Evidence for the Use of Ischemic Compression and Dry Needling in the Management of Trigger Points of the Upper Trapezius in Patients with Neck Pain: A Systematic Review

The Effectiveness of Ischemic Compression Technique on Pain and Function in Individuals With Shoulder Pain: A Systematic Review

OBJECTIVE

To systematically review current literature to determine the effectiveness of the ischemic compression (IC) technique on pain and function in individuals with shoulder pain.

METHODS

This review was conducted according to recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Collaboration for Systematic Reviews; a search was performed in the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence Database, and Web of Science. Randomized clinical trials and quasi-randomized clinical trials were included, and the methodological quality was evaluated through the Physiotherapy Evidence Database scale.

RESULTS

The search found 572 studies; of these, 71 were selected by title and, subsequently, 29 were selected through abstract analyses. After critical analyses, 5 studies were included. The methodological quality ranged from 4 (reasonable) to 9 (excellent) points. Pain was assessed by all studies using the visual analog scale, Global Perceived Effect scale, Numerical Rating Scale, pressure pain threshold, or Perceived Amelioration Numerical Scale. Function was evaluated by 3 studies through the Shoulder Pain and Disability Index; Neck Disability Index; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment; and Disabilities of the Arm, Shoulder, and Hand questionnaires. The studies showed that the IC technique produces immediate and short-term positive effects for pain, and positive short-term effects for shoulder function in individuals with shoulder pain.

CONCLUSION

The IC technique seems to be beneficial for pain and shoulder function. However, caution is needed when considering this evidence owing to the limited quality of some studies, the few articles found, and the lack of standardization of the application parameters of the technique to facilitate its reproducibility.

The effect of vibration therapy on neck myofascial trigger points: A randomized controlled pilot study

BACKGROUND

The purpose of this study was to evaluate the effect of low-frequency self-administered vibration therapy into myofascial trigger points in the upper trapezius and levator scapulae on patients with chronic non-specific neck pain.

METHODS

Twenty-eight patients with chronic non-specific neck pain were randomly assigned into a vibration group, receiving 10 self-applied sessions of vibration therapy in the upper trapezius and levator scapulae trigger points; or a control group, receiving no intervention. Self-reported neck pain and disability (Neck Disability Index) and pressure pain threshold were assessed at baseline and after the first, fifth and 10th treatment sessions.

FINDINGS

Significant differences were found in the vibration group when compared to the control group after the treatment period: the vibration group reached lower Neck Disability Index scores (F = 4.74, P = .033, η² = 0.07) and greater pressure pain threshold values (F = 7.56, P = .01, η² = 0.10) than the control group. The vibration group reported a significant reduction in Neck Disability Index scores (χ2 = 19,35, P = .00, Kendall's W = 0.28) and an increase in pressure pain threshold (χ2 = 87,10, P = .00, Kendall's W = 0.73) between the assessment times over the course of the treatment. The mean increase in pressure pain threshold in the vibration group after the 10 sessions was 8.54 N/cm2, while the mean reduction in Neck Disability Index scores was 4.53 points.

INTERPRETATION

Vibration therapy may be an effective intervention for reducing self-reported neck pain and disability and pressure pain sensitivity in patients with chronic non-specific neck pain. This tool could be recommended for people with non-specific neck pain.

Myofascial pain syndrome and trigger points: evaluation and treatment in patients with musculoskeletal pain

PURPOSE OF REVIEW

Myofascial pain syndrome is a chronic pain condition characterized by the presence of myofascial trigger point, a hyperirritable painful spot involving a limited number of muscle fibers. The literature suggest that myofascial trigger points should be considered peripheral pain generators and this critical review will summarize recent findings concerning the clinical evaluation and the treatment of myofascial trigger points.

RECENT FINDINGS

The clinical features of myofascial trigger points and their contribution to the patient pain and disability have been detailed in several recent studies, which support the clinical relevance of the condition. Recent studies reported that manual palpation to identify MTrPs has good reliability, although some limitations are intrinsic to the diagnostic criteria. During the last decade, a plethora of treatments have been proposed and positive effects on pain and function demonstrated.

SUMMARY

The myofascial trigger point phenomenon has good face validity and is clinically relevant. Clinicians are encouraged to consider the contribution of myofascial trigger points to the patient's pain and disability through a careful medical history and a specific manual examination. Patients with myofascial trigger points will benefit from a multimodal treatment plan including dry needling and manual therapy techniques. Internal and external validity of research within the field must be improved.

[Effectiveness of invasive and non-invasive tecniques for neck myofascial pain syndrome: a systematic review]

INTRODUCTION

Myofascial pain is a muscular alteration caused by one or more myofascial trigger points and is considered one of the most frequent musculoskeletal disorders. This study compared the effectiveness of invasive and non-invasive techniques in the treatment of neck myofascial pain syndrome.

MATERIALS AND METHODS

A literature search were performed in PubMed with a combination of key words related to myofascial pain syndrome and invasive and non-invasive therapies. Articles were included according to whether they were published less than 10 years previously and other inclusion criteria. Pain intensity, pressure pain threshold, range of movement, disability and quality of life were evaluated in the 26 articles finally selected.

RESULTS

There are multiple publications on pain intensity reduction and range of movement. Reports of invasive techniques are more important than those of non-invasive techniques. However, there are only a few publications on threshold pressure pain, functionality and quality of life irrespective of the type of technique.

CONCLUSION

Invasive and non-invasive techniques are effective in the treatment of neck myofascial pain syndrome, but it is difficult to conclude the superiority of one type of technique over the other due to multiple methodological differences among the evaluated studies.

