Journal of Bodywork & Movement Therapies 23 (2019) 65e73

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

MYOFASCIAL PAIN AND TREATMENT: EDITORIAL

A critical overview of the current myofascial pain

literature e November 2018

a b s t r a c t

Keywords: This is the first issue of this review column since the passing of Dr. Leon Chaitow. We would like to take a
Myofascial pain syndrome brief moment to acknowledge how much his mentorship, friendship, and confidence have meant to us.
Trigger points Leon was a force in osteopathic and naturopathic medicine and his influence reaches to all corners of the
Dry needling
musculoskeletal realm crossing over many disciplines through his lectures, workshops, and of course, his
Manual therapy
many books, editorials, and articles. In the foreword to one of his books, Jan Dommerholt wrote that
“Leon Chaitow […] continued the work of Travell and Simons, but also of many others, whose contri-
butions he has skillfully woven into an intricate tapestry of clinical pearls, practical tips, and solid
evidence-informed research.” Dr. Chaitow was a synthesizer, who always considered what different
clinicians and researchers could possibly contribute to a better understanding of pain and dysfunction
and provide real solutions to real problems. Even when he would not necessarily agree with all suggested
remedies, he maintained an open mind and was able to take a step back and consider the bigger picture.
For example, Leon was not a big fan of dry needling, yet, he valued the importance of this approach and
encouraged the inclusion of dry needling papers in this review article and in his journal. The Journal of
Bodywork and Movement Therapies became his baby and, considering the growth of the journal, there is
no question that Leon's intense focus and efforts are appreciated by many around the globe. We wish to
extend our condolences to Leon's wife Alkmini and daughter Sasha. He will surely be missed, but we can
find peace in knowing that his legacy will stay with us forever.
In this issue, we have included several basic myofascial pain research articles. As usual, dry needling (DN)
studies and case reports are the most commonly referenced papers, but we also included neuroscience
and electromyography studies, sleep studies, interrater reliability studies, and case reports of adverse
events.
© 2018 Elsevier Ltd. All rights reserved.

1. Basic research tested to ensure each patient understood what to do. Prior to the
study, the authors performed a pilot study with 10 separate sub-
jects to determine the intrarater reliability of the testing used in
Cheatham SW, Kolber MJ, Mokha M, Hanney WJ. 2018. Concurrent
the main study. Results of the pilot study demonstrated good intra-
validity of pain scales in individuals with myofascial pain and fi-
rater reliability. Results of the primary study demonstrated that
bromyalgia. 2018. Journal of Bodywork and Movement Therapies,
there was an excellent relationship for the NPRS and VAS for both
22(2):355-360
the MPS and FM groups. This study was well organized and easy
to follow. The authors did a good job organizing the content should
Investigators from the USA compared the concurrent validity of anyone chose to perform a similar study. Because this was the first
the Numeric Pain Rating Scale (NPRS) and the Visual Analog Scale of its kind for these populations it is good to know that both the
(VAS) in patients with myofascial pain syndrome (MPS) and fibro- NPRS and the VAS can be utilized with these populations. One thing
myalgia (FM). A total of 60 patients were recruited. Thirty had FM of note, however, is the authors did not report if the patients re-
based on the 1990 American College of Rheumatology criteria ported on the NPRS or the VAS first when reporting pain. It could
(Wolfe et al., 1990), and 30 had MPS and did not meet the FM be possible that reporting on the NPRS first versus the VAS could
criteria. Each patient was tested with a pressure algometer at 18 alter results. Also, the 1990 ACR criteria have been replaced with
pre-determined tender points for fibromyalgia. After each point several other more recent criteria dating back to 2010 and it is
was tested with the algometer with up to 4 kg/cm2, or until somewhat surprising that the authors opted to use outdated
maximum pressure was reported, patients recorded their level of criteria to diagnose FM (Wolfe et al 2010, 2011; Bennett et al., 2014).
tenderness with the NPRS and VAS. Prior to testing each patient
Dibai-Filho AV, de Jesus Guirro RR, Ferreira VTK, de Oliveira AK, de
was familiarized with the process by having two control points
Oliveira Guirro EC. 2018. Analysis of chronic myofascial pain in the

https://doi.org/10.1016/j.jbmt.2018.11.002
1360-8592/© 2018 Elsevier Ltd. All rights reserved.
66 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73

