Active Myofascial Trigger Points Research Articles

Comparison of High-Power Pain Threshold Ultrasound Therapy With Local Injection in the Treatment of Active Myofascial Trigger Points of the Upper Trapezius Muscle

Unalan H, Majlesi J, Aydin FY, Palamar D. Comparison of high-power pain threshold ultrasound therapy with local ınjection 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.

Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients

IntroductionIt has previously been reported that local and referred pain from active myofascial trigger points (MTPs) in the neck and shoulder region contribute to fibromyalgia (FM) pain and that the pain pattern induced from active MTPs can reproduce parts of the spontaneous clinical FM pain pattern. The current study investigated whether the overall spontaneous FM pain pattern can be reproduced by local and referred pain from active MTPs located in different muscles.MethodsA spontaneous pain pattern in FM was recorded in 30 FM patients and 30 healthy subjects served as controls. Local and referred pain patterns induced from active (patients) and latent (controls) MTPs were recorded following manual stimulation. The existence of MTPs was confirmed by intramuscular electromyographical registration of spontaneous electrical activity.ResultsLocal and referred pain areas induced from key active MTPs in FM were larger than pain areas from latent MTPs in healthy controls (P < 0.001), but were similar to the overall spontaneous FM pain area in FM (P > 0.05). The induced pain area was positively associated with current spontaneous pain intensity in FM (P < 0.01). The locations of key active MTPs in FM patients were found to have latent MTPs in healthy subjects. The muscles containing key active MTPs in FM are often observed in the muscles of extensor digitorum, trapezius, infraspinatus in the upper part of the body and of quadratus lumborum, gluteus medius in the lower part of the body.ConclusionsThe overall spontaneous FM pain pattern can be reproduced by mechanical stimulation of active MTPs located in different muscles, suggesting that fibromyalgia pain is largely composed of pain arising from muscle pain and spasm. Targeting active MTPs and related perpetuating factors may be an important strategy in FM pain control.Trial registrationISRCTN ISRCTN43167547.

Development of active myofascial trigger points in neck and shoulder musculature is similar after lumpectomy or mastectomy surgery for breast cancer

Our aim was to describe the differences in the presence of myofascial trigger points (TrPs) in neck and shoulder muscles after 2 surgery approaches for breast cancer: mastectomy or lumpectomy. Thirty-two women (mean age: 50 ± 7 years) who received lumpectomy, 16 women (mean age: 48 ± 10 years) who had received mastectomy after breast cancer, and 16 women (mean age: 49 ± 9 years) with breast cancer who had not received either surgical treatment, participated. Myofascial TrPs in the upper trapezius, sternocleidomastoid, levator scapulae, scalene, infraspinatus and pectoralis major muscles were bilaterally explored by an assessor blinded to the women's condition. TrPs were considered active when palpation reproduced local and referred pain symptoms recognized by the patient as familiar pain symptoms. The number of active TrPs within mastectomy (mean ± SD: 4.6 ± 1) and lumpectomy (mean ± SD: 4.5 ± 1) groups was significantly higher (P < 0.001) as compared to the control group (mean ± SD: 1.1 ± 1.3), but not significantly different between them (P = 0.641). Women who received either lumpectomy or mastectomy showed similar distribution of active TrPs and a higher prevalence of active TrPs as compared to the control group. Active TrPs in the pectoralis major muscle were the most prevalent in both surgery groups The number of active TrPs was weakly correlated with neck (r(s) = 0.385; P = 0.029) and shoulder/axillary (r(s) = 0.397; P = 0.024) pain intensity within the lumpectomy, but not the mastectomy group. This study found active TrPs in neck and shoulder musculature in women who had received lumpectomy or mastectomy. The induced local and referred pain pattern from active TrPs reproduced neck and shoulder/axillary symptoms and pain patterns in women after breast cancer surgery. Few active TrPs were found in a control group of women with breast cancer who had not received any surgical treatment.

Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial

BackgroundShoulder pain is a common musculoskeletal problem that is often chronic or recurrent. Myofascial trigger points (MTrPs) cause shoulder pain and are prevalent in patients with shoulder pain. However, few studies have focused on MTrP therapy. The aim of this study was to assess the effectiveness of multimodal treatment of MTrPs in patients with chronic shoulder pain.MethodsA single-assessor, blinded, randomized, controlled trial was conducted. The intervention group received comprehensive treatment once weekly consisting of manual compression of the MTrPs, manual stretching of the muscles and intermittent cold application with stretching. Patients were instructed to perform muscle-stretching and relaxation exercises at home and received ergonomic recommendations and advice to assume and maintain good posture. The control group remained on the waiting list for 3 months. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score (primary outcome), Visual Analogue Scale for Pain (VAS-P), Global Perceived Effect (GPE) scale and the number of muscles with MTrPs were assessed at 6 and 12 weeks in the intervention group and compared with those of a control group.ResultsCompared with the control group, the intervention group showed significant improvement (P < 0.05) on the DASH after 12 weeks (mean difference, 7.7; 95% confidence interval (95% CI), 1.2 to 14.2), on the VAS-P1 for current pain (mean difference, 13.8; 95% CI, 2.6 to 25.0), on the VAS-P2 for pain in the past 7 days (mean difference, 10.2; 95% CI, 0.7 to 19.7) and VAS-P3 most severe pain in the past 7 days (mean difference, 13.8; 95% CI, 0.8 to 28.4). After 12 weeks, 55% of the patients in the intervention group reported improvement (from slightly improved to completely recovered) versus 14% in the control group. The mean number of muscles with active MTrPs decreased in the intervention group compared with the control group (mean difference, 2.7; 95% CI, 1.2 to 4.2).ConclusionsThe results of this study show that 12-week comprehensive treatment of MTrPs in shoulder muscles reduces the number of muscles with active MTrPs and is effective in reducing symptoms and improving shoulder function in patients with chronic shoulder pain.Trial registration numberISRCTN: ISRCTN75722066

Myofascial trigger points: spontaneous electrical activity and its consequences for pain induction and propagation

Active myofascial trigger points are one of the major peripheral pain generators for regional and generalized musculoskeletal pain conditions. Myofascial trigger points are also the targets for acupuncture and/or dry needling therapies. Recent evidence in the understanding of the pathophysiology of myofascial trigger points supports The Integrated Hypothesis for the trigger point formation; however unanswered questions remain. Current evidence shows that spontaneous electrical activity at myofascial trigger point originates from the extrafusal motor endplate. The spontaneous electrical activity represents focal muscle fiber contraction and/or muscle cramp potentials depending on trigger point sensitivity. Local pain and tenderness at myofascial trigger points are largely due to nociceptor sensitization with a lesser contribution from non-nociceptor sensitization. Nociceptor and non-nociceptor sensitization at myofascial trigger points may be part of the process of muscle ischemia associated with sustained focal muscle contraction and/or muscle cramps. Referred pain is dependent on the sensitivity of myofascial trigger points. Active myofascial trigger points may play an important role in the transition from localized pain to generalized pain conditions via the enhanced central sensitization, decreased descending inhibition and dysfunctional motor control strategy.

Fibromyalgia, myofascial pain, tender points and trigger points: splitting or lumping?

Myofascial trigger points (MTPs) have long been a contentious issue in relation to fibromyalgia, and poorly defined pain complaints in general. Can MTPs be reproducibly identified? Do MTPs have valid objective findings, such as spontaneous electromyographic activity, muscle microdialysis evidence for an inflammatory milieu or visualization with newer ultrasound techniques? Is fibromyalgia a syndrome of multiple MTPs, or is focal muscle tenderness a manifestation of central sensitization? These issues are discussed with relevance to a recent paper reporting that manual palpation of active MTPs elicits the spontaneous pain experienced by fibromyalgia patients.

Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders

To investigate the effects of dry needling over active trigger points (TrPs) in the masseter muscle in patients with temporomandibular disorders (TMD).Twelve females, aged 20 to 41 years old (mean = 25, standard deviation +/- 6 years) diagnosed with myofascial TMD were recruited. Each patient attended two treatment sessions on two separate days and received one intervention assigned in a random fashion, at each visit: deep dry needling (experimental) or sham dry needling (placebo) at the most painful point on the masseter muscle TrP. Pressure pain threshold (PPT) over the masseter muscle TrP and the mandibular condyle and pain-free active jaw opening were assessed pre- and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A two-way repeated-measures analysis of variance (ANOVA) with intervention as the between-subjects variable and time as the within-subjects variable was used to examine the effects of the intervention.The ANOVA detected a significant interaction between intervention and time for PPT levels in the masseter muscle (F = 62.5; P < .001) and condyle (F = 50.4; P < .001), and pain-free active mouth opening (F = 34.9; P < .001). Subjects showed greater improvements in all the outcomes when receiving the deep dry needling compared to the sham dry needling (P < .001).The application of dry needling into active TrPs in the masseter muscle induced significant increases in PPT levels and maximal jaw opening when compared to the sham dry needling in patients with myofascial TMD.

Differences in cervical musculoskeletal impairment between episodic and chronic tension-type headache

Tension-type headache (TTH) is a headache in which musculoskeletal impairments of the craniocervical region may play an important role in its pathogenesis. We investigated the presence of myofascial, postural and mechanical abnormalities in patients with frequent episodic and chronic tension-type headache (ETTH and CTTH, respectively). The study population consisted of 36 patients with ETTH, 23 with CTTH and 42 control subjects. Myofascial trigger points (MTrPs) were identified in the upper trapezius, sternocleidomastoid, temporalis and suboccipital muscles. Sagittal C7-tragus angle was measured to evaluate flexor head posture (FHP), and neck mobility was assessed using an inclinometer. Only active MTrPs were significantly different between the ETTH and CTTH groups (p < .001). Patients with CTTH showed a larger sagittal C7-tragus angle (p = .011), that is, greater FHP and restricted neck mobility for both rotations compared to controls (p < .001). Although active MTrPs were correlated with the frequency and duration of headache, no correlations were observed for FHP or neck mobility. Active MTrPs in the craniocervical region contribute to triggering or maintenance of TTH and posture or neck mobility may be a result of chronic headache.

Prevalence of Myofascial Trigger Points in Fibromyalgia: The Overlap of Two Common Problems

With the objective evidence of their existence, myofascial trigger points (MTrPs) contribute to an increasing number of chronic regional and widespread pain conditions. The widespread spontaneous pain pattern in fibromyalgia (FM) is a summation of multiple regional pains due to active MTrPs. A regional pain in FM is from local active MTrPs and/or referred from remote active MTrPs. Positive tender points specified in FM are MTrPs, either active or latent. Manual stimulation of active MTrPs located in the muscles in different body regions completely reproduced overall spontaneous FM pain pattern. Active MTrPs as tonic peripheral nociceptive input contribute tremendously to the initiation and maintenance of central sensitization, to the impairment of descending inhibition, to the increased excitability of motor units, and to the induction of sympathetic hyperactivity observed in FM. The considerable overlap of MTrPs and FM in pain characteristics and pathophysiology suggests that FM pain is largely due to MTrPs.

근근막 발통점의 활성도에 따른 초음파 영상구조 및 전기생리학적 특성

Purpose : This study is to offer clinical primary data that examines the change of imaging structure and the quantitative evaluation of muscle activity on myofascial trigger points. This study examines neuromuscular physiological characteristic by comparing the differences in physical findings, pressure pain threshold, imaging, and electrophysiological characteristics in latent and active myofascial trigger points muscle and normal muscle through the following experimental procedures. Methods : The participants for the study were thirty-three adults in their twenties. We divided three groups into normal, latent and active myofascial trigger points groups by physical findings. We analyzed the results of measured pressure pain, threshold for pain, ultrasound imaging perform for structure characteristic of muscle, surface EMG according to type of muscle contraction for function of muscle contraction. Results : Significant differences were indicated in pressure pain threshold (p

