An integration of these three methods into one sequence is proposed (Chaitow) in which palpation leads to trigger point identification followed by use of one of several patterns of application of inhibitory pressure, followed immediately by Strain/counterstrain application to identify that points' precise 'position of ease'. After appropriate holding of this position to induce muscle spindle resetting of the tissues surrounding the trigger point a standard muscle energy method is employed to stretch the muscle to its normal resting length (Travell) either via post isometric relaxation or, if fibrosis is a feature, via an isolytic procedure (Mitchell).

Clinical results employing this combined approach of inhibition/positional release/Muscle energy (tentatively titled Integrated Neuromuscular Inhibition Technique - INIT) indicate it to be superior to use of single elements of the approach.

Key Words:
Myofascial trigger points, hyperventilation, Musculoskeletal dysfunction, Pain, Soft tissue manipulation, Inhibitory pressure, Muscle Energy Techniques, Strain/counterstrain, Integrated Neuromuscular Inhibitory Techniques.

Review
Travell and Simons have demonstrated the clear connection between myofascial trigger point activity and a wide range of pain problems and sympathetic nervous system aberrations.

Melzack and Wall confirm that there are few chronic pain problems which do not have myofascial trigger point activity as a component, with these acting, in many instances, as prime maintaining factors of the pain.

Trigger (and other non-referring pain) points commonly lie in muscles which have been stressed in a variety of ways including postural imbalances congenital factors (warping of fascia via cranial distortions, short leg problems, small hemi-pelvis etc), occupational or leisure overuse patterns, emotional states reflecting into the soft tissues , referred/ reflex involvement of the viscera producing facilitated segments paraspinally and trauma.

The repercussions of trigger point activity go beyond simple musculoskeletal pain - take for example their involvement in hyperventilation, chronic fatigue and apparent pelvic inflammatory disease.

Trigger point activity is particularly prevalent in the muscles of the neck/shoulder region which also act as accessory breathing muscles. In situations of increased anxiety the incidence of borderline or frank hyperventilation is frequent, and may be associated with chronic fatigue problems. Clinically these muscles palpate as tense, often fibrotic, with active trigger points being common . Successful breathing retraining, and normalisation of energy levels, seems in such cases to be accelerated and enhanced following initial normalisation of the functional integrity of the involved muscles.

Slocumb has shown in a large proportion of chronic pelvic pain problems in women, often destined for surgical intervention, that the prime cause involves trigger point activity in muscles of the lower abdomen, perineum, inner thigh and even the vagina.