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A Multimodal Approach for Myofascial Pain Syndrome: A Prospective Study
A Multimodal Approach for Myofascial Pain Syndrome: A Prospective Study María Segura-Pérez, PT, a M. Teresa Hernández-Criado, PT, a César Calvo-Lobo, PhD, MSc, PT, b Lorena Vega-Piris, MSc, c Raquel Fernández-Martín, PT, a and David Rodríguez-Sanz, PT, DP, PhD d
ABSTRACT Objective: The purpose of this study was to analyze pain intensity in patients with myofascial pain syndrome (MPS) following a multimodal rehabilitation protocol. Methods: A prospective study was carried out following the Template for Intervention Description and Replication criteria. Patients were recruited from the rehabilitation unit of a university hospital in Spain between 2009 and 2013. Patients were included if they had a medical diagnosis of MPS in any of the following regions: cervicobrachial (n = 102), lumbosacral (n = 30), elbow (n = 14), ankle and foot (n = 10), and temporomandibular jaw (n = 1). The multimodal rehabilitation protocol included myofascial trigger point dry needling, spray and stretching, Kinesio taping, eccentric exercise, and patient education. The protocol was applied for 4 weeks (5 sessions) for the active and/or latent myofascial trigger points in each body region. Pain intensity was measured by using the visual analog scale (VAS) immediately before beginning of the study and 1 week after completion of the protocol. Results: The study sample comprised 150 patients (mean ± standard deviation age, 51.5 ± 1.19 years). Statistically significant differences were obtained for reduction in pain intensity (4 ± 2.03; P = .002). Clinically relevant reductions (VAS ≥30 mm; P b .001) were obtained in 78.7% of the interventions. Four treatment sessions reduced the VAS score by 10 mm in 83.55% of the sample. There were no statistically significant differences (P = .064) for reduction in pain intensity in the different body regions. Conclusions: A multimodal rehabilitation protocol showed clinically relevant differences in the reduction in pain intensity in different body regions in patients with MPS. (J Manipulative Physiol Ther 2017;xx:1-7) Key Indexing Terms: Myofascial Pain Syndromes; Musculoskeletal Disorders; Musculoskeletal Pain; Rehabilitation; Trigger Points
INTRODUCTION There is a high rate of musculoskeletal pain among the general adult population (26%), general older adult a Physical Therapy Unit, University Hospital la Princesa, Madrid, Spain. b Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, University of León, León, Spain. c Health Research Institute, University Hospital la Princesa, Madrid, Spain. d Physical Therapy & Health Sciences Research Group, Physiotherapy Department, Faculty of Health, Exercise and Sport, European University, Madrid, Spain. Corresponding author: César Calvo-Lobo, PhD, MSc, PT, Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, University of León, Av. Astorga, s/n, 24401 Ponferrada, León, Spain. Tel.: +34 987 442 053. (e-mail: [email protected]). Paper submitted June 6, 2017; in revised form June 7, 2017; accepted June 15, 2017. 0161-4754 © 2017 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2017.06.001
population (39%), and workers (86%). 1 Myofascial pain syndrome (MPS) is a condition prevalent in patients who report spinal and upper and lower limb pain. 2-4 The prevalence of MPS in people with musculoskeletal pain varied from 30% in primary care to 85% to 93% in specialized pain units. 5 Indeed, 48.9% of medical specialists and physical therapists treat more than 4 patients with MPS per week and estimate a prevalence of active myofascial trigger points (MTrPs) in 46.1% of the general population and 52.8% of their patients. A higher rate is reported by clinical professionals who attend pain conferences (55.4% and 63.4%, respectively). 6 As a possible consequence, 60% of the cost of treating pain in the Spanish public health system is spent on ineffective treatments. 7 Signs and symptoms recorded at MTrPs may generate sensory, motor, and autonomic conditions. On the one hand, MTrPs produce spontaneous and recognizable pain when they are active; on the other hand, they produce nonrecognizable local or referred pain upon stimulation when they are latent. 8-10 Nevertheless, MTrPs are hyperirritable spots in a taut band of muscle fibers, which may be
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identified with palpation (distinguishing subjects with pain from subjects with no pain), 11 analysis of the biochemical milieu (distinguishing MTrPs from muscular tissue with no-MTrPs), 12 sonoelastography, 13 electromyography, 14 thermography, 15 and magnetic resonance elastography. 16 Both invasive and conservative interventions have been proposed for the treatment of MTrP. 17 Among the invasive treatments, MTrP dry needling (MTrP-DN) is recommended to relieve pain immediately or in the short term. 18 Studies by Mayoral et al. have shown a medium-term analgesic effect of MTrP-DN against placebo under anesthesia. 19,20 Deep, fast in-and-out techniques with multiple rapid insertions trigger a regenerative process (6-7 days) and reduced acetylcholine in the motor end plate that are affected by peripheral and central pain modulation mechanisms. 20-24 Active and latent MTrP-DN could reduce pain and mechanosensitivity in patients with MPS. 25-27 Additional conservative interventions include spray and stretching, which reduces postneedling soreness in the short term (b6 hours), 28 and Kinesio taping, which modifies MTrP pain, stiffness, and contraction amplitude. 29-31 In addition, eccentric exercise and an MPS educational program could be combined with MTrPs-DN to decrease pain. 32-35 MTrP-DN, 18 spray and stretching, 28 Kinesio taping, 29-31 eccentric exercise, 32-34 and education 35 may modulate the pain intensity after MPS treatment of latent and active MTrPs. Nevertheless, there are controversial studies reporting that pain relief after the inclusion of MTrP-DN in a multimodal therapy program depends on the body regions affected. 36,37 Therefore, the aim of this study was measure pain intensity following a multimodal rehabilitation protocol for MPS in different body regions.
