Deep dry needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction

Synthesis of temporomandibular disorders management intervention outcomes for development of core outcome sets: A systematic review

INTRODUCTION

The selection of appropriate outcomes in clinical trials and systematic reviews is a crucial factor in determining the results that are useful, reliable, and relevant for both patients and healthcare professionals. Clinicians and researchers have been encouraged to develop and apply core outcome sets (COS) to minimise the discrepancy between studies.

AIM

This systematic review is the first phase of the COS development project for clinical trials in temporomandibular disorders (COS-TMD). It aims to identify and synthesise the outcomes used in the randomised controlled trials (RCT) that evaluated the effectiveness of interventions used in TMD management.

MATERIALS AND METHODS

An electronic search was performed in several databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library and EMBASE. The eligibility criteria comprised RCT that applied any intervention to treat temporomandibular joint disorders or masticatory muscle disorders. The identified outcomes were categorised according to domains of the Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT).

RESULTS

The electronic search resulted in 1606 studies. After removing duplicates and applying the eligibility criteria, 106 RCT were included. A total of 43 studies evaluated masticatory muscle disorders, 27 evaluated temporomandibular joint disorders, and 36 analysed mixed TMD.

CONCLUSIONS

The evaluation showed significant variability in the types of outcomes and their measurement instruments. In addition, some domains such as physical and emotional functioning, participant ratings of global improvement and adverse events have been neglected when determining the effectiveness of treatments for TMD.

Mouth opening, jaw disability, neck disability, pressure pain thresholds, and myofascial trigger points in patients with disc displacement with reduction: A descriptive and comparative study

OBJECTIVE

To assess jaw and neck function, pressure pain threshold (PPT), and the presence of trigger points (TrPs) in disc displacement with reduction (DDWR) subjects compared to healthy subjects.

METHODS

One hundred DDWR subjects and 100 matched controls were studied. Clinical evaluations included demographic data, range of motion, jaw and neck disability, PPT, and muscle TrPs.

RESULTS

DDWR subjects have limited pain-free opening limitation (p < 0.001), jaw and neck disability limitation (p < 0.001), and higher presence of active and latent TrPs limitation (p < 0.001) compared to healthy subjects.

CONCLUSION

DDWR subjects present a limited pain-free mouth opening, higher jaw and neck disability, lower PPT, and major presence of active and latent TrPs compared to healthy subjects. Cervical spine and TMJ evaluation and treatment should be considered in DDWR patients.

Efficacy of acupuncture and laser acupuncture in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this study is to perform a qualitative and quantitative analysis of the scientific literature regarding the use of acupuncture and laser acupuncture in the treatment of pain associated with temporomandibular disorders (TMDs). The aim of this article was to assess the clinical evidence for acupuncture and laser acupuncture therapies as treatment for temporomandibular joint disorder (TMD).

MATERIALS AND METHODS

This systematic review includes randomized clinical trials (RCTs) of acupuncture and laser acupuncture as a treatment for TMD compared to other treatments. Systematic searches were conducted in 3 electronic databases up to July 2023; PubMed, EMBASE, and SCOPUS databases. All RCTs of acupuncture for TMD were searched without language restrictions. Studies in which no clinical data and complex interventions were excluded. The Cochrane risk of bias tool (RoB 2) tool was employed to analyze randomized controlled trials. A Meta-analysis was performed in order to investigate a quantitative analysis comparing acupuncture and laser acupuncture to placebo.

RESULTS

A total of 11 RCTs met our inclusion criteria. The findings show that acupuncture is short-term helpful for reducing the severity of TMD pain with muscle origin. Meta-analysis revealed that the Acupuncture group and Laser Acupuncture group had a higher efficacy rate than the Placebo control group, showing a high efficacy of Acupuncture and Laser Acupuncture group in the treatment of temporomandibular.

CONCLUSIONS

In conclusion, our systematic review demonstrate that the evidence for acupuncture as a symptomatic treatment of TMD is limited. Further rigorous studies are, however, required to establish beyond doubt whether acupuncture has therapeutic value for this indication. However high efficacy of Laser Acupuncture in the treatment of temporomandibular disorders was reported.

The effects of dry needling and face yoga on pain, depression, function, and sleep quality in patients with temporomandibular dysfunction

CONTEXT

Temporomandibular joint dysfunction (TMD) poses significant challenges due to its diverse symptoms and impact on patients' daily lives.

OBJECTIVE

This study aimed to explore the effectiveness of two innovative interventions, dry needling and face yoga, in managing TMD-related issues such as pain, depression, and sleep quality.

DESIGN AND STUDY PARTICIPANTS

Ninety patients with TMD symptoms were enrolled in a prospective randomized controlled trial. The patients were divided into three groups: dry needling, face yoga, and a control group. Various assessments, including Visual Analog Scale for pain, Beck Depression Inventory for depression, and Pittsburgh Sleep Quality Index for sleep quality, were conducted before and 6 weeks after the interventions.

RESULTS

A decrease in pain levels and a statistically significant increase in jaw joint movements (mouth opening, protrusive movement, lateral movements) were observed in the dry needling and face yoga groups after treatment (p <0.05). Additionally, improvements in sleep quality were observed (p <0.05).

CONCLUSION

Dry needling and face yoga interventions demonstrated efficacy in managing TMD symptoms, including pain relief and improved jaw movement. The findings suggest that these interventions can be valuable additions to the treatment regimen for patients suffering from TMD-related issues. However, further research is warranted to explore the long-term effects and mechanisms underlying these interventions in TMD management.

