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EBP Manual Pressure Release of Myofascial Trigger Points

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Camille Lee

on 6 November 2014

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Transcript of EBP Manual Pressure Release of Myofascial Trigger Points

Titin is the spring-like molecule holding the myosin chain in place
Algometry assesses Pain Pressure Threshold (PPT)
Purpose
Trigger Point Release as an Intervention for Immediate Pain Reduction at Myofascial Trigger Points in the Upper Trapezius Muscle: A Systematic Review and Meta-Analysis
Introduction
Myofascial Trigger Point (MTrP): Hyperirritable point of tenderness in a palpable taut band
Methods
Results
Discussion
Camille Lee, DPTc
Other Interventions for MTrPs
Stretching
Massage
Laser therapy
TENS
Magnets
Ultrasound
(Simons 1999)
Trauma
Repetitive stress
Forward head posture
Injured or overloaded muscle fibers
Local shortening in response
Sustained muscle contraction
Abnormal acetylcholine (ACh) release at the motor endplate of the neuromuscular junction
Local Energy Crisis
Brain's response to hypoxia and lack of energy supply
(Gerwin et al., 2004)
as the surrounding sarcomeres are stretched
unifr.ch.com
Titin
(Simons et al., 2008)
ks.uiuc.edu
kob-one.com
Substance P,
prostaglandins, etc.
(Shah et al., 2005)
(Simons 1999)
Clinical Problem
Secondary Question
Trigger Point Release
(TPR)
(Simons and Travell, 1999)
Return sarcomere to normal length
Significance
MTrPs are the primary source of myofascial pain syndrome, one of the leading causes of muscular pain
15% of routine medical visits
85% of pain clinic visits
Compressing the MTrP returns involved sarcomeres to normal length
(Staud et al., 2007)
(Simons & Travell, 1999)
(Gerwin et al., 2004)
MTrP treatment is underused and not well-understood, even though studies have shown moderately strong evidence for its use in clinical practice
Relevance to PT
Not enough rigorous evidence to prove beyond placebo (Fryer et al., 2005)
Physical therapists not allowed to perform these procedures in California
Dry needling
Acupuncture
Hydrocortisone or saline injections
MTrPs are often the underlying problem of myofascial pain and can go untreated
Fewer visits to PT covered by insurance
Patients want to see results of immediate change and pain relief
The "Integrated Hypothesis"
MTrPs can masquerade as common biomechanical pain problems
If so, is a 60-sec or 90-sec application of TPR more effective for immediate pain relief of the upper trapezius muscle?
neckpainsupport.typepad.com
MTrP-related pain is common in the patient population, yet MTrP treatment is underutilized and not well-understood
(de las Penas et al., 2003)
This study will update the literature to determine whether TPR is evidence-based and has a specific efficacy in the treatment of MTrPs
Gap in the PT Practice and Literature
There is a difference in effectiveness between 60-sec and 90-sec hold time
Normalized length allows:
Return of nutritive blood flow
Return to homeostasis
(Moraska et al., 2013)
Diagnostic Criteria for Assessing MTrPs
4. Local twitch response to snapping of taut band
The trapezius muscle is the most commonly affected with MTrPs
(Simons et al., 1999)
Over half of the total employed Americans use the computer at work
MTrPs in the trapezius can develop from improper postures and repetitive stress from computer work.
P: Patients with active or latent MTrPs
I: Application of TPR
C: Placebo or no treatment
O: Pain sensitivity relief (increase in PPT) immediately after treatment
Primary Question
Foreground
Databases
Search Terms
Myofascial trigger points
MTrP treatment
Physical therapy
Search Procedures
Inclusion Criteria
TPR as an intervention performed on the upper trapezius muscle
PPT as an outcome measure
Published within the past 15 years
Exclusion Criteria
Home-based programs
Not in English
Statistical Summary
Within-group and between-group comparison for PPT following TPR treatment
Individual study effect size (ES)
Weighted by inverse variance
Q statistic to address homogeneity
Grand ES using 95% confidence interval (CI)
Conversion back to clinical units
Primary References
Secondary References
(Simons et al., 2002 and Gerwin et al., 2004)
(Simons et al., 2002)
(Simons et al., 1999)
(Sciotti, 2004)
(Hoyle et al., 2011)
(Treaster, 2006)
To investigate the efficacy of TPR in treating MTrPs in the upper trapezius muscle
(Chesterton 2004)
Outcome Measure Assessing Effectiveness of TPR
(Simons et al., 2002)
wikimedia.org
greenbechiropractic.com
1. Cagnie B, Dewitte V, Coppieters I, Van Oosterwijck J, Cools A, Danneels L. Effect of ischemic compression on trigger points in the neck and shoulder muscles in office workers: A cohort study. J Manipulative Physiol Ther. 2013.
