Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective

Abstract

The relationship between muscle trigger points (TrPs) and joint hypomobility is frequently recognized by clinicians. Among different manual therapies aimed at inactivating muscle TrPs, ischemic compression and spinal manipulation have shown moderately strong evidence for immediate pain relief. Reduction of joint mobility appears related to local muscles innervated from the segment, which suggests that muscle and joint impairments may be indivisible and related disorders in pain patients. Two clinical studies have investigated the relationship between the presence of muscle TrPs and joint hypomobility in patients with neck pain. Both studies reported that all patients exhibited segmental hypomobility at C3-C4 zygapophyseal joint and TrPs in the upper trapezius, sternocleidomastoid, or levator scapulae muscles. There are several theories that have discussed the relationship between TrP and joint hypomobility. First, increased tension of the taut muscular bands associated with a TrP and facilitation of motor activity can maintain displacement stress on the joint. Alternatively, it may be that the abnormal sensory input from the joint hypomobility may reflexively activate TrPs. It is also conceivable that TrPs provide a nociceptive barrage to the dorsal horn neurons and facilitate joint hypomobility. There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation.     

Differential diagnosis and treatment in a patient with posterior upper thoracic pain

BACKGROUND AND PURPOSE: Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. CASE DESCRIPTION: The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV/CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV/CT joint mobilizations, TrP release, and flexibility and postural exercises. OUTCOMES: The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. DISCUSSION: This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.     

Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy

(Headache 2011;51:246‐261) Objective.— To identify prognostic factors from the history and physical examination in women with tension‐type headache (TTH) who are likely to experience self‐perceived clinical improvement following a multimodal physical therapy session including joint mobilization and muscle trigger point (TrP) therapies. Background.— No definitive therapeutic intervention is available for TTH. It would be useful for clinicians to have a clinical prediction rule for selecting which TTH patients may experience improved outcomes following a multimodal physical therapy program. Methods.— Women diagnosed with pure TTH by 3 experienced neurologists according to the International Headache Society criteria from different neurology departments were included. They underwent a standardized examination (neck mobility, pressure pain thresholds, total tenderness score, presence of muscle TrPs, Medical Outcomes Study 36‐Item Short Form, the Neck Disability Index [NDI], the Beck Depression Inventory, and the Headache Disability Inventory) and then a multimodal physical therapy session including joint mobilization and TrP therapies. The treatment session included a 30‐second grade III or IV central posterior‐anterior nonthrust mobilization applied from T4 to T1 thoracic vertebrae, at C7‐T1 cervico‐thoracic junction and C1‐C2 vertebrae for an overall intervention time of 5 minutes Different TrP techniques, particularly soft tissue stroke, pressure release, or muscle energy were applied to head and neck–shoulder muscles (temporalis, suboccipital, upper trapezius, splenius capitis, semispinalis capitis, sternocleidomastoid) to inactivate active muscle TrPs. Participants were classified as having achieved a successful outcome 1 week after the session based on their self‐perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of success. Results.— Data for 76 subjects were included in the analysis, of which 36 experienced a successful outcome (48%). Eight prognostic variables were retained in the regression model: mean age <44.5 years, presence of left sternocleidomastoid TrP, presence of suboccipital TrP, presence of left superior oblique muscle TrP, cervical rotation to the left > 69°, total tenderness score <20.5, NDI <18.5, referred pain area of right upper trapezius muscle TrP >42.23. Conclusions.— The current clinical prediction rule may allow clinicians to make an a priori identification of women with TTH who are likely to experience short‐term self‐report improvement with a multimodal session including joint mobilizations and TrP therapies. Future studies are necessary to validate these findings.     

