Manual therapy for trigger points.pdf

ARTICLE IN PRESS

Journal of Bodywork and Movement Therapies (2005) 9,27–34

Journal of

Bodywork and

Movement Therapies

www.intl.elsevierhealth.com/journals/jbmt

SYSTEMATIC REVIEW: MYOFASCIAL SYNDROME

Manual therapies in myofascial trigger point

treatment: a systematic review

Cesar Fernandez de las Pe nas*, Monica Sohrbeck Campo,

Josue Fernandez Carnero, Juan Carlos Miangolarra Page

Teaching and Research Unit of Physiotherapy, Occupational Therapy, Physical Medicine and Rehabilitation,

Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorc

on,

Madrid, Spain

Received 24 September 2003; received in revised form 20 November 2003; accepted 26 November 2003

KEYWORDS

Myofascial pain;

Myofascial trigger points;

Pressure pain threshold;

Systematic review

Abstract Background and purpose: Myofascial pain syndrome (MPS) is thought by

some authors the main cause of headache and neck pain. MPS is characterized by

Myofascial Trigger Points (MTrPs). However, there are not many controlled studies

that have analyzed the effects of the manual therapies in their treatment. The aim

of this systematic review is to establish whether manual therapies have speciﬁc

efﬁcacy in the management of MPS, based on published studies.

Methods: Data sources: PubMed (from 1975), Ovid MEDLINE (from 1975), Ovid

EMBASE (from 1975), the Cochrane Database of Systematic Reviews, AMED

(Alternative Medicine), Science Direct and PEDRO (Physiotherapy Evidence Data-

base), databases were used to the searches.

Study selection: Clinical or Controlled trials in which some form of manual therapy

treatment was used to treat MTrPs.

Data extraction: Two blinded reviewers independently extracted data concerning

trial methods, quality and outcomes.

Quality assessment: Physiotherapy Evidence Database (PEDRO) quality score

method was used in this review.

Results: Data synthesis. 7 studies were included in this review. One manual

therapy treatment was investigated in 4 studies (one of them included a group

treated with manual therapy combined with other physical medicine modalities);

a combination of various manual therapies was investigated in 2 studies, and

manual therapy combined with other physical medicine modality was investigated

in 2 trials.

Quality of the included studies: Two papers obtained 6 points, another two scored

5 points, one scored 3 points, one scored 2 point and the remaining one scored 1

point.

Discussion: Results did not produce any rigorous evidence that some manual

therapies have an effect beyond placebo in treatment of MPS. Some of the studies

reviewed conﬁrmed that MTrP treatment is effective in reducing the pressure pain

threshold, and scores on visual analogue scales. Pressure pain threshold and visual

analogue scale were the outcome measures most used in the analyzed studies. MPS is

*Corresponding author. Tel.: þ 34-91-488-88-84; fax: þ 34-91-488-88-31.

E-mail address: cesarfdlp@yahoo.es, cpena@cs.urjc.es (C.F. de las Penas).

doi:10.1016/j.jbmt.2003.11.001

ARTICLE IN PRESS

C.F. de las Pe˜as et al.

characterized by restricted range of motion (ROM), which suggests the need to

include ROM measurements in future studies.

Conclusions: The principal conclusion of this review is that there have been very

few randomized controlled trials that analyse treatment of MPS using manual

therapy. The second conclusion is that the hypothesis that manual therapies have

speciﬁc efﬁcacy, beyond placebo, in the management of MPS is neither supported

nor refuted by research to date. Controlled trials are needed to investigate whether

manual therapy has an effect beyond placebo on MTrP management.

Introduction

for the presence of an active trigger point diagnosis

involves the combination of the presence of:

Myofascial pain syndrome (MPS) is thought by some

authors to be the main cause of headache and neck

pain ( Grosshandler et al., 1985 ). There are also

many epidemiologic studies suggesting that MPS is

an important source of musculoskeletal dysfunction

( Fricton et al., 1985 ; Skootsky et al., 1989 ; Gerwin,

1995 ). A study of musculoskeletal disorders in

Thailand found that MPS was the primary diagnosis

in 36% of 431 patients with pain arising within the

previous week ( Chaiamnuay et al., 1998 ). Although

these studies show that MPS has a high prevalence,

there is much controversy relating to clinical

aspects of MPS ( Bohr, 1996 ; Quintner and Cohen,

1994 ). MPS is characterized by Myofascial Trigger

Points (MTrPs). A trigger point can be located in

fascia, ligaments, muscles, and tendons; however,

MTrPs are also found in skeletal muscles and/or

their fascia. A MTrP is a hyperirritable spot,

associated with a taut band of a skeletal muscle

that is painful on compression or stretch, and

that can give rise to a typical referred pain

pattern as well as autonomic phenomena ( Simons

et al., 1999 ).

