myofascial pain syndrome

Myofascial Pain Syndrome (MPS) is a prevalent condition characterized by tense muscle bands and hypersensitive Trigger Points (TrPs), contributing to musculoskeletal pain. The objective of this study is to investigate and assess the effectiveness of Advanced High-Power Pain Threshold Static Ultrasound (AHPPTSU) and Muscle Energy Technique (MET) in altering pain thresholds and enhancing functional outcomes in individuals with myofascial trigger points.  In this randomized clinical trial involving 86 individuals with TrPs in the upper trapezius muscle, the participants were divided into experimental and control groups. 33 males and 53 females, underwent six sessions of treatment over two weeks. A repeated measure Analysis of variance was used to compare baseline values and altered values at 1 and 2 weeks. The study demonstrated that the Pressure Pain Threshold (PPT) and the Neck Pain Disability Index (NPDI) score, showed a significant improvements in participants receiving AHPPTUS in experimental group compared to the other group. Experimental group showed a significantly greater improvement in PPT (p=0.001) and both groups experienced a significant enhancement in function. However, when comparing the two groups, experimental group showed a significantly greater improvement (p=0.001). Importantly, no adverse effects were reported in either group. In the treatment of myofascial trigger point, AHPPTSU can be considered as an alternative therapy method, which is more effective than previously used High-Power Pain Threshold Static Ultrasound (HPPTSU) therapy and it also shortens the total treatment protocol to 2 weeks.

Myofascial pain syndrome is a common musculoskeletal injury, especially among athletes, typically treated with symptomatic invasive and non-invasive methods. This study compares the effects of massage guns and radial extracorporeal shock wave therapies on myofascial pain syndrome symptoms in amateur athletes.

In this clinical trial, 45 amateur athletes (18-30 years old) were recruited, who were randomly assigned to 15-member groups of shock wave, massage gun, and control (routine treatment included electrotherapy and stretching, which was applied on three groups). After initial evaluations of the pain intensity, pain pressure threshold (PPT), isometric muscle strength, and range of motion (ROM), the patients received single-session treatment and were immediately reassessed.

The results showed pain relief and improved PPT following shock wave plus routine treatment (P=0.03). The control group had less pain, while pain intensity and PPT did not change. The variables were not significantly different between the groups (P=0.12). Shock wave along with routine treatment increased plantar flexion ROM (P=0.00), unlike the massage gun. Additionally, dorsiflexion ROM (P=0.63) and maximal isometric gastrocnemius muscle strength (P=0.95) remained unchanged in all groups.

One session of massage gun therapy immediately reduced gastrocnemius muscle pain, while it failed to change PPT, maximal isometric gastrocnemius muscle strength, or dorsiflexion and plantar flexion ROM. However, shock wave therapy immediately increased plantar flexion ROM and PPT, and reduced pain intensity. These modalities led to limited changes, suggesting the need for repeated sessions and supplementary treatments.

Forward Head Posture (FHP), which refers to the head being more forward than the shoulder, is one of the most common postural defects of all ages. Therefore, in this study, we aimed to compare the effectiveness of exercise therapy and electroacupuncture in patients with FHP and myofascial pain syndrome (MPS).  

The present study was an open-label randomized clinical trial. A total of 61 patients with FHP and MPS who were referred to the physical medicine clinic of Besat Hospital between 2020 and 2021 were analyzed. Patients in one group were treated with electroacupuncture, and another one was treated with exercise therapy. The primary outcomes were FHP angles (CVA, CA, and shoulder angle), pain intensity (VAS), and quality of life (SF-12). Paired t-test was used to compare the results obtained in the pre-test and post-test. To detect differences over time, the analysis of variance models was used to repeat the observations. If the p-test result is less than the test significance level of 0.05, the null hypothesis is not confirmed.  

The rate of final CVA and increase in CVA in the exercise therapy group were significantly higher than in the electroacupuncture group (P < 0.001). The average shoulder angle in the exercise therapy group increased from 47.1° ± 3.0° to 51.9° ± 3.3° (P < 0.001) and in the electroacupuncture group from 47.9° ± 3.1° to 51.0° ± 2.8° (P < 0.001). A significant difference was observed between the two groups in terms of pain intensity changes during the study.  

Overall, the results of this study showed that both exercise therapy and electroacupuncture significantly improved patients' posture, reduced pain intensity, and increased quality of life in FHP patients with MPS; But exercise therapy was more effective in improving FHP angles and electroacupuncture was more successful in reducing patients' pain intensity.

