A History of Manual Trigger Point Therapy
Today Janet Travell is known as an American physician, medical researcher and pioneer in myofascial pain syndrome, yet she was also a hands-on healer.
I came across this description of Janet Travell: “Janet Graham Travell was an American physician and medical researcher1.” While this is true, it is a painfully inadequate summary of the extraordinary human being that happened to be my grandmother. As I’m no expert on myofascial trigger point therapy, I write this as an amateur historian, as someone who grew up with Janet Travell, and as someone who cares very much that her legacy is accurately preserved, reflecting her true contribution to medicine and to society.
Recently, I picked up a copy of Bonnie Prudden’s book, Pain Erasure, The Bonnie Prudden Way, which was originally published in 1980, and I was baffled to read Bonnie’s summation of Janet Travell’s discoveries:
“Dr. Travell had pioneered a medical discipline called trigger point injection therapy. In this therapy, the doctor usually probes with a finger until a tender spot, indicating the presence of a trigger point, is found. The spot is then injected with a solution, usually saline and procaine. The doctors tell you the injections don’t hurt, but that’s because they are on the painless end of the needle. Dr. Travell follows her injections with a gentle passive stretch, usually aided by the coolant spray, Flouri-Methane.
While myotherapy and trigger point injection therapy have elements in common, there is one major difference. Myotherapy involves no injections whatsoever.”2
In reality, Janet Travell pioneered a medical discipline of diagnosing and treating myofascial pain, based on many years of clinical research, and her treatment modalities included injection, dry needling, stretch and spray, and manual therapies; namely ischemic compression, massage, and stretch without spray. And Janet Travell’s discovery of referred pain patterns is one of her most notable accomplishments.
I had thought it was a well known fact among the trigger point community that Janet Travell taught Bonnie Prudden about manual trigger point techniques — not the other way around. However upon further inquiry, I discovered that many myofascial trigger point therapists, and myotherapists, credit Bonnie Prudden with inventing manual trigger point therapy techniques and teaching them to Travell. This is backwards, chronologically speaking. Let me explain.
This excerpt from the Bonnie Prudden Myotherapy® website gets to the heart of the matter.
Bonnie Prudden said that there were three friends in her life who made Bonnie Prudden Myotherapy possible. The first was Hans Kraus, who taught her Corrective Exercise beginning in 1943. The second was Janet Travell, who mapped trigger points and referred pain patterns in patients, in the early 1940s. The third was Desmond Tivy, who encouraged Prudden’s research and coined what she had developed as Myotherapy.3
In 1980, Janet Travell was not a researcher from the distant past. Her pinnacle achievement was well underway; the writing and publication of the first trigger point manual with co-author, Dr. David Simons. In fact, Travell went on to enjoy nearly twenty more years of practicing medicine, doing research, teaching, lecturing, and co-authoring three volumes of the trigger point manuals.
In Pain Erasure, The Bonnie Prudden Way, Prudden describes her first experience of accidentally releasing a trigger point while palpating a patient to prepare them for trigger point injection therapy by Dr. Desmond Tivy, a physician in Lenox, Massachusetts. In 1976, one patient came in “with a very stiff neck” and another patient came in suffering from “tennis elbow.” Prudden called Travell to ask her to explain what had happened when pressing on the trigger point had surprisingly eliminated the pain — no injection needed.
“As soon as the patient left, I raced for the phone and called Washington to tell Dr. Travell about my exciting discovery.
She asked one question, ‘How long did you hold the pressure?’
‘About four seconds.’
‘May not be long enough. Try longer’.”4
This conversation between Bonnie and Janet demonstrates that Janet had prior experience with using manual trigger point techniques for inactivating trigger points, and was coaching Bonnie over the phone. By 1976, when Bonnie first discovered this manual trigger point therapy technique, Janet was in the midst of writing “Myofascial Pain Syndrome, The Trigger Point Manual,” First Edition, Vol. 1, Upper Extremities” with Dr. David Simons. By 1977, the text for the trigger point manual was completed, and Barbara Cummings began work on the many illustrations for the book. After ten years on the project, the first trigger point manual was published in 1983. Janet Travell had been perfecting manual trigger point techniques for many years, as well as stretch and spray, and injection therapy.
In Myofascial Pain and Dysfunction, The Trigger Point Manual, First Edition, Vol. 1, Upper Extremities, Travell and Simons write this about Bonnie Prudden and Myotherapy:
“The technique that we have described as ischemic compression is essentially what Prudden calls myotherapy. This method, which she developed from the TP concepts of Travell and Kraus, she described in detail for major regions of the body. Ischemic compression applies sustained pressure to the TP with sufficient force and for long enough time to inactivate it. We termed it ischemic compression because, on release, the skin is at first blanched, and then shows reactive hyperemia. The changes in perfusion of the skin very likely correspond to circulatory changes in the muscle beneath, which was subjected to the same pressure.