Effectiveness of deep dry needling versus manual therapy in the treatment of myofascial temporomandibular disorders: a systematic review and network meta-analysis

BACKGROUND

Temporomandibular disorders (TMDs) are the most common cause of orofacial pain of non-dental origin, with approximately 42% of diagnoses corresponding to myofascial pain. Manual therapy and dry needling are commonly used interventions for the treatment of myofascial temporomandibular disorders. However, it is unclear whether one of them could be superior to the other.

OBJECTIVES

The aim of the present systematic review and network meta-analysis was to compare the effectiveness of manual therapy and dry needling in patients with myofascial TMD.

METHODS

This is a systematic review and network meta-analysis. Randomized clinical trials were searched in the databases of Pubmed, PEDro, CINAHL, Web of Science, Scopus, Cochrane, Google Academic and EMBASE. The methodological quality of studies included in this review was judged using the Physiotherapy Evidence Database (PEDro) scale. A frequentist network meta-analysis was carried out, assuming random effects, to estimate the effects of interventions for temporomandibular joint pain measured on a 10-point visual analogue scale.

RESULTS

Out of 3190 records identified, 17 met the inclusion criteria for qualitative analysis and eight were included in the network meta-analysis. Indirect comparisons between dry needling and manual therapy showed no significant differences in their effects on pain reduction (Odds Ratio [95%CI]; - 0.263 [- 1.517, 0.992]). The ranking of treatments shows that manual therapy (SUCRA = 0.932) followed by deep dry needling (SUCRA = 0.775) present the highest values of estimation and can be considered the most likely to reduce pain.

CONCLUSIONS

The results of the network meta-analysis should be considered with caution due to the low quality of the evidence available and the high variability of the study protocols in terms of the method of application of dry needling and manual therapy interventions. PROSPERO under identifier: (CRD42020186470).

Is acupuncture an effective treatment for temporomandibular disorder?: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture is used for treating various disorders, but its effects on temporomandibular disorder (TMD) remain unclear. This study aimed to assess the effectiveness and safety of acupuncture for TMD via a systematic review of randomized clinical trials.

METHODS

A total of 11 Korean and worldwide databases were searched to identify acupuncture studies in adults with TMD. A Cochrane risk of bias assessment was performed on all articles; a meta-analysis, which involved the categorization according to the type of control used (inactive control, active control, or add-on), was subsequently performed. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation methodology.

RESULTS

The qualitative analysis of randomized clinical trials with acupuncture as the intervention included 32 articles, 22 of which were included in the quantitative analysis (471 participants). Acupuncture significantly improved outcomes (effect rate, relative risk [RR]: 7.00, 95% confidence interval [CI]: 1.91, 25, 62; visual analog scale, standardized mean difference: 0.49, 95% CI: 0.24, 0.73) versus active controls (effect rate, RR: 1.19; 95% CI: 1.12, 1.27). In the analysis of add-ons, acupuncture significantly improved the effect rate and pain intensity (effect rate, RR: 1.36; 95% CI: 1.04, 1.77; visual analog scale, mean difference: -1.23; 95% CI -1.79, -0.67). However, the quality of evidence was determined to range from low to very low.

CONCLUSION

Acupuncture in TMD significantly improved outcomes versus active controls and when add-on treatments were applied. However, as the quality of evidence was determined to be low, well-designed clinical trials should be conducted in the future.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial

OBJECTIVE

To compare the effects of dry needling and upper cervical spinal manipulation with interocclusal splint therapy, diclofenac, and temporomandibular joint (TMJ) mobilization in patients with temporomandibular disorder (TMD).

METHODS

One hundred-twenty patients with TMD were randomized to receive six treatment sessions of dry needling plus upper cervical spinal manipulation (n = 62) or interocclusal splint therapy, diclofenac, and joint mobilization to the TMJ (n = 58).

RESULTS

Patients receiving dry needling and upper cervical spinal manipulation experienced significantly greater reductions in jaw pain intensity over the last 7 days (VAS: F = 23.696; p < 0.001) and active pain-free mouth opening (F = 29.902; p < 0.001) than those receiving interocclusal splint therapy, diclofenac, and TMJ mobilization at the 3-month follow-up.

CONCLUSION

Dry needling and upper cervical spinal manipulation was more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.

Evaluation of the Effectiveness of Dry Needling in the Treatment of Myogenous Temporomandibular Joint Disorders

Background and Objectives: The objective of our clinical trial was to determine the effectiveness of the deep dry needling technique (DDN) (neuromuscular deprogramming) as a first step in the treatment of temporomandibular disorders. Methods and Materials: The double-blind randomized clinical trial comprised 36 patients meeting the inclusion criteria who had signed the corresponding informed consent form. The participants were randomly distributed into two groups, the Experimental group (Group E) and the Control group (Group C). Group E received bilateral DDN on the masseter muscle, while Group C received a simulation of the technique (PN). All the participants were evaluated three times: pre-needling, 10 min post-needling, and through a follow-up evaluation after 15 days. These evaluations included, among other tests: pain evaluation using the Visual Analog Scale (VAS) and bilateral muscle palpation with a pressure algometer; evaluation of the opening pattern and range of the mouth, articular sounds and dental occlusion using T-scans; and electromyography, which was used to evaluate the muscle tone of the masseter muscles, in order to control changes in mandibular position. Results: Digital control of occlusion using Tec-Scan (digital occlusion analysis) showed a significant reduction both in the time of posterior disclusion and in the time needed to reach maximum force in an MI position after needling the muscle, which demonstrated that there were variations in the static position and the trajectory of the jaw. The symmetry of the arch while opening and closing the mouth was recovered in a centric relation, with an increase in the opening range of the mouth after the procedure. Conclusions: facial pain is significantly reduced and is accompanied by a notable reduction in muscle activity after needling its trigger points.

