Trigger Point Manual Therapy for the Treatment of Chronic Noncancer Pain in Adults: A Systematic Review and Meta-analysis

Effectiveness of trigger point manual therapy for rotator cuff related shoulder pain: a systematic review and meta-analysis

PURPOSE

To evaluate the effectiveness of trigger point manual therapy (TPMT) in treating rotator cuff related shoulder pain (RCRSP).

METHODS

Randomized controlled trials that compared the effects of TPMT with no or other conservative treatments in patients with RCRSP were included. Primary outcomes were shoulder pain intensity and function. Secondary outcomes were pressure pain threshold (PPT) and number of myofascial trigger points (MTrPs). The Cochrane Risk of Bias 2.0 tool, PEDro scale and GRADE approach were employed.

RESULTS

Ten studies were included in this systematic review and seven in the meta-analysis. Very low to low quality of evidence showed no statistically significant difference between TPMT and other conservative treatments in rest and activity pain reduction in the short term (3 days to 12 weeks), and the difference in shoulder function was statistically significant in favor of TPMT. Furthermore, TPMT was found to be effective in the improvement of PPT and the inactivation of active MTrPs in the short term.

CONCLUSION

TPMT may be equally effective as other passive treatments for the pain reduction in patients with RCRSP in the short term, and slightly more effective for functional improvement. TPMT seems to be effective to treat the active MTrPs in RCRSP.

REGISTRATION NUMBER

CRD42023409101.

Association between myofascial trigger point therapy and conditioned pain modulation

INTRODUCTION

Myofascial trigger point therapy (MTrP) is a widely used therapeutic approach, although the underlying mechanisms remain unclear. Mechanisms discussed include peripheral involvement of muscles as well as central pain modulating processes such as the conditioned pain modulation (CPM). The aim of this study was to investigate whether the analgesic response of MTrP and the analgesic response of CPM correlate in asymptomatic participants in order to identify shared underlying mechanisms of MTrP and CPM.

METHOD

Both, CPM and MTrP protocols consisted of heat-based test stimuli (heat pain thresholds before and after the intervention) and pressure-based (conditioning) stimuli. Asymptomatic participants (n = 94) were randomly assigned to receive either mild, intense or no pressure stimuli (between-group design) to both the fingernail and the MTrP of the infraspinatus muscle (within-group design). Pressure stimuli at both locations (fingernail, MTrP) were applied with a pressure algometer for 120 s and continuously adjusted to maintain a constant pain intensity of mild or intense pain. All thermal stimuli were applied on the lower leg with a thermal stimulator.

RESULTS

A significant correlation was shown between the analgesic effect of CPM and MTrP therapy for mild (r = 0.53, p = 0.002) and intensive stimuli (r = 0.73, p < 0.001). 17.3% of the variance of the MTrP effect were explained by CPM after mild stimulation, and 47.1% after intense stimulation. Pain-related characteristics did not explain the variance within the analgesic response using a regression analysis.

CONCLUSIONS

Between the analgesic responses following MTrP and CPM paradigms, a moderate to strong correlation was observed, suggesting shared underlying mechanisms.

Massage for neck pain

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness of Manual Trigger Point Therapy in Patients with Myofascial Trigger Points in the Orofacial Region-A Systematic Review

The objective was to compile, synthetize, and evaluate the quality of the evidence from randomized controlled trials (RCTs) regarding the effectiveness of manual trigger point therapy in the orofacial area in patients with or without orofacial pain. This project was registered in PROSPERO and follows the PRISMA guidelines. Searches (20 April 2021) were conducted in six databases for RCTs involving adults with active or latent myofascial trigger points (mTrPs) in the orofacial area. The data were extracted by two independent assessors. Four studies were included. According to the GRADE approach, the overall quality/certainty of the evidence was very low due to the high risk of bias of the studies included. Manual trigger point therapy showed no clear advantage over other conservative treatments. However, it was found to be an equally effective and safe therapy for individuals with myofascial trigger points in the orofacial region and better than control groups. This systematic review revealed a limited number of RCTs conducted with patients with mTrPs in the orofacial area and the methodological limitations of those RCTs. Rigorous, well-designed RCTs are still needed in this field.

Lviv State University of Physical Culture named after Ivan Bobersky, Romanchuk O. Comparative features of the immediate impact of manual therapy traction manipulations on the cardiorespiratory system of men and women

