Interrater reliability in myofascial trigger point examination Intertester reliability of judgments of the presence of trigger points in patients with low back pain. The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. DRY NEEDLING IN SUBJECTS WITH MUSCULAR TRIGGER POINTS IN THE LOWER QUARTER: A SYSTEMATIC REVIEW. Effectiveness of trigger point dry needling for multiple body regions: a systematic review Trigger point treatment with radial shock waves in musicians with nonspecific shoulder-neck pain: data from a special physio outpatient clinic for musicians. Effect of helium-neon laser on musculoskeletal trigger points. Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis Trigger Point Acupuncture for Treatment of Knee Osteoarthritis – a Preliminary Rct for a Pragmatic Trial Trigger Point Acupuncture Treatment of Chronic Low Back Pain in Elderly Patients – a Blinded Rct Randomised trial of trigger point acupuncture compared with other acupuncture for treatment of chronic neck pain. Stimulation of myofascial trigger points with ultrasound induces segmental antinociceptive effects: A randomized controlled study Treatment of trigger points with microamperage transcutaneous electrical nerve stimulation (TENS)--(the Electro-Acuscope 80). Ultrasound-Guided Myofascial Trigger Point Injection Into Brachialis Muscle for Rotator Cuff Disease Patients With Upper Arm Pain: A Pilot Study Pain relief at trigger points: a comparison of moist heat and shortwave diathermy.
Abstract The myofascial trigger point ( MTrP ) is the hallmark physical finding of the myofascial pain syndrome ( MPS ) . The MTrP itself is characterized by distinctive physical features that include a tender point in a taut b and of muscle , a local twitch response ( LTR ) to mechanical stimulation , a pain referral pattern characteristic of trigger points of specific areas in each muscle , and the reproduction of the patient 's usual pain . No prior study has demonstrated that these physical features are reproducible among different examiners , thereby establishing the reliability of the physical examination in the diagnosis of the MPS . This paper reports an initial attempt to establish the interrater reliability of the trigger point examination that failed , and a second study by the same examiners that included a training period and that successfully established interrater reliability in the diagnosis of the MTrP. The study also showed that the interrater reliability of different features varies , the LTR being the most difficult , and that the interrater reliability of the identification of MTrP features among different muscles also varies The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed The presence of a trigger point is essential to the myofascial pain syndrome . This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms . Using the symptoms and signs as described by Simons ' 1990 definition and two other former sets of criteria , 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers , working in pairs . From the two major criteria of Simons ' 1990 definition only ' localized tenderness ' has good discriminative ability and inter-rater reliability ( kappa > 0.5 ) . This study does not find proof for the clinical usefulness of ' referred pain ' , which has neither of these two abilities . The criteria ' jump sign ' and ' recognition ' , on the condition that localized tenderness is present , also have good discriminative ability and inter-rater reliability . Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls . This is not the case with trigger points defined by Simons ' 1990 criteria . Concerning reliability there is also a significant difference between the two different criteria sets . This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient 's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius OBJECTIVES To determine the interexaminer reliability of palpation of three characteristics of trigger points ( taut b and , local twitch response , and referred pain ) in patients with subacute low back pain , to determine whether training in palpation would improve reliability , and whether there was a difference between the physiatric and chiropractic physicians . DESIGN Reliability study . SETTING Whittier Health Campus , Los Angeles College of Chiropractic . PARTICIPANTS Twenty-six nonsymptomatic individuals and 26 individuals with subacute low back pain . INTERVENTION Twenty muscles per individual were first palpated by an expert and then r and omly by four physician examiners . MAIN OUTCOME MEASURES Palpation findings . RESULTS Kappa scores for palpation of taut b and s , local twitch responses , and referred pain were .215 , .123 , and .342 , respectively , between the expert and the trained examiners , and .050 , .118 , and .326 , respectively , between the expert and the untrained examiners . Kappa scores for agreement for palpation of taut b and s , twitch responses , and referred pain were .108 , -.001 , and .435 , respectively , among