Two approaches to ischemic compression are used. As described in the chapters throughout this volume, the first attempts to completely inactivate the TP in one treatment. In the case of recent, moderately active TPs, this is often successful. However, in chronic and hyperirritable TPs, a second approach, the myotherapy technique, progressively eliminates the TP activity in a succession of small steps that may take days.”
Digital pressure techniques are useful as self-treatment by the patient. They can be adapted to reach muscles that are otherwise inaccessible in the upper back by substituting a tennis ball for the digits, as described in Section 12 of Chapter 22.
Ischemic compression may fail to afford relief: (1) because the TP is too irritable and requires many applications of pressure; (2) because the operator released pressure, rather than gradually increasing it; (3) when the operator pressed too hard at first, causing excessive pain and autonomic responses with involuntary tensing by the patient; and (4) when the patient has perpetuating factors that continue to make TPs hyperirritable.5
Janet Travell and her father, Willard Travell, M.D.
Janet Travell and her sister, Virginia, both became medical doctors in the early 1900s, when few women attended medical school. Their father, Willard Travell, M.D., practiced medicine at 9 West 16th Street, in New York City. Dr. Willard Travell described himself as a family doctor and “only part specialist” in physical medicine. Janet Travell began a small private practice in her father’s office following the birth of Janet’s second daughter, Virginia Powell, in 1935. Virginia remembers coming home from school and passing by the waiting room, on the way to the Travell family’s residential apartment upstairs. The patients would call out, “Hello! We love your mother. She takes away the pain.”
In Office Hours: Day and Night, Janet Travell wrote about her father:
“Dysfunction of joints locked slightly out of position was another mechanical source of skeletal muscle spasm. First, when I was a medical student living at home, and later, when a New York Hospital intern, my father was my preceptor in some techniques of manipulation — the passive movement of joints through their normal range of motion. To him, that kind of therapy was an integral part of physical medicine; he left no facet of that discipline unexplored. I learned from him that in the appropriate condition and with proper safeguards the benefits of manipulation in muskuloskeletal pain might be significant, and I used my father’s techniques effectively. I was aware of the dangers of manipulation when excessive force was applied and when a patient was wrongly selected without adequate diagnostic studies to rule out fracture, fragility (osteoporosis), infection, tumor, and other defects of bone and joints. My high degree of kinesthetic dexterity undoubtedly contributed to the success that I had with manipulative methods.”6
Janet Travell’s manual trigger point technique on a feline patient in the 1960s
One of the earliest memories I have of my grandmother treating a “patient” was in the mid 1960s, at our home in Nashville, Tennessee. My older brother, Gordon, was around seven years old at the time. Gordon climbed up on the kitchen counter to get a glass from the top cabinet. When he jumped off of the counter, he accidentally landed on our Siamese kitten, Andy. Andy was in excruciating pain, his body twisted and contorted. Fortunately, my grandmother happened to be visiting from Washington, DC, and she worked her magic on Andy’s tiny back and neck muscles, until he was pain-free and moving normally again.
Memories of Bonnie Prudden from 1969-1974
My family spent summers in Sheffield, Massachusetts, at “Merryfield Farm,” a one hundred and twenty acre property owned by my grandmother, Janet, and her sister, Virginia Weeks. In the summer of 1968, Janet Travell’s autobiography, Office Hours: Day and Night, had just been published. In 1969, Bonnie visited Janet’s office in Washington, DC for treatments, and for several summers, Janet would visit Bonnie’s home in Lenox, Massachusetts.
My grandmother had a habit of “calling on” friends, (dropping in on friends unannounced) which mortified me and seemed to be a throwback to an earlier time before people had telephones. Off we would go in my grandparents’ boatlike car ( I think was a Pontiac Bonneville), dropping in on friends in the Sheffield area. It usually was either uneventful or unexpectedly fun. My mother Virginia Street, my brothers Gordon and Hunt, and I happily accompanied my grandmother on visits to Bonnie’s house. We swam and floated on rafts in Bonnie’s pool while Janet Travell and Bonnie met for trigger point therapy sessions in the house.
Bonnie and Janet were clearly kindred spirits, with a love of the outdoors, physical fitness, sports and wellness. Bonnie taught gymnastics in her spacious home gym, which included a trampoline and other equipment. The house was built into the side of a steep hill, with an exposed rock wall in the downstairs office. Her gentle giant mastiffs, James and later Elizabeth, enjoyed gnawing on the large river stones under the hammock next to the swimming pool. My brothers and I adored Bonnie, and visited her in Lennox each summer from 1969 to around 1974. My younger brother attended Bonnie’s gymnastics classes.