Lumbar multifidus muscle provides stability to the spine. The present study aimed to evaluate the reliability of ultrasound findings in patients with lumbar multifidus myofascial pain syndrome (MPS). A total of 24 cases (7 females, 17 males, mean age: 40.13± 5.69, BMI: 26.48±4.96) with multifidus MPS were assessed. The variables were muscle thickness in rest and contraction, thickness changes, and cross-sectional area (CSA) in rest and contraction. Two examiners performed the test and retest sessions. The active trigger points of lumbar multifidus on the right and left side of the cases were 45.8 % and 54.2%, respectively. The intraclass correlation coefficient (ICC) values for muscle thickness and thickness changes showed moderate to very high reliability for both within and between intra-examiner measurements. (ICC, 1st examiner: 0.78-0.96; ICC, 2nd examiner: 0.86-0.95). In addition, the ICC values of within and between-session intra-examiner for CSA were high. (ICC, 1st examiner: 0.83-0.88; ICC, 2nd examiner: 0.84-0.89). The ICC and standard error of measurement (SEM) of inter-examiner reliability ranged between 0.75 to 0.93 and 0.19 to 0.88 for multifidus muscle thickness and thickness changes. The ICC and SEM of inter-examiner reliability ranged between 0.78 to 0.88 and 0.33 to 0.90 for CSA of the multifidus muscle.  The within and between-session reliability of multifidus thickness, thickness changes, and CSA was moderate to very high in patients with lumbar MPS when taken by two examiners. Furthermore, the inter-examiner reliability of these sonographic findings was high. Level of evidence: III

Neck pain is the fourth leading cause of disability worldwide. This study aims to investigate the effects of Electro Acupuncture (EA) versus Laser Acupuncture (LA) on symptoms of women with chronic cervical myofascial pain syndrome.

This is a single-blind randomized controlled clinical trial. Thirty women with chronic cervical myofascial pain syndrome were randomly divided into three groups: EA, LA, and sham. The EA group received electrical stimulation through needles at standard acupuncture points, while the LA group received low-intensity laser irradiation at the same points. The passive laser probe was applied for the sham group. The outcome measures were neck pain pressure threshold, neck pain severity, neck disability, and cervical range of motion

The pain severity and disability were significantly lower in the EA group than in the other two groups. The neck range of motion (cervical lateral flexion and rotation) and pain pressure threshold increased significantly in the EA group immediately and one week after the intervention.

Both EA and LA interventions may be effective in alleviating the symptoms of cervical myofascial pain syndrome, but the EA can be more effective in reducing neck pain and disability in women with cervical myofascial pain syndrome.

Myofascial pain syndrome (MPS) is a non-inflammatory disorder with muscle stiffness and pain that occurs with the appearance of palpable and irritating nodules in the muscular system. Stroke is one of the most common neurological diseases that in many cases leads to disability and reduction of quality of life (QOL).

This study aimed to evaluate the relationship between MPS and physical and mental health (MH) status in patients with stroke.

Using available sampling method, this case-control study included 260 patients with stroke. To collect data, demographic characteristics, Visual Analogue Scale (VAS), 36-item Short Form Survey (SF-36), and Depression, Anxiety and Stress Scale (DASS-21) were used. Data analysis was performed using SPSS 16. Mean and standard deviation were used for descriptive statistics and independent t-test, paired t-test, and analysis of variance (ANOVA) were used for inferential tests.

While the pain score was 6.35 (1.39), QOL score was 38.86 (11.69), and MH score was 16.26 (2.75) in the intervention group, these scores were 2.15 (0.96), 63.96 (17.52), and 9.02 (4.63), respectively, in the control group. The results showed no statistically significant relationship between MPS and QOL. But there was a statistically significant relationship between MPS and MH, so that the MH status of patients with MPS was lower than the MH status of other patients.

Necessary interventions have been done to improve the health status of patients with MPS, which will lead to an increase in the health status of these patients.

Myofascial pain syndrome is one of the most common complaints in patients referring to orthopedic treatment centers. The present study aimed to examine the effects of instrument-assisted soft tissue mobilization (IASTM) and dry needling (DN) on active myofascial trigger points (AMTrP) of the upper trapezius muscle (UTM).

