Randomized controlled study of the antinociceptive effect of ultrasound on trigger point sensitivity: novel applications in myofascial therapy?

Effects of transcutaneous radiofrequency diathermy versus ultrasound on latent myofascial trigger points in the upper trapezius: A randomized crossover trial

BACKGROUND

Currently, the use of radiofrequency diathermy for the treatment of neck pain is booming.

OBJECTIVE

This study aimed to evaluate the clinical efficacy of Digital Capacitive Diathermy (DCD®) on stiffness, pain, cervical range of motion, and cervical disability and to compare it with ultrasound (US) in patients with latent myofascial trigger point (MTrP) in the upper trapezius.

METHODS

Nineteen participants with latent MTrPs in the upper trapezius were included in the assessor-masked, randomized, clinical crossover trial. Subjects were exposed to both interventions: US and DCD® and treatment effectiveness was measured by myotonometric variables, pressure pain threshold (PPT), visual analog scale (VAS), cervical side-bending flexion ranges, and the neck disability index scale (NDI).

RESULTS

There were no significant differences between US and DCD® interventions regarding changes in outcome measures. The US group achieved a statistically significant difference of 2.16 to 1.13 points (p= 0.005; r= 0.646) for the VAS. The DCD® intervention showed a statistically significant improvement of 1.11 points for the NDI at 1-week following intervention (95% CI 0.14-2.07; p= 0.27; d= 0.217).

CONCLUSION

Our findings suggest that DCD® and US can both be considered effective modalities for the treatment of latent MTrPs, having a longer duration of action with DCD® therapy.

Short-term effects of low-level laser versus ultrasound therapy on children's neck posture after long-term use of electronic devices

The purpose of the study was to compare the effect of low-level laser therapy (LLLT), ultrasound therapy (US), and strengthening and stretching exercise in children diagnosed with cervical straightening caused by long-term use of electronic devices. A total of 60 patients from 12 to 18 years of both gender diagnosed with straight neck syndrome which is losing the normal C shape of cervical vertebrae. Patients were randomized into three groups. In group A, patients received LLLT plus exercise, while in group B, they received US plus exercise, and group C received exercise. In group A and B, Cobb angle and VAS showed a significant improvement (more significant in group A) with P < 0.001, while in group C P = 0.006. LLLT, US, and exercise improved the cervical straight curve, and reduced pain with maximum effect was done by LLLT.

The immediate effects of deep transverse friction massage, high- power pain threshold ultrasound and whole body vibration on active myofascial trigger points

BACKGROUND

The most important clinical problem in myofascial pain syndrome (MPS) is trigger points (TrPs). The aim of the present study was to investigate the comparison of immediate effect of deep transverse friction massage (DTFM), high-power pain threshold ultrasound (HPPTUS), and whole body vibration (WBV) on treatment of active myofascial trigger points (MTrPs).

MATERIALS AND METHODS

sixty six men with active TrPs of upper trapezius muscle were randomly divided into three equal groups: DTFM, HPPT US, and WBV. Pain intensity based on the Visual Analogue Scale (VAS), pressure pain threshold (PPT) and active contralateral lateral flexion range of motion (CLF ROM) of the neck were evaluated before and immediately after the interventions.

RESULTS

The VAS, PPT and the active CLF ROM were substantially improved after intervention in all groups (P < 0.01). When the three groups were compared regarding VAS, participants in the WBV group reported significantly more reduction in pain (P < 0.01). On comparing the interventions, there were no significant differences in PPT values (P > 0.05). The CLF ROM value in HPPTUS and WBV groups have significant increase in comparison to the DTFM group.

CONCLUSION

All three interventions can improve neck pain, PPT and ROM in participants with active TrPs in upper trapezius muscle, but due to the fact that the DTFM has more pressure on therapist fingers, and the HPPTUS technique requires proper interaction with the participants, WBV can be used as one of the effective intervention on active MTrPs of upper trapezius.

CLINICAL TRIAL REGISTRATION NUMBER

IRCT20200518047498N1.

Criteria Used for the Diagnosis of Myofascial Trigger Points in Clinical Trials on Physical Therapy: Updated Systematic Review

OBJECTIVE

The objective of this study was to conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019.

METHODS

MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points," "trigger point," "myofascial trigger point," "myofascial trigger points," "myofascial pain," and "myofascial pain syndrome." The MeSH keywords were combined by using Boolean operators "OR"/"AND." All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least 1 active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines.

RESULTS

Of 478 possibly relevant publications, 198 met the inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the 6 criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness," "referred pain," and "local twitch response" (n=28 studies, 22%).