Myofascial trigger points in the suboccipital muscles in episodic tension-type headache

Referred pain evoked by suboccipital muscle trigger points (TrPs) spreads to the side of the head over the occipital and temporal bones and is usually perceived as bilateral headache. This paper describes the presence of referred pain from suboccipital muscle TrPs in subjects with episodic tension-type headache (ETTH) and in healthy controls. Ten patients presenting with ETTH and 10 matched controls without headache were examined by a blinded assessor for the presence of suboccipital muscle TrPs. Diagnostic criteria described by Simons and Gerwin were adapted to diagnose TrPs, i.e. presence of tenderness in the suboccipital region, referred pain evoked by maintained pressure for 10 s, and increased referred pain on muscle contraction. Six ETTH patients (60%) had active TrPs and 4 had latent TrPs (40%). On the other hand, 2 control subjects also had latent TrPs. Differences in the presence of suboccipital muscle TrPs between both groups were significant for active TrPs (P<0.001), but not for latent TrPs. Active TrPs were only present in ETTH patients, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. Myofascial TrPs in the suboccipital muscles might contribute to the origin and/or maintenance of headache, but a comprehensive knowledge of the role of these muscles in tension-type headache awaits further research.     

Myofascial trigger points are very prevalent in patients with chronic tension-type headache: a double-blinded controlled study

OBJECTIVES: Myofascial pain syndromes due to trigger points (TrPs) are clinical entities, but more evidence is needed to evaluate TrP palpation. Chronic tension-type headache (CTTH) is the most prevalent chronic headache with high socioeconomic costs. The primary aim was to study whether TrP palpation can distinguish patients with headache patients from healthy controls. DESIGN: Double-blinded, controlled design. PATIENTS: Twenty patients with the diagnosis of CTTH, and 20 healthy age-matched and sex-matched control participants. RESULTS: TrP palpation revealed more TrPs in patients (N=17) versus controls (N=6) (P=0.0005). Referred pain was also more frequent in patients (N=17) versus controls (N=9) (P=0.04). Further, TrP palpation also identified a higher pain intensity than at a control point (CtP) in both groups (P=0.0001). Pain intensity at TrPs in patients was higher than in controls (P=0.0010), and CtPs were also more tender in patients than in controls (P=0.0167). For spontaneous electromyographic activity no difference between TrPs versus CtPs within or between groups could be detected. CONCLUSIONS: These findings suggest that active TrPs are much more frequent in CTTH than in controls and the number and pain intensity of TrPs may be used to distinguish between the 2 groups. Spontaneous electromyographic activity could not be demonstrated, and the underlying biology of TrPs is still unclear.     

Referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache.

Referred pain and pain characteristics evoked from the upper trapezius muscle was investigated in 20 patients with chronic tension-type headache (CTTH) and 20 age- and gender-matched controls. A headache diary was kept for 4 weeks in order to confirm the diagnosis and record the pain history. Both upper trapezius muscles were examined for the presence of myofascial trigger points (TrPs) in a blinded fashion. The local and referred pain intensities, referred pain pattern, and pressure pain threshold (PPT) were recorded. The results show that referred pain was evoked in 85% and 50% on the dominant and non-dominant sides in CTTH patients, much higher than 55% and 25% in controls (P<0.01). Referred pain spread to the posterior-lateral aspect of the neck ipsi-lateral to the stimulated muscle in both patients and controls, with additional referral to the temple in most patients, but none in controls. Nearly half of the CTTH patients (45%) recognized the referred pain as their usual headache sensation, i.e. active TrPs. CTTH patients with active TrPs in the right upper trapezius muscle showed greater headache intensity and frequency, and longer headache duration than those with latent TrPs. CTTH patients with bilateral TrPs reported significantly decreased PPT than those with unilateral TrP (P<0.01). Our results showed that manual exploration of TrPs in the upper trapezius muscle elicited referred pain patterns in both CTTH patients and healthy subjects. In CTTH patients, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual headache pain, consistent with active TrPs. Our results suggest that spatial summation of perceived pain and mechanical pain sensitivity exists in CTTH patients.     

