Ultrasound and Laser as Stand-Alone Therapies for Myofascial Trigger Points: A Randomized, Double-Blind, Placebo-Controlled Study

The importance of context (placebo effects) in conservative interventions for musculoskeletal pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented.

RESULTS

The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses.

CONCLUSION

The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component.

SIGNIFICANCE

Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.

The effect of therapeutic physical modalities on pain, function, and quality of life in patients with myofascial pain syndrome: a systematic review

BACKGROUND

Myofascial pain syndrome (MPS) is a common musculoskeletal pain and dysfunction, which is characterised by myofascial trigger points. Therapeutic physical modalities, as potentially effective treatment options, are commonly used in the clinical setting for the patients with MPS.

OBJECTIVE

This systematic review aimed to evaluate the safety and effectiveness of therapeutic physical modalities in the treatment of MPS, investigate its therapeutic mechanisms and provide a scientific evidence-based decision.

METHODS

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Cochrane Central Library, Embase, and CINAHL databases were searched for randomized controlled clinical studies published from database inception to October 30, 2022. A total of 25 articles met the study inclusion criteria. Data were extracted from these studies and a qualitative analysis was performed.

RESULTS

Transcutaneous electrical nerve stimulation therapy, extracorporeal shock wave therapy, laser therapy, and other therapeutic physical modalities have been demonstrated to improve the pain symptoms, joint mobility, psychological state, and quality of life in the patients with MPS and no side effects have been reported. The curative effect of therapeutic physical modalities was found to be possibly associated with increased blood perfusion and oxygen supply in ischaemic tissues, reduced hyperalgesia in the peripheral and central nerves, and decreased involuntary muscle contractions.

CONCLUSION

The systematic review has shown that therapeutic physical modalities could provide a safe and effective therapeutic option for MPS. However, the consensus is currently lacking regarding the optimal treatment paradigm, therapeutic parameters, and mutual combination of therapeutic physical modalities. The clinical trials with robust quality are required to further promote the evidence-based application of therapeutic physical modalities for MPS.

The Effectiveness Of Trigger Point Treatment In Chronic Pelvic Pain; A Pilot Randomised Controlled Trial

Objective To investigate the effectiveness of ischemic compression and low-level laser therapy methods combined with exercise on the myofascial trigger points in women with Chronic Pelvic Pain and to determine which method is more effective.

Methods It was a parallel designed, single-blind pilot randomized clinical trial. Patients were recruited at physiotherapy laboratory of the Istanbul University from September 2017 to June 2019. Twenty-eight women patients with Chronic Pelvic Pain were included into the trial. Patients were randomized into two groups. Group 1 received ischemic compression and Group 2 received low-level laser therapy twice a week for 6 weeks. Both groups received the same standard exercise program. Pain, range of motion, pelvic floor symptom severity, quality of life, satisfaction, anxiety, and depression were assessed after 6 weeks, and 1-year follow up.

Results Following the treatment, significant differences were observed within both group subjects in pain, range of motion, symptom severity, quality of life, and anxiety-depression (p<0.05). This significant improvement in pain, symptom severity, symptoms related quality of life and pain subgroup of Short Form 36, continued after 1-year follow up (p<0.05). In comparison between group, Group 1 have more significant improvement than Group 2 in terms of symptoms related quality of life (p<0.05).

Conclusion Both methods have shown efficacy and can be used safely in chronic pelvic pain patients. Because it is more effective on symptoms related quality of life, the ıschemic compression method may be preferred for primary use.

Pressure Pain Threshold of the Upper Trapezius Trigger Point: A Systematic Review with Meta-Analysis of Baseline Values and Their Modification after Physical Therapy

BACKGROUND

Myofascial trigger points (TrP) are diagnosed upon the presence of clinical signs among which hypersensitivity is considered one of the most important. The detection of the pressure pain threshold (PPT) is used to quantify the degree of hypersensitivity. However, there is a lack of normative data about how hypersensitive a TrP is. Therefore, the objective was to quantify the PPT for myofascial TrP in the upper trapezius muscle and its modification after manual or instrumental physical therapy interventions.

