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

Massage for neck pain

BACKGROUND

Massage is widely used for neck pain, but its effectiveness remains unclear.

OBJECTIVES

To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache.

SEARCH METHODS

We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive.

MAIN RESULTS

We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events).

AUTHORS' CONCLUSIONS

The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

Dynamics of disability and pain indicators under the influence of physical therapy for adhesives capsulitis and myofascial pain syndrome

OBJECTIVE

Aim: To compare the effectiveness of end-range mobilization and therapeutic exercises, used in combination with ischemic compression, on disability and pain indicators among patients with adhesive capsulitis of the shoulder joint and thoracic myofascial pain syndrome.

PATIENTS AND METHODS

Materials and Methods: The study involved 68 patients. Goniometry of the shoulder joint, assessment of pain in myofascial trigger points, and the Shoulder Pain and Disability Index questionnaire were used before and after physical therapy. The duration of physical therapy comprised 3 weeks. Physical therapy of the first group of patients consisted of end-range mobilization and ischemic compression. Patients of the second group performed therapeutic exercises and ischemic compression.

RESULTS

Results: Both groups demonstrated positive dynamics of shoulder joint mobility, Shoulder Pain and Disability Index and pain in trigger points. However, the final results of the studied indicators were better in the first group of patients.

CONCLUSION

Conclusions: Physical therapy based on the combination of end-range mobilization and ischemic compression had a more positive impact on disability and pain indicators for adhesive capsulitis of the shoulder joint and myofascial pain syndrome as compared to the combination of therapeutic exercises and ischemic compression.

The immediate effects of deep transverse friction massage, high- power pain threshold ultrasound and whole body vibration on active myofascial trigger points

BACKGROUND

The most important clinical problem in myofascial pain syndrome (MPS) is trigger points (TrPs). The aim of the present study was to investigate the comparison of immediate effect of deep transverse friction massage (DTFM), high-power pain threshold ultrasound (HPPTUS), and whole body vibration (WBV) on treatment of active myofascial trigger points (MTrPs).

MATERIALS AND METHODS

sixty six men with active TrPs of upper trapezius muscle were randomly divided into three equal groups: DTFM, HPPT US, and WBV. Pain intensity based on the Visual Analogue Scale (VAS), pressure pain threshold (PPT) and active contralateral lateral flexion range of motion (CLF ROM) of the neck were evaluated before and immediately after the interventions.

RESULTS

The VAS, PPT and the active CLF ROM were substantially improved after intervention in all groups (P < 0.01). When the three groups were compared regarding VAS, participants in the WBV group reported significantly more reduction in pain (P < 0.01). On comparing the interventions, there were no significant differences in PPT values (P > 0.05). The CLF ROM value in HPPTUS and WBV groups have significant increase in comparison to the DTFM group.

CONCLUSION

All three interventions can improve neck pain, PPT and ROM in participants with active TrPs in upper trapezius muscle, but due to the fact that the DTFM has more pressure on therapist fingers, and the HPPTUS technique requires proper interaction with the participants, WBV can be used as one of the effective intervention on active MTrPs of upper trapezius.

CLINICAL TRIAL REGISTRATION NUMBER

IRCT20200518047498N1.

Effect of myofascial cupping vs integrated neuromuscular inhibition techniques on pain and neck movement in individuals with latent trigger point in trapezius

Background

Pain is the most common symptom for seeking therapeutic alternative to conventional medicine. Trigger points (TrP) being the most debilitating cause of nonspecific neck pain, are found to be more prevalent in trapezius muscle. Various instrument-based and other manual therapy techniques are effective in the treatment of TrP.

Objective

To compare the effect of Myofascial Cupping (MFC) and Integrated Neuromuscular Inhibition Technique (INIT) on the upper trapezius latent TrP on pain intensity, pressure pain threshold (PPT) & cervical range.

Method

A randomized trial controlled on 40 individuals aged 20-40 years, both gender with latent TrPs in upper trapezius excluding ones who have taken treatment for upper trapezius TrPs within 6 months. Participants were randomly allocated into 2 groups by chit method, one group received MFC and other INIT. Pre- and post-intervention assessment was done using NPRS, pressure algometer and goniometer.

