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PubMed1997

Inter-therapist reliability in locating latent myofascial trigger points using palpation.

SUMMARY. Myofascial trigger points (TPs) are sites in muscle or fascia which are tender to palpate and are located in a taut band of tissue. The significance of TPs is underlined by claims that treatment applied to TPs can be effective in treating pain. Before such claims can be validated, the ability of clinicians to identify these points reliably using palpation needs to be established. The location of such sites is also important for studies which try to determine the relationship of these points to other measures of pathology, e.g. EMG and thermographic abnormalities. Intertester reliability in the localization of these points, therefore, appears to be of primary importance. This study examined the concordance between two experienced clinicians in being able to identify TPs in the upper trapezius muscle. The results indicated that the agreement between these clinicians in identifying TPs in asymptomatic subjects was poor. There was a lack of concordance not only in the location of sites of TPs but also in the numbers of TPs identified. This outcome challenges claims that TPs can be reliably identified using palpation. Copyright 1997 Harcourt Publishers Ltd.

Journal Article↗
PubMed1989

Effects of transcutaneous electrical nerve stimulation on myofascial pain and trigger point sensitivity.

The effects of transcutaneous electrical nerve stimulation (TENS) on myofascial pain and trigger point sensitivity were assessed. Four modes of TENS and a no-stimulation control were compared in a double-blind design. Stimulation, carried out for 10 min on 60 subjects (12/group), showed significant pain reductions with 100 Hz, 250 msec stimulation followed by 100 Hz, 50 msec and then pain suppressor TENS. No pain reductions were found in the 2 Hz, 250 msec TENS or the control. No significant alteration in myofascial trigger point sensitivity, assessed with the pressure algometer, was found between the groups. The results suggest that high frequency, high intensity TENS is effective in reducing myofascial pain, and that these pain reductions do not reflect changes in local trigger point sensitivity.

Adult↗
PubMed2005

Evidence against trigger point injection technique for the treatment of cervicothoracic myofascial pain with botulinum toxin type A.

BACKGROUND: Traditional strategies for myofascial pain relief provide transient, incomplete, variable, or unpredictable outcomes. Botulinum toxin is itself an analgesic but can also cause sustained muscular relaxation, thereby possibly affording even greater relief than traditional therapies. METHODS: The study goal was to determine whether direct injection of botulinum toxin type A (BoNT-A) into trigger points was efficacious for cervicothoracic myofascial pain, and if so, to determine the presence or absence of a dose-response relation. One hundred thirty-two patients with cervical or shoulder myofascial pain or both and active trigger points were enrolled in a 12-week, randomized, double-blind, placebo-controlled trial. After a 2-week washout period for all medications, patients were injected with either saline or 10, 25, or 50 U BoNT-A into up to five active trigger points. The maximum doses in each experimental group were 0, 50, 125, and 250 U per patient, respectively. Patients subsequently received myofascial release physical therapy and amitriptyline, ibuprofen, and propoxyphene-acetaminophen napsylate. Follow-up visits occurred at 1, 2, 4, 6, 8, and 12 weeks. Outcome measures included visual analog pain scores, pain threshold as measured by pressure algometry, and rescue dose use of propoxyphene-acetaminophen napsylate. RESULTS: No significant differences occurred between placebo and BoNT-A groups with respect to visual analog pain scores, pressure algometry, and rescue medication. CONCLUSIONS: Injection of BoNT-A directly into trigger points did not improve cervicothoracic myofascial pain. The role of direct injection of trigger points with BoNT-A is discussed in comparison to other injection methodologies in the potential genesis of pain relief.

Adult↗
PubMed1986

Treatment of trigger points with microamperage transcutaneous electrical nerve stimulation (TENS)--(the Electro-Acuscope 80).

One-half of the students taking part in a double-blind study received a microamperage electrical stimulation of trigger points in the neck and shoulder region with the Electro-Acuscope 80. All the subjects were evaluated by digital palpatory physical examination for the presence of trigger points before each of their treatments. Results indicate that the subjects who received treatment had a higher change of trigger-point indicators compared to those receiving the placebo treatment. A two-tailed t-test indicated significant results (P less than 0.001). It appears that microamperage electrical stimulation is effective in the treatment of trigger points.