upper trapezius muscle of breast cancer survivors and women with between skin temperature to the left and median frequency of right
neck pain. Journal of Bodywork and Movement Therapies, shoulder elevation isometrics and the median frequency of left side
22(2):237e241. resting EMG activity.
Of clinical significance, the authors noted that the higher the
resting EMG activity, the lower the skin temperature. This reported
Researchers from Brazil conducted a cross-sectional study to
observation could be the result of higher EMG muscle activity at
compare the intensity of myofascial pain, catastrophizing, and the
rest, which would result in increased intramuscular pressure
pressure pain threshold (PPT) at upper trapezius TrPs between
creating compression upon the vascular structures within the mus-
breast cancer survivors and women with neck pain. The authors hy-
cle causing local ischemia (Bar~ ao et al., 2011; Rodrigues-Bigaton
pothesized that myofascial pain in breast cancer survivors produces
et al., 2014). In addition, as a result of the increased muscular activ-
greater symptoms than in women with neck pain as a result of a
ity, a higher sympathetic response can result in a reduction of pe-
greater severity of disease and extent of injury from surgical and
ripheral flow with consequent reduction of temperature (Prato
adjuvant treatment breast cancer survivors have endured. Thirty
and Yucha, 2013).
female subjects over the age of 18 were recruited with complaints
This article demonstrates a change in muscle physiology as
of myofascial cervical pain for more than 90 days, and a Neck
measured by a change in skin temperature in patients with chronic
Disability Index (NDI) score
5. Thirty breast cancer survivors
neck pain. Clinical interventions to promote muscle relaxation and
greater than 18 years of age with complaints of myofascial pain in
treating local TrPs can help restore normal muscle tone and flexi-
the upper trapezius muscle region for more than 90 days, who
bility in this patient population.
had previously undergone treatment for breast cancer (surgery,
chemotherapy, and/or radiation therapy) at least six months prior Jafari M, Bahrpeyma F, Mokhtari-Dizaji M, Nasiri A. 2018. Novel
to the study, were included in this study. Subjects in both groups method to measure active myofascial trigger point stiffness using
had the presence of a bilateral, active, and centrally located TrP in ultrasound imaging. Journal of Bodywork and Movement Thera-
the upper trapezius muscle. Each subject was measured for pain in- pies, 22 (2): 374-378
tensity (Numeric Rating Scale), catastrophizing (Pain-Related Self-
Statement Scale), and PPT using an algometer at the bilateral upper
Myofascial trigger points are an important aspect of the patho-
trapezius muscle TrPs.
physiology of MPS. Current assessment is commonly based on
The authors reported a significant difference when comparing
palpation techniques and clinical experience. Diagnostic ultra-
pain intensity (p < 0.001) between the breast cancer survivors (me-
sound has been widely used in real-time for non-invasive imaging
dian score 8) and women with neck pain (median score 2.50). No sig-
and can provide an objective assessment of TrPs. There is growing
nificant difference was noted in catastrophizing and PPT. The authors
elastography evidence that TrPs have a different level of stiffness
concluded that the breast cancer survivors have a higher intensity of
compared to normal adjacent tissues, but elastography is not
myofascial pain in the upper trapezius as compared to patients with
commonly available due to a lack of familiarity and high cost of
neck pain. It is important to note that the breast cancer survivors had
the equipment. Jafari and his colleagues from Iran developed a
a significantly higher age (54 years vs. 22 years) and body mass index
low-cost and simple method to distinguish TrPs from normal adja-
(29.69 kg/m2 vs 21.22 kg/m2) than the neck pain group. The authors
cent tissues through quantitative measurement of elastic modulus
included the utilization of NDI in the comparison group but did not
based on ultrasound imaging.
utilize this in the breast cancer group. The incorporation of this
Twenty-nine female subjects were included in this study based
outcome tool could have allowed a further comparison of dysfunc-
on their history and physical findings of the sternocleidomastoid
tion for both groups. As a result of the outcomes of this study, the au-
(SCM) muscle. The subjects underwent an ultrasound examination
thors report the need for evaluation and intervention for potential
using a clinical ultrasound system targeted at the active TrPs in the
myofascial dysfunction for breast cancer survivors as a result of cen-
SCM muscle. TrPs in ultrasound images were usually considered as
tral sensitization.
hypoechoic focal points with heterogeneous echotexture. To gain
Girasol CE, Dibai-Filho AV, de Oliveira AK1 de Jesus Guirro RR. 2018. elastic modulus in both TrPs and normal part of the muscle, images
Correlation between skin temperature over myofascial trigger of with and without stress states were recorded and measured.
points in the upper trapezius muscle and range of motion, elec- The authors presented a new objective method for the quantita-
tromyographic activity, and pain in chronic neck pain patients. tive measurement of TrPs elastic modulus and distinguished it from
Journal of Manipulative and Physiological Therapeutics, normal adjacent muscular tissue. This non-invasive method can
41(4):350e357. provide informative data after treating TrPs, and it is possible to
study the effect of the proposed therapeutic modalities on TrP stiff-
ness and to investigate the relation between the biomechanical
Researchers from Brazil conducted a single-blinded cross-
properties of TrP and its signs and symptoms.
sectional study to evaluate the correlation between skin tempera-
ture measured using infrared thermography over a TrP in the upper Lin WC, Shen CC, Tsai SJ, Yang AC. 2017. Increased risk of myofascial
trapezius muscle, cervical range of motion (ROM), electromyo- pain syndrome among patients with insomnia. Pain Medicine,
graphic activity (EMG), and pain in subjects with chronic neck 18(8):1557-1565
pain. Forty subjects (38 females, 2 males) with a mean age of
24.31 (range 18e45) years and mean chronic cervical pain duration
Sleep disturbance may induce pain symptoms, especially in
of 55.09 months participated in this study.
chronic pain disorders such as MPS. Poor sleep and pain are closely
The authors reported a positive association between the right
related (Mathias et al., 2018), and further research into their rela-
upper trapezius muscle skin temperature with cervical flexion
tionship is important from a clinical perspective. Researchers
ROM, median frequency of right shoulder elevation isometrics,
from Taiwan conducted a population-based cohort study of the
and the resting median frequency of the left upper trapezius mus-
Taiwan National Health Insurance Research Database (NHIRD)
cle. A negative association was noted between skin temperature of
based on the hypothesis that prolonged or frequent nocturnal sleep
the right upper trapezius TrP and the resting median frequency of
disturbances lead to more subsequent suffering and pain.
the right upper trapezius muscle and a positive correlation
 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73 67

