Brendyn Kaintz

MA, ATC, CSCS

A COMPARISON OF

MYOFASCIAL TRIGGER

POINT THERAPIES: A

SYSTEMATIC REVIEW

There is no reported conflict of interest for the

research performed or this presentation.

CONFLICT OF INTEREST

Background

Objective

Methods

Studies

Data Synthesis

Conclusions

OUTLINE

A trigger point is an area in tissue of hyper -irritability that is

very tender when palpated, refers pain and creates a twitch -

response when it is palpated (Unalan et al., 2011).

Location

A trigger point must have:

palpable taut band

exquisite tender spot in that taut band,

patient recognition of the pain as “familiar”

pain should be recognized when stretching the tissues (de las Penas

et al., 2005).

BACKGROUNDDEFINITIONS

Latent Trigger Points Can be found in patients

who do not have pain.

Patients often use less analgesic substances for treatment.

Patients often have a higher pain threshold.

Can change activation patterns of muscles and related functional muscles

Can limit ROM (Trampaset al., 2011).

BACKGROUNDLATENT VERSUS ACTIVE TRIGGER POINTS

Active Trigger Points

Patients will experience

more pain.

Reactive to

stretching/compression.

Will exhibit familiar pain

patterns to the patient.

ROM and function of the

patient can be limited

(Trampas et al., 2011).

BACKGROUND

LATENT VERSUS ACTIVE TRIGGER POINTS

Modalit ies

Ultrasound

Electrical stimulation

Heat/Cold

Injections

Botulinum toxin A

Bupivacaine/Lidocaine

Manual Therapies

Ischemic Compression

Muscle Stripping

PNF

Self-myofascial release

Lidocaine Patches

Nerve Root Stimulators

BACKGROUNDTREATMENTS

To examine the efficacy of various trigger

point treatments and determine which

provides the best patient-oriented outcomes.

OBJECTIVE

This systematic review was performed utilizing

the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines

Search engines:

PubMed

SPORTDiscus

Medline Complete

Web of Science.

METHODSLITERATURE SEARCH

Search terms for this review included:

“Trigger points [Title]”

“Trigger point therapies [Title]”,

“Trigger point manual therapy [Title]”

“Trigger point massage [Title]”

“Trigger point AND ultrasound [Title/Abstract ]”

“Trigger point AND injection [Title/Abstract ]”

“Trigger point AND manual therapy [Title/Abstract ]”

METHODSSEARCH TERMS

Distinct outcome for use of one of the aforementioned therapies.

Use of a visual analogue scale (VAS) as well as comparing ROM

Comparison of a therapy versus another therapy or a control group.

No restriction

Location of trigger points

Latent versus active trigger points.

Peer reviewed journal

Preference of a Randomized Controlled Trial (RCT).

METHODSINCLUSION CRITERIA

Lack of comparison group or a comparison of

treatments.

Lack of utilization of one of the aforementioned

modalities/treatments.

METHODS EXCLUSION CRITERIA

Articles were graded using the Physiotherapy

Evidence Database (PEDro) scale and were

preferably used if they rated at a “6” or higher on

the scale.

No restriction on age, race or sex.

Language not restricted.

METHODSASSESSMENT OF RISK OF BIAS

Studies were categorized by modality:

4 articles chosen per modality

Ultrasound Therapy

Injection Therapy

Manual Therapy

Title/abstract review was used to determine

study inclusion.

VAS and ROM were compared for each therapy.

It was determined on an article by article basis if

ROM was a significant predictor for return to

function.

METHODSDATA COLLECTION AND SYNTHESIS OF RESULTS

The 12 articles compiled had a mean average of

6.3 ± 1.3 on the PEDro scale.

This score was consistent with the desired

average of this systematic review.

METHODSQUALITY OF STUDIES SCORES

STUDIES

Included Study Comparisons Major Results PEDro

Affaitati et al. 2009 1: Lidocaine patch

2: Placebo patch3: Injection

• Lidocaine patch/injection >

Baseline/placebo: VAS pain, PPT, QOL

6

Ay et al. 2011 1: Phonophoresis

2: US3: Placebo US

• Phonophoresis/ultrasound > placebo: VAS pain, cervical ROM, # TPs

7

Ga et al. 2007 1: IM stimulation2: Injection

• IM stim > injection: pain VAS, cervical ROM, depression

7

Graboski et al. 2005 1: Injection (Botulinum Toxin A)2: Injection (bupivacaine)

• Both treatments effective for ↓ VAS

pain

• No difference in duration/magnitude of relief/function/satisfaction

5

Included Study Comparisons Major Results PEDro

Llamas-Ramos et al. 2014 1: Dry needling

2: Manual therapy

• Similar immediate outcomes: neck

pain VAS/ROM

• Dry needling > MT 2 weeks post

6

Kim et al. 2013 1: Injection

2: Injection + ischemic

compression (30s)

3: Injection + ischemic

compression (60s)

• Injection + ischemic > injection

• No difference b/n 30s and 60 s

6

Majlesi et al. 2004 1: High-power, pain-threshold

US

2: Conventional US

• High-power > conventional

• Less total tx with high-power

8

Montanez-Aguilera et al.

