1 BMC Medicine 2011 Vol: 9(1):8. DOI: 10.1186/1741-7015-9-8

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

Shoulder 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. A 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. Compared 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). The 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 number ISRCTN: ISRCTN75722066

Mentions
Figures
Figure 1: Referred pain pattern (red) from supraspinatus muscle MTrP Figure 2: Referred pain pattern (red) from infraspinatus muscle MTrP Figure 3: Referred pain pattern from teres minor muscle MTrP Figure 4: Referred pain pattern from subscapularis muscle MTrP. The referred pain patterns according to Simons et al. 26. MTrPs are indicated by X. Illustrations courtesy of LifeART/MEDICLIP 88. Figure 5: Manual compression on the MTrP in the infraspinatus muscle of the left shoulder. Figure 6: Stroking with ice (in a polystyrene cup) in unidirectional parallel strokes combined with gentle muscle stretching applied for the infraspinatus muscle of the left shoulder while the patient was lying on one side. Figure 7: Cross-body muscle-stretching exercise for posterior shoulder muscles, including the infraspinatus muscle. Figure 8: Schematic showing patient participation. Figure 9: The mean Disability of Arm, Shoulder, and Hand outcome measure (DASH) scores (error bars represent 95% confidence intervals) at intake, after 6 weeks and after 12 weeks for the intervention group (n = 34) and the control group (n = 31). Figure 10: The number of patients who improved by more than 10 points (minimal clinically important difference) on the DASH outcome measure after 12 weeks for the intervention group (n = 34) and the control group (n = 31).
Altmetric
References
  1. PM Bongers The cost of shoulder pain at work BMJ 322, 64-65 (2001) .
    • . . . In several countries, the 1-year prevalence is estimated to be 20% to 50% 1 2 . . .
  2. GJ Van der Heijden Shoulder disorders: a state-of-the-art review Baillieres Best Pract Res Clin Rheumatol 13, 287-309 (1999) .
    • . . . In several countries, the 1-year prevalence is estimated to be 20% to 50% 1 2 . . .
  3. SD Bot; JM van der Waal; CB Terwee; DA van der Windt; FG Schellevis; LM Bouter; J Dekker Incidence and prevalence of complaints of the neck and upper extremity in general practice Ann Rheum Dis 64, 118-123 (2005) .
    • . . . The annual incidence of shoulder pain and symptoms in Dutch primary care practice ranges from 19 to 29.5 per 1,000 3 4 . . .
  4. A Feleus; SM Bierma-Zeinstra; HS Miedema; RM Bernsen; JA Verhaar; BW Koes Incidence of non-traumatic complaints of arm, neck and shoulder in general practice Man Ther 13, 426-433 (2008) .
    • . . . The annual incidence of shoulder pain and symptoms in Dutch primary care practice ranges from 19 to 29.5 per 1,000 3 4 . . .
  5. C Mitchell Shoulder pain: diagnosis and management in primary care BMJ 331, 1124-1128 (2005) .
    • . . . Shoulder pain is the main contributor to nontraumatic upper-limb pain, in which chronicity and recurrence of symptoms are common 5 6 . . .
  6. DA Van der Windt; BW Koes; AJ Boeke; W Devillé; BA De Jong; LM Bouter Shoulder disorders in general practice: prognostic indicators of outcome Br J Gen Pract 46, 519-523 (1996) .
    • . . . Shoulder pain is the main contributor to nontraumatic upper-limb pain, in which chronicity and recurrence of symptoms are common 5 6 . . .
  7. LU Bigliani; WN Levine Subacromial impingement syndrome J Bone Joint Surg Am 79, 1854-1868 (1997) .
    • . . . The most common cause of shoulder pain is considered to be subacromial impingement syndrome (SIS), which causes inflammation and degeneration of subacromial bursae and tendons 7 8 . . .
