Myofascial Pain Syndromes Trigger Points

David G. Simons
Four articles this quarter present major progress in new experimental data. Hou et al. demonstrated in rabbits that motor endplate potentials [spontaneous electrical activity] of trigger spots are partially dependent on increased calcium channel permeability. Delaney et al. report an elegant way to measure the effect of myofascial trigger point [TrP] massage on autonomic nervous system activity. This opens a new research window through which to explore the close relation between TrP activity and autonomic nervous system activity. Esenyel et al. present a randomized, controlled, unblinded comparison of the results of ultrasound application and injection of TrPs and found that both were equally and significantly effective. This is one of the very few scientific papers that address the effectiveness of treating TrPs with ultrasound. Pongratz reported a noteworthy histological study specifically of TrPs. In addition, the efficacy of needling TrPs is becoming firmly established, and one review article presents in detail the importance of considering TrPs in patients with symptoms of radiculopathy. CLINICAL STUDIES Infrared Skin Temperature Measurement Cannot Be Used to Detect Myofascial Tender Spots: M. Radhakrishna, R. Burnham. Arch Phys Med Rehabil 82: 902-905, 2001. Summary There is great need for an objective test to identifying myofascial trigger points [TrPs] and hot spots of skin overlying TrPs have been recomDavid G. Simons, MD, is Clinical Professor [voluntary], Department of Rehabilitation Medicine, Emory University, Atlanta, GA. Address correspondence to: David G. Simons, MD, 3176 Monticello Street, Covington, GA 30014-3535 [E-mail: loisanddavesimons@earthlink.net]. Journal of Musculoskeletal Pain, Vol. 10(4) 2002 http://www.haworthpressinc.com/store/product.asp?sku=J094 2002 by The Haworth Press, Inc. All rights reserved.

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mended as an objective test. In this study, two blinded examiners studied 16 subjects, 11 myofascial pain and five fibromyalgia patients. In each subject, the examiners marked 36 squares over the back of the shoulders that included some of the upper trapezius and most of the middle trapezius muscles. Next, one examiner measured skin temperature at the center of each square using a hand-held infrared thermometer [area sampled not identified] and measured the pain pressure threshold at the same location with an algometer. The second, blinded, examiner located any tender spots deemed painful by the subject where manual pressure elicited a jump sign and then noted in which squares tender spots occurred. Findings within squares were compared. Algometer readings correlated strongly [P < 0.001] with tender spots. Temperature readings of tender spots and of contralateral squares were essentially the same [32.0 and 32.1C]. Thermometry is not a useful tool for diagnosing TrPs. Comment The authors are to be commended for distinguishing patients with fibromyalgia and those with only myofascial pain. They reconfirm that thermometry is not reliable for identifying TrPs. Swerdlow et al. (1) using much more rigorous criteria for a TrP [spot tenderness in a taut band, local twitch response, and jump response] and examining much the same musculature with thermography reached essentially the same conclusion as this study. Although the methods section in this study refers to TrPs, the authors criteria of only locating tenderness sufficient to elicit a jump sign would only identify a tender spot. The tenderness could also be caused by fibromyalgia in the absence of a TrP. When available [as it is in the trapezius muscle], the presence of a taut band identifies a TrP in either group of patients. The TrP diagnosis is strongly reinforced by finding a local twitch response. Since no significant difference was found between the two diagnostic groups of patients and since TrPs are very common in fibromyalgia patients, there is a strong likelihood that most of the tender spots studied were TrPs. The low average normal threshold [nontender squares] of 2.1 kg/cm2 is much lower than the published value of 3.7 kg/cm2. The small average threshold difference of only 0.3 kg/cm2 between tender and nontender squares emphasizes a serious weakness of this algometer, which is unable to measure below 1.0 kg/cm2. A more sensitive and reliable electronic instrument is needed.