Association of cross-sectional area of the rectus capitis posterior minor muscle with active trigger points in chronic tension-type headache: a pilot study

OBJECTIVE: To investigate whether cross-sectional area (CSA) of the suboccipital muscles was associated with active trigger points (TrPs) in chronic tension-type headache (CTTH). DESIGN: Magnetic resonance imaging (MRI) of the cervical spine was performed in 11 females with CTTH aged from 26 to 50 yrs old. CSA for both rectus capitis posterior minor (RCPmin) and rectus capitis posterior major (RCPmaj) muscles were measured from axial T1-weighted images, using axial MRI slices aligned parallel to the C2/3 intervertebral disc. A headache diary was kept for 4 wks to record the pain history. TrPs in the suboccipital muscle were identified by eliciting referred pain to palpation, and increased referred pain with muscle contraction. TrPs were considered active if the elicited referred pain reproduced the head pain pattern and features of the pattern seen during spontaneous headache attacks. RESULTS: Active TrPs were found in six patients (55%), whereas the remaining five patients showed latent TrPs. CSA of the RCPmin was significantly smaller (F = 13.843; P = 0.002) in the patients with active TrPs (right side: 55.9 +/- 4.4 mm; left side: 61.1 +/-: 3.8 mm) than in patients with latent TrPs (right side: 96.9 +/- 14.4 mm; left side: 88.7 +/- 9.7 mm). No significant differences were found for CSA of the RCPmaj between the patients with either active or latent TrP (P > 0.5). CONCLUSIONS: It seems that muscle atrophy in the RCPmin, but not in the RCPmaj, was associated with suboccipital active TrPs in CTTH, although studies with larger sample sizes are now required. It may be that nociceptive inputs in active TrPs could lead to muscle atrophy of the involved muscles. Muscle disuse or avoidance behavior can also be involved in atrophy.     

Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache

OBJECTIVE: To assess the presence of trigger points (TrPs) in several head and neck muscles in subjects with chronic tension-type headache (CTTH) and in healthy subjects; and to evaluate the relationship of these TrPs with forward head posture (FHP), headache intensity, duration, and frequency. BACKGROUND: Tension-type headache (TTH) is a headache in which myofascial TrPs in head and neck muscles might play an important etiologic role. DESIGN: A blinded, controlled, pilot study. METHODS: Twenty-five CTTH subjects and 25 matched controls without headache were studied. TrPs in bilateral upper trapezius, sternocleidomastoids, and temporalis muscles were identified according to Simons et al's diagnostic criteria: tenderness in a hyperirritable spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation. A TrP was considered active if the subject recognized the evoked referred pain as familiar headache. If the evoked referred pain was not recognized as familiar headache, the TrP was considered as latent. Side-view pictures of each subject were taken in both sitting and standing positions in order to assess FHP by measuring the cranio-vertebral angle. Both measurements were made by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration. RESULTS: The mean number of TrPs on each CTTH subject was 3.9 (SD: 1.2), of which 1.9 (SD: 1.2) were active TrPs and 1.9 (SD: 0.8) were latent TrPs. Control subjects only exhibited latent TrPs (mean: 1.4; SD: 0.8). There was a significant difference between the CTTH group and the controls for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of active and latent TrPs within each muscle were also significant for all the analyzed muscles (P < .01). CTTH subjects with active TrPs in the right upper trapezius muscle or left sternocleidomastoid muscle showed a greater headache intensity and duration, but not headache frequency, compared to those with latent TrPs (P < .05). Active TrPs in the right temporalis muscle were associated with longer headache duration (P < .01), whereas active TrPs in the left temporalis muscle were associated with greater headache intensity (P < .05). CTTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions. Differences were only significant for TrPs in the left sternocleidomastoid and FHP in the sitting position (P < .01). CONCLUSIONS: Active TrPs in upper trapezius, sternocleidomastoid, and temporalis muscles were associated with CTTH. CTTH subjects with active TrPs usually reported a greater headache intensity and longer headache duration than those with latent TrPs. CTTH subjects with active TrPs tended to have a greater FHP than CTTH subjects with latent TrPs.     