Adult↗
PubMedDate not supplied

Effects of the electrical stimulation of myofascial trigger points with tension headache.

The effects of electrical stimulation by simple pocket size stimulator were evaluated on myofascial trigger points by pain threshold (PTH) algometry. The study consisted 14 patients with 76 treated trigger points in randomly selected double blind cross-over study protocol. The effects of 30 seconds stimulation increased the PTH values 0.58 kg/cm2 in study group, but only 0.13kg/cm2 in controls (p < 0.01). These results suggested that the stimulation had positive effects on myofascial trigger points, but these effects were seen only on the treated points.

Adult↗
PubMed2005

[Pain sites in the sternocleidomastoid muscle trigger points and the gender-related factors].

OBJECTIVE: To study gender-related factors in the painful sites and degree of pains in the trigger points of the sternocleidomastoid muscle. METHODS: The trigger points of the sternocleidomastoid muscle of healthy volunteers of either gender with different ages were examined by measurable pressure using the right thumb, and the pain degree was assessed with visual analog scale (VAS). RESULT: The VAS score was 5.226+/-0.331 in senior male subjects and 5.531+/-0.379 in senior female subjects, without significant differences between them (P>0.05). Nor was significant difference detected between the scores of young male and female subjects (2.940+/-0.331 vs 3.982+/-0.405, P>0.05). In terms of the pain severity, the difference was significant between the medial and anterior areas and between the medial and posterior areas of the mastoid process (P<0.05), but not between the anterior and posterior areas of the mastoid process (P>0.05). CONCLUSION: There is no significant gender-related difference in the pain in the trigger points of the sternocleidomastoid muscle elicited by compression with the right thumb. The anterior and posterior areas of the mastoid process are relatively sensitive to compression pain.

Aged↗
PubMed2005

Myofascial trigger point development from visual and postural stressors during computer work.

The mechanism of musculoskeletal pain underlying low level static exertions, such as those experienced during computer work, is poorly understood. It was hypothesized that static postural and visual stress experienced during computer work might contribute to trigger point development in the trapezius muscles, resulting in myofascial pain. A study was conducted to observe the development of myofascial trigger points while 16 female subjects used a computer under conditions of high and low postural and visual stress. Trigger point development was monitored via expert opinion, subject self-report, and electromyographic activity. Only the high visual stress conditions resulted in greater trigger point sensitivity as reported by subjects and the myofascial specialist. Cyclic trends in median frequency of the EMG signal were assessed for the trapezius muscle. When high visual stress was combined with low postural stress condition there were significantly fewer cycles (1.6 cycles) as compared to the condition of low visual and low postural stress (2.8 cycles), and the condition of high visual and high postural stress (3.5 cycles). These significant differences between conditions were found for the right trapezius but not for the left. The findings suggest that high visual stress may be involved in the development of the myofascial pain response.

Adult↗
PubMed2006

The frozen shoulder syndrome. Description of a new technique and five case reports using the subscapular nerve block and subscapularis trigger point infiltration.

BACKGROUND AND OBJECTIVES: A frozen shoulder is considered by some authors to be a common stage of many disorders affecting the shoulder, while others regard it as an independent idiopatic condition. A consistent finding is that subscapularis muscle trigger points play a key role in the development of the frozen shoulder syndrome. Apart from the conventional treatment, a selective subscapularis fossa nerve block combined with subscapularis trigger points infiltration, may be an effective treatment in preventing chronic pain. METHODS: In this manuscript the posterior injection technique of the subscapularis fossa nerve block is described. RESULTS: Five patients with typical symptoms of frozen shoulder, who did not respond to conventional treatment, but obtained pain relief after a combination of a subscapularis nerve block with the infiltration of trigger points, are presented. CONCLUSION: The results of this block in various painful situations of the shoulder region suggest the importance of subscapularis muscle in the etiology of the frozen shoulder. Using this technique, we could demonstrate that a subscapular nerve block and subscapularis trigger points infiltration have both a diagnostic and therapeutic value for the treatment of the frozen shoulder.

Adult↗
PubMed1994

Factors associated with failure of trigger point injections.