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The Short-Term Effects of Myofascial Trigger Point Massage Therapy on Cardiac Autonomic Tone in Healthy Subjects: J. Delaney, K.S. Leong, A. Watkins, D. Brodie. J Adv Nurs 37(4):364-371, 2002. Summary Myofascial trigger-point massage therapy [TPT] is commonly used in sports therapy for alleviation of pain and to induce muscle relaxation following injury. This study compares the effect on 30 healthy subjects of receiving TPT for 20 minutes in group 1 to the effect on control group 2 of sitting quietly, relaxing. Trigger points were identified as discrete hyperirritable areas within a taut band of muscle that are painful on compression and can evoke referred pain. The specific myofascial trigger point [TrP] massage procedures included effleurage, petrissage, cross-fiber stroking, and tapotement. Deeper, more focused pressure and circular frictions were applied to Trp areas in the upper, middle, and lower trapezius and suboccipitalis muscle regions. In addition, gentle circular frictions and palmar kneading were applied to frontalis and occipitalis muscle regions, and linear stroking added for the sternocleidomastoid muscles. Cardiac autonomic tone was assessed by heart rate variability. Heart rate was recorded for five minutes before and five minutes after treatment. Reduced heart rate variability is associated with increased coronary heart disease, cardiac sudden death, and all-cause mortality. Time domain of variability was measured as standard deviation of R-R intervals and root mean square of successive intervals. The frequency domain was measured in three discrete frequency components: high, low, and very low based on spectral analysis of R-R intervals. High frequencies reflect parasympathetic activity [calm and relaxation] and low frequencies reflect sympathetic activity [emotional distress]. Following TPT, there was a significant decrease in heart rate [P < 0.01], systolic blood pressure [P = 0.02], and diastolic blood pressure [P < 0.01], indicating a significant increase in parasympathetic tone [P < 0.01]. The TPT effectively increased cardiac parasympathetic activity and improved measures of relaxation. Comments This is an unprecedented, well-designed, carefully documented study that uses powerful analytic methods to determine autonomic effects of

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TPT. The diagnostic criteria make it clear that part of the treatment was directed specifically to TrPs and that part of it concerned less specific myofascial pain in general. Several lines of evidence indicate that autonomic activity can strongly influence TrPs and that TrPs can influence autonomic activity. This is a groundbreaking contribution to what promises to be a useful new tool for future TrP research. ETIOLOGICAL MECHANISMS Effects of a Calcium Channel Blocker on Electrical Activity in Myofascial Trigger Spots of Rabbits: C.R. Hou, K.C. Chung, J.T. Chen, C.Z. Hong. Am J Phys Med Rehabil 81(5):342-349, 2002. Summary Previous studies demonstrated that phentolamine, a sympathetic nervous system blocking agent, reduces the spontaneous electrical activity characteristic of myofascial trigger points (2). This study examined the effect of a calcium channel blocker, verapamil. The spontaneous electrical activity of rabbit trigger spots exposed to verapamil by intravenous injection declined significantly compared to that of trigger spots exposed to injection of normal saline. This applied to individual trigger spots followed for 80 seconds after injection and to 25 trigger spots sampled three times during the 20 minutes after injection. Comments This decrease in the endplate potentials [endplate noise and endplate spikes, if present] that were identified as spontaneous activity in this study, adds a major new consideration to the integrated hypothesis. The last link in the positive feedback loop of that hypothesis postulates that increased autonomic activity releases a substance or substances that increases the rate of abnormal spontaneous release of acetylcholine by the nerve terminals of involved motor endplates (3,4). This study suggests a way that substances released by sympathetic nerve activity could cause the increased acetylcholine release into the synaptic cleft. They could do so by increasing the permeability of calcium channels in the interior/exterior cell membrane of the nerve terminal.