Clinical precision of myofascial trigger point location in the trapezius muscle

Myofascial trigger points (TrPs) have been clinically described as discrete areas of muscle tenderness presenting in taut bands of skeletal muscle. Using well-defined clinical criteria, prior investigations have demonstrated interrater reliability in the diagnosis of TrPs within a given muscle. No reports exist, however, with respect to the precision with which experienced clinicians can determine the anatomic locations of TrPs within a muscle. This paper details a study wherein four trained clinicians achieved statistically significant reliability (see below) in estimating the precise locations of latent TrPs in the trapezius muscle of volunteer subjects (n=20). To do so, the clinicians trained extensively together prior to the study. The precise anatomic location of each subject's primary TrP was measured in a blinded fashion using a 3 dimensional (3-D) camera system. Use of this measurement system permitted the anatomic co-ordinates of each TrP to be located without providing feedback to subsequent clinicians. The clinicians each used a pressure algometer along with patient feedback to document the sensitivity of each suspected TrP site, however unlike routine clinical practice, the algometry was performed with a double-blinded approach hence the results were only examined post-hoc. At the time of data collection (algometry readings unknown), 16 of the 20 subjects were judged to present with a latent TrP. Subsequently, when subjected to a criterion pressure threshold value of <3.0 kg.cm(-2), 12 of these TrPs were classified as being clinically sensitive. To assess the 3-D measurement precision, and the reliability of the TrP estimates, statistical measures of the SEM and the Generalizability coefficient (G-coeff) were determined for all suspected TrP sites in the superior-inferior, medial-lateral and anterior-posterior directions. The best results were determined by pooling the measurements of all 4 clinicians, however, based upon exceeding a criterion reliability threshold of 80%, the use of just two testers was found to produce reliable results. The two-tester condition yielded a precision of 7.5, 7.6 and 6.5 mm (SEM) with reliability (G-coeff) of 0.92, 0.86 and 0.83, respectively. Given the double-blinded methodology, the use of pressure algometry was also found to demonstrate internal validity. The algometer responses associated with TrP estimates varied inversely with respect to the clinical group's reliability in identify the TrP locations. To summarize, for the trapezius muscle, this study demonstrates that two trained examiners can reliably localize latent TrPs with a precision that essentially approaches the physical dimensions of the clinician's own fingertips. Finally, it should be recognized that the ability to precisely document TrP location appears critical to the success of future studies that may be designed to investigate the etiology and pathogenesis of this commonly diagnosed clinical disorder.     

Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache

OBJECTIVE: To assess the differences in the presence of trigger points (TrPs) in head and neck muscles, forward head posture (FHP) and neck mobility between episodic tension-type headache (ETTH) subjects and healthy controls. In addition, we assess the relationship between these muscle TrPs, FHP, neck mobility, and several clinical variables concerning the intensity and the temporal profile of headache. BACKGROUND: TTH is a headache in which musculoskeletal disorders of the craniocervical region might play an important role in its pathogenesis. Design.-A blinded, controlled pilot study. METHODS: Fifteen ETTH subjects and 15 matched controls without headache were studied. TrPs in both upper trapezius, both sternocleidomastoids, and both temporalis muscles were identified according to Simons and Gerwin diagnostic criteria (tenderness in a hypersensible spot within a palpable taut band, local twitch response elicited by snapping palpation, and elicited referred pain with palpation). Side-view pictures of each subject were taken in both sitting and standing positions, in order to assess FHP by measuring the craniovertebral angle. A cervical goniometer was employed to measure neck mobility. All measures were taken by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration. RESULTS: The mean number of TrPs for each ETTH subject was 3.7 (SD: 1.3), of which 1.9 (SD: 0.9) were active, and 1.8 (SD: 0.9) were latent. Control subjects only had latent TrPs (mean: 1.5; SD: 1). TrP occurrence between the 2 groups was significantly different for active TrPs (P < .001), but not for latent TrPs (P > .05). Differences in the distribution of TrPs were significant for the right upper trapezius muscles (P= .04), the left sternocleidomastoid (P= .03), and both temporalis muscles (P < .001). Within the ETTH group, headache intensity, frequency, and duration outcomes did not differ depending on TrP activity, whether the TrP was active or latent. The craniovertebral angle was smaller, ie, there was a greater FHP, in ETTH patients than in healthy controls for both sitting and standing positions (P < .05). ETTH subjects with active TrPs in the analyzed muscles had a greater FHP than those with latent TrPs in both sitting and standing positions, though differences were only significant for certain muscles. Finally, ETTH patients also showed lesser neck mobility than healthy controls in the total range of motion as well as in half-cycles (except for cervical extension), although neck mobility did not seem to influence headache parameters. CONCLUSIONS: Active TrPs in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in ETTH subjects than in healthy controls, although TrP activity was not related to any clinical variable concerning the intensity and the temporal profile of headache. ETTH patients showed greater FHP and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.     