Result

Within group, pain has significantly reduced after MFC and INIT with mean difference of 6 . 05 ± 0 . 8 and 4 . 95 ± 0 . 7 , respectively (p < 0 . 001 ). PPT increased in both groups (p < 0 . 001 ) with mean difference of 0 . 63 ± 0 . 3 and 0 . 28 ± 0 . 11 , respectively. Comparison between the groups showed significant difference in pain intensity (p = 0 . 003 ) suggesting MFC was more effective in reducing pain. However, a PPT (p=0.606) and neck lateral flexion to the contralateral side of TrP (p = 0 . 74 ) were not significant.

Conclusion

MFC was more effective than INITs in improving pain, however both interventions showed similar effect on PPT and neck lateral flexion on latent TrP in trapezius.

Effectiveness of ischemic compression on myofascial trigger points in relieving neck pain: A systematic review and meta-analysis

BACKGROUND

Ischemic compression is widely used to clinically treat neck pain. However, no meta-analysis has been conducted to evaluate the effects of this process on neck pain.

OBJECTIVE

This study aimed to evaluate the effects of ischemic compression on the myofascial trigger points for improving neck pain-related symptoms (mainly pain, joint mobility limitation and function limitation) and to compare ischemic compression with other therapies.

METHODS

Electronic searches were conducted in PubMed, OVID, Web of Science, EBSCO, SCOUPS, Cochrane Library, PEDro, Wanfang, CNKI and Chinese VIP Database in June 2021. Only randomised controlled trials on the effects of ischemic compression on neck pain were included. The major outcomes were pain intensity, pressure pain threshold, pain-related disability and range of motion.

RESULTS

Fifteen studies involving 725 participants were included. Significant differences were observed between ischemic compression and sham/no treatment group in pain intensity, pressure pain threshold and range of motion immediately and in the short term. Significant effect sizes of dry needling were observed over ischemic compression in terms of improving pain intensity (SMD = 0.62; 95% CI: 0.08 to 1.16; P= 0.02), pain-related disability (SMD = 0.68; 95% CI: 0.19 to 1.17; P= 0.007) and range of motion (MD =-2.12; 95% CI: -2.59 to -1.65; P< 0.001) immediately after treatment. Dry needling also showed a significant small effect size for the short-term reduction of pain (SMD = 0.44; 95% CI: 0.04 to 0.85; P= 0.03).

CONCLUSION

Ischemic compression can be recommended in the immediate and short-term pain relief and increase in the pressure pain threshold and range of motion. Dry needling is superior to ischemic compression in relieving pain and improving pain-related disability and range of motion immediately after treatment.

Cupping alleviates lung injury through the adenosine/A2BAR pathway

Background

Acute lung injury (ALI) is a serious condition. Inflammation plays a crucial role in the pathogenesis of ALI. Cupping, as a part of traditional Chinese medicine, is still a popular complementary and alternative therapy for a variety of ailments including respiratory diseases. However, reliable scientific data about cupping therapy are scarce. Adenosine, a purine nucleoside produced under metabolic stress by the action of extracellular ectonucleotidases (i.e. CD39 and CD73), can attenuate ALI through the A_2BAR receptor. The aim of this study was to investigate the protective effect of cupping in a rat model of ALI and the role of adenosine in it.

Methods

Male adult rats were subjected to ALI by intratracheal LPS instillation (0.3 mg/kg). Immediately after intratracheal LPS instillation, vacuum pressure was applied to a sanitized plastic bell cup on the back of the rat by suction for 10 min. Pulmonary injury and inflammation were assessed at 4 h after LPS challenge. The role of adenosine and A_2BAR in cupping's protection after LPS instillation were evaluated.

Results

Cupping alleviated LPS-induced lung injury, reduced inflammation and inhibited NF-kB activation in rats. Cupping upregulated CD39 and CD73 mRNA expression of the skin tissue at the cupping site and increased circulating levels of adenosine. Administration of PSB1115, a specific adenosine A_2BAR receptor antagonist, abolished cupping's beneficial effects in LPS-induced ALI.

Conclusions

Cupping attenuates lung inflammation and injury through the adenosine/A_2BAR pathway. The current study provides evidence-based information about cupping therapy in ALI.

Acupuncture as Part of Multimodal Analgesia for Chronic Pain

Background

Chronic pain is a multifactorial condition that is afflicting populations worldwide causing an increasing economic, physical, mental, and emotional burden. Treatments range from medications to interventional procedures to complementary and alternative medicine (CAM), such as acupuncture. This review aims to discuss the use of acupuncture in the treatment of chronic pain, proposed mechanisms, indications, and efficacy for various chronic pain conditions.