What conservative interventions improve bite function in those with temporomandibular disorders? A systematic review using self-reported and physical measures

BACKGROUND

Bite is an important function of the human stomatognathic system. Despite this, it is commonly impaired in temporomandibular disorder (TMD) populations. The aim of this review is to evaluate the effectiveness of conservative interventions on self-reported and physical measures of bite function in individuals with TMD.

METHODS

This review was performed in compliance with PRISMA guidelines. An electronic search was performed on databases including Pubmed, CINAHL, Embase, and Cochrane Central. Inclusion criteria were journal articles evaluating the effect of any non-pharmacological conservative interventions on bite function in participants diagnosed with TMD. Risk of bias for individual studies was assessed using the Cochrane risk-of-bias v2 tool, and the NIH NHLBI pre-post tool. Data was synthesised based on outcome measures of bite function, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Eleven studies were eligible for this review. Interventions included splinting, photobiomodulation, needling, exercise, manual therapy, and patient education; which were evaluated using mastication-related pain, self-reported chewing difficulty, and bite force/endurance outcome measures. Findings suggested manual therapy, needling, oral splinting, exercise and PBM interventions may improve bite function in TMD, although confidence in cumulative evidence ranged from moderate to very low. There was no evidence that patient education improved bite function.

CONCLUSION

Conservative interventions may be helpful to address bite-related impairments associated with TMD, although further research is needed to improve the quality of evidence and direct clinical guidelines.

Temporomandibular disorder treatment algorithm for otolaryngologists

OBJECTIVE

To review current literature describing the management of temporomandibular disorder (TMD) and to propose an evidence-based algorithm for otolaryngologists.

DATA SOURCES

A literature review using PubMed and Scopus was conducted to identify manuscripts that describe TMJ disorder etiology, diagnostic methods, and management across the fields of otolaryngology, general practice medicine, physical therapy, dentistry, and maxillofacial surgery.

REVIEW METHODS

Two reviewers subjectively evaluated the studies based on the inclusion criteria, incorporating them into a comprehensive algorithm.

CONCLUSIONS

TMD is one of the most common conditions presenting to otolaryngology outpatient clinics. Etiologies of TMD vary widely, including myofascial, intraarticular, neurologic, traumatic, or psychiatric in origin. When conservative measures fail to produce symptom relief, alternative treatments and referral to outside specialists including psychiatry, physical therapy, dentistry, and maxillofacial surgery may be indicated. Premature or inappropriate referrals may lead to patients suffering TMD for extended periods of time, with alternating referrals between various specialists. Thus, we present a TMD treatment algorithm for otolaryngologists to aid in the decision-making process in managing TMD.

IMPLICATIONS FOR PRACTICE

Patients frequently present to otolaryngology outpatient clinics for symptoms of TMD. Multidisciplinary practice may be necessary to effectively treat TMD of varying etiology and severity. Following conservative treatment, appropriate referrals and treatment plans will reduce ineffective use of resources, deferral of treatment, and patient suffering. For this reason, a comprehensive algorithm for otolaryngologists will improve resource utilization and efficiency of treatment to ultimately provide improved treatment outcomes for patients.

The hierarchy of different treatments for myogenous temporomandibular disorders: a systematic review and network meta-analysis of randomized clinical trials

The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo.  At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling  therapy (71.2%, moderate quality), and occlusal appliances  (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances  (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments.  This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances  . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.

Intramuscular Injections and Dry Needling within Masticatory Muscles in Management of Myofascial Pain. Systematic Review of Clinical Trials

Background: Myofascial pain is an important cause of disability among the whole population, and it is a common symptom of temporomandibular joint disorders (TMDs). Its management techniques vary widely; however, in recent years, there has been a growing interest especially in needling therapies within masticatory muscles, due to their simplicity and effectiveness in pain reduction. Methods: The construction of the following study is based on PICOS and PRISMA protocols. A systematic literature search was conducted based on the PubMed and BASE search engines. Searching the abovementioned databases yielded a total of 367 articles. The screening procedure and analysis of full texts resulted in the inclusion of 28 articles for detailed analysis. Results: According to analyzed data, clinicians manage myofascial pain either with wet or dry needling therapies. The most thoroughly studied approach that prevails significantly within the clinical trials is injecting the botulinum toxin into the masseter and temporalis. Other common methods are the application of local anesthetics or dry needling; however, we notice the introduction of entirely new substances, such as platelet-rich plasma or collagen. In the analyzed articles, the target muscles for the needling therapies are most commonly localized by manual palpation although there are a variety of navigational support systems described: EMG, MRI or EIP electrotherapy equipment, which often aid the access to located deeper lateral and medial pterygoid muscle. Conclusions: Needling therapies within masticatory muscles provide satisfactory effects while being simple, safe and accessible procedures although there still is a need for high quality clinical trials investigating especially injections of non-Botox substances and needling within lateral and medial pterygoid muscles.

Current advances and novel research on minimal invasive techniques for musculoskeletal disorders

The present review summarized the current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Different invasive approaches were proposed in the physical therapy field for the management of musculoskeletal disorders, such as ultrasound-guided percutaneous needle electrolysis, dry needling, acupuncture and other invasive therapy techniques, discussing about their worldwide status, safety and interventional ultrasound imaging. Indeed, dry needling may be one of the most useful and studies invasive physical therapy applications in musculoskeletal disorders of different body regions, such as back, upper limb, shoulder, arm, hand, pelvis, lower limb, neck, head, or temporomandibular joint, and multiple soreness location disorders, such as fibromyalgia. In addition, the assessment and treatment by acupuncture or electro-acupuncture was considered and detailed for different conditions such as plantar fasciitis, osteoarthritis, spasticity, myofascial pain syndrome, osteoporosis and rheumatoid arthritis. As an increasing technique in physical therapy, the use of ultrasound-guided percutaneous needle electrolysis was discussed in injuries of the musculoskeletal system and entrapment neuropathies. Also, ultrasound-guided percutaneous neuromodulation was established as a rising technique combined with ultrasound evaluation of the peripheral nerve system with different clinical applications which need further studies to detail their effectiveness in different musculoskeletal conditions. Thus, invasive physical therapy may be considered as a promising approach with different novel applications in several musculoskeletal disorders and a rising use in the physiotherapy field.