METHODS

A systematic review and meta-analysis were conducted among three databases (MEDLINE, Cochrane Library, and PEDro). Two independent reviewers conducted the electronic search and assessed the methodological quality of the included studies.

RESULTS

Eleven studies with a high-risk bias indicated that the PPT at TrP sites was 105.11 kPa lower (95% CI: -148.93; -61.28) at active TrP sites (Chi-squared = 1.07, df = 1 (p = 0.30), I² = 7%) compared to the PPT of the upper trapezius muscles of healthy subjects. In addition, the PPT of TrP was also lower than the reference values coming from the pain-free population. Moreover, the PPT increased after both manual and instrumental treatment by 28.36 kPa (95% CI: 10.75; 45.96) and 75.49 kPa (95% CI: 18.02; 132.95), respectively.

CONCLUSIONS

The results of the present study show that TrP has a decreased PPT when compared to healthy muscles and that physical therapy may increase the PPT. However, the clinical relevance of this decreased PPT needs to be further elucidated. Further, the high risk of bias in all the retrieved studies undermines the validity of the results.

Efficacy of low-level laser therapy on pain, disability, pressure pain threshold, and range of motion in patients with myofascial neck pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Low-level laser therapy (LLLT) is one of recent modalities for treatment of myofascial neck pain (MNP). Several RCTs have been conducted on its effectiveness. The aim of this comprehensive meta-analysis was to evaluate the effectiveness of LLLT on MNP. Electronic databases were searched for identifying eligible studies comparing the effectiveness of LLLT using any wavelength with placebo or active control in myofascial neck pain up to June 2022. Data related to pain intensity, pain pressure threshold (PPT), range of motion (ROM), and disability was analyzed as a pooled estimate of mean difference or standard mean difference (SMD) with 95% confidence intervals (CIs) using random/fixed-effect model. Funnel plot and Egger's linear regression test were also conducted to examine the risk of publication bias. A total of 13 randomized controlled trials were included in this systematic review and meta-analysis. The data assessing laser effectiveness on different outcomes of 556 patients were considered for meta-analysis. Pooled results revealed that LLLT was significantly effective in pain reduction (MD =  - 1.29, 95% CI =  - 2.36; - 0.23, P < 0.001). Also, secondary outcomes including PPT (SMD of 2.63, 95% CI = 0.96; 4.30, P < 0.01) and right bending ROM (SMD of 3.44, 95% CI = 0.64; 6.24, P < 0.01) were improved, while disability (MD of - 7.83, 95% CI =  - 17.1; 0.08, P = 1.34) did not improve significantly after LLLT. Our meta-data revealed that LLLT may reduce myofascial neck pain and its related outcomes. LLLT is suggested to be used by clinicians along with other therapies such as manual and exercise therapy.

Photobiomodulation and myofascial temporomandibular disorder: Systematic review and meta-analysis followed by cost-effectiveness analysis

Background

Photobiomodulation (PBM) is a non-invasive and non-pharmacological treatment, which, has shown beneficial results in the treatment of temporomandibular disorders (TMD) related pain. This systematic review and meta-analysis study aimed to evaluate the efficacy of photobiomodulation in the treatment of myofascial pain associated with (TMD by analyzing randomized clinical trials published from 2007 to February 2019. The secondary objective of the study was to perform a cost-effectiveness analysis of TMD treatment with photobiomodulation in patients with myofascial pain.

Material and Methods

International databases were used: Pubmed, Medline and Web of Science; the initial search raised 316 papers, and only 17 papers met the inclusion criteria for the systematic review (SR). Of these, only 04 papers met the inclusion criteria for meta-analysis: VAS data represented by numerical scores and placebo control group.

Results

As for the wavelength, the most used value was 780nm (followed by 830nm. The most used treatment time was 4 offered treatments for 4 weeks; followed by 10 sessions. Regarding periodicity, 9 studies used 2 times a week. The meta-analysis showed that laser-treated groups had painful symptoms improvement that was superior to the control group (mean difference 1.49;95% CI = -1.67; -1.32). Laser therapy showed a cost-effectiveness of $1,464.28 by controlled pain intensity and placebo showed $2,866.20 by controlled pain intensity.