METHODS Design A prospective longitudinal experimental study was carried out in the hospital rehabilitation service in Madrid Spain from October 2009 to June 2013. The template for intervention description and replication (TIDieR) checklist and guide was followed. 38 The study was approved by the Clinic Research Ethics Committee of the Princess University Hospital, Madrid (Spain). A signed informed consent document was obtained from each patient before the study. The ethical standards of the Declaration of Helsinki were followed. 39
Subjects A convenience sample of 164 patients was recruited over 4 years (October 2009 to June 2013). Inclusion criteria were a diagnosis of MPS and a recommendation by the rehabilitation physician for MTrP-DN for the body regions affected by various subacute and chronic musculoskeletal conditions, including cervicobrachial (MPS in the infraspinatus, middle deltoid, levator scapulae, and trapezius;
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infraspinatus tendon rupture and tendinopathy; complete rotator cuff rupture and tendinopathy; supraspinatus tendinopathy and rupture; cervicobrachialgia; neck pain; shoulder pain; calcific tendinitis; capsulitis; contusion; subacromial syndrome; acromioclavicular dislocation; subscapularis tendinopathy; and subacromial bursal calcification), lumbosacral (piriformis syndrome and MPS; trochanteritis; disc herniation and protrusion; lumbar sciatic and back pain; MPS in the gluteus medius and maximus; and spondylolisthesis), elbow (lateral and medial epicondyle tendinopathy and wrist tendinopathy), foot (plantar fasciitis), and temporomandibular joint regions. Exclusion criteria were as follows: need for more than 5 protocol-based treatment sessions; neurological, visceral, inflammatory, and acute conditions in the medical records; cognitive deficits; previous surgery; conservative or invasive physical therapy (during the previous 6 months or follow-up); infiltration (corticosteroid or local anesthetic during the previous year or follow-up); current medication (antiplatelet agents, anticoagulants, analgesics, or anti-inflammatory drugs 1-week before treatment or during follow-up); and needle phobia. 8,19,26-28
Outcome Measures At each session, the data recorded were sociodemographic data (age and gender), medical diagnosis (body region) before the start of the study, and treatment (number of sessions and muscles treated). Pain intensity was measured using a visual analogue scale (VAS) before the beginning of the study and 1 week after the treatment protocol had finished (1-5 treatment sessions). The minimum clinically significant difference (MCSD) in VAS was considered to range from 4 to 18 mm (95% confidence interval [CI]) with no differences in the severity of pain (mild pain, ≤30 mm; moderate pain, 31-69 mm; and severe pain, ≥70 mm), age, or gender. 40 The VAS is a reliable and valid scale with excellent reproducibility. 41
Procedures The multimodal intervention protocol (1-5 treatment sessions) was applied for 1 to 4 weeks. One week was maintained between each treatment session to allow for the MTrP-DN regenerative process (6-7 days). 21 The first session (beginning of the study), second session (at 1 week), third session (at 2 weeks), fourth session (at 3 weeks), and fifth session (at 4 weeks) comprised diagnosis of MPS, MTrP-DN, spray and stretching, Kinesio taping, eccentric exercise, and patient education for all patients in each treatment session. If the VAS score was ≤10 mm at the beginning of each treatment session, the review by the rehabilitation physician was performed before the fifth session, and the maximum number of sessions was not carried out.
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MPS Diagnosis First, MPS was diagnosed by a rehabilitation physician from the university hospital. Evaluation and treatment of MPS were carried out by a therapist with the same degree (physiotherapist), specialization (postgraduate studies in myofascial pain), and experience in MPS (5-6 years and 20-30 hours per week), as suggested by Myburg et al. 42 and Hsieh et al. 43 These rater characteristics have shown good interexaminer reproducibility (κ = 0.63; 95% CI) in palpation of MTrPs. 42 Diagnosis was based on the criteria for MTrPs (taut band, tender spot, recognition of pain by the patient, and limitation of range of movement due to pain), as proposed by Simons et al. 8,10 Furthermore, active MTrPs generate spontaneous and recognizable pain, whereas latent MTrPs generate nonrecognizable local pain or pain upon stimulation. 8-11,19,20,25-27 The order of the multimodal rehabilitation protocol was MTrP-DN, 18 spray and stretching, 28 Kinesio taping, 29-31 eccentric exercise, 32-34 and MPS education, 35 for all patients in each treatment session.
MTrP-DN Intervention Active and/or latent MTrP-DN was performed according to the positions and procedures recommended by Simons et al. 8,10 and Travell et al. 9 for each muscle in the spine and upper and lower limbs. Both types of MTrPs were treated to reduce mechanosensitivity and pain intensity in the affected area. 26,27 The Hong fast-in and fast-out technique, with multiple rapid insertions into the MTrP, was applied to achieve at least 1 local twitch response (LTR) and until the LTRs disappeared. 8-10,23,26,27 An LTR is considered a nonvoluntary contraction of the taut band secondary to a spinal reflex that is directly correlated with the effectiveness of treatment and the irritability of MTrPs. 8,23,44,45 Headless needles (Suzhou Tianxie Acupuncture Instruments Co., Ltd., Suzhou, China) of different sizes (0.32 × 40 mm, 50 mm × 0.32, and 0.32 × 75 mm) and a guide-tube were used, depending on the muscle treated in each body area. 8-10 Finally, hemostasis was applied to the MTrP-DN area for 1 minute to reduce bleeding and postneedling pain. 8,26,27
Spray and Stretching Three progressive spray and stretching sequences were performed for each treated muscle in order to reduce short-term postneedling pain (b6 hours). 28 Maximum passive stretch was carried out after cold spray (Ethyl Chloride spray 100 mL; Walter Ritter GmbH, Hamburg, Germany) was applied (30 cm distance, 30° angle, and 10 cm/s speed) to the MTrP-DN–treated muscle and the pain area. 8,28
Kinesio Taping Kinesio taping was put on the MTrP-DN–treated muscle to modify pain, stiffness, and contraction amplitude. 29-31
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The Kinesio Tape (Kinesio Tex Gold Fingerprint KTG-FP01; 5 cm × 5 m; elasticity of 130%-140%; same color) was applied for each treated muscle following the protocol and tension suggested by Kase et al. 46
Eccentric Exercise Eccentric exercise of each muscle treated with MTrP-DN was added to the protocol. The combination of eccentric exercise and MTrPs-DN can decrease pain intensity in patients with various conditions. 32-34 One session per week with 3 sets × 10 repeats was carried out, taking into account recommendations on eccentric exercise for minimally invasive muscle procedures. 47
MPS Education Education programs for patients with MPS have been shown to reduce pain. 35 MPS information and education were provided weekly for approximately 8 minutes. The MPS educational program comprised the following contents: (1) MPS definition, (2) MTrP mechanisms, (3) clinical characteristics and incidence, (4) MPS treatments efficacy, (5) perpetuating factors, (6) treatment modalities, and (7) conclusion. 35,48
Statistics Statistical analysis was performed with Stata Data Analysis and Statistical Software version 12 (StataCorp, College Station, TX). A descriptive analysis of all variables was performed. Qualitative variables and their categories were described with frequencies and percentages. If quantitative variables followed a normal distribution, they were described with mean and standard deviation (SD). If qualitative variables followed a non-normal distribution, they were described as median, minimum, and maximum. The 95% CI was also calculated. The χ 2 test was used to study the association between qualitative variables. The association between quantitative and qualitative variables was studied by using several tests, depending on the distribution of the quantitative variables and the number of categories in the qualitative variables (t test, Mann-Whitney, or Kruskal-Wallis analysis of variance). The association between 2 quantitative variables was analyzed by using the Pearson or Spearman correlation coefficient according to the distribution of variables. Finally, the 95% CI (P b .05) was calculated for all the analyses.