  8. MC Koester; MS George; JE Kuhn Shoulder impingement syndrome Am J Med 118, 452-455 (2005) .
    • . . . The most common cause of shoulder pain is considered to be subacromial impingement syndrome (SIS), which causes inflammation and degeneration of subacromial bursae and tendons 7 8 . . .
  9. DS Morrison; AD Frogameni; P Woodworth Non-operative treatment of subacromial impingement syndrome J Bone Joint Surg Am 79, 732-737 (1997) .
    • . . . SIS was first described in 1867 by French anatomist and surgeon Jarjavay 9 , was reintroduced in 1972 by Neer 10 . . .
  10. CS Neer Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report J Bone Joint Surg Am 54, 41-50 (1972) .
    • . . . SIS was first described in 1867 by French anatomist and surgeon Jarjavay 9 , was reintroduced in 1972 by Neer 10 . . .
  11. HB Park; A Yokota; HS Gill; G El Rassi; EG McFarland Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome J Bone Joint Surg Am 87, 1446-1455 (2005) .
    • . . . Although the interpretation of the physical signs during shoulder examinations is far from reliable 11 12 , the diagnosis of SIS is based mainly on the clinical picture of pain in the shoulder as described by Neer 13 . . .
    • . . . The clinical picture consists of an arc of pain, crepitus and muscle weakness as well as a positive impingement test, which means complete relief of pain with forced forward elevation of the upper arm after injection of a local anesthetic into the subacromial space 11 . . .
  12. LA Michener; MK Walsworth; WC Doukas; KP Murphy Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement Arch Phys Med Rehabil 90, 1898-1903 (2009) .
    • . . . Although the interpretation of the physical signs during shoulder examinations is far from reliable 11 12 , the diagnosis of SIS is based mainly on the clinical picture of pain in the shoulder as described by Neer 13 . . .
  13. CS Neer Impingement lesions Clin Orthop Relat Res 173, 70-77 (1983) .
    • . . . Although the interpretation of the physical signs during shoulder examinations is far from reliable 11 12 , the diagnosis of SIS is based mainly on the clinical picture of pain in the shoulder as described by Neer 13 . . .
  14. NH Andersen; JO Søjbjerg; HV Johannsen; O Sneppen Self-training versus physiotherapist-supervised rehabilitation of the shoulder in patients treated with arthroscopic subacromial decompression: a clinical randomized study J Shoulder Elbow Surg 8, 99-101 (1999) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  15. GJ Bergman; JC Winters; KH Groenier; B Meyboom-de Jong; K Postema; GJ van der Heijden Manipulative therapy in addition to usual care for patients with shoulder complaints: results of physical examination outcomes in a randomized controlled trial J Manipulative Physiol Ther 33, 96-101 (2010) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  16. B Blair; AS Rokito; F Cuomo; K Jarolem; JD Zuckerman Efficacy of injections of corticosteroids for subacromial impingement syndrome J Bone Joint Surg Am 78, 1685-1689 (1996) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  17. R Buchbinder; S Green; JM Youd Corticosteroid injections for shoulder pain Cochrane Database Syst Rev 1, CD004016 (2003) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  18. RL Diercks; SJ Ham; JM Ros [Results of anterior shoulder decompression surgery according to Neer for shoulder impingement syndrome; little effect on fitness for work] [in Dutch] Ned Tijdschr Geneeskd 142, 1266-1269 (1998) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  19. OM Ekeberg; E Bautz-Holter; EK Tveitå; NG Juel; S Kvalheim; JI Brox Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study BMJ 338, a3112 (2009) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  20. J Camarinos; L Marinko Effectiveness of manual physical therapy for painful shoulder conditions: a systematic review J Man Manip Ther 17, 206-215 (2009) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  21. O Dorrestijn; M Stevens; JC Winters; K van der Meer; RL Diercks Conservative or surgical treatment for subacromial impingement syndrome? a systematic review J Shoulder Elbow Surg 18, 652-660 (2009) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  22. JA Coghlan; R Buchbinder; S Green; RV Johnston; SN Bell Surgery for rotator cuff disease Cochrane Database Syst Rev 1, CD005619 (2008) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  23. LA Michener; MK Walsworth; EN Burnet Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review J Hand Ther 17, 152-164 (2004) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  24. F Desmeules; CH Côté; P Frémont Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review Clin J Sport Med 13, 176-182 (2003) .