Short-Term Morphological Changes in Asymptomatic Perimandibular Muscles after Dry Needling Assessed with Rehabilitative Ultrasound Imaging: A Proof-of-Concept Study

Facial anatomical structures are not easily accessible to manual palpation. The aim of our study is to objectively assess temporomandibular joint and perimandibular muscles dimensions by means of sonographic measurements before and after dry needling (DN) in asymptomatic subjects. Seventeen subjects participated in this before-after study with a within-subject control. After random allocation, one side of the face was used for the intervention and the contralateral as control. DN was performed on the temporal, masseter, and sternocleidomastoid muscles. Each subject was examined bilaterally before, immediately after, and one month after the intervention through Rehabilitative Ultrasound Imaging (RUSI) of the temporomandibular articular disc and the three target muscles. Maximum mouth opening was measured at baseline and at one month. After a single DN session, articular disc thickness significantly decreased; muscles’ thicknesses (except for temporal thickness) significantly decreased immediately and at follow-up on the treated side; no significant changes resulted for the control side. The maximum mouth opening increased from 4.77 mm to 4.86 mm. RUSI may be useful to assess the dimensions and thickness of the temporomandibular disc and muscles before and after an intervention. DN influences muscle morphology, and it has a positive influence on mouth opening in the short term.

Treatment of Localized and Referred Masticatory Myofascial Pain with Botulinum Toxin Injection

Botulinum toxin type A (BTA) injection is considered an available alternative treatment for myofascial pain. However, its efficacy in treating masticatory myofascial pain syndrome (MMPS) remains unclear. The purpose of this study was to evaluate whether the BTA injection into the affected muscles would significantly reduce pain and improve function, and to assess its efficacy, safety, and therapeutic indications in a randomized, single-center clinical trial. Sixty patients with MMPS were randomized into three groups evenly to receive a single session injection of saline solution (SS group), lidocaine (LD group), and BTA (BTA group) in the masseter, temporal, and pterygoid muscles after an electromyographic study. Patients’ pain was classified as localized or referred according to the DC/TMD classification. Assessments were performed on pre-treatment, and subsequently, on days 7, 14, 28, 60, 90, and 180. A significant reduction in pain and improvement of mandibular movements was found in the BTA group compared to the SS and LD groups. The response lasted until day 180 and was more intense in patients with localized myalgia and focused myofascial pain than in referred remote pain. No significant adverse reactions were observed. A single BTA injection can be considered an effective treatment option in patients with localized MMPS by reducing pain and improving mandibular movements, which persisted up to 6 months.

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.

Clinical Reasoning for the Examination and Physical Therapy Treatment of Temporomandibular Disorders (TMD): A Narrative Literature Review

The current narrative literature review aims to discuss clinical reasoning based on nociceptive pain mechanisms for determining the most appropriate assessment and therapeutic strategy and to identify/map the most updated scientific evidence in relation to physical therapy interventions for patients with temporomandibular disorders (TMDs). We will also propose an algorithm for clinical examination and treatment decisions and a pain model integrating current knowledge of pain neuroscience. The clinical examination of patients with TMDs should be based on nociceptive mechanisms and include the potential identification of the dominant, central, or peripheral sensitization driver. Additionally, the musculoskeletal drivers of these sensitization processes should be assessed with the aim of reproducing symptoms. Therapeutic strategies applied for managing TMDs can be grouped into tissue-based impairment treatments (bottom-up interventions) and strategies targeting the central nervous system (top-down interventions). Bottom-up strategies include joint-, soft tissue-, and nerve-targeting interventions, as well as needling therapies, whereas top-down strategies include exercises, grade motor imagery, and also pain neuroscience education. Evidence shows that the effectiveness of these interventions depends on the clinical reasoning applied, since not all strategies are equally effective for the different TMD subgroups. In fact, the presence or absence of a central sensitization driver could lead to different treatment outcomes. It seems that multimodal approaches are more effective and should be applied in patients with TMDs. The current paper also proposes a clinical decision algorithm integrating clinical diagnosis with nociceptive mechanisms for the application of the most appropriate treatment approach.

Efficacy of lidocaine versus mepivacaine in the management of myofascial pain

Objectives

There are many treatment modalities for myofascial pain, and recent findings reported in the literature highlight the superiority of using local anesthetics as the treatment of choice. The objective of the present study was to compare the effectiveness of two of the most used local anesthetic agents—lidocaine and mepivacaine—in the management of myofascial pain.

Materials and methods

Thirty patients (20 females, 10 males) were randomly assigned to one of two groups: 50% received lidocaine and 50% received mepivacaine. Trigger point injections in the orofacial region were administered 4 times, 10 days between each injection, with 4 weeks of follow-up after the end of the treatment course. Pain levels were recorded using a visual analog scale (VAS) at the time of follow-up and 30 min after injection.

Results

All patients exhibited statistically significant improvement when comparing pre- and post-treatment mean values. Both local anesthetics (i.e., lidocaine and mepivacaine) were similarly effective for the management of myofascial pain (p = 0.875). The mepivacaine-treated group exhibited significantly lower post-injection tenderness than the lidocaine group (p = 0.038). There was no relationship between sex and treatment response. Female and male patients both reported similar responses in terms of VAS scores (p = 0.818).

Conclusion

No drug was superior in the long term; thus, the clinician’s choice can be based on drug availability and patient medical history.