Myofascial trigger points in subjects presenting with mechanical neck pain: a blinded, controlled study

The aim of this study was to describe the differences in the presence of myofascial trigger points (TrPs) in the upper trapezius,sternocleidomastoid, levator scapulae and suboccipital muscles between patients presenting with mechanical neck pain and control healthy subjects. Twenty subjects with mechanical neck pain and 20 matched healthy controls participated in this study. TrPs were identified, by an assessor blinded to the subjects' condition, when there was a hypersensible tender spot in a palpable taut band, local twitch response elicited by the snapping palpation of the taut band, and reproduction of the referred pain typical of each TrP. The mean number of TrPs present on each neck pain patient was 4.3 (SD: 0.9), of which 2.5 (SD: 1.3) were latent and 1.8 (SD: 0.8) were active TrPs. Control subjects also exhibited TrPs (mean: 2; SD: 0.8). All were latent TrPs. Differences in the number of TrPs between both study groups were significant for active TrPs (P < 0.001), but not for latent TrPs (P > 0.5). Moreover, differences in the distribution of TrPs within the analysed cervical muscles were also significant (P < 0.01) for all muscles except for both levators capulae. All the examined muscles evoked referred pain patterns contributing to patients' symptoms. Active TrPs were more frequent in patients presenting with mechanical neck pain than in healthy subjects.     

Referred Pain from Muscle Trigger Points in the Masticatory and Neck-Shoulder Musculature in Women With Temporomandibular Disoders

Our aim was to describe the referred pain patterns and size of areas of trigger points (TrPs) in the masticatory and neck-shoulder muscles of women with myofascial temporomandibular disorders (TMD). Twenty-five women with myofascial TMD and 25 healthy matched women participated. Bilateral temporalis, deep masseter, superficial masseter, sternocleidomastoid, upper trapezius and suboccipital muscles were examined for TrPs by an assessor blinded to the subjects' condition. TrPs were identified with manual palpation and categorized into active and latent according to proposed criteria. The referred pain areas were drawn on anatomical maps, digitalized, and measured. The occurrence of active (P < .001) and latent TrPs (P = .04) were different between groups. In all muscles, there were significantly more active and latent TrP in patients than controls (P < .001). Significant differences in referred pain areas between groups (P < .001) and muscles (P < .001) were found: the referred pain areas were larger in patients (P < .001), and the referred pain area elicited by suboccipital TrPs was greater than the referred pain from other TrPs (P < .001). Referred pain areas from neck TrPs were greater than the pain areas from masticatory muscle TrPs (P < .01). Referred pain areas of masticatory TrPs were not different (P > .703). The local and referred pain elicited from active TrPs in the masticatory and neck-shoulder muscles shared similar pain pattern as spontaneous TMD, which supports the concept of peripheral and central sensitization mechanisms in myofascial TMD.     