CONCLUSIONS

A number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain, and local twitch response were the 3 most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.

Dry Needling and Photobiomodulation Decreases Myofascial Pain in Trapezius of Women: Randomized Blind Clinical Trial

OBJECTIVE

The purpose of this study was to assess whether dry needling (DN) added to photobiomodulation (PBM) has effects on the treatment of active myofascial trigger points in the upper trapezius.

METHODS

This study was a randomized clinical trial, with 43 participants divided into 3 groups: DN and PBM (DNP), DN, and DN outside of the trigger point (DNout). Each group received 1 session of DN followed by PBM therapy with the machine turned on or off. Pain, disability, pain pressure threshold, and muscle activity were assessed before the intervention and afterward at intervals of 10 minutes, 30 minutes, 1 week, and 1 month.

RESULTS

Pain decreased after intervention in the DNP and DNout groups, with mean differences, respectively, of 1.33 cm (95% confidence interval [CI], 0.019-2.647) and 2.78 cm (95% CI, 1.170-2.973). Scores for the disability questionnaire decreased in all groups after intervention (F = 36.53, P < .0001) after the intervention, with mean differences of 3.8 points in the DNP group (95% CI, 1.082-5.518), 3.57 in the DN group (95% CI, 0.994-6.149), and 5.43 in the DNout group (95% CI, 3.101-7.756). There were no significant differences between or within groups in pain pressure threshold (F = 2.14, P = .139), with mean differences after 30 minutes of 0.139 kgf for the DNP group (95% CI, -0.343 to 0.622), 0.273 for the DN group (95% CI, -0.661 to 1.209), and -0.07 for the DNout group (95% CI, -0.465 to 0.324). Muscle activation for the DN group increased 8.49% after the intervention, where for the DNP group it decreased 11.5%, with a significant difference between groups.

CONCLUSION

DN added to PBM presented similar results compared to DNout and DN. In this sample, the effects of the application of DN outside of the trigger point had better effects on pain and disability scores than DN applied directly on the trigger point.

Effects of Therapeutic Ultrasound Applied to the Lumbar Region on Renal Function: A Randomized Controlled Prospective Trial

OBJECTIVES

Therapeutic ultrasound (TUS) is one of the most commonly used modalities in low back pain treatment. The objective of this study was to determine whether TUS applied to the low back region in patients with chronic low back pain had any effect on renal function.

METHODS

Forty patients with chronic low back pain were randomized to 2 groups by a block randomization method. Thirty-seven patients completed the final evaluation. All patients were treated for 5 sessions per week for 3 weeks with the same physiotherapy modalities (superficial heating and transcutaneous electrical nerve stimulation) and exercise therapy; in addition to these treatments, the second group was treated with TUS for 10 minutes (frequency, 1 MHz; intensity, 1.5 W/cm² ; and effective irradiation area of the transducer head, 5 cm² ). The serum creatinine, serum cystatin C, 24-hour urine creatinine, creatinine clearance, 24-hour urine microalbumin and microprotein, urine volume, and glomerular filtration rate were measured. The patients were evaluated at baseline (day 0) and the end of the treatment (day 21).

RESULTS

The serum cystatin C levels were increased in both groups, but this increase was not significant (P > .05). There was no difference between the groups in the percent change in all outcome measures (P > .05).

CONCLUSIONS

This showed that TUS applied to the low back region does not affect renal function.

Immediate Effects of Simultaneous Application of Transcutaneous Electrical Nerve Stimulation and Ultrasound Phonophoresis on Active Myofascial Trigger Points: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to investigate the efficacy of phonophoresis with combined therapy on active myofascial trigger points.

PARTICIPANTS

One hundred participants with acute mechanical neck pain and at least one active myofascial trigger point in the upper trapezius were randomly assigned into four equal groups.

INTERVENTION

Groups consisted of diclofenac phonophoresis with combined therapy, diclofenac phonophoresis, ultrasound (US) with coupling gel, and sham US and applied for 10 mins over myofascial trigger points.

MEASUREMENTS

Measurements included pressure pain threshold and active cervical lateral flexion.

RESULTS

There were statistically significant improvements in postintervention pressure pain threshold and range of motion values in treatment groups (P < 0.0001). As for the sham US, no significant difference was found between the preintervention and postintervention values (P > 0.05). Bonferroni correction test revealed that there was a significant difference between all the four groups in pressure pain threshold values (P < 0.0001); however, it was nonsignificant (P > 0.05) for range of motion.