This study showed that patients with insomnia were 1.93 times during TrP compression based on spectral frequency-domain ana-
more likely to develop MPS than control patients after adjusting for lyses of heart rate variability (HRV). The LF/HF ratio was decreased.
age, sex, monthly income, urbanization, and comorbidities. There Besides, prefrontal hemodynamic activity was significantly
were differences depending upon whether patients lived in urban decreased during TrP compression compared with non-TrP
settings or in rural areas, with an increased risk of developing compression. As the Oxy-Hb concentration was significantly
MPS for those patients living in urban settings independent of decreased in the PFC during compression at TrPs, the authors sug-
monthly income level. The prevalence of MPS in urban vs rural pop- gested that Oxy-Hb concentration may be the most consistent
ulations has been reported with inconsistent results. The authors parameter for cortical activity. Furthermore, changes in Oxy-Hb
suggested that elevated cytokine levels in both insomnia and MPS concentration were significantly correlated with changes in HRV
might explain why patients with insomnia are at risk of developing parameters during compression. These findings suggest that unbal-
MPS. anced activity within the PFC might be associated with chronic pain
and hyperactivity in the medial PFC might be involved in altered
Lin YeC, Yu NeY, Jiang CeF, Chang SeH. 2018. Characterizing the
autonomic activity in chronic pain states and that compression at
SEMG patterns with myofascial pain using a multi-scale wavelet
TrPs might suppress sympathetic activity via the medial PFC.
model through machine learning approaches. Journal of Electro-
This is a very interesting study of cortical changes following
myography and Kinesiology, 41:147-153
compression of TrPs and as such, the first such study. Given the pre-
limary results of this pilot study, further studies with greater
Surface electromyography (SEMG) is a common non-invasive numbers of subjects are warranted. The authors clearly identified
measure used to examine neuromuscular function. A new SEMG significant precortical differences between compression of TrPs
model, named multi-scale wavelet energy variation (MSWEV) and non-TrPs, which is more proof that skeptics who keep insisting
graphs, was developed to circumvent the difficulties of handling that TrPs do not exist may need to reconsider their belief system.
between-patient comparisons due to individual-dependent varia-
Poveda-Paga n EJ, Catala
n García I, Catala
n García A, Segura Heras
tions. Uncertainty in human decision making and insufficiency in
JV, Lozano-Quijada C. 2018. Fiabilidad interexaminador de la
classification in different stages of MPS have contributed to the
exploracion de puntos gatillo miofasciales en la musculatura de las
low accuracy in the visual-determined classification process. Re-
regiones cervical y lumbar (in Spanish: Inter-examiner reliability of
searchers from Taiwan conducted a study to employ machine
the examination of trigger points in the cervical and lumbar spine
learning technology to reduce human bias and see if the low accu-
regions. Fisioterapia. 40(2):79-87
racy problem can be resolved.
First, a template matching method was adopted to replace the
previous visually-determined classification process and to mini- During the past few years, several intra- and interrater studies of
mize rater-dependent bias. Classification accuracy of the SEMG the identification of TrPs have been published (Rathbone et al.,
model to differentiate MPS patients from normal subjects was 2017; Rivers et al., 2015; Bron et al., 2007; Grosman-Rimon et al.,
77% using template matching and 60% using K-means clustering. 2017; Mora-Relucio et al., 2016; Zuil-Escobar et al., 2015; Sanz
Second, an auto-clustering process was adopted to automatically et al., 2016; Sales do Nascimento et al., 2018; Rozenfeld et al.,
classify the interference pattern (IP) data into a normal and an 2017; Licht et al., 2007; Mayoral del Moral et al., 2018; De Groef
MPS group. The results were compared to evaluate the efficacy of et al., 2018). Most studies report acceptable degrees of agreement
using the MSWEV graphs to detect MPS. Classification consistency including several excellent ratings. In this prospective observa-
between the two machine learning methods was 87% in the normal tional interrater reliability study from Spain, two non-expert phys-
group and 93% in the MPS group. The 2D feature graphs, MSWEV, iotherapists and one expert therapist examined the
reveal distinct patterns between normal subjects and MPS patients. sternocleidomastoid, upper trapezius, levator scapula, infraspina-
The high consistency of classification results between the two tus, quadratus lumborum, gluteus medius, and piriformis muscles
methods, template matching and K-means clustering, suggests in 30 subjects. They examined the subjects for the presence of a
the potential of using the MSWEV graph to characterize SEMG taut band and a sensitive spot, referred pain, familiar pain provoca-
signal changes associated with MPS. tion, and a local twitch response.
The degree of agreement was nearly perfect except for the local
Morikawa Y, Takamoto K, Nishimaru H, Taguchi T, Urakawa S, Sakai
twitch response and referred pain in some muscles, such as the
S, Ono T, Nishijo H. 2017. Compression at myofascial trigger point
infraspinatus muscle. The intraclass correlation was good or very
on chronic neck pain provides pain relief through the prefrontal
good for all muscles, except for the levator scapula muscle. This
cortex and autonomic nervous system: a pilot study. Frontiers in
study is yet another study that demonstrates that TrPs can be reli-
Neuroscience, 11:186
ably identified.
Rozenfeld, E, Finestone, AS, Moran, U, Damri, E & Kalichman, L,
The prefrontal cortex is involved in the experience of chronic
2017. Test-retest reliability of myofascial trigger point detection in
pain through abnormal activation of the autonomic nervous sys-
hip and thigh areas. Journal of Bodywork and Movement Therapies,
tem. Morikawa and his colleagues in Japan hypothesized that
21, 914e919.
ischemic compression of TrPs might affect the medial prefrontal
cortex (PFC) involved in autonomic regulation, which in turn would
induce pain relief. Through a pilot study of 21 subjects, they This Israeli study examined the intra- and interrater reliability of
analyzed the relationships between prefrontal hemodynamic activ- the TrP identification in the lower extremities. The authors claimed
ity, activity of the autonomic nervous system, and subjective pain in that this was the first such study of the lower extremity, but there
patients with chronic neck pain, with and without TrP compres- are several other lower limb interrater reliability studies such as
sion. Prefrontal hemodynamic activity includes changes in Oxy- Sanz et al. and Zuil-Escobar et al. (Sanz et al., 2016; Zuil-Escobar
hemoglobin (Hb), Deoxy-Hb, and total-Hb concentrations. The re- et al., 2015). Twenty-one subjects with various pain locations
searchers found that a low frequency (LF) component of HRV was were examined four times by two experienced physical therapists
decreased, but a high frequency (HF) component was increased in a random order for the presence of a taut band, tenderness,
68 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73

