's a misconception. You have to feel the local twitch response during the injection, and that's different from just setting off the referred pain.

DR. WHITE So the injection technique tells you whether you've hit the trigger point or not?

DR. TRAVELL There is usually a cluster of trigger points, and if you hit one or two there may still be another one. As soon as the injection is done, the muscle is passively stretched. If you have hit all of the trigger points, you should be able to achieve the full resting normal length of the muscle. Whatever treatment you are applying to the muscle, you need to stretch that particular band of muscle to check on the effectiveness of the therapy.

DR. WHITE If the range of motion doesn't increase, then your diagnosis or therapy is wrong?

DR. TRAVELL That's usually correct. If the patient can't put the ear on the shoulder on side-bending of the neck and then you loosen up the trapezius so that the ear does touch the shoulder, the surprise is evident: "Oh, my goodness." You can see what's happened. The cause is muscular; you haven't changed the bones or the joints. It's very objective.

DR. WHITE Is it the injection that is important?

DR. TRAVELL Yes, but it's the stretch that's most important. Even when you spray and stretch, it's the gradual passive stretch that returns the muscle to full normal length.

DR. WHITE I notice that you always spray in one direction. Why just one direction?

DR. TRAVELL I did a lot of subjective testing, and when I sprayed patients in one direction, they loved it. When they came in the next time, I sprayed back and forth and they'd say they didn't like it like that--"What are you doing?"

DR. WHITE Was the back-and-forth spraying too cold?

DR. TRAVELL No, it's like rubbing a cat's fur the wrong way. And the spray should follow the direction of referred pain. I did an enormous amount of testing. You must be careful not to chill the muscle, only to cool the skin.

DR. WHITE Try to do something like activate those large myelinated fibers that Melzack and Wall talked about?

DR. TRAVELL The Gate Theory?

DR. WHITE Yes, the gate control mechanism of pain. And you use Fluori-Methane spray instead of ethyl chloride?

DR. TRAVELL Well, ethyl chloride was introduced by Hans Kraus, and it's a little too cold and may be dangerous for several reasons. You know why?

DR. WHITE It's flammable, for one thing.

DR. TRAVELL Right, and also explosive in the right mixture of air. It's also a rapidly acting general anesthetic, but with necessary precautions, it can be used effectively.

I don't think that people should breathe the Fluori-Methane spray. The vapor is heavy and pools on the floor; the head should be raised somewhat, the nose shielded, and the eyes protected, of course. The Air Force used to use it as a fire extinguisher.

DR. WHITE What was ethyl chloride used for originally?

DR. TRAVELL It was used as a rapidly acting general anesthetic. We used to use it many years ago for some quick surgical procedures like taking sutures out or changing a dressing over a large wound.

DR. WHITE You don't typically use any muscle relaxants for treating myofascial pain?

DR. TRAVELL It's common for the patient with trigger points in several muscles of a functional unit to complain that they were given a muscle relaxant and it made them worse. The dose of relaxant given was such that it relaxed the guarding, splinting muscles and not the primary muscle. Thus, muscle relaxants actually may overload the primary muscle. When patients receive muscle relaxants and the pain is worse, it is hard sometimes to convince them that their problem is muscular.

DR. WHITE Do you ever use anything like antihistamines?

DR. TRAVELL Yes. Many of these patients have allergies, and one that I depend on is Dramamine. Dramamine, of course, is over-the-counter and it's non-addictive and doesn't develop tolerance. It was introduced as an antihistamine. I use practically no narcotics. In fact, I get patients off narcotics. Other antihistamines may be very helpful. A sustained action tablet is prescribed--one in the morning and one in the afternoon--and Dramamine at bedtime. This program can be helpful because many of these people have active allergies that contribute to the muscle problems.

DR. WHITE You use a ½% procaine solution for your injections?

DR. TRAVELL I purchase a 2% solution of procaine (novocaine) in a 10cc multiple-dose vial. Then I dilute it one part to four in the syringe with sterile isotonic solution to make the procaine ½%.

DR. WHITE Is there any particular reason why you won't use a longer-acting local anesthetic like marcaine?

DR. TRAVELL Procaine is an ester. Marcaine and Idocaine are amides. Procaine is metabolized in the bloodstream; it is degraded by procaine esterase. Within two or three circulations of the blood, it's out of the bloodstream. The amides are largely metabolized in the liver. Any small impairment of liver function can make them toxic. A person who takes alcohol in excess or has any cirrhosis of the liver should definitely not be given lidocaine or marcaine. The amide local anesthetics, especially the most long-acting types, also cause local muscle necrosis. Lidocaine is less likely to cause necrosis than marcaine. Procaine has no necrotic effect. Procaine isn't just a local anesthetic; it's also a vasodilator, and the vasodilator effect can last many hours. The trigger point is an area of vasoconstriction and procaine is a vasodilator. Procaine also partially blocks the myoneural junction and has a partial curare-like effect. Thus, it produces direct muscle relaxation. It blocks the high-frequency impulses, but does not produce complete curarization. If I were working on the peroneus longus muscle, which has a trigger point close to the deep peroneal and superficial peroneal nerves, and I used marcaine and while injecting the trigger point produced a nerve block, the patient wouldn't be able to walk for how long?