CONCLUSIONS

Diclofenac phonophoresis with combined therapy, phonophoresis, and US were all effective in increasing pressure pain threshold values and range of motion. In addition, phonophoresis with combined therapy was shown to be superior over phonophoresis, and phonophoresis was superior over US in terms of reducing pain sensitivity. However, none of the treatment groups were found to be superior over the other in increasing range of motion.

Effectiveness of Ultrasound Therapy on Myofascial Pain Syndrome of the Upper Trapezius: Randomized, Single-Blind, Placebo-Controlled Study

Objectives

This study aims to evaluate the effectiveness of conventional ultrasound (US) therapy in the treatment of myofascial pain syndrome.

Patients and methods

Fifty-four patients (23 males, 31 females; mean age 29.8±5.2 years; range, 22 to 46 years) with myofascial pain syndrome were included in this prospective, randomized, single-blind, placebo-controlled study. Patients were randomized into two groups by computerized method as US group (n=27) and placebo group (n=27). Ten sessions of US were applied to the US group and 10 sessions of placebo US were applied to the placebo group. Treatment effectiveness was evaluated with Visual Analog Scale (VAS), algometer, palpable muscle spasm degree (PMSD), and Beck Depression Inventory (BDI) before and after treatment.

Results

Pain values after treatment in both groups decreased significantly (p<0.05) compared to before treatment. In the US group, the decrease in VAS and palpable muscle degree before and after treatment was significantly higher (p<0.05) than in the placebo group. In the US group, the decrease in PMSD after treatment was significantly higher than the placebo group (p<0.05). The amount of decrease in BDI score before and after treatment in the US group did not differ significantly from the placebo group (p>0.05).

Conclusion

Our findings show that conventional US therapy is effective in the treatment of myofascial pain syndrome.

Effectiveness of ultrasound therapy for myofascial pain syndrome: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to assess the therapeutic effect of ultrasound (US) on myofascial pain syndrome (MPS).

DATE SOURCES

PubMed, Embase, and Cochrane Library were searched to find relevant studies from January 1966 to May 2016 using keywords. Four investigators performed the data extraction.

STUDY SELECTION

Randomized controlled trials (RCTs) investigating the outcomes of pain and physical function between MPS patients receiving and not receiving US were selected by two researchers independently.

DATA EXTRACTION

Data were extracted from the RCTs. Risk of bias and study quality were evaluated following the recommendations of Cochrane Collaboration. Standardized mean difference (SMD) and 95% confidence interval (CI) were calculated.

DATA SYNTHESIS

A total of 10 studies involving 428 MPS patients were included. US therapy significantly reduced pain intensity (SMD [CI]=-1.41 [-2.15, -0.67], P=0.0002) and increased pain threshold (SMD [CI]=1.08 [0.55, 1.60], P<0.0001), but had no significant effect on cervical range of motion (ROM) of lateral flexion (SMD [CI]=0.40 [-0.19, 0.99], P=0.19), rotation (SMD [CI]=0.10 [-0.33, 0.52], P=0.66), or extension or flexion (SMD [CI]=0.16 [-0.35, 0.68], P=0.53). Heterogeneity between studies was mainly attributed to differences in the follow-up time, parameter of US, course of treatment, and the control group. The overall risk of bias from the included studies was high, and the evidence proving these effect calculations were assessed as low quality.

CONCLUSION

Owing to the high risk of bias and the across-trial heterogeneity of the studies, the current evidence is not clear enough to support US as an effective method to treat MPS. Clinical trials with methodological rigorousness and adequate power are needed to confirm it in the future.

Myofascial Pain Syndrome in the Elderly and Self-Exercise: A Single-Blind, Randomized, Controlled Trial

OBJECTIVE

This study aimed to demonstrate the effect of self-exercise with a therapeutic inflatable ball (SEIB) in elderly patients with myofascial pain syndrome.

DESIGN

Single-blind, randomized, controlled noninferiority trial.

SETTING

University campus.

PARTICIPANTS

Forty elderly patients with myofascial pain syndrome completed the study. They were randomly allocated to SEIB (n = 22; mean age, 70.23 ± 6.11 years) or ultrasound (US) therapy (n = 18; mean age, 67.99 ± 5.64 years).

INTERVENTION

SEIB and US therapy (twice weekly for 4 consecutive weeks).

OUTCOME MEASURES

Visual analog scale (VAS), pressure pain threshold (PPT), and cervical lateral flexion (CLF) were measured at baseline and at 1, 2, 3, and 4 weeks.