referred pain, and relevance of referred pain to the patient's Neck pain is a common musculoskeletal condition presenting
complaint. The rectus femoris (proximal), vastus medialis (middle with varying degrees of disability. Frequently, there is no identifi-
and distal), vastus lateralis (middle and distal), and gluteus medius able underlying disease or abnormal anatomic structure leading to
(anterior, posterior and distal) muscles were included for a total of the use of the term “nonspecific neck pain.” Chou et al. reported
16 locations. The authors concluded that the inter- and intra-tester on the effects of acupuncture on the electromyographic (EMG) ac-
reliability of active and latent TrP evaluation was moderate to sub- tivity of the upper trapezius (UT) muscle in individuals with TrPs
stantial with Cohen's kappa values ranging from 0.25 to 0.77. following ACP of acupoints known as triple energizer 5 (TE-5;
There were individual differences between muscles; the examina- ”Wai-guan”) and large intestine 11 (LI-11; ”Qu-chi”) (Chou et al.,
tion of the distal vastus medialis was the most reliable for latent 2009). There are no studies that have examined this treatment
and active TrP's. Palpation of TrPs in the lower extremity is a moder- in patients with nonspecific neck pain. The authors of this study
ately reliable diagnostic tool, which can be used in the clinic and in conducted a randomized, single-blinded, sham-controlled cross-
research studies. over study to assess changes in UT EMG activity and pain in pa-
tients with nonspecific neck pain following a single session of
2. Reviews acupuncture. Fifteen patients with nonspecific neck pain and 15
healthy participants that served as a control group (CG) were
enrolled in this study. Inclusion criteria for the nonspecific neck
Adah F, Huang M. 2018. The effectiveness of dry needling on the
pain group were: neck pain for a minimum of 3 months, restricted
reduction of proximal upper quadrant pain using Cohen's d: a
neck movement in at least 1 direction, a score on the Neck
systematic review. Journal of the Mississippi Academy of Sciences,
Disability Index (NDI) between 15 and 24 (out of 50), and a score
63(2) Supplemental:194-201
on the Numeric Rating Scale (NRS) for perceived pain intensity be-
tween 3 and 7 on an 11-point scale (range 0e10). Subjects were
This systematic review was conducted to determine if DN to the included in the CG if they were physically active with no self-
trapezius muscle in patients with proximal upper quadrant pain reported history or positive signs of cervical spine or scapular
reduced pain intensity compared to controls and other interven- dysfunction with physical examination. Prior to any testing, a
tions using Cohen's d to measure outcomes. Cohen's d was used baseline NRS was collected. EMG of the UT was assessed as each
to describe the standardized mean difference of an effect (Cohen, subject performed shoulder elevation at 5 force levels (15%, 20%,
1988). The authors maintain using Cohen d for magnitude of effects 25%, 30%, and again at 20%) to examine possible manifestations
of intervention may be clinically more useful as a difference be- of fatigue. Following one minute of rest, NRS scores were recorded
tween statistical significance and outcomes measures like Cohen's again and the acupuncture needles were inserted and left in-situ
d that provide a magnitude of the difference and whether that dif- for 30 minutes in both groups. Each subject received a single ses-
ference is significant or not looking at the Confidence Interval (CI). sion of acupuncture and sham acupuncture. Acupuncture was per-
This article contends that the effectiveness of DN may be depen- formed using a 0.25  13 mm needle that was inserted in LI-11 in
dent on which statistical analysis is used, either p-value or effect the direction of the lateral epicondyle and in at TE-5 to a depth
size. Eleven randomized clinical trials were assessed in this system- where participants reported a sensation of de-qi. The LI-11 point
atic review. Using Cohen's d to measure the efficacy, the authors re- is located at the outermost point of the skinfold of elbow flexion.
ported DN had a large effect and was more superior for pain control The TE-5 point is located 3 cm above the joint line of the wrist, at
in five studies compared to controls/interventions (Effect Size [ES] the dorsal face of the forearm between the radius and ulna. Partic-
range 0.81e17.46; CI: 0.08e1.50 and 15.19e19.50 respectively), ipants in the CG received needles that were inserted superficially
moderate effect in one study which was not significant (ES 0.52; 1 cm to the side of each acupuncture point. In both groups, the
CI: 0.15e1.8), and a small effect which was not significant in needles were rotated in both the clockwise and counterclockwise
two studies (ES 0.07 to 0.23; CI -0.86e1.00 and 0.18e0.63). In directions for 10 seconds every 3 minutes, at an approximate fre-
three studies, DN appeared to be less effective but insignificant quency of 60 times per minute. After 30 minutes, the needles were
when compared to either control or other interventions (ES range removed and the NRS was recorded again, followed by a second
0.32 to 0.14; CI 0.18e0.63 and 0.89e0.60 respectively). EMG examination that was performed in the same manner as pre-
This article outlines varying methods to examine outcomes in a viously described. This was followed by a final NRS evaluation
study. The authors compared the findings using p-value to that of following rest for 2 minutes.
Cohen's d to determine effect size. The authors utilized eleven arti- The authors reported significant effects for the nonspecific neck
cles in this systematic review whose sample sizes ranged from 17 to pain group following treatment in both the acupuncture and sham
128. Although Cohen's d can be utilized to calculate effect size, acupuncture for NRS scores. EMG amplitude was significantly
when sample sizes are small the effect size can be biased and over- decreased in both groups following acupuncture treatment. In
stated. Therefore, to correct for this bias, Hedge's g may be used for addition, the authors reported no significant differences between
small sample sizes. It can easily be calculated and may have been the acupuncture and sham acupuncture treatment for the NRS or
warranted in this study. This article does examine the varying EMG amplitude. The authors concluded that the effects of both
means of interpreting outcomes as both statistically and clinically acupuncture at acupoints TE-5 and LI-11 or in close proximity
relevant. contribute to pain relief in patients with nonspecific neck pain
and muscle fatigue and decreased EMG activity of the upper trape-
3. Dry needling, acupuncture, and injections zius muscle activity in both healthy individuals and patients with
nonspecific neck pain. Limitations of this study include the use of
sham acupuncture points approximate to the target acupoint as
Calamita SAP, Biasotto-Gonzalez DA, De Melo NC, Fumagalli MA, well as using the same needle insertion depth that may have not
Amorim CF, de Paula Gomes CAF, Politti F. 2018. Immediate effect of allowed for a true control group. Further studies using another
acupuncture on electromyographic activity of the upper trapezius form of sham acupuncture are warranted to examine the use of
muscle and pain in patients with nonspecific neck pain: a ran- acupoints or peripheral acupuncture for patients presenting with
domized, single-blinded, sham-controlled, crossover study. Journal nonspecific neck pain.
of Manipulative and Physiological Therapeutics, 41(3):208e217.
 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73 69