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Neuere Ergebnisse zur Pathogenese Myofaszialer Schmerzsyndrome [New Aspects on Pathogenesis of Myofascial Pain Syndrome]: D. Pongratz. Nervenheilkunde 21(1):35-37, 2002. Summary Myofascial pain caused by trigger points [TrPs] is the cause of most chronic low back pain. Trigger points are caused by microtrauma, macrotrauma, and nerve root compression. Two figures illustrate histological findings from human active TrPs. A light microscopic longitudinal section illustrates a series of so-called contraction discs, and an electron microscopic longitudinal section shows an example of the transition between regions of shortened and lengthened sarcomeres. This sample was taken from a region of recurring segments of abnormally shortened sarcomeres. Under light microscopy, this part of the TrP showed what appear to be repeated abnormal segmental contractions. Comments This is a pioneering histological study of human TrPs that were located by palpation and confirmed electrophysiologically. It shows sarcomere contraction phenomena that would increase the tension of that muscle fiber and contribute to a taut band, but the nature of these changes and how they develop is unknown. TREATMENT Comparison of Superficial and Deep Acupuncture in the Treatment of Lumbar Myofascial Pain: A Double-Blind Randomized Controlled Study: F. Ceccherelli, M.T. Rigoni, G. Gagliardi, L. Ruzzante. Clin J Pain 18:149-153, 2002. Summary The relative value of superficial and deep dry needling of myofascial trigger points [TrPs] needs clarification. Forty-two patients with chronic lumbosacral myofascial pain [one or more active TrPs in lumbar or limb muscles] were randomly divided into one group that receiving superficial [2 mm] insertion and another group receiving deep [1.5 cm] intramuscular insertion of acupuncture needles. The needles were inserted into four pre-

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selected acupuncture sites and over, or into, four TrPs or into the four most painful muscle tender points and stimulated four times in 15 minutes by rotation. [Criteria used for identifying active TrPs were not stated.] Pretreatment compared to post-treatment McGill Pain Questionnaire responses were not statistically significantly improved, and only deep insertions resulted in statistically significant improvement three months after treatment. Immediately following eight treatment sessions, the superficial group improved 36 percent and the deep group 59 percent. At three months, the deep group progressed to 79 percent improvement, which was significantly more improvement [P < 0.05] than seen in the superficial group at that time. The statistically nonsignificant improvements immediately following treatment were considered of considerable clinical importance in this well-controlled study. Comment I agree. Too often we throw the baby out with the bath water. This well-conducted study combined two different concepts of treatment that leaves unanswered the question of whether combined therapy is more effective than either approach alone would be for inactivating TrPs. A number of clinicians find that combining acupuncture methods with specific TrP treatment is more effective than either alone. From a TrP point of view the study would have been strengthened if a specific measure of TrP activity [such as algometry] had been included pre- and posttreatment. Treatment of Myofascial Pain: M. Esenyel, N. Caglar, T. Aldemir. Am J Phys Med Rehabil 79(1):48-52, 2000. Summary In order to compare the effectiveness of ultrasound and injection as treatments of myofascial trigger points [TrPs], the authors selected 102 patients who had pain for at least six months and TrPs in one side of the upper trapezius muscle. They divided the patients into three treatment groups: ultrasound, injection, and control. All three groups performed the same neck-stretching exercises. Trigger points were identified by a tender spot in a palpable band, typical referred pain pattern, visible or palpable local twitch response, and restricted lateral side bending to the opposite side. Treatment groups showed no significant differences in outcome, but compared with controls they showed significant reduction in pain inten-