RESULTS Of the 162 subjects initially included, a sample of 150 patients was analyzed. Twelve subjects were excluded during follow-up because of patient refusal to participate or need for more than 5 sessions. There were no statistically
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Table 1. Number of Treated Muscles per Patient in Each Body Region Number of Treated Muscles (n [%] Patients) Region
1
2
3
4
5
Overall Cervicobrachial Lumbosacral Elbow Ankle and foot Temporomandibular
27 (18%) 13 (8.6%) 14 (9.3%) 0 0 0
50 (33%) 36 (24%) 8 (5.3%) 5 (3.3%) 1 (0.6%) 0
48 (32%) 34 (22.6%) 4 (2.6%) 7 (4.6%) 2 (1.3%) 1 (0.6%)
16 (10.6%) 16 (10.6%) 0 0 0 0
9 (6%) 9 (6%) 0 0 0 0
Table 2. Comparison of the Intensity of Pain Before and 1 Week After the Intervention According to the Number of Patients Total, After Intervention Before Intervention
VAS Score Range 1 Week After the Intervention, n (%) Patients
VAS Score Range
n (%) Patients
0 22 (14.67%)
0-3 97 (64.67%)
3-6 27 (18%)
6-10 4 (2.67%)
≤3 3-6 6-10
15 (9.9%) 66 (44.1 %) 69 (46 %)
2 (13.33%) 10 (15.15%) 10 (14.49%)
13 (86.67%) 50 (75.76%) 34 (49.28%)
0 (0%) 6 (9.06%) 21 (30.43%)
0 (0%) 0 (0%) 4 (5.80%)
VAS, visual analog scale.
significant differences in age (range 24-80 years; P N .05) between women (n = 111; 73%; 51.72 years) and men (n = 44; 27%; 51 years). As for the region treated, the intervention was applied to ≥1 muscles. The cervicobrachial region (n = 102; 68%) was treated simultaneously with the infraspinatus (n = 87; 32.3%) and the lower (n = 71; 26.4%) and upper trapezius muscles (n = 65; 24.2%). The lumbosacral region (n = 30; 20 %) was treated simultaneously with the gluteus medius and minimus (n = 28; 46.7%), piriformis (n = 11; 18.3%), and quadratus lumborum (n = 9; 15%). The elbow region (n = 14; 9.33%) was treated simultaneously with the supinator brevis (n = 14; 35%), extensor digitorum communis (n = 10; 25%), and brachioradialis (n = 9; 22.5%). The ankle and foot region (n = 3; 2%) was treated simultaneously with the gastrocnemius (n = 3; 37.5%), tibialis posterior (n = 2; 25%), and soleus (n = 2; 25%). The temporomandibular region (n = 1; 0.67%) was treated simultaneously with the masseter (n = 1; 33.3%), temporalis (n = 1; 33.3%), and sternocleidomastoid (n = 1; 33.3%). Finally, the mean ± SD of treated muscles for each patient was 2.53 ± 0.109 (range 1-5 depending on the region) (Table 1). The number of treatment sessions per patient was 1 (n = 6; 3.95%), 2 (n = 23; 15.13%), 3 (n = 38; 25%), 4 (n = 60; 39.47%), and 5 (n = 25; 16.45%). Pain intensity (VAS mean ± SD) decreased from moderate (5.9 ± 1.95) to mild (1.9 ± 1.83). The comparison between VAS scores before and 1 week after the treatment protocol is shown in association with the number of patients in Table 2 and Figure 1. Statistically significant differences were obtained for reduction in pain intensity (4 ± 2.03; P = .002). Clinically relevant reductions (VAS ≥30 mm; P b .001) were obtained in 78.7% of the interventions (Fig 2). Four treatment sessions reduced the VAS score by 10 mm in 83.55% of the sample. There were no statistically
significant differences (P = .064) for reduction in pain intensity in the following regions: cervicobrachial (4.3 ± 2.03), lumbosacral (3.5 ± 2.19), elbow (3.2 ± 1.28), ankle and foot (5.9 ± 1.31), and temporomandibular (2.1 ± 0).
DISCUSSION According to previous studies, the combination of dry needling, 8-10,19,20,26,27 spray and stretching, 8,28 Kinesio taping, 29-31,43 eccentric exercise, 32-34,44 and patient education in MPS 35,48 for active and latent MTrPs could decrease the intensity of pain in several body regions. Our results agree with those of systematic reviews and meta-analyses that recommend the use of MTrP-DN for treating several conditions. 49-52 The present study examined a multimodal approach, including MTrP-DN with conservative treatments in a hospital rehabilitation protocol. Campa-Moran et al., 53 Arias-Buría et al., 36 and Espí-López et al. 37 recently combined MTrP-DN and conservative interventions with rehabilitation protocols in primary care centers and hospital units, respectively. First, Campa-Moran et al. 53 showed that orthopedic manual therapy, dry needling and stretching, or soft tissue techniques may improve myofascial chronic neck pain. Second, Arias-Buría et al. 36 reported that 1 session of TrP-DN in the first week of a multimodal physical therapy approach may increase functionality and demonstrated similar improvements in pain intensity in individuals with postoperative shoulder pain. Finally, Espí-López et al. 37 determined that the inclusion of 3 sessions of TrP DN in a manual therapy and exercise program may not reduce pain intensity or disability in patients with patellofemoral pain. With regard to our study,
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Segura-Pérez et al Dry Needling in a Rehabilitation Protocol
Fig 1. Comparison of the intensity of pain before and 1 week after the intervention protocol. The main strength of the present study was that the VAS score MCSD was achieved irrespective of the body region treated. The intensity of pain was reduced by 10 mm in 83.55% of patients after a maximum of 4 sessions. This number is lower than that reported by Arias-Buría et al. 36 However, Campa-Moran et al. 53 suggested that the same number of sessions is needed with conservative orthopedic manual therapy and invasive MTrP-DN treatments. Controlled randomized clinical trials are necessary to improve our knowledge of the effectiveness of this protocol to treat MPS.