Comparison of the effect of two different types of dry-needling techniques on subacromial impingement syndrome

INTRODUCTION

Infraspinatus is one of the main muscles that is involved in the subacromial impingement syndrome. Dry needling and routine physical therapy can improve this syndrome. However, the dry needling technique is not well defined.

DESIGN

randomized controlled clinical trial, single-blind study.

METHOD

Sixty-six patients diagnosed with shoulder impingement syndrome were recruited and randomly divided into three groups.

INTERVENTIONS

In 1st group; patients received deep dry needling technique in addition to routine physical therapy, in Hong's group; patients received Hong's dry needling technique in addition to routine physiotherapy and in third group; patient just received routine physical therapy.

MAIN OUTCOME MEASURE(S)

Before, immediately after and 4 weeks after the intervention, pain, disability and the pressure pain threshold were measured.

RESULTS

The findings of this study indicated that in DDN group, pain and disability reduction was significantly more than two other groups. Although, the pressure pain tolerance increased in all three groups after treatment, but the increase between groups was not significantly different. All study groups showed reduction in pain, while there was no significant difference between the three groups.

CONCLUSION

Pain and disability reduction in the DDN group compared to the other two groups may reveal the treatment with deep dry needling technique along with routine physiotherapy is more effective than receiving dry needling with Hong's technique or routine physiotherapy alone. However, there was no significant difference between the three groups in pressure pain tolerance threshold and pain reduction.

Acupuncture in Temporomandibular Disorders Painful Symptomatology: An Evidence-Based Case Report

Temporomandibular dysfunction (TMD) is complex and multifactorial. Its etiology involves various factors, such as malocclusion, psychological patterns, parafunctional habits, and the temporomandibular joint anatomy. Symptoms include myofascial pain, joint clicking, mouth opening limitation, headaches, earaches, and neck pain, comprising one of the greatest causes of nondental pain. Acupuncture has been used to treat these conditions by acting locally both in muscle relaxation and pain management as well as reaching physical, mental, and emotional balance. The aim of this study is to present a brief literature review reporting the efficacy of acupuncture on TMDs and a case report in which the painful symptomatology of TMD was treated with a systemic protocol, based on scientific evidence and concepts of traditional Chinese medicine. Acupuncture may be a complementary treatment for TMD, and in this case report, it eliminated the patient's painful symptomatology.

Graded exposure and orthopedic manual physical therapy for kinesiophobia and function in chronic temporomandibular dysfunction: A case report

BACKGROUND

This case report describes the successful use of multi-modal physical therapy (PT), including orthopedic manual physical therapy (OMPT) and graded exposure, in a patient with chronic temporomandibular dysfunction (TMD).

CLINICAL PRESENTATION

A 41-yr old female presented with a five-year history of bilateral chronic myofascial TMD and comorbid neck/right arm pain. The patient was treated for 12 weeks with a focus on OMPT and graded exposure. The patient demonstrated clinically significant improvements on the Tampa Scale of Kinesiophobia-TMD, maximal mouth opening, Global Rating of Change, and Jaw Functional Limitation Scale.

CLINICAL RELEVANCE

Mechanisms underlying chronic TMD are complex. Current evidence supports PT management of physical impairments; however, neglecting central drivers or psychosocial factors may result in suboptimal outcomes. Physical therapists are able to address both peripheral and central mechanisms of pain, and future research should examine the utilization of multi-modal PT to improve kinesiophobia and function in patients with chronic TMD.

ADVERSE EVENTS ASSOCIATED WITH THERAPEUTIC DRY NEEDLING

BACKGROUND

There is a paucity of literature about the adverse events associated with Therapeutic Dry Needling (TDN). Much of the literature surrounding adverse events associated with TDN has been extrapolated from the acupuncture literature. Given that acupuncture and TDN are distinctly different in their application and proposed mechanisms, adverse events associated with TDN should be examined specifically.

PURPOSE

To determine and report the type of adverse events associated with the utilization of TDN.

STUDY DESIGN

Prospective Questionnaire.

METHODS

Four hundred and twenty physical therapists participated in this study. Information related to minor and major adverse events that occurred during 20,464 TDN treatment sessions was collected. Each physical therapist respondent was asked to fill out two weekly self-reported electronic surveys over a six-week period. One survey was related to "minor adverse events" (i.e. pain, bleeding, bruising), while the other was related to "major adverse events" (i.e. pneumothorax, excessive bleeding, prolonged aggravation). Following the six-week period, descriptive statistics were used to describe the adverse events (AE) associated with TDN and calculate the frequencies of those events.

RESULTS

A total of 7,531 minor AE's were reported, indicating that 36.7% of the reported TDN treatments resulted in a minor AE. The top three minor AE's were bleeding (16%), bruising (7.7%), and pain during dry needling (5.9 %). The average ratio of minor AE's for all respondents across all weeks was 0.53 or approximately one event for every two patients. Twenty major AE's were reported out of the 20,494 treatments for a rate of <0.1% (1 per 1,024 TDN treatments). No associations were noted between the frequency of adverse events and the number of patients treated, practitioner age, level of education, years in practice, level of training or months experience with dry needling.

CONCLUSION

Expected minor AE's such as mild bleeding, bruising, and pain during TDN were common and major AE's were rare. Physical therapists and other medical practitioners need to be aware of the risks of TDN. Based on the findings of this study the overall risk of a major adverse event during TDN is small.

LEVEL OF EVIDENCE

3, survey research.

Temporomandibular disorders: improving outcomes using a multidisciplinary approach

Patients with temporomandibular disorders (TMD) can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.