Results

Evidence is varied on the efficacy and quality of data on the use of acupuncture in the treatment of chronic pain. Recent studies have demonstrated promising results in the support of acupuncture for the use in the treatment of cancer, neck, and back pain, functional dyspepsia, and various chronic abdominal pain syndromes.

Conclusion

Acupuncture, deemed well-tolerated and safe to use, has been increasingly studied and is regarded as effective in clinical practice, but its efficacy is limited by the lack of well-conducted, high-quality clinical trials, lower quality evidence, and conflicting study results. Additionally, the exact analgesic mechanism of acupuncture remains to be fully elucidated. Increasing evidence supports the role of acupuncture as therapy in the treatment of cancer, neck, and back pain and functional dyspepsia. Further rigorous studies are needed to fully assess the use of acupuncture in various chronic pain conditions, determine its indications, and optimal treatment schedule. Overall, future studies could benefit from better designed experimental studies, larger groups, and more objectives ways to measure pain reduction and symptom improvement.

Trigger point therapy – ischemic compression or perhaps cupping?

Study aim: To evaluate and compare the effectiveness of single ischemic compression and cupping therapy on the most common trigger point, on the descending part of the trapezius muscle.

Materials and methods: Twenty-five students (15 women and 10 men) aged 24.20 ± 1.27 years were enrolled in the study. The mobility of the cervical spine area was measured with a measuring tape. The pain pressure threshold of the trigger point of the trapezius muscle was tested using a Wagner FDX 50 Force Gage digital algometer. Each person participated in three tests with an interval of approximately one week between them. The following study protocol was followed; 1) cupping therapy, with a cup statically positioned on the trigger point for two minutes, 2) at a minimum interval of 7 days, ischemic compression performed with the thumb twice for 1 minute on each side 3) control test at an interval of another 7 days.

Results: Ischemic compression resulted in a statistically significant difference in cervical spine mobility scores (except for extension) and pain pressure threshold values. After applying cups, statistically significant differences were also observed in the results of cervical spine mobility and pain pressure threshold values. No statistically significant differences were found in the effectiveness of the therapies tested.

Conclusions: In the present study, single trigger point cupping and ischemic compression therapies improved cervical spine mobility and resulted in an increase in the pain pressure threshold in the trapezius muscle trigger point. These two therapies did not differ in terms of their effectiveness.

Pressing Intervention Promotes the Skeletal Muscle Repair of Traumatic Myofascial Trigger Points in Rats

Objective

To observe the effect of pressing intervention on the skeletal muscle repair of myofascial trigger points (MTrPs) in rats and explore the mechanism of pressing intervention on the deactivation of trigger points.

Methods

Thirty SPF rats were randomly divided into blank group, model group and press group, with 10 rats in each group. The MTrPs models were established by blunt striking plus eccentric exercise, and then evaluated. The press group was given a pressing intervention with a self-made device for 14 days, and the rats in the other two groups were fed normally. Soft tissue tension (STT) D_0.2 and pressure pain threshold (PPT) were measured before and after intervention. The skeletal muscle tissue at MTrPs was extracted and assessed by hematoxylin–eosin (HE) and Masson staining. The expression of collagen I, collagen III, α- smooth muscle actin (α-SMA), myosin heavy chain (MHC) and fibronectin (FN) were detected by Western Blotting. Enzyme linked immunosorbent assay (ELISA) was used to evaluate the expression of substance P (SP), 5-hydroxytryptamine (5-HT), cyclooxygenase 2 (COX-2) and prostaglandin E2 (PGE2).

Results

(1) Compared with the blank group, the PPT and D_0.2 reduced (P < 0.05) in the model group; while compared with the model group, the PPT and D_0.2 increased (P < 0.05) in the press group. (2) Compared with the blank group, the model group showed obvious spontaneous potentials with higher amplitude and frequency, which were also much higher than those of the press group (P < 0.05). (3) The HE and Masson staining results showed evident fibrosis in the muscle tissue of the model group, with a larger area of collagen fibers relative to that of the press group (P < 0.05). (4) The amount of collagen I, collagen III, FN, α- SMA, SP, 5-HT, COX-2 and PGE2 increased and the content of MHC decreased (P < 0.05) in the model group, as compared to the blank group; while all the substances (P < 0.05), instead of MHC which increased (P < 0.05), in the press group were decreased as compared to the model group.

Conclusion

Pressing intervention on the MTrPs in rats can alleviate chronic inflammation, inhibit fibrosis, promote skeletal muscle repair and relieve pain.