Limitations
Fig 2. Clinically relevant differences in pain intensity. there was no apparent variation in reduction of pain intensity in the different body regions. In the present study, 4 sessions were sufficient to reduce the VAS score by 10 mm in most patients. The applicability of our results was expanded to the cervicobrachial and lumbosacral regions because these were the most prevalent regions affected in our study patients. Moderate pain was reduced to mild pain in N83% of patients. The difference in pain intensity led to an almost 40-mm reduction in 78% of the subjects (P b .001) and an MCSD in the VAS score (N18 mm), with no differences between severity of pain ranges, according to the criteria of Kelly. 40 The most promising results of our study were seen in patients who had moderate or severe pain before treatment. This may be because of the higher irritability of the MTrPs, which leads to a greater number of LTRs and better effectiveness during MTrP-DN. 23,44,45
The limitations of the study are that it was not a randomized controlled clinical trial and did not take into account variables other than intensity of pain (eg, range of movement and functionality). In addition, the follow-up was short, and there was no control or placebo group. Nevertheless, Mayoral et al. 19 performed a double-blinded study of a new MTrP-DN procedure under anesthesia, demonstrating that LTR and postneedling soreness can be studied in a blinded fashion. In addition, in our study, a prior sample size calculation was not carried out. The number of patients treated per body area and the number of treated muscles per patient in each body region were variable. The multimodal intervention did not permit us to consider the effect of each treatment modality separately. Therefore, the results of this study should be considered with caution.
CONCLUSIONS For the sample of patients studied, a multimodal rehabilitation protocol produced clinically relevant reductions in the intensity of pain in patients with MPS in different body regions.
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FUNDING SOURCES
AND
CONFLICTS
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OF INTEREST
No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): M.S.P., T.H.C. Design (planned the methods to generate the results): M.S.P., T.H.C. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.S.P., T.H.C. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.S.P., T.H.C., R.F.M. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): L.V.P. Literature search (performed the literature search): C.C.L. Writing (responsible for writing a substantive part of the manuscript): C.C.L. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): C.C.L., D.R.S.
Practical Applications • The present research showed that 4 sessions of the protocol treatment were sufficient to reduce the VAS score to b10 mm in the majority of the study sample. • The applicability of results overall may be expanded to the cervicobrachial and lumbosacral regions because of the high prevalence. • “Moderate pain” was reduced to “mild pain” in N86% of the study patients. • The pain intensity difference achieved nearly 40 mm of reduction in 78% of the study subjects, which is a statistically and clinically significant change (P b .001) and an MCSD in VAS score (N18 mm) without differences between severity of pain ranges and body regions. • This study was carried out in the public health care system in Spain.
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18. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014;19(4):252-265. 19. Mayoral O, Salvat I, Martín MT, et al. Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: a randomized, double-blinded, placebocontrolled trial. Evid Based Complement Alternat Med. 2013; 2013:694941. 20. Mayoral O. Dry needling treatments for myofascial trigger points. J Musculoskelet Pain. 2010;18(4):411-416. 21. Domingo A, Mayoral O, Monterde S, Santafé MM. Neuromuscular damage and repair after dry needling in mice. Evid Based Complement Alternat Med. 2013;2013:260806. 22. Chou LW, Kao MJ, Lin JG. Probable mechanisms of needling therapies for myofascial pain control. Evid Based Complement Alternat Med. 2012;2012:705327. 23. Chou LW, Hsieh Y-L, Kuan T-S, Hong C-Z. Needling therapy for myofascial pain: recommended technique with multiple rapid needle insertion. Biomedicine (Taipei). 2014; 4(2):13. 24. Dommerholt J. Dry needling—peripheral and central considerations. J Man Manip Ther. 2011;19(4):223-227. 25. Mense S. How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculoskelet Pain. 2010;18(4):348-353. 26. Calvo-Lobo C, Pacheco-da-Costa S, Hita-Herranz E. Efficacy of deep dry needling on latent myofascial trigger points in older adults with non-specific shoulder pain: a randomized, controlled clinical trial pilot study. J Geriatr Phys Ther. 2017; 40(2):63-73. 27. Calvo-Lobo C, Pacheco-da-Costa S, Martínez-Martínez J, Rodríguez-Sanz, Cuesta-Álvaro P, López-López D. Dry needling on the infraspinatus latent and active myofascial trigger points in older adults with nonspecific shoulder pain: a randomized clinical trial. [e-pub ahead of print] J Geriatr Phys Ther. 2016, http://dx.doi.org/10.1519/JPT.0000000000000079. Accessed on July 16, 2017. 28. Martín-Pintado Zugasti A, Rodríguez-Fernández ÁL, GarcíaMuro F, et al. Effects of spray and stretch on postneedling soreness and sensitivity after dry needling of a latent myofascial trigger point. Arch Phys Med Rehabil. 2014; 95(10) 1925-1932.e1. 29. Chao YW, Lin JJ, Yang JL, Wang WT. Kinesio taping and manual pressure release: short-term effects in subjects with myofasical trigger point. J Hand Ther. 2016;29(1):23-29. 30. García-Muro F, Rodríguez-Fernández AL, Herrero-de-Lucas A. Treatment of myofascial pain in the shoulder with Kinesio taping. A case report. Man Ther. 2010;15(3):292-295. 31. Halski T, Ptaszkowski K, Słupska L, et al. Short-term effects of Kinesio taping and cross taping application in the treatment of latent upper trapezius trigger points: a prospective, single-blind, randomized, sham-controlled trial. Evid Based Complement Alternat Med. 2015;2015:191925. 32. Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014;85(3):314-322. 33. Jayaseelan DJ, Moats N, Ricardo CR. Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling: 2 case reports. J Orthop Sports Phys Ther. 2014;44(3):198-205. 34. Dembowski SC, Westrick RB, Zylstra E, Johnson MR. Treatment of hamstring strain in a collegiate pole-vaulter integrating dry needling with an eccentric training program: a resident’s case report. Int J Sports Phys Ther. 2013;8(3):328-339.