Novel application of dry needling for neuropathic myofascial ankle pain and dysfunction following insidious integumentary infection: A case report

BACKGROUND

Dry needling (DN) was effectively applied to a patient whose primary complaint was hyperalgesia and decreased ankle function meeting criteria for neuropathic myofascial pain following an integumentary infection, skin grafting and immobilization.

CASE DESCRIPTION

A 33-year-old male serving on active duty in the United States Air Force was referred to physical therapy for decreased ankle range of motion and pain, eight weeks after an integumentary infection on his ankle. The infection was complicated by tissue loss requiring skin grafting for closure. Two months of traditional rehabilitation was unsuccessful and this patient was referred for DN treatment.

OUTCOMES

Clinically relevant improvements were achieved after one treatment. After 48 hours, the patient's reported Pain Quality Assessment Scale (PQAS) dropped from a baseline 67 to 34 and Lower Extremity Functional Scale (LEFS) increased from 44 to 56. Plantarflexion and dorsiflexion improved by 15° and inversion and eversion by five degrees. After one year and 11 DN treatments, function continued to improve as demonstrated by single leg stance time improvement from 4 s to more than 60 seconds, without pain, a final LEFS of 72 and a return to unrestricted full duty.

CONCLUSION

DN is an increasingly utilized treatment option for myofascial pain. This case report represents a unique application of DN to an atypical patient presenting with neuropathic myofascial pain syndrome that demonstrated improvement with DN as the sole intervention. Further research regarding the application of DN as a treatment option for neuropathic myofascial pain syndromes is needed.

Comparison of dry needling and ischaemic compression techniques on pain and function in patients with patellofemoral pain syndrome: a randomised clinical trial

BACKGROUND

To compare the effectiveness of ischaemic compression (IC) applied directly to the knee versus dry needling (DN) with respect to pain, functional status and sensitivity to mechanical stimulation of vastus medialis obliquus (VMO) myofascial trigger points (MTrPs) in patients with patellofemoral pain syndrome (PFPS).

METHODS

A total of 54 patients with unilateral PFPS aged 20-30 years were selected randomly from patients referred to physical therapy clinics of Babol University of Medical Sciences in Iran. Twenty-seven patients were allocated to either IC or DN groups. Three sessions of treatment were applied over 1 week with follow-up at 1 week, 1 month and 3 months. Primary outcome measures comprised the Kujala questionnaire score for functional status, numerical pain rating scale (NPRS) for pain intensity and pressure pain threshold (PPT) for sensitivity to mechanical stimulation; these were measured and recorded before treatment and 1 week, 1 month and 3 months after the last treatment session.

RESULTS

There were no statistically significant differences in the between-group comparisons of any variables at the various follow-up points. Both groups (n = 27 participants each) had significant improvements (p < 0.05) in pain, functional status and PPT values at follow-up.

CONCLUSIONS

There were no differences in markers of pain, function or pressure sensitivity over a 3-month follow-up period between patients with PFPS treated with DN and IC. Temporal improvements in both groups suggested that the two techniques may be similarly effective for the treatment of PFPS.

Effects of dry needling of active trigger points in the scalene muscles in individuals with mechanical neck pain: a randomized clinical trial

OBJECTIVE

The aim of this study was to compare the effects of dry needling (DN) versus pressure release over scalene muscle trigger points (TrPs) on pain, related disability, and inspiratory vital capacity in individuals with neck pain.

METHODS

In this randomized, single-blind trial, 30 patients with mechanical neck pain and active TrPs in the scalene musculature were randomly allocated to trigger point dry needling (TrP-DN; n = 15) or pressure release (n = 15) groups. The DN group received a single session of DN of active TrPs in the anterior scalene muscles, and the pressure release group received a single session of TrP pressure release over the same muscle lasting 30 s. The primary outcome was pain intensity as assessed by a numerical pain rate scale (NPRS, 0-10). Secondary outcomes included disability (neck disability index, NDI) and inspiratory vital capacity. Outcomes were assessed at baseline and 1 day (immediately post), 1 week, and 1 month after the treatment session. Data were expressed as mean score difference (Δ) and standardized mean difference (SMD).

RESULTS

Patients receiving DN exhibited a greater decrease in pain intensity than those receiving TrP pressure release at 1 month (Δ 1.2 (95% CI-1.8, -0.6), p = 0.01), but not immediately (1 day) or 1 week after. Patients in the DN group exhibited a greater increase in inspiratory vital capacity at all follow-up time points (Δ 281 mm (95% CI 130, 432) immediately after, Δ 358 mm (95% CI 227, 489) 1 week after, and Δ 310 mm (95% CI 180, 440) 1 month after treatment) than those in the pressure release group (p = 0.006). Between-group effect sizes were large at all follow-up time points (1.1 > SMD > 1.3) in favor of DN.

CONCLUSION

This trial suggests that a single session of DN over active TrPs in the scalene muscles could be effective at reducing pain and increasing inspiratory vital capacity in individuals with mechanical neck pain. Future studies are needed to further confirm these results.