DR. WHITE At least eight hours.

DR. TRAVELL A long time. If I inject ½% procaine and I get a nerve block, it's gone in 15 or 20 minutes.

DR. WHITE So it's not the duration of time that's making this trigger point injection work, it's the placement of the needle.

DR. TRAVELL Yes. A dry needle inserted into the trigger point may accomplish the same thing, without any local anesthetic solution, although it hurts a great deal more. I think that procaine adds something to the relief of pain. But the needle itself does quite a lot.

DR. WHITE You recommend using moist heat after you spray and stretch and after you inject and stretch, even though the heat may not penetrate deeply into the muscle.

DR. TRAVELL There are reflexes from the skin that interrupt pain impulses when moist heat is used. We are creatures of the sea. But if you have nerve entrapment, it can't stand heat. Cold will make the edematous nerve feel better and heat will make it worse.

DR. WHITE So the effect of heat can be a diagnostic aid?

DR. TRAVELL Yes, a possible signal of nerve entrapment. And if a patient tells you that using moist heat made it feel better, but now the heat makes the pain worse, you may have added a nerve entrapment problem to the original myofascial syndrome.

DR. WHITE Are there other things that are effective--massage, for instance?

DR. TRAVELL Yes. I described ischemic compression 25 years ago--sustained compression of the trigger point. If you press hard enough to block the blood flow, you produce anoxia, which causes a nerve conduction block somewhat similar to local anesthesia. And various kinds of massage and electrical stimulation may be effective in inactivating trigger points.

DR. WHITE How long should a clinician work with these therapies without success before suspecting the diagnosis?

DR. TRAVELL The clinician should look at both sides of the coin. The patient should have a complete history and physical examination and probably a neurological examination, as well as many laboratory tests, to rule out complicating disease. There may be a more serious systemic problem associated with the muscular one, and we mustn't overlook that. Even though the many tests may be negative, they really should be done.

DR. WHITE Should the patient be given Fluori-Methane spray to use at home?

DR. TRAVELL The patient, as a rule, cannot use it alone.

DR. WHITE I mean with somebody helping.

DR. TRAVELL It's not as simple as it looks. And the person has to know what they are doing, and how to exert the passive stretch, and not cause pain, not overdo it, and not chill the muscle. I do teach some members of the family how to use it. You need to be very cautious, and you can't just hand out a bottle of spray; it won't work.

DR. WHITE Many people don't know that you write poetry. Have you written any lately that you would like to share with us?

DR. TRAVELL Not really. It's good mental gymnastics, a lot of fun.

DR. WHITE I like one published in your autobiography:

To dwell above all man's follies

Is cowardly resignation.

Better to climb on life's trolleys

With hope and high destination.

DR. TRAVELL "Keep Riding Those Trolleys". That's what we do. Don't look back; look ahead (Fig. 3).

DR. WHITE You know, in rereading your autobiography, I was impressed by the relationship you had with your husband, Mr. Powell.

DR. TRAVELL He's the hero of that book.

DR. WHITE He seemed decades ahead of his peers in encouraging and supporting your professional life.

DR. TRAVELL He was always absolutely wonderful. Incredible. And we had such a happy time and so much fun together with our children, Janet and Virginia.

DR. WHITE Your most famous patient, of course, was John F. Kennedy; and you served him and President Johnson and their families. But did you have other patients at the White House?

DR. TRAVELL The President and the first family were my primary responsibility. The Vice President, too, and they said if I could, I should do something for members of the cabinet and subcabinet, but not to go beyond that. I was responsible for visiting heads of state at Blair House if they needed medical care, but I used to do something for anybody and everybody in the White House--the cooks, the maids, the chauffeurs. Everybody made a little racetrack to my door; I loved to help them.

DR. WHITE You once visited President Eisenhower's physician in the White House and left thinking what a terrible job that poor man had.

DR. TRAVELL Oh, yes, but that was before I ever knew I was going to be there. I was nearly 60 years old, you know, when I was appointed in 1961. I was of the age when many people would be ready to retire, but I started a new life.

DR. WHITE Have you had any special projects lately?

DR. TRAVELL I did a lot of work on seating design; and we haven't talked about chairs at all. I think the dental chair is a problem.

DR. WHITE You think it's too uncomfortable?