RESULTS

The noninferiority test indicated that SEIB was not inferior to US for VAS, PPT, and CLF. Between-group comparisons showed no significant differences in the VAS (F = 2.579; p = 0.117), the PPT (F = 0.245; p = 0.624), and the CLF (F = 2.072; p = 0.159). In within-group comparisons, both groups presented significant differences in VAS (SEIB after 1 week and US after 1 week), PPT (SEIB after 3 weeks and US after 4 weeks), and CLF (SEIB after 4 weeks and US after 4 weeks) compared with baseline values.

CONCLUSIONS

SEIB for 4 weeks has an effect similar to that of US for desensitizing myofascial pain and increasing joint flexibility. High accessibility and low cost would make SEIB a practical self-treatment method in elderly patients with myofascial pain syndrome.

Effect of Therapeutic Sequence of Hot Pack and Ultrasound on Physiological Response Over Trigger Point of Upper Trapezius

Background:

Musculoskeletal pain is a common problem among athletes. Apart from sport injuries, the myofascial pain syndrome is another important problem that affects performance of the athlete.

Objectives:

The aim of this study was to evaluate the effects of therapeutic sequences of the hot pack in combination with ultrasound on the physiological responses over the latent myofascial trigger point (LMTrP) of upper trapezius muscle.

Materials and Methods:

Thirty subjects with a latent myofascial trigger point (LMTrP) in both sides of the upper trapezius muscle participated in the study (age 27.33 ± 4.34 years, weight 58.11 ± 7.47 kg, height 161.50 ± 5.82 cm, pressure pain threshold 2.28 ± 0.24 kg/cm², pain intensity 7.17 ± 2.25 VAS). All subjects received both treatments (hot pack followed by ultrasound: HP + US; and ultrasound followed by hot pack: US + HP) by randomization with a 24 to 48-hour interval between sessions. Outcome measures, including the tissue blood flow (TBF), pressure pain threshold (PPT), supra-thermal threshold (STT) and visual analog scale (VAS) were evaluated at baseline, immediately, after 30 minutes and after 60 minutes.

Results:

The TBF and PPT significantly increased from baseline in both treatment conditions (i.e. HP + US and US + HP), while the HP + US condition showed a trend toward significant difference in VAS and STT in 45°C.

Conclusions:

The application of HP and US treatment induces physiological responses (especially, TBF and PPT) on the LMTrP. This finding provides the direction toward the management of MTrPs condition.

Botulinum toxin for myofascial pain syndromes in adults

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 4, 2012. Myofascial pain syndrome (MPS) is a regional muscular pain syndrome characterised by the presence of trigger points, which are painful points in one or more muscles. The pain can be felt at the site where the trigger point is located or it can be felt away from that place when the muscle is pressed (referred pain). Botulinum toxin is a protein produced by the bacterium Clostridium botulinum and is a potent neurotoxin that eventually inhibits muscle contractions. It is capable of selectively weakening painful muscles and interrupting the pain cycle.

OBJECTIVES

To assess the effectiveness and safety of botulinum toxin A (BTXA) in the treatment of myofascial pain syndrome (MPS), excluding MPS in neck and head muscles.

SEARCH METHODS

This is an updated version of the original Cochrane review published in Issue 4, 2012. The search strategy for the update was the same as in the original review and we searched CENTRAL in The Cochrane Library (2013, Issue 11 of 12), MEDLINE (Ovid) (2012 to 29 November 2013) and EMBASE (Ovid) (2012 to 27 November 2013). The search strategy was composed of terms for myofascial pain and botulinum toxin. For the original review, we also searched the Cochrane Pain, Palliative and Supportive Care (PaPaS) Review Group Specialised Register until December 2011, PubMed (from 1966 to 2011) and LILACS (from 1982 to 2011). There was no language restriction.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving botulinum toxin for treating participants with MPS. We excluded studies with MPS of the neck and head from this review as they have already been assessed in existing systematic reviews. We considered a diagnosis of MPS to be based on the identification of trigger points in the taut band through palpation of sensitive nodules, local twitch response and specific patterns of referred pain associated with each trigger point.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened identified studies, extracted data, assessed trial quality and analysed results using the Cochrane PaPaS Review Group criteria.

MAIN RESULTS

Four studies with a total of 233 participants, comparing BTXA with placebo, met the inclusion criteria. In one study with 145 participants, significant improvement rates of pain intensity scores and duration of daily pain were demonstrated when comparing BTXA with placebo. The three other studies showed that there was no statistically significant difference between BTXA and placebo in pain intensity.