OBJECTIVE: The purpose of this study was to investigate factors that may influence the outcome of trigger point injections for myofascial pain syndrome. No prior studies have correlated preexisting factors with treatment outcome or assessed the magnitude of risk of treatment failure associated with such factors. DESIGN AND PATIENTS: Thirty-one factors derived from patient evaluation and physical examination were selected according to prior studies of mixed pain groups focusing on clinical importance and ease of assessment in a typical clinic setting. Included in the analysis were 193 patients who received trigger point injections and who completed baseline questionnaires. Factors were analyzed via univariate and logistic regression analyses both for independent association with short-term treatment outcome and for magnitude of risk of failure associated with each factor following adjustment for other factors. RESULTS: In univariate analysis an increased risk of treatment failure was associated with unemployment due to pain at the start of treatment, no relief from analgesic medication, constant pain, high levels of pain-at-its-worst and pain-at-its least, prolonged duration of pain, change in social activity, and lower levels of coping ability. Alcohol use was associated with a decreased risk of treatment failure. In logistic regression analysis, only lack of employment, prolonged duration, and change in social activity were independently associated with treatment outcome. Constant-versus-intermittent pain was included in the logistic model because there was an increase in risk that may be clinically important and because it influenced the effect of change in social activity. These results were not affected by the number or type of additional treatments the patients had. CONCLUSIONS: These results suggest that several factors should be considered in treating myofascial pain patients with trigger point injections, and this study supports the belief that pain is a multidimensional problem and that a variety of factors may influence treatment outcome.

Adult↗
PubMed1993

Reduction of pain and EMG activity in the masseter region by trapezius trigger point injection.

In this open, uncontrolled trial, 20 patients with upper trapezius muscle trigger point pain and ipsilateral masseter muscle pain received a single trigger point injection of 2% lidocaine solution (without epinephrine) in the upper trapezius muscle. Following the trapezius injection, there was a significant (P < 0.001) reduction in pain intensity ratings for pain in the masseter region. In addition, there was a significant (P < 0.03) reduction in EMG activity in the masseter muscle. Overall, however, a significant relationship between EMG activity in the masseter and the self-report of pain was not found with the present data set. These clinical findings support the contention that sources of deep pain can produce heterotopic sensory and motor changes in distant anatomical regions.

Adolescent↗
PubMed2002

Management of myofascial trigger point pain.

Successful management of myofascial trigger point (MTrP) pain depends on the practitioner finding all of the MTrPs from which the pain is emanating, and then deactivating them by one of several currently used methods. These include deeply applied procedures, such as an injection of a local anaesthetic into MTrPs and deep dry needling (DDN), and superficially applied ones, including an injection of saline into the skin and superficial dry needling (SDN) at MTrP sites. Reasons are given for believing that DDN should be employed in cases where there is severe muscle spasm due to an underlying radiculopathy. For all other patients SDN is the treatment of choice. Following MTrP deactivation, correction of any postural disorder likely to cause MTrP reactivation is essential, as is the need to teach the patient how to carry out appropriate muscle stretching exercises. It is also important that the practitioner excludes certain biochemical disorders.

Acupuncture Analgesia↗
PubMed2001

Needling therapies in the management of myofascial trigger point pain: a systematic review.

OBJECTIVE: To establish whether there is evidence for or against the efficacy of needling as a treatment approach for myofascial trigger point pain. DATA SOURCES: PubMed, Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, AMED, and CISCOM databases, searched from inception to July 999. STUDY SELECTION: Randomized, controlled trials in which some form of needling therapy was used to treat myofascial pain. DATA EXTRACTION: Two reviewers independently extracted data concerning trial methods, quality, and outcomes. DATA SYNTHESIS: Twenty-three papers were included. No trials were of sufficient quality or design to test the efficacy of any needling technique beyond placebo in the treatment of myofascial pain. Eight of the 10 trials comparing injection of different substances and all 7 higher quality trials found that the effect was independent of the injected substance. All 3 trials that compared dry needling with injection found no difference in effect. CONCLUSIONS: Direct needling of myofascial trigger points appears to be an effective treatment, but the hypothesis that needling therapies have efficacy beyond placebo is neither supported nor refuted by the evidence from clinical trials. Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug. Controlled trials are needed to investigate whether needling has an effect beyond placebo on myofascial trigger point pain.

Acupuncture Therapy↗
PubMed1994

Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation.