2. de las Peñas, César Fernández, Sohrbeck Campo M, Fernández Carnero J, Miangolarra Page JC. Manual therapies in myofascial trigger point treatment: A systematic review. J Bodywork Movement Ther. 2005;9(1):27-34.
3. de-las-Peñas C, Alonso-Blanco C, Fernández-Carnero J, Carlos Miangolarra-Page J. The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: A pilot study. J Bodywork Movement Ther. 2006;10(1):3-9.
4. Fryer G, Hodgson L. The effect of manual pressure release on myofascial trigger points in the upper trapezius muscle. J Bodywork Movement Ther. 2005;9(4):248-255.
5. Gemmell H, Allen A. Relative immediate effect of ischaemic compression and activator trigger point therapy on active upper trapezius trigger points: A randomised trial. Clinical Chiropractic. 2008;11(4):175-181.
6. Hou C, Tsai L, Cheng K, Chung K, Hong C. Immediate effects of various physical therapeutic modalities on cervical myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002;83(10):1406-1414.
7. Okhovatian F, Mehdikhani R. Comparison between the immediate effect of manual pressure release and strain/counterstrain techniques on latent trigger point of upper trapezius muscle. Clinical Chiropractic. 2012;15(2):55-61.
8. Oliveira-Campelo NM, de Melo CA, Alburquerque-Sendin F, Machado JP. Short- and medium-term effects of manual therapy on cervical active range of motion and pressure pain sensitivity in latent myofascial pain of the upper trapezius muscle: A randomized controlled trial. J Manipulative Physiol Ther. 2013;36(5):300-309.
9. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. International Journal of Osteopathic Medicine. 2006;9(4):120-136.
10. Sarrafzadeh J, Ahmadi A, Yassin M. The effects of pressure release, phonophoresis of hydrocortisone, and ultrasound on upper trapezius latent myofascial trigger point. Arch Phys Med Rehabil. 2012;93(1):72-77.
1. Celik D, Kaya Mutlu E. The relationship between latent trigger points and depression levels in healthy subjects. Clin Rheumatol. 2012;31(6):907-911.
2. Fernández-de-las-Peñas C, Simons DG, Cuadrado ML, Pareja JA. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007;11(5):365-372.
3. Gerber LH, Sikdar S, Armstrong K, et al. A systematic comparison between subjects with no pain and pain associated with active myofascial trigger points. PM R. 2013.
4. Gerwin RD, Dommerholt J, Shah JP. An expansion of simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8(6):468-475.
5. Munoz-Munoz S, Munoz-Garcia MT, Alburquerque-Sendin F, Arroyo-Morales M, Fernandez-de-las-Penas C. Myofascial trigger points, pain, disability, and sleep quality in individuals with mechanical neck pain. J Manipulative Physiol Ther. 2012;35(8):608-613.
6. Sciotti VM, Mittak VL, DiMarco L, et al. Clinical precision of myofascial trigger point location in the trapezius muscle. Pain. 2001;93(3):259-266.
7. Scudds RJ, Scudds RA, Simmonds MJ. Pain in the physical therapy (pt) curriculum: A faculty survey. Physiotherapy Theory and Practice. 2001;17(4):239-256.
8. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16-23.
9. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004;14(1):95-107.
10. Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med. 1989;151(2):157-160.
11. Staud R. Future perspectives: Pathogenesis of chronic muscle pain. Best Pract Res Clin Rheumatol. 2007;21(3):581-596.
12. Tozzi P, Bongiorno D, Vitturini C. Fascial release effects on patients with non-specific cervical or lumbar pain. J Bodyw Mov Ther. 2011;15(4):405-416.
13. Vernon H, Schneider M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: A systematic review of the literature. J Manipulative Physiol Ther. 2009;32(1):14-24.
Algometer: a rubber disk attached to a gauge and records pressure in kilograms (kg).
High intraclass correlation coefficient with basic training period
positive intervention
effect
PPT
myalgia.com
bodyevolutionacupuncture.com
Minimum acceptable criteria
PRISMA Diagram
Search completed Dec. 13, 2013
Two outside reviewers confirmed articles
Comparison of Primary Studies
Level of
Evidence
N
Control
Intervention
Gemmell
2008
Cagnie
2013
Hou
2002
Fernández-de-las-Peňas
2006
2b
2b
2b
24
None
None
19
119
40
None
Hot pack (20 min)
C-spine AROM
exercise
TPR (perpendicular pressure) 30-60 s, 1 session
TPR (perpendicular pressure) 60 s,
8 sessions
TPR (pincer grip) 90 s, 1 session
TPR (perpendicular pressure) 90 s
Level of
Evidence
N
Control
Intervention
1b
1b
1b
1b
66
Sham
ultrasound
Sham
'myofascial
release'
37
117
60
No treatment
Wait-and-see,
Placebo passive
stretching
TPR (perpendicular pressure) 60 s
TPR (perpendicular pressure) 60 s
TPR (perpendicular pressure) 90 s (x4)
TPR (pincer grip)
Okhovatian
2012
Fryer
2005
Oliveira-
Campelo
2013
Sarrafzadeh
2012
Within-Group Forest Plot of Effects of TPR Technique
Between-Group Forest Plot of Effects of TPR Technique
Results in Forest Plots
Combined Within-Group and Between-Group Forest Plot