AUTHORS' CONCLUSIONS

Since the first publication of this review, no new studies were found. There is inconclusive evidence to support the use of botulinum toxin in the treatment of MPS based on data from four studies with a total of 233 participants, which we considered were of sufficient quality to be included in this review. Meta-analyses were not possible due to the heterogeneity between studies. We suggest that in future studies the same methodology to assess pain, a standardised dose of treatment, follow-up of at least four months (to observe the maximum and minimum curve of the drug effect) and appropriate data presentation should be used. More high-quality RCTs of botulinum toxin for treating MPS need to be conducted before firm conclusions on its effectiveness and safety can be drawn.

Myofascial pain syndrome treatments

Myofascial pain syndrome (MPS) is a regional pain disorder caused by taut bands of muscle fibers in skeletal muscles called myofascial trigger points. MPS is a common disorder, often diagnosed and treated by physiatrists. Treatment strategies for MPS include exercises, patient education, and trigger point injection. Pharmacologic interventions are also common, and a variety of analgesics, antiinflammatories, antidepressants, and other medications are used in clinical practice. This review explores the various treatment options for MPS, including those therapies that target myofascial trigger points and common secondary symptoms.

Clinical implication of latent myofascial trigger point

Myofascial trigger points (MTrPs) are hyperirritable points located within a taut band of skeletal muscle or fascia, which cause referred pain, local tenderness and autonomic changes when compressed. There are fundamental differences between the effects produced by the two basic types of MTrPs (active and latent). Active trigger points (ATrPs) usually produce referred pain and tenderness. In contrast, latent trigger points (LTrPs) are foci of hyperirritability in a taut band of muscle, which are clinically associated with a local twitch response, tenderness and/or referred pain upon manual examination. LTrPs may be found in many pain-free skeletal muscles and may be "activated" and converted to ATrPs by continuous detrimental stimuli. ATrPs can be inactivated by different treatment strategies; however, they never fully disappear but rather convert to the latent form. Therefore, the diagnosis and treatment of LTrPs is important. This review highlights the clinical implication of LTrPs.

Comparison of dry needling and physiotherapy in treatment of myofascial pain syndrome

To compare the effects of dry needling and physiotherapy in treatment of myofascial pain syndrome, a randomized controlled trial was performed on 28 patients with myofascial pain syndrome (MPS) of upper trapezius muscle in the Physical Medicine and Rehabilitation Center of Shohadaye Tajrish Hospital from April 2009 to April 2010. After matching the age, sex, duration of symptoms, pain severity, and quality of life measures, subjects were randomly assigned into two subgroups of case (dry needling) and control (physiotherapy). One week and 1 month after receiving standard therapeutic modalities, outcomes and intragroup and intergroup changes in pain severity, pressure pain of trigger point (TP), and quality of life measures were evaluated and compared. After 1 month, both the physiotherapy and dry needling groups had decreased resting, night, and activity pain levels (p<0.05). Pressure pain threshold of TP and some scores of quality of life (SF-36) were improved (p<0.05). Overall results were similar in both groups. It seems that both physiotherapy modalities and dry needling have equal effect on myofascial pain of the upper trapezius muscle.

A comparison of the effectiveness of low-, moderate- and high-dose ultrasound therapy applied in the treatment of myofascial pain syndrome

OBJECTIVE

This study aimed to compare and evaluate the effects of ultrasound (US) treatment applied at low-, medium- and high-power-pain threshold (HPPT) doses to trigger points in the treatment of myofascial pain syndrome (MPS).

METHODS

The study comprised 61 (40 female and 21 male) patients diagnosed with MPS, aged between 18 and 60 years. The patients were randomly allocated to three groups for the US application at different dosages. Group I patients received treatment of medium-dose US (1.5 Watt/cm(2)), Group II received HPPT US, and Group III received low-dose US (0.5 W/cm(2)). The patients were evaluated pre-treatment and 3 weeks after treatment in respect of visual analogue scale (VAS) scores, number of trigger points (NTP), pressure pain threshold (PPT), Range of Tragus-Acromioclavicular joint (RT-AJ) and neck pain disability scores (NPDS).

RESULTS

A significant improvement was determined after treatment in all scores except PPT in Group I, in all scores in Group II, and only in the VAS score in Group III. When the groups were compared post-treatment in respect of improvement in NTP, VAS, RT-AJ and NPDS scores, Group II showed significant superiority over Group I, and Group I was determined to have significant superiority over Group III in respect of VAS, RT-AJ and NPDS scores (p < 0.05).

CONCLUSIONS

In the treatment of MPS, US therapy at HPPT dose can be considered as an alternative therapy method, which is more economical and more effective than low-dose and conventional US therapy.