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35. Lin S-Y, Neoh C-A, Huang Y-T, Wang K-Y, Ng H-F, Shi HY. Educational program for myofascial pain syndrome. J Altern Complement Med. 2010;16(6):633-640. 36. Arias-Buría JL, Valero-Alcaide R, Cleland JA, et al. Inclusion of trigger point dry needling in a multimodal physical therapy program for postoperative shoulder pain: a randomized clinical trial. J Manip Physiol Ther. 2015;38(3):179-187. 37. Espí-López GV, Serra-Añó P, Vicent-Ferrando J, et al. Effectiveness of inclusion of dry needling in a multimodal therapy program for patellofemoral pain: a randomized parallelgroup trial. J Orthop Sports Phys Ther. 2017;47(6):392-401. 38. Hoffmann TC, Glasziou PP, Boutron I, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. 39. General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014;81(3):14-18. 40. Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J. 2001;18(3):205-207. 41. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14(7):798-804. 42. Myburgh C, Lauridsen HH, Larsen AH, Hartvigsen J. Standardized manual palpation of myofascial trigger points in relation to neck/shoulder pain: the influence of clinical experience on interexaminer reproducibility. Man Ther. 2011;16(2):136-140. 43. Hsieh CY, Hong CZ, Adams AH, et al. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil. 2000;81(3):258-264. 44. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-263. 45. Kuan T-S, Hong C-Z, Chen S-M, et al. Myofascial pain syndrome: correlation between the irritability of trigger points and the prevalence of local twitch responses during trigger point injection. J Musculoskelet Pain. 2012;20(4):250-256. 46. Kase K, Wallis J, Kase T. Clinical Therapeutic Applications of the Kinesio Taping Method. . 2nd ed. Tokyo, Japan: Ken Ikai Co Ltd; 2003. 47. Valera Garrido F, Minaya Muñoz F. Advanced Techniques in Musculoskeletal Medicine & Physiotherapy using minimally invasive therapies in practice. 1st ed. Madrid, SP: Elsevier; 2015. 48. Gerwin RD. A review of myofascial pain and fibromyalgia– factors that promote their persistence. Acupunct Med. 2005; 23(3):121-134. 49. Tough EA, White AR, Cummings TM, Richard SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009;13(1):3-10. 50. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43:620-634. 51. Liu L, Huang QM, Liu QG, et al. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2015;96(5):944-955. 52. Ong J, Claydon LS. The effect of dry needling for myofascial trigger points in the neck and shoulders: a systematic review and meta-analysis. J Bodyw Mov Ther. 2014;18(3):390-398. 53. Campa-Moran I, Rey-Gudin E, Fernández-Carnero J, et al. Comparison of dry needling versus orthopedic manual therapy in patients with myofascial chronic neck pain: a single-blind, randomized pilot study. Pain Res Treat. 2015;2015:327307.
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ABSTRACT Objective: The purpose of this study was to analyze pain intensity in patients with myofascial pain syndrome (MPS) following a multimodal rehabilitation protocol. Methods: A prospective study was carried out following the Template for Intervention Description and Replication criteria. Patients were recruited from the rehabilitation unit of a university hospital in Spain between 2009 and 2013. Patients were included if they had a medical diagnosis of MPS in any of the following regions: cervicobrachial (n = 102), lumbosacral (n = 30), elbow (n = 14), ankle and foot (n = 10), and temporomandibular jaw (n = 1). The multimodal rehabilitation protocol included myofascial trigger point dry needling, spray and stretching, Kinesio taping, eccentric exercise, and patient education. The protocol was applied for 4 weeks (5 sessions) for the active and/or latent myofascial trigger points in each body region. Pain intensity was measured by using the visual analog scale (VAS) immediately before beginning of the study and 1 week after completion of the protocol. Results: The study sample comprised 150 patients (mean ± standard deviation age, 51.5 ± 1.19 years). Statistically significant differences were obtained for reduction in pain intensity (4 ± 2.03; P = .002). Clinically relevant reductions (VAS ≥30 mm; P b .001) were obtained in 78.7% of the interventions. Four treatment sessions reduced the VAS score by 10 mm in 83.55% of the sample. There were no statistically significant differences (P = .064) for reduction in pain intensity in the different body regions. Conclusions: A multimodal rehabilitation protocol showed clinically relevant differences in the reduction in pain intensity in different body regions in patients with MPS. (J Manipulative Physiol Ther 2017;xx:1-7) Key Indexing Terms: Myofascial Pain Syndromes; Musculoskeletal Disorders; Musculoskeletal Pain; Rehabilitation; Trigger Points
INTRODUCTION There is a high rate of musculoskeletal pain among the general adult population (26%), general older adult a Physical Therapy Unit, University Hospital la Princesa, Madrid, Spain. b Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, University of León, León, Spain. c Health Research Institute, University Hospital la Princesa, Madrid, Spain. d Physical Therapy & Health Sciences Research Group, Physiotherapy Department, Faculty of Health, Exercise and Sport, European University, Madrid, Spain. Corresponding author: César Calvo-Lobo, PhD, MSc, PT, Nursing and Physical Therapy Department, Institute of Biomedicine (IBIOMED), Faculty of Health Sciences, University of León, Av. Astorga, s/n, 24401 Ponferrada, León, Spain. Tel.: +34 987 442 053. (e-mail: [email protected]). Paper submitted June 6, 2017; in revised form June 7, 2017; accepted June 15, 2017. 0161-4754 © 2017 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2017.06.001
population (39%), and workers (86%). 1 Myofascial pain syndrome (MPS) is a condition prevalent in patients who report spinal and upper and lower limb pain. 2-4 The prevalence of MPS in people with musculoskeletal pain varied from 30% in primary care to 85% to 93% in specialized pain units. 5 Indeed, 48.9% of medical specialists and physical therapists treat more than 4 patients with MPS per week and estimate a prevalence of active myofascial trigger points (MTrPs) in 46.1% of the general population and 52.8% of their patients. A higher rate is reported by clinical professionals who attend pain conferences (55.4% and 63.4%, respectively). 6 As a possible consequence, 60% of the cost of treating pain in the Spanish public health system is spent on ineffective treatments. 7 Signs and symptoms recorded at MTrPs may generate sensory, motor, and autonomic conditions. On the one hand, MTrPs produce spontaneous and recognizable pain when they are active; on the other hand, they produce nonrecognizable local or referred pain upon stimulation when they are latent. 8-10 Nevertheless, MTrPs are hyperirritable spots in a taut band of muscle fibers, which may be