Gascon-Garcia J, Bagur-Calafat C, Girabent-Farr es M, Balius R. they combined TDN with other forms of needling such as superfi-
2018. Validation of the range of dry needling with the fascial cial needling, needling of non-trigger points, or injection treatment.
winding technique in the carpal tunnel using ultrasound. Journal of Eleven randomized trials involving 496 subjects were included
Bodywork and Movement Therapies, 22(2):348-353 in this review that compared TDN to a control or sham needling,
no intervention, other interventions, including acupuncture, wet
needling, medication, exercises, or manual therapy, such as soft tis-
Spanish investigators performed an interesting validation study
sue mobilizations, joint mobilizations and manipulations, or exer-
showing how solid filament needles placed in the region of the car-
cise training. Primary outcomes of pain and dysfunction were
pal tunnel can reach the transverse carpal ligament (TCL) and cause
evaluated as well as other secondary outcome measures including
a traction-stretching of the ligament when the needles are rotated.
pain pressure threshold and self-rated recovery. In addition, the fre-
The authors used sonography to perform the assessment. Addition-
quency and severity of adverse effects were assessed.
ally, they determined the possible risks associated with the tech-
The authors reported very low evidence to support the use of
nique. A total of 9 healthy subjects who met the inclusion and
TDN in the shoulder region for treating patients with upper ex-
exclusion criteria where included. Both wrists were utilized for a
tremity pain or dysfunction. Two studies reported adverse effects
total of 18 assessments. The authors did determine the sample
from TDN, with post-needling soreness being the most common.
size needed prior to initiating the study for better interpretation
The meta-analysis was limited to two studies that were conducted
of results. The clinician, who inserted the needles and conducted
by the same principal authors, which therefore limit generalization
the ultrasound had 12 and 25 years of experience respectively.
of its findings. The findings of this review agree with those by
Four 0.30  25 mm needles were inserted in an oblique, dorsal
Kietrys et al., (2013) and demonstrate the need for well-designed
midline direction at a 45-degree angle at the scaphoid, pisiform,
clinical trials that can likely impact treatment effects.
trapezium, and hamate bones until a firm elastic resistance was
felt. This resistance was believed to be the TCL. The needle place- Nystrom NA, Freeman MD. 2018. Central sensitization is modulated
ment was confirmed with the ultrasound once for each of the following trigger point anesthetization in patients with chronic
four locations. The needles were rotated unidirectionally. Data pain from whiplash trauma. a double-blind, placebo-controlled,
collected with the ultrasound included the distance of the needle crossover study. Pain Medicine, 19(1):124-129
tip to the TCL and/or contact with the ligament, the distance of
the needle tip to the median nerve, the distance of the needle tip
The relationship between central sensitization (CS) and TrPs is a
to the ulnar artery, and traction stretching of the TCL. They also
topic of debate within the literature. TrPs may be expressions of CS
tracked whether there was any surface bleeding or bruising and
and CS may be a promoter of TrPs (Ferna ndez-de-las-Pen~ as and
the pain intensity with needling measured on the Visual Analog
Dommerholt, 2014; Srbely, 2010). Others have purported that
Scale (VAS).
TrPs do not play a role in CS (Curatolo et al., 2001). This study
Results showed that 93.1% of the needles came into direct con-
was conducted to investigate the immediate response of CS to alter-
tact with the TCL, with 81.9% of them being in contact and 11.1%
ations in nociceptive input. Thirty-one subjects with chronic pain
going through the TCL. No contact with the TCL was found in
(trapezius myalgia) and CS after whiplash were included in this
6.9% of the needle insertions with an average distance of 1.41
study. One TrP or “tender point” was identified with a permanent
mm. The distance of the tip of the needle to the median nerve
marker on the upper trapezius muscle of the affected side for
ranged from 2.55 mm to 5.81 mm depending on the location of
each subject. Subjects were then randomized into two treatment
the needle being inserted. The distance of the tip of the needle to
groups: Group A (N ¼ 15) and Group B (N ¼ 16). Group A received
the ulnar artery ranged from 3.82 mm to 11.22 depending on the
a subfascial injection of 2mL bupivacaine 0.25mg/mL using a 25 g
location of where the needle was inserted. Visualization of stretch-
needle at the upper trapezius skin mark. Group B received a
ing of the TCL was observed in 80.6% of the needles. Pain was expe-
sham injection of 0.5 ML local anesthetic solution (bupivacaine
rienced with 98.5% of needle withdrawals, with the average VAS
0.25 mg/mL) given intra-dermally at the upper trapezius skin
score being 1.52. After 10 minutes, 16.67% continued to experience
mark. Repeat measurements for pressure pain thresholds (PPT),
pain that averaged 0.74 on the VAS, but a week later no pain was
grip strength, jaw opening, and resting pain (Visual analog scale)
reported. There was minimal and superficial bleeding only from
were recorded beginning after 2 min following the injection and
the proximal needle insertions in 8.3%. This was an interesting
completed within 5 min.
study highlighting how the TCL can be accessed safely with needles
The authors reported significantly higher PPT and maximum
and be stretched in a majority of cases. The impact on this tech-
voluntary jaw opening observed in Group A but not in Group B.
nique on patients with carpal tunnel syndrome is not known, but
VAS scores were significantly lower in both groups. Following 30
it does offer an interesting approach to treat patients.
minutes of the injection subjects in Group B were informed of
Hall ML, Mackie AC, Ribeiro DC. 2018. Effects of dry needling trigger the randomization and a TrP injection was then performed as pre-
point therapy in the shoulder region on patients with upper ex- viously described for Group A followed by repeated measurements.
tremity pain and dysfunction: a systematic review with meta- Significant improvements were noted for all variables following
analysis. Physiotherapy, 104(2):167-177 this second injection in Group B. As a result of this study the au-
thors discuss surgical ablation of TrPs as a potential treatment for
CS.
Hall and coworkers conducted a systematic review with meta-
This study has several shortcomings that should be noted prior
analysis on trigger point dry needling (TDN) to determine its effec-
to recommending surgical intervention including a small sample
tiveness of the shoulder region for management of upper extremity
size, no long-term follow-up, cervical range of motion was not
pain or dysfunction and to examine the reports of adverse effects
observed, and the authors did not offer a description of the inclu-
during the treatment. Randomized controlled trials comparing
sion criteria of “prior failed conservative treatment.” Furthermore,
the effects of TDN of at least one TrP in the shoulder region for
although the authors concluded that since subjects in Group B
shoulder or upper extremity pain or dysfunction were included.
described the first injection as no less painful or uncomfortable
Cohort and case-controlled studies were included if they assessed
than subjects in Group A, the authors consider phase II free from
the adverse effects of TDN in the study. Studies were excluded if
expectation bias; however, as it should be noted since the authors
70 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73

