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Journal of Bodywork and Movement Therapies (2006) 10, 3 9

Journal of Bodywork and Movement Therapies

www.intl.elsevierhealth.com/journals/jbmt

PAIN THRESHOLD RESEARCH

The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study
Ce sar Ferna ndez-de-las-Pen as, PT, Cristina Alonso-Blanco, PT, Josue Ferna ndez-Carnero, PT, Juan Carlos Miangolarra-Page, MD, PhD
Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos (URJC), Avenida de Atenas s/n, 28922 Alcorco n, Spain
Received 17 March 2005; received in revised form 9 May 2005; accepted 11 May 2005

KEYWORDS
Ischemic compression; Transverse friction massage; Myofascial trigger point; Pressure pain threshold; Visual analogue scale

Summary The aim of this pilot study was to compare the effects of a single treatment of the ischemic compression technique with transverse friction massage for myofascial trigger point (MTrP) tenderness. Forty subjects, 17 men and 23 women, aged 1938 years old, presenting with mechanical neck pain and diagnosed with MTrPs in the upper trapezius muscle, according to the diagnostic criteria described by Simons and by Gerwin, participated in this pilot study. Subjects were divided randomly into two groups: group A which was treated with the ischemic compression technique, and group B which was treated with a transverse friction massage. The outcome measures were the pressure pain threshold (PPT) in the MTrP, and a visual analogue scale assessing local pain evoked by a second application of 2.5 kg/cm2 of pressure on the MTrP. These outcomes were assessed pre-treatment and 2 min post-treatment by an assessor blinded to the treatment allocation of the subject. The results showed a signicant improvement in the PPT (P 0:03), and a signicant decrease in the visual analogue scores (P 0:04) within each group. No differences were found between the improvement in both groups (P 0:4). Ischemic compression technique and transverse friction massage were equally effective in reducing tenderness in MTrPs. & 2005 Elsevier Ltd. All rights reserved.

Corresponding author. Tel.: +34 91 488 88 84;

Background
Myofascial pain syndrome (MPS) is thought by some authors to be the main cause of neck and shoulder

fax: +34 91 488 89 56. E-mail addresses: cesarfdlp@yahoo.es, cesar.fernandez@urjc.es (C. Ferna ndez-de-las-Pen as).

1360-8592/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2005.05.003

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4 pain (Simons et al., 1999, pp. 1316). Chaiamnuay et al. (1998) reported the disease rate prevalence for MPS to be 11.3% over a sample of 2456 subjects. MPS is characterized by myofascial trigger points (MTrPs). A MTrP is a sensitive spot in a taut band of a skeletal muscle that is painful on compression and/or stretch and that can give rise to a typical referred pain pattern. An active MTrP produces spontaneous referred pain, and always evokes clinical symptoms. A latent MTrP is usually asymptomatic, and may cause referred pain in response to compression, stretch or overload of the affected tissues (Simons et al., 1999, pp. 2324). MTrPs are typically located by physical examination and palpation. The diagnosis of a MTrP is accomplished by the identication of clinical signs on physical examination, which may include the presence of a taut band in a skeletal muscle, the presence of a tender spot within the taut band; palpable or visible local twitch response on snapping palpation, and/or needle, of the MTrP; a jump sign; the presence of the typical referred pain pattern of the MTrP, and restricted range of motion of the affected tissues (Simons et al., 1999, pp. 2627). The aim of the treatment is to reduce the pain and restore normal function. There are many treatments aimed at eliminating MTrPs: ischemic compression (Simons et al., 1999), spray and stretch (Simons et al., 1999), strain and counterstrain (DAmbrogio and Roth, 1997; Dardzinski et al., 2000), trigger point pressure release (Lewit, 1991), ultrasound deep heat therapy (Gam et al., 1998), thermotherapy (Lee et al., 1997), laser therapy (Po ntinen and Airaksinen, 1995), needling therapies (Cummings and White, 2001). A recent systematic review of manual therapies in treatment of MTrPs concluded that there were few studies analysing treatment of MTrPs using manual therapy (Ferna ndez de las Pen as et al., 2005). This review found no studies in the peer-reviewed literature documenting the isolated effects of transverse friction massage in the management of MTrPs. The aim of this pilot study was to compare the immediate effect, on pain threshold, and local pain perceived, following a single treatment involving ischemic compression technique or transverse friction massage. C. Ferna ndez-de-las-Pen as et al. Medicine and Rehabilitation of the Universidad Rey Juan Carlos. It was approved by the Ethical Committee in Clinical Research of the University. All subjects signed the required consent before beginning the study.

