Reliability of muscle stiffness measures in popliteus, medial and lateral gastrocnemius muscles by ultrasound shear wave elastography in participants with knee osteoarthritis accompanied by myofascial trigger points

BACKGROUND

The objective of this investigation is to evaluate the consistency of intra-rater and inter-rater assessments utilizing ultrasound elastography to examine the muscle stiffness of the popliteus and gastrocnemius (medial and lateral heads) in patients with knee osteoarthritis accompanied by myofascial trigger points.

METHODS

Thirty individuals with knee osteoarthritis accompanied by myofascial trigger points were assessed. Two examiners independently measured the muscle stiffness levels of the popliteus and gastrocnemius (medial and lateral heads) three times using ultrasound elastography in the first session. The second session was conducted one week later.

RESULTS

In the initial test session, the mean shear modulus values for the popliteus and gastrocnemius (medial and lateral heads) muscles were measured as follows for tester 1 (12.75, 13.72, 14.13 kPa) and tester 2 (11.66, 12.81, 13.17 kPa). During the retest session, the previously measured variables by tester 1 and tester 2 yielded the following values: (12.61, 13.43, 14.26 kPa) and (11.62, 12.87, 13.30 kPa) respectively." Good to excellent intra-rater reliability (ICC = 0.912-0.986) and inter-rater reliability (ICC = 0.766-0.956) were reported for the shear moduli of the popliteus, medial and lateral gastrocnemius muscles.

CONCLUSIONS

The assessment of muscle stiffness in the popliteus and gastrocnemius (medial and lateral heads) using ultrasound elastography is a reliable method in patients with knee osteoarthritis accompanied by myofascial trigger points.

The effect of simultaneous administration of occipital nerve block and cervical myofascial trigger point injection (MTrPI) on headache parameters in chronic migraine patients

BACKGROUND AND AIM

Peripheral myofascial mechanisms have been identified as contributors to migraine pathophysiology. The specific comorbid relationship between migraine and cervical trigger points may exacerbate the occurrence and severity of migraine attacks. Trigger point injections (TPIs) are frequently employed to address headaches and alleviate migraine symptoms. The current study explores the impact of concurrent myofascial trigger point injection (MTrPI) and occipital nerve block (greater occipital nerve block [GONB] + lesser occipital nerve block [LONB]) on the severity of headaches and the number of migraine attacks in individuals with chronic migraine (CM) and cervical myofascial trigger points (MTrPs), with a comparison of occipital nerve block alone (GONB + LONB). During trigger point examination and injection, trapezius, levator scapulae, splenius capitis, temporalis, and sternocleidomastoid muscles were targeted. We planned the treatment based on whether they were in the muscle groups we determined, rather than the number of trigger points.

MATERIALS AND METHOD

This study enrolled 62 individuals experiencing CM with bilateral headache and cervical MTrP who sought care at the Algology Unit within the Departments of Neurology and Physical Therapy and Rehabilitation at Siirt Training and Research Hospital between 2020 and 2022. The CM cohort was stratified into two groups: group 1 received trigger point injections (TrPI), while group 2 underwent concurrent bilateral occipital nerve block (GONB + LONB) and TrPI. Both groups underwent three treatment sessions with bupivacaine 0.5% (1 ml = 5 mg) in weeks 1, 2, and 4. Visual analog scale (VAS) was used to measure the patients' pain intensity. The evaluation included the assessment of the monthly migraine frequency and visual analog scale (VAS) p score for pain before treatment (BT) and after treatment (AT), conducted at baseline and during follow-up visits. Analysis of the data was conducted utilizing IBM SPSS Statistics for Windows version 28.0 software.

RESULTS

Among patients diagnosed with CM and MTrPs, 32 individuals (51.6%) underwent GONB and LONB, while 30 patients (48.4%) received simultaneous GONB, LONB, and cervical MTrPI. Within the entire sample, 51 participants (82.3%) were female, and 11 (17.7%) were male, with a mean age of 32.81 ± 10.75 years. With an average age of 32.81 ± 10.75 years, there was no statistically significant variance between the two groups (p = 0.516). Of the total cohort, 45 individuals (72.6%) reported experiencing headaches persisting for 12 months or longer. Among CM patients, 80% had active trigger points, while 20% had latent trigger points. No statistically significant difference was observed between the groups concerning TrPs (p = 0.158), and the distribution of TrPs was homogenous across the two groups. In group 1, the median (min-max) monthly frequency of migraines reduced from 18.5 days (range: 15.0 to 25.0 days) before treatment to 12.0 days (range: 7.0 to 17.0 days) after treatment (p = 0.000). In group 2, the median monthly frequency of migraines reduced from 16.5 days (range: 15.0 to 22.0 days) before treatment to 4.0 days (range: 2.0 to 8.0 days) after treatment (p = 0.000). The median (min-max) VAS score in group 1 was 8.0 (range: 5.0 to 9.0) before treatment, 4.0 (range: 2.0 to 6.0) at week 1, and 5.0 (range: 4.0 to 8.0) at week 4 (p = 0.000). In group 2, the median VAS score was 7.0 (range: 5.0 to 9.0) before treatment, 0.0 (range: 0.0 to 0.3) at week 1, and 2.0 (range: 0.0 to 0.3) at week 4 (p = 0.000). There were significant distinctions between the groups in terms of both the monthly count of migraine days and the severity of headaches (p = 0.000).

CONCLUSION

The combination of repeated MTrPIs and ONB proves more effective than ONB alone in managing patients with CM and cervical MTrP. In patients with CM, performing TrPs examination and adding treatments for this may contribute to the treatment. In cases where patients endure prolonged episodes of headache associated with chronic migraine, the inclusion of trigger point injections alongside peripheral nerve blocks may offer enhanced therapeutic benefits.

Extracorporeal shockwave therapy of the perineum for male patients with chronic pelvic pain syndrome: a pilot study

Background

Chronic pelvic pain syndrome (CPPS) is a complex condition that is often difficult to treat and may sometimes require a multidisciplinary team. Among the wide array of treatment options is extracorporeal shockwave therapy (ESWT). However, its role in CPPS remains controversial. The purpose of our study is to assess the efficacy and safety of ESWT of the perineum in male patients with CPPS.

Methods

Fourteen patients aged between 21 and 85 years were recruited in this single-center, single-arm prospective trial from October 2018 to October 2020. ESWT was delivered to the perineum weekly for up to 8 weeks. Assessment was done via International Index for Erectile Function, International Prostate Symptom Score, King's Health Questionnaire, National Institutes of Health - Chronic Prostatitis Symptom Index, Visual Analogue Scale, Analgesic Questionnaire, and UPOINT (urinary symptoms [U], psychosocial dysfunction [P], organ-specific symptoms [O], infection-related symptoms [I], neurological/systemic conditions [N], tenderness of skeletal muscles [T]) phenotype system. The parameters are assessed before the start and end of treatment as well as at regular time points on follow-up appointments up to 20 weeks.

Results

Thirteen patients completed the study. There was improvement in the Visual Analogue Scale pain score, Tenderness domain on UPOINT, King's Health Questionnaire, and National Institutes of Health - Chronic Prostatitis Symptom Index scores. In terms of erectile function, improvement in the erectile function domain of International Index for Erectile Function was observed. There was also significant improvement in lower urinary tract symptoms assessed on International Prostate Symptom Score. There were no adverse events reported post treatment and during the follow-up period.

Conclusions

ESWT improved pain and quality of life of male patients with CPPS. It can be a safe and effective treatment modality in the armamentarium of CPPS.

A comparison between effectiveness of gluteal trigger point and epidural steroid injection in lumbosacral canal stenosis patients: a randomized clinical trial

BACKGROUND

Lumbosacral Spinal Stenosis (LSS) is a degenerative spine disease and a major cause of pain and disability, especially in geriatrics. Primary symptom control in patients with LSS includes conservative treatment and non-surgical methods. In this study, we aimed to compare the effect of steroid injection via epidural and gluteal trigger point techniques.

METHODS

Patients aged 40-75 years old who had pain and other clinical signs of spinal stenosis in the last 6 months were included in our study and divided into two groups of gluteal trigger point (TP) or epidural steroid injection (ESI). The patients were evaluated based on the visual analog scale (VAS), Roland-Morris Disability Questionnaire (RDQ), Oswestry Disability Index (ODI), and the Quebec back pain disability scales during their pre-injection period and 2 weeks after follow-ups till 8 weeks. A P value of less than 0.05 was considered significant.