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identified with palpation (distinguishing subjects with pain from subjects with no pain), 11 analysis of the biochemical milieu (distinguishing MTrPs from muscular tissue with no-MTrPs), 12 sonoelastography, 13 electromyography, 14 thermography, 15 and magnetic resonance elastography. 16 Both invasive and conservative interventions have been proposed for the treatment of MTrP. 17 Among the invasive treatments, MTrP dry needling (MTrP-DN) is recommended to relieve pain immediately or in the short term. 18 Studies by Mayoral et al. have shown a medium-term analgesic effect of MTrP-DN against placebo under anesthesia. 19,20 Deep, fast in-and-out techniques with multiple rapid insertions trigger a regenerative process (6-7 days) and reduced acetylcholine in the motor end plate that are affected by peripheral and central pain modulation mechanisms. 20-24 Active and latent MTrP-DN could reduce pain and mechanosensitivity in patients with MPS. 25-27 Additional conservative interventions include spray and stretching, which reduces postneedling soreness in the short term (b6 hours), 28 and Kinesio taping, which modifies MTrP pain, stiffness, and contraction amplitude. 29-31 In addition, eccentric exercise and an MPS educational program could be combined with MTrPs-DN to decrease pain. 32-35 MTrP-DN, 18 spray and stretching, 28 Kinesio taping, 29-31 eccentric exercise, 32-34 and education 35 may modulate the pain intensity after MPS treatment of latent and active MTrPs. Nevertheless, there are controversial studies reporting that pain relief after the inclusion of MTrP-DN in a multimodal therapy program depends on the body regions affected. 36,37 Therefore, the aim of this study was measure pain intensity following a multimodal rehabilitation protocol for MPS in different body regions.
METHODS Design A prospective longitudinal experimental study was carried out in the hospital rehabilitation service in Madrid Spain from October 2009 to June 2013. The template for intervention description and replication (TIDieR) checklist and guide was followed. 38 The study was approved by the Clinic Research Ethics Committee of the Princess University Hospital, Madrid (Spain). A signed informed consent document was obtained from each patient before the study. The ethical standards of the Declaration of Helsinki were followed. 39
Subjects A convenience sample of 164 patients was recruited over 4 years (October 2009 to June 2013). Inclusion criteria were a diagnosis of MPS and a recommendation by the rehabilitation physician for MTrP-DN for the body regions affected by various subacute and chronic musculoskeletal conditions, including cervicobrachial (MPS in the infraspinatus, middle deltoid, levator scapulae, and trapezius;
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infraspinatus tendon rupture and tendinopathy; complete rotator cuff rupture and tendinopathy; supraspinatus tendinopathy and rupture; cervicobrachialgia; neck pain; shoulder pain; calcific tendinitis; capsulitis; contusion; subacromial syndrome; acromioclavicular dislocation; subscapularis tendinopathy; and subacromial bursal calcification), lumbosacral (piriformis syndrome and MPS; trochanteritis; disc herniation and protrusion; lumbar sciatic and back pain; MPS in the gluteus medius and maximus; and spondylolisthesis), elbow (lateral and medial epicondyle tendinopathy and wrist tendinopathy), foot (plantar fasciitis), and temporomandibular joint regions. Exclusion criteria were as follows: need for more than 5 protocol-based treatment sessions; neurological, visceral, inflammatory, and acute conditions in the medical records; cognitive deficits; previous surgery; conservative or invasive physical therapy (during the previous 6 months or follow-up); infiltration (corticosteroid or local anesthetic during the previous year or follow-up); current medication (antiplatelet agents, anticoagulants, analgesics, or anti-inflammatory drugs 1-week before treatment or during follow-up); and needle phobia. 8,19,26-28
Outcome Measures At each session, the data recorded were sociodemographic data (age and gender), medical diagnosis (body region) before the start of the study, and treatment (number of sessions and muscles treated). Pain intensity was measured using a visual analogue scale (VAS) before the beginning of the study and 1 week after the treatment protocol had finished (1-5 treatment sessions). The minimum clinically significant difference (MCSD) in VAS was considered to range from 4 to 18 mm (95% confidence interval [CI]) with no differences in the severity of pain (mild pain, ≤30 mm; moderate pain, 31-69 mm; and severe pain, ≥70 mm), age, or gender. 40 The VAS is a reliable and valid scale with excellent reproducibility. 41
Procedures The multimodal intervention protocol (1-5 treatment sessions) was applied for 1 to 4 weeks. One week was maintained between each treatment session to allow for the MTrP-DN regenerative process (6-7 days). 21 The first session (beginning of the study), second session (at 1 week), third session (at 2 weeks), fourth session (at 3 weeks), and fifth session (at 4 weeks) comprised diagnosis of MPS, MTrP-DN, spray and stretching, Kinesio taping, eccentric exercise, and patient education for all patients in each treatment session. If the VAS score was ≤10 mm at the beginning of each treatment session, the review by the rehabilitation physician was performed before the fifth session, and the maximum number of sessions was not carried out.
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MPS Diagnosis First, MPS was diagnosed by a rehabilitation physician from the university hospital. Evaluation and treatment of MPS were carried out by a therapist with the same degree (physiotherapist), specialization (postgraduate studies in myofascial pain), and experience in MPS (5-6 years and 20-30 hours per week), as suggested by Myburg et al. 42 and Hsieh et al. 43 These rater characteristics have shown good interexaminer reproducibility (κ = 0.63; 95% CI) in palpation of MTrPs. 42 Diagnosis was based on the criteria for MTrPs (taut band, tender spot, recognition of pain by the patient, and limitation of range of movement due to pain), as proposed by Simons et al. 8,10 Furthermore, active MTrPs generate spontaneous and recognizable pain, whereas latent MTrPs generate nonrecognizable local pain or pain upon stimulation. 8-11,19,20,25-27 The order of the multimodal rehabilitation protocol was MTrP-DN, 18 spray and stretching, 28 Kinesio taping, 29-31 eccentric exercise, 32-34 and MPS education, 35 for all patients in each treatment session.