    • . . . Scientific evidence from randomized, controlled trials (RCTs), meta-analyses or systematic reviews of RCTs regarding the effectiveness of multimodal rehabilitation, injection therapy, medication, surgery, physical therapy or the application of other therapies in patients with shoulder pain is conflicting or lacking 14 15 16 17 18 19 20 21 22 23 24 , which justifies a search for an alternative explanation of shoulder pain, regardless of whether the patient is diagnosed with SIS. . . .
  25. A Hidalgo-Lozano; C Fernández-de-las-Peñas; C Alonso-Blanco; HY Ge; L Arendt-Nielsen; M Arroyo-Morales Muscle trigger points and pressure pain hyperalgesia in the shoulder muscles in patients with unilateral shoulder impingement: a blinded, controlled study Exp Brain Res 202, 915-925 (2010) .
    • . . . A common cause of muscle pain is myofascial pain caused by myofascial trigger points (MTrPs) [ 25 ; Bron et al, unpublished work] . . .
    • . . . These interventions may have an unintentional effect on MTrPs in shoulder muscles because MTrPs seem to be prevalent in patients with shoulder pain, which may have contributed to the results of other studies [ 25 ; Bron et al, unpublished work] . . .
  26. DG Simons; JG Travell; LS Simons Travell &amp; Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Upper Half of Body 0, (1999) .
    • . . . MTrPs in the shoulder muscles produce symptoms similar to those of other shoulder pain syndromes, including pain at rest and with movement, sleep disturbances and pain provocation during impingement tests 26 . . .
    • . . . The referred pain patterns according to Simons et al. 26 . . .
    • . . . It is always tender, prevents full lengthening of the muscle, weakens the muscle, refers a patient-recognized pain on compression, mediates a local twitch response of muscle fibers when adequately stimulated and, when compressed within the patient's pain tolerance, produces referred motor phenomena and often autonomic phenomena, generally in its pain reference zone, and causes tenderness in the pain reference zone" [ 26 , page 1] . . .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
    • . . . These manual techniques could be preceded or followed by "intermittent cold application by using ice-cubes followed by stretching the muscle" according to Simons et al. 26 . . .
    • . . . When the pain was only local and not familiar, MTrPs were considered to be latent 26 37 53 . . .
    • . . . The management of MTrPs is not restricted to MTrP inactivation, but it requires correction of perpetuating factors that are clinically apparent but not yet necessarily scientifically established 26 41 43 . . .
  27. RD Gerwin; J Dommerholt; JP Shah An expansion of Simons' integrated hypothesis of trigger point formation Curr Pain Headache Rep 8, 468-475 (2004) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  28. CZ Hong; DG Simons Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points Arch Phys Med Rehabil 79, 863-872 (1998) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  29. S Mense; DG Simons; U Hoheisel; B Quenzer Lesions of rat skeletal muscle after local block of acetylcholinesterase and neuromuscular stimulation J Appl Physiol 94, 2494-2501 (2003) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  30. JP Shah; JV Danoff; MJ Desai; S Parikh; LY Nakamura; TM Phillips; LH Gerber Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points Arch Phys Med Rehabil 89, 16-23 (2008) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  31. S Sikdar; JP Shah; T Gebreab; RH Yen; E Gilliams; J Danoff; LH Gerber Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue Arch Phys Med Rehabil 90, 1829-1838 (2009) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
    • . . . Although magnetic resonance elastography and ultrasound imaging studies have shown potential in allowing clinicians to visualize MTrPs, their clinical usefulness has yet to be established 31 32 . . . .
