Journal of Bodywork & Movement Therapies (2015) 19, 337e349

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REVIEW: LITERATURE REVIEW

A critical overview of current myofascial

pain literature e March 2015
Jan Dommerholt, PT, DPT, DAAPM a,b,c,*,
Michelle Layton, PT, DPT, OCS, FAAOMPT a,b,
Todd Hooks, PT, ATC, OCS, SCS, FAAOMPT d,
Rob Grieve, PT, PhD e

a
Bethesda Physiocare, Bethesda, MD, USA
b
Myopain Seminars, Bethesda, MD, USA
c
PhysioFitness, Rockville, MD, USA
d
Champion Sports Medicine in Birmingham, Alabama, USA
e
Department of Allied Health Professions, Faculty of Health and Life Sciences, University of the West
of England, Blackberry Hill, Bristol, United Kingdom

KEYWORDS Summary The second article in this review series considers multiple recent publications
Myofascial pain about myofascial pain, trigger points (TrPs) and other related topics. The article is divided into
syndrome; several sections, including a Basic Research section (4 articles), a section on Soft Tissue Ap-
Trigger points; proaches (5 articles), a Dry Needling and Acupuncture section (7 articles), an Injection section
Dry needling; (2 articles), a section on. Modalities (1 article), Other Clinical Approaches (3 articles) and
Manual therapy finally a Reviews section (7 articles). The thirty publications reviewed in this article originated

REVIEW: LITERATURE REVIEW

in all corners of the world.
2015 Elsevier Ltd. All rights reserved.

Basic research estudio piloto transversal (in Spanish: Presence of myo-

n-Cerezoa, J & Torres-Lacomba, M, 2014. Presencia
Bailo
de puntos gatillo miofasciales y discinesia escapular en
nadadores de competicio n con y sin dolor de hombro:
* Corresponding author. Bethesda Physiocare, Bethesda, MD, USA
E-mail addresses: dommerholt@myopainseminars.com (J.
Dommerholt), mbfpt77@gmail.com (M. Layton), trhooks@hotmail.
com (T. Hooks), Rob.Grieve@uwe.ac.uk (R. Grieve).
fascial trigger points and scapular dyskinesis in compet-
itive swimmers with and without shoulder pain: a cross-
sectional pilot study). Fisioterapia, 36, 266e273.
Ten to thirty-five percent of competitive swimmers have
frequent shoulder pain, commonly referred to as swim-
mers shoulder. Fifteen male competitive swimmers (5 with
shoulder pain and 10 without pain) were examined for the
presence of active and latent TrPs in 19 shoulder and upper
extremity muscles and scapular dyskinesis in this Spanish