My grandfather, Jack Powell, sent a letter to my mother in 1969, mentioning Bonnie’s improvement after undergoing Travell’s myofascial trigger point therapy:
“A wonderful letter today from Bonnie Prudden! Her “level of work” has improved so much she is getting things done that she was not able to do. She has a new date line - ‘B.T.’ (Before Travell).”
During our summers in Sheffield, my grandmother taught me some basic knowledge of referred pain patterns, perpetuating factors, Morton’s toe (which I have), leg length, stretch and spray, and manual techniques for eliminating trigger points — at least as much as I could manage to absorb. She used stretch and spray and manual techniques to treat my knee pain. I remember getting accustomed to feeling the sharp pain of pressing an “exquisitely tender” spot, and then the wonderful feeling of the trigger point (which we also called a “muscle knot”) releasing.
Bonnie Prudden’s 1980 release of Pain Erasure: The Bonnie Prudden Way, introduced the general public to myotherapy, and the concepts of trigger points and referred pain patterns (the basis for pain mapping) which Bonnie learned form Janet Travell. Travell and Simons introduced their clinical research and detailed protocol for diagnosis and treatment of myofascial trigger points to the medical community in 1983. Both books provided invaluable instruction for practitioners to learn these techniques and help countless numbers of people find relief from debilitating chronic pain due to myofascial trigger points.
Janet Travell and John F. Kennedy meet in 1955
In April 1955, Janet Travell was confined to a neck brace and bed rest after suffering an acute rupture of an intervertebral disk in the neck. In May 1955, Janet Travell’s most famous patient, Senator John F. Kennedy, arrived for his first appointment on crutches. In November 1960, Kennedy had won the presidential election and in January 1961, Janet Travell and her husband, Jack Powell, left their home in Pelham, New York and moved to Washington, DC. Janet Travell’s tenure at Sea View Hospital and Beth Israel Hospital ended with the move to DC and the new position as Personal Physician to President Kennedy. In addition to her White House position, Travell began teaching at George Washington University as an Associate Clinical Professor.
President Kennedy advised Travell:
“Doctor, have you accepted that appointment at George Washington University yet? You should do it right away. You should align yourself with academic medicine in Washington.”
This directive proved to be a very wise one, as Janet Travell’s teaching position at GWU continued for the rest of her lifetime.
By the end of 1963, after President Kennedy had been tragically assassinated, Janet Travell stayed on for a few more years as White House Physician under the Johnson administration. She then left the White House, returned to private practice, continued teaching at GWU, and began working on her autobiography.
Janet Travell and David Simons first meet in 1963
Janet Travell first met Dr. David Simons in 1963, when Simons attended Travell’s two day lecture at the School of Aerospace Medicine at Brooks Air Force Base in Texas. Dr. Lawrence Lamb had recommended that Simons attend Travell’s lecture, and it was Dr. Lamb who encouraged Travell to write a medical textbook. Over the next several years, Travell and Simons developed a friendship and began working on the first volume of “Myofascial Pain and Dysfunction, The Trigger Point Manual, around 1973.
Over time, I see that Janet Travell is remembered as a researcher and early pioneer in the discovery of trigger points and referred pain, but it is somehow forgotten that she successfully diagnosed and treated patients suffering from chronic pain, from the 1930s through the 1990s. That’s sixty years dedicated to providing pain relief in her patients. Janet Travell was both a brilliant researcher and a hands-on healer. Travell’s deep knowledge gained over a lifetime allowed her to eliminate trigger points causing pain in her patients, and return her patients to a pain-free life. This was the driving force of her work, solving the problem of chronic pain, one patient at a time.
President Kennedy said Janet Travell was a genius, and he was right. Janet Travell healed people with her keen mind and strong hands. She deserves to be remembered for this gift. I suppose it is impossible to sum up a life in a word or two, especially for someone as unique as Janet Travell. I’ll have to go with “American physician, trigger point pioneer and hands-on healer.”
49 Notable alumni of Weill Cornell Medical College; https://edurank.org/uni/weill-cornell-medical-college/alumni/
Prudden B: Pain Erasure: The Bonnie Prudden Way. M. Evans & Co., New York, 1980. (pp. 3,4).
Prudden B: Pain Erasure: The Bonnie Prudden Way. M. Evans & Co., New York, 1980. (pp. 3,4).
Prudden B: Pain Erasure: The Bonnie Prudden Way. M. Evans & Co., New York, 1980. (pp. 3,4).
Travell J and Simons D: Myofascial Pain and Dysfunction, The Trigger Point Manual, First Edition, Volume One, Upper Extremities. Lippincott, Williams & Wilkins, 1983. (pp. 86,87).
Travell J: Office Hours: Day and Night; The Autobiography of Janet Travell, M.D. The World Publishing Company, New York and Cleveland, 1968. (pp. 289, 290)