  32. Q Chen; J Basford; KN An Ability of magnetic resonance elastography to assess taut bands Clin Biomech (Bristol, Avon) 23, 623-629 (2008) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
    • . . . Although magnetic resonance elastography and ultrasound imaging studies have shown potential in allowing clinicians to visualize MTrPs, their clinical usefulness has yet to be established 31 32 . . . .
  33. C Couppé; A Midttun; J Hilden; U Jørgensen; P Oxholm; A Fuglsang-Frederiksen Spontaneous needle electromyographic activity in myofascial trigger points in the infraspinatus muscle: a blinded assessment J Musculoskel Pain 9, 7-16 (2001) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  34. C Fernández-de-las-Peñas; ML Cuadrado; L Arendt-Nielsen; DG Simons; JA Pareja Myofascial trigger points and sensitization: an updated pain model for tension-type headache Cephalalgia 27, 383-393 (2007) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  35. DM Niddam; RC Chan; SH Lee; TC Yeh; JC Hsieh Central representation of hyperalgesia from myofascial trigger point Neuroimage 39, 1299-1306 (2008) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  36. CW Chang; YR Chen; KF Chang Evidence of neuroaxonal degeneration in myofascial pain syndrome: a study of neuromuscular jitter by axonal microstimulation Eur J Pain 12, 1026-1030 (2008) .
    • . . . Clinical, histological, biochemical and electrophysiological research has provided biological plausibility for the existence of MTrPs 27 28 29 30 31 32 33 34 35 36 . . .
  37. C Bron; J Franssen; M Wensing; RA Oostendorp Interrater reliability of palpation of myofascial trigger points in three shoulder muscles J Man Manip Ther 15, 203-215 (2007) .
    • . . . Previous studies have shown that trained physical therapists can reliably detect MTrPs by palpation 37 38 . . .
    • . . . When the pain was only local and not familiar, MTrPs were considered to be latent 26 37 53 . . .
  38. AM Al-Shenqiti; JA Oldham Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis Clin Rehabil 19, 482-487 (2005) .
    • . . . Previous studies have shown that trained physical therapists can reliably detect MTrPs by palpation 37 38 . . .
  39. FJ Aguilera; DP Martín; RA Masanet; AC Botella; LB Soler; FB Morell Immediate effect of ultrasound and ischemic compression techniques for the treatment of trapezius latent myofascial trigger points in healthy subjects: a randomized controlled study J Manipulative Physiol Ther 32, 515-520 (2009) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
  40. M Cummings; P Baldry Regional myofascial pain: diagnosis and management Best Pract Res Clin Rheumatol 21, 367-387 (2007) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
  41. J Dommerholt; C Bron; J Franssen Myofascial trigger points: an evidence-informed review J Man Manip Ther 14, 203-221 (2006) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
    • . . . The management of MTrPs is not restricted to MTrP inactivation, but it requires correction of perpetuating factors that are clinically apparent but not yet necessarily scientifically established 26 41 43 . . .
  42. J Edwards; N Knowles Superficial dry needling and active stretching in the treatment of myofascial pain: a randomised controlled trial Acupunct Med 21, 80-86 (2003) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
  43. RD Gerwin A review of myofascial pain and fibromyalgia: factors that promote their persistence Acupunct Med 23, 121-134 (2005) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
    • . . . The management of MTrPs is not restricted to MTrP inactivation, but it requires correction of perpetuating factors that are clinically apparent but not yet necessarily scientifically established 26 41 43 . . .
  44. WP Hanten; SL Olson; NL Butts; AL Nowicki Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points Phys Ther 80, 997-1003 (2000) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
    • . . . Others have examined the effect of single ischemic compression or a combination of ischemic compression and stretching and concluded that both interventions had positive effects on patients' recovery 44 . . .
  45. CZ Hong Treatment of myofascial pain syndrome Curr Pain Headache Rep 10, 345-349 (2006) .
    • . . . MTrP inactivation may be combined with ergonomic advice, active exercises, postural correction and relaxation if and when appropriate 26 39 40 41 42 43 44 45 . . .