MTrPs are typically located by physical examina-

tion and palpation. The diagnosis of a MTrP is

accomplished by physical exploration by an experi-

enced therapist, who must take into account the

physical signs demonstrated ( Simons et al., 1999 ),

including: presence of a palpable taut band in a

skeletal muscle; the presence of a hypersensitive

tender spot in the taut band; palpable or visible

local twitch response on snapping palpation, and/

or needling of the MTrP ( Hong, 1994 ); a ‘jump’

sign; the presence of the typical referred pain

pattern of the MTrP; restricted range of motion

(ROM) of the affected tissues; muscular fatigue and

autonomic phenomena. However, the reliability

of these criteria has been questioned ( Nice

et al., 1992 ; Njoo, 1994 ; Wolfe et al., 1992 ; Gerwin

et al., 1995 ).

Simons et al. (1999) and Gerwin et al. (1997)

recommend that the minimum acceptable criteria

1. a palpable taut band,

2. an exquisite tender spot in the taut band,

3. patient’s recognition of pain as ‘familiar’,

4. pain on stretching the tissues.

Further work is underway relative to MTrP

clinical examination ( Russell, 1999 ). Readers might

usefully explore current thinking on these issues

via papers by Sciotti et al. (2001) , as well as

Gerwin et al. (1997) .

The formation of a MTrP may result from a

variety of factors, such as a severe trauma,

overuse, overstress ( Rubin, 1981 ), psychological

stress ( Mcnulty et al., 1994 ) and joint dysfunction

( Kuan et al., 1997 ). The mechanism of activation of

the MTrP is not clearly understood. Recent studies

have hypothesized that the pathophysiology of MPS

and the formation of MTrPs result from injured or

overloaded muscle ﬁbers, leading to involuntary

shorting and loss of oxygen and nutrient supply,

with increased metabolic demand on local tissues

( Han and Harrison, 1997 ; Hong and Simons, 1998 ).

Furthermore, adaptive lengthening and eccentric

strain of the muscle may represent other mechan-

isms for activation of MTrPs ( Simons et al., 1999 ).

Currently, research continues to explore the nature

of MTrPs ( Simons, 2001 , Simons and Hong, 2002 ;

Shah and Phillips, 2003 ).

The aim of physical therapy treatment is to

reduce the pain and restore normal function. Most

physical therapy treatments of MPS are targeted at

deactivation of MTrPs. Physical therapy techniques

can be divided into 3 categories:

1. Manual therapies: ischemic compression, spray

and stretch, strain and counterstrain ( Jones,

1981 ; D’Ambrogio and Roth, 1997 ), muscle

energy techniques ( Chaitow, 2001 ), trigger point

pressure release ( Lewit, 1991 ), transverse fric-

tion massage ( Cyriax and Cyriax, 1992 ).

2. Needling therapies ( Cummings and White, 2001 ).

ARTICLE IN PRESS

Manual therapies in the myofascial trigger point treatment

3. Other techniques: thermotherapy ( Lee et al.,

1997 ), ultrasound therapy ( Gam et al., 1998 ),

laser therapy ( P

ontinen and Airaksinen, 1995 ).

design and the original idea of the review. For each

study, the following details were extracted: inclu-

sion and exclusion criteria, design, randomization,

description of dropouts and blinding, outcome

measures, details of the intervention used and

results.

Hey and Helewa (1994) concluded, following a

literature review of MPS treatment, that no

reported treatment had been more efﬁcacious than

control intervention. Not many controlled trials

have been published analyzing the effects of the

manual therapies. To establish whether manual

therapies have speciﬁc efﬁcacy in the treatment of

MPS, and to update the literature to include recent

papers, we undertook a systematic review.

Quality assessment

There are many methods of achieving a quality

score. In a previous systematic review of needling

therapies in the management of MPS ( Cummings

and White, 2001 ), Jadad’s principles were used

( Jadad et al., 1996 ):

Methods

* 1 point for a study that is described as

randomized.

* If the method of randomization is appropriate 1

point, if the method is inappropriate 1 point is

deducted.

* 2 points if the assessor and subjects are blinded

(one respectively), and another point if dropouts

and withdrawals are described.

* Clinical trials with 3 or more points, from the

maximum score of 5, were considered of higher

quality.