Safety Events and Privilege Utilization Rates in Advanced Practice Physical Therapy Compared to Traditional Primary Care: An Observational Study

Introduction

The general practitioner shortage in the United States coupled with a growing number of Americans living with disability has fueled speculation of non-physician providers assuming a greater role in musculoskeletal healthcare. Previous physician shortages have been similarly addressed, and expanding physical therapy (PT) scope of practice may best serve to fill this need. Resistance to expanding PT practice focuses on patient safety as PTs assume the roles traditionally performed by primary care providers. While studies have shown advanced practice PT to be safe, none have compared safety events in advanced practice PT compared to primary care to determine if there are increased patient risks. Therefore, the purpose of our study is to examine the rate of safety events and utilization of services in an advanced practice PT clinic compared to a primary care clinic. A secondary aim of our study was to report safety events associated with spinal manipulation and dry needling procedures.

Materials and Methods

Productivity and safety data were retrospectively collected from Malcolm Grow Medical Center from 2015 to 2017 for the Family Health Clinic (FHC) and an advanced practice Physical Therapy Clinic (PTC). Chi-square tests for independence, risk ratios (RR) and 95% confidence intervals (95%) were used to compare the relationship between the frequency of (1) patient encounters and clinical procedures and (2) clinical procedures and safety events.

Results

Seventy-five percent (12/16) of safety events reported in the PTC were defined as near misses compared to 50% (28/56) within the FHC (RR 1.5; 95% CIs: 1.0 to 2.2). Safety events were more likely to reach patients in the FHC compared to the PTC (RR 1.9; 95% CIs: 0.8 to 4.7). Safety events associated with minor harm to patients was n = 4 and n = 3 in the FHC and PTC respectively. No sentinel events, intentional harm events, nor actual events with more than minor harm were reported in either clinic. Significant relationships indicated that prescriptions, laboratory studies, imaging studies and referrals, were all more likely to be ordered in the FHC than the PTC (p < 0.01). The PTC ordered one diagnostic imaging study for every 37 encounters compared to one in every 5 encounters in the FHC. The PTC similarly referred one patient to another healthcare provider for every 52 encounters, fewer than the one per every 3 encounters in the FHC. There was a significant relationship between encounters and diagnoses, indicating a higher number of diagnoses per encounter in the FHC, though the difference of 0.31 diagnoses per encounter may not be clinically meaningful (p < 0.01). A total of 1,818 thrust manipulations and 2,910 dry needling procedures were completed without any reported safety events.

Conclusion

These results suggest advanced practice PT has a similar safety profile to primary care. The authority to order musculoskeletal imaging and refer to other clinicians were among the most commonly utilized privileges and may be of primary importance when establishing an advanced practice PT clinic. These results support research showing advanced practice PT may lead to reductions in specialty referrals, diagnostic imaging, and pharmaceutical interventions.

Nivel de satisfacción sobre la seguridad y complicaciones a cuatro años de la introducción de la técnica Microelectrólisis Percutánea (MEP®) Sport como práctica fisioterapéutica

RESUMEN El objetivo de este trabajo es investigar la experiencia de los fisioterapeutas formados en microeletrólisis percutánea sport y conocer la cantidad de aplicaciones realizadas semanalmente, los efectos adversos presentados y el nivel de satisfacción de los terapeutas con sus pacientes. Se realizó una encuesta que evaluó la opinión y la experiencia de profesionales certificados en microelectrolisis percutánea sport. Los datos fueron obtenidos a través de la plataforma virtual SurveyMonkey, enviando por correo electrónico una invitación a 1.096 fisioterapeutas de América Latina. Respondieron el cuestionario 315 profesionales, entre los cuales 165 (56,51%) atienden de uno a cinco pacientes por semana. Las respuestas sobre efectos adversos fueron: nunca he tenido complicaciones (56,79% - 159 respuestas); choque hipotensivo (19,64% - 55 respuestas.); alergia al metal (5,36% - 15 respuestas). Los sitios/patologías a que más se aplican la microelectrolisis percutánea sport son: tendón rotuliano (10,77% - 198 respuestas.); tendón de aquiles (9,58% - 176 respuestas); tendón supraespino (9,36% - 172 respuestas.); fascitis plantar/espolón calcáneo (8,05% - 148 respuestas.); y puntos-gatillo (7,18% - 132 respuestas.). La satisfacción de los profesionales fue: satisfecho (51,87% - 152 respuestas) y muy satisfecho (40,96% - 120 respuestas). Las respuestas de los pacientes fueron: satisfecho (61,90% - 182 respuestas) y muy satisfecho (29,93% - 88 respuestas). La técnica MEP se aplica principalmente en tendinopatías y produce resultados satisfactorios y muy satisfactorios tanto para los pacientes como para los terapeutas, con baja presencia de efectos adversos.

The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis

BACKGROUND

Orofacial pain of myofascial origin is often associated with temporomandibular joint dysfunction, affects chewing muscles and may lead to functional limitations. Dry needling is an intervention commonly used for inactivating myofascial pain trigger points.

OBJECTIVE

To systematically review the effects of dry needling on orofacial pain of myofascial origin in patients with temporomandibular joint dysfunction.

METHODS

This systematic review has pain intensity as primary outcome. Searches were conducted on April 13th, 2018 in eight databases, without publication date restrictions. We selected randomized controlled trials published in English, Portuguese, or Spanish, with no restrictions regarding subject ethnicity, age or sex.

RESULTS

Seven trials were considered eligible. There was discrepancy among dry needling treatment protocols. Meta-analysis showed that dry needling is better than other interventions for pain intensity as well as than sham therapy on pressure pain threshold, but there is very low-quality evidence and a small effect size. There were no statistically significant differences in other outcomes.

CONCLUSION

Clinicians can use dry needling for the treatment of temporomandibular joint dysfunction, nevertheless, due the low quality of evidence and high risk of bias of some included studies, larger and low risk of bias trials are needed to assess the effects of dry needling on orofacial pain associated with temporomandibular joint dysfunction.