  46. RS Ingber Shoulder impingement in tennis/racquetball players treated with subscapularis myofascial treatments Arch Phys Med Rehabil 81, 679-682 (2000) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  47. C Bron; JLM Franssen; BGM de Valk Een posttraumatische schouderklacht zonder aanwijsbaar letsel [A post-traumatic shoulder complaint without apparent injury] [in Dutch] Ned Tijdschrift v Fysiotherapie 111, 97-102 (2001) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  48. ND Weed When shoulder pain isn't bursitis: the myofascial pain syndrome Postgrad Med 74, 97-98 (1983) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  49. SL Grosshandler; NE Stratas; TC Toomey; WF Gray Chronic neck and shoulder pain: focusing on myofascial origins Postgrad Med 77, 149-151 (1985) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  50. CW Daub A case report of a patient with upper extremity symptoms: differentiating radicular and referred pain Chiropr Osteopat 15, 10 (2007) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  51. MD Reynolds Myofascial trigger points in persistent posttraumatic shoulder pain South Med J 77, 1277-1280 (1984) .
    • . . . However, several case studies have suggested that the treatment of MTrPs in patients with shoulder pain may be beneficial, although well-designed controlled studies are still lacking 46 47 48 49 50 51 . . .
  52. G Hains; M Descarreaux; F Hains Chronic shoulder pain of myofascial origin: a randomized clinical trial using ischemic compression therapy J Manipulative Physiol Ther 33, 362-369 (2010) .
    • . . . Recently, Hains et al. 52 compared ischemic compression of relevant MTrPs (intervention) with ischemic compression of irrelevant MTrPs (sham treatment) . . .
    • . . . Recently, Hains et al. 52 published the first report on the effectiveness of ischemic compression therapy of MTrPs in shoulder muscles in patients with chronic shoulder conditions compared with sham compression . . .
    • . . . The intervention group showed a significant improvement on the Shoulder Pain and Dysfunction Index compared with the sham group 52 . . .
  53. C Bron; M Wensing; JL Franssen; RA Oostendorp Treatment of myofascial trigger points in common shoulder disorders by physical therapy: a randomized controlled trial [ISRCTN75722066] BMC Musculoskelet Disord 8, 107 (2007) .
    • . . . This RCT is registered at Current Controlled Trials [ISRCTN75722066], and the study protocol was published previously 53 . . . .
    • . . . All individual treatments, however, were consistent with the limits of the treatment protocol (Figures 5, 6, 7) 53 . . . .
    • . . . A detailed description of the goniometric measurement of the PROM is published in the report describing the design of this study 53 . . . .
    • . . . When the pain was only local and not familiar, MTrPs were considered to be latent 26 37 53 . . .
  54. CD Mallen; G Peat; E Thomas; KM Dunn; PR Croft Prognostic factors for musculoskeletal pain in primary care: a systematic review Br J Gen Pract 57, 655-661 (2007) .
    • . . . A detailed medical history was completed, which included demographic variables and potential prognostic factors 54 55 and a set of self-administered questionnaires regarding outcome measurements, including the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, the Visual Analogue Scale for Pain (VAS-P), the RAND Medical Outcomes Study 36-Item Short Form Health Survey (RAND-36) and the Beck Depression Inventory, Second Edition (BDI-II) . . .
  55. T Kuijpers; DA van der Windt; GJ van der Heijden; LM Bouter Systematic review of prognostic cohort studies on shoulder disorders Pain 109, 420-431 (2004) .
    • . . . A detailed medical history was completed, which included demographic variables and potential prognostic factors 54 55 and a set of self-administered questionnaires regarding outcome measurements, including the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, the Visual Analogue Scale for Pain (VAS-P), the RAND Medical Outcomes Study 36-Item Short Form Health Survey (RAND-36) and the Beck Depression Inventory, Second Edition (BDI-II) . . .
