Myofascial Pain Relief Using Trigger Point Injections

Gain insights into trigger point injections for myofascial pain and how they can help you find relief from chronic discomfort.

Abstract

Hello, I’m Dr. Alex Jimenez, and on behalf of my entire team at Injury Medical Clinic, I am delighted to share some insights from the forefront of pain management and functional medicine. This educational post will take you on a journey into the complex world of myofascial trigger points and the innovative, evidence-based treatments we use to address them. We will explore the physiological underpinnings of why muscles develop these painful knots, leading to chronic pain, restricted movement, and a diminished quality of life. The discussion will detail the specifics of our advanced trigger point injection therapy, explaining the rationale behind our choice of agents, such as lidocaine and the plant-based anti-inflammatory, Sarapin. We will contrast this technique with others like dry needling, prolotherapy, and PRP, clarifying their distinct mechanisms and appropriate clinical applications. A significant focus will be placed on the critical importance of a deep understanding of musculoskeletal anatomy for the safe and effective application of these therapies, including needle depth and injection patterns. This post will also illuminate our unique, multidisciplinary clinical model at Injury Medical Clinic. We will showcase how my work as a Doctor of Chiropractic (DC) and Advanced Practice Registered Nurse (APRN) integrates seamlessly with the invaluable medical oversight provided by our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD. This collaborative framework ensures a comprehensive, safe, and patient-centered approach to care, combining chiropractic adjustments, rehabilitation, functional medicine, and targeted medical interventions to achieve superior outcomes for our patients in El Paso, Texas.

Introduction to Our Integrative Practice

Welcome to our practice. I am Dr. Alex Jimenez, and my journey in healthcare has been driven by a passion for understanding the intricate connections within the human body. With qualifications as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN) certified as a Family Nurse Practitioner (FNP-BC), and advanced certifications in Functional Medicine (CFMP, IFMCP), Applied Traumatology (ATN), and Cranial Spinal Integration (CCST), my goal has always been to bridge the gaps between different medical disciplines.

At Injury Medical Clinic PA (also known as Mission Plaza Injury Medical Clinic), we have cultivated a unique environment that embodies this philosophy. Our practice is a multidisciplinary, integrative clinic where different specialties converge to provide holistic and robust care, particularly for patients suffering from personal injuries, chronic pain, and complex musculoskeletal conditions. A cornerstone of this integrative model is my collaboration with Dr. Maria Guadalupe Cardenas, MD.

Dr. Cardenas is a highly respected physician, board-certified in Internal Medicine, with over four decades of clinical experience. As our Medical Director and Collaborative Physician, she provides essential medical oversight, diagnostic expertise, and a depth of knowledge that enriches our treatment protocols. Her NPI is #1164426749, and she holds Texas MD License #J2933. This partnership between a chiropractor/nurse practitioner and an internist is fundamental to our approach. It allows us to offer a spectrum of care that includes:

• Chiropractic Care: Precise spinal and joint manipulations to restore biomechanical function and nervous system integrity.
• Medical Oversight: Comprehensive medical evaluations, diagnostic interpretation, and prescription management under the direction of Dr. Cardenas.
• Functional Medicine: Investigating the root causes of disease and dysfunction through advanced diagnostics and personalized lifestyle interventions.
• Rehabilitation & Physical Therapy: Customized exercise programs to restore strength, flexibility, and functional movement.
• Advanced Pain Management: Including the trigger point injection therapies we will discuss in detail today.

This structure ensures that our patients receive a well-rounded and thoroughly vetted treatment plan, benefiting from the strengths of both chiropractic and conventional medicine. Today, I want to guide you through one of our key therapeutic modalities: advanced trigger point injection therapy for myofascial pain syndrome.

Understanding Myofascial Trigger Points: The Root of Chronic Pain

Before we delve into the treatment, it’s crucial to understand the target: the myofascial trigger point. Many people refer to these as “knots” in their muscles, and that’s a reasonably accurate lay description. However, from a physiological standpoint, they are far more complex.

A myofascial trigger point is a hyperirritable, taut band of skeletal muscle fibers. When you press on an active trigger point, it doesn’t just hurt at that specific location; it often causes referred pain—pain that is felt in a different, often distant, part of the body. For example, a trigger point in the upper trapezius muscle in the shoulder can refer pain up into the neck and behind the eye, causing a tension-type headache. This phenomenon is a hallmark of myofascial pain syndrome.