2010

1: Ischemic compression • ↑ AROM in neck

• ↓ sensitivity of TP according to VAS

3

STUDIES

STUDIES

Included Study Comparisons Major Results PEDro

Renan-Ordine et al. 2011 1: Self stretching

2: Self stretching w/manual

therapy

• Group 2 > Group 1: physical

function, SF-36, PPT over calf

6

Sarrafzadeh et al. 2012 1: Manual therapy

2: Phonophoresis

w/hydrocortisone

3: US

4: Control

• 3 tx groups > con: VAS pain, PPT,

cervical ROM

• MT/phonophoresis > US

7

Trampas et al. 2010 1: PNF stretching

2: Manual therapy + PNF

stretching

3: Control

• MT + PNF > PNF/Control: VAS Pain,

knee ROM, PPT

7

Unalan et al. 2011 1: High-power, pain-threshold

US

2: Injection

• No difference between VAS

pain/cervical ROM or length of tx

7

Manual therapy

Ischemic compression effective when combined

with PNF protocols.

Effective with injection therapy

Not statistically different from injection therapy or

dry needling.

High-power US to patients’ pain threshold and

phonophoresis > conventional ultrasound

treatment.

DATA SYNTHESIS

Manual therapy, when combined with another modality or

therapy, produces superior results.

High-power US or phonophoresis may result in better

outcomes compared to conventional US.

Length of symptomatic relief from each modality was

unclear which warrants further investigation.

Future research should emphasize a quantitative

assessment of pain reduction and range of motion

improvement to identify the effectiveness of myofascial TP

therapies.

CONCLUSIONS

Clinician skill and experience

Patient experience

Location of the trigger point

Age

Occupation (clinical setting versus athletic

population)

CONCLUSIONSFACTORS TO CONSIDER

Moving Forward

Utilizing new treatments on trigger points that have not responded to

traditional therapy

Manual Therapy versus Injection versus Ultrasound Therapy.

Lidocaine Patches versus Nerve Root Stimulators.

Research Going Forward

Objective research comparing VAS and ROM changes with statistical

analyses.

Latent versus Active Trigger Points

Conservative versus Aggressive treatment.

Applying treatments in your practice!

CONCLUSIONSTYING IT ALL TOGETHER

1 . A f f a i t a t i G e t a l . ( 2 0 0 9 ) . A R a n d o m i z e d , C o n t r o l l e d S t u d y C o m p a r i n g a L i d o c a i n e P a t c h , a P l a c e b o P a t c h , a n d A n e s t h e t i c I n j e c t i o n f o r T r e a t m e n t o f T r i g g e r P o i n t s i n P a t i e n t s w i t h M y o f a s c i a l P a i n S y n d r o m e : E v a l u a t i o n o f P a i n a n d S o m a t i c P a i n T h r e s h o l d s . C l i n T h e r , 3 1 ( 4 ) , 7 0 7 - 7 2 0 .

2 . A y S e t a l . ( 2 0 1 1 ) . C o m p a r i s o n t h e e f f i c a c y o f p h o n o p h o r e s i s a n d u l t r a s o u n d t h e r a p y i n m y o f a s c i a l p a i n s y n d r o m e . R h e u m I n t , 3 1 , 1 2 0 3 - 1 2 0 8 .

3 . d e l a s P e n a s C e t a l . ( 2 0 0 5 ) . M a n u a l t h e r a p i e s i n m y o f a s c i a l t r i g g e r p o i n t t r e a t m e n t : a s y s t e m a t i c r e v i e w . J B o d y w M o v T h e r , 9 , 2 7 - 3 4 .

4 . G a H e t a l . ( 2 0 0 7 ) . I n t r a m u s c u l a r a n d n e r v e r o o t s t i m u l a t i o n v s l i d o c a i n e i n j e c t i o n o f t r i g g e r p o i n t s i n m y o f a s c i a l p a i n s y n d r o m e . J R e h a b M e d , 3 9 , 3 7 4 - 3 7 8 .