Myofascial low back pain

Low back pain is a common condition that is encountered by both primary care physicians as well as various specialists, which include: orthopedic surgeons, physical medicine and rehabilitation specialists, neurologists, rheumatologists, and pain management specialists. Associated muscular pain is very common and often a reactive response from nociception from other structures. Myofascial pain may arise, which is characterized by the presence of myofascial trigger points (MTrPs) that are located in fascia, tendons, and/or muscle. This article reviews the current evidence regarding the pathophysiology, assessment, and recommended treatment options for myofascial low back pain.

Botulinum toxin for treating muscular temporomandibular disorders: a systematic review

OBJECTIVE: This study, through a systematic literature review, aims to analyze the effectiveness of Botulinum Toxin as a treatment for masticatory myofascial pain and muscles temporomandibular disorders (TMD). METHODS: Survey in research bases: MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs and BBO, between the years of 1966 and April 2011, with focus in randomized or quasi-randomized controlled clinical trials, blind or double-blind. RESULTS: After applying the inclusion criteria, 4 articles comprised the final sample: 3 were double-blind randomized controlled clinical trials and 1 was single-blind randomized controlled clinical trial. CONCLUSIONS: According to the literature, there is lack of evidence about the real effectiveness of botulinum toxin in the treatment of masticatory myofascial pain and muscular TMD. Thus, further randomized controlled clinical trials, with representative samples and longer follow-up time, to assess the real effectiveness of the technique are needed.

Botulinum toxin for myofascial pain syndromes in adults

BACKGROUND

Myofascial pain syndrome (MPS) is a regional muscular pain syndrome characterised by the presence of trigger points, which are painful points in one or more muscles. The pain can be felt at the site where the trigger point is located or it can be felt away from that place when the muscle is pressed (referred pain). Botulinum toxin is a protein produced by the bacterium Clostridium botulinum and is a potent neurotoxin that eventually inhibits muscle contractions. It is capable of selectively weakening painful muscles and interrupting the pain cycle.

OBJECTIVES

To assess the effectiveness and safety of botulinum toxin in treating MPS, excluding MPS in neck and head muscles.

SEARCH METHODS

The search strategy was composed of terms for myofascial pain and botulinum toxin. We searched the Cochrane Pain, Palliative and Supportive Care (PaPaS) Review Group's Specialised Register until December 2011, CENTRAL (Cochrane Database of Systematic Reviews 2011, Issue 4), PUBMED (from 1966 to 2011), EMBASE (from 1980 to 2011) and LILACS (from 1982 to 2011). There was no language restriction.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving botulinum toxin for treating participants with MPS. We excluded studies with MPS of the neck and head from this review, as they have already been assessed in existing systematic reviews. We considered a diagnosis of MPS to be based on the identification of trigger points in the taut band through palpation of sensitive nodules, local twitch response and specific patterns of referred pain associated with each trigger point.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened identified studies, extracted data, assessed trial quality and analysed results using the Cochrane PaPaS Review Group criteria.

MAIN RESULTS

Four studies with a total of 233 participants, comparing botulinum toxin A (BTXA) with placebo, met the inclusion criteria. In one study with 145 participants, a significant improvement rate of pain intensity scores, as shown by the mean difference (MD) of -0.23 (95% confidence interval (CI) -0.26 to -0.20; P value < 0.00001) and duration of daily pain (MD -1.11; 95% CI -1.37 to -0.85; P value < 0.00001), was demonstrated when comparing BTXA with placebo. The three other studies showed that there was no statistically significant difference between BTXA and placebo in pain intensity.

AUTHORS' CONCLUSIONS

There is inconclusive evidence to support the use of botulinum toxin in the treatment of MPS based on data from four studies with a total of 233 participants, which we considered adequate to be included in this review. Meta-analyses were not possible due to the heterogeneity between studies. We suggest that in future studies the same methodology to assess pain, a standardised dose of treatment, follow-up of at least four months (to observe the maximum/minimum curve of the drug effect) and appropriate data presentation should be used. More high-quality RCTs of botulinum toxin for treating MPS need to be conducted before firm conclusions on its effectiveness and safety can be drawn.

Myofascial pain syndromes and their evaluation

This article reviews the available published knowledge about the diagnosis, pathophysiology and treatment of myofascial pain syndromes from trigger points. Furthermore, epidemiologic data and clinical characteristics of these syndromes are described, including a detailed account of sensory changes that occur at both painful and nonpainful sites and their utility for diagnosis and differential diagnosis; the identification/diagnostic criteria available so far are critically reviewed. The key role played by myofascial trigger points as activating factors of pain symptoms in other algogenic conditions--headache, fibromyalgia and visceral disease--is also addressed. Current hypotheses on the pathophysiology of myofascial pain syndromes are presented, including mechanisms of formation and persistence of primary and secondary trigger points as well as mechanisms beyond referred pain and hyperalgesia from trigger points. Conventional and most recent therapeutic options for these syndromes are described, and their validity is discussed on the basis of results from clinical controlled studies.