RESULTS

A total of 44 patients were included in our study. The TP group had a significant decrease in comparison with their follow-ups; however, in the epidural group, the significant decrease was only observed compared to the pre-injection period and the scores did not have any significant decreases after the second week regarding the ODI, RQM, and VAS scales. The TP group demonstrated significantly higher scores of decreases of ODI and Quebec score compared to the epidural group at weeks 4 and 8. Regarding RQM, the TP groups demonstrated significantly higher scores of decreases compared to the epidural group at weeks 2, 4 and 8. (p < 0.001 p = 0.008, and p < 0.001, respectively).

CONCLUSION

Both epidural and TP steroid injection significantly reduced the patients' pain and improved their QoL and function; however, more satisfactory results were observed in the TP group during the patients' follow-ups, while the epidural group demonstrated only statistically significant improvement during the short-term follow-up.

The effect of perturbation training with and without applying the dry needling on leg muscles in patients with chronic ankle sprain

INTRODUCTION

Ankle sprain is a common musculoskeletal injury that leads to recurrent instability. Repeated ankle sprain can be a mechanism for creating trigger point. Proper treatment of trigger points, in addition to preventing recurrence of sprains, may reduce pain and improve muscle function. This improvement can be the result of preserving the surrounding tissues from excessive pressure.

OBJECTIVE

Investigate the added value of dry needling into perturbation training protocol for chronic ankle sprain.

DESIGN

Randomized clinical trial; assessor-blind; before and after comparison.

SETTING

Treatment of patients referred to the institutional rehabilitation clinics.

MAIN OUTCOME MEASURE(S)

Functional assessment with FAAM questionnaire score, Pain with NPRS scale, ankle instability severity with Cumberland tool.

METHODS

Twenty-four patients with chronic ankle instability participated in this clinical trial and were randomly divided into two groups. Intervention was 12 sessions in which one group received only perturbation training and the other group received perturbation training along with dry needling. Repeated measures ANOVA was used to investigate the effect of treatment.

RESULTS

Data Analysis showed significant difference in NPRS and FAAM and Cumberland score before and after treatment in each group (P < 0.001). Comparison of the results between the groups did not show any significant difference (P > 0.05).

CONCLUSION

The findings showed that adding dry needling technique to the perturbation training does not have greater effects on the pain and function of patients with chronic ankle instability.

The Role of Manual Therapies in the Treatment of Headache Disorders

PURPOSE OF REVIEW

A comprehensive headache treatment plan typically requires both medication and non-medication treatment strategies. Manual therapies offer another therapeutic approach to headache treatment. This article reviews the evidence for manual therapies in the treatment of headache disorders.

RECENT FINDINGS

Current evidence shows potential benefit from myofascial trigger point injections, myofascial release, and massage for the treatment of various headache types. There is also evidence for strain counterstrain technique, ischemic compression, and spinal manipulative therapies for cervicogenic headache. Although larger randomized clinical trials are necessary for many of these modalities, recent findings show that manual therapies could be an important tool for the treatment of some headache disorders.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial

BACKGROUND

Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery.

METHODS

Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events.

DISCUSSION

This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery.

TRIAL REGISTRATION

This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Myofascial pain syndrome in the oncologic patient: general considerations

This article aims to make visible a common non-oncologic pain condition in cancer patients. Myofascial pain syndrome can generate an increase in the symptomatic burden of the oncologic patient, increase the demand for opioid medication, and decrease the quality of life. We consider that health professionals involved in the care of cancer patients in its different stages should be aware of it, diagnose it, and treat it early to avoid processes of pain chronification, peripheral tissue modification, and deterioration of the functional condition of patients with oncologic diseases.

Arthrocentesis and soft tissue aspiration and injection

Accessing a joint with a needle (arthrocentesis) to extract synovial fluid is a skill intrinsic to the rheumatologist's praxis. Joint aspirations are essential for diagnosing or excluding septic joints, are the gold standard for diagnosing acute crystal arthritis, and can provide valuable information about the nature of other forms of arthritis. In appropriate settings, injecting medications into joints can provide rapid, temporary, or even prolonged relief of pain and swelling and can provide a window of relief until other treatment modalities (anti-inflammatories, immunomodulators, and physical therapy) can enforce durable responses. Soft tissue aspirations (e.g., of bursae) and soft tissue injections (of bursae, tendons, trigger points, and areas of nerve compression) can provide similar relief, earning the practitioner the gratitude of the patient. Here, we provide a primary on joint and soft tissue aspiration and injection, including indications for and against procedures, preparing for procedures, and approaches to specific musculoskeletal structures.

Hair Follicle Melanocytes Initiate Autoimmunity in Alopecia Areata: a Trigger Point

Alopecia areata (AA) is characterized by common non-scarring alopecia due to autoimmune disorders. To date, the specific pathogenesis underlying AA remains unknown. Thus, AA treatment in the dermatological clinic is still a challenge. Numerous clinical observations and experimental studies have established that melanocytes may be the trigger point that causes hair follicles to be attacked by the immune system. A possible mechanism is that the impaired melanocytes, under oxidative stress, cannot be repaired in time and causes apoptosis. Melanocyte-associated autoantigens are released and presented, inducing CD8⁺ T cell attacks. Thereafter, amplification of the immune responses further spreads to the entire hair follicle (HF). The immune privilege of HF subsequently collapses, leading to AA. Herein, we present a narrative review on the roles of melanocytes in AA pathogenesis, aiming to provide a better understanding of this disease from the melanocyte's perspective.

Comparison of dry needling and self-stretching in muscle extensibility, pain, stiffness, and physical function in hip osteoarthritis: A randomized controlled trial

BACKGROUND AND PURPOSE

Patients with hip osteoarthritis (OA) present myofascial trigger points in the hip muscles that may reduce muscle extensibility, provoke pain and stiffness, and decrease physical function. The purpose of the study was to compare the effects of dry needling (DN) intervention with a self-stretching protocol on muscle extensibility, pain, stiffness, and physical function in patients with hip OA.

MATERIALS AND METHODS

A single-blinded randomised controlled trial was designed. Thirty-eight participants with hip OA were randomly assigned to the DN group (n = 19) or the stretching group (n = 19). The DN group received three sessions of DN, and the stretching group followed a 3-week protocol. Hip muscle extensibility was the primary outcome and was measured using the Ely test, the modified Ober test, and the Active Knee Extension test. Pain, stiffness, and physical function were the secondary outcomes measured with the WOMAC questionnaire. The variables were assessed before and after treatment by blinded examiners.

RESULTS

DN was more effective than self-stretching for improving hip flexor and abductor muscles extensibility (p < 0.05). DN and self-stretching techniques improved hip extensor muscles extensibility, pain, stiffness, and physical function in patients with hip OA (<0.05). The DN group showed large effect sizes in all the variables (d > 0.8).

CONCLUSION

Three sessions of DN were more effective than three weeks of self-stretching to improve hip muscle extensibility in patients with hip OA. DN and self-stretching techniques decreased pain and stiffness and improved physical function in patients with hip OA.

Effect of ischemic compression on myofascial pain syndrome: a systematic review and meta-analysis

Background

Myofascial pain syndrome (MPS) is a condition with local and referred pain characterized by trigger points (taut bands within the muscle). Ischemic compression is a noninvasive manual therapy technique that has been employed for the treatment of MPS in past decades. However, little attention has been devoted to this topic.

Objectives

The present review was designed to explore the efficacy of ischemic compression for myofascial pain syndrome by performing a descriptive systematic review and a meta-analysis to estimate the effect of ischemic compression on MPS.

Methods

A systematic review and meta-analysis concerning randomized controlled trials (RCTs) with myofascial pain subjects who received ischemic compression versus placebo, sham, or usual interventions. Five databases (PubMed, The Cochrane Library, Embase, Web of Science, Ovid) were searched from the earliest data available to 2022.1.2. The standardized mean difference (SMD) and the 95% confidence interval (CI) were used for statistics. Version 2 of the Cochrane risk of tool 2 (RoB 2) was used to assess the quality of the included RCTs.

Results

Seventeen studies were included in the systematic review, and 15 studies were included in the meta-analysis. For the pressure pain threshold (PPT) index, 11 studies and 427 subjects demonstrated statistically significant differences compared with the control at posttreatment (SMD = 0.67, 95% CI [0.35, 0.98], P < 0.0001, I² = 59%). For visual analog scale (VAS) or numeric rating scale (NRS) indices, 7 studies and 251 subjects demonstrated that there was no significant difference between ischemic compression and controls posttreatment (SMD = − 0.22, 95% CI [− 0.53, 0.09], P = 0.16, I² = 33%).