  56. C Gummesson; I Atroshi; C Ekdahl The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery BMC Musculoskelet Disord 4, 11 (2003) .
    • . . . The planned sample size was determined on the basis of an assumed mean improvement of the primary outcome, a DASH questionnaire score of 15 points (SD ± 22), which implies an effect size of 0.68 56 . . .
    • . . . The Minimal Clinically Important Difference (MCID) is approximately a 10-point difference between pre- and posttreatment 56 61 62 . . .
    • . . . However, the mean of the baseline DASH questionnaire score was smaller than expected on the basis of results from other studies 56 75 76 . . .
  57. Research Randomizer: Free Random Sampling and Random AssignmentLink , .
    • . . . A research assistant (IS) performed the randomization by generating random numbers using Research Randomizer software (http://www.randomizer.org/) 57 . . .
  58. GP Szeto; LM Straker; PB O'Sullivan EMG median frequency changes in the neck-shoulder stabilizers of symptomatic office workers when challenged by different physical stressors J Electromyogr Kinesiol 15, 544-555 (2005) .
    • . . . All patients received ergonomic advice and instructions to assume and maintain good posture 58 59 . . .
  59. E Peper; VS Wilson; KH Gibney; K Huber; R Harvey; DM Shumay The integration of electromyography (SEMG) at the workstation: assessment, treatment, and prevention of repetitive strain injury (RSI) Appl Psychophysiol Biofeedback 28, 167-182 (2003) .
    • . . . All patients received ergonomic advice and instructions to assume and maintain good posture 58 59 . . .
  60. S Solway; D Beaton; S McConnell; C Bombardier The DASH Outcome Measure User's Manual , (2002) .
    • . . . The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire is an internationally widely used multidimensional 30-item self-report measure focusing on physical function, pain and emotional and social parameters 60 . . .
  61. JS Roy; JC MacDermid; LJ Woodhouse Measuring shoulder function: a systematic review of four questionnaires Arthritis Rheum 61, 623-632 (2009) .
    • . . . The Minimal Clinically Important Difference (MCID) is approximately a 10-point difference between pre- and posttreatment 56 61 62 . . .
    • . . . The DASH questionnaire is a reliable, valid questionnaire and is considered to be one of the best questionnaires for patients with shoulder symptoms 61 63 . . . .
  62. JS Schmitt; RP Di Fabio Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria J Clin Epidemiol 57, 1008-1018 (2004) .
    • . . . The Minimal Clinically Important Difference (MCID) is approximately a 10-point difference between pre- and posttreatment 56 61 62 . . .
  63. DE Beaton; JN Katz; AH Fossel; JG Wright; V Tarasuk; C Bombardier Measuring the whole or the parts? validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity J Hand Ther 14, 128-146 (2001) .
    • . . . The DASH questionnaire is a reliable, valid questionnaire and is considered to be one of the best questionnaires for patients with shoulder symptoms 61 63 . . . .
  64. HM McCormack; DJ Horne; S Sheather Clinical applications of visual analogue scales: a critical review Psychol Med 18, 1007-1019 (1988) .
    • . . . The Visual Analogue Scale for Pain (VAS-P) is a self-report scale consisting of a horizontal line 100 mm in length that is anchored by the ratings "no pain" at the left side (score 0) and "worst pain imaginable" at the right side (score 100) 64 65 66 . . .
  65. A Williamson; B Hoggart Pain: a review of three commonly used pain rating scales J Clin Nurs 14, 798-804 (2005) .
    • . . . The Visual Analogue Scale for Pain (VAS-P) is a self-report scale consisting of a horizontal line 100 mm in length that is anchored by the ratings "no pain" at the left side (score 0) and "worst pain imaginable" at the right side (score 100) 64 65 66 . . .
  66. PS Myles; S Troedel; M Boquest; M Reeves The pain visual analog scale: is it linear or nonlinear? Anesth Analg 89, 1517-1520 (1999) .