Efficacy of Combination Therapies on Neck Pain and Muscle Tenderness in Male Patients with Upper Trapezius Active Myofascial Trigger Points

Myofascial pain syndrome, thought to be the main cause of neck pain and shoulder muscle tenderness in the working population, is characterized by myofascial trigger points (MTrPs). This study aimed to examine the immediate and short-term effect of the combination of two therapeutic techniques for improving neck pain and muscle tenderness in male patients with upper trapezius active MTrPs. This study was a pretest-posttest single-blinded randomized controlled trial. Sixty male subjects with mechanical neck pain due to upper trapezius active MTrPs were recruited and randomly allocated into group A, which received muscle energy technique (MET) and ischemic compression technique (ICT) along with conventional intervention; group B, which received all the interventions of group A except ICT; and group C, which received conventional treatment only. Baseline (Pr), immediate postintervention (Po), and 2-week follow-up (Fo) measurements were made for all variables. Pain intensity and pressure pain threshold (PPT) were assessed by a visual analog scale (VAS) and pressure threshold meter, respectively. All the three groups received their defined intervention plans only. Repeated-measures analysis of variance was used to perform intra- and intergroup analyses. Cohen's d test was used to assess the effect size of the applied interventions within the groups. The intergroup analysis revealed significant differences among groups A, B, and C in VAS and PPT at Po (VAS-Po: F = 13.88, p=0.0001; PPT-Po: F = 17.17, p=0.0001) and even after 2 weeks of follow-up (VAS-Fo: F = 222.35, p=0.0001; PPT-Fo: F = 147.70, p=0.0001). Cohen's d revealed a significant treatment effect size within all groups except group C (only significant for VAS-Po-VAS-Pr: mean difference = 1.33, p < 0.05, d = 1.09); however, it showed a maximum effect size in group A for its variables (VAS-Fo-VAS-Pr: mean difference = 5.27, p=0.01, d = 4.04; PPT-Fo-PPT-Pr: mean difference = 2.14, p < 0.01, d = 3.89). Combination therapies (MET plus ICT) showed immediate and short-term (2-week follow-up) improvements in neck pain and muscle tenderness in male patients with upper trapezius active MTrPs.

Pain management for patients with chronic kidney disease in the primary care setting

Pain is routinely reported in patients with chronic kidney disease. Pain is often multifaceted, making the treatment of this complex patient population even more challenging. Understanding pain types as well as treatment options for this patient population is an important skillset for the primary care provider.

Manual therapy as a prophylactic treatment for migraine: design of a randomized controlled trial

Background

People with migraine often experience disability with serious consequences for their social life and work productivity. The pharmacological prophylactic management of migraine is effective in reducing migraine attacks. However, many people are reluctant to use daily prophylactic medication, leading to a demand for non-pharmacological treatment options. We present the design for and discuss the feasibility of a pragmatic, randomized controlled trial on the effectiveness of a multimodal manual therapy (MT) treatment compared to usual care by the general practitioner (GP) for the prophylactic treatment of migraine.

Methods

Eligible participants will be recruited in primary care using the International Classification of Headache Disorders III criteria for migraine of the International Headache Society. Participants will be randomized to either multimodal MT treatment or usual care provided by the GP. GPs will be asked to treat the usual care group according to the Dutch GP guideline for headache. The multimodal MT intervention will include manual pressure techniques, neck muscle-strength exercises and mobilization of the cervical and thoracic spine.

The trial will consist of a 12-week treatment period and follow-up measurements at 12, 26 and 52 weeks. The primary outcome measure is the number of migraine days per 4 weeks, assessed with a headache diary. Secondary outcome measures are the number of migraine attacks, medication use, disability due to headache, headache intensity, number of participants reporting a 50% migraine reduction, measurement of cervical pressure pain thresholds, presence of allodynia, endurance of cervical flexor muscles, days of absence of work and global perceived effect.

Discussion

The results of the trial will show whether a multimodal MT intervention is an effective non-pharmacological treatment option for people with migraine.

Trial registration

Dutch Trial Register, NL7504. Registered on 7 February 2019.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Effectiveness between Dry Needling and Ischemic Compression in the Triceps Surae Latent Myofascial Trigger Points of Triathletes on Pressure Pain Threshold and Thermography: A Single Blinded Randomized Clinical Trial

BACKGROUND

Deep dry needling (DDN) and ischemic compression technic (ICT) may be considered as interventions used for the treatment of Myofascial Pain Syndrome (MPS) in latent myofascial trigger points (MTrPs). The immediate effectiveness of both DDN and ICT on pressure pain threshold (PPT) and skin temperature of the latent MTrPs of the triceps surae has not yet been determined, especially in athletes due to their treatment requirements during training and competition.

OBJECTIVE

To compare the immediate efficacy between DDN and ICT in the latent MTrPs of triathletes considering PPT and thermography measurements.

METHOD

A total sample of 34 triathletes was divided into two groups: DDN and ICT. The triathletes only received a treatment session of DDN (n = 17) or ICT (n = 17). PPT and skin temperature of the selected latent MTrPs were assessed before and after treatment.

RESULTS

Statistically significant differences between both groups were shown after treatment, showing a PPT reduction (p < 0.05) in the DDN group, while PPT values were maintained in the ICT group. There were not statistically significant differences (p > 0.05) for thermographic values before and treatment for both interventions.

CONCLUSIONS

Findings of this study suggested that ICT could be more advisable than DDN regarding latent MTrPs local mechanosensitivity immediately after treatment due to the requirements of training and competition in athletes' population. Nevertheless, further studies comparing both interventions in the long term should be carried out in this specific population due to the possible influence of delayed onset muscle soreness and muscle damage on PPT and thermography values secondary to the high level of training and competition.

Dry Cupping, Ischemic Compression, or Their Combination for the Treatment of Trigger Points: A Pilot Randomized Trial

Background: Chronic neck pain (NP) attributed to myofascial pain syndrome is one of the particularly common skeletal muscle disorder associated with the hyperirritable zone in the taut band of muscle. Trigger points (TPs) are the physical interpretation of the myofascial pain syndrome. In the United States, 30%–85% of pain patients have been affected by myofascial TPs.