Subjects
Forty subjects, 17 men and 23 women, aged 1938 years old (mean age: 28.5; SD: 6.1 years), participated in this pilot study. Inclusion requirements to be participants in this study were subjects, who were at least 18 years old, presenting with mechanical neck pain for at least 2 weeks, and diagnosed with MTrPs, either latent or active, in the upper bres of the trapezius muscle. For the purpose of this study, mechanical neck pain was dened as generalized neck and/or shoulder pain with mechanical characteristics including: symptoms provoked by maintained neck postures or by neck movement and/or by palpation of the cervical muscles. Subjects were excluded if they exhibited any of the following: 1. diagnosis of bromyalgia syndrome according to the American College of Rheumatology (Wolfe et al., 1990), 2. history of a whiplash injury, 3. history of cervical spine surgery, 4. diagnosis of cervical radiculopathy or myelopathy determined by their primary care physician; or 5. having undergone myofascial pain therapy within the past month before the study. The presence of MTrPs was determined using the diagnostic criteria described by Simons et al. (1999): 1. presence of a palpable taut band in a skeletal muscle, 2. presence of a hypersensitive tender spot in the taut band, 3. local twitch response provoked by the snapping palpation of the taut band, 4. reproduction of the typical referred pain pattern of the MTrP in response to compression, 5. spontaneous presence of the typical referred pain pattern and/or patient recognition of the referred pain as familiar (Gerwin et al., 1997). If only the four rst criteria were satised, the MTrP was considered to be latent. If all of the aforementioned criteria were present, the MTrP

Material and methods

Overview
This pilot study was supervized by the Department of Physical Therapy, Occupational Therapy, Physical

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The immediate effect of ischemic compression technique and transverse friction massage was considered to be active (Simons et al., 1999; Gerwin et al., 1997). For criteria 4, MTrP pressure tolerance was assessed using a mechanical pressure algometer. The assessor applied continuous pressure with the algometer at approximately a rate of 1 kg/cm2/s, until it recorded a pressure of 2.5 kg/cm2. Pressure thresholds lower than 3 kg are considered to be abnormally low (Fischer, 1996). If the referred pain evoked by the MTrP was obtained before 2.5 kg/ cm2, criteria 4 was seen to be fullled. In the present study, MTrPs were located in the middle of the front edge of the most vertical bres of the upper trapezius muscle. The referred pain pattern produced by these MTrPs spread from the ipsilateral posterolateral region of the neck, behind the ear to the mastoids process of the temporal bone (Simons et al., 1999, p. 353). 5

Cyriax and Cyriax (1992), and was applied for 3 min. Frictions were applied slowly with a pressure slightly painful, approximately at the pressure pain threshold (PPT) level of each patient.

Outcome measures and instrumentation

The outcome measures were the PPT at the MTrP, and the visual analogue scale (VAS) assessing local pain elicited by 2.5 kg/cm2 of pressure on the MTrP. These outcomes were assessed by an examiner blinded to the treatment allocation of the subject. The PPT is dened as the minimal amount of pressure where a sense of pressure rst changes to discomfort or pain in a certain point (Fischer, 1990). A pressure threshold meter (PTM), algometer, distributed by Pain Diagnosis and Rehabilitation (233 East Shore Road, Suite 108, Great Neck, New York 11023) was used in this study. The PTM consists on a rubber disk with 1 cm2 surface. The rubber disk is connected to a pressure pole, which inserts into a gauge which records pressure in kilograms (kg). Pressure measurements are expressed in kg/cm2. Pressure ranged from 0 to 10 kg/cm2, recording values each 0.1 kg. Previous papers have reported an intra-examiner reliability (I.C.C.) of use of a PTM, ranging from 0.6 to 0.97 and an interexaminer reliability ranging from 0.4 to 0.98 (Levoska, 1993; Takala, 1990). The VAS is an instrument that has been widely used to quantify the intensity of pain. The patient placed a vertical mark on a continuous 10 cm line to indicate his/her pain, ranging from no pain or discomfort (0), to the worst pain you could possibly feel (10). The reliability and validity of the VAS as a measure of pain has been established previously (Jensen et al., 1999). The VAS measurement was used to assess local pain evoked by 2.5 kg/cm2 of pressure, applied with the algometer, on the MTrP.