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sity [P < 0.001], increase in pain pressure thresholds [P < 0.001], and increased range of motion [P < 0.05] at two weeks and at three months after treatment. Controls showed no improvement at two weeks. Psychological testing showed depression in 23 percent and high anxiety scores in 90 percent of patients and showed no correlation with the three measures described above. Psychological test results did correlate with the duration of symptoms. Ultrasound and injection were found to be equally effective and significantly better than just neck stretching exercises and to be independent of the severity or duration of pain. Improvement lasted for at least three months. Anxiety or depression did not limit the effectiveness of these two treatments. Comments More detail as to the treatments administered would be desirable. The authors found that psychological distress increased as the cause of the pain remained unsuccessfully treatedmaybe the pain and unsuccessful pain treatments were driving the patient crazy. The favorable response to TrP treatment in the presence of psychological distress is compatible with the distress being the result of and not the cause of the persistent TrP pain. This emphasizes the importance of prompt recognition and effective treatment of the cause of the pain. The Immediate Effects of Lidocaine Iontophoresis on Trigger-Point Pain: T.A. Evans, J.R. Kunkle, K.M. Zinz, J.L. Walter, C.R. Denegar. J Sport Rehabil 10(4):287-297, 2001. Summary This randomized, double blind, placebo-controlled study compared pressure sensitivity of active or latent trigger points [TrPs] in the upper trapezius muscles of 23 young adult volunteer subjects following three procedures. They were iontophoresis of one percent lidocaine treatment over the TrP, control treatment of distilled water, and placebo treatment without current or lidocaine. Trigger points were identified as the most sensitive spot in a palpable taut band and sensitivity measured with a pressure algometer. A small but statistically significant pretreatment posttreatment decrease in TrP sensitivity to lidocaine treatment compared to control and placebo treatments was not considered clinically significant because the improvement did not compare favorably with reported effectiveness of dry needling.

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Comments Since lidocaine is an effective local anesthetic, reduction in local tenderness immediately following treatment is not surprising. An effect observed several hours later would have told more about its effect on the TrPs. Reporting change in the clinical pain coming from active TrPs would be more relevant to clinical practice. Since dry needling of TrPs without evoking twitch responses is ineffective (5) and injection of anesthetics is no more effective than dry needling (6), it is not surprising that lidocaine iontophoresis would be ineffective for treatment of TrPs. Myofascial Pain Syndrome Induced by Malpositioning During SurgeryA Case Report: S.T. Hsin, Y.C. Yin, C.H. Juan, J.S. Hu, M.Y. Tsou, S.K. Tsai. Acta Anaesthesiologica Sinica. 40(1): 37-41, 2002. Summary The patient awoke following cholecystectomy for gallstones with intense pain in, other sensory changes in, and motor weakness of the left arm. Examination revealed an active myofascial trigger point [TrP] in the left pectoralis minor muscle. Electromyographic and nerve conduction studies diagnosed a left musculocutaneous nerve lesion. Passive stretch and dry needling of the pectoralis minor TrP every three days for three times produced complete recovery. Comment This is another typical case of thoracic outlet syndrome due to a pectoralis minor TrP. Water-Diluted Local Anesthetic for Trigger-Point Injection in Chronic Myofascial Pain Syndrome: Evaluation of Types of Local Anesthetic and Concentrations in Water: H. Iwama, S. Ohmori, T. Kaneko, K. Watanabe. Regional Anesthesia & Pain Med 26(4): 333-336, 2001. Summary This extends a previous study that demonstrated the improved effectiveness of diluting one percent lidocaine 1:3 with water for myofascial trigger point [TrP] injections. Various dilutions of lidocaine or mepivacaine diluted with water or saline were injected into the upper trapezius muscle of 20 adult healthy volunteers to test injection pain, and different