Purpose: the aim of this study was to determine the principal differences of changes in the cardiorespiratory system activity under the influence of traction manipulations in the thoracic spine of men and women. Material & Methods: the 26 adults were involved in the study, including 18 women aged 39.6±12.1 years and 8 men aged 36.3±8.3 years. All patients were diagnosed with osteochondrosis of the thoracic spine, which was confirmed by radiographic examination. The study of the cardiorespiratory system was conducted in the first procedure of SMT before and after the use of traction manipulations directly in the physician office. The integrated method of studying the cardiorespiratory system defined as spiroarteriocardiorhythmography (SACR) was used. It simultaneously records the heart rate, rhythms of systolic and diastolic pressure at each heartbeat and respiratory rhythms, which provides significant time savings to determine the functional state of the heart, vessels and respiration, as well as to identify the important parameters of their interaction. Results: characterizing the changes in the cardiorespiratory system as a whole under the influence of traction manipulations on the thoracic spine, it should be noted that men and women had some significant unidirectional changes in HR (min–1), CO (dm3), CI (dm3/m2), IH (n. u.), which are determined primarily by the decrease in HR (min–1) under the influence of traction manipulations. As to the men, the significant effects were more related to the impact on the contractile function of the heart, which was confirmed by the improvement of the electrical systole of the ventricles (QTC, s), the increase in the activity of the effects of the parasympathetic branch of the ANS on the cardiac rhythm (HF, ms2) and a certain increase in the stroke index within the normative values (SI, cm3/m2), then to the women the significant effects were more related to the influence on the breathing pattern and vascular tone. Thus, characteristic and positive effects in women can be considered a decrease in the variability of diastolic blood pressure in the very-low-frequency range (VLFDBP, mmHg2), which is combined with a decrease in the total power of diastolic pressure variability (TPDBP, mmHg2) and an increase in the total peripheral vascular resistance (GPVR, dyn/s/cm−5). Conclusions: summarizing the results of the impact of traction manipulations in the thoracic spine on the cardiorespiratory system of men and women, it can be stated that their effect is different and has features associated with the use of different mechanisms. For men, the predominant effect is on the heart contractile function, and for women it is on the respiratory system and autonomous regulation of vascular tone.

Lviv State University of Physical Culture named after Ivan Bobersky, Romanchuk O. Comparative features of the immediate impact of manual therapy traction manipulations on the cardiorespiratory system of men and women

Purpose: the aim of this study was to determine the principal differences of changes in the cardiorespiratory system activity under the influence of traction manipulations in the thoracic spine of men and women. Material & Methods: the 26 adults were involved in the study, including 18 women aged 39.6±12.1 years and 8 men aged 36.3±8.3 years. All patients were diagnosed with osteochondrosis of the thoracic spine, which was confirmed by radiographic examination. The study of the cardiorespiratory system was conducted in the first procedure of SMT before and after the use of traction manipulations directly in the physician office. The integrated method of studying the cardiorespiratory system defined as spiroarteriocardiorhythmography (SACR) was used. It simultaneously records the heart rate, rhythms of systolic and diastolic pressure at each heartbeat and respiratory rhythms, which provides significant time savings to determine the functional state of the heart, vessels and respiration, as well as to identify the important parameters of their interaction. Results: characterizing the changes in the cardiorespiratory system as a whole under the influence of traction manipulations on the thoracic spine, it should be noted that men and women had some significant unidirectional changes in HR (min–1), CO (dm3), CI (dm3/m2), IH (n. u.), which are determined primarily by the decrease in HR (min–1) under the influence of traction manipulations. As to the men, the significant effects were more related to the impact on the contractile function of the heart, which was confirmed by the improvement of the electrical systole of the ventricles (QTC, s), the increase in the activity of the effects of the parasympathetic branch of the ANS on the cardiac rhythm (HF, ms2) and a certain increase in the stroke index within the normative values (SI, cm3/m2), then to the women the significant effects were more related to the influence on the breathing pattern and vascular tone. Thus, characteristic and positive effects in women can be considered a decrease in the variability of diastolic blood pressure in the very-low-frequency range (VLFDBP, mmHg2), which is combined with a decrease in the total power of diastolic pressure variability (TPDBP, mmHg2) and an increase in the total peripheral vascular resistance (GPVR, dyn/s/cm−5). Conclusions: summarizing the results of the impact of traction manipulations in the thoracic spine on the cardiorespiratory system of men and women, it can be stated that their effect is different and has features associated with the use of different mechanisms. For men, the predominant effect is on the heart contractile function, and for women it is on the respiratory system and autonomous regulation of vascular tone.

Effects of Radial Extracorporeal Shock Wave Therapy in Reducing Pain in Patients with Temporomandibular Disorders: A Pilot Randomized Controlled Trial

Temporomandibular disorders (TMD) are primarily characterized by pain as well as issues concerning the proper functioning of individual elements of the stomatognathic system. The aim of the study was to assess the safety and efficacy of physical exercise, with or without radial Extracorporeal Shock Wave Therapy (rESWT), in patients with TMD. Eligible patients were adults (≥18 years) with diagnosed myofascial pain with or without mouth opening limitation (Group Ia, Ib) based on the Diagnostic Criteria for TMD (DC/TMD). Enrolled patients (n = 15) were randomly assigned 1:1 to receive physical exercise combined with rESWT (n = 8) or sham rESWT (n = 7) for four weeks. The primary endpoint was the pain intensity measured by a visual analogue scale (VAS). The secondary endpoints were muscle activity and function assessed through the surface electromyography evaluation of the anterior temporalis and the masseter muscles. The rESWT group (mean age: 28.50 ± 8.85 years) showed a statistically significant pain reduction (VAS Right side: ΔT0-T1 MD = −3.00; p = 0.023, Left side: ΔT0-T1, MD = 3.57, p = 0.021), whereas patients in the sham WBV group (mean age: 30.71 ± 8.98 years), did not reach statistical significance (VAS: Right side: ΔT0-T1 MD = 1.00, p = 0.155; Left side: ΔT0-T1 MD = 1.25 SE = 0.25, p = 0.094). Concurrently, muscle activity and performance significantly improved in the active rESWT group, with an improvement in the percentage of the overlapping coefficient (POC) compared to the control group. No dropouts and no side effects were recorded. Taken together, the findings of this pilot RCT suggested that rESWT combined with physical therapy could be effective in relieving pain and improving function in muscle-related TMD patients.