informed the subjects in Group B prior to their second injection was very weak at best. It did not include extensive palpation of
that the initial injection was a “sham injection,” it is possible that the tissues in the upper extremity to determine possible referral
subjects within this group were indeed biased as a result of this of pain from proximal muscles to the medial epicondyle region.
information. As a result, there is no justification for the use of needles. The au-
thors did not include any clinical reasoning considerations for the
nchez-Mila Z, Salom-Moreno J, Ferna
Sa ndez-de-las-Pen
~ as C Effects
location of needle insertions or why the needles were left in situ
of dry needling on post-stroke spasticity, motor function and sta-
versus manipulated in the tissue. They did not use any outcome
bility limits: a randomised clinical trial Acupuncture in Medicine
forms to assess disability or function. The authors relied solely on
Published Online First: 09 July 2018
the patient's self-report. Additionally, they reported that “subjec-
tive measures of this study were based on observing localized
Dry needling is used increasingly with patients suffering from tenderness just below the medial epicondyle with pain and having
neurological problems, such as CVA, Parkinson, and multiple scle- a limitation in forceful wrist flexion and a limitation in forearm pro-
rosis, among others. Initially, clinicians focused primarily on pain nation against resistance.” While this appears to be an objective ex-
reduction, but more recently researchers are exploring whether amination, the authors suggested that the patient was reporting the
DN can reduce the degree of spasticity (Ansari et al., 2015; Calvo findings. Additionally, it is not clear how localized tenderness can
et al., 2016; Mendigutia-Gomez et al., 2016; Salom-Moreno et al., be observed without palpation. Due to the many issues with this
2014). In the current study from Spain, 26 CVA patients were paper, the paper does not really contribute much to our under-
randomly assigned to one of two groups. Subjects in group 1 standing of dry needling. Clearly, the athlete benefitted from the
were treated with the Bobath method only, while subjects in group intervention, but other recovery mechanisms cannot be excluded.
2 also received a single session of ultrasound-guided DN of the
Sheikhhoseini, R., Massoud Arab, AM. 2018. Dry Needling in myo-
tibialis posterior muscle. Subjects in both groups participated in
fascial tracks in Non-Relaxing Pelvic Floor Dysfunction: A case
strengthening, stretching and reconditioning exercises. Outcome
study. Journal of Bodywork & Movement Therapies 22:337-340
measures included the Modified Ashworth Scale for spasticity,
the Fugl-Meyer Scale for function, and stability limits including
movement velocity, maximum excursion, end-point excursion, Clinicians from Iran described the case of a 42-year old man
and directional control using computerized dynamic posturogra- with a 20-year history of frequent urination. He had to urinate
phy with the SMART EquiTest System. A blinded examiner collected every 30 minutes, described difficulty initiating urination and had
the data. The researchers found a significantly greater decrease in a sense of incomplete evacuation. He was diagnosed with Non-
spasticity in the subjects in the DN group and improved balance, Relaxing Pelvic Floor Dysfunction (NRPFD), for which there is no
range of motion, and accuracy of maintaining stability. This study gold treatment standard. The authors emphasized the need to
supports the use of DN to decrease spasticity and suggests that appreciate the pelvic anatomy and especially the connections of
DN should possibly be considered before resorting to injections the endopelvic fascia with the visceral and abdominal fascia, the
with botulinum toxin. Dry needling also improved balance and sta- pelvic floor muscles, and hip and core muscles. The patient denied
bility, which is not all that easy to achieve with other treatment ap- a history of low back and pelvic pain, sexual dysfunction and other
proaches. When considering DN for spasticity, it is important to related symptoms. He did acknowledge that the symptoms wors-
realize that the target of the needling procedure is a spastic muscle ened with occupational and general stress. Previous physical ther-
and not a particular TrP or acupuncture point. The mechanisms un- apy, including interferential therapy, biofeedback, and massage,
derlying DN for spasticity remain somewhat speculative and more was unsuccessful. Upon physical examination, he presented with
research is certainly needed. tenderness in the hip adductors, piriformis and obturator internus
muscles. The patient was treated with DN of the adductor longus,
Shariat A, Noormohammadpour P, Memari AH, Ansari NN, Cleland
magnus, and brevis, obturator internus, piriformis, gluteus maxi-
JA, Kordi R. 2018. Acute effects of one session dry needling on a
mus and medius, and rectus abdominis muscles as described by
chronic golfer's elbow disability. Journal of Exercise Rehabilitation
Dommerholt and Ferna ndez-de-las-Pen~ as (Dommerholt and
14(1):138-142
Fernandez-de-las-Pen~ as, 2013). The patient had 10 sessions of
DN, 2 or 3 times per week. The patient's home exercise program
Investigators from Iran and the US published a case report on a included stretches of the hip adductor and flexor, piriformis and
single session of dry needling on a retired elite athlete with medial hamstrings muscles.
epicondylalgia that started 2 years ago after training with thera- During the treatment period, the patient's symptoms slowly
band and elastic ropes. The patient had seen 3 different providers improved. By the 7th session, he was able to go walking and
in the past year and also had an MRI that did not yield any signifi- jogging. Three months after discharge, he reported no urinary fre-
cant findings. The patient's shoulder, elbow, and hand were exam- quency or any adverse events. This is a nice case report of the suc-
ined following a standardized method for assessment by the cessful treatment of a patient with severe urinary frequency that
American Shoulder and Elbow surgeons committee in 1999. The resolved with DN.
elbow was also examined with sonography. The patient received
Silva de Camargo P, Lima CR, de Andrade E Rezende ML, Silva
dry needling with 10 needles left in situ for 20 minutes in the wrist
Santos AT, Rodrigues Hernandez JW, Silva AM. 2018. The effect of
flexor region at the medial epicondyle. After the needles were
auricular and systemic acupuncture on the electromyographic
removed the patient had an ice pack to the area. The time frame
activity of the trapezius muscle with trigger pointsda pilot study.
was not specified.
Journal of Acupuncture and Meridian Studies, 11(1):18-24
Immediately after the treatment range of motion or pain did not
change. Two days later, however, the patient reported decreased
pain and increased tolerance to functional activities, and seven Researchers from Brazil conducted a study to analyze and
days later he was able to start using exercise bands pain-free. compare the intra and intergroup comparisons of the immediate
Although this article reports positive effects of dry needling, there effect of the auricular and systemic acupuncture LR8 (QuQuan) on
are several issues with the paper. First, the objective examination the surface electromyographic (EMG) activity of the trapezius
 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73 71