Conclusion

Ischemic compression, as a conservative and noninvasive therapy, only enhanced tolerance to pain in MPS subjects compared with inactive control. Furthermore, there was no evidence of benefit for self-reported pain. The number of currently included subjects was relatively small, so the conclusion may be changed by future studies. Big scale RCTs with more subjects will be critical in future.

Effects of ischemic compression and instrument-assisted soft tissue mobilization techniques in trigger point therapy in patients with rotator cuff pathology: randomized controlled study

PURPOSE

To compare the ischaemic compression (IC) and instrument-assisted soft tissue mobilization (IASTM) in the treatment of MTrPs in addition to standard rehabilitation program in patients with rotator cuff tears.

METHODS

Participants with rotator cuff tears were included the study (n = 46). Patients were randomly divided into two groups; which were Group 1 (IC + standard rehabilitation program (n = 23)), and Group 2 (IASTM + standard rehabilitation program (n = 23)) groups. Pain were assessed by visual analog scale (VAS). Range of motion (ROM) was assessed by a universal goniometer. Active MTrPs were assessed according to the Travel and Simons criteria. Pressure pain threshold (PPT) were assessed by a digital algometer. Function were evaluated by the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) and American Shoulder and Elbow Surgeons Standardised Shoulder Assessment (ASES) Form. Anxiety and depression were evaluated by the Hospital Anxiety and Depression (HAD) scale. Satisfaction was assessed by the Global Rating of Change scale after 6 weeks treatment.

RESULTS

After the treatment, pain, ROM and the DASH, ASES, HAD scores improved in both groups (p < 0.05). The active MTrPs of 2 muscles, PPT of 4 muscles and DASH in Group 1 significantly improved compared to Group 2 (p < 0.05).

CONCLUSION

Although patients with low functionality accumulated in the IC group, the IC is more effective than the IASTM in increasing the PPT and functional improvement according to the results of the DASH score.

Positional release therapy and therapeutic massage reduce muscle trigger and tender points

OBJECTIVE

To determine if positional release therapy (PRT) or therapeutic massage (TM) was more effective in the treatment of trigger and tender points in the upper trapezius muscle.

BACKGROUND

Trigger points in the upper trapezius muscle are common and can be painful. Trigger points are commonly treated using TM however, PRT is a novel treatment that deserves further investigation.

METHODS

Sixty healthy male (24) and female (36) participants, (age = 27.1 ± 8.8 years, wt = 75.2 ± 17.9 kg, ht = 172.8 ± 9.7 cm) presenting with upper trapezius pain and a trigger point were recruited and randomized into either the TM or PRT group. Upper trapezius trigger points were found via palpation. Pain level was evaluated using a visual analog scale (VAS) and pain pressure threshold (PPT) was assessed using a pressure algometer. Muscle thickness was measured by B-mode ultrasound, while muscle stiffness was measured by shear-wave elastography (SWE). Participants were measured at baseline, posttreatment and again 48 h later.

RESULTS

Both treatments were effective in treatment of pain and muscle stiffness. Although no statistical group differences existed, treatment using PRT showed decreased pain averages and decreased pressure sensitivity at both post treatment, and 48 h later. Neither treatment was able to maintain the reduced muscle stiffness at the 48-h measure in males.

CONCLUSION

Both treatments showed a significant ability to reduce pain and acutely decrease muscle stiffness. Although not statistically different, clinically PRT is more effective at decreasing pain, and decreasing pressure sensitivity. Neither treatment method produced a long lasting effect on muscle stiffness in males.

Myofascial pain in temporomandibular disorders: Updates on etiopathogenesis and management

OBJECTIVES

Temporomandibular disorders (TMDs) are an umbrella term encompassing disorders of both the temporomandibular joint (TMJD) and masticatory musculature (MMD). The objective of this review is to provide an overview of the etiopathogenesis, clinical features and diagnosis of MMD, and to summarize the current trends in the therapeutic management.

METHODS

A review of the literature was performed from 1985 to 2020. The keywords included were "temporomandibular disorders OR temporomandibular joint disorders" AND "myofascial pain OR masticatory myofascial pain OR trigger point". A total of 983 articles were screened with abstracts and approximately 500 full text articles were included in the review based on their relevance to the topic.

RESULTS

MMD's present significant challenges in diagnosis and treatment. Effective treatment requires a clear diagnosis based on an understanding of pathophysiologic mechanisms, a detailed history with assessment of predisposing local and systemic factors, perpetuating factors, a comprehensive clinical evaluation and a diagnostic workup.

CONCLUSION

A thorough history and clinical examination are the gold standards for diagnosis of MMD. Serological testing may help identify underlying co-morbidities. Recent diagnostic modalities including ultrasound sonoelastography and magnetic resonance elastography (MRE) have shown promising results. The treatment goals for MMD are to control pain, restore mandibular function and facilitate the return to normal daily activity and improve the overall quality of life of a patient. Conservative modalities including home care regimens, pharmacotherapy, intraoral appliance therapy, local anesthetic trigger point injections, physiotherapy and complementary modalities may be beneficial in patients with MMD's.

The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache: A Randomized Controlled Trial

OBJECTIVE

To compare the long-term effect of adding real or sham dry needling with conventional physiotherapy in cervicogenic headache.

DESIGN

A randomized controlled trial.

SETTING

Physiotherapy Clinic, Rouhani Hospital of Babol University of Medical Sciences, Iran.

SUBJECTS

Sixty-nine patients with cervicogenic headache.

METHODS

Patients were randomly assigned into a control group (n = 23) receiving conventional physical therapy; a dry needling group (n = 23) receiving conventional physical therapy and dry needling on the cervical muscles; placebo needling group (n = 23) receiving conventional physical therapy and superficial dry needling at a point away from the trigger point. The primary outcome was the headache intensity and frequency. Neck disability, deep cervical flexor performance and range of motion were secondary outcomes. Outcomes were assessed immediately after treatment and one, three and six months later.

RESULTS

Sixty-five patients were finally included in the analysis. Headache intensity and neck disability decreased significantly more in the dry needling compared to sham and control groups after treatment and during all follow-ups. The frequency of headaches also reduced more in the dry needling than in control and sham groups, but it did not reach statistical significance. Higher cervical range of motion and enhancement of deep cervical flexors performance was also observed in the dry needling compared to sham and control groups.

CONCLUSION

Dry needling has a positive effect on pain and disability reduction, cervical range of motion and deep cervical flexor muscles performance in patients with cervicogenic headache and active trigger points, although the clinical relevance of the results was small.

The efficacy of intramuscular electrical stimulation in the management of patients with myofascial pain syndrome: a systematic review

Introduction

Myofascial pain syndrome (MPS) is one of the most common disorders causing chronic muscle pain. Almost one-third of patients with musculoskeletal complaints meet the MPS criteria. The aim of this study is to evaluate the effectiveness of intramuscular electrical stimulation (IMES) in patients with MPS through a systematic review method.

Methods

PubMed, Scopus, Embase, ProQuest, PEDro, Web of Science, and CINAHL were systematically searched to find out the eligible articles without language limitations from 1990 to December 30, 2020. All relevant randomized controlled trials that compared the effectiveness of IMES with sham-IMES, dry needling, or exercise therapy in patients with MPS were included. Full texts of the selected studies were critically appraised using Revised Cochrane risk-of-bias tool for randomized trials (RoB2).

Results

Six studies (out of 397) had met our inclusion criteria (involving 158 patients) and were entered to the systematic review. Outcome measures examined in these studies included pain, range of motion, pressure pain threshold, biochemical factors, disability, and amount of analgesic use. In the most studies, it has been shown that IMES is more effective than the control group in improving some outcome measurements such as pain.

Conclusion

There is preliminary evidence from a few small trials suggesting the efficacy of IMES for the care of myofascial pain syndrome. The data support the conduct of larger trials investigating the efficacy of IMES.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00396-z.

The effect of dry needling & muscle energy technique separately and in combination in patients suffering shoulder impingement syndrome and active trigger points of infraspinatus

OBJECTIVE

The aim of this study was to investigate the effects of a combination of dry needling (DN) and muscle energy technique (MET) on pain intensity (PI), pressure pain threshold (PPT) and shoulder active range of motion (ROM) in patients with shoulder impingement syndrome and active trigger points in the infraspinatus muscle.

METHODS

39 patients, aged 20-50 participated in this study. All the cases were randomly assigned into three groups: group 1 (n = 13) received DN, group 2 (n = 13) received MET, and group 3 (n = 13) received DN & MET. The patients were treated for three sessions in a one-week period with at least a two-day break between sessions.