5 . G r a b o s k i C e t a l . . ( 2 0 0 5 ) . B o t u l i n u m t o x i n A v e r s u s b u p i v a c a i n e t r i g g e r p o i n t i n j e c t i o n s f o r t h e t r e a t m e n t o f m y o f a s c i a l p a i n s y n d r o m e : A r a n d o m i z e d d o u b l e b l i n d c r o s s o v e r s t u d y . P a i n , 1 1 8 , 1 7 0 - 1 7 5 .

6 . K i m S . e t a l . ( 2 0 1 3 ) . I s c h e m i c C o m p r e s s i o n a f t e r T r i g g e r P o i n t I n j e c t i o n A f f e c t t h e T r e a t m e n t o f M y o f a s c i a l T r i g g e r P o i n t s . A n n R e h a b M e d , 3 7 ( 4 ) , 5 4 1 - 5 4 6 .

7 . L l a m a s - R a m o s R e t a l . . ( 2 0 1 4 ) . C o m p a r i s o n o f t h e s h o r t - t e r m o u t c o m e s b e t w e e n t r i g g e r p o i n t d r y n e e d l i n g v s . t r i g g e r p o i n t m a n u a l t h e r a p y f o r t h e m a n a g e m e n t o f c h r o n i c m e c h a n i c a l n e c k p a i n : A r a n d o m i z e d c o n t r o l t r i a l . J O r t h o p P h y s T h e r , 1 - 3 4 .

8 . M a j l e s i J . a n d U n a l a n H . ( 2 0 0 4 ) . H i g h - P o w e r P a i n T h r e s h o l d U l t r a s o u n d T e c h n i q u e i n t h e T r e a t m e n t o f A c t i v e M y o f a s c i a l T r i g g e r P o i n t s : A R a n d o m i z e d , D o u b l e - B l i n d , C a s e - C o n t r o l S t u d y . A r c h P h y s M e d R e h a b , 8 5 , 8 3 3 - 8 3 6 .

9 . M o n t a n e z - A g u i l e r a F e t a l . ( 2 0 1 0 ) . C h a n g e s i n a p a t i e n t w i t h n e c k p a i n a f t e r a p p l i c a t i o n o f i s c h e m i c c o m p r e s s i o n a s a t r i g g e r p o i n t t h e r a p y . J B a c k M u s c u l o S k e l e t , 2 3 , 1 0 1 - 1 0 4 .

1 0 . R e n a n - O r d i n e R e t a l . ( 2 0 1 1 ) . E f f e c t i v e n e s s o f M y o f a s c i a l T r i g g e r P o i n t M a n u a l T h e r a p y C o m b i n e d w i t h a S e l f - S t r e t c h i n g P r o t o c o l f o r t h e M a n a g e m e n t o f P l a n t a r H e e l P a i n : A R a n d o m i z e d C o n t r o l l e d T r i a l . J O r t h o pP h y s T h e r , 4 1 ( 2 ) , 4 3 - 5 0 .

1 1 . S a r r a f z a d e h J e t a l ( 2 0 1 2 ) . T h e E f f e c t s o f P r e s s u r e R e l e a s e , P h o n o p h o r e s i s o f H y d r o c o r t i s o n e a n d U l t r a s o u n d o n U p p e r T r a p e z i u s L a t e n t M y o f a s c i a l T r i g g e r P o i n t . A r c h P h y s M e d R e s , 9 3 , 7 2 - 7 7 .

1 2 . S c o t t N e t a l . ( 2 0 0 9 ) . T r i g g e r P o i n t I n j e c t i o n s f o r C h r o n i c N o n - M a l i g n a n t M u s c u l o s k e l e t a l P a i n : A S y s t e m a t i c R e v i e w . J P a i n M e d , 1 0 ( 1 ) , 5 4 - 6 9 .

1 3 . T r a m p a s A e t a l . ( 2 0 1 0 ) . C l i n i c a l m a s s a g e a n d m o d i f i e d P r o p r i o c e p t i v e N e u r o m u s c u l a r F a c i l i t a t i o n s t r e t c h i n g i n m a l e s w i t h l a t e n t m y o f a s c i a l t r i g g e r p o i n t s . P h y s T h e r S p o r t , 1 1 , 9 1 - 9 8 .

1 4 . U n a l a n H e t a l . ( 2 0 1 1 ) . C o m p a r i s o n o f H i g h - P o w e r P a i n T h r e s h o l d U l t r a s o u n d T h e r a p y w i t h L o c a l I n j e c t i o n i n t h e T r e a t m e n t o f A c t i v e M y o f a s c i a l T r i g g e r P o i n t s o f t h e U p p e r T r a p e z i u s M u s c l e . A r c h P h y s M e d R e s , 9 2 , 6 5 7 - 6 6 2 .

RESOURCES

QUESTIONS