the nonexpert , trained examiners , and -.019 , .022 , and .320 , respectively , among the nonexpert , untrained examiners . CONCLUSIONS Among nonexpert physicians , physiatric or chiropractic , trigger point palpation is not reliable for detecting taut b and and local twitch response , and only marginally reliable for referred pain after training BACKGROUND Trigger points , which have been defined as highly localized , hyperirritable locations in a palpable taut b and of skeletal muscle fibers , have been identified with a variety of musculoskeletal conditions . The incidence of trigger point pain is high , with studies showing them as the primary source of pain in 30 - 85 % of patients presenting in a primary care setting or pain clinic .  Dry needling has emerged as a possible intervention for trigger points , but its effectiveness has not yet fully been determined . PURPOSE To assess and provide a summary on the current literature for the use of dry needling as an intervention for lower quarter trigger points in patients with various orthopedic conditions . STUDY DESIGN Systematic review . METHODS CINAHL , NCBI- PubMed , PEDro , SPORTD iscus , Cochrane Library , and APTA 's PTNow were search ed to identify relevant r and omized controlled trials . Six studies meeting the inclusion criteria were analyzed using the PEDro scale . RESULTS Four of the studies assessed by the PEDro scale were deemed ' high ' quality and two were ' fair ' quality . Each of the six included studies reported statistically significant improvements with  dry needling  for the reduction of pain intensity in the short-term . Only one study reported a statistically significant improvement in short-term functional outcomes ; however , there was no maintenance of improved function at long-term follow-up . Furthermore , none of the studies reported statistically significant changes regarding the effect of dry needling on quality of life , depression , range of motion , or strength . CONCLUSION A review of current literature suggests that dry needling is effective in reducing pain associated with lower quarter trigger points in the short-term . However , the findings suggest that dry needling does not have a positive effect on function , quality of life , depression , range of motion , or strength . Further high quality research with long-term follow-up investigating the effect of dry needling in comparison to and in conjunction with other interventions is needed to determine the optimal use of dry needling in treating patients with lower quarter trigger points . LEVELS OF EVIDENCE 1 Background : Trigger point dry needling ( TDN ) is commonly used to treat musculoskeletal pain related to myofascial trigger points ( MTrPs ) . To date , no systematic review of high- quality r and omised controlled trials ( RCTs ) investigating TDN to multiple body regions exists . Purpose : The aim of this review is to determine the effectiveness of TDN based on high- quality RCTs for all body regions . Methods : To ensure thorough reporting , Preferred Reporting Items for Systematic Review s and Meta-Analyses ( PRISMA ) guidelines were followed as the method ological basis for this systematic review . PubMed , Physiotherapy Evidence Data base ( PEDro ) , Cinahl , Cochrane and reference lists were search ed for the years 2000–2014 and the terms ‘ TDN ’ , ‘ dry needling NOT trigger point ’ , ‘ functional dry needling ’ and ‘ intramuscular manual therapy ’ . Inclusion criteria : RCTs with PEDro scores 6–10 investigating TDN . Exclusion criteria : duplicates , non-human participants , non-English language , exclusive focus on acupuncture or medicinal injections . Three investigators search ed data bases , applied criteria , read and assigned PEDro scores to every RCT . Nineteen studies met the criteria . As compared to either baseline or control groups , significant differences were found for pain ( 14 studies ) , range of motion ( ROM ) ( five studies ) and at least one item on function and quality of life measures ( six studies ) . Limitations : This review was limited by inclusion criteria , timeframe , language and data bases search ed . Conclusion : The majority of high- quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas , suggesting broad applicability of TDN treatment for multiple muscle groups . Further high- quality research is warranted to st and ardise TDN methods to determine clinical applicability UNLABELLED Musicians often suffer from disorders of the musculoskeletal system that are related to their instrument playing . Among the most frequent symptoms are complaints in the shoulder-neck area . Radial shock wave therapy is increasingly used in trigger point treatment , but only few high-level studies have examined of shock wave therapy used together with physical therapy in the treatment of musicians . METHODS This r and omized blinded study in musicians ( n = 26 ) with nonspecific shoulder-neck problems was done to examine the effect of shock wave therapy in