RESULTS

The results showed a significant improvement in visual analog scale (VAS), PPT and shoulder ROM over time (P < 0.001) in all three groups. There were no significant differences BETWEEN VAS (P = 0.406) PPT (P = 0.293), external rotation(EXT.ROT) (0.476), internal rotation (INT.ROT)(P = 0.476) and extension(EXT) (P = 0.574) ROMs in the three groups; however, DN group was significantly more effective on abduction(ABD) (P = 0.003) and flexion(FLEX) (0.012) ROM compared with other two groups.

CONCLUSION

In line with previous studies, the present study found that the application of DN, MET and combined of these treatment on active trigger points in the infraspinatus muscle of patients with shoulder impingement syndrome helps reduce pain, increase PPT and enhance the shoulder ROM. Both techniques are effective in the treatment of trigger points. Nevertheless, DN is more effective in enhancing the ROM of flexion & abduction.

Dry Needling and Acupuncture in Treatment of Dance-Related Injuries, MD, and PT Perspectives

Dancers frequently present to health care professionals with musculoskeletal impairments. The role of the health care practitioner, whether physician, physical therapist, or acupuncturist, is to decrease pain and restore function in the short term and to restore adaptive potential and neural connectivity in the long term. When dysfunction is treated, pain improves. Acupuncture and dry needling improve tissue perfusion by improving vasomotor control and can improve strength by removing motor inhibition. Acupuncture and dry needling are safe, complementary modalities aimed at improving the function of the dancer.

Comparison of the prevalence of myofascial trigger points of muscles acting on knee between patients with moderate degree of knee osteoarthritis and healthy matched people

INTRODUCTION

Trigger points have been implicated in the development of several musculoskeletal disorders. Trigger points harbored in lower limb muscles might represent a ubiquitous source of pain in patients with knee osteoarthritis (OA). This study was carried out to evaluate the prevalence of Myofascial Trigger Points (MTrPs) in muscles acting on the knee in patients with OA.

METHODS

Thirty-seven patients aged at least 55 years old with a moderate degree of OA (grade III of Kellgren and Lawrence scale) were recruited. Thirty asymptomatic people, matched on age and body mass index, were considered as the control group. Ten muscles acting on the knee joint were selected. Taut bands were also identified using a skin rolling method. A pressure of 3 kg/cm² was used to identify myofascial trigger points in all muscles except the popliteus (8 kg/cm²).

RESULTS

Chi-square was performed to compare the prevalence of trigger points between the groups. The McNemar test was administered to compare the prevalence of trigger points in the right and left sides of participants. Prevalence of the trigger points was significantly higher in patients with knee OA compared with asymptomatic people in all muscles except for right (p = 0.17) and left (p = 0.41) rectus femoris, right (p = 0.61) and left (p = 0.22) sartorius and left biceps femoris (p = 0.08). Comparison of the prevalence of MTrPs bilaterally revealed that only the right and left sartorius differed significantly (p = 0.008).

CONCLUSIONS

The prevalence of MTrPs in the muscles acting on the knee joint is higher in patients with a moderate degree of knee OA compared with asymptomatic subjects.

Needling on trigger point promotes muscle regeneration after bupivacaine injection induced injury

Dry needling treatment has a promising relieving effect on Myofascial Pain Syndrome (MPS). In China, acupuncture practitioners use acupuncture needle instead to insert the "A-Shi" acupoint to treat MPS which is defined as the same as the trigger point of dry needling. This method has been applied for thousands of years in China. In this study, bupivacaine injection induced gastrocnemius muscle injury in mice. We applied the clinical improved needling method on animal model by making the angle between the skin and needle less than 30 degree. Animals got needling treatment 24 h later at the point where the bupivacaine was injected. Results of muscle H.E. staining showed that, compared to bupivacaine injection group without needling, acupuncture treatment group showed more intact muscle fibers, less inflammatory cell infiltration and fractured muscle fibers. By RNA sequencing analysis, our work firstly demonstrated that the physical stimulation of needling changed the gene expression of muscle tissue to accelerate the muscular regeneration process. Therefore, our study proved that simple needling at "A-Shi" acupoint promoted muscle regeneration and revealed underlying mechanisms of the beneficial effects of acupuncture and dry needle treatments.

Comparison of efficacy of corticosteroid injection versus extracorporeal shock wave therapy on inferior trigger points in the quadratus lumborum muscle: a randomized clinical trial

BACKGROUND

In this study, we aimed to compare the efficacy of corticosteroid trigger point injection (TPI) versus extracorporeal shock wave therapy (ESWT) on inferior trigger points in the quadratus lumborum (QL) muscle.

METHODS

In this single-blind randomized clinical trial, 54 low back pain patients with myofascial trigger points on QL muscle were investigated. Participants were randomly allocated into two groups with A and B pockets. Patients in group A underwent radial ESWT and received 5 treatment sessions (1 per week) and actually were not followed-up. However, patients in group B received corticosteroid TPI and received one session of corticosteroid treatment and followed-up for 4 weeks after injection. Oswestry Disability Index (ODI), visual analogue scale (VAS), pain pressure threshold (PPT) and short form (36) health survey (SF-36) were measured in both groups before, two weeks after and four weeks after intervention.

RESULTS

The between group comparison indicated that corticosteroid TPI leaded to significant higher improvements of ODI (P-value< 0.01), VAS (P value< 0.001), and PPT (P-value = 0.001) scores compared to the ESWT group at two-week follow-up time-point. ESWT group recorded significant higher improvement of ODI (P-value< 0.01) and SF-36 (P-value< 0.001) compared to the corticosteroid TPI at 4th week post treatment evaluation. At four-week follow-up time-point, the patients in the ESWT group were 1.46 times more likely to achieve 30% reduction in VAS, 2.67 times more likely to achieve 30% reduction in ODI, and 2.30 times more likely to achieve 20% improvement in SF-36 compared to the participants in corticosteroid TPI group. These results refer to large effect size for all study outcomes in ESWT group (d = 4.72, d = 1.58, d = 5.48, and d = 7.47 for ODI, PPT, SF-36, and VAS, respectively).

CONCLUSION

Corticosteroid TPI was more effective compared to ESWT in short-term controlling of pain and disability caused by myofascial pain syndrome of QL muscle. However, after 4 weeks treatment, ESWT further improved the quality of life and disability and was related with more probability of achievement the minimal clinically important difference concerning pain, disability and quality of life and large effect size for all study outcomes in treated patients compared to corticosteroid TPI.

TRIAL REGISTRATION

www.irct.ir , IRCT20100827004641N14 , retrospectively registered 2019-01-19.

Dry needling for spine related disorders: a scoping review

Introduction/Background

The depth and breadth of research on dry needling (DN) has not been evaluated specifically for symptomatic spine related disorders (SRD) from myofascial trigger points (TrP), disc, nerve and articular structures not due to serious pathologies. Current literature appears to support DN for treatment of TrP. Goals of this review include identifying research published on DN treatment for SRD, sites of treatment and outcomes studied.

Methods

A scoping review was conducted following Levac et al.’s five part methodological framework to determine the current state of the literature regarding DN for patients with SRD.

Results

Initial and secondary search strategies yielded 55 studies in the cervical (C) region (71.43%) and 22 in the thoracolumbar-pelvic (TLP) region (28.57%). Most were randomized controlled trials (60% in C, 45.45% in TLP) and clinical trials (18.18% in C, 22.78% in TLP). The most commonly treated condition was TrP for both the C and TLP regions. In the C region, DN was provided to 23 different muscles, with the trapezius as treatment site in 41.88% of studies. DN was applied to 31 different structures in the TLP region. In the C region, there was one treatment session in 23 studies (41.82%) and 2–6 treatments in 25 (45.45%%). For the TLP region, one DN treatment was provided in 8 of the 22 total studies (36.36%) and 2–6 in 9 (40.9%). The majority of experimental designs had DN as the sole intervention. For both C and TLP regions, visual analogue scale, pressure pain threshold and range of motion were the most common outcomes.

Conclusion

For SRD, DN was primarily applied to myofascial structures for pain or TrP diagnoses. Many outcomes were improved regardless of diagnosis or treatment parameters. Most studies applied just one treatment which may not reflect common clinical practice. Further research is warranted to determine optimal treatment duration and frequency. Most studies looked at DN as the sole intervention. It is unclear whether DN alone or in addition to other treatment procedures would provide superior outcomes. Functional outcome tools best suited to tracking the outcomes of DN for SRD should be explored.