muscle with the TrPs. Forty volunteers were randomly assigned to with increased neck and shoulder ROM. Interestingly, she also
of four groups: GI (mustard seed applicated in the auricular point); noted a considerable improvement in her sleep quality. At a 1-
GII (bilateral needling in the LR8 acupoint); GIII (the combination of year follow up, she had maintained good quality sleep for 7e8
GI and GII); and GIV (mustard seed applicated to an acupoint not hours without any residual problems.
linked to the muscle tendon as a control group). Finally, they found Although DN is commonly indicated for reducing pain, it may
that 5 min of systemic and auricular acupuncture did not promote also help with sleep disorders. Perhaps DN contributes to stress
changes in the EMG activity of the muscle during maximum volun- reduction through an effect on the limbic system. Several acupunc-
tary contraction (MVC). ture studies have shown that acupuncture can also regulate various
The authors’ hypothesis that either auricular acupoint or sys- neurotransmitters and hormonal factors, which can play major
temic acupoint may act on the EMG activity of TrPs in the upper roles in sleep regulation.
trapezius muscle was rejected as neither technique changed the
EMG activity. The authors suggested that possibly there were no
changes because of the small sample size and the short treatment
4. Manual therapy
duration. Based on the current study, auricular and systemic acu-
points stimulation cannot be recommended unless more studies
demonstrate relaxation of muscles and tendons. Ginszt M, Berger M, Gawda P, Boz_ yk A, Gawda J, Szkutnik J, Suwała
M, Majcher P, Kapelan M. 2017. The immediate effect of masseter
Uzar T, Turkmen I, Menekse EB, Dirican A, Ekaterina P, Ozkaya S.
trigger points compression on masticatory muscle activity. Ortho-
2018. A case with iatrogenic pneumothorax due to deep dry
dontic Forum; 13: 79-88
needling. Radiology Case Reports 13:1246-1248