Description of the employed manual therapies

The manual therapies employed in the current pilot study were ischemic compression technique and transverse friction massage. 1. For the ischemic compression technique, the patient lay supine with the cervical spine in a neutral position. The therapist applied gradually increasing pressure to the MTrP until the sensation of pressure became one of pressure and pain. At that moment, the pressure was maintained until the discomfort and/or pain eased by around 50%, perceived by the own patient, at which time pressure was increased until discomfort appeared again (Fig. 1a). This process was repeated for 90 s. This technique is claimed to be more effective when executed with the muscle in a lengthened position (Simons et al., 1999). 2. Transverse friction massage was applied with the forenger and reinforced with the middle nger (Fig. 1b). This technique was executed with the muscle in relaxed position, as recommended by

Procedure
1. Subjects presenting with mechanical neck pain were recruited from a private clinic of manual therapy from January to June of 2004. The MTrPs examination was performed by Therapist 1 who marked the MTrP with a felt-tip pen. Pretreatment measurement of the PPT was assessed by Therapist 2, who was blinded to the treatment allocation of the subject. This procedure was performed following the guidelines described by Fischer (1990, 1996): (a) The

Figure 1 The ischemic compression technique and transverse friction massage over myofascial trigger point in the upper trapezius muscle: (a) ischemic compression technique: (b) transverse friction massage.

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6 C. Ferna ndez-de-las-Pen as et al. distribution of quantitative data was assessed by means of the KolmogorovSmirnov test (P 40:05). Baseline features were compared between groups using the independent t-tests for continuous data, and w2 tests of independence for categorical data. Within-group differences were assessed with the dependent t-test. Within-group effect sizes were calculated using Cohens d coefcient (Cohen, 1988). Inter-group comparisons between both study groups were also achieved with the independent ttest. The statistical analysis was conducted at a 95% condence level. A P value less than 0.05 was considered as statistically signicant.
Figure 2 Position of the pressure threshold meter over the myofascial trigger point in the upper trapezius muscle.

Results
At the beginning of the study, no signicant differences were found for gender (P 0:4), age (P 0:5) or the type of MTrp (P 0:3) between both study groups. Moreover, there were no differences between groups for the PPT (P 0:3) or the VAS (P 0:4). It could therefore be assumed that both groups were comparable in all respects at the start of the study. The intra-examiner repeatability of pre-test readings of the PPT was 0.89 (I.C.C.), suggesting high repeatability of PPT measurements. Baseline data of each group are given in Table 1. The results showed a signicant improvement in the PPT (P 0:03), and a signicant decrease in the VAS (P 0:04) within each group. Within-group effects sizes for both groups were found to be large (d 41) in both outcomes. An independent t-test revealed no differences between the improvement in both groups (P40:4), suggesting that both experienced a similar improvement in the outcomes. Differences between the scores of males and females did not reach the signicant level (P40:2). Furthermore, there were no differences in the improvement
Table 1 Characteristics of the groups.

patient lay supine; (b) The PTM was placed perpendicular to the MTrP (Fig. 2); (c) The patient was instructed to report to the assessor the instant the sensation of pressure became one of pressure and pain; (d) The pressure was applied approximately at a rate of 1 kg/cm2/s until the moment that the pressure was perceived as pressure and pain (e) The application of pressure was stopped and the maximum pressure displayed by the algometer was recorded. Three consecutive measurements were obtained by the same assessor and the mean was considered in further analysis. 2. After the pre-treatment data of the PPT, a second application of 2.5 kg/cm2 of pressure was also applied by the same assessor. Subjects were told to mark a line on the VAS assessing local pain evoked by the application of that amount of pressure. 3. After pre-treatment measurements, subjects were divided randomly into two groups, using a table of random numbers: group A was treated with ischemic compression technique, and group B was treated with a transverse friction massage. The appropriate technique was applied by Therapist 1, who was blinded to pre-treatment data. 4. Post-manipulative values were assessed 2 min after the application of the technique by Therapist 2 in the same way as in the pretreatment data.