How Do Trigger Points Form?

The formation of trigger points is a multifactorial process, but it often begins with some form of muscle overload or stress. This can be:

• Acute Trauma: Such as from a car accident (whiplash), a fall, or a sports injury.
• Repetitive Micro-trauma: Like poor posture while sitting at a desk, repetitive lifting with improper mechanics, or even clenching your jaw.
• Chronic Overload: Holding a muscle in a contracted or shortened position for extended periods.

This initial stress leads to localized damage to the muscle tissue, specifically to a structure called the sarcoplasmic reticulum. This organelle within the muscle cell is responsible for storing and releasing calcium ions (Ca²+). When damaged, it leaks excess calcium into the muscle fiber.

This is where the cascade really begins. Calcium is the “on” switch for muscle contraction. The flood of calcium binds to troponin, a regulatory protein, which in turn moves another protein, tropomyosin, out of the way. This allows the primary contractile proteins, actin and myosin, to bind and form cross-bridges, causing the muscle fiber to contract.

Normally, this contraction is followed by relaxation when an enzyme called the calcium-ATPase pump actively pumps the calcium back into the sarcoplasmic reticulum. However, in the dysfunctional state of a trigger point, this process is impaired. The sustained contraction of the muscle fibers puts immense pressure on the local blood vessels (capillaries) that run through the muscle. This compression restricts blood flow, creating a state of ischemia (lack of oxygen) and hypoxia (low oxygen levels).

This lack of oxygen creates an energy crisis. The calcium-ATPase pump, which is essential for muscle relaxation, is an energy-intensive process that requires a lot of ATP (adenosine triphosphate), the cell’s energy currency. Without sufficient oxygen, the muscle cannot produce enough ATP to power these pumps. The result is a vicious cycle:

1. Sustained Contraction: Caused by the initial calcium leak.
2. Blood Flow Restriction: The contracted muscle fibers squeeze local capillaries.
3. Energy Crisis: Lack of oxygen and nutrients prevents the production of ATP needed for relaxation.
4. Metabolic Waste Buildup: The area becomes acidic, and inflammatory substances like bradykinin, prostaglandins, and substance P accumulate.
5. Nerve Sensitization: These substances irritate and sensitize the local nerve endings (nociceptors), causing pain and tenderness.
6. Further Contraction: The pain signals can cause a reflexive tightening of the muscle, perpetuating the cycle.

This self-sustaining loop is what makes a trigger point so persistent and painful. The palpable “knot” you feel is this dysfunctional segment of muscle fibers, locked in a state of metabolic distress.

The Goal of Trigger Point Therapy: Breaking the Pain Cycle

Given the physiology of a trigger point, our therapeutic goal is clear: we must interrupt this vicious cycle. We need to:

• Mechanically disrupt the contracted muscle fibers.
• Improve Local Blood Flow to flush out metabolic waste and deliver oxygen and nutrients.
• Deactivate the Sensitized Nerve Endings to reduce the pain signals.
• Reduce Local Inflammation to calm the irritated tissues.

There are several ways to approach this, from manual therapies to more invasive techniques. At our clinic, we often utilize trigger point injection therapy as a powerful tool to achieve these goals simultaneously and effectively.

Advanced Trigger Point Injection Therapy: Our Methodology

When performing trigger point injections, precision, safety, and the choice of injectate are paramount. We don’t just “poke the knot”; we engage in a systematic process designed to maximize therapeutic benefit while ensuring patient comfort and safety. Let’s break down the procedure and the rationale behind each step.

The “Star Pattern” Technique: More Than Just an Injection

A common question I get is about the technique itself. When we perform these injections, we don’t just insert the needle, inject the solution, and pull it out. We use a method often described as a “star pattern” or “fanning” technique. This concept is borrowed from and evolved from the practice of dry needling.

In traditional dry needling, a thin filiform needle (like an acupuncture needle) is inserted into the trigger point. The practitioner then manipulates the needle—moving it in and out, rotating it, and fanning it in different directions within the taut band. The purpose of this mechanical stimulation is to:

• Elicit a Local Twitch Response (LTR): This is an involuntary spinal cord reflex where the muscle fibers in the taut band contract and then release. Eliciting an LTR is strongly associated with successful deactivation of the trigger point and immediate pain relief.
• Mechanically Break Up Scar Tissue: Chronic muscle spasm and inflammation can lead to the formation of fibrous adhesions and scar tissue within the muscle. The physical action of the needle helps to break apart these adhesions, restoring the muscle’s normal texture and elasticity.