Objectives: To reveal preliminary evidence on the clinical efficacy of ischemic compression therapy, dry cupping, and their combination on improving the TPs' pressure pain threshold (PPT), neck range of motion (NROM), and neck disability index (NDI) in patients with TPs and nonspecific NP. Besides, assess the feasibility of conducting a randomized clinical trial (RCT).

Design: A randomized pilot study was conducted on 24 patients with TPs and nonspecific NP. Patients were randomly assigned to three groups: the cupping group, the ischemic compression group, and the combination therapy group. PPT, NROM, and NDI were assessed before and after 4 weeks of treatment.

Results: The results showed a statistically significant improvement in NDI, PPT, and NROM compared with values before the treatment (p < 0.05) in all groups. Although no significant difference was detected between ischemic compression (IC) and dry cupping, the combination approach showed significantly higher and faster improvement (p < 0.05).

Conclusions: It is feasible to conduct a main RCT. Both IC and dry cupping may hold promise in treating TPs; a combination of the two therapies may provide superior improving rate.

Effects of an integrated neuromuscular inhibition technique program on neck muscle strength and endurance in individuals with chronic mechanical neck pain

BACKGROUND

The aim of this study was to investigate whether the application of the integrated neuromuscular inhibition technique (INIT) combined with therapeutic exercise (TE) can provide faster and greater improvement in maximum isometric strength and isometric endurance of the neck muscles in patients with chronic mechanical neck pain (CMNP).

METHODS

In this 10-week, single-blind clinical trial, 40 participants (men and women) with CMNP were divided into two groups. The intervention group (IG) followed a TE program in combination with the INIT, while the control group (CG) followed the same TE program without the INIT technique. Changes in maximum isometric strength and isometric endurance of the neck muscles were evaluated before, during, and after the intervention, with follow-up measurements taken at 1, 3, and 6 months after the intervention. Analysis of variance with repeated measures was applied.

RESULTS

Both groups showed a significant improvement in all dependent measures after the intervention (p < .05). These changes were maintained for both groups 6 months after the intervention. However, the IG showed a greater improvement in the maximum isometric strength of neck flexion and an improved craniocervical flexion test score compared with the CG.

CONCLUSION

The combination of TE and INIT had a positive effect on neck muscle strength and endurance in individuals suffering from CMNP as compared with TE alone.

Identification of the optimal points for the acupuncture treatment of neck pain in China: protocol for a multicenter, matched, case-control study

INTRODUCTION

Neck pain (NP) is a common condition that can be effectively treated by acupuncture. However, several treatment point prescriptions (ie, local acupoints, distal acupoints, and sensitised acupoints) may be used. The present study aims to identify the types of sensitisation and the distribution of sensitised points in patients with NP, to analyse the cut-off values and sensitisation rate for acupoint sensitisation, and to summarise the dominant forms of optimally sensitised points. This information will be helpful when choosing the optimal points to treat NP.

METHODS AND ANALYSIS

This multicentre, matched, case-control study will enrol 224 patients with NP, and 224 age-matched and sex-matched healthy participants as controls. Body surface temperature, mechanical pain threshold, pressure pain threshold and skin resistance will be assessed at the 15 acupoints most frequently used to treat NP, and at the five body regions in which pain occurs most frequently. Hypothesis testing will be used to compare the differences in variables between cases and controls. In addition, receiver operating characteristic curve analysis will be used to explore the cut-off values of the sensitive states of heat, pain and electrical resistance, which indicate sensitisation of the acupoint. The optimal points will be comprehensively determined by the acupoint sensitisation rate and OR.

ETHICS AND DISSEMINATION

Ethical approval of this study has been granted by the Research Ethical Committee of the Teaching Hospital of Chengdu University of Traditional Chinese Medicine (ID: 2018 KL-016). The outcomes of the study will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION

ChiCTR1800016220.

The effectiveness of trigger point treatment in rotator cuff pathology: A randomized controlled double-blind study

BACKGROUND

Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles.

OBJECTIVE

Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies.

METHODS

Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs. Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed manually, and the number of MTrPs on the shoulder complex was counted.

RESULTS

There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM, function, or anxiety and depression (p> 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was significantly decreased in Group 1 (p= 0.001).

CONCLUSION

A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.

Differences in the Mitochondrial and Lipid Droplet Morphology in Female Office Workers With Trapezius Myalgia, Compared With Healthy Controls: A Muscle Biopsy Study

OBJECTIVE

Trapezius myalgia or, more specifically, myofascial dysfunction of the upper trapezius mainly affects women performing jobs requiring prolonged low level activation of the muscle. This continuous low muscle load can be accompanied by a shift to a more anaerobic energy metabolism, causing pain. The aim of the study was to investigate whether morphological signs of an impaired aerobic metabolism are present in female office workers with trapezius myalgia.

DESIGN

Muscle biopsy analysis, using electron and light microscopy, was performed to compare mitochondrial and fat droplet morphology, and irregular muscle fibers, between female office workers with (n = 17) and without (n = 15) work-related trapezius myalgia.

RESULTS

The patient group showed a significantly higher mean area (P = 0.023) and proportion (P = 0.029) for the subsarcolemmal and intermyofibrillar mitochondria respectively, compared with the control group. A significantly lower mean area of subsarcolemmal lipid droplets was found in the patient group (P = 0.015), which also displayed a significantly higher proportion of lipid droplets touching the mitochondria (P = 0.035). A significantly higher amount of muscle fibers with cytochrome c oxidase-deficient areas were found in the patient group (P = 0.030).

CONCLUSIONS

The results of the present study may be indicative for an impaired oxidative metabolism in work-related trapezius myalgia. However, additional research is necessary to confirm this hypothesis.