The current study was designed as a randomized clinical trial and a total of 81 patients, aged 18-40 years, with active myofascial trigger points in the upper trapezius muscle were randomly divided into 3 groups: group 1 (n = 30) received DN treatment, group 2 (n = 26) received IASTM treatment, and group 3 (n = 25) was considered as the control group (no intervention). The numeric pain scale (NPS), pain pressure threshold (PPT), active cervical contra-lateral flexion (ACLF), neck disability index (NDI), and muscle thickness (MT), according to rehabilitative ultrasonic imaging (RUSI), were measured at baseline, immediately after the last session (session 4 in week 2), and 1 month after the last session. The statistical analysis was conducted at a 95% confidence level. The P values less than .05 were considered as statistically significant.

Both techniques were effective in treating active trigger point of the upper trapezius (p<0.05), but there was no significant difference between the treatment groups in terms of any of the above variables except for ACLF (p>0.05)

Both IASTM and DN were determined to improve NPS, PPT, ROM, and NDI in participants with active trigger points in the upper trapezius, although IASTM was more effective in increasing ACLF in these patients.

Myofascial pain syndrome is one of the most common disorders of the musculoskeletal system with skeletal muscle origin. It is characterized by the presence of trigger points, which are very sensitive points in the muscle and are often found in the tight band of skeletal muscle; they are sensitive to stimulation (pressure or use of dry needles) and create a referral pain in an area far from that points. The prevalence of trigger points is higher in the postural muscles of the upper quarter, especially the trapezius muscle. The aim of this study was to compare the short-term effects of transcutaneous electrical nerve stimulation (TENS) with dry needling on pain, disability, and pressure pain threshold in subjects with trigger points in upper trapezius muscle.

In this clinical trial, 45 patients with upper trapezius muscle trigger points were randomly divided into three groups: TENS and stretching exercise (group A), dry needling and stretching exercise (group B), and stretching exercise alone (group C, control). The joint program between the three groups was to perform trapezius muscle stretching exercises at home for two weeks. In addition to stretching exercise training, group A was treated with TENS for ten sessions during two weeks (5 days a week). Group B, besides stretching exercise training, was treated with three sessions of dry needling for two weeks. Group C was the control group and was trained only in stretching exercises. The outcomes were pain intensity, disability, and pressure pain threshold that were measured using Visual Analog Scale (VAS), Neck Disability Index (NDI), and digital algometer. Paired t-test was used to compare before and after treatment in each group and one-way analysis of variance (ANOVA) test was used to compare mean changes between the three groups.

After treatment, significant improvement was seen in pain intensity and NDI in all three groups (P < 0.001), but there was no significant difference in pressure pain threshold in any of the three groups before and after the intervention (P > 0.05). Moreover, there was no significant difference between the three groups in mean changes of pain, pressure pain threshold, and NDI scores after the intervention compared to before the intervention (P > 0.05).

Although the use of TENS and dry needling along with stretching exercises in subjects with upper trapezius muscle trigger points helps to reduce pain and disability, but it has no additional effect and only stretching exercise in these patients helps to reduce pain and disability to the same extent.

The most critical clinical presentation in myofascial pain syndrome is trigger points. Trigger points are the main problem in 30% of the patients presenting to general internal medicine practice. One of the treatments used for trigger points is ultrasound therapy. The high-power pain threshold ultrasound (HPPTUS) technique is one of the therapeutic ultrasound modifications used to treat trigger points. The present randomized clinical trial aimed to investigate the immediate effect of high-power pain threshold ultrasound on treating active trigger points of the upper trapezius muscle in men with mechanical neck pain.

Fourteen men with mechanical neck pain (Mean±SD age: 34.50±5.24 years) who met the inclusion and exclusion criteria participated in this study. The visual analog scale (VAS), pressure pain threshold (PPT), and range of motion of cervical lateral flexion (CLF) were assessed before and after the treatment. The ultrasound probe was placed on the trigger point. The frequency was set to 1 MHz, and the intensity increased from 0.5 to 2 until the patient reported an unpleasant sensation. The probe was held there for 4 seconds. Then, the intensity was reduced by 50%, and the probe was moved over and around the trigger point. This process was done several times for three minutes.

Analysis of pre-treatment and post-treatment findings showed that the VAS (P<0.001), PPT (P=0.001), and CLF (P<0.001) improved significantly after applying the HPPTUS to trigger points.

Ultrasound significantly improved the muscular symptoms of the trigger points.

 This study aimed to assess the effects of using Extracorporeal Shock Wave Therapy (ECSWT) and phonophoresis therapy on pain and neck disability in patients with neck myofascial pain syndrome (MPS).

