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(1). Supporting trigger points of the first subtype are located in the neighboring areas in respect to the chief trigger points and are connected with the same pathological process. However, expressivity of the pain and neuro-distrophic changes are much lower than in chief trigger points. Most often they can be found on the border between the epicenter of the periosteal pathology and normal parts of the periosteum.

(2). Supporting trigger points of the second subtype match with chief trigger points, but they are located on the opposite, unaffected side (if the disorder is unilateral). The practitioner can treat the chief trigger points indirectly by acting on supporting trigger points of the second subtype. In this case, the treatment is realized through the common reflex pathways of the peripheral nervous system. PM treatment on these supporting trigger points is recommended in particular for older patients or those patients who have a low threshold of pain, or are in the initial stages of PM treatment.

We recommend all detected trigger points be marked on the skin with a marker. It is helpful to estimate the whole picture of the periosteal changes in this section. The chief trigger points should be marked either with another symbol or in a different color. As soon as the diagnostic evaluation is over, transfer all the information onto body diagrams for future use. For facilitation of the diagnostic procedure, we display the topography of the most frequently occurring chief trigger points in Fig. 76-80.

 3. The general duration of a PM treatment involves 15-20 procedures. PM can be performed as often as twice a day, once a day, or after a day long break between sessions. The duration also depends onthe patient's age and the character of pathology.

E. TECHNICAL DISTINCTIONS OF PM.
A session of PM generally lasts 15-30 minutes. During the first session, use only 2-3 chief trigger points and 2-3 supporting trigger points. Remember: the treatment should begin with supporting trigger points and then later include chief trigger points. The quantity of points increases from procedure to procedure. The practitioner can use up to 10-15 points during one session. All detected chief trigger points have to undergo PM treatment. If the segment has several trigger points with the same intensity of pain, begin the treatment on the more distal points, gradually moving to the proximal ones.

PM is completed by using the tips of the thumb, the index, or the middle finger (see Fig. 75; a), both thumbs (see Fig. 75; b) or a bent index finger (see Fig. 75; c).

After determining the trigger points and mobilizing the soft tissues, make contact with the bone and begin the massage by using a small circular strokes from the periphery to the center of the trigger point, while maintaining pressure for 5 seconds at the end. Apply also strokes using a permanent, fixed superficial vibration.

The duration of the each trigger point treatment is from 1 to 3 minutes, depending on the quantity of trigger points, the clinical results, and the expressivity of pain.

If a patient feels sharp pain during treatment of the chief trigger point, we recommend beginning massage with the supporting trigger points of the first subtype, followed by a gradual approach to the chief trigger points. Another variant of PM treatment starts with the supporting trigger points of the second subtype, located on the normal, unaffected side.

In cases of cardiac or pulmonary disorders PM on the ribs should be applied only during the expiration phase.

Complications are practically absent even in an incorrectly conducted PM. It is possible to see various local reactions, including: pain, hyperemia, and edema in the massaged areas. In such cases, it is necessary to take a one to two days break in the treatment.