Conclusions

The studies were considered to have moderate quality of evidence. Laser-treated groups had painful symptoms improvement that was superior to the control group and photobiomodulation was more cost-effective than placebo in patients with TMD and myofascial pain. Key words:Temporomandibular disorder, Myofascial pain, Photobiomodulation, Placebo, Cost-effectiveness.

Low-Intensity Continuous Ultrasound Therapies—A Systematic Review of Current State-of-the-Art and Future Perspectives

Therapeutic ultrasound has been studied for over seven decades for different medical applications. The versatility of ultrasound applications are highly dependent on the frequency, intensity, duration, duty cycle, power, wavelength, and form. In this review article, we will focus on low-intensity continuous ultrasound (LICUS). LICUS has been well-studied for numerous clinical disorders, including tissue regeneration, pain management, neuromodulation, thrombosis, and cancer treatment. PubMed and Google Scholar databases were used to conduct a comprehensive review of all research studying the application of LICUS in pre-clinical and clinical studies. The review includes articles that specify intensity and duty cycle (continuous). Any studies that did not identify these parameters or used high-intensity and pulsed ultrasound were not included in the review. The literature review shows the vast implication of LICUS in many medical fields at the pre-clinical and clinical levels. Its applications depend on variables such as frequency, intensity, duration, and type of medical disorder. Overall, these studies show that LICUS has significant promise, but conflicting data remain regarding the parameters used, and further studies are required to fully realize the potential benefits of LICUS.

Effect of Therapeutic Ultrasound for Neck Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects and safety of therapeutic ultrasound in patients with neck pain.

DATA SOURCES

The PubMed, EMBASE, CENTRAL, and Physiotherapy Evidence databases were searched for articles published before December 1, 2020.

STUDY SELECTION

Randomized controlled trials that compared the effects of therapeutic ultrasound on neck pain were included in this review. The included studies compared therapeutic ultrasound plus other treatments with the other treatments alone or compared therapeutic ultrasound with sham or no treatment. Outcome measures involved the effects on pain, disability, and quality of life. Other treatments included all nonultrasonic therapies (eg, various exercises, massage, electrotherapy).

DATA EXTRACTION

Data on the study population, therapeutic ultrasound intervention, combined intervention, outcome measures, and follow-up were extracted.

DATA SYNTHESIS

Twelve randomized controlled trials (705 patients) fulfilled the inclusion criteria. Seven studies compared therapeutic ultrasound plus other treatments vs the other treatments alone (449 patients). Therapeutic ultrasound yielded additional benefits for pain, but there was high heterogeneity and we could not draw a clear conclusion. Ultrasound did not have a better effect on disability or quality of life when it was combined with other treatments. Five studies compared therapeutic ultrasound with sham or no treatment (256 patients), and the pooled data showed that therapeutic ultrasound significantly reduced pain intensity. No adverse events of therapeutic ultrasound were reported in the included studies.

CONCLUSIONS

Therapeutic ultrasound may reduce the intensity of pain more than sham or no treatment, and it is a safe treatment. Whether therapeutic ultrasound in combination with other conventional treatments produced additional benefits on pain intensity, disability, or quality of life is not clear. The randomized trials included in this review had different levels of quality and high heterogeneity. A large trial using a valid methodology is warranted.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

Dry Needling and Photobiomodulation Decreases Myofascial Pain in Trapezius of Women: Randomized Blind Clinical Trial

OBJECTIVE

The purpose of this study was to assess whether dry needling (DN) added to photobiomodulation (PBM) has effects on the treatment of active myofascial trigger points in the upper trapezius.

METHODS

This study was a randomized clinical trial, with 43 participants divided into 3 groups: DN and PBM (DNP), DN, and DN outside of the trigger point (DNout). Each group received 1 session of DN followed by PBM therapy with the machine turned on or off. Pain, disability, pain pressure threshold, and muscle activity were assessed before the intervention and afterward at intervals of 10 minutes, 30 minutes, 1 week, and 1 month.