0.89 (0.31, 0.1.47)
2.17 (1.45, 2.9)
0.92 (-0.11, 1.95)
0.80 (0.16, 1.44)


Effect Size (CI)
1.17 (0.82, 1.51)

1.53 (0.85, 2.20)
1.21 (0.54, 1.88)
1.34 (0.55, 2.13)
2.00 (1.31, 2.69)



Effect Size (CI)
1.50 (1.15, 1.85)
Statistically Significant
Statistically Significant
(P<0.05, Random effects model)

(P<0.05, Random effects model)

Converting Back to Clinical Units
Harm, Adverse Events, Cost
(Okhovatian, 2012)
No adverse side effects for recipients of TPR
Inexpensive and can be used anywhere and without equipment
Summary of Results
YES
YES
UCSF/SFSU Graduate Program in Physical Therapy
Spring Symposium

Previous Literature
This Meta-Analysis
Most recent systematic review: (Vernon and Schneider, 2009)
2 RCTs and 2 cohort studies
Included 4 additional studies since 2009
5 RCTs and 3 cohort studies
Multiple manual therapies
Multimodal treatment regimens
Varied follow-up time
Included only TPR performed by an experienced clinician
Immediate follow-up
1 RCT using a placebo control
3 RCTs with placebo control
Implications for Clinical Practice
TPR is an effective treatment in as few as one intervention of 60-90s
Limitations
TPR handhold
Perpendicular
thumb pressure
Pincer grip
massagemag.com
Oliviera-Campelo, 2013
Subject recruitment
Female vs. Male
Latent vs. Active
Locations worldwide
Amount of pressure used
Heterogeneity in:
Areas of Future Research
Based on this research, specifics in protocol are insignificant
One included study examined hold times and the amount of pressure utilized
This study revealed that the two trials with the largest effect sizes used higher pressure
One study found large effect sizes with follow-up times of 24 hours and one week after a single treatment session
Primary Question
Is TPR effective for immediate pain relief of the upper trapezius muscle?
Null Hypothesis
Alternative
Hypothesis
Alternative Hypothesis
There is no change in PPT
There is an increase in PPT (pain relief)
Primary Question:
Effectiveness of TPR
Null Hypothesis
There is no difference in effectiveness between 60-sec or 90-sec
Secondary Question: TPR Application Time
2b
90 s
Statistically
Significant
Grand Effect
Sizes
Conclusion
TPR is an effective treatment method for immediate pain relief of MTrPs in the upper trapezius regardless of handhold or application time of 60-90 sec
Acknowledgments
Diane Allen, PT, PhD
Angela Giertych, DPTc
Christina Cu-Unjieng, DPTc
Christine Zampach, PT, MEd, DPT
Felicia Ferlin, PT, DPT
Jeannette Lee, PT, PhD
Monica Rivera, PT, DPTSc
Class of 2014
Questions?
Primary Question: Is TPR effective?
Fail to reject the null because
the point values are similar and confidence intervals overlap
Secondary Question: Is there a difference in effectiveness with 60-sec or 90-sec application time?
MTrPs can be ACTIVE or LATENT
Improves with
Intervention
Favors
TPR
Favors
control
neuroanatomyblog.tumblr.com
Grand effect size > 0.8 is large
Persistent, moderate pressure against tissue barrier of the MTrP, 60-90 seconds or until softening of the MTrP occurs
Perpendicular
thumb pressure
massagemag.com
Oliviera-Campelo, 2013
Pincer grip
Normal sarcomere
MTrP
(Simons et al., 2002)
No consensus on a practice guideline to treat MTrPS
(Vernon and Schneider, 2009)
To date, no meta-analysis has been conducted to evaluate the effectiveness of TPR
(Simons et al., 2002)
1. Hypersensitive tender spot in palpable taut band
2. Recognition of pain as familiar
3. Reproduction of typical referred pain pattern
Individual cohort studies
RCTs
Sufficient Level I and II evidence to give TPR an A grade of strong recommendation in clinical practice
Long-term Follow-up
Hold Times
and Pressure
Amount of pressure
Long-term follow-up
(Hou et al., 2002)
(Oliviera-Campelo et al. , 2013)
(Cagnie et al., 2013 & Oliviera-Campelo et al. , 2013)
imperial.ac.uk
drshmaltz.com
burtchiropractic.com
ACh
Expected Findings: 5-8 well-controlled randomized trials (RCTs) and cohort studies
98
8
1bp.blogspot.com
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