Effects of Local Ischemic Compression on Upper Limb Latent Myofascial Trigger Points: A Study of Subjective Pain and Linear Motor Performance

OBJECTIVE

To analyse the effect of the manual ischemic compression (IC) on the upper limb motor performance (MP) in patients with LTrPs.

MATERIALS AND METHODS

A quasiexperimental study was performed in twenty subjects allocated to either patients group with LTrPs (PG, n=10) or healthy group with no symptoms (HG, n=10). Subjective pain and linear MP (movement time and Fitts' Law) were assessed before and after a linear tapping task. Data were analysed with mixed factorial ANOVA for intergroup linear motor performance differences and dependent t-student test for intragroup pain differences.

RESULTS

PG had a linear MP lower than the HG before treatment (p < 0.05). After IC, the PG showed a significant decrease of pain (4.07 ± 1.91 p < 0.001). Furthermore, the movement time (15.70 ± 2.05 p < 0.001) and the Fitts' Law coefficient (0.80 ± 0.53 p < 0.001) were significantly reduced. However, one IC session did not allow the PG to get the same MP than the HG (p < 0.05).

CONCLUSION

The results suggest the IC effectiveness on pain and MP impairment in subjects with LTrPs. However, the MP of these patients is only partially improved after the IC application.

Dry needling versus trigger point compression of the upper trapezius: a randomized clinical trial with two-week and three-month follow-up

Objectives: The purpose of this randomized controlled trial was to investigate the long-term clinical effect of dry needling with two-week and three-month follow up, on individuals with myofascial trigger points in the upper trapezius muscle. Methods: A sample of convenience (33 individuals) with a trigger point in the upper trapezius muscle, participated in this study. The individuals were randomly assigned to two groups: trigger point compression (N = 17) or dry needling (N = 16). Pain intensity, neck disability, and disability of the arm, hand, and shoulder (DASH) were assessed before treatment, after treatment sessions, and at two-week and three-month follow ups. Results: The result of repeated measures ANOVA showed significant group-measurement interaction effect for VAS (p = .02). No significant interaction was found for NPQ and DASH (p > .05). The main effect of measurements for VAS, NPQ, and DASH were statistically significant (p < .0001). The results showed a significant change in pain intensity, neck disability, and DASH after treatment sessions, after two weeks and three months when compared with before treatment scores in both groups.  There was no significant difference in the tested variables after two-week or three-month as compared to after treatment sessions between the two groups. However, pain intensity after treatment sessions was significantly different between the two groups (p = .02). Discussion: Dry needling and trigger point compression in individuals with myofascial trigger point in the upper trapezius muscle can lead to three-month improvement in pain intensity and disability.

Changes in Muscle Stiffness of the Trapezius Muscle After Application of Ischemic Compression into Myofascial Trigger Points in Professional Basketball Players

The study aimed to assess the effects of compression trigger point therapy on the stiffness of the trapezius muscle in professional basketball players (Part A), and the reliability of the MyotonPRO device in clinical evaluation of athletes (Part B). Twelve professional basketball players participated in Part A of the study (mean age: 19.8 ± 2.4 years, body height 197 ± 8.2 cm, body mass: 91.8 ± 11.8 kg), with unilateral neck or shoulder pain at the dominant side. Part B tested twelve right-handed male athletes (mean ± SD; age: 20.4 ± 1.2 years; body height: 178.6 ± 7.7 cm; body mass: 73.2 ± 12.6 kg). Stiffness measurements were obtained directly before and after a single session trigger point compression therapy. Measurements were performed bilaterally over 5 points covering the trapezius muscle. The effects were evaluated using a full-factorial repeated measure ANOVA and the Bonferroni post-hoc test for equal variance. A p-value < .05 was considered significant. The RM ANOVA revealed a significant decrease in muscle stiffness for the upper trapezius muscle. Specifically, muscle stiffness decreased from 243.7 ± 30.5 to 215.0 ± 48.5 N/m (11.8%), (p = .008) (Part A). The test-retest relative reliability of trapezius muscle stiffness was found to be high (ICC from 0.821 to 0.913 for measurement points). The average SEM was 23.59 N/m and the MDC 65.34 N/m, respectively (Part B). The present study showed that a single session of compression trigger point therapy can be used to significantly decrease the stiffness of the upper trapezius among professional basketball players.

Electrical impedance of the torso is associated with the pressure pain threshold on myofascial trigger points in patients with chronic neck pain: A cross-sectional study

BACKGROUND

Myofascial trigger points are dysfunctional structures present in skeletal muscles and are related to sensory, motor, and autonomic changes. Despite scientific advances in recent decades in the measurement of musculoskeletal pain, evaluation of this clinical phenomenon is supported with instruments that, although valid and reliable, have a considerable degree of subjectivity.

OBJECTIVE

To correlate electrical impedance of the upper limbs and torso with pain intensity, functional capacity, catastrophizing, pressure pain threshold, and skin temperature on myofascial trigger points in the upper trapezius muscle of patients with neck pain.

METHODS

A single-blind cross-sectional study. Twenty-eight volunteers of both genders were included in the study, were aged 18-45 years, and had chronic neck pain and myofascial trigger points in the upper trapezius. The volunteers were assessed using the Numeric Rating Scale, the Neck Disability Index, the Pain-Related Self-Statement Scale, algometry, infrared thermography, and electrical bioimpedance.