 Forty eligible patients were randomly divided into two groups of ECSWT (received three sessions of ECSWT, once a week for three weeks) and phonophoresis (received ultrasound using hydrocortisone gel 1% over the trigger point on trapezius muscle, three times a week for three weeks). Patients in both groups received the same stretching exercise program and drug regimen during the intervention.

 Pain and NDI scores in both groups were significantly improved at the end of the treatment and four weeks later. At the end of the treatment, the pain score was similar between the groups. Four weeks after the treatment, the pain score in the ECSWT group was significantly lower than in the phonophoresis group (P-value = 0.030). The NDI score was not significantly different between the groups at the end of the treatment. However, four weeks after the treatment, the NDI score was significantly lower in the ECSWT group than in the phonophoresis group (P-value=0.032). The trend of changes in the pain and NDI scores was not significantly different between the groups.

 Both phonophoresis and ECSWT groups effectively decreased pain and neck disability in patients with MPS, with the superiority of ECSWT with a more lasting effect for a month after the end of the treatment.

 Tension type headache is the most common type of headache that is associated with myofascial pain syndrome and trigger points. The aim of this study was to evaluate the efficacy of deep dry needling into trigger points of temporalis, sternocleidomastoid and upper trapezius muscles of females with episodic tension type headache.

 The study was a clinical randomized, single-blind, parallel-group trial in which 24 participants were allocated into two groups. The first group received dry needling with passive stretching treatment and the second group (control group) received only passive stretching. Subjects were asked to record headache indices (headache intensity and frequency) for 4 weeks before treatment. Headache intensity and frequency and quality of life (SF-36) were measured at baseline and 4 weeks after the intervention.

 In the dry needling group, the intensity and frequency of headache and physical functioning scores of quality of life questionnaire were significantly improved after treatment (p <0.05).

 Due to the positive effects of deep dry needling and passive stretching in females with episodic tension type headache, the use of deep dry needling into trigger points of head and neck musculature is recommended in the presence of episodic tension type headache.

Nonspecific chronic neck pain is increasing according to work-related gestures and modern lifestyle. Myofascial pain syndrome is a common problem and may be a primary disease. This study was designed to evaluate the prevalence of cervical myofascial pain syndrome in patients with chronic non-specific neck pain with normal MRI. We also examined the correlation between patients’ age as well as pain severity and duration. Patients with neck pain radiating to their upper extremity were examined despite normal MRI findings. We evaluated 10 different muscles based on myofascial pain syndrome criteria and also recorded pain intensity and functional ability using visual analogue scale and neck disability index, respectively. A physical therapist with at least 10 years of clinical experience with myofascial pain syndrome performed all physical examinations A total of 126 patients (69 females and 57 males) participated in this study, out of whom, 14 patients (11.1%) had no muscular involvement, while 112 cases (88.9%) revealed at least one trigger point. The infraspinatus and scalene muscles were the most commonly involved muscles accounting for 38.9% and 34.9% of all the involvements, respectively. The severity of pain was significantly associated with the disability of the patients (r=0.64, P<0.001). However, the correlation between pain and the number of trigger points was not significant (r=-0.19, P=0.31). Finally, the least significantly correlated variables were disability and the number of trigger points (r=-0.17, P=0.05). Patient’s age was significantly correlated neither with the number of trigger points (r=-0.04, P=0.62), nor the pain duration (r=0.07, P=0.39). Myofascial pain syndrome is a common disorder in patients with nonspecific chronic neck pain, despite normal MRI findings. Although, pain is not correlated with the number of trigger points in these patients, we demonstrated a small correlation between patients’ disability and the latter variable. Level of evidence: II

The purpose of the present study was to examine the effectiveness of dry needling as local treatment of upper trapezius trigger points related to chronic neck pain on pain and pain pressure threshold in women with chronic nonspecific neck pain.

Thirty females with an active myofascial trigger point of the upper trapezius muscle were randomly divided into two groups: dry needling with passive stretch (n=15) and passive stretch alone (n=15). They received 5 sessions of the intervention for three weeks. The outcomes were pain intensity and pain pressure threshold. Every outcome was recorded at baseline and 2 days after the fifth session. 

Significant improvement in pain and pain pressure threshold was observed in both groups (P=0.0001) after the treatment. The results of the independent t-test showed a significant difference in measurements between the dry needling and passive stretch groups (P<0.05). 

Dry needling with passive stretch can be more effective on pain and pain pressure threshold than passive stretching alone in short term in women with nonspecific neck pain.

This study aimed to compare the effects of Low-Level Laser Therapy (LLLT) combined with Dry Needling (DN) with DN alone on pain and neck disability index following myofascial pain syndrome.