In our practice, we have adopted this effective mechanical disruption and enhanced it. By using a hypodermic needle instead of a solid filiform needle, we can perform this same star-pattern disruption while simultaneously delivering a therapeutic solution directly into the heart of the dysfunctional tissue.

Here’s how it works: I palpate the muscle to identify the most irritable spot—the epicenter of the trigger point within the taut band. After sterilizing the skin, I insert the needle to the appropriate depth. Then, instead of just injecting, I perform the fanning motion. I withdraw the needle slightly (without exiting the skin) and re-advance it at a slightly different angle, repeating this several times to form a star-like pattern of disruption radiating from the central insertion point. A small amount of the solution is injected with each pass. This ensures that we both mechanically break up the fibrotic tissue and distribute the therapeutic agents throughout the entire volume of the trigger point.

This approach is far more effective than a single bolus injection because it addresses both the physical and the biochemical aspects of the trigger point simultaneously.

Our Choice of Injectate: Lidocaine and Sarapin

The solution we inject is just as important as the technique. While some practitioners use a local anesthetic like lidocaine or Marcaine alone, or even just saline, my clinical experience and a review of the evidence have led me to a specific combination: Lidocaine and Sarapin.

1. Lidocaine: The Anesthetic and Membrane Stabilizer

Lidocaine is a local anesthetic that works by blocking sodium channels on nerve cell membranes. Pain signals are transmitted as electrical impulses (action potentials) along nerve fibers. These impulses are generated by a rapid influx of sodium ions into the nerve cell. By blocking these channels, lidocaine prevents the nerve from depolarizing and firing, effectively stopping the transmission of the pain signal to the brain.

This has two immediate benefits in trigger point therapy:

• Pain Relief During the Procedure: It makes the fanning and mechanical disruption of the trigger point much more tolerable for the patient.
• Breaking the Pain-Spasm-Pain Cycle: The intense pain generated by a trigger point can cause a reflexive increase in muscle tension, further perpetuating the problem. By numbing the area, lidocaine helps to break this reflexive loop, allowing the muscle to relax.

The concentration we use is typically 1% lidocaine. This provides effective anesthesia without being excessive. It’s important to be mindful of allergies; while rare, an allergy to “-caine” anesthetics is a contraindication. Statistics suggest that a true IgE-mediated allergy to lidocaine is exceptionally rare, with many reported “allergies” being vasovagal responses or reactions to preservatives like methylparaben in multi-dose vials. Nonetheless, a thorough patient history is non-negotiable.

2. Sarapin: The Natural Anti-Inflammatory Powerhouse

This is where our approach often diverges from more conventional protocols. Instead of using corticosteroids (like cortisone), I almost exclusively use Sarapin.

Sarapin is a biological medicine, an aqueous extract derived from the pitcher plant (Sarracenia purpurea). It has been used for neuropathic and musculoskeletal pain for decades, but it’s often overlooked in mainstream medicine. Unlike corticosteroids, Sarapin’s primary mechanism of action is not systemic immunosuppression. Instead, it is believed to work as a selective neurolytic agent on sensory C-fibers. These are the small, unmyelinated nerve fibers responsible for transmitting dull, burning, chronic pain signals.

Sarapin appears to interfere with the function of these specific nerve fibers without affecting motor nerves or larger sensory nerves responsible for touch and proprioception. This means it can effectively “turn off” the chronic pain signal coming from the trigger point without causing muscle weakness or loss of normal sensation.

Furthermore, it has a powerful anti-inflammatory effect localized to the injection site. Remember the “inflammatory soup” of bradykinin, prostaglandins, and substance P that accumulates in a trigger point? Sarapin helps to neutralize this inflammatory environment, further calming the irritated tissues and facilitating the healing process.

Why Sarapin Over Steroids?