RESULTS

The following significant results were observed: a negative association between the pressure pain threshold on myofascial trigger point in the right upper trapezius and electrical impedance of the torso at 5 kHz (rs=-0.392, p= 0.032), 50 kHz (rs=-0.406, p= 0.026), 250 kHz (rs=-0.388, p= 0.034), and to the frequency 500 kHz (rs=-0.444, p= 0.014).

CONCLUSION

Electrical impedance of the torso is associated with the pressure pain threshold of myofascial trigger points on the upper trapezius of individuals with neck pain. Thus, individuals with a lower pressure pain threshold have higher electrical impedance values of the torso and vice versa.

Effectiveness of Trigger Point Manual Treatment on the Frequency, Intensity, and Duration of Attacks in Primary Headaches: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

A variety of interventions has been proposed for symptomatology relief in primary headaches. Among these, manual trigger points (TrPs) treatment gains popularity, but its effects have not been investigated yet.

Objective

The aim was to establish the effectiveness of manual TrP compared to minimal active or no active interventions in terms of frequency, intensity, and duration of attacks in adult people with primary headaches.

Methods

We searched MEDLINE, COCHRANE, Web Of Science, and PEDro databases up to November 2017 for randomized controlled trials (RCTs). Two independent reviewers appraised the risk-of-bias (RoB) and the grading of recommendations, assessment, development, and evaluation (GRADE) to evaluate the overall quality of evidence.

Results

Seven RCTs that compared manual treatment vs minimal active intervention were included: 5 focused on tension-type headache (TTH) and 2 on Migraine (MH); 3 out of 7 RCTs had high RoB. Combined TTH and MH results show statistically significant reduction for all outcomes after treatment compared to controls, but the level of evidence was very low. Subgroup analysis showed a statistically significant reduction in attack frequency (no. of attacks per month) after treatment in TTH (MD −3.50; 95% CI from −4.91 to −2.09; 4 RCTs) and in MH (MD −1.92; 95% CI from −3.03 to −0.80; 2 RCTs). Pain intensity (0–100 scale) was reduced in TTH (MD −12.83; 95% CI from −19.49 to −6.17; 4 RCTs) and in MH (MD −13.60; 95% CI from −19.54 to −7.66; 2RCTs). Duration of attacks (hours) was reduced in TTH (MD −0.51; 95% CI from −0.97 to −0.04; 2 RCTs) and in MH (MD −10.68; 95% CI from −14.41 to −6.95; 1 RCT).

Conclusion

Manual TrPs treatment of head and neck muscles may reduce frequency, intensity, and duration of attacks in TTH and MH, but the quality of evidence according to GRADE approach was very low for the presence of few studies, high RoB, and imprecision of results.

Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial

OBJECTIVE

The aim of this study was to investigate short-term and long-term treatment effects of dry needling (DN) and manual pressure (MP) technique with the primary goal of determining if DN has better effects on disability, pain, and muscle characteristics in treating myofascial neck/shoulder pain in women.

METHODS

In this randomized clinical trial, 42 female office workers with myofascial neck/shoulder pain were randomly allocated to either a DN or MP group and received 4 treatments. They were evaluated with the Neck Disability Index, general numeric rating scale, pressure pain threshold, and muscle characteristics before and after treatment. For each outcome parameter, a linear mixed-model analysis was applied to reveal group-by-time interaction effects or main effects for the factor "time."

RESULTS

No significant differences were found between DN and MP. In both groups, significant improvement in the Neck Disability Index was observed after 4 treatments and 3 months (P < .001); the general numerical rating scale also significantly decreased after 3 months. After the 4-week treatment program, there was a significant improvement in pain pressure threshold, muscle elasticity, and stiffness.

CONCLUSION

Both treatment techniques lead to short-term and long-term treatment effects. Dry needling was found to be no more effective than MP in the treatment of myofascial neck/shoulder pain.

Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain

The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.

Effects of Myofascial Release on Pressure Pain Thresholds in Patients With Neck Pain: A Single-Blind Randomized Controlled Trial

OBJECTIVE

This study aimed to investigate the efficacy of myofascial release therapy (MRT) for improving pressure pain thresholds (PPTs) and pain in patients with mechanical neck pain.

DESIGN

Forty-one participants with neck pain were randomly allocated to either a MRT group (five sessions) or a physical therapy (PT) group (ten sessions) for 2 wks. The multimodal PT program included ultrasound therapy (US), transcutaneous electric nerve stimulation, and massage. Visual analog scale (VAS) and PPTs in suboccipital and upper trapezius muscles were measured at baseline, at the end of treatment, and at 1 month follow-up.

RESULTS

At the end of treatment, significant mean differences in VAS (-0.99, 95% confidence interval [CI] = -1.82 to -0.16), in both left (0.28, 95% CI = 0.06 to 0.50) and right (0.40, 95% CI = 0.16 to 0.63) suboccipital PPTs and in the right trapezius PPT (0.38, 95% CI = 0.07 to 0.69) were observed. At 1-month follow-up, significant mean differences were found for VAS (-1.85, 95% CI = -2.76 to -0.94) and both left (0.46, 95% CI = 0.12 to 0.80) and right (0.38, 95% CI = 0.06 to 0.69) suboccipital PPTs.

CONCLUSIONS

This study provides evidence that MRT could be better than a multimodal PT program for short-term improvement of pain and PPTs in patients with neck pain.

Assessing the viscoelastic properties of upper trapezius muscle: Intra- and inter-tester reliability and the effect of shoulder elevation

BACKGROUND

Increasing stiffness in the upper trapezius muscle may contribute to imbalance of scapular motion, and result in shoulder and neck discomfort during shoulder flexion. Therefore, it is essential to quantify upper trapezius stiffness in various shoulder positions in order to aid in the prevention of these disorders and to optimize rehabilitation.