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dilutions of lidocaine into active trapezius TrPs of pain patients, to test pain relief. No difference in painfulness of the injection was noted between lidocaine and mepivacaine. Water dilutions were significantly less painful than saline dilutions. Dilutions of 0.2 percent or 0.25 percent lidocaine were equally effective in relieving patients TrP pain. Comment This finding is reminiscent of Dr. Travells experimental determination that injection of 0.5 percent rather than one percent procaine was more effective. Since the main advantage of injecting an anesthetic agent is to reduce postinjection soreness the next day or two (5) and since TrP pain relief is similar with dry needling (6), a more pertinent question would have been the degree of postinjection soreness experienced by these patients. Geloid Masses in a Patient with Fibromyalgia and Chronic Myofascial Pain: D.J. Starlanyl, J.L. Jeffrey. Phys Therapy Case Reports 4(1):22-31, 2001. Summary This case report presents detailed accounts of many treatments received over the years and their effectiveness. A myofascial trigger point [TrP] was identified by exquisite spot tenderness and a tender nodule in a palpable taut band, patient recognition of pain elicited by pressure on the tender spot, and painful limitation of full stretch range of motion. In addition there were firm, clearly definable masses indicative of interstitial swelling that occurred in tissues in the vicinity of multiple TrPs and sometimes were as large as 44.5 cm in diameter. The masses felt like tense indurated tissue but not fibrotic or calcified and are described in detail. Finding the optimal dose for manual therapy was difficult because of the fine line [that could shift from day to day] between sufficient therapy to be effective and too much therapy that exacerbated symptoms. Experience indicated that strengthening exercises should not be started until the patient is free of continuous pain and normal range of motion has been restored. Apparently geloid masses are a complication that can appear in some patients with severe fibromyalgia and many active TrPs.

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Comment Apparently geloid masses are a complication that can appear in some patients with severe fibromyalgia and many active TrPs. Their relation to impaired thyroid metabolism is being investigated. REVIEWS AND COMMENTS Trigger Points: Diagnosis and Management: D.J. Alvarez, P.G. Rockwell. Am Family Physician 65(4):653-660, 2002. Diagnosis of myofascial trigger points is based on finding a hard hypersensitive bundle or nodule of muscle fibers, eliciting a twitch response and eliciting characteristic referred pain. Treatment emphasized elimination of perpetuating factors, spray and stretch with Fluori-Methane spraywhich [contrary to authors note] is still commercially availableand injection. Three Clinical Sports Massage Approaches for Treating Injured Athletes: P.A. Archer. Athletic Therapy Today 6(3):14-20, 2001. Summary This review of massage techniques of value for treating the results of muscular over activity discusses myofascial release, site-specific friction, and lymphatic massage. The section on neuromuscular/trigger-point techniques presents a five-step technique that starts with gentle myofascial trigger point release then positions the muscle in a position of ease and ends with muscle stretch. Comment The proposed rationale presented for why the combination of these two release techniques works is not convincing to this reviewer, but a number of skilled clinicians find this combination of treatments very effective.

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Management of Myofascial Trigger Point Pain: P. Baldry. Acupuncture in Medicine 20(1):2-10, 2002. Summary The objective is to treat the cause of the pain, not just the symptom. First one locates myofascial trigger point [TrP] tenderness by palpating its taut band. Digital pressure elicits a jump or shout reaction and reproduces the patients pain. A scholarly historical review and detailed description compares superficial [subcutaneous penetration only] and deep [intramuscular penetration] dry needling techniques. The review concludes with a hypothesis of pathophysiology to explain the effectiveness of superficial dry needling and the importance of identifying strong, average, and weak responders to superficial needling. Comment This use of superficial dry needling for treatment of TrPs has been presented in this journal (7) and in a book (8). Clinically, this technique apparently is frequently effective, but the neurophysiological mechanism by which it inactivates an TrP remains obscure and deserves serious experimental study. Modulation of sympathetic nervous system activity by the procedure would be a likely place to start. The effect of this procedure on the autonomic nervous system could be tested using heart rate variability as the indicator (see Delaney et al., reviewed above). The results of Ceccherelli et al., reviewed above, are relevant and indicate that deep dry needling is clinically clearly more effective than superficial dry needling of acupuncture points and trigger points. Myofascial Pain: J. Borg-Stein, D.G. Simons. Arch Phys Med Rehabil 83(Sup.1):S40-S47, 2002. Summary This prevalent trigger point [TrP] cause of musculoskeletal pain is diagnosed only by history and physical exam. There are many other conditions that present with confusingly similar symptoms. The most likely explanation of its cause is the integrated hypothesis that postulates a 5-step positive feedback loop starting with excessive acetylcholine release at involved motor endplates. There is also important spinal,