addition to current physical therapy on the symptoms and quality of life of the musicians as well as their habits of playing musical instruments ( intervention group shock wave vs reference group placebo ) . The effects were documented by a pain VAS and other instruments . A question naire design ed specifically for musicians ( with initial and final questions ) recorded intensity and manifestation of pain and h and icaps in daily life , especially when practicing and playing . The Shoulder Pain and Disability Index ( SPADI ) and the Neck Pain Disability Index Question naire ( NPDIQ ) were also used . RESULTS Both groups reported subjective improvement in pain , but significance was found only for the intervention group for the SPADI and NPDIQ . CONCLUSIONS Trigger point treatment with radial shock wave used in combination with physical therapy makes the subjects feel temporarily relieved of neck and shoulder pains . The effects of radial shock wave without physical therapy will need to be examined in further studies Cold lasers have been proposed recently as a therapeutic tool for treating a wide variety of pathological conditions , including wounds , arthritis , orthopedic problems , and pain . These proposed therapeutic effects largely have been unsubstantiated by research . A r and omized , double blind study was undertaken to ascertain the effect of a helium-neon ( He-Ne ) laser on the resistance of areas of skin overlying musculoskeletal trigger points . These areas usually demonstrate decreased skin resistance when compared with the surrounding tissue . Thirty patients with musculoskeletal trigger points were assigned r and omly to either an experimental or a placebo group . In addition to st and ard physical therapy , each patient received three 15-second applications of a He-Ne laser or placebo " stimulation " from an identical unit that did not emit a laser . The results of a two-way analysis of covariance with one repeated measure showed a statistically significant increase ( p less than .007 ) in skin resistance . This increase in an abnormal skin resistance pattern may accompany the resolution of pathological conditions Objectives : To investigate the test-retest reliability of the following clinical diagnostic characteristics of myofascial trigger points : taut b and , spot tenderness , jump sign , pain recognition , referred pain and local twitch responses ( LTRs ) . Design : Test-retest reliability study . Setting : This study was undertaken in an outpatient physiotherapy department . Subjects : Fifty-eight patients ( 31 males and 27 females ) with rotator cuff tendonitis were recruited into this study . Intervention : Rotator cuff muscles were assessed by an expert for the presence or absence of the main clinical diagnostic characteristics of trigger point assessment . The process was then repeated three days later by the same expert . Main measures : Outcomes included the presence or absence of : a taut b and , spot tenderness , jump sign , pain recognition , referred pain and LTRs . Results : Kappa values between testing situations for the taut b and , spot tenderness , jump sign and pain recognition were 1 . Kappa scores for referred pain ranged between 0.79 and 0.88 and for the local twitch response between 0.75 and 1 depending on the muscles under investigation . Conclusions : The presence or absence of the taut b and , spot tenderness , jump sign and pain recognition was highly reliable between sessions . Referred pain and local twitch response reliability varied depending on the muscle being studied Background There is evidence for the efficacy of acupuncture treatment in knee osteoarthritis , but it remains unclear which acupuncture modes are most effective . We evaluated the effects of trigger point acupuncture on pain and quality of life in knee osteoarthritis patients , compared with acupuncture at st and ard points , and sham acupuncture . Methods Thirty patients ( 27 women , 3 men ; aged 61–82 years ) with non-radiating knee osteoarthritis pain for at least six months and normal neurological examination were r and omised to one of three groups for the study period of 21 weeks . Each group received five acupuncture treatment sessions . The st and ard acupuncture point group ( n=10 ) received treatment at traditional acupuncture points for knee pain ; the trigger point acupuncture group ( n=10 ) received treatment at trigger points ; and the third group ( n=10 ) received sham acupuncture treatment at the trigger points . Outcome measures were pain intensity ( visual analogue scale , VAS ) and WOMAC index ( Western Ontario and McMaster Universities Arthritis Index ) . The groups were compared by the area under the curve method . Results Five patients dropped out of the study because of lack of improvement , and one patient ( in the trigger point acupuncture group ) dropped out because of deterioration of symptoms ; the remaining 24 patients were included in the analysis . After treatment , the trigger point