MTrP-DN Intervention Active and/or latent MTrP-DN was performed according to the positions and procedures recommended by Simons et al. 8,10 and Travell et al. 9 for each muscle in the spine and upper and lower limbs. Both types of MTrPs were treated to reduce mechanosensitivity and pain intensity in the affected area. 26,27 The Hong fast-in and fast-out technique, with multiple rapid insertions into the MTrP, was applied to achieve at least 1 local twitch response (LTR) and until the LTRs disappeared. 8-10,23,26,27 An LTR is considered a nonvoluntary contraction of the taut band secondary to a spinal reflex that is directly correlated with the effectiveness of treatment and the irritability of MTrPs. 8,23,44,45 Headless needles (Suzhou Tianxie Acupuncture Instruments Co., Ltd., Suzhou, China) of different sizes (0.32 × 40 mm, 50 mm × 0.32, and 0.32 × 75 mm) and a guide-tube were used, depending on the muscle treated in each body area. 8-10 Finally, hemostasis was applied to the MTrP-DN area for 1 minute to reduce bleeding and postneedling pain. 8,26,27
Spray and Stretching Three progressive spray and stretching sequences were performed for each treated muscle in order to reduce short-term postneedling pain (b6 hours). 28 Maximum passive stretch was carried out after cold spray (Ethyl Chloride spray 100 mL; Walter Ritter GmbH, Hamburg, Germany) was applied (30 cm distance, 30° angle, and 10 cm/s speed) to the MTrP-DN–treated muscle and the pain area. 8,28
Kinesio Taping Kinesio taping was put on the MTrP-DN–treated muscle to modify pain, stiffness, and contraction amplitude. 29-31
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The Kinesio Tape (Kinesio Tex Gold Fingerprint KTG-FP01; 5 cm × 5 m; elasticity of 130%-140%; same color) was applied for each treated muscle following the protocol and tension suggested by Kase et al. 46
Eccentric Exercise Eccentric exercise of each muscle treated with MTrP-DN was added to the protocol. The combination of eccentric exercise and MTrPs-DN can decrease pain intensity in patients with various conditions. 32-34 One session per week with 3 sets × 10 repeats was carried out, taking into account recommendations on eccentric exercise for minimally invasive muscle procedures. 47
MPS Education Education programs for patients with MPS have been shown to reduce pain. 35 MPS information and education were provided weekly for approximately 8 minutes. The MPS educational program comprised the following contents: (1) MPS definition, (2) MTrP mechanisms, (3) clinical characteristics and incidence, (4) MPS treatments efficacy, (5) perpetuating factors, (6) treatment modalities, and (7) conclusion. 35,48
Statistics Statistical analysis was performed with Stata Data Analysis and Statistical Software version 12 (StataCorp, College Station, TX). A descriptive analysis of all variables was performed. Qualitative variables and their categories were described with frequencies and percentages. If quantitative variables followed a normal distribution, they were described with mean and standard deviation (SD). If qualitative variables followed a non-normal distribution, they were described as median, minimum, and maximum. The 95% CI was also calculated. The χ 2 test was used to study the association between qualitative variables. The association between quantitative and qualitative variables was studied by using several tests, depending on the distribution of the quantitative variables and the number of categories in the qualitative variables (t test, Mann-Whitney, or Kruskal-Wallis analysis of variance). The association between 2 quantitative variables was analyzed by using the Pearson or Spearman correlation coefficient according to the distribution of variables. Finally, the 95% CI (P b .05) was calculated for all the analyses.
RESULTS Of the 162 subjects initially included, a sample of 150 patients was analyzed. Twelve subjects were excluded during follow-up because of patient refusal to participate or need for more than 5 sessions. There were no statistically
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Table 1. Number of Treated Muscles per Patient in Each Body Region Number of Treated Muscles (n [%] Patients) Region
1
2
3
4
5
Overall Cervicobrachial Lumbosacral Elbow Ankle and foot Temporomandibular
27 (18%) 13 (8.6%) 14 (9.3%) 0 0 0
50 (33%) 36 (24%) 8 (5.3%) 5 (3.3%) 1 (0.6%) 0
48 (32%) 34 (22.6%) 4 (2.6%) 7 (4.6%) 2 (1.3%) 1 (0.6%)
16 (10.6%) 16 (10.6%) 0 0 0 0
9 (6%) 9 (6%) 0 0 0 0
Table 2. Comparison of the Intensity of Pain Before and 1 Week After the Intervention According to the Number of Patients Total, After Intervention Before Intervention
VAS Score Range 1 Week After the Intervention, n (%) Patients
VAS Score Range
n (%) Patients
0 22 (14.67%)
0-3 97 (64.67%)
3-6 27 (18%)
6-10 4 (2.67%)
≤3 3-6 6-10
15 (9.9%) 66 (44.1 %) 69 (46 %)
2 (13.33%) 10 (15.15%) 10 (14.49%)
13 (86.67%) 50 (75.76%) 34 (49.28%)
0 (0%) 6 (9.06%) 21 (30.43%)
0 (0%) 0 (0%) 4 (5.80%)
VAS, visual analog scale.