Dry needling technique decreases spasticity and improves general functioning in incomplete spinal cord injury: A case report

Context: Spasticity in neurological disorders (i.e. stroke patients and cerebral palsy) is positively improved by dry needling. However, reports are scarce regarding the potential effects of dry needling in reducing spasticity and improving functionality in patients with an incomplete spinal cord injury. The aim of this case report was to study the immediate, short-term effects of dry needling treatment (10 weeks) on spasticity, dynamic stability, walking velocity, self-independence, and pain in a single patient with an incomplete spinal cord injury.Findings: The dry needling treatment resulted in immediate, short-time effects on basal spasticity in the upper (reduction from 2 to 0 point median) and lower (reduction from 2 to 0 point median) limbs, as measured by the modified Ashworth Scale. Dynamic-stability, assessed by trunk accelerometry, improved more than 50% (Root Mean Squared of acceleration, Root Mean Squared of Jerk and step variability), and gait speed improved by 24.7 s (i.e. time to walk 20 m). Self-independence and pain were respectively scored by the Spinal Cord Independence Measure (21 points improvement) and visual analog scale (4 points improvement).Conclusions: This case report demonstrates that dry needling treatment can have positive effects on spasticity, dynamic stability, walking velocity, self-independence, and pain in patients with incomplete spinal cord injury. Further research is needed in a larger patient population to deeply understand the mechanism(s) associated with the obtained results and regarding the clinical significances of dry needling treatment for incomplete spinal cord injury.

The effect of dry needling on the active trigger point of upper trapezius muscle: Eliciting local twitch response on long-term clinical outcomes

BACKGROUND

Pain from myofascial trigger points is often treated by dry needling (DN). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential. Muscle damage after eliciting LTR can increase the risk of tissue fibrosis in some cases.

OBJECTIVE

This study aimed to compare two methods of DN including with and without LTR on clinical parameters.

METHODS

Twenty-six participants suffering from chronic non-specific neck pain with an active trigger point (TrP) in their upper trapezius muscles were recruited via the convenience sampling method. Participants were randomly assigned in DN with LTR (control group) and without eliciting LTR or "de qi" (experimental group). Then, they received 3 sessions of dry needling, 3 days apart. We evaluated pain, pain pressure threshold, active cervical lateral flexion range of motion, and Neck Disability Index before the intervention and 4 weeks after the treatment.

RESULTS

After the treatment, significant higher changes were seen in the experimental group compared to the control group (p< 0.05) regarding pain, pain pressure threshold, and active cervical lateral flexion. However, there was no significant difference between groups according to the disability (p> 0.05).

CONCLUSION

DN without eliciting LTR has superiority over the DN along with eliciting LTR while the treatment aimed to receive long-term effects.

Comparison of pressure release, phonophoresis and dry needling in treatment of latent myofascial trigger point of upper trapezius muscle

BACKGROUND

Latent myofascial trigger point (LMTP) is a small hypersensitive area in skeletal muscles that becomes painful under compression or stimulation. LMTPs are relevant for various musculoskeletal disorders. Although several treatments have been introduced to treat LMTP, the most efficient one is yet to be found.

OBJECTIVE

The main purpose of the present study was to compare pressure release, phonophoresis of betamethasone and dry needling on the upper trapezius latent myofascial trigger point.

METHODS

Sixty participants (mean ± SD age, 23.6 ± 2.1 y), with at least one latent myofascial trigger point in the upper trapezius muscle, participated in this study. Subjects were randomly divided into three groups (pressure release, phonophoresis with betamethasone and dry needling groups) for two weeks. Pain intensity, pain pressure threshold and active cervical range of motion were assessed.

RESULTS

Significant pain decrease, active cervical range of motion and pain pressure threshold increase were observed in the three groups (p< 0.001). The dry needling and phonophoresis groups reported more significant improvement compared to the pressure release group (p< 0.001). There was no difference between the dry needling and phonophoresis groups.

CONCLUSIONS

Considering the significant, positive effects of all three methods, dry needling and phonophoresis seem to be more effective than pressure release.

[Effect of warm acupuncture on pathological morphology and pain-induced inflammatory mediators in rats with myofascial pain trigger]

OBJECTIVE

Based on the establishment of a rat model of trigger point, this study was to intervene with warm acupuncture, and to evaluate the effect on pathological morphology and pain-induced inflammation of the rat model by microscopic pathology and microdialysis.

METHODS

Sixty-four SD rats were randomly divided into group A (blank control), group B (model control) and group C (model and intervention control). Groups A and B were divided into 3 groups (A0, A1, A2 and B0, B1, B2), the group C was divided into 2 groups (C1 and C2). The MTrPs model was established in both groups B and C, warm acupuncture intervention were given to the C1 group for 7 days and the C2 group for 15 days. Rats were sacrificed in batches. MTrPs were locally sampled and stained with hematoxylin-eosin after the preparation. The pathological changes were observed under light microscopy. The iocal interleukin-1β and prostaglandin E2 were detected by microdialysis technique.

RESULTS

Microscopically, the muscle fibers of the model were arranged disorderly, broken, twisted, local fibrosis, contracture thickening and so on; macrophage and other inflammatory cell invasion in local area and a large area of adhesion occurred on the contracture nodule, the pathological state of local muscle fibers was significantly improved after warm needle intervention, local microvascular formation and maturation, local muscle fiber repair. After successful modeling, the amount of interleukin-1β and prostaglandin E2 in group B0 was significantly higher than that in group A0 before warm needle intervention (P<0.01). After warming intervention for 7 days, there was no significant difference in the amount of interleukin-1β and prostaglandin E2 between group C1 and group B1 (P>0.05). Group C1 and B1 were significantly higher than group A1 (P<0.01); warm needle intervention for 15 days, the amount of interleukin-1β and prostaglandin E2 in group C2 were lower than those in group B2 (P<0.05), but those in group C2 and B2 were significantly higher than group A2 (P<0.01), and the amount of interleukin-1β and prostaglandin E2 in group C2 was lower than group C1 (P<0.05).

CONCLUSIONS

The modeling method of exercise combined hitting used in this study was proved to be effective by histopathology; warm acupuncture can improve the pathological and inflammatory state of local muscle fiber in myofascial pain trigger of rat, promote local microvascular formation and maturation, and help the trigger point local muscle fiber repair.

The relative risk to the femoral nerve as a function of patient positioning: potential implications for trigger point dry needling of the iliacus muscle

Objectives: Prudent dry needling techniques are commonly practiced with the intent to avoid large neurovascular structures, thereby minimizing potential excessive bleeding and neural injury. Patient position is one factor thought to affect the size of the safe zone during dry needling of some muscles. This study aimed to compare the size of the needle safe zone of the iliacus muscle during two different patient positions using ultrasound imaging. Methods: The distance from the anterior inferior iliac spine (AIIS) to the posterior pole of the femoral nerve was measured in 25 healthy participants (11 male, 14 female, mean age = 40) in both supine and sidelying positions using a Chison Eco1 musculoskeletal ultrasound unit. The average distance was calculated for each position and a two-tailed, paired t-test (α < 0.05) was used to examine the difference between positions. Results: The mean distance from the AIIS to the posterior pole of the femoral nerve was statistically greater with participants in the sidelying position (mean[SD] = 35.7 [6.2] mm) than in the supine position (mean[SD] = 32.1 [7.3] mm, p < .001). Discussion: Although more study is needed, these results suggest that patient positioning is one of several potential variables that should be considered in the optimization of patient safety/relative risk when performing trigger point dry needling. Level of Evidence: Level 4 (Pre-Post Test).

Effects of Integrated Neuromuscular Inhibition Technique on pain threshold and pain intensity in patients with upper trapezius trigger points

INTRODUCTION

Upper trapezius trigger points are among the most common causes of neck pain. This study aimed to investigate the effects of integrated Neuromuscular Inhibition Technique (INIT) on pain intensity and threshold.

MATERIALS & METHODS

Thirty two female participants with upper trapezius trigger points were recruited in this study. The participants were assigned to control (n = 16) or intervention (n = 16). The intervention group received INIT in one session, consisted of muscle energy technique, ischemic compression and strain-counter strain. Pain threshold and intensity were measured using Pressure Pain Threshold (PPT) and Numerical Pain Scale (NPS). These measurements were performed at baseline, immediately after treatment and 24 h after treatment.

FINDINGS

The results showed that pain intensity significantly decreased in the intervention group immediately after treatment (P = .01) and 24 h after treatment (P = .009) in comparison with the control group. There were no significant differences in pressure pain threshold between both groups.