acupuncture group reported less pain intensity on VAS than the st and ard acupuncture or sham treatment group , but both the trigger point acupuncture and st and ard acupuncture groups reported improvement of function of knee . There was a significant reduction in pain intensity between pre-treatment and five weeks after treatment for the trigger point acupuncture ( P<0.01 ) and st and ard acupuncture groups ( P<0.01 ) included in the analysis , but not for the sham treatment group . Group comparison using the area under the curves demonstrated a significant difference only between trigger point acupuncture and sham treatment groups analysed ( P<0.025 for VAS , and P<0.031 for WOMAC ) . Conclusion These results suggest that trigger point acupuncture therapy may be more effective for osteoarthritis of the knee in some elderly patients than st and ard acupuncture therapy Objective There is some evidence for the efficacy of acupuncture in chronic low back pain , but it remains unclear which acupuncture modes are most effective . Our objective was to evaluate the effects of two different modes of trigger point acupuncture on pain and quality of life in chronic low back pain patients compared to st and ard acupuncture treatment . Methods Thirty five consecutive out- patients ( 25 women , 10 men ; age range : 65–81 years ) from the Department of Orthopaedic Surgery , Meiji University of Oriental Medicine , with non-radiating low back pain for at least six months and normal neurological examination , were r and omised to one of three groups over 12 weeks . Each group received two phases of acupuncture treatment with an interval between them . Nine patients dropped out during the course of the study . The st and ard acupuncture group ( n=9 ) received treatment at traditional acupuncture points for low back pain , while the other acupuncture groups received superficial ( n=9 ) or deep ( n=9 ) treatments on trigger points . Outcome measures were VAS pain intensity and Rol and Morris Question naire . Results After treatment , the group that received deep needling to trigger points reported less pain intensity and improved quality of life compared to the st and ard acupuncture group or the group that received superficial needling to trigger points , but the differences were not statistically significant . There was a significant reduction in pain intensity between the treatment and interval in the group that received deep needling to trigger points ( P<0.01 ) , but not in the st and ard acupuncture group or the group that received superficial needling to trigger points . Conclusion These results suggest that deep needling to trigger points may be more effective in the treatment of low back pain in elderly patients than either st and ard acupuncture therapy , or superficial needling to trigger points INTRODUCTION There is some evidence for the efficacy of acupuncture in chronic neck pain ( CNP ) treatment , but it remains unclear which acupuncture modes are most effective . Objective was to evaluate the effects of trigger point acupuncture on pain and quality of life ( QOL ) in CNP patients compared to three other acupuncture treatments ( acupoints , non-trigger point and sham treatment ) . METHODS Forty out- patients ( 29 women , 11 men ; age range : 47 - 80 years ) from the Department of Orthopaedic Surgery , Meiji University of Oriental Medicine , with non-radiating CNP for at least 6 months and normal neurological examination were r and omised to one of four groups over 13 weeks . Each group received two phases of acupuncture treatment with an interval between them . The acupoint group ( st and ard acupuncture ; SA , n=10 ) received treatment at traditional acupoints for neck pain , the trigger point ( TrP , n=10 ) and non-trigger point ( non-TrP , n=10 ) groups received treatment at tenderness points for the same muscle , while the other acupuncture group received sham treatments on the trigger point ( SH , n=10 ) . Outcome measures were pain intensity ( visual analogue scale ; VAS 0 - 100 mm ) and disease specific question naire ( neck disability index ; NDI , 60-point scale ) . RESULTS After treatment , the TrP group reported less pain intensity and improved QOL compared to the SA or non-TrP group . There was significant reduction in pain intensity between the treatment and the interval for the TrP group ( p<0.01 , Dunnett 's multiple test ) , but not for the SA or non-TrP group . CONCLUSION These results suggest that trigger point acupuncture therapy may be more effective on chronic neck pain in aged patients than the st and ard acupuncture therapy Abstract Musculoskeletal pain affects a significant proportion of the general population . The myofascial trigger point is recognized as a key factor in the pathophysiology of musculoskeletal pain . Ultrasound is commonly employed in the treatment and management of soft tissue pain and , in this study , we set out to investigate the segmental antinociceptive effect of ultrasound .  