Characteristics of referred muscle pain to the head from active trigger points in women with myofascial temporomandibular pain and fibromyalgia syndrome

Our aim was to compare the differences in the prevalence and the anatomical localization of referred pain areas of active trigger points (TrPs) between women with myofascial temporomandibular disorder (TMD) or fibromyalgia (FMS). Twenty women (age 46 ± 8 years) with TMD and 20 (age 48 ± 6 years) with FMS were recruited from specialized clinic. Bilateral temporalis, masseter, sternocleidomastoid, upper trapezius, and suboccipital muscles were examined for TrPs. TrPs were identified by palpation and considered active when the pain reproduced familiar pain symptom experienced by the patient. The referred pain areas were drawn on anatomical maps, digitalized and also measured. A new analysis technique based on a center of gravity (COG) method was used to quantitative estimate of the localization of the TrP referred pain areas. Women with FMS exhibited larger areas of usual pain symptoms than women with myofascial TMD (P < 0.001). The COG coordinates of the usual pain on the frontal and posterior pain maps were located more superior in TMD than in FMS. The number of active TrPs was significantly higher in TMD (mean ± SD 6 ± 1) than in FMS (4 ± 1) (P = 0.002). Women with TMD exhibited more active TrPs in the temporalis and masseter muscles than FMS (P < 0.01). Women with FMS had larger referred pain areas than those with TMD for sternocleidomastoid and suboccipital muscles (P < 0.001). Significant differences within COG coordinates of TrP referred pain areas were found in TMD, the referred pain was more pronounced in the orofacial region, whereas the referred pain in FMS was more pronounced in the cervical spine. This study showed that the referred pain elicited from active TrPs shared similar patterns as usual pain symptoms in women with TMD or FMS, but that distinct differences in TrP prevalence and location of the referred pain areas could be observed. Differences in location of referred pain areas may help clinicians to determine the most relevant TrPs for each pain syndrome in spite of overlaps in pain areas.     

Dry needling for the management of thoracic spine pain

Abstract

Thoracic spine pain is as disabling as neck and low back pain; however, it has not received as much attention as the cervical and lumbar spine in the scientific literature. Among the different structures that can refer pain to the thoracic spine, muscles often play a relevant role. In fact, myofascial trigger points (TrPs) from several neck, shoulder and spinal muscles can induce pain in the region of the thoracic spine. There is a lack of evidence reporting the presence of myofascial TrPs in the thoracic spine, but clinical evidence suggests that TrPs can be a potential source of thoracic spine pain. The current paper discusses the role of myofascial TrPs in the thoracic spine and summarises the proper and safe application of dry needling (DN) for the management of myofascial TrPs in two main spinal muscles involved in thoracic spine pain: the thoracic multifidi and longissimus thoracis. In addition, this paper discusses the application of DN in other tissues such as tendons, ligaments and scars.     

Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients

OBJECTIVES: To compare the efficacies of dry needling of trigger points (TrPs) with and without paraspinal needling in myofascial pain syndrome of elderly patients. DESIGN: Single-blinded, randomized controlled trial. SUBJECTS: Forty (40) subjects, between the ages of 63 and 90 with myofascial pain syndrome of the upper trapezius muscle. INTERVENTIONS: Eighteen (18) subjects were treated with dry needling of all the TrPs only and another 22 with additional paraspinal needling on days 0, 7, and 14. RESULTS: At 4-week follow-up the results were as follows: (1) TrP and paraspinal dry needling resulted in more continuous subjective pain reduction than TrP dry needling only; (2) TrP and paraspinal dry needling resulted in significant improvements on the geriatric depression scale but TrP dry needling only did not; (3) TrP and paraspinal dry needling resulted in improvements of all the cervical range of motions but TrP dry needling only did not in extensional cervical range of motion; and (4) no cases of gross hemorrhage were noted. CONCLUSIONS: TrP and paraspinal dry needling is suggested to be a better method than TrP dry needling only for treating myofascial pain syndrome in elderly patients.     

Manual Treatment for Cervicogenic Headache and Active Trigger Point in the Sternocleidomastoid Muscle: A Pilot Randomized Clinical Trial

Objective

The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).