CONCLUSION

It seems that Integrated Neuromuscular Inhibition Technique can reduce pain intensity in patients with upper trapezius trigger points.

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.

The prevalence of myofascial trigger points in neck and shoulder-related disorders: a systematic review of the literature

Background

Neck and shoulder disorders may be linked to the presence of myofascial trigger points (MTrPs). These disorders can significantly impact a person’s activities of daily living and ability to work. MTrPs can be involved with pain sensitization, contributing to acute or chronic neck and shoulder musculoskeletal disorders. The aim of this review was to synthesise evidence on the prevalence of active and latent MTrPs in subjects with neck and shoulder disorders.

Methods

We conducted an electronic search in five databases. Five independent reviewers selected observational studies assessing the prevalence of MTrPs (active or latent) in participants with neck or shoulder disorders. Two reviewers assessed risk of bias using a modified Downs and Black checklist. Subject characteristics and prevalence of active and latent MTrPs in relevant muscles was extracted from included studies.

Results

Seven articles studying different conditions met the inclusion criteria. The prevalence of MTrPs was compared and analysed. All studies had low methodologic quality due to small sample sizes, lack of control groups and blinding. Findings revealed that active and latent MTrPs were prevalent throughout all disorders, however, latent MTrPs did not consistently have a higher prevalence compared to healthy controls.

Conclusions

We found limited evidence supporting the high prevalence of active and latent MTrPs in patients with neck or shoulder disorders. Point prevalence estimates of MTrPs were based on a small number of studies with very low sample sizes and with design limitations that increased risk of bias within included studies. Future studies, with low risk of bias and large sample sizes may impact on current evidence.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2157-9) contains supplementary material, which is available to authorized users.

Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis

QUESTION

What is the effectiveness and what are the adverse effects.

DESIGN

Systematic review with meta-analysis.

PARTICIPANTS

Patients with shoulder or upper extremity pain or dysfunction.

INTERVENTION

Trigger point dry needling (TDN) compared to control, another intervention or another needling technique.

OUTCOME MEASURES

Primary outcome measures included shoulder or upper limb pain, shoulder or upper limb dysfunction.

RESULTS

Eleven randomized trials involving 496 participants were appraised. There was very low evidence that trigger point dry needling of the shoulder region is effective for reducing pain and improving function in the short term. There is some evidence that needling both active and latent trigger points is more effective than needling an active trigger point alone for pain immediately and 1-week after treatment (SMD=-0.74, 95%CI=-1.2 to -0.3; and SMD=-1.0, 95%CI=-1.52 to -0.59).

CONCLUSION

There is very low evidence to support the use of TDN in the shoulder region for treating patients with upper extremity pain or dysfunction. Two studies reported adverse effects to TDN interventions. Most common adverse effects included bruising, bleeding, and pain during or after treatment. Future studies are likely to change the estimates of the effectiveness of TDN for patients with upper extremity pain or dysfunction.

PROSPERO

CRD42016045639.

Efficacy of Trigger Point Injections in Patients with Lumbar Disc Hernia without Indication for Surgery

Study Design

Prospective comparative study.

Purpose

To investigate the efficacy of gluteal trigger point (TP) injections with prilocaine in patients with lumbosacral radiculopathy complaining of gluteal pain.

Overview of Literature

TP injections can be performed using several anesthetic agents, primarily lidocaine and prilocaine. While several studies have used lidocaine, few have used prilocaine.

Methods

A total of 65 patients who presented at the polyclinic with complaints of lower back pain with lumbar disc herniation (based on physical examination and magnetic resonance imaging) and TPs in the gluteal region were included in this prospective comparative study. Group 1 comprised 30 patients who were given TP injections, a home exercise program, and oral medications, and group 2 comprised 35 patients who were only treated with a home exercise program and oral medications. The patients' demographic data, Oswestry Disability Index (ODI) scores, and Visual Analog Scale (VAS) scores were recorded, and these data were evaluated at 1- and 3-month follow-ups.

Results

The ODI and VAS scores of both groups significantly decreased initially and at the follow-up examinations, but the decreases were more marked in group 1.

Conclusions

We obtained better results with TP injections than only a home exercise program and oral medications in patients with radiculopathy and TPs in the gluteal region.

[Effect of Dry Needling Stimulation of Myofascial Trigger Point on Sample Entropy of Electromyography of Gastrocnemius Injured Site in Rats]

OBJECTIVE

To attempt to establish an objective quantitative indicator to characterize the trigger point activity, so as to evaluate the effect of dry needling on myofascial trigger point activity.

METHODS

Twenty-four male Sprague-Dawley rats were randomly divided into blank control group, dry needling (needling) group, stretching exercise (stretching) group and needling plus stretching group (n＝6 per group). The chronic myofascial pain (trigger point) model was established by freedom vertical fall of a wooden striking device onto the mid-point of gastrocnemius belly of the left hind-limb to induce contusion, followed by forcing the rat to make a continuous downgrade running exercise at a speed of 16 m/min for 90 min on the next day which was conducted once a week for 8 weeks. Electromyography (EMG) of the regional myofascial injured point was monitored and recorded using an EMG recorder via electrodes. It was considered success of the model if spontaneous electrical activities appeared in the injured site. After a 4 weeks' recovery, rats of the needling group were treated by filiform needle stimulation (lifting-thrusting-rotating) of the central part of the injured gastrocnemius belly (about 10 mm deep) for 6 min, and those of the stretching group treated by holding the rat's limb to make the hip and knee joints to an angle of about 180°, and the ankle-joint about 90° for 1 min every time, 3 times altogether (with an interval of 1 min between every 2 times). The activity of the trigger point was estimated by the sample entropy of the EMG signal sequence in reference to Richman's and Moorman's methods to estimate the curative effect of both needling and exercise.

RESULTS

After the modeling cycle, the mean sample entropies of EMG signals was significantly decreased in the model groups (needling group [0.034±0.010], stretching group [0.045±0.023], needling plus stretching group [0.047±0.034]) relevant to the blank control group (0.985±0.196, P<0.01). After the treatment, the mean sample entropy of EMG signals was evidently increased in both needling (0.819±0.088), stretching (0.532±0.25) and needling plus stretching (0.810±0.117) groups (P<0.01). The mean sample entropy of the needling and needling plus stretching groups were significantly higher than that of the stretching group (P<0.01), without remarkable difference between the two needling groups in the mean sample entropy (P>0.05), suggesting a better efficacy of dry needling in easing trigger point activity.

CONCLUSION

Dry needling is able to relieve myofascial trigger point activity in rats, which is better than that of simple passive stretching therapy.

[Multimodal therapeutic approach of vaginismus: an innovative approach through trigger point infiltration and pulsed radiofrequency of the pudendal nerve]

Vaginismus is a poorly understood disorder, characterized by an involuntary muscular spasm of the pelvic floor muscles and outer third of the vagina during intercourse attempt, which results in aversion to penetration. It is reported to affect 1-7% of women worldwide. With this report the authors aim to describe the case of a young patient with vaginismus in whom techniques usually from the chronic pain domain were used as part of her multimodal therapeutic regimen.

Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache

OBJECTIVE

The purpose of this study was to compare the acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache.

METHODS

Thirty participants (8 men, 22 women) aged 19-60 years (mean age ± SD, 39 ± 10 y) with a clinical diagnosis of cervicogenic headache were randomly divided into superficial and deep groups. Headache index, trigger points tenderness, cervical range of motion (CROM), functional rating index was assessed at baseline, immediate and 1 week after the treatment.

RESULTS

Two approaches of dry needling showed reduction in headache index and trigger points tenderness. Deep dry needling showed greater improvement of cervical range of motion (p < 0.001) and functional rating index (p < 0.01).

CONCLUSION

The application of dry needling into trigger points of suboccipital and upper trapezius muscles induces significant improvement of headache index, trigger points tenderness, functional rating index and range of motion in patients with cervicogenic headache. Deep dry needling had greater effects on CROM and function.

Friction massage versus kinesiotaping for short-term management of latent trigger points in the upper trapezius: a randomized controlled trial

Background

Latent trigger points in the upper trapezius muscle may disrupt muscle movement patterns and cause problems such as cramping and decreased muscle strength. Because latent trigger points may spontaneously become active trigger points, they should be addressed and treated to prevent further problems. In this study we compared the short-term effect of kinesiotaping versus friction massage on latent trigger points in the upper trapezius muscle.