Data sources

During 2003 computerized literature searches were

performed searching for clinical/controlled trials

and reviews of manual therapy treatment of MPS

caused by MTrPs, using the following databases:

PubMed (from 1975), Ovid MEDLINE (from 1975),

Ovid EMBASE (from 1975), the Cochrane Database

of Systematic Reviews, AMED (Alternative Medi-

cine), Science Direct and PEDRO (Physiotherapy

Evidence Database).

Search terms used were: MPS OR MTrP OR

musculoskeletal disorders, combined with manual

therapy treatment, strain/counterstrain, spray and

stretch therapy, ischemic compression, ischemic

pressure, massage therapy, physical therapy, myo-

fascial release therapy, muscle energy techniques,

trigger point pressure release, and transverse

friction massage.

When database facilities permitted, searches

were limited to clinical or controlled trials.

In this systematic review, the Physiotherapy

Evidence Database (PEDRO) quality score method

has been used:

* Random allocation: 1 point.

* Concealed allocation: 1 point.

* Baseline comparability: 1 point.

* Blinded assessors: 1 point.

* Blinded subjects: 1 point.

* Blinded therapist: 1 point.

* Adequate follow-up: 1 point.

* Intention to treat analysis: 1 point ( Hollis and

Campbell, 1999 ).

* Between group comparisons: 1 point.

* Points estimates and variability: 1 point.

* Possible total: 10 points.

Study selection

Papers were included if they described clinical or

randomized controlled trials in which some form of

manual therapy treatment (strain/counterstrain,

ischemic compression, transverse friction massage,

spray and stretch, muscle energy technique) was

used to treat MTrPs. Comparative trials were

included if at least 1 group had a form of manual

therapy treatment.

Results

Data synthesis

The searches revealed 20 relevant trials, 11 of

which were subsequently excluded, because there

was not any form of manual therapy treatment in

the methodology used. Another 2 clinical trials

( Halkovich et al., 1981 ; Lewit and Simons, 1984 )

were excluded because musculoskeletal dysfunc-

tion, not MPS, was analyzed. In the ﬁrst study

( Halkovich et al., 1981 ) normal subjects were

Data extraction

Data were extracted independently by two blinded

reviewers, using a specially designed form. Differ-

ences were resolved by discussion between all the

authors. All authors participated previously in the

ARTICLE IN PRESS

C.F. de las Pe˜as et al.

analyzed. Although musculoskeletal dysfunction

might be a synonym of MPS in some cases, in the

second trial ( Lewit and Simons, 1984 ) patients were

diagnosed for muscle-tension shortening, and mus-

cle tenderness. Furthermore, authors did not

describe the minimum acceptable criteria for MTrPs

diagnosis, i.e. presence of a spot tenderness in a

palpable taut band in a skeletal muscle, and

patient recognition of the referred pain ( Simons

et al., 1999 ; Gerwin et al., 1997 ). Finally, the

authors decided to exclude these trials because the

inclusion criteria were not homogeneous with the

other 7 papers.

were represented, but in all the trials, neck and

shoulder pain were involved, speciﬁcally upper

trapezius and levator scapulae muscles.

Quality of the included trials

Two papers obtained 6 points each ( Gam et al.,

1998 ; Hong et al., 1993 ), another two scored 5

points each ( Hou et al., 2002 ; Hanten et al., 2000 ),

one scored 3 points ( Hanten et al., 1997 ), one

scored 2 point ( Jaeger and Reeves, 1986 ) and the

remaining one scored 1 point ( Dardzinski et al.,

2000 ). Table 1 summarizes the details of the PEDRO

scale scored of these trials.

Description of included clinical trials

The 7 trials that met the inclusion criteria of this

review described different manual therapy treat-

ment modalities: ischemic compression, spray and

stretch, deep pressure soft tissue massage, mas-

sage combined with exercise, active head retraction

and retraction/extension exercises (as described by

Robin McKenzie), occipital release, myofascial re-

lease, and strain/counterstrain technique.

It became clear that the trials could be classiﬁed

into 3 categories:

Outcomes

* Table 2 summarizes some details of the 7 studies

that were included in this review. Spray and

stretch technique was used in 2 studies ( Jaeger

and Reeves, 1986 ; Hong et al., 1993 ).

* Soft tissue massage was used in another 2 trials

( Gam et al., 1998 ; Hong et al., 1993 ).

* Ischemic compression technique was analyzed in

an other 2 ( Hou et al., 2002 ; Hanten et al.,

2000 ).

* Occipital release, active head retraction and

retraction/extension exercises as described by

Robin McKenzie ( Hanten et al., 1997 ), strain/

counterstrain ( Dardzinski et al., 2000 ) and

myofascial release ( Hou et al., 2002 ), were

studied in 1 trial each.