significant differences in age (range 24-80 years; P N .05) between women (n = 111; 73%; 51.72 years) and men (n = 44; 27%; 51 years). As for the region treated, the intervention was applied to ≥1 muscles. The cervicobrachial region (n = 102; 68%) was treated simultaneously with the infraspinatus (n = 87; 32.3%) and the lower (n = 71; 26.4%) and upper trapezius muscles (n = 65; 24.2%). The lumbosacral region (n = 30; 20 %) was treated simultaneously with the gluteus medius and minimus (n = 28; 46.7%), piriformis (n = 11; 18.3%), and quadratus lumborum (n = 9; 15%). The elbow region (n = 14; 9.33%) was treated simultaneously with the supinator brevis (n = 14; 35%), extensor digitorum communis (n = 10; 25%), and brachioradialis (n = 9; 22.5%). The ankle and foot region (n = 3; 2%) was treated simultaneously with the gastrocnemius (n = 3; 37.5%), tibialis posterior (n = 2; 25%), and soleus (n = 2; 25%). The temporomandibular region (n = 1; 0.67%) was treated simultaneously with the masseter (n = 1; 33.3%), temporalis (n = 1; 33.3%), and sternocleidomastoid (n = 1; 33.3%). Finally, the mean ± SD of treated muscles for each patient was 2.53 ± 0.109 (range 1-5 depending on the region) (Table 1). The number of treatment sessions per patient was 1 (n = 6; 3.95%), 2 (n = 23; 15.13%), 3 (n = 38; 25%), 4 (n = 60; 39.47%), and 5 (n = 25; 16.45%). Pain intensity (VAS mean ± SD) decreased from moderate (5.9 ± 1.95) to mild (1.9 ± 1.83). The comparison between VAS scores before and 1 week after the treatment protocol is shown in association with the number of patients in Table 2 and Figure 1. Statistically significant differences were obtained for reduction in pain intensity (4 ± 2.03; P = .002). Clinically relevant reductions (VAS ≥30 mm; P b .001) were obtained in 78.7% of the interventions (Fig 2). Four treatment sessions reduced the VAS score by 10 mm in 83.55% of the sample. There were no statistically
significant differences (P = .064) for reduction in pain intensity in the following regions: cervicobrachial (4.3 ± 2.03), lumbosacral (3.5 ± 2.19), elbow (3.2 ± 1.28), ankle and foot (5.9 ± 1.31), and temporomandibular (2.1 ± 0).
DISCUSSION According to previous studies, the combination of dry needling, 8-10,19,20,26,27 spray and stretching, 8,28 Kinesio taping, 29-31,43 eccentric exercise, 32-34,44 and patient education in MPS 35,48 for active and latent MTrPs could decrease the intensity of pain in several body regions. Our results agree with those of systematic reviews and meta-analyses that recommend the use of MTrP-DN for treating several conditions. 49-52 The present study examined a multimodal approach, including MTrP-DN with conservative treatments in a hospital rehabilitation protocol. Campa-Moran et al., 53 Arias-Buría et al., 36 and Espí-López et al. 37 recently combined MTrP-DN and conservative interventions with rehabilitation protocols in primary care centers and hospital units, respectively. First, Campa-Moran et al. 53 showed that orthopedic manual therapy, dry needling and stretching, or soft tissue techniques may improve myofascial chronic neck pain. Second, Arias-Buría et al. 36 reported that 1 session of TrP-DN in the first week of a multimodal physical therapy approach may increase functionality and demonstrated similar improvements in pain intensity in individuals with postoperative shoulder pain. Finally, Espí-López et al. 37 determined that the inclusion of 3 sessions of TrP DN in a manual therapy and exercise program may not reduce pain intensity or disability in patients with patellofemoral pain. With regard to our study,
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Fig 1. Comparison of the intensity of pain before and 1 week after the intervention protocol. The main strength of the present study was that the VAS score MCSD was achieved irrespective of the body region treated. The intensity of pain was reduced by 10 mm in 83.55% of patients after a maximum of 4 sessions. This number is lower than that reported by Arias-Buría et al. 36 However, Campa-Moran et al. 53 suggested that the same number of sessions is needed with conservative orthopedic manual therapy and invasive MTrP-DN treatments. Controlled randomized clinical trials are necessary to improve our knowledge of the effectiveness of this protocol to treat MPS.
Limitations
Fig 2. Clinically relevant differences in pain intensity. there was no apparent variation in reduction of pain intensity in the different body regions. In the present study, 4 sessions were sufficient to reduce the VAS score by 10 mm in most patients. The applicability of our results was expanded to the cervicobrachial and lumbosacral regions because these were the most prevalent regions affected in our study patients. Moderate pain was reduced to mild pain in N83% of patients. The difference in pain intensity led to an almost 40-mm reduction in 78% of the subjects (P b .001) and an MCSD in the VAS score (N18 mm), with no differences between severity of pain ranges, according to the criteria of Kelly. 40 The most promising results of our study were seen in patients who had moderate or severe pain before treatment. This may be because of the higher irritability of the MTrPs, which leads to a greater number of LTRs and better effectiveness during MTrP-DN. 23,44,45
The limitations of the study are that it was not a randomized controlled clinical trial and did not take into account variables other than intensity of pain (eg, range of movement and functionality). In addition, the follow-up was short, and there was no control or placebo group. Nevertheless, Mayoral et al. 19 performed a double-blinded study of a new MTrP-DN procedure under anesthesia, demonstrating that LTR and postneedling soreness can be studied in a blinded fashion. In addition, in our study, a prior sample size calculation was not carried out. The number of patients treated per body area and the number of treated muscles per patient in each body region were variable. The multimodal intervention did not permit us to consider the effect of each treatment modality separately. Therefore, the results of this study should be considered with caution.
CONCLUSIONS For the sample of patients studied, a multimodal rehabilitation protocol produced clinically relevant reductions in the intensity of pain in patients with MPS in different body regions.
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FUNDING SOURCES
AND
CONFLICTS
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OF INTEREST
No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP INFORMATION Concept development (provided idea for the research): M.S.P., T.H.C. Design (planned the methods to generate the results): M.S.P., T.H.C. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.S.P., T.H.C. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): M.S.P., T.H.C., R.F.M. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): L.V.P. Literature search (performed the literature search): C.C.L. Writing (responsible for writing a substantive part of the manuscript): C.C.L. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): C.C.L., D.R.S.
Practical Applications • The present research showed that 4 sessions of the protocol treatment were sufficient to reduce the VAS score to b10 mm in the majority of the study sample. • The applicability of results overall may be expanded to the cervicobrachial and lumbosacral regions because of the high prevalence. • “Moderate pain” was reduced to “mild pain” in N86% of the study patients. • The pain intensity difference achieved nearly 40 mm of reduction in 78% of the study subjects, which is a statistically and clinically significant change (P b .001) and an MCSD in VAS score (N18 mm) without differences between severity of pain ranges and body regions. • This study was carried out in the public health care system in Spain.
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