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supraspinal, and autonomic nervous system involvement. Recommended treatments include manual release techniques, acupuncture, postural and ergonomic corrections, modalities, dry needling, and injection of TrPs. Comment This succinct focused review was written by and for physiatrists. It critically examines the state of the art and knowledge of myofascial pain caused by Trps. Myofascial Pain and Fibromyalgia: Trigger Point Management, Ed. 2: E.S. Rachlin, I.S. Rachlin. Mosby, St. Louis, 2002. This second edition is coauthored by Eds daughter, Isabel Rachlin, PT, whose chapter, and two other chapters by physical therapists, has added a much-needed appreciation of the importance of manual therapy in addition to injection techniques that were the bulk of the book. Isabel emphasizes the importance of treating the trigger points of fibromyalgia patients with utmost gentleness. The manual therapy chapter by Beth Paris reflects the fact that she is also a massage therapist and was trained by an outstandingly competent disciple of Dr. Janet Travell. Interventional Approaches to the Management of Myofascial Pain Syndrome: C.M. Criscuolo. Current Pain & Headache Reports 5(5): 407-411, 2001. The introduction notes that myofascial pain characterized by myofascial trigger points accounts for at least half of patient encounters at a busy university anesthesiology pain clinic. Injection therapy is described in detail and acupuncture mentioned. Radicular and Myofascial Pain Syndromes: Evaluation and Management: P.K. Richardson. Trauma 43(1):71-95, 2001. Summary After an extensive review of pertinent anatomy and the pathogenesis of both conditions, the neurologist author summarized their clinical features. Myofascial trigger points [TrPs] were identified by the location of the pain

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symptoms, the presence of tenderness in muscles that characteristically refer pain to that location, and by elicited pain that was familiar to the patient. No mention was made of palpating for a taut band. Radicular syndromes at various spinal levels were described in detail and the muscles likely to have TrPs that could produce a confusingly similar pain distribution were well listed. Treatment of TrPs was described only for patients free of radiculopathy. Treatment of perpetuating factors was appropriately strongly emphasized. The thorough listing of treatment options included manual therapy and injection methods. The author appropriately noted that no compelling evidence supports traditional physical modalities for treatment of TrPs as usually administered [emphasis mine]. Comment Several articles have reported significantly greater prevalence of TrPs in muscles supplied by nerves suffering radicular compression (9-12). Sometimes, especially after a month or more, much of the pain complaint by these patients is coming from treatable TrPs that have developed a life of their own. As the difference between pain originating from radiculopathy and TrPs becomes more difficult to distinguish, the identification of palpable taut bands and local twitch responses helps considerably to reliably distinguish by physical exam the presence of TrPs, but identifying these TrPs may require considerable specialized skill (13).

Understanding Effective Treatments of Myofascial Trigger Points: D.G. Simons. J Bodywork Movement Therapies 6(2):81-88, 2002. The effectiveness of manual therapy techniques including trigger point pressure release, contract-relax [or contract-release], reciprocal inhibition, and trigger point massage are explained and illustrated based on the principles of the integrated hypothesis (3,4). Do Cerebral Potentials to Magnetic Stimulation of Paraspinal Muscles Reflect Changes in Palpable Muscle Spasm, Low Back Pain, and Ac-