OBJECTIVES

The objectives of the present study were to examine the intra and inter-tester reliability of MyotonPRO device in measuring upper trapezius stiffness and its ability to determine changes in stiffness during shoulder flexion.

METHODS

Twenty healthy male subjects (mean age: 28.3±4.8 years) were studied. The stiffness of upper trapezius was quantified using the MyotonPRO device.

RESULTS

The results revealed excellent intra and inter-tester reliability for measuring upper trapezius stiffness with the shoulder in a neutral position, and also found a 14.2% increase in stiffness upon shoulder flexion between 0° and 60° of flexion. Minimal detectable change (MDC) was 26.3 N/m.

CONCLUSIONS

Our findings indicate that MyotonPRO device is a feasible tool to quantify upper trapezius stiffness as well as changes in muscle stiffness. Thus, it is important to assess the changes in upper trapezius muscle stiffness due to pathology or treatments for future studies.

Responsiveness of Myofascial Trigger Points to Single and Multiple Trigger Point Release Massages: A Randomized, Placebo Controlled Trial

OBJECTIVE

This study aimed to assess the effects of single and multiple massage treatments on pressure-pain threshold (PPT) at myofascial trigger points (MTrPs) in people with myofascial pain syndrome expressed as tension-type headache.

DESIGN

Individuals (n = 62) with episodic or chronic tension-type headache were randomized to receive 12 twice-weekly 45-min massage or sham ultrasound sessions or wait-list control. Massage focused on trigger point release (ischemic compression) of MTrPs in the bilateral upper trapezius and suboccipital muscles. PPT was measured at MTrPs with a pressure algometer pre and post the first and final (12th) treatments.

RESULTS

PPT increased across the study timeframe in all four muscle sites tested for massage, but not sham ultrasound or wait-list groups (P < 0.0001 for suboccipital; P < 0.004 for upper trapezius). Post hoc analysis within the massage group showed (1) an initial, immediate increase in PPT (all P values < 0.05), (2) a cumulative and sustained increase in PPT over baseline (all P values < 0.05), and (3) an additional immediate increase in PPT at the final (12th) massage treatment (all P values < 0.05, except upper trapezius left, P = 0.17).

CONCLUSIONS

Single and multiple massage applications increase PPT at MTrPs. The pain threshold of MTrPs have a great capacity to increase; even after multiple massage treatments additional gain in PPT was observed.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand the contribution of myofascial trigger points to myofascial pain; (2) Describe an effective treatment for decreasing tenderness of a myofascial trigger point; and (3) Discuss the relative values of single vs. multiple massage sessions on increasing pressure-pain thresholds at myofascial trigger points.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Evolution of the methodological quality of controlled clinical trials for myofascial trigger point treatments for the period 1978-2015: A systematic review

BACKGROUND

The methodological quality of controlled clinical trials (CCTs) of physiotherapeutic treatment modalities for myofascial trigger points (MTrP) has not been investigated yet.

OBJECTIVES

To detect the methodological quality of CCTs for physiotherapy treatments of MTrPs and demonstrating the possible increase over time.

DESIGN

Systematic review.

METHODS

A systematic search was conducted in two databases, Physiotherapy Evidence Database (PEDro) and Medicine Medical Literature Analysis and Retrieval System online (MEDLINE), using the same keywords and selection procedure corresponding to pre-defined inclusion criteria. The methodological quality, assessed by the 11-item PEDro scale, served as outcome measure. The CCTs had to compare at least two interventions, where one intervention had to lay within the scope of physiotherapy. Participants had to be diagnosed with myofascial pain syndrome or trigger points (active or latent).

RESULTS

A total of n = 230 studies was analysed. The cervico-thoracic region was the most frequently treated body part (n = 143). Electrophysical agent applications was the most frequent intervention. The average methodological quality reached 5.5 on the PEDro scale. A total of n = 6 studies scored the value of 9. The average PEDro score increased by 0.7 points per decade between 1978 and 2015.

CONCLUSIONS

The average PEDro score of CCTs for MTrP treatments does not reach the cut-off of 6 proposed for moderate to high methodological quality. Nevertheless, a promising trend towards an increase of the average methodological quality of CCTs for MTrPs was recorded. More high-quality CCT studies with thorough research procedures are recommended to enhance methodological quality.

A critical overview of the current myofascial pain literature - June 2017

We would like to welcome Dr. Li-Wei Chou, MD, PhD as our newly appointed contributing author. Dr. Chou is Assistant Professor at China Medical University in Taichung, Taiwan and he has an impressive publication record with many research studies and book chapters. The current overview includes several articles comparing dry needling (DN) to acupuncture with sharply contrasting points of view. Several basic studies shed further light on the nature of myofascial pain, myalgia, fascia and examination techniques, such as sonoelastography. Neuroimaging studies demonstrated microstructural abnormalities in brain gray matter of chronic myofascial pain patients, which is an important new finding. As usual, many manual TrP papers and DN papers were published in the past several months.

Neck Pain: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

Effect of fascia dry needling on non-specific thoracic pain - A proposed dry needling grading system

This case report describes a 42-year-old female who presented with complaints of diffuse pain in her thoracic paraspinal region from T2 to T7. Physical examination revealed tenderness, increased turgor and restriction of her superficial fascia. A potential first time description of successful management utilizing fascia dry needling is described in this report with improvements noted in pain, range of motion, and functional activities. The patient was discharged from physiotherapy after four treatment sessions, and a follow-up after 3 months revealed that she was pain free and fully functional. A grading system (Sudarshan and Murugavel Dry Needling Grading Scale^©) is proposed describing the various grades of dry needling to guide clinical reasoning and decision-making.