Subjects ( n = 50 ) with identifiable myofascial trigger points in the supraspinatus , infraspinatus and gluteus medius muscles were selected from an outpatient rehabilitation clinic and r and omly assigned to test or control groups . Test subjects received a therapeutic dose of ultrasound to the right supraspinatus trigger point while control groups received a sham ( null ) exposure .  Baseline pain pressure threshold ( PPT ) readings were recorded at the ipsilateral infraspinatus and gluteus medius trigger‐point sites prior to ultrasound exposure . The infraspinatus point was chosen due to its segmental neurologic link with the supraspinatus point ; the gluteus medius acted as a segmental control point . Following the ultrasound intervention , PPT readings were recorded at 1 , 3 , 5 , 10 and 15 min intervals at both infraspinatus and gluteus medius trigger points ; the difference between infraspinatus and gluteus medius PPT values , PPTseg , represents the segmental influence on the PPT . The ultrasound test group demonstrated statistically significant increases in PPTseg ( decreased infraspinatus sensitivity ) at 1 , 3 and 5 min , when compared with PPTseg in the sham ultrasound group . These results establish that low‐dose ultrasound evokes short‐term segmental antinociceptive effects on trigger points which may have applications in the management of musculoskeletal pain One-half of the students taking part in a double-blind study received a microamperage electrical stimulation of trigger points in the neck and shoulder region with the Electro-Acuscope 80 . All the subjects were evaluated by digital palpatory physical examination for the presence of trigger points before each of their treatments . Results indicate that the subjects who received treatment had a higher change of trigger-point indicators compared to those receiving the placebo treatment . A two-tailed t-test indicated significant results ( P less than 0.001 ) . It appears that microamperage electrical stimulation is effective in the treatment of trigger points Objective To assess the efficacy of trigger point injection into brachialis muscle for rotator cuff disease patients with upper arm pain . Methods A prospect i ve , r and omized , and single-blinded clinical pilot trial was performed at university rehabilitation hospital . Twenty-one patients clinical ly diagnosed with rotator cuff disease suspected of having brachialis myofascial pain syndrome ( MPS ) were r and omly allocated into two groups . Effect of ultrasound (US)-guided trigger point injection ( n=11 ) and oral non-steroidal anti-inflammatory drug ( NSAID ) ( n=10 ) was compared by visual analog scale ( VAS ) . Results US-guided trigger point injection of brachialis muscle result ed in excellent outcome compared to the oral NSAID group . Mean VAS scores decreased significantly after 2 weeks of treatment compared to the baseline in both groups ( 7.3 vs. 4.5 in the injection group and 7.4 vs. 5.9 in the oral group ) . The decrease of the VAS score caused by injection ( ДVAS=-2.8 ) was significantly larger than caused by oral NSAID ( ДVAS=-1.5 ) ( p<0.05 ) . Conclusion In patients with rotator cuff disease , US-guided trigger point injection of the brachialis muscle is safe and effective for both diagnosis and treatment when the cause of pain is suspected to be originated from the muscle This study compared the pain-relieving effects of shortwave diathermy and moist heat on trigger points . Patients with trigger points on the neck or back were r and omly assigned one of these treatments . The sensitivity of each trigger point was measured with a pressure algometer before treatment , 5 minutes after treatment , and 30 minutes after treatment . Sensitive trigger points , at which 2000 grams of force or less caused pain , were more responsive to treatment than moderate trigger points ( painful only at 2000 grams or greater force ) . Both treatments were effective in relieving the pain of sensitive trigger points but shortwave diathermy was more effective at decreasing the sensitivity of both sensitive and moderate trigger points ( P > 0.0581 ) . The pressure algometer was shown to be a useful device for objective ly measuring pain and may be useful in selecting the most effective type of treatment for trigger points . J Orthop Sports Phys Ther 1984;5(4):175 - 178
On the basis of the limited number of studies available , and significant problems with their design , reporting , statistical integrity , and clinical applicability , physical examination can not currently be recommended as a reliable test for the diagnosis of trigger points .
BACKGROUND Trigger points are promoted as an important cause of musculoskeletal pain .
There is no accepted reference st and ard for the diagnosis of trigger points , and data on the reliability of physical examination for trigger points are conflicting .
OBJECTIVES To systematic ally review the literature on the reliability of physical examination for the diagnosis of trigger points .