Association of facial massage, dry needling, and laser therapy in Temporomandibular Disorder: case report

This case report aims to evaluate the treatment of Temporomandibular Disorder (TMD) of muscular origin by associating facial massage (FM), dry needling (DN), and low-level laser therapy (LLLT). The pre- and post-treatment evaluations consisted of clinical examinations based on the Research Diagnostic Criteria (RDC) for TMD, pain intensity quantification by means of the Visual Analog Scale (VAS), mandibular movement measurement, and electromyographic (EMG) analysis of the masseter and temporal muscles. Post-therapy assessment indicated a decrease in pain sites of 58%, in pain intensity mean (1.3), and an increase in the maximum aperture of 10 mm, in addition to normalization of EMG signals. We conclude that, after application of the treatment protocol, there was a decrease in painful sites, gain in amplitude of mandibular movements, and normalization of EMG activity.

Randomized, double-blind study comparing percutaneous electrolysis and dry needling for the management of temporomandibular myofascial pain

BACKGROUND

To assess whether the techniques of percutaneous needle electrolysis (PNE) and deep dry needling (DDN) used on trigger points (TrP) of lateral pterygoid muscle (LPM) can significantly reduce pain and improve function in patients with myofascial pain syndrome (MPS) compared to a control group treated with a sham needling procedure (SNP).

MATERIAL AND METHODS

Sixty patients diagnosed with MPS in the LPM were selected and randomly assigned to one of three groups. The PNE group received electrolysis to the LPM via transcutaneous puncture. The DDN group received a deep puncture to the TrP without the introduction of any substance. In the SNP group, pressure was applied to the skin without penetration. Procedures were performed once per week for 3 consecutive weeks. Clinical evaluation was performed before treatment, and on days 28, 42 and 70 after treatment.

RESULTS

Statistically significant differences (p <0.01) were measured for the PNE and DDN groups with respect to pain reduction at rest, during chewing, and for maximum interincisal opening (MIO). Values for the PNE group showed significantly earlier improvement. Differences for PNE and DDN groups with respect to SNP group were significant (p <0.05) up to day 70. Evaluation of efficacy as reported by the patient and observer was better for PNE and DDN groups. No adverse events were observed for either of the techniques.

CONCLUSIONS

PNE and DDN of the LPM showed greater pain reduction efficacy and improved MIO compared to SNP. Improvement was noted earlier in the PNE group than in the DDN group.

Evaluation of pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder according to the Research Diagnostic Criteria of Temporomandibular Disorders

ABSTRACT Purpose: to evaluate the pain threshold upon palpation of the masticatory muscles in women with temporomandibular disorder (TMD) according to the Research Diagnostic Criteria of Temporomandibular Disorders (RDC/TMD). Methods: a cross-sectional study was conducted involving the evaluation of pain threshold upon palpation of the extraoral muscles (temporal, masseter, posterior mandibular region, submandibular region) and intraoral muscles (lateral pterygoid area and temporal tendon) in women using the RDC/TMD clinical examination. Results: 60 women were evaluated. Statistically significant differences were found among the muscles evaluated regarding the pain threshold. The lateral pterygoid area, bilaterally, had the lowest pain threshold, followed by the masseter and temporal muscles. Conclusion: this study suggests that the lateral pterygoid muscle, bilaterally, has the lowest pain threshold upon palpation among the masticatory muscles, followed by masseter and temporal muscles, in women with TMD, according to the RDC/TMD evaluation.

Muscular diagnostics and the feasibility of microsystem acupuncture as a potential adjunct in the treatment of painful temporomandibular disorders: results of a retrospective cohort study

AIMS

To investigate the effect of microsystem acupuncture on painful temporomandibular disorders (TMD).

METHODS

We retrospectively analysed 887 treatments in 407 TMD-patients (mean age 45±1.5 years), who received microsystem acupuncture (mouth, scalp or fingers) with a focus on oral acupuncture. All patients systematically underwent palpation of specific muscular tender points and their pain rating was assessed on a four-point Likert scale (no pain to strong pain) before and after treatment. In 42 cases, the pain intensity was determined using a visual analogue scale (0-100 mm). As the data were normally distributed, analysis was performed with unpaired t-tests.

RESULTS

The pterygoid muscles were most painful to palpation, with the lateral pterygoid rated moderate to strong by 76% of patients and the medial pterygoid by 48% of patients. The palpation of microsystem acupuncture points revealed the strongest sensitivity (moderate or strong pain) of the oral retromolar points at the upper jaw (83%). After treatment, the pain intensity of all tender points had significantly decreased (P<0.001). The proportion of moderate to strong pain ratings was below 3% at most tender points. Overall pain intensity of the subjects (n=42) before treatment was 55.5±19.7 mm on the VAS scale and was significantly reduced to 29.6±20.9 mm (P<0.001) post-treatment.

CONCLUSIONS

This analysis suggests microsystem acupuncture could reduce the pain intensity of TMD in the short term. Considering the increased local muscular tenderness, further investigations regarding the key role of myofascial trigger points in the occurrence of TMDs are warranted and could lead to new comprehensive treatment strategies.

Management of pain in patients with temporomandibular disorder (TMD): challenges and solutions

Thanks to advances in neuroscience, biopsychosocial models for diagnostics and treatment (including physical, psychological, and pharmacological therapies) currently have more clinical support and scientific growth. At present, a conservative treatment approach prevails over surgery, given it is less aggressive and usually results in satisfactory clinical outcomes in mild–moderate temporomandibular disorder (TMD). The aim of this review is to evaluate the recent evidence, identify challenges, and propose solutions from a clinical point of view for patients with craniofacial pain and TMD. The treatment we propose is structured in a multi-modal approach based on a biobehavioral approach that includes medical, physiotherapeutic, psychological, and dental treatments. We also propose a new biobehavioral model regarding pain perception and motor behavior for the diagnosis and treatment of patients with painful TMD.