OBJECTIVES: To compare the effects of dry needling of myofascial trigger points in the neck region to metoprolol in migraine prophylaxis. DESIGN: Randomized, group comparative study. patients, investigator and statistician were blinded as to treatment, the therapist was blinded as to results. SETTING: Outpatient pain clinic in the northern Copenhagen area. Patients were referred by general practitioners or respondents to newspaper advertisements. SUBJECTS: Included were patients with a history of migraine with or without aura for at least 2 years. Excluded were persons with contraindications against treatment with beta blockers, chronic pain syndromes, pregnancy or previous experience with acupuncture or beta-blocking agents. A total of 85 patients were included; 77 completed the study. INTERVENTIONS: After a 4-week run-in period, patients were allocated to a 17-week regimen either with acupuncture and placebo tablets or to placebo stimulation and metoprolol 100 mg daily. RESULTS: Both groups exhibited significant reduction in attack frequency (P < 0.01). No difference was found between the groups regarding frequency (P > 0.20) or duration (P > 0.10) of attacks, whereas we found a significant difference in global rating of attacks in favour of metoprolol (P < 0.05). CONCLUSIONS: Trigger point inactivation by dry needling is a valuable supplement to the list of migraine prophylactic tools, being equipotent to metoprolol in the influence on frequency and duration (but not severity) of attacks, and superior in terms of negative side-effects.

Acupuncture Therapy↗
PubMedDate not supplied

Trigger point injections for myofascial pain during epidural analgesia for labor.

BACKGROUND AND OBJECTIVES: Myofascial pain is the leading cause of chronic low back pain and in most cases can be successfully resolved with trigger point injections of local anesthetics. This type of pain can exist during pregnancy and exceed the analgesia provided by an epidural for labor. METHODS: A 31-year-old primiparous woman received an epidural infusion for labor analgesia. Despite complete resolution of labor pain and a solid, bilateral T10 block, the patient reported discomfort at two discrete locations in her right lumbar paraspinous muscle. RESULTS: The administration of local anesthetic via trigger point injections resulted in successful palliation of the myofascial pain. CONCLUSIONS: Myofascial pain can be an etiology of back pain in the parturient. Trigger point injections, even when used concomitantly with a functioning epidural infusion, can be a valuable aid for the provision of complete analgesia.

Adult↗
PubMed1990

Effects of warming imagery aimed at trigger-point sites on tissue compliance, skin temperature, and pain sensitivity in biofeedback-trained patients with chronic pain: a preliminary study.

13 subjects were trained in biofeedback and self-regulation strategies for reducing chronic pain. Upon demonstrating ability to hand warm, subjects were exposed to an imagery exercise designed to increase skin temperature at trigger-point sites, which are small tender irritative foci located in the soft tissue. Skin temperature, tissue compliance, and pressure-pain sensitivity were recorded before and after imagery intervention. Subjects showed significant increases in skin temperature and muscle relaxation at trigger-point sites and decreases in pressure-pain sensitivity. This suggests that localized trigger-point warming may be an effective adjunct in treating chronic pain.

Adult↗
PubMed1996

Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia.

OBJECTIVE: To compare responses to trigger point (TrP) injection between patients having both myofascial pain syndrome (MPS) caused by active TrPs and fibromyalgia syndrome (FMS) and patients with MPS due to TrPs but without FMS. DESIGN: Prospective design blinded measurement, before- after trial. SETTING: A pain control medical clinic. PATIENTS: Group 1: MPS + FMS; Group 2: MPS only. All patients (9 in each group) had active TrPs in the upper trapezius muscle. INTERVENTION: Myofascial TrP injection with 0.5% xylocaine. MAIN OUTCOME MEASURES: Subjective pain intensity (PI), pain threshold (PT), and range of motion (ROM) were assessed before, immediately after, and 2 weeks after TrP injection. RESULTS: In a comparison of preinjection measures to immediate postinjection measures, only ROM was significantly improved (p < .05) in Group 1 patients; all three parameters were significantly improved (p < .05) in the Group 2 patients who had only MPS. Two weeks after injection, both groups showed significant improvement (p < .05) in all three measured parameters as compared to preinjection measurements. In a comparison of the two groups, the immediate effectiveness of TrP injection was significantly less (p < .05) in Group 1 than in Group 2 for all three parameters. Two weeks after injection, the degree of improvement in PT or ROM (but not PI) was not significantly different between two groups. Postinjection soreness (different from myofascial pain) was more severe, developed sooner, and lasted longer in Group 1 than in Group 2. CONCLUSION: Trigger point injection is a valuable procedure for pain relief for patients in both group. Patients with FMS are likely to experience significant but delayed and attenuated pain relief following injection of their active TrPs compared to myofascial pain patients with similar TrPs but without FMS. Also, FMS patients are likely to experience significantly more postinjection soreness for a longer period of time.