The local twitch response during trigger point dry needling: Is it necessary for successful outcomes?

BACKGROUND

Myofascial trigger point (MTrP) injection and trigger point dry needling (TrPDN) are widely accepted therapies for myofascial pain syndrome (MPS). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential.

OBJECTIVE

This is the first review exploring the available literature, regardless of study design, on the neurophysiological effects and clinical significance of the LTR as it relates to reductions in pain and disability secondary to MTrP needling.

METHODS

PubMed, MEDLINE, Science Direct and Google Scholar were searched up until October 2016 using terms related to trigger point needling and the LTR.

RESULTS

and Discussion: Several studies show that eliciting a LTR does not correlate with changes in pain and disability, and multiple systematic reviews have failed to conclude whether the LTR is relevant to the outcome of TrPDN. Post needling soreness is consistently reported in studies using repeated in and out needling to elicit LTRs and increases in proportion to the number of needle insertions. In contrast, needle winding without LTRs to MTrPs and connective tissue is well supported in the literature, as it is linked to anti-nociception and factors related to tissue repair and remodeling. Additionally, the positive biochemical changes in the MTrP after needling may simply be a wash out effect related to local vasodilation. While the LTR during TrPDN appears unnecessary for managing myofascial pain and unrelated to many of the positive effects of TrPDN, further investigation is required.

The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis

Study Design Systematic review and meta-analysis. Background An increasing number of physical therapists in the United States and throughout the world are using dry needling to treat musculoskeletal pain. Objective To examine the short- and long-term effectiveness of dry needling delivered by a physical therapist for any musculoskeletal pain condition. Methods Electronic databases were searched. Eligible randomized controlled trials included those with human subjects who had musculoskeletal conditions that were treated with dry needling performed by a physical therapist, compared with a control or other intervention. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. Results The initial search returned 218 articles. After screening, 13 were included. Physiotherapy Evidence Database quality scale scores ranged from 4 to 9 (out of a maximum score of 10), with a median score of 7. Eight meta-analyses were performed. In the immediate to 12-week follow-up period, studies provided evidence that dry needling may decrease pain and increase pressure pain threshold when compared to control/sham or other treatment. At 6 to 12 months, dry needling was favored for decreasing pain, but the treatment effect was not statistically significant. Dry needling, when compared to control/sham treatment, provides a statistically significant effect on functional outcomes, but not when compared to other treatments. Conclusion Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(3):133-149. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7096.

Beneficial Effects of Dry Needling for Treatment of Chronic Myofascial Pain Persist for 6 Weeks After Treatment Completion

BACKGROUND

Dry needling is an effective treatment for reducing pain associated with active myofascial trigger points (a-MTrPs) in the short term. The duration of the benefits of this treatment have not been fully assessed.

OBJECTIVE

To determine whether the benefits of dry needling (DN) of a-MTrPs are sustained 6 weeks posttreatment.

DESIGN

Follow-up of a prospective study.

SETTING

University.

PARTICIPANTS

A total of 45 patients (13 male and 32 female) with cervical pain >3 months and a-MTrPs in the upper trapezius who completed 3 DN treatments and who were evaluated 6 weeks posttreatment.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Primary outcomes were changes from baseline to follow-up in scores for the verbal analogue scale (VAS), Brief Pain Inventory (BPI), and MTrP status. MTrPs were rated as active (spontaneously painful), latent (painful only on compression), and nonpalpable nodule. Responders were patients whose MTrP status changed from active to latent or nonpalpable nodule (resolved). Secondary outcomes were pain pressure threshold (PPT), Profile of Mood States, Oswestry Disability Index (ODI), MOS 36-Item Short-Form Health Survey (SF-36), and cervical range of motion.

RESULTS

Pain measures remained significantly improved 6 weeks posttreatment (P < .003), as did the SF-36 physical functioning score (0.01) and ODI (P = .002). Side bending and PPT for subjects with unilateral MTrPs had sustained improvement (P = .002). The number of subjects with sustained MTrP response at 6 weeks was significant (P < .001). Comparing responders to nonresponders, the changes in VAS and BPI were statistically significant (P = .006, P = .03) but the change in PPT was not. Patients with higher baseline VAS scores had a higher risk of not responding to DN; those with a greater drop in VAS score from baseline had a higher probability of sustained response. A 1-unit decrease in VAS at baseline resulted in a 6.3-fold increase in the odds of being a responder versus a nonresponder (P = .008).

CONCLUSIONS

In this study, there was sustained reduction of pain scores after completion of DN, which is more likely with a greater drop in VAS score. Patients with higher baseline VAS scores are less likely to respond to DN. Early intervention toward significant pain reduction is likely to be associated with sustained clinical response.

LEVEL OF EVIDENCE

IV.

Conservative treatment of Myofascial Trigger Points and joint mobilization for management in patients with thumb carpometacarpal osteoarthritis

In an attempt to decrease pain and increase function in patients with CMC OA, these authors have described the combination of two techniques that can be performed to treat this common problem. Before applying the techniques, each therapist must determine if the application of the technique falls within their scope of practice. - KristinValdes, OTD, OT, CHT, Practice Forum Editor.

Managing Osteoarthritis and Other Chronic Musculoskeletal Pain Disorders

Osteoarthritis (OA) is a common problem in society and can lead to significant disability and impairment of a patient's capacity to perform activities of daily living. The focus of this article is various treatment options for the management of OA, with emphasis on conservative management. The emphasis is on the role of exercise, pharmacology, intra-articular joint injections, and bracing options in the management of OA.