DR. TRAVELL It needs a better design. It has a rounded footrest and the weight is supported on the calf, but the weight of the lower leg should be supported from the heel. The dental chair has, as a rule, no lumbar support. It needs to have this support to maintain the normal lumbar curve. Also, the person can't change the angle of the hips; they are kind of locked in, and if it's a long dental procedure, the patient should get up and stand or hang their legs over the side and stretch every little while. Immobility is so hard on muscles.

DR. WHITE Has any dental company showed an interest in redesigning dental chairs along this line?

DR. TRAVELL I think there are people working on it. I have worked on airplane seating; I designed the John Deere tractor seat; I enjoyed occupational seating design. If I hadn't studied medicine, I would have been an engineer.

DR. WHITE I wonder if maybe you didn't inherit some of that.

DR. TRAVELL Well, one of my father's younger brothers was Warren Travell. He was an engineer and he was an inventor. He had patents on cranes and all kinds of things, and he worked for Thomas A. Edison.

DR. WHITE Weren't there several physicians in your family?

DR. TRAVELL Yes, there were eight: my father, one of his brothers, my sister, three of her children, one stepbrother, and myself. Four of the eight were women, and I never felt discriminated against in any way.

DR. WHITE When did you decide to become a physician?

DR. TRAVELL When I was 7 years of age. I was very positive about it from that early in my years. And everyone said, "Oh, no, you won't do that, you'll give that up." But I never changed mymind.

DR. WHITE How influential was your father in that career decision?

DR. TRAVELL He was influential in all aspects of my life. He sent my sister and me to good schools, but he, rather than the schools, taught me to think. He pointed out the value of time and the importance of concentration. He also taught me to focus on the things I did not know. Mental discipline and enjoying the challenge of the unknown were implanted in me early by my father.

DR. WHITE Wasn't your father a pioneer in the diagnosis and treatment of musculoskeletal and neurological pain?

DR. TRAVELL Yes, he was a pioneer in physical medicine and was especially skilled in the treatment of musculoskeletal pain.

DR. WHITE I suppose he was a good collaborator as you developed your techniques of restoring muscle health, wasn't he?

DR. TRAVELL My father was a great clinician, and I cannot measure how much I gained by exposure to his practical wisdom and specialized knowledge of physical medicine and rehabilitation. He certainly directed my interest toward relieving obstinate muscular pain.

DR. WHITE Wasn't your father one of the first people in America to use an electric current to treat myospasms?

DR. TRAVELL My father loved to work with tools and machines. He had a complete workshop in our house and made crystal radio sets. Fifteen years before Singer Sewing Machine Co. manufactured an electrified machine, my father put a motor on my mother's treadle-operated sewing machine. And he was a pioneer in the use of the temperamental Toepler-Holtz static-electric machine used to treat painful muscles, nerves, and joints. It was hard to regulate, but he was more than a match for it. He served as president of the American Electrotherapeutic Association and received one of the first four honorary certificates of the American Board of Physical Medicine when it was organized in the mid-1940s.

DR. WHITE Could we have one last piece of advice about avoiding muscle problems?

DR. TRAVELL If the muscles aren't moved, lengthened, and shortened, they develop tension and spasm. One of my favorite prescriptions is an interval timer. You should set it for 20 minutes and place it on the opposite side of the room where you work. When it rings you get up, stand up, stretch, walk over, and turn it off and start it again. It doesn't tell you what time it is, doesn't have to interrupt your train of thought. You don't depend on anybody to tell you to get up and do it, but you train yourself to use an interval timer so that you get up every 15 or 20 minutes, walk over and turn it off, and come back and go on with your work. I am reminded of an old proverb: "The mind can absorb no more than the seat can endure."

DR. WHITE Dr. Travell, JCO and its readers thank you for this interview, but more important, for your scholarly persistence as a champion of an idea about which everyone needs to know more.

Fig. 1 The Xs locate trigger points in various parts of the masseter muscle. Solid black shows essential referred pain zones, and the stippled areas are spillover pain zones. A. Superficial layer, upper portion. B. Superficial layer, mid-belly. C. Superficial layer, lower portion. D. Deep layer, upper part--just below the temporomandibular joint. (From Travell, J.G. and Simons, D.G.: Myofascial Pain and Dystunction: The Trigger Point Manual, © 1983, Williams & Wlikins Co., Baltimore. Reprinted by permission.)
Fig. 2 Referred pain patterns from trigger points (X) in the left temporalis muscle (essential zone solid black, spillover zone stippled). A. Anterior "spokes" of pain arising from the anterior fibers (trigger point one region). B,C. Middle "spokes" (trigger point two and trigger point three regions). D. Posterior supra-auricular "spoke" (trigger point four region). (From Travell, J.G. and Simons, D.G.: Myofascial Pain and Dysfunction: The Trigger Point Manual,© 1983, Wllliams & Wilkins Co., Baltimore. Reprinted by permission.)
Fig. 3 Dr. Travell at a California ostrich farm during a 1924 cross-country motor tour.





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