Changes in a patient with neck pain after application of ischemic compression as a trigger point therapy

To describe the immediate effects of ischemic compression (IC) as a trigger point therapy in a case of a patient with neck pain. The application of IC is a safe and effective method to successfully treat elicited myofascial trigger points. The purpose of this method is to deliberate the blockage of blood in a trigger point area in order to increase local blood flow. This washes away waste products, supplies necessary oxygen and helps the affected tissue to heal. In this case study, we treated a 27-year-old female patient with a medical report of neck pain for at least four months. The physical examination revealed a neck pain and stiffness at the left side and pain increases when moving the neck. An active myofascial trigger point was found in the left trapezius muscle. The following data were recorded: active range of motion of cervical rachis measured with a cervical range of motion instrument, basal electrical activity of the left trapezius measured with electromyography, and pressure tolerance of the myofascial trigger point measured with visual analogue scale, assessing local pain evoked by the application of 2.5 kg/cm2 pressure with an analogue algometer. Immediately after application of the IC, all measured parameters improved compared to base line. The application of IC has been shown effective in the treatment of myofascial trigger points in a patient with neck pain. The results show a relation between active range of motion of cervical rachis, basal electrical activity of the trapezius muscle and myofascial trigger point sensitivity. In this case of a patient with neck pain, active range of motion of cervical rachis, basal electrical activity of the trapezius muscle and myofascial trigger point sensitivity gaining short-term positive effects with the application of one single ischemic compression session. Nevertheless, randomized controlled double-blinded studies should be conducted in future to examine the effectiveness of this ischemic compression technique in case of the presence of myofascial trigger points in the neck.

The immediate effect of soleus trigger point pressure release on restricted ankle joint dorsiflexion: A pilot randomised controlled trial

The primary aim of this study was to investigate the immediate effect on restricted active ankle joint dorsiflexion range of motion (ROM), after a single intervention of trigger point (TrP) pressure release on latent soleus myofascial trigger points (MTrPs). The secondary aim was to assess aspects of the methodological design quality, identify limitations and propose areas for improvement in future research. A pilot randomised control trial. Twenty healthy volunteers (5 men and 15 women; mean age 21.7±2.1 years) with a restricted active ankle joint dorsiflexion. Participants underwent a screening process to establish both a restriction in active ankle dorsiflexion and the presence of active and latent MTrPs in the soleus muscle. Participants were then randomly allocated to an intervention group (TrP pressure release) or control group (no therapy). The results showed a statistically significant (p=0.03) increase of ankle ROM in the intervention compared to the control group. This study identified an immediate significant improvement in ankle ROM after a single intervention of TrP pressure release on latent soleus MTrPS. These findings are clinically relevant, although the treatment effect on ankle ROM is smaller than a clinical significant ROM (5°). Suggestions for methodological improvements may inform future MTrP research and ultimately benefit clinical practice in this under investigated area.

Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey

BackgroundMyofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population. Current guidelines for the management of myofascial pain are not available. In this study we investigated how physicians on the basis of prescription behaviour evaluate the effectiveness of treatment options in their management of myofascial pain.MethodsWe conducted a cross-sectional, nationwide survey with a standardized questionnaire among 332 physicians (79.8% male, 25.6% female, 47.5 ± 9.6 years) experienced in treating patients with myofascial pain. Recruitment of physicians took place at three German meetings of pain therapists, rheumatologists and orthopaedists, respectively. Physicians estimated the prevalence of myofascial pain amongst patients in their practices, stated what treatments they used routinely and then rated the perceived treatment effectiveness on a six-point scale (with 1 being excellent). Data are expressed as mean ± standard deviation.ResultsThe estimated overall prevalence of active myofascial trigger points is 46.1 ± 27.4%. Frequently prescribed treatments are analgesics, mainly metamizol/paracetamol (91.6%), non-steroidal anti-inflammatory drugs/coxibs (87.0%) or weak opioids (81.8%), and physical therapies, mainly manual therapy (81.1%), TENS (72.9%) or acupuncture (60.2%). Overall effectiveness ratings for analgesics (2.9 ± 0.7) and physical therapies were moderate (2.5 ± 0.8). Effectiveness ratings of the various treatment options between specialities were widely variant. 54.3% of all physicians characterized the available treatment options as insufficient.ConclusionsMyofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of myofascial pain syndrome.