Methods

Fifty-eight male students enrolled with a stratified sampling method participated in this single-blind randomized clinical trial (Registration ID: IRCT2016080126674N3) in 2016. Pressure pain threshold was recorded with a pressure algometer and grip strength was recorded with a Collin dynamometer. The participants were randomly assigned to two different treatment groups: kinesiotape or friction massage. Friction massage was performed daily for 3 sessions and kinesiotape was used for 72 h. One hour after the last session of friction massage or removal of the kinesiotape, pressure pain threshold and grip strength were evaluated again.

Results

Pressure pain threshold decreased significantly after both friction massage (2.66 ± 0.89 to 2.25 ± 0.76; P = 0.02) and kinesiotaping (2.00 ± 0.74 to 1.71 ± 0.65; P = 0.01). Grip strength increased significantly after friction massage (40.78 ± 9.55 to 42.17 ± 10.68; P = 0.03); however there was no significant change in the kinesiotape group (39.72 ± 6.42 to 40.65 ± 7.3; P = 0.197). There were no significant differences in pressure pain threshold (2.10 ± 0.11 & 1.87 ± 0.11; P = 0.66) or grip strength (42.17 ± 10.68 & 40.65 ± 7.3; P = 0.53) between the two study groups.

Conclusions

Friction massage and kinesiotaping had identical short-term effects on latent trigger points in the upper trapezius. Three sessions of either of these two interventions did not improve latent trigger points.

Trial registration

Registration ID in IRCT: IRCT2016080126674N3.

Myofascial Pain: Mechanisms to Management

More than 100 million adults in the United States have chronic pain conditions, costing more than $500 billion annually in medical care and lost productivity. They are the most common reason for seeking health care, for disability and addiction, and the highest driver of health care costs. Myofascial pain is the most common condition causing chronic pain and can be diagnosed through identifying clinical characteristics and muscle palpation. Management is focused on integrating patient training in changing lifestyle risk factors with evidence-based treatment. Understanding the cause, diagnosis, and management of myopain conditions will help prevent the impact of chronic pain.

A case study utilizing myofascial release, acupressure and trigger point therapy to treat bilateral "Stringhalt" in a 12 year old Akhal-Teke horse

"Stringhalt" is a horse condition that causes one or both hind legs to spasm when walking, trotting or backing. The condition is thought to be related to a neurological cause from either plant toxicity or peripheral nerve injury. The prognosis is poor and the horse's performance and quality of life can be affected. Treatment has included surgically cutting the digital extensors with varied results. The objective of the study is to utilize soft tissue release via acupressure, trigger point and myofascial release to decrease symptoms of stringhalt. The case study is a 12 year old Akhal-Teke horse of excellent pedigree. In 2011, she was caught in barbed wire overnight and sustained lacerations to the bone in her hindlimbs. Shortly after the injury the horse was placed in a stall for several months and was unable to walk or run, developing stringhalt. Currently, her condition is aggravated by stress and alleviated by certain types of massage (myofascial, acupressure, and trigger point release). The incidence of stringhalt occurs every 3-5 min, with more frequent and severe symptoms on the right hindlimb. The horse is unable to run or back up. Six 1 to 1½ hour bi-weekly treatments were performed. The treatments consisted of myofascial release at the cervical, sacrum and iliums, acupressure of the bladder meridian (including c-spine, t-spine, l-spine, and hamstring), and trigger point release of the iliacus. The stringhalt symptoms were monitored for 30 min prior to each of the 6 treatment sessions. After 6 treatments, the horse was observed running and standing in a position that promotes hip extension. She has not been able to do either since the injury. The frequency and severity of the spasms have decreased to every 10-20 min. The horse's owners report that her disposition, stress and quality of life are much improved. The results suggest that myofascial release, acupressure and trigger point therapy may be utilized to provide a positive treatment outcome in the case of stringhalt. However, please note that the scope of practice varies by state and special training is needed to work with the equine population.

The immediate effect of multiple mechanical impulses on electromyography and pressure pain threshold of lumbar latent trigger points: an experimental study

BACKGROUND

Myofascial pain is a common syndrome, which has not been studied extensively in the low back. Despite a variety of manual and instrument assisted interventions available, little work has targeted the possible effects of fast mechanical impulses on myofascial trigger points (MTrPs) on its sensitivity and electrical activity. The purpose of this experimental study was to quantify the immediate effect of one session of mechanical impulses to lumbar latent MTrPs and to normal muscle tissue with pressure pain threshold (PPT) and surface electromyography (sEMG) as outcome measures.

METHODS

During the autumn of 2009, in 41 asymptomatic subjects between 17-40 years of age the lumbar musculature was searched for a latent MTrP by a trained clinician. Using 3 disposable pre-gelled electrodes bilaterally, sEMG was recorded continuously from muscle containing either latent or no MTrP. Both the trigger point group and control group received the intervention and were blinded to group allocation. The immediate effects of mechanical impulses were assessed by sEMG and PPT before and after intervention using Wilcoxon matched-pairs signed-ranks test, Mann-Whitney U test and paired t-tests.

RESULTS

The PPT increased significantly across both groups (p < 0.01) after intervention. The proportionate increase (14.6 %) was comparable in both MTrP and control groups. The electrical activity on the MTrP side was not significantly higher in the MTrP group compared to the contralateral side. The decrease of resting electrical activity after intervention was significant in the MTrP group on the side of the latent MTrP (P = 0.001) as well as the contralateral side (p=0.022), and not significant in the control group on either side (p=0.33 and p=0.93).

CONCLUSION

In this study, the immediate effect of one session of mechanical impulses was associated with a significant increase in PPT for both groups and a significant decrease in the resting electrical activity of the lumbar muscles only in the MTrP group. It is unknown if these effects have clinical significance.

Evaluation of the Sympathetic Skin Response to the Dry Needling Treatment in Female Myofascial Pain Syndrome Patients

Background

The aim of this study was to evaluate sympathetic nervous system (SNS) activity following dry needling (DN) treatment, by using the sympathetic skin response (SSR) method in female patients diagnosed with myofascial pain syndrome (MPS).

Methods

Twenty-nine MPS patients with trapezius muscle pain and 31 healthy subjects were included in this study. During a single treatment session, DN treatment was applied into trigger points, for a duration of 10 minutes. Healthy patients were subjected to SSR in weeks 1 and 4; whereas the patient group was subjected to SSR 1 week prior to their treatment and in the first, second, third and fourth weeks following the completion of their treatment.

Results

We found diminished latency on both sides. A significantly high algometer measurement (P < 0.05) was observed in the control group. DN treatment was effective in diminishing the visual analog scale (VAS) (P < 0.001), pressure pain threshold (PPT) (P < 0.01), and SSR (P < 0.001). No SSR change was detected in the healthy group after the follow-up period (P > 0.05).

Conclusion

DN is an effective treatment in MPS and trigger point (TP). This original study is the first to deal with the SSR in MPS and weekly SSR trailing, requiring further investigation to solidy findings.

The influence of Positional Release Therapy on the myofascial trigger points of the upper trapezius muscle in computer users

OBJECTIVE

The purpose of the present study was to investigate the effect of Positional Release Therapy (PRT) in computer users via latent trigger points (LTrPs) of the upper trapezius muscle.

MATERIALS AND METHODS

Twenty-eight women with the upper trapezius MTrPs participated in this study. Subjects were randomly classified into two groups (14 in each group): the subjects in the Group 1 received PRT in shortened position while those in the group 2 received sham control in the neutral position of the upper trapezius muscle. They received three therapy sessions every other day for one week. The local pain intensity and Pressure pain threshold (PPT) were measured via Visual Analogue Scale (VAS) and algometry, respectively, before interventions and repeated 5 min after the first and third treatment sessions in each group.

RESULTS

One-way ANOVA was used for data analysis. After treatment, between groups comparison revealed that for PPT and VAS, there were significant differences between the two groups (VAS and PPT; P < 0.05).

CONCLUSION

Both groups (PRT and sham control) showed alleviation of pain and increase in PPT during three sessions of therapy although PRT showed to be more effective in these patients.

Myofacial Trigger Points in Advanced Cancer Patients

Myofascial pain syndrome is started to be recognized as one of important factors of pain in cancer patients. However, no reports on features of myofascial trigger points were found in terminally-ill cancer populations. This time, we encountered 5 patients with myofascial pain syndrome and terminal cancer in whom delirium developed due to increased doses of opioid without a diagnosis of myofascial pain syndrome on initial presentation. The delirium subsided with dose reductions of opioid and treatment of myofascial pain syndrome. The common reason for a delayed diagnosis among the patients included an incomplete palpation of the painful sites, which led to unsuccessful myofascial trigger points identification. The features of myofascial trigger points included single onset in the cancer pain management site with opioid and the contralateral abdominal side muscles of the non-common sites. Withdrawal reflexes associated with cancer pain in the supine position, which are increasingly seen in the terminal cancer patients, were considered to have contributed to this siuation. We consider that careful palpation of the painful site is important, in order to obtain greater knowledge and understanding of the features of myofascial trigger points.