My preference for Sarapin over corticosteroids is based on several key factors:

• Safety Profile: Corticosteroids, while powerful anti-inflammatories, come with significant potential side effects, especially with repeated use. These can include tissue atrophy (thinning of the skin and subcutaneous fat), tendon rupture, cartilage damage, systemic effects like elevated blood sugar, and suppression of the adrenal system. Sarapin, being a natural biological agent, does not carry these risks. It is non-toxic and does not damage local tissues.
• Targeted Action: Steroids are potent but non-specific immunosuppressants. They shut down the entire inflammatory cascade. While this reduces pain, it can also inhibit the body’s natural healing and regenerative processes. Inflammation is a double-edged sword; it causes pain, but it is also the first step in tissue repair. Sarapin’s more selective action on sensory pain fibers allows it to reduce pain without impeding the crucial healing phase.
• Avoiding the “Rebound” Effect: Sometimes, after a steroid injection wears off, the pain can return with a vengeance. Because Sarapin helps reset the local neurochemical environment more fundamentally, I find the results are often more durable.

The combination of lidocaine and Sarapin, typically in a one-to-one ratio, provides a synergistic effect. The lidocaine gives immediate relief and allows for the mechanical disruption, while the Sarapin provides sustained, non-destructive, anti-inflammatory and neurolytic effects that promote long-term healing.

Safety and Anatomy: The Foundation of Effective Treatment

Performing these injections requires more than just knowing where it hurts. It demands a profound and constantly refreshed understanding of three-dimensional anatomy. This is something I cannot stress enough, whether for trigger point injections, chiropractic adjustments, or any other manual therapy.

The Importance of Needle Depth and Location

Every time I prepare to perform an injection, I am mentally mapping the structures beneath the skin. I am considering:

• The target muscle and its fiber direction.
• The muscles lying above and below it.
• The location of major nerves and blood vessels in the vicinity.
• The depth of the underlying bone or, critically, the thoracic cage.

A frequent and valid concern is the risk of pneumothorax (puncturing the lung) when injecting in the thoracic region. This is where anatomical knowledge becomes a matter of patient safety. The needle length and injection depth must be carefully chosen based on the patient’s body habitus (build) and the injection site.

• Cervical and Upper Thoracic Spine: In this region, the muscles are generally more superficial. I typically use a 30-gauge, 1-inch needle. In most individuals, this length is insufficient to reach the pleura (the lining of the lungs), especially when inserting the needle perpendicular to the skin over a muscle belly. For a very thin, frail, elderly individual, one must be even more cautious, but a 1-inch needle, properly handled, is generally very safe. We typically inject 1 mL per site in this region. The tissue is denser and cannot accommodate larger volumes without causing excessive pressure and discomfort.
• Lower Thoracic and Lumbar Spine: Here, the muscles (like the erector spinae and quadratus lumborum) are much thicker and deeper. We can safely use a longer and slightly larger needle, for example, a 5-inch needle. This allows us to reach deeper trigger points effectively. The musculature here can also accommodate a larger volume so that we might inject up to 2 mL per site. However, even here, caution is key. A 1.5-inch needle in a very small, slender person still requires careful depth control. As a general rule of thumb, going beyond 1.5 inches starts to introduce unnecessary risk in most patient populations.

It’s not just about avoiding the lungs. In the neck, you must be aware of the carotid artery, jugular vein, and the brachial plexus. In the lumbar region, you have to consider the depth of the kidneys. This is why I always urge practitioners to go back and review their anatomy. It’s not a subject you learn once and are done with; it’s a constant companion in clinical practice. I personally had to work hard to master it, as most students do, but that dedication is what separates a safe, effective practitioner from a dangerous one.

The Patient Experience: Managing Comfort and Expectation

The psychological aspect of the procedure is also critical. Many patients have a fear of needles. My approach is to build trust and manage their experience to make it as positive as possible.

I’ve learned through experience to save the most painful trigger point for last. If you start with the one that is going to make the patient jump, they will be tense and fearful for the rest of the procedure. They might even refuse to continue. I’ve had that happen early in my career. You end up trying to coax a patient through a treatment they’ve already decided against.

Instead, I start with the less sensitive points. This allows the patient to acclimate to the sensation. They realize it’s tolerable. By the time we get to the most tender spot, they have built confidence in me and the process. It’s a small detail, but it makes a world of difference in patient compliance and the overall therapeutic relationship.

Contextualizing Trigger Point Injections: Comparing Therapies

It’s important to understand where trigger point injections fit within the broader landscape of regenerative and pain management therapies. Patients often ask me about the difference between what we do and other treatments they’ve heard about, like PRP or Prolotherapy.