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tivity Scores?: D.G. Simons. J Manip Physiol Ther 25(1): 77-78, 2002 [letter]. This is a letter-to-the-editor that responded to the original paper by the same title (14). The original article described cerebral evoked responses to magnetic stimulation of paraspinal muscles at muscle locations that showed myofascial trigger point [TrP] characteristics in low back pain patients. The letter questioned the authors avoidance of TrP terminology and suggested that the responses that they observed were apparently specific to TrPs. If so, this testing could serve as a TrP research tool and might provide an objective diagnostic test or confirmatory finding for TrPs. The prime author of the original article responded that current terminology for TrPs was too confusing for him to use that term, but raised no objection to the likely relation of the response to TrPs. Handbuch der Muskel-Triggerpunkte [Handbook of Muscular Trigger Points]: J.G. Travell, D.G. Simons, 2. Auflage [Ed. 2]. Urban & Fischer, Mnchen [Munich], 2002. This is a German translation of the 1999, second edition of volume 1 of The Trigger Point Manual (3) that has an erroneous version of the authorship carried over from the first edition. As usual with foreign translations of this book [there are now seven], I had no contact with the translator. Travell y Simons Dolor y Disfuncin Miofascial; El Manual de los Puntos Gatillo [Travell and Simons Myofascial Pain and Dysfunction: The Trigger Point Manual], Volumen 1, Segunda edicin [V.1, Ed 2]. D.G. Simons, J.G. Travell, L.S. Simons. Editorial Medica Panamericana, Madrid, 2002. This Spanish Edition (3) was meticulously and conscientiously translated by a Spanish physical therapist who understood what he was translating, refined by considerable Email correspondence with me during the years of translation. REFERENCES
1. Swerdlow B, Dieter JNI: An evaluation of the sensitivity and specificity of medical thermography for the documentation of myofascial trigger points. Pain 48:205-213, 1992.

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2. Chen J-T, Chen S-U, Kuan T-S, Chung K-C, Hong C-Z: Phentolamine effect on spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal muscle. Arch Phys Med Rehabil 79:790-794, 1998. 3. Simons DG, Travell JG, Simons LS: Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol.1, Ed. 2. Williams & Wilkins, Baltimore, 1999, pp. 57-82. 4. Mense S, Simons DG: Muscle Pain Understanding its Nature, Diagnosis, and Treatment: Lippincott Williams & Wilkins, Baltimore, 2001, pp. 240-259. 5. Hong C-Z: Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response. Am J Phys Med Rehabil 73:256-263, 1994. 6. Cummings TM, White AR: Needling therapies in the management of myofascial trigger point pain: A systematic review. Arch Phys Med Rehabil 82:986-992, July 2001. 7. Baldry P: Superficial dry needling at myofascial trigger point sites. J Musculoske Pain 3(3):117-126, 1995. 8. Baldry PE, Yunus MB, Inanici F: Myofascial Pain and Fibromyalgia Syndromes. Churchill Livingstone, Edinburgh, 2001. 9. Wu C-M, Chen H-H, Hong C-Z: Inactivation of myofascial trigger points associated with lumbar radiculopathy: surgery versus physical therapy. Arch Phys Med Rehabil 78:1040-1041, 1997 (Abstr). 10. Wu C-M, Chen H-H, Hong C-Z: Myofascial trigger points in patients with lumbar radiculopathy due to disc herniation before and after surgery. J Surgical Association Republic of China 30(3):175-185, 1997. 11. Hsueh T-C, Yu S, Kuan T-S, Hong C-Z: Association of active myofascial trigger points and cervical disc lesions. J Formos Med Assoc 97:174-180, 1998. 12. Chu J: Twitch-obtaining intramuscular stimulation: observations in the management of radiculopathic chronic low back pain. J Musculoske Pain 7(4):131-146, 1999. 13. Gerwin RD, Shannon S, Hong C-Z, Hubbard D, Gevirtz R: Interrater reliability in myofascial trigger point examination. Pain 69:65-73, 1997. 14. Zhu Y, Haldeman S, Hsieh C-Y J, Pingjia W, Starr A: Do cerebral potentials to magnetic stimulation of paraspinal muscles reflect changes in palpable muscle spasm, low back pain, and activity scores? J Manip Physiol Ther 23 (7): 458-464, 2000.