    • . . . The Visual Analogue Scale for Pain (VAS-P) is a self-report scale consisting of a horizontal line 100 mm in length that is anchored by the ratings "no pain" at the left side (score 0) and "worst pain imaginable" at the right side (score 100) 64 65 66 . . .
  67. AM Kelly The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain Emerg Med J 18, 205-207 (2001) .
    • . . . A 14-mm change is considered to be a MCID in patients with rotator cuff disease 67 68 69 70 . . . .
  68. MJ Loos; S Houterman; MR Scheltinga; RM Roumen Evaluating postherniorrhaphy groin pain: Visual Analogue or Verbal Rating Scale? Hernia 12, 147-151 (2008) .
    • . . . A 14-mm change is considered to be a MCID in patients with rotator cuff disease 67 68 69 70 . . . .
  69. DA O'Connor; LS Chipchase; J Tomlinson; J Krishnan Arthroscopic subacromial decompression: responsiveness of disease-specific and health-related quality of life outcome measures Arthroscopy 15, 836-840 (1999) .
    • . . . A 14-mm change is considered to be a MCID in patients with rotator cuff disease 67 68 69 70 . . . .
  70. EC Huskisson Measurement of pain Lancet 2, 1127-1131 (1974) .
    • . . . A 14-mm change is considered to be a MCID in patients with rotator cuff disease 67 68 69 70 . . . .
  71. SJ Kamper; RW Ostelo; DL Knol; CG Maher; HC de Vet; MJ Hancock Global Perceived Effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status J Clin Epidemiol 63, 760-766.e1 (2010) .
    • . . . The GPE scale has good test-retest reliability and correlates well with changes in pain and disability 71 . . . .
  72. KK Zakzanis Statistics to tell the truth, the whole truth, and nothing but the truth: formulae, illustrative numerical examples, and heuristic interpretation of effect size analyses for neuropsychological researchers Arch Clin Neuropsychol 16, 653-667 (2001) .
    • . . . Effect sizes measured using Cohen's d were calculated to examine the average impact of the intervention 72 . . .
  73. J Cohen Statistical Power Analysis for the Behavioral Sciences , (1988) .
    • . . . According to the method of Cohen, d ≈ 0.2 indicates small effect and negligible clinical importance, d ≈ 0.5 indicates medium effect and moderate clinical importance and d ≈ 0.8 indicates a large effect and crucial clinical importance 73 . . .
  74. AR Tate; PW McClure; IA Young; R Salvatori; LA Michener Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series J Orthop Sports Phys Ther 40, 474-493 (2010) .
    • . . . The difference 74 of the DASH questionnaire scores between groups was smaller than the MCID . . .
    • . . . For example, exercise therapy or manual therapy interventions included soft tissue massage and muscle-stretching exercises, which generally are performed for anterior and posterior muscle tightness 74 77 78 79 . . .
  75. I Lombardi; AG Magri; AM Fleury; AC Da Silva; J Natour Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial Arthritis Rheum 59, 615-622 (2008) .
    • . . . However, the mean of the baseline DASH questionnaire score was smaller than expected on the basis of results from other studies 56 75 76 . . .
  76. CA Kennedy; M Manno; S Hogg-Johnson; T Haines; L Hurley; D McKenzie; DE Beaton Prognosis in soft tissue disorders of the shoulder: predicting both change in disability and level of disability after treatment Phys Ther 86, 1013-1032 (2006) .
    • . . . However, the mean of the baseline DASH questionnaire score was smaller than expected on the basis of results from other studies 56 75 76 . . .
  77. K Bennell; E Wee; S Coburn; S Green; A Harris; M Staples; A Forbes; R Buchbinder Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial BMJ 340, c2756 (2010) .
    • . . . For example, exercise therapy or manual therapy interventions included soft tissue massage and muscle-stretching exercises, which generally are performed for anterior and posterior muscle tightness 74 77 78 79 . . .