Characteristics of both groups Group A B Number of cases 20 subjects 20 subjects Gender (M/F) 8/12 9/11 Age (X SD) 27.775.5 years 29.776.2 years MTrP (A/L) 14/6 14/6 PPT pre-treatment1.870.5 kg/cm2 270.4 kg/cm2 VAS pre-treatment 4.671.2 4.971.5
M Male; X Mean; F Female; SD Standard deviation; A Active MTrP; L Latent MTrP; MTrP Myofascial trigger point; PPT Pressure pain threshold; VAS Visual analogue scale (expressed in centimetres).

Analysis of data
Data was analysed with the SPSS package (version 11.5). Mean and standard deviations of the values were calculated for each variable. A normal

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The immediate effect of ischemic compression technique and transverse friction massage 7

Scores are expressed as means (standard deviation). PPT Pressure pain threshold (expressed in kg/cm2); VAS Visual analogue scale (expressed in centimetres); P P value based on intra-group comparison (based on the dependent t-test).

Intra-group cohens d

between active and latent MTrPs (P 40:3). Table 2 summarizes within-group pre-post scores and withingroup effect sizes of each group.

VAS

2.6 1.75

Discussion
The present pilot study demonstrated that MTrP sensitivity decreased in response to both ischemic compression technique and transverse friction massage. Both groups obtained a similar improvement in the PPT, and a similar decrease in the VAS. This is the rst paper that has analyzed the effects of transverse friction massage for MTrP tenderness (Ferna ndez de las Pen as et al., 2005). There are three papers that have previously analysed the effectiveness of the ischemic compression technique in the management of MTrPs (Hong et al., 1993; Hanten et al., 2000; Fryer and Hodgson, 2005).

PPT VAS PPT VAS

P value

Prepost treatment data

0.4 (0.19) 0.35 (0.09)

0.8 (0.3) 0.7 (0.4)

0.03 0.03

0.03 0.04

2.1 3.8

Post-treatment data

Pre- and post-treatment values of each group.

Group A (Ischemic compression) Group B (Transverse friction massage)

Hong et al. (1993) reported that the best results in decreasing pain from MTrPs were obtained with a deep pressure soft tissue massage which included conventional massage and different compression techniques. Hanten et al. (2000) examined the effectiveness of a home program of ischemic compression followed by sustained stretching over active MTrPs. The results from this study showed that the combination of these techniques was effective in reducing tenderness from MTrPs. However, we do not know if the improvement in their patients was produced by the effects of the ischemic compression technique, by the sustained stretch or by the combination of both techniques. The substantial heterogeneity in the methodology of application of ischemic compression technique in these trials makes it difcult to compare the results. Fryer and Hodgson (2005, in press) have recently demonstrated that the ischemic compression technique is better than sham-myofascial technique in reducing tenderness on latent MTrPs in the upper trapezius muscle. The results obtained by these authors are similar than those reported in the present pilot study for ischemic compression technique.

PPT VAS PPT VAS PPT

Pre-treatment data

1.8 (0.5) 2 (0.4)

4.6 (1.2) 4.9 (1.5)

2.2 (0.6) 2.35 (0.4)

3.8 (0.9) 4.2 (0.4)

Mechanisms
Different therapeutic mechanisms for pressure treatment have been proposed: 1. Simons (2002) has proposed that local pressure may equalize the length of sarcomeres in the