The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial

Objective: To investigate the effect of forward head posture correction on pain and nerve root function in cases of cervical spondylotic radiculopathy.

Design: A randomized controlled study with six months follow-up.

Setting: University research laboratory.

Subjects: Ninety-six patients with unilateral lower cervical spondylotic radiculopathy (C5–C6 and C6–C7) and craniovertebral angle measured less than or equal to 50° were randomly assigned to an exercise or a control group.

Interventions: The control group ( n = 48) received ultrasound and infrared radiation, whereas the exercise group ( n = 48) received a posture corrective exercise programme in addition to ultrasound and infrared radiation.

Main outcome measures: The peak-to-peak amplitude of dermatomal somatosensory evoked potentials, craniovertebral angle, visual analogue scale were measured for all patients at three intervals (before treatment, after 10 weeks of treatment, and at follow-up of six months).

Results: There was a significant difference between groups adjusted to baseline value of outcome at 10 weeks post-treatment for craniovertebral angle, pain, C6 and C7 peak-to-peak amplitude of dermatomal somatosensory evoked potentials P = 0.000, 0.01, 0.000, 0.001 respectively and at follow-up for all previous variables ( P = 0.000).

Conclusion: Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.

New trends in the treatment and management of myofascial pain syndrome

Myofascial pain syndrome presents a significant physical and financial burden to society. In view of the aging demographics, myofascial pain promises to be an even greater challenge to health care in the future. Myofascial trigger points have been identified as important anatomic and physiologic phenomena in the pathophysiology of myofascial pain. While their pathophysiologic mechanisms are still unclear, emerging research suggests that trigger points may be initiated by neurogenic mechanisms secondary to central sensitization, and not necessarily by local injury. A variety of treatments are employed in the management of trigger points, including manual therapy, electrotherapy, exercise, and needle therapy. Therapeutic ultrasound demonstrates significant potential as a safe, cost-effective, and relatively noninvasive therapeutic alternative in the treatment and management of this modern day medical enigma.

Comparison of high-power pain threshold ultrasound therapy with local injection in the treatment of active myofascial trigger points of the upper trapezius muscle

OBJECTIVE

To compare the effects of high-power pain threshold ultrasound (HPPTUS) therapy and local anesthetic injection on pain and active cervical lateral bending in patients with active myofascial trigger points (MTrPs) of the upper trapezius muscle.

DESIGN

Randomized single-blinded controlled trial.

SETTING

Physical medicine and rehabilitation department of university hospital.

PARTICIPANTS

Subjects (N=49) who had active MTrPs of the upper trapezius muscle.

INTERVENTIONS

HPPTUS or trigger point injection (TrP).

MAIN OUTCOME MEASURES

Visual analog scale, range of motion (ROM) of the cervical spine, and total length of treatments.

RESULTS

All patients in both groups improved significantly in terms of pain and ROM, but there was no statistically significant difference between groups. Mean numbers of therapy sessions were 1 and 1.5 in the local injection and HPPTUS groups, respectively.

CONCLUSIONS

We failed to show differences between the HPPTUS technique and TrP injection in the treatment of active MTrPs of the upper trapezius muscle. The HPPTUS technique can be used as an effective alternative to TrP injection in the treatment of myofascial pain syndrome.

Conservative treatment for neck pain: medications, physical therapy, and exercise

This article offers conservative treatment strategies for patients suffering from musculoskeletal causes of neck pain. Basic pharmacology is reviewed, including that of opioids, nonsteroidal anti-inflammatory drugs, adjuvants, and topical analgesics. Moreover, indications for therapeutic exercise, manual therapy, and modalities are reviewed, along with any supporting literature. Treatment considerations with each category of medication and physical therapy are discussed. This article is meant to serve as a resource for physicians to tailor conservative treatment options to their individual patients.

Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial trigger points in healthy subjects: a randomized controlled study

OBJECTIVE

The purpose of this study was to determine immediate effects of ischemic compression (IC) and ultrasound (US) for the treatment of myofascial trigger points (MTrPs) in the trapezius muscle.