Dry Needling vs. Wet Needling (Trigger Point Injections)

As discussed, dry needling uses a solid needle to create a mechanical disruption and elicit a twitch response. It can be very effective. Our technique, sometimes called “wet needling,” builds upon this by adding the therapeutic injectate. The advantage of wet needling is the added biochemical effect—the anesthesia from the lidocaine and the anti-inflammatory/neurolytic action from the Sarapin. This often leads to more significant and longer-lasting relief than dry needling alone. For patients who are allergic to “-caine” anesthetics, dry needling remains an excellent alternative. Many skilled acupuncturists and physical therapists achieve great results with it.

Prolotherapy: Stimulating Ligament and Tendon Repair

Prolotherapy (short for “proliferative therapy”) is a different concept. Its goal is to stimulate the body’s natural healing cascade to strengthen and repair lax or injured connective tissues, primarily ligaments and tendons. The injection solution is typically a mild irritant, such as a dextrose (sugar) solution, which creates a localized, controlled inflammatory response. This “tricks” the body into thinking there is a new injury, and it mounts a healing response, sending growth factors and fibroblasts to the area to lay down new collagen and strengthen the tissue.

Prolotherapy is primarily used for joint instability, chronic ligament sprains, and tendinopathies. It’s not typically used for trigger points within the muscle belly itself. While both use injections, their targets and mechanisms are fundamentally different.

Platelet-Rich Plasma (PRP) Therapy: Harnessing Your Body’s Growth Factors

Platelet-Rich Plasma (PRP) therapy is a more advanced form of regenerative medicine. It involves drawing a sample of the patient’s own blood, spinning it in a centrifuge to separate the components, and extracting the portion that is highly concentrated with platelets. This platelet-rich plasma is then injected back into the injured area.

Why platelets? Platelets are not just for clotting blood. They are tiny storehouses of powerful growth factors—proteins that orchestrate the entire tissue repair process. When injected into an injury site, these growth factors (like PDGF, TGF-?, and VEGF) signal the body’s stem cells to come to the area, proliferate, and differentiate into the types of cells needed to rebuild the damaged tissue (e.g., tendon, cartilage, muscle).

PRP is excellent for moderate to severe tendinopathies, ligament tears, and early-stage osteoarthritis. It provides a much more powerful regenerative stimulus than prolotherapy.

Can you use PRP for trigger points? You could, but in my clinical opinion, it’s often overkill. A trigger point is primarily a metabolic and neurological problem, not a major structural tissue tear. Using the powerful (and more expensive) tool of PRP to address a trigger point is like using a sledgehammer to crack a nut. The combination of mechanical disruption with lidocaine and Sarapin is typically more than sufficient to resolve the issue effectively and cost-efficiently.

Ozone therapy is sometimes combined with Prolotherapy or PRP. Ozone (O3) has powerful antimicrobial and anti-inflammatory properties and can stimulate oxygen metabolism. When used in injections, it can help reduce pain and stimulate local tissue regeneration. A “Prolozone” treatment often involves a combination of procaine, vitamins, and ozone gas. However, its primary application remains in joint and ligamentous rejuvenation, similar to prolotherapy.

The Root Causes of Pain- Video

The Role of Integrative Chiropractic Care in Long-Term Resolution

This is a critical point. Trigger point injections are a powerful tool, but they are not a cure-all in isolation. They are most effective when integrated into a comprehensive treatment plan that addresses the root cause of why the trigger points formed in the first place. This is where integrative chiropractic care becomes essential.

Trigger points are often a symptom of an underlying biomechanical problem. For instance:

• A misaligned vertebra in the cervical spine (subluxation) can cause nerve irritation and reflexive, protective muscle splinting in the neck and shoulders. This chronic muscle tension is a perfect breeding ground for trigger points.
• Poor posture, such as a forward head carriage, places chronic strain on the posterior neck muscles and upper trapezius, leading to overload and trigger point formation.
• An unlevel pelvis or a functional leg length discrepancy can cause compensatory muscle imbalances all the way up the spine, leading to chronic trigger points in the low back, glutes, and quadratus lumborum.