Combined Effects of Extracorporeal Shockwave Therapy and Integrated Neuromuscular Inhibition on Myofascial Trigger Points of Upper Trapezius: A Randomized Controlled Trial

Objective

To investigate the combined effect of extracorporeal shockwave therapy (ESWT) and integrated neuromuscular inhibition (INI) on myofascial trigger points in the upper trapezius.

Methods

Sixty subjects aged 18–24 years old with active myofascial trigger points in the upper trapezius were studied. Participants were assigned randomly to either group A who received ESWT one session/week, group B who received INI three sessions/week, or group C who received ESWT in addition to INI. All groups completed 4 weeks of intervention. The following main outcome measures were evaluated at baseline and after 4 weeks of intervention: pain intensity, functional disability, pressure pain threshold (PPT), sympathetic skin response (SSR), and neuromuscular junction response (NMJR).

Results

Within-group analysis revealed a significant decline in visual analog scale (VAS), Arabic neck disability index (ANDI), and NMJR and incline in PPT and SSR latency post-intervention (p<0.001). Multiple comparison analysis showed a substantial difference between the groups, while the major changes favored group C (p<0.05).

Conclusion

Combined treatment with ESWT and INI for treating myofascial trigger points in the upper trapezius is more effective than using only one of the two approaches in terms of clinical, functional, and neurophysiological aspects.

Efficacy of Dry Needling and Acupuncture in the Treatment of Neck Pain

CONTEXT

Neck pain is a common phenomenon and affects a large segment of the population. Chronic neck pain, lasting more than 3 months, likely occurs in 10% - 30% of patients with acute neck pain and affects up to 288 million cases globally, carrying a significant cost in terms of quality of life, disability, and healthcare dollars. Here we review neck pain background, acupuncture and the evidence that exist to support acupuncture use in chronic neck pain.

RESULTS

Neck pain not only affects quality of life directly, but also contributes to depression, job dissatisfaction and reduced productivity. Unfortunately, neck pain is strongly linked to office and computer work and is likely to continue increasing in prevalence. Traditional treatments, such as analgesics, physical therapy, exercise, and non-invasive therapy bring some relief, and invasive therapy is indicated if anatomical pathologies exist. Acupuncture is a form of integrative medicine, originally described and practiced in traditional Chinese medicine and now expanded to include methods including acupressure, dry needling, and others. Traditionally, it focused on restoring the patient's flow of Qi by puncturing specific points along the meridians. It has previously been shown to be effective in other forms of chronic pain and disability. Clinical trials studying acupuncture for neck pain have shown significant reduction in both pain and associated symptoms. These therapies are reviewed in this text.

CONCLUSIONS

Neck pain is a common and significant global problem. Acupuncture, dry needling, and cupping were all shown to be effective in alleviating pain both immediately after treatment, as well as provide long-lasting relief. These treatments are generally safe and inexpensive and should be considered as part of a multimodal approach for the treatment of neck pain. More head-to-head studies will provide better data to support a choice of a specific treatment over another.

Influence of quantified dry cupping on soft tissue compliance in athletes with myofascial pain syndrome

PURPOSE

This study aimed to develop a quantitative dry cupping system that can monitor negative pressure attenuation and soft tissue pull-up during cupping to quantify soft tissue compliance.

METHODS

Baseball players with myofascial pain syndrome were recruited to validate the benefits of cupping therapy. Nine of 40 baseball players on the same team were diagnosed with trapezius myofascial pain syndrome; another nine players from the same team were recruited as controls. All participants received cupping with a negative pressure of 400 mmHg for 15 minutes each time, twice a week, for 4 weeks. Subjective perception was investigated using upper extremity function questionnaires, and soft tissue compliance was quantified objectively by the system.

RESULTS

During the 15-minute cupping procedure, pressure attenuation in the normal group was significantly greater than that in the myofascial group (p = 0.017). The soft tissue compliance in the normal group was significantly higher than that in the myofascial group (p = 0.050). Moreover, a 4-week cupping intervention resulted in an obvious increase in soft tissue lift in the myofascial pain group (p = 0.027), although there was no statistical difference in the improvement of soft tissue compliance. Shoulder (p = 0.023) and upper extremity function (p = 0.008) were significantly improved in both groups, but there was no significant difference between the two groups.

CONCLUSION

This quantitative cupping monitoring system could immediately assess tissue compliance and facilitate the improvement of soft tissues after cupping therapy. Hence, it can be used in athletes to improve their functional recovery and maintain soft tissues health during the off-season period.

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.