* Only 2 studies attempted to test the speciﬁc

efﬁcacy (efﬁcacy beyond placebo) of various

manual therapies in the treatment of MPS

( Gam et al., 1998 ; Hanten et al., 1997 ). These

studies found no difference between interven-

tions.

1. only one manual therapy treatment;

2. a combination of various manual therapies;

3. manual therapy combined with another physical

medicine modality.

Use of just one manual therapy treatment was

investigated in 4 trials ( Jaeger and Reeves, 1986 ;

Hanten et al., 1997 ; Hong et al., 1993 ; Hou et al.,

2002 ); a combination of various manual therapies in

2 studies ( Hanten et al., 2000 ; Dardzinski et al.,

2000 ), and manual therapy combined with another

physical medicine modality in 2 studies ( Gam et al.,

1998 ; Hou et al., 2002 ). Many parts of the body

Table 1 Pedro score rated details of the studies included in this review.

Study

Random

alloc.

Conce.

alloc.

Basel.

comp.

Blind

assesors

Blind

subjects

Blind

therapist

Intention

to treat

analysis

Between-

group

comp.

Points

estimates

and varia.

Total

score

Gam (1998)

Yes

Yes Yes No

Yes No

Yes

6/10

Jaeger (1986) a

No No Yes No

No No

Yes

2/10

Hanten (1997) Yes No No No

No No

Yes

3/10

Hong (1993) a

Yes

Yes Yes Yes No

No No

Yes

6/10

Hou (2002) a

Yes

Yes Yes No

No No

Yes

5/10

Hanten (2000) Yes No

Yes No

Yes

5/10

Dardzinski (2000) a

No No No

Yes No

1/10

Alloc. ¼ allocation; Basel. comp. ¼ baseline comparability; Conce ¼ concealed; Comp. ¼ comparisons; Varia. ¼ variability;

a Pedro score rated by the authors of the review.

Table 2 Manual therapy clinical trials included in this systematic review.

Study

Design Pedro

scale

Mtrp

examined

Number

patients

Treatment

applied

(n patients)

Outcome

measures

Number

sessions

Follow up

Results

Gam AN (1998)

RCT

6/10

Neck and

shoulder pain

(A)US þ massage þ

exercise

VAS scale, daily

analgesic usage,

tenderness

(2 weekly/

4 weeks)

6 months

No signiﬁcant

differences in

VAS and analgesic

usage. A and B

causes signiﬁcantly

less tenderness

(p o 0; 05) than C.

(B) Sham US þ mass.

þ exercise

Jaeger B (1986)

Clinical

trial

2/10

(rated by

authors)

Neck pain

(upper trapezius

and levator

scapulae muscles)

Spray & stretch

VAS scale, PPT

(Immediate

effects)

There are signiﬁcant

differences (p o 0; 01)

in VAS and PPT after

treatment

Hanten W (1997)

RCT

3/10

Cervical and

scapular pain

(A) Occipital release

(B) Active head retraction

& retraction/extension

PPT

(Immediate

effects)

No signiﬁcant

differences between

interventions

Hong C (1993)

RCT

6/10

(rated by

authors)

Upper trapezius

muscle

(A) Spray & stretch

(B) Deep pressure soft

tissue massage

PPT

(Immediate

effects)

Deep pressure

soft tissue massage

was more effective

than other modalities

Hou C (2002)

RCT

(Not

placebo

group)

5/10

(rated by

authors)

Upper trapezius

muscle

119

(A) Ischemic compress.

(B) Isch. Compr. þ

interferential current þ

myofascial release

PPT, PPTol., VAS scale,

cervical

range of motion

(Immediate

effects)

Hanten W (2000)

RCT

(Not

placebo

group)

5/10

Neck and

back pain

(A) Ischemic compress.

þ stretch

(B) Active exercises

VAS scale, PPT,

percentage of

time in pain over

24 hours

5 days

(2 treatment

daily)

(Immediate

effects of 5

sessions)

A superior to B in

reducing the VAS scale

& PPT. No differences

for percentage of time

in pain.

Dardzinski JA (2000) Clinical

trial

1/10

(rated by

authors)

Chronic myofascial

pain syndrome and

ﬁbromyalgia

Strain/counterstrain þ body

ﬂexibility and stretching

techniques performed by

the patient

Range of motion,

posture,

tenderness

2–10

sessions

6 months

50–75% immediate

resolution of symptoms.

Partial improvement was

maintained for 6 months

RCT ¼ randomized controlled trial; PPT ¼ pressure pain treshold; PPTol ¼ pressure pain tolerance; VAS ¼ visual analoge scale.

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