My role as a chiropractor is to identify and correct these underlying structural and biomechanical faults. A chiropractic adjustment, or spinal manipulative therapy, is a precise, controlled force applied to a joint to restore its normal motion and alignment. By correcting the subluxation, we can:

• Reduce Nerve Irritation: Taking pressure off the spinal nerves can decrease the reflexive muscle guarding.
• Improve Biomechanics: Restoring proper joint movement reduces abnormal stresses on the surrounding muscles and ligaments.
• Re-educate the Nervous System: The adjustment provides powerful proprioceptive input to the brain, helping to “reset” the faulty movement patterns that contributed to the problem.

The synergy between trigger point injections and chiropractic care is profound. The injections provide rapid pain relief and release the tightly bound muscle tissue. This makes the body more receptive to the chiropractic adjustment. It’s much easier to adjust a spine when the surrounding muscles are not in a state of severe spasm.

Conversely, the chiropractic adjustment addresses the underlying structural issue that was causing the muscle to spasm in the first place. This prevents the trigger point from simply reforming a week later.

Our comprehensive approach at Injury Medical Clinic completes this picture with:

• Rehabilitative Exercise: We teach patients specific stretches and strengthening exercises to correct muscle imbalances, improve posture, and build resilience against future injury.
• Functional Medicine: We may investigate whether nutritional deficiencies (e.g., magnesium, B vitamins) or systemic inflammation are contributing to their muscle dysfunction.
• Ergonomic and Lifestyle Counseling: We help patients identify and modify the activities in their daily life (e.g., their desk setup, sleeping position) that are perpetuating their condition.

This integrated model ensures we are not just chasing pain. We deactivate the immediate pain generator (the trigger point), correct the underlying biomechanical cause (the subluxation), and empower the patient with the tools to prevent recurrence.

Conclusion: A Patient-Centered, Evidence-Informed Approach

The management of myofascial pain requires a multifaceted approach that is both scientifically grounded and artfully applied. The advanced trigger point injection therapy we utilize at Injury Medical Clinic, combining the mechanical disruption of the “star pattern” with the synergistic biochemical action of lidocaine and Sarapin, represents a powerful modality for breaking the chronic pain cycle.

However, its true power is only unlocked when it is part of a larger, integrated strategy. The collaboration between me, with my background in chiropractic and functional nursing, and Dr. Maria Cardenas, our guiding internist, creates a clinical environment where we can safely and effectively deploy such therapies. We then contextualize this treatment within a framework of chiropractic care to correct structural faults and rehabilitative strategies to restore function for the long term.

By constantly revisiting our anatomical knowledge, staying abreast of the latest research in pain science and regenerative medicine, and, most importantly, listening to and working with our patients, we strive to offer a level of care that is not just about alleviating symptoms, but about restoring health, function, and quality of life. Thank you for joining me on this deep dive into one of the ways we accomplish that mission.

References

• Chou, R., & Huffman, L. H. (2007). Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147(7), 505–514. https://doi.org/10.7326/0003-4819-147-7-200710020-00008
• Dommerholt, J., & Fernández-de-las-Peñas, C. (2018). Trigger Point Dry Needling: An Evidence- and Clinical-Based Approach (2nd ed.). Elsevier.
• Manchikanti, L., Singh, V., Falco, F. J., Cash, K. A., & Pampati, V. (2010). Evaluation of the effectiveness of facet joint nerve blocks in chronic thoracic pain: a randomized, double-blind, controlled trial. Pain Physician, 13(1), 3–15.
• Partanen, J. V., Ojala, T. A., & Arokoski, J. P. (2010). Myofascial syndrome and pain: A neurophysiological approach. Pathophysiology, 17(1), 19-28. https://doi.org/10.1016/j.pathophys.2009.04.001
• Shah, J. P., Thaker, N., Heimur, J., Aredo, J. V., Sikdar, S., & Gerber, L. (2015). Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM&R, 7(7), 746-761. https://doi.org/10.1016/j.pmrj.2015.01.024
• Simons, D. G., Travell, J. G., & Simons, L. S. (1999). Travell &Simons’’ Myofascial Pain and Dysfunction: The Trigger Point Manual (Vol. 1, 2nd ed.). Williams & Wilkins.
• Winsor, T., & Thompson, W. A. (1951). The pitcher plant in the treatment of diseases of the nervous system. Review of Gastroenterology, 18(2), 95-107.

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