Investigators from Turkey examined the immediate effect of TrP

As an invasive intervention, dry needling is prone to significant
compression to latent masseter TrPs on pressure pain threshold
adverse events (Cummings et al., 2014; Mccutcheon and Yelland,
(PTT) and muscle activity in healthy individuals. Fifteen subjects,
2011; Karavis et al., 2015; Norheim, 1996; Yamashita et al., 2000).
10 women and 5 men, with unilateral latent TrPs in the masseter
Although the risk of significant adverse events was less than
muscle were included in the study. The researchers used Simons
0.04% in a prospective Irish study (Brady et al., 2014), the authors
et al.'s criteria (Simons et al., 1999). Muscle activity of the bilateral
of this paper present a case of a 36-year old male who was admitted
masseter, anterior temporalis, and anterior digastric muscles was
to the emergency room of a Turkish hospital with complaints of
recorded with surface electrodes under three different conditions:
right chest pain following a dry needling treatment 2 h earlier for
rest, maximum voluntary clenching, and maximum voluntary
pain in his back muscles. X-rays appeared to be normal initially,
clenching with cotton rolls. Each clenching activity was performed
but on further examination, a minimal pneumothorax was seen
three times for 3 s each with a 2 s rest in between each repetition.
as a thin line on the right hemithorax. The patient was scanned
The PPT of the masseter muscle was assessed with a digital algo-
with high-resolution computed tomography, which did reveal a
meter. The average of three measurements was taken. Both the
pneumothorax. The entrance areas of the needles to lung paren-
muscle activity and PPT were measured before and after the
chyma was visible on the scan. Fortunately, the patient recovered
masseter muscle compression treatment, which was performed
in three days without further intervention. This report reminds cli-
for 90 seconds with a constant pressure of 2 kg/cm2. Results of
nicians that proper technique based on a solid anatomical under-
the study showed that there was no significant difference between
standing remain important to avoid such serious adverse events.
the mean muscle activity of the masseter, anterior temporalis, and
In general, dry needling by physical therapists is a safe proced-
masseter muscles on either side during any of the three positions
ure. During the past 5 years, the major malpractice insurance com-
tested. The PPT of the masseter muscle was decreased on the TrP
pany for physical therapists in the USA has processed 34 liability
side compared to the non-treated/non-TrP side. There was a signif-
cases related to DN, which made up only 1% of the total number
icant difference in the mean muscle activity at rest after the TrP
of liability cases. We estimate that during the 5-year period at least
compression versus before in the masseter muscle with the TrP
125 million DN treatments were administered by physical thera-
and both sides of the digastric muscles.
pists in the US.
Although it is interesting to see that manual TrP treatment can
Yaghoubi Z, Pardehshenas H, Takamjani IE. 2018. The effect of upper influence the PPT and some muscle activity, the value of this
trapezius muscle dry needling treatment on sleep quality: A case research is somewhat limited. First, the number of participants in
report. Journal of Bodywork & Movement Therapies, 22(2): 333- the study is very small. Second, healthy subjects were utilized
336 instead of patients with a diagnosis of temporomandibular
dysfunction. The experience of the clinicians identifying TrPs and
treating the TrPs was not discussed, nor the experience of the per-
Poor sleep quality is significantly associated with MPS (Lin et al.,
son using the surface electromyography. This can have an impact on
2017). The relationship between the presence of active TrPs, the in-
outcomes and also results. Furthermore, the authors did not offer a
tensity of pain, disability, and sleep quality in individuals with neck
plausible explanation for why the anterior digastric muscles bilat-
pain has been studied and should be addressed in a patient with
erally had reduced muscle activity at rest after masseter TrP
MPS. The authors from Iran reported a case of a 34-year old, female
compression. Finally, this study only looked at the immediate effect
hairstylist, who complained of increasing chronic pain and early fa-
of TrP compression of the masseter, there was no short-term or
tigue in both shoulder and upper back during working hours. Be-
long-term follow-up. With that, caution should be taken with inter-
sides, she had difficulty falling asleep, and could only stay asleep
preting these results.
for an average 3 or 4 hours. Previous physical therapy and medica-
tions only provided temporary improvements over the past three Maistrello LF, Geri T, Gianola S, Zaninetti M, Testa M. 2018. Effec-
years. After she received six weekly sessions of DN of active TrPs tiveness of trigger point manual treatment on the frequency, in-
in the upper trapezius (UT) muscle, she reported a significant tensity, and duration of attacks in primary headaches: a systematic
decrease in pain and muscle relaxation in the shoulder region review and meta-analysis of randomized controlled trials. Frontiers
in Neurology, 9:254
72 Myofascial pain and treatment: Editorial / Journal of Bodywork & Movement Therapies 23 (2019) 65e73

kinesiotherapy increases the pressure pain threshold of TrPs in

Investigators from Italy and Austria performed a systematic re- the upper trapezius muscle and reduces the intensity of pain in
view and meta-analysis to explore the effectiveness of manual breast cancer survivors with myofascial pain.
treatment of TrPs and its effectiveness in reducing the frequency, The authors explained that the objective of ischemic compres-
intensity, and duration of primary headaches in patients. Primary sion is to inhibit TrPs, by improving blood flow and tissue nutrition,
headaches included tension-type headache (TTH), migraine head- which would facilitate increased perfusion and increased oxygen
ache (MH), and cluster headache (CH). They also examined whether supply to the skeletal muscle, even there is no evidence that this
a particular manual technique or dosage would be superior to actually happens. Travell and Simons discontinued the use of the
another. A total of 7 studies met the inclusion and exclusion criteria. term “ischemic compression” when it became clear that TrPs are
Treatments had to target TrPs and be either direct or indirect tech- hypoxic already, but clinicians and researchers continue to use
niques. The manual treatment had to be compared to some type of the term even when ischemia most likely does not even occur
intervention such as placebo, sham, routine medications, or waitlist with pressures of just 2.5 kg/cm2, which is what the authors used
with routine medications. Primary outcomes included the fre- in this study.
quency, duration, and intensity of headache attacks. Secondary out-
comes included quality of life (QOL), medication consumption, 5. Statement of interest
effects on TrPs, and adverse events. The Cochrane Risk of Bias
(RoB) tool was used to assess internal validity. The Grading of Rec- Jan Dommerholt, Michelle Finnegan, and Todd Hooks are affili-
ommendations Assessment, Development and Evaluation (GRADE) ated with Myopain Seminars, LLC, Bethesda, MD, USA, an organiza-
approach was used to evaluate the overall quality of evidence. tion that promotes the recognition and treatment of individuals
The frequency, intensity, and duration of headache attacks with myofascial pain.
showed a significant improvement when comparing manual TrP
treatment to other interventions for TTH and MH, however, several
studies had a high RoB. Similarly, when examining the manual TrP References
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