Methods

Twenty patients, 7 males and 13 females (mean ± SD age, 39 ± 13 years), with a clinical diagnosis of CeH and active TrPs in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received TrP therapy (manual pressure applied to taut bands and passive stretching), and the other group received simulated TrP therapy (after TrP localization no additional pressure was added, and inclusion of longitudinal stroking but no additional stretching). The primary outcome was headache intensity (numeric pain scale) based on the headaches experienced in the preceding week. Secondary outcomes included neck pain intensity, cervical range of motion (CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor performance. Outcomes were captured at baseline and 1 week after the treatment.

Results

Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those receiving the simulation (P < .001). Patients receiving the TrP therapy experienced greater improvements in motor performance of the deep cervical flexors, active CROM, and PPT (all, P < .001) than those receiving the simulation. Between-groups effect sizes were large (all, standardized mean difference, > 0.84).

Conclusion

This study provides preliminary evidence that a trial of this nature is feasible. The preliminary findings show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing headache and neck pain intensity and increasing motor performance of the deep cervical flexors, PPT, and active CROM in individuals with CeH showing active TrPs in this muscle. Studies including greater sample sizes and examining long-term effects are needed.     

A critical overview of the current myofascial pain literature – July 2018

In the current issue of this clinical overview, we are pleased to include several basic research studies ranging from the differentiation of radicular and non-radicular low back pain based on the presence of trigger points (TrPs) to the role of TrPs in patients with osteoarthritis, the diagnostic criteria of TrP, the accurate placement of needles in the piriformis muscle with dry needling (DN), and the reliability of TrP identification, among others. As usual, there are many new DN studies, but also several review papers, and manual TrP research. Contributing authors come from as many as 15 different countries!     

Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia

OBJECTIVE: Referred pain and pain characteristics evoked from the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles was investigated in 20 patients with lateral epicondylalgia (LE) and 20-matched controls. METHODS: Both groups were examined for the presence of myofascial trigger points (TrPs) in a blinded fashion. The quality and location of the evoked referred pain, and the pressure pain threshold (PPT) at the lateral epicondyle on the right upper extremity (symptomatic side in patients, and dominant-side on controls) were recorded. Several lateral elbow pain parameters were also evaluated. RESULTS: Within the patient group, the elicited referred pain by manual exploration of 13 out of 20 (65%) extensor carpi radialis brevis muscles, 12/20 (70%) extensor carpi radialis longus muscles, 10/20 (50%) brachioradialis muscles, and 5/20 (25%) extensor digitorum communis muscles, shares similar pain patterns as their habitual lateral elbow and forearm pain. The mean number of muscles with TrPs for each patient was 2.9 [95% confidence interval (CI) 1,4] of which 2 (95% CI 1,3) were active, and 0.9 (95% CI 0,2) were latent TrPs. Control participants only had latent TrPs (mean: 0.4; 95% CI 0,2). TrP occurrence between the 2 groups was significantly different for active TrPs (P<0.001), but not for latent TrPs (P>0.05). The referred pain pattern was larger in patients than in controls, with pain referral to the lateral epicondyle (proximally) and to the dorso-lateral aspect of the forearm in the patients, and confined to the dorso-lateral aspect of the forearm in the controls. Patients with LE showed a significant (P<0.001) lower PPT (mean: 2.1 kg/cm; 95% CI 0.8, 4 kg/cm) as compared with controls (mean: 4.5 kg/cm; 95% CI 3, 7 kg/cm). Within the patient group, PPT at the lateral epicondyle was negatively correlated with both the total number of TrPs (rs=-0.63; P=0.003) and the number of active TrPs (rs=-0.5; P=0.02): the greater the number of active TrPs, the lower the PPT at the lateral epicondyle. DISCUSSION: Our results suggest that in patients with LE, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual elbow and forearm pain, consistent with active TrPs. Lower PPT and larger referred pain patterns suggest that peripheral and central sensitization exists in LE.