Referred Pain Patterns of the Infraspinatus Muscle Elicited by Deep Dry Needling and Manual Palpation

OBJECTIVES

To identify the most common referred pain (ReP) pattern of the infraspinatus myofascial trigger point (MTrP) and compare its coincidence with the original ReP pattern, to verify whether there are any significant differences by sex and types of technique and to determine the observed signs and symptoms evoked by deep dry needling (DDN) and manual palpation (MPal).

DESIGN

A cohort study of patients randomized to two different examination methods (July and August 2016).

SETTINGS

Students and staff recruited from Miguel Hernandez University (Southeast Spain).

PATIENTS

One hundred thirty-three participants (70.7% women) with shoulder complaints were randomly assigned to either an MPal (n = 67) or DDN group (n = 66).

INTERVENTIONS

The same physiotherapist carried out the techniques on all participants, and the same protocol was followed for both the DDN and MPal groups. The physiotherapist did not ask participants about their pain features or other relevant issues.

OUTCOME MEASURES

Local twitch response (LTR) and ReP assessed through a visual analogue scale and features of ReP of the infraspinatus muscle.

RESULTS

The areas with the highest percentage of ReP were the front (area 3; 27.1%) and back (area 11; 21.1%) of the arm, anterior (area 4; 36.1%) and posterior (area 12; 42.1%) shoulder, and infraspinatus muscle area. DDN proved to be significantly easier than MPal in evoking an LTR (p ≤ 0.001). There were significant differences between sexes in zone 2 (p = 0.041) and no statistically significant differences were found by technique.

CONCLUSIONS

The ReP pattern of the infraspinatus muscle coincides with the original pattern described by Travell and Simons, although the neck area should be questioned. The study found no significant differences in the ReP pattern by sex and when comparing MPal with DDN of MTrP of the infraspinatus muscle. DDN proved to be significantly easier than MPal in evoking an LTR.

Magnetic resonance and sonographic imagings of masticatory muscle myalgia in temporomandibular disorder patients

This article reviews recently published studies investigating the MRI and sonographic diagnosis of masticatory muscle myalgia in temporomandibular disorder patients. The MRI and sonographic features of muscle after treatment are also discussed. Literature published within the last 15 years was obtained from the PubMed database using the following Mesh terms: magnetic resonance imaging (MRI) or sonography, masticatory muscle pain, and treatment. MRI and sonography enable accurate visualization and evaluation of the masticatory muscles, thereby increasing our understanding of pathology and cause of pain associated with these muscles. Although therapeutic efficacy is often evaluated based on clinical findings, MR and sonographic imaging studies may also be valuable.

Effects of Myofascial Trigger Point Dry Needling in Patients with Sleep Bruxism and Temporomandibular Disorders: A Prospective Case Series

Objectives

To investigate the effects of deep dry needling (DN) of myofascial trigger points (MTrPs) of the masseter and temporalis on pain, pressure pain threshold (PPT), pain-free maximal jaw opening and temporomandibular disorder (TMD)-related disability in patients with sleep bruxism (SB) and myofascial TMD.

Methods

Seventeen subjects (11 women, 6 men) aged 39±13 years (range 23–66) diagnosed with SB and myofascial TMD were invited to participate in this prospective case series study. Each subject received a deep DN intervention in the masseter and temporalis MTrPs. Pain intensity, PPT, pain-free maximal jaw opening and TMD-related disability were assessed before treatment, immediately after treatment and at 1-week follow-up. Jaw disability was assessed using the jaw disability checklist (JDC) at baseline and 1 week post-treatment only.

Results

One-way analyses of variance showed significant improvements in pain intensity, PPT and jaw opening (p<0.001). Post-hoc analysis revealed significant differences between baseline and post-intervention follow-up time points in pain (immediate: Cohen's d=1.72, p<0.001; 1 week: d=3.24, p<0.001), jaw opening (immediate: d=0.77, p<0.001; 1 week: d=1.02, p<0.001) and PPT in the masseter (immediate: d=1.02, p<0.001; 1 week: d=1.64, p<0.001) and temporalis (immediate: d=0.91, p=0.006; 1 week: d=1.8, p<0.001). A dependent t-test showed a significant improvement in jaw functioning, reflected by a large reduction in 1-week JDC scores relative to baseline (d=3.15, p<0.001).

Conclusions

Deep DN of active MTrPs in the masseter and temporalis in patients with myofascial TMD and SB was associated with immediate and 1-week improvements in pain, sensitivity, jaw opening and TMD-related disability.

Trial registration number

Results.

A critical overview of the current myofascial pain literature - January 2016

Reflecting on the past year, the number of publications on myofascial pain continues to increase in a steady rate. The current review includes 30 basic and clinical studies, case reports, reviews, and reports from fifteen different countries about trigger points (TrP), myofascial pain (MP), dry needling (DN) and other related interventions. We are pleased that during 2015 this article made the top 15 of most downloaded articles as many as three times! In general, the quality of published papers is improving as well. Nevertheless, several papers included in this overview, mention the application of "ischemic compression", which is a questionable concept in the context of TrP inactivation. As we have outlined previously, in the current thinking about myofascial pain, TrPs feature significant hypoxia and a lowered pH (Ballyns et al., 2011; Shah and Gilliams, 2008), and attempts to induce more ischemia would be counterproductive. Already in 1999, Simons, Travell and Simons changed the terminology from ischemic compression to TrP compression (Simons et al., 1999) and we recommend that contemporary researchers and clinicians adopt the new terminology and stop using the term "ischemic compression."