METHODS

Sixty-six volunteers, all CEU-Cardenal Herrera University, Valencia, Spain, personnel, participated in this study. Subjects were healthy individuals, diagnosed with latent MTrPs in the trapezius muscle. Subjects were randomly placed into 3 groups: G1, which received IC treatment for MTrPs; G2, which received US; and G3 (control), which received sham US. The following data were recorded before and after each treatment: active range of motion (AROM) of cervical rachis measured with a cervical range of motion instrument, basal electrical activity (BEA) of muscle trapezius measured with surface electromyography, and pressure tolerance of MTrP measured with visual analogue scale assessing local pain evoked by the application of 2.5 kg/cm(2) of pressure using a pressure analog algometer.

RESULTS

The results showed an immediate decrease in BEA of the trapezius muscle and a reduction of MTrP sensitivity after treatment with both therapeutic modalities. In the case of IC, an improvement of AROM of cervical rachis was also been obtained.

CONCLUSION

In this group of participants, both treatments were shown to have an immediate effect on latent MTrPs. The results show a relation among AROM of cervical rachis, BEA of the trapezius muscle, and MTrP sensitivity of the trapezius muscle gaining short-term positive effects with use of IC.

Capsaicin-induced central sensitization evokes segmental increases in trigger point sensitivity in humans

This study investigated whether inducing central sensitization evokes segmental increases in trigger point pressure sensitivity. We evoked central sensitization at the C(5) segment and validated its presence via mechanical cutaneous sensitivity (brush allodynia) testing. Trigger point pressure sensitivity was quantified using the pain pressure threshold (PPT) value. A 50 cm(2) area of the C(5) dermatome at the right lateral elbow was pretreated with 45 degrees heat for 10 minutes. Test subjects (n = 20) then received topical capsaicin cream (0.075%; Medicis, Toronto, Canada) to the C(5) dermatome, whereas control subjects (n = 20) received a topical placebo cream (Biotherm Massage, Montreal, Canada). PPT readings were recorded from the infraspinatus (C(5,6)) and gluteus medius (L(4,5)S(1)) trigger points at zero (pre-intervention), 10, 20, and 30 minutes after intervention; all PPT readings were normalized to pre-intervention (baseline) values. The difference between the PPT readings at the 2 trigger point sites represents the direct influence of segmental mechanisms on the trigger point sensitivity at the infraspinatus site (PPT(seg)). Test subjects demonstrated statistically significant increases in Total Allodynia scores and significant decreases in PPT(seg) at 10, 20, and 30 minutes after application, when compared with control subjects. These results demonstrate that increases in central sensitization evoke increases in trigger point pressure sensitivity in segmentally related muscles.

PERSPECTIVE

Myofascial pain is the most common form of musculoskeletal pain. Myofascial trigger points play an important role in the clinical manifestation of myofascial pain syndrome. Elucidating the role of central sensitization in the pathophysiology of trigger points is fundamental to developing optimal strategies in the management of myofascial pain syndrome.

Performing arts medicine - instrumentalist musicians: part III - case histories

In parts I and II of this article series, the basic principles of examining musicians in a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine - instrumentalist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, J. Performing arts medicine - instrumentalist musicians: part II: the examination. J. Bodyw. Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, interfering with their ability to play their instruments. The musicians consulted with a performing arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treatment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction.

Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: a randomized controlled study

Musculoskeletal pain affects a significant proportion of the general population. The myofascial trigger point is recognized as a key factor in the pathophysiology of musculoskeletal pain. Ultrasound is commonly employed in the treatment and management of soft tissue pain and, in this study, we set out to investigate the segmental antinociceptive effect of ultrasound. Subjects (n=50) with identifiable myofascial trigger points in the supraspinatus, infraspinatus and gluteus medius muscles were selected from an outpatient rehabilitation clinic and randomly assigned to test or control groups. Test subjects received a therapeutic dose of ultrasound to the right supraspinatus trigger point while control groups received a sham (null) exposure. Baseline pain pressure threshold (PPT) readings were recorded at the ipsilateral infraspinatus and gluteus medius trigger-point sites prior to ultrasound exposure. The infraspinatus point was chosen due to its segmental neurologic link with the supraspinatus point; the gluteus medius acted as a segmental control point. Following the ultrasound intervention, PPT readings were recorded at 1, 3, 5, 10 and 15 min intervals at both infraspinatus and gluteus medius trigger points; the difference between infraspinatus and gluteus medius PPT values, PPT seg, represents the segmental influence on the PPT. The ultrasound test group demonstrated statistically significant increases in PPT seg (decreased infraspinatus sensitivity) at 1, 3 and 5 min, when compared with PPT seg in the sham ultrasound group. These results establish that low-dose ultrasound evokes short-term segmental antinociceptive effects on trigger points which may have applications in the management of musculoskeletal pain.