Peripheral, Central, and Cross Sensitization in Endometriosis-Associated Pain and Comorbid Pain Syndromes

Endometriosis-associated pain and the mechanisms responsible for its initiation and persistence are complex and difficult to treat. Endometriosis-associated pain is experienced as dysmenorrhea, cyclical pain related to organ function including dysuria, dyschezia and dyspareunia, and persistent pelvic pain. Pain symptomatology correlates poorly with the extent of macroscopic disease. In addition to the local effects of disease, endometriosis-associated pain develops as a product of peripheral sensitization, central sensitization and cross sensitization. Endometriosis-associated pain is further contributed to by comorbid pain conditions, such as bladder pain syndrome, irritable bowel syndrome, abdomino-pelvic myalgia and vulvodynia. This article will review endometriosis-associated pain, its mechanisms, and its comorbid pain syndromes with a view to aiding the clinician in navigating the literature and terminology of pain and pain syndromes. Limitations of our current understanding of endometriosis-associated pain will be acknowledged. Where possible, commonalities in pain mechanisms between endometriosis-associated pain and comorbid pain syndromes will be highlighted.

How Might We Screen for Psychological Factors in People With Pelvic Pain? An e-Delphi Study

OBJECTIVE

Persistent pelvic pain (PPP) is a complex condition often influenced by psychological factors that can alter treatment outcomes. These factors are potentially modifiable; however, currently there is no instrument to screen for them. The purpose of this study was to determine: (1) which psychological factors should be screened in individuals with PPP, and (2) the most appropriate statements to represent these psychological factors.

METHODS

The study used a focus group design followed by an electronic-Delphi (e-Delphi) process. A focus group consisting of 8 experts was conducted to determine the relevant psychological factors to screen. These results informed round 1 of the e-Delphi process, consisting of a panel of 14 pain/pelvic pain experts. The e-Delphi process consisted of 3 rounds of online surveys and 2 teleconference discussions to establish consensus on the most appropriate statement to screen for each of the psychological factors.

RESULTS

The focus group identified 13 relevant psychological factors. During the e-Delphi process, relevant screening statements were assessed using a 100-point allocation system. Experts could reword and suggest new statements. Statements were assessed for consensus and stability and were eliminated as the rounds progressed if they met the exclusion criteria. At the termination of round 3, there were 15 statements remaining.

CONCLUSION

The final list of 15 statements will assist clinicians in screening for psychological factors and is an important step for clinicians in providing psychologically informed care to people with PPP. Future research should determine the psychometric properties of the statements to determine their clinical utility as a questionnaire.

IMPACT

This study has refined a list of statements to help screen for psychological factors in individuals with PPP. Developed robustly using an e-Delphi method, this list is an important first step forward for clinicians to provide psychologically informed care to these individuals.

The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients

INTRODUCTION

The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination.

OBJECTIVES

The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function.

METHODS

We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions.

RESULTS

Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed.

CONCLUSION

Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.

Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial

INTRODUCTION AND HYPOTHESIS

Dyspareunia, the symptom of painful sexual intercourse, is a common sexual dysfunction in reproductive-aged women. Because of its multifactorial etiology, a multidisciplinary approach may be required to treat it. Musculoskeletal factors play an important role; thus, rehabilitating the pelvic floor and modifying the tone of the pelvic floor muscles (PFMs) may be an effective way to treat this dysfunction. The aim of this randomized controlled clinical study was to evaluate the effects of pelvic floor rehabilitation techniques on dyspareunia.

METHODS

Of 84 women, assessed for eligibility, 64 women with dyspareunia were randomized into two groups: the experimental group (n = 32) received electrotherapy, manual therapy, and PFM exercises and the control group (n = 32) had no treatment while on the waiting list. Evaluations of PFM strength and endurance, sexual function, and pain were made directly before and after 3 months of treatment and at the 3-month follow-up.

RESULTS

Between-group changes showed significant improvement in the experimental group in comparison with control group. Mean difference in the PFM strength (according to the 0-5 Oxford scale) between groups was 2.01 and the mean difference of endurance was 6.26 s. Also, the mean difference in the Female Sexual Function Index score (the score ranges from 2 to 95) was 51.05, and the mean difference in the VAS score was 7.32. All of the changes were statistically significant (p < 0.05).

CONCLUSIONS

According to the results, pelvic floor rehabilitation is an important part of a multidisciplinary treatment approach to dyspareunia.