Differential activation of scapular muscles, during arm elevation, with and without trigger points

BACKGROUND

Latent Myofascial Trigger Points (LMTrPs) are defined as certain pain-free hyperirritable spots in a muscle taut band which lead to muscle activation pattern alternation in both loaded and unloaded conditions during scaption. The current study aimed to investigate the onset of upward scapular rotator muscle activations during rapid arm elevation in three planes of movement in patients with upper trapezius LMTrPs compared to healthy control participants.

METHOD

Three planes of scapular movement were evaluated. The onset of Deltoid (DEL) was considered as the starting point in marking the onset of Upper Trapezius (UT) and Serratus Anterior (SA) muscle activations.

RESULTS

There were significant differences in the relative muscle latencies between the LMTrPs and the control group. Those with LMTrPs showed a delayed and inconsistent activity of UT during all three planes of elevation (p < 0.05) and the same pattern happened for SA during flexion (p < 0.05).

CONCLUSIONS

Both hosted and synergistic muscles experience delay in muscle activation and alterations in their recruitment pattern during rapid arm elevation in all planes of movement. These changes may serve as adaptive motor control strategies due to the presence of LMTrPs in UT muscles.

Efficacy of regional nerve block in management of myofascial pain of masseteric origin

OBJECTIVE

To compare the efficacy of a regional masseteric nerve block (MNB) in the management of myofascial pain of masseteric origin, relative to trigger point injection (TrP-Inj) and intra-oral stabilization appliance (IOA).

STUDY DESIGN

A retrospective chart review of 200 patients treated for myofascial pain of masseteric origin was performed. Sixty patients met the eligibility criteria and were grouped based on their treatment regimen; IOA, TrP-Inj or MNB. Pain scores recorded at pre-treatment (baseline), 30 minutes post-treatment, and 2 weeks post-treatment were analyzed.

RESULTS

Treatment with MNB resulted in significant reduction in pain at 30 minutes and two weeks post-treatment compared to TrP-Inj and IOA.

CONCLUSION

MNB provided an immediate and sustained therapeutic effect for the management of myofascial pain for at least up to two weeks. MNB is a simple and valuable tool in the management of myogenous pain, especially for the non-orofacial pain practitioner.

Cross friction algometry (CFA): Comparison of pressure pain thresholds between patients with chronic non-specific low back pain and healthy subjects

Palpation is widely used to assess muscular sensitivity in clinical settings but still remains a subjective evaluation. This cross-sectional study assessed a newly developed cross-friction algometry making palpation measurable. The objective was to investigate the reliability of pressure pain thresholds obtained using Cross-Friction Algometry (CFA-PPTs) measured at the level of Erector spinae and Gluteus maximus central muscle parts, and to compare the CFA-PPTs between patients with chronic nonspecific low back pain (nCLBP) and matching healthy subjects.

PARTICIPANTS

Patients presenting nCLBP to GP's and send into a Pain Center and healthy subjects recruited via university ad valvas & flyers distribution.

OUTCOME MEASURES

30 patients with nCLBP were measured for cross-friction algometry. Other evaluations consisted of the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI).

RESULTS

The inter- and intra-reliability were tested and found to be sufficient. The mean CFA-PPT values of the Erector spinae at levels T8, T10, L1 & L3 and the Gluteus maximus of the nCLBP group were significantly lower (p ≤ 0.001) when compared to the CFA-PPT values of the healthy group. The greatest difference (-58%) was found at L1 Erector spinae level and at the superior part of the Gluteus maximus measuring point (-59%). Within the group of patients with nCLBP it was surprising to notice that there was no significant correlation between all the reference points measured using CFA-PPTs and the outcomes of the VAS and ODI scores.

CONCLUSIONS

With the aid of CFA, the importance of local muscular disorder in the lumbar part of the Erector spinae and Gluteus maximus in patients with nCLBP is obviously demonstrated, but also reveals the very large inter-individual differences in muscular fibrosis sensitivity and/or pain behavior in daily life. This possibly re-opens the debate on which influences can be put forward as the most important: the central or the peripheral sensitization system.

Intraperitoneal onlay mesh reinforcement of the abdominal wall: a new surgical option for treatment of anterior cutaneous nerve entrapment syndrome-a retrospective cohort analysis of 30 consecutive patients

BACKGROUND

The aim of the study was to introduce a new surgical treatment for anterior cutaneous nerve entrapment syndrome, a frequently unrecognised disorder in the general population responsible for chronic abdominal wall pain with limited treatment options to date. We hypothesised that intraperitoneal onlay mesh reinforcement could dissipate excessive increases in intra-abdominal pressure and prevent entrapment of the neurovascular bundle.

METHODS

Retrospective cohort analysis was performed between September 2002 and March 2014. All consecutive patients diagnosed with anterior cutaneous nerve entrapment syndrome refractory to conservative treatment (n = 30) underwent laparoscopic intraperitoneal onlay mesh reinforcement of the painful area in the abdominal wall. Planned follow-up took place at 2, 6 and 12 weeks after surgery and at time of analysis (March 2015). Primary outcome was patients' satisfaction after treatment at short and long term (last follow-up) using a verbal rating score as measurement (1 = I am very satisfied; I never experience pain, 2 = I am satisfied; I occasionally experience some pain, 3 = I have improved but experience pain on a regular basis, 4 = I have had no result on this treatment, 5 = my pain is worse after treatment). Scores 1 and 2 were classified as success, and scores 4 and 5 as failure of the treatment.

RESULTS

Thirty patients underwent laparoscopic intraperitoneal onlay mesh reinforcement. None were lost to follow-up (mean 54 ± 44 months, range 12-122, median 38). Short- and long-term success rates were 90 and 71 %, respectfully.

CONCLUSIONS

Intraperitoneal onlay mesh reinforcement of the abdominal wall seems to be a promising option for the treatment of intractable anterior cutaneous nerve entrapment syndrome.

The effect of the combination of dry needling and MET on latent trigger point upper trapezius in females

AIM

The purpose of this clinical trial experiment was to compare the effects of the combination of dry needling (DN) and the muscle energy technique (MET) on the upper trapezius latent myofascial trigger point.

METHOD

Sixty female patients, aged 18-30 with latent myofascial trigger points in the upper trapezius muscle were randomly divided into three groups: group 1 (n = 20) received DN and MET, group 2 (n = 20) received only MET, and group 3 (n = 20) received only DN. The visual analogue scale (VAS), pressure pain threshold (PPT), and range of active contra lateral flexion (CLF) were measured before each treatment. The patients were treated for three sessions in a one-week period with at least a two-day break between each session, and in session four, an assessment of primary outcomes was conducted without any treatment.

RESULTS

All three treatment groups showed decreases in pain (p = 0.001) and increases in PPT levels (p = 0.001) as well as increases in CLF (p = 0.001). But the group receiving trigger point DN together with MET showed more significant improvement than the other two groups in VAS, PPT and ROM. No significant differences were found between the MET-only group and the DN-only group.

CONCLUSION

Our results indicate that all three treatments used in this study were effective for treating MTP. According to this study, DN and MET is suggested as a new method for the treatment of MTP.

Orofacial pain and fibromyalgia pain: Being aware of comorbid conditions

Orofacial pain originating from myofascial pain of temporomandibular disorders is the second most common source of pain, after tooth pain. However, diagnosis of myofascial pain is challenging due to its characteristic referral pattern. Furthermore, pain arising from structures in the orofacial region may be a presentation of fibromyalgia and treatment directed at temporomandibular disorders fails to alleviate the pain. Similarly, patients with fibromyalgia may present with pain in the orofacial region. The physician in this case should be aware of temporomandibular disorders, its characteristic findings and treatment approaches that might be included in the treatment plan.

Dry needling: a literature review with implications for clinical practice guidelines

BACKGROUND

Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an 'intramuscular' procedure involving the isolated treatment of 'myofascial trigger points' (MTrPs).

OBJECTIVES

To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions.

MAJOR FINDINGS

According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. 'sensitive loci' or 'nociceptors') when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners.

CONCLUSIONS

Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as 'pistoning' or 'sparrow pecking'; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical 'acupuncture' literature that have used the very same 'dry needles' to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just 'TrPs'.