Sixteen women with active Trigger Points (TrPs) in their upper trapezius muscles participated in this study. They were divided into two groups: Experimental and control. The experimental group received one session of the DN plus the LLLT with 6 j/cm2 energy at their TrPs. The patients in the control group were under a similar procedure, but they did not receive any energy by the LLLT (placebo). The pain score was assessed before, immediately, and 48 hours after the treatment. Neck Disability Index (NDI) was assessed before and 48 hours after the treatment.

There was a significant improvement in pain intensity and NDI scores 48 hours after the treatment in both groups compared with the baseline scores (P<0.05). The pain was also significantly reduced at the patients following laser therapy immediately after the treatment (P=0.01).

A combination of the LLLT and DN might be more effective compared with using DN alone, and reduce immediate pain at the patients with the active TrPs. There was no difference between the groups 48 hours after the treatment. It seems that LLLT has no considerable effect on NDI and pain intensity 48 hours after the treatment.

Musculoskeletal disorders are among the main causes of disability in modern life. Myofascial trigger points are very common among musculoskeletal disorders and may occur through ordinary common activities. This study aimed to determine the combined effects of laser therapy and Ischemic Compression (IC) on the treatment of Myofascial Trigger Points (MTrPs) at the upper trapezius muscle.

Twenty men with at least one active trigger point at their upper trapezius muscle voluntarily participated in this study. Trigger points were under treatment of laser irradiation (6 Joules per point) and also ischemic compression. Treatment approaches were applied over the pain point every other day for 5 sessions in 10 days. Neck disability index, pain intensity by visual analog scale, pressure pain threshold by algometry, and cervical lateral flexion by goniometer were assessed and recorded before the intervention, and immediately after the last session.

At the end of treatment, statistically significant improvements were seen in the neck disability index, VAS value, pressure pain threshold, and cervical lateral flexion. VAS values of the treatment and control groups were compared with the baseline (P<0.001).

Application of combined laser and compression therapy was effective on the pain and level of disability of patients with trigger points in the upper trapezius muscle.

To determine the effects of a bioenergy economy program on the severity of symptoms and quality of life of patients with myofascial pain syndrome

In this randomized clinical-trial, 30 patients with myofascial pain syndrome were assigned to two groups. Patients in the case group participated in a bioenergy economy program for 6 sessions. The data collection tools were the McGill Pain Questionnaire and the WHO Quality of Life -BREF Questionnaire. In addition, the Beck Depression Inventory and the Beck Anxiety Inventory were also applied to patients in both groups. Repeated measures analysis of variance was used to analysis of the changes between the two groups.

According to the analysis, the test of between-subject effect was not significant for pain, QOL, anxiety, and depression (p-value>0.05 for all variables) while the results of the test of within-subject effect were significant (p-value<0.05 for all variables). The effect of the time-group interaction was not significant for pain (P=0.139) and QOL (P=0.169) while it was significant for anxiety (P<0.001) and depression (P=0.026). The mean scores of anxiety and depression decreased during the measurement times in both groups although the decrease was more prominent in the intervention group.

The bioenergy economy program can effectively decrease the pain intensity, depression, and anxiety and improve the quality of life of patients with myofascial pain syndrome. This program can reduce the patients’ distress through modifying attention bias and improving the self-efficacy and acceptance in these patients.

Myofascial Trigger Point (MTrP) is one of the most common musculoskeletal disorders. The MTrP includes highly sensitive points within a taut band, is painful to palpation, and causes pain in a specific pattern. The MTrP is more prevalent in the upper trapezius muscle because this muscle plays an important role in maintaining the posture of the head and neck. 
This study aimed to compare the effects of dry needling and high-intensity laser therapy on the clinical signs of females with active trigger points in the upper trapezius muscle.

Thirty females with the active MTrP of the upper trapezius muscle were randomly assigned into two groups: high-intensity laser therapy group (n=15) and dry needling group (n=15); they received the interventions in five sessions for three weeks. The outcome measures included pain intensity and pain pressure threshold, which were assessed before and two days after the interventions. 

In both study groups, the scores of the visual analogue scale of pain were significantly decreased, also, the pain pressure threshold was significantly increased (P=0.001), after the treatment. However, the two groups did not significantly differ in any of the outcome measures (P>0.05).

Both high-intensity laser therapy and dry needling can be employed to treat the MTrP of the upper trapezius muscle. Considering the effectiveness of the two treatments, each of the methods can be alternatively selected for these patients.