Remote Effects of Dry Needling on the Irritability of the Myofascial Trigger Point in the Upper Trapezius Muscle

To investigate the remote effect of dry needling on the irritability of a myofascial trigger point in the upper trapezius muscle. Thirty-five patients with active myofascial trigger points in upper trapezius muscles were randomly divided into two groups: 18 patients in the control group received sham needling, and 17 patients in the dry-needling group received dry needling into the myofascial trigger point in the extensor carpi radialis longus muscle. The subjective pain intensity, pressure pain threshold, and range of motion of the neck were assessed before and immediately after the treatment. Immediately after dry needling in the experimental group, the mean pain intensity was significantly reduced, but the mean pressure threshold and the mean range of motion of cervical spine were significantly increased. There were significantly larger changes in all three parameters of measurement in the dry-needling group than that in the control group. This study demonstrated the remote effectiveness of dry needling. Dry needling of a distal myofascial trigger point can provide a remote effect to reduce the irritability of a proximal myofascial trigger point.

The Predetermined Sites of Examination for Tender Points in Fibromyalgia Syndrome Are Frequently Associated With Myofascial Trigger Points

The aim of this present study is to test the hypotheses that the 18 predetermined sites of examination for tender points (TP sites) in fibromyalgia syndrome (FMS) are myofascial trigger points (MTrPs), and that the induced pain from active MTrPs at TP sites may mimic fibromyalgia pain. Each TP site was evaluated with manual palpation followed by intramuscular electromyographic (EMG) registration of spontaneous electrical activity to confirm or refute the existence of an MTrP in 30 FMS patients. Overall spontaneous pain intensity and pain pattern were recorded before manual identification of MTrPs. Local and referred pain pattern from active MTrPs were drawn following manual palpation at TP sites. Showed that most of the TP sites are MTrPs. Local and referred pain from active MTrPs reproduced partly the overall spontaneous pain pattern. The total number of active MTrPs (r = .78, P < .0001), but not latent MTrPs (r = -.001, P = .99), was positively correlated with spontaneous pain intensity in FMS. The current study provides first evidence that pain from active MTrPs at TP sites mimics fibromyalgia pain. MTrPs may relate to generalized increased sensitivity in FMS due to central sensitization. This article underlies the importance of active MTrPs in FMS patients. Most of the TP sites in FMS are MTrPs. Active MTrPs may serve as a peripheral generator of fibromyalgia pain and inactivation of active MTrPs may thus be an alternative for the treatment of FMS.

Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue

Sikdar S, Shah JP, Gebreab T, Yen R-H, Gilliams E, Danoff J, Gerber LH. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Objective To apply ultrasound (US) imaging techniques to better describe the characteristics of myofascial trigger points (MTrPs) and the immediately adjacent soft tissue. Design Four sites in each patient were labeled based on physical examination as active myofascial trigger points (A-MTrPs; spontaneously painful), latent myofascial trigger points (L-MTrPs; nonpainful), or normal myofascial tissue. US examination was performed on each subject by a team blinded to the physical findings. A 12∼5MHz US transducer was used. Vibration sonoelastography (VSE) was performed by color Doppler variance imaging while simultaneously inducing vibrations (∼92Hz) with a handheld massage vibrator. Each site was assigned a tissue imaging score as follows: 0, uniform echogenicity and stiffness; 1, focal hypoechoic region with stiff nodule; 2, multiple hypoechoic regions with stiff nodules. Blood flow in the neighborhood of MTrPs was assessed using Doppler imaging. Each site was assigned a blood flow waveform score as follows: 0, normal arterial flow in muscle; 1, elevated diastolic flow; 2, high-resistance flow waveform with retrograde diastolic flow. Setting Biomedical research center. Participants Subjects (N=9) meeting Travell and Simons' criteria for MTrPs in a taut band in the upper trapezius. Interventions Not applicable. Main Outcome Measures MTrPs were evaluated by (1) physical examination, (2) pressure algometry, and (3) three types of US imaging including gray-scale (2-dimensional [2D] US), VSE, and Doppler. Results MTrPs appeared as focal, hypoechoic regions on 2D US, indicating local changes in tissue echogenicity, and as focal regions of reduced vibration amplitude on VSE, indicating a localized, stiff nodule. MTrPs were elliptical, with a size of .16±.11cm 2. There were no significant differences in size between A-MTrPs and L-MTrPs. Sites containing MTrPs were more likely to have a higher tissue imaging score compared with normal myofascial tissue ( P<.002). Small arteries (or enlarged arterioles) near A-MTrPs showed retrograde flow in diastole, indicating a highly resistive vascular bed. A-MTrP sites were more likely to have a higher blood flow score compared with L-MTrPs ( P<.021). Conclusions Preliminary findings show that, under the conditions of this investigation, US imaging techniques can be used to distinguish myofascial tissue containing MTrPs from normal myofascial tissue (lacking trigger points). US enables visualization and some characterization of MTrPs and adjacent soft tissue.

Contribution of the local and referred pain from active myofascial trigger points in fibromyalgia syndrome

The generalized hypersensitivity associated with fibromyalgia syndrome (FMS) may in part be driven by peripheral nociceptive sources. The aim of the study was to investigate whether local and referred pain from active myofascial trigger points (MTrPs) contributes to fibromyalgia pain. FMS patients and healthy controls (n=22 each, age- and gender-matched) were recruited. The surface area over the upper trapezius muscle on each side was divided into 13 sub-areas (points) of 1cm in diameter for each point. Pressure pain threshold (PPT) and the local and referred pain pattern induced by manual palpation at 13 points bilaterally in the upper trapezius were recorded. Results showed that PPT levels at all measured points were significantly lower in FMS than controls. Multiple active MTrPs (7.4±2.2) were identified bilaterally in the muscle in FMS patients, but no active MTrPs were found in controls. The mid-fiber region of the muscle had the lowest PPT level with the largest number of active MTrPs in FMS and with the largest number of latent MTrPs in controls. The local and referred pain pattern induced from active MTrPs bilaterally in the upper trapezius muscle were similar to the ongoing pain pattern in the neck and shoulder region in FMS. In conclusion, active MTrPs bilaterally in the upper trapezius muscle contribute to the neck and shoulder pain in FMS. Active MTrPs may serve as one of the sources of noxious input leading to the sensitization of spinal and supraspinal pain pathways in FMS.

Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache

Our aim was to analyze the differences in the referred pain patterns and size of the areas of those myofascial trigger points (TrPs) involved in chronic tension type headache (CTTH) including a number of muscles not investigated in previous studies. Thirteen right handed women with CTTH (mean age: 38 ± 6 years) were included. TrPs were bilaterally searched in upper trapezius, sternocleidomastoid, splenius capitis, masseter, levator scapulae, superior oblique (extra-ocular), and suboccipital muscles. TrPs were considered active when both local and referred pain evoked by manual palpation reproduced total or partial pattern similar to a headache attack. The size of the referred pain area of TrPs of each muscle was calculated. The mean number of active TrPs within each CTTH patient was 7 (95% CI 6.2-8.0). A greater number (T = 2.79; p = 0.016) of active TrPs was found at the right side (4.2 ± 1.5) when compared to the left side (2.9 ± 1.0). TrPs in the suboccipital muscles were most prevalent (n = 12; 92%), followed by the superior oblique muscle (n =11/n = 9 right/left side), the upper trapezius muscle (n = 11/n = 6) and the masseter muscle (n = 9/n=7). The ANOVA showed significant differences in the size of the referred pain area between muscles (F = 4.7, p = 0.001), but not between sides (F = 1.1; p = 0.3): as determined by a Bonferroni post hoc analysis the referred pain area elicited by levator scapulae TrPs was significantly greater than the area from the sternocleidomastoid (p = 0.02), masseter (p = 0.003) and superior oblique (p = 0.001) muscles. Multiple active TrPs exist in head, neck and shoulder muscles in women with CTTH. The referred pain areas of TrPs located in neck muscles were larger than the referred pain areas of head muscles. Spatial summation of nociceptive inputs from multiple active TrPs may contribute to clinical manifestations of CTTH.

Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial

BackgroundRotator cuff tendinopathy and subacromial impingement syndrome present complex patomechanical situations, frequent difficulties in clinical diagnosis and lack of effectiveness in treatment. Based on clinical experience, we have therefore considered the existence of another pathological entity as the possible origin of pain and dysfunction. The hypothesis of this study is to relate subacromial impingement syndrome (SIS) with myofascial pain syndrome (MPS), since myofascial trigger points (MTrPs) cause pain, functional limitation, lack of coordination and alterations in quality of movement, even prior to a tendinopathy. MTrPs can coexist with any degenerative subacromial condition. If they are not taken into consideration, they could perpetuate and aggravate the problem, hindering diagnosis and making the applied treatments ineffective.The aims and methods of this study are related with providing evidence of the relationship that may exist between this condition and MPS in the diagnosis and treatment of rotator cuff tendonitis and/or SIS.Method/designA descriptive transversal study will be made to find the correlation between the diagnosis of SIS and rotator cuff tendonitis, positive provocation test responses, the existence of active MTrPs and the results obtained with ultrasonography (US) and Magnetic Renonance Imaging (MRI). A randomized double blinded clinical trial will be carried out in experimental conditions: A Protocolized treatment based on active and passive joint repositioning, stabilization exercises, stretching of the periarticular shoulder muscles and postural reeducation. B. The previously described protocolized treatment, with the addition of dry needling applied to active MTrPs with the purpose of isolating the efficacy of dry needling in treatment.DiscussionThis study aims to provide a new vision of shoulder pain, from the perspective of MPS. This syndrome can, by itself, account for shoulder pain and dysfunction, although it can coexist with real conditions involving the tendons.Trail RegistrationISRCTN Number: 30907460

Multiple Active Myofascial Trigger Points and Pressure Pain Sensitivity Maps in the Temporalis Muscle Are Related in Women With Chronic Tension Type Headache

To describe the common locations of active trigger points (TrPs) in the temporalis muscle and their referred pain patterns in chronic tension type headache (CTTH), and to determine if pressure sensitivity maps of this muscle can be used to describe the spatial distribution of active TrPs. Forty women with CTTH were included. An electronic pressure algometer was used to assess pressure pain thresholds (PPT) from 9 points over each temporalis muscle: 3 points in the anterior, medial and posterior part, respectively. Both muscles were examined for the presence of active TrPs over each of the 9 points. The referred pain pattern of each active TrP was assessed. Two-way analysis of variance detected significant differences in mean PPT levels between the measurement points (F=30.3; P<0.001), but not between sides (F=2.1; P=0.2). PPT scores decreased from the posterior to the anterior column (P<0.001). No differences were found in the number of active TrPs (F=0.3; P=0.9) between the dominant side the nondominant side. Significant differences were found in the distribution of the active TrPs (chi2=12.2; P<0.001): active TrPs were mostly found in the anterior column and in the middle of the muscle belly. The analysis of variance did not detect significant differences in the referred pain pattern between active TrPs (F=1.1, P=0.4). The topographical pressure pain sensitivity maps showed the distinct distribution of the TrPs indicated by locations with low PPTs. Multiple active TrPs in the temporalis muscle were found, particularly in the anterior column and in the middle of the muscle belly. Bilateral posterior to anterior decreased distribution of PPTs in the temporalis muscle in women with CTTH was found. The locations of active TrPs in the temporalis muscle corresponded well to the muscle areas with lower PPT, supporting the relationship between multiple active muscle TrPs and topographical pressure sensitivity maps in the temporalis muscle in women with CTTH.