  78. DP Crawshaw; PS Helliwell; EM Hensor; EM Hay; SJ Aldous; PG Conaghan Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial BMJ 340, c3037 (2010) .
    • . . . For example, exercise therapy or manual therapy interventions included soft tissue massage and muscle-stretching exercises, which generally are performed for anterior and posterior muscle tightness 74 77 78 79 . . .
  79. K Engebretsen; M Grotle; E Bautz-Holter; L Sandvik; N Juel; O Ekeberg; J Brox Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study BMJ 339, b3360 (2009) .
    • . . . For example, exercise therapy or manual therapy interventions included soft tissue massage and muscle-stretching exercises, which generally are performed for anterior and posterior muscle tightness 74 77 78 79 . . .
  80. R Gerwin Myofascial pain syndrome: here we are, where must we go? J Musculoskeletal Pain 18, 18 (2010) .
    • . . . One explanation might be that the state of MTrPs is more or less dynamic and that changes from active to latent and vice versa occur, depending on the degree of irritability 80 . . . .
    • . . . Restricted range of motion may be observed secondary to a contracted taut band 80 82 83 . . .
  81. S Mense How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculoskelet Pain 18, 348-353 (2010) .
    • . . . This means that a neuron can acquire new receptive fields in the presence of nociceptive input" [ 81 , page 350] . . .
  82. D Falla; D Farina; T Graven-Nielsen Experimental muscle pain results in reorganization of coordination among trapezius muscle subdivisions during repetitive shoulder flexion Exp Brain Res 178, 385-393 (2007) .
    • . . . Restricted range of motion may be observed secondary to a contracted taut band 80 82 83 . . .
  83. KR Lucas; PA Rich; BI Polus Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of latent myofascial trigger points Clin Biomech 25, 765-770 (2010) .
    • . . . Restricted range of motion may be observed secondary to a contracted taut band 80 82 83 . . .
  84. AM Cools; EE Witvrouw; GA Declercq; LA Danneels; DC Cambier Scapular muscle recruitment patterns: trapezius muscle latency with and without impingement symptoms Am J Sports Med 31, 542-549 (2003) .
    • . . . A changed motor activation pattern has often been reported in the shoulder pain literature 84 . . .
  85. D Treaster; WS Marras; D Burr; JE Sheedy; D Hart Myofascial trigger point development from visual and postural stressors during computer work J Electromyogr Kinesiol 16, 115-124 (2006) .
    • . . . Further research is needed to clarify the importance of perpetuating factors, such as mechanical factors, in patients with shoulder pain 85 . . . .
  86. MR DiMatteo Evidence-based strategies to foster adherence and improve patient outcomes JAAPA 17, 18-21 (2004) .
    • . . . Awareness of educational levels is important, as it may affect patients' motivation and compliance 86 87 , but adding the level of education as a covariate in multiple linear regression analysis did not alter the results. . . .
  87. MR DiMatteo Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research Med Care 42, 200-209 (2004) .
    • . . . Awareness of educational levels is important, as it may affect patients' motivation and compliance 86 87 , but adding the level of education as a covariate in multiple linear regression analysis did not alter the results. . . .
  88. LifeART/MEDICLIP, Manual Medicine 1, Version 1.0aBaltimore, MD: Lippincott Williams & Wilkins1997 , (1997) .
    • . . . Illustrations courtesy of LifeART/MEDICLIP 88. . . .
  89. K Van der Zee; R Sanderman RAND-36 Manual , (1993) .
    • . . . VAS-P1, current pain score; VAS-P2, average pain score for the past 7 days; VAS-P3, most severe pain score for the past 7 days. eHigher scores on the Beck Depression Inventory, 2nd edition, Dutch-language version (BDI-II-DLV) indicate more symptoms of depression (range, 0-63). fOnly the subscales of the nine subscales of the RAND Medical Outcomes Study 36-Item Short Form Health Survey, Dutch-language version (RAND-36-DLV) that differ significantly from a normal Dutch population are presented here 89 . . .
Expand