Adult↗
PubMedDate not supplied

Myofascial pain syndrome and trigger-point management.

BACKGROUND AND OBJECTIVES: Myofascial pain syndrome (MPS) is a common condition often resulting in referral to a pain clinic. The epidemiology, pathogenesis, and various diagnostic tools are reviewed, and a variety of treatment methods are discussed. METHODS: Extensive periodical literature and textbooks are reviewed, and selected manuscripts are critically analyzed. RESULTS: The incidence of MPS with associated trigger points appears to vary between 30 and 85% of people presenting to pain clinics, and the condition is more prevalent in women than in men. Patients complain of regional persistent pain, ranging in intensity and most frequently found in the head, neck, shoulders, extremities, and low back. Muscle histologic abnormalities have been described in some studies. Similarly, electromyographic, thermographic, and pressure algometric studies have inconsistently identified abnormalities. A multidisciplinary approach to treatment appears to be most beneficial and may include such modalities as trigger-point injections, dry needling, stretch and spray, and transcutaneous electrical nerve stimulation. CONCLUSIONS: The definitive pathogenesis of MPS is currently unknown, and no single diagnostic method is consistently positive. While trigger-point injection is the most widely employed method of treatment, other modes of therapy have also proved to be effective.

Adult↗
PubMed2001

Clinical precision of myofascial trigger point location in the trapezius muscle.

Myofascial trigger points (TrPs) have been clinically described as discrete areas of muscle tenderness presenting in taut bands of skeletal muscle. Using well-defined clinical criteria, prior investigations have demonstrated interrater reliability in the diagnosis of TrPs within a given muscle. No reports exist, however, with respect to the precision with which experienced clinicians can determine the anatomic locations of TrPs within a muscle. This paper details a study wherein four trained clinicians achieved statistically significant reliability (see below) in estimating the precise locations of latent TrPs in the trapezius muscle of volunteer subjects (n=20). To do so, the clinicians trained extensively together prior to the study. The precise anatomic location of each subject's primary TrP was measured in a blinded fashion using a 3 dimensional (3-D) camera system. Use of this measurement system permitted the anatomic co-ordinates of each TrP to be located without providing feedback to subsequent clinicians. The clinicians each used a pressure algometer along with patient feedback to document the sensitivity of each suspected TrP site, however unlike routine clinical practice, the algometry was performed with a double-blinded approach hence the results were only examined post-hoc. At the time of data collection (algometry readings unknown), 16 of the 20 subjects were judged to present with a latent TrP. Subsequently, when subjected to a criterion pressure threshold value of <3.0 kg.cm(-2), 12 of these TrPs were classified as being clinically sensitive. To assess the 3-D measurement precision, and the reliability of the TrP estimates, statistical measures of the SEM and the Generalizability coefficient (G-coeff) were determined for all suspected TrP sites in the superior-inferior, medial-lateral and anterior-posterior directions. The best results were determined by pooling the measurements of all 4 clinicians, however, based upon exceeding a criterion reliability threshold of 80%, the use of just two testers was found to produce reliable results. The two-tester condition yielded a precision of 7.5, 7.6 and 6.5 mm (SEM) with reliability (G-coeff) of 0.92, 0.86 and 0.83, respectively. Given the double-blinded methodology, the use of pressure algometry was also found to demonstrate internal validity. The algometer responses associated with TrP estimates varied inversely with respect to the clinical group's reliability in identify the TrP locations. To summarize, for the trapezius muscle, this study demonstrates that two trained examiners can reliably localize latent TrPs with a precision that essentially approaches the physical dimensions of the clinician's own fingertips. Finally, it should be recognized that the ability to precisely document TrP location appears critical to the success of future studies that may be designed to investigate the etiology and pathogenesis of this commonly diagnosed clinical disorder.

Adult↗