RESULTS

Pain decreased after intervention in the DNP and DNout groups, with mean differences, respectively, of 1.33 cm (95% confidence interval [CI], 0.019-2.647) and 2.78 cm (95% CI, 1.170-2.973). Scores for the disability questionnaire decreased in all groups after intervention (F = 36.53, P < .0001) after the intervention, with mean differences of 3.8 points in the DNP group (95% CI, 1.082-5.518), 3.57 in the DN group (95% CI, 0.994-6.149), and 5.43 in the DNout group (95% CI, 3.101-7.756). There were no significant differences between or within groups in pain pressure threshold (F = 2.14, P = .139), with mean differences after 30 minutes of 0.139 kgf for the DNP group (95% CI, -0.343 to 0.622), 0.273 for the DN group (95% CI, -0.661 to 1.209), and -0.07 for the DNout group (95% CI, -0.465 to 0.324). Muscle activation for the DN group increased 8.49% after the intervention, where for the DNP group it decreased 11.5%, with a significant difference between groups.

CONCLUSION

DN added to PBM presented similar results compared to DNout and DN. In this sample, the effects of the application of DN outside of the trigger point had better effects on pain and disability scores than DN applied directly on the trigger point.

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.

The Use of Laser Therapy for Patients with Fibromyalgia: A Critical Literary Review

The management of pain - despite many anaesthetic drugs - remains to be an urgent task. If the goal is to achieve permanent pain relief - and not to temporarily mask the pain (masking pathology) - then this goal can only be achieved by treating pain with physiotherapeutic methods, the most universal and effective of which, is low level laser therapy (LLLT). The treatment methods vary fundamentally in the case of neuropathic (nonspecific, primary) pain, which includes pain with the localization of the trigger points (TP) and nociceptive (specific, secondary), which includes all types of pain resulting from trauma, inflammation, etc. When treating patients with fibromyalgia (FM), a comprehensive approach is required, using different methods of laser therapy and guided by well-known rules. These rules include setting all the correct parameters of the laser exposure (wavelength, operating mode, power, exposure, etc), limiting exposure and power to optimal values and limiting the total time of the procedure and the number of procedures per course.

Effectiveness of ultrasound therapy for myofascial pain syndrome: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to assess the therapeutic effect of ultrasound (US) on myofascial pain syndrome (MPS).

DATE SOURCES

PubMed, Embase, and Cochrane Library were searched to find relevant studies from January 1966 to May 2016 using keywords. Four investigators performed the data extraction.

STUDY SELECTION

Randomized controlled trials (RCTs) investigating the outcomes of pain and physical function between MPS patients receiving and not receiving US were selected by two researchers independently.

DATA EXTRACTION

Data were extracted from the RCTs. Risk of bias and study quality were evaluated following the recommendations of Cochrane Collaboration. Standardized mean difference (SMD) and 95% confidence interval (CI) were calculated.

DATA SYNTHESIS

A total of 10 studies involving 428 MPS patients were included. US therapy significantly reduced pain intensity (SMD [CI]=-1.41 [-2.15, -0.67], P=0.0002) and increased pain threshold (SMD [CI]=1.08 [0.55, 1.60], P<0.0001), but had no significant effect on cervical range of motion (ROM) of lateral flexion (SMD [CI]=0.40 [-0.19, 0.99], P=0.19), rotation (SMD [CI]=0.10 [-0.33, 0.52], P=0.66), or extension or flexion (SMD [CI]=0.16 [-0.35, 0.68], P=0.53). Heterogeneity between studies was mainly attributed to differences in the follow-up time, parameter of US, course of treatment, and the control group. The overall risk of bias from the included studies was high, and the evidence proving these effect calculations were assessed as low quality.

CONCLUSION

Owing to the high risk of bias and the across-trial heterogeneity of the studies, the current evidence is not clear enough to support US as an effective method to treat MPS. Clinical trials with methodological rigorousness and adequate power are needed to confirm it in the future.