Table 2

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8 involved MTrP and consequently decrease the pain. 2. On the other hand, Hou et al. (2002) suggested that pain relief from pressure treatment may result from reactive hyperemia in the MTrP region, or a spinal reex mechanism for the relief of muscle spasm. Further research is required to clearly dene the therapeutic mechanism of pressure treatment. There is also no agreement as to the amount of pressure that it is necessary to apply during a pressure technique. Hou et al. (2002) found that a higher pressure (an average of PPT and pain tolerance) applied for 90 s produced the most signicant pain relief; however, signicant improvement was also obtained with lower pressure at the PPT level each patient. Some authors claim that is unnecessary to apply excessive force provoking ischemia (Simons et al., 1999; Lewit, 1991). There seems to be no reason to provoke additional ischemia in a point already suffering severe hypoxemia and loss of oxygen (Hong and Simons, 1998; Mense et al., 2000). The ischemic compression technique has tended to be replaced by the trigger point pressure release technique. This technique was described by Lewit (1991),who recommended the concept of the barrier release. The difference between this approach and ischemic compression technique is that the therapist gradually applies pressure to the MTrP until a denitive increase in resistance is perceived, i.e. the barrier, which is usually perceived as not being painful by the subject (Lewit, 1991). We were unable to locate any study analysing the effectiveness of trigger point pressure release technique (Ferna ndez de las Pen as et al., 2005). Therefore, future studies are required to clearly dene the amount of pressure that it is necessary to apply to a MTrP to obtain clinical improvement. Readers may consider that reduction in perceived tenderness may be caused by an unintentional release of pressure by the clinician. Fryer and Hodgson (2005, in press) have recently demonstrated that decreased local MTrP tenderness appeared to be due to a change in tissue sensitivity rather than any unintentional release of pressure by the practitioner. On the other hand, Hong et al. (1993), hypothesized that deep massage can offer effective stretching and mobilization of taut bands. Therefore, transverse friction massage may offer a useful transverse mobilization to the taut band. The present paper has shown that transverse mobilization of the taut band is effective in reducing C. Ferna ndez-de-las-Pen as et al. tenderness on MTrPs to a similar degree to that produced by pressure treatment. MTrPs diagnosis needs adequate ability, training, and clinical practice to develop a high degree of reliability in the examination (Sciotti et al., 2001; Gerwin et al., 1997). Moreover, some muscles are consistently more reliably examined than others. Simons et al. (1999) and Gerwin et al. (1997) recommend that the minimum acceptable criteria for active MTrP diagnosis is the combination of the presence of a spot tenderness in a palpable taut band, in a skeletal muscle, and patient recognition of referred pain that is elicited by pressure applied to the tender spot. In the present study, these two minimum criteria identied active MTrPs. Furthermore, the local twitch response, a conrmatory sign of MTrP diagnosis (Simons et al., 1999), was also an inclusion requirement in the diagnosis of MTrPs, although some studies have reported that its interexaminer reliability depends on the examined muscle (Sciotti et al., 2001; Gerwin et al., 1997). A few limitations exist to our pilot study. The most critical are the small sample size and the absence of a control group. Without a control group it could not be assumed that a cause and effect relationship existed between both interventions and decreased tenderness. Both study groups improved, but we do not know if our results were due to each intervention, to a placebo effect, or to a systematic bias from our examiner, who was blinded to the treatment allocation, but were presumably aware of the treatment status, treated or untreated, of every subject. However, Fryer and Hodgson (2005, in press) have demonstrated that sham-myofascial release technique had no effect in reducing pain on latent MTrPs. A stronger design should include a third group undergoing a sham control intervention, which may then demonstrate that both treatments were better than sham intervention. Moreover, this study was limited to an immediate effect. Further studies are needed to examine long-term effects of these techniques. Finally, it would be interesting analyse which MTrPs in the cervical musculature reproduce the subjects neck symptoms and the long-term repercussion of the treatment methods used.

Conclusion
Our results suggest that ischemic compression technique and transverse friction massage are comparably effective in reducing tenderness of myofascial trigger points (MTrPs). The lack of

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The immediate effect of ischemic compression technique and transverse friction massage published trials analysing the effectiveness of manual therapies in the management of MTrPs, in addition to the lack of similar methodology of application of those, makes it difcult to draw any conclusion. Further studies are required to investigate the effects of the different manual therapies that are being used in clinical practice. 9

Acknowledgments
We would like to acknowledge Dr. David Simons for his kind encouragement and support.

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