http://dx.doi.org/10.1016/j.jbmt.2015.01.003
1360-8592/ 2015 Elsevier Ltd. All rights reserved.
 338
cross-sectional pilot study. Scapular dsykinesis was
measured with the Scapular Dyskinesis Test, while TrPs were
identified using the Simons, Travell, and Simons criteria
(Simons et al., 1999). Five swimmers (2 with pain and 3
without) showed scapular dyskinesis. Active TrPs were pre-
sent in 36 out of 95 muscles in the shoulders of swimmers
with pain, most notably in muscles involved in the propul-
sive phase of the swim strokes, including the subscapularis
(4/5), pectoralis major, teres major, teres minor, long head
of triceps brachialis, and upper trapezius (3/5). In the
swimmers without pain, latent TrPs were present in 51 out
of 190 muscles, most commonly in the upper trapezius,
pectoralis major, infraspinatus, and teres major muscles.
This is an important pilot study that demonstrates that TrPs
are very common in swimmers with and without shoulder
pain. In a previous study, Hidalgo-Lozano and colleagues
established that active TrPs are more commonly observed in
swimmers with shoulder pain (Hidalgo-Lozano et al., 2013).
Further studies are indicated and should include female
swimmers and a greater number of subjects. In a next
phase, the effect of inactivation of TrPs on shoulder dyski-
nesis and sports performance should be explored. Bron and
colleagues confirmed that manual treatment of TrPs in the
shoulder is effective (Bron et al., 2011), but this has not yet
been studied in competitive swimmers.
Hallgren, RC, Rowan, JJ, Bai, P, Pierce, SJ, Shafer-
Crane, GA & Prokop, LL, 2014. Activation of rectus cap-
itis posterior major muscles during voluntary retraction
of the head in asymptomatic subjects. Journal of
Manipulative and Physiological Therapeutics, 37,
433e440.
A forward head posture is a common clinical presentation
associated with head and neck pain. Clinicians frequently
use cervical retraction as part of a postural re-education
program, which may activate the rectus capitis posterior
major muscle (RCPM). Fifteen healthy subjects participated
in this study of the muscle activity of the RCPM during a
neutral head position (NHP) and a retracted head position
REVIEW: LITERATURE REVIEW
(RHP). Activation of RCPM was found to significantly in-
crease (P < 0.0001) during RHP (26e37% Maximum Voluntary
Isometric Contraction or MVIC) as compared to NHP (10e15%
MVIC). This article demonstrates the importance of the
RCPM to allow for posturing of the cervical spine. Hyperto-
nicity and TrPs within the RCPM would limit a patients
ability to restore normal neutral head posture (Ferna ndez
de las Penas et al., 2006b; Ferna
ndez de las Penas et al.,
2006c), which implies that clinicians should consider the
normalization of myofascial tissues, including the RCPM to
allow for optimal functional positioning and posture.
Kraus, SL, 2014. Characteristics of 511 patients with
temporomandibular disorders referred for physical
therapy. Oral Surgery, Oral Medicine, Oral Pathology and
Oral Radiology, 118 (4), 432e439.
A retrospective study was conducted on 511 patients with
temporomandibular disorders (TMD) referred by dental
professionals to a US based physical therapy outpatient
clinic. This study aimed to identify the diagnostic subsets of
a patient population with TMD and to use the characteristics
J. Dommerholt et al.
of this TMD population to assist clinical decision-making in
the management of TMD. The researcher followed the
diagnostic guidelines of axis I of the Research Diagnostic
Criteria for Temporomandibular Disorders (RDC/TMD). Of
diagnostic and clinical interest was that overall myofascial
pain was the most common diagnostic subset of TMD, with
arthralgia the most common concurrent diagnosis. Of the
muscle disorders, 84% of the patient population had myo-
fascial pain, with or without limited mouth opening. Clini-
cally the researcher identified the importance of treating
TrPs in the sternocleidomastoid and upper trapezius muscles
as well as the more obvious temporalis and masseter muscles
for TMD. Apart from treating TrPs, a multimodal and team
approach among health care professionals was recom-
mended. This study could have included some information
on statistical analysis procedure. Overall this study will add
to the evidence in relation to myofascial pain and TMD.
Soydan, SS, Deniz, K, Uckan, S, Unal, AD & Tutuncu,
NB, 2014. Is the incidence of temporomandibular disor-
der increased in polycystic ovary syndrome? British
Journal of Oral and Maxillofacial Surgery, 52, 822e826.
Soydan and coworkers conducted a prospective study to
examine the prevalence rate of temporomandibular disor-
ders in patients with polycycstic ovary syndrome (PCOS).
PCOS is the most common endocrinopathy in women during
the premenopausal period and is characterized by chronic
low-grade inflammation and excess of androgenic hormones
that lead to metabolic aberrations and ovarian dysfunction.
A high female-to-male ratio of degenerative joint disease
has been reported and may be related to the effect of fe-
male sex hormones, including estrogen, progesterone, and
relaxin (Wang et al., 2009; Warren and Fried, 2001). The
authors divided 100 premenopausal women into 2 groups;
50 women diagnosed with PCOS at the endocrinology
department and 50 controls.
The temporomandibular joint and the masticatory mus-
cles were evaluated and assessed for tenderness and pain,
including the masseter, temporalis, medial and lateral
pterygoid, sternocleidomastoid, trapezius, splenius capitis,
and digastric muscles. In addition, maximum interincisal
distance, restriction of laterotrusion and protrusion, joint
sounds, deviations, and visual analogue scale (VAS) were
assessed. The authors reported significant differences
(p < 0.001) in the incidence of temporomandibular disor-
ders (86% in the PCOS group compared with 24% in the
control group), muscle tenderness (64% in PCOS group
versus 28% in the control group), and pain in the TMJ (mean
VAS 2.9 compared to 0.3). Additionally, the incidence of
unilateral and bilateral internal derangements, disc
displacement, history of closed lock, deviations, and
clicking were significantly greater in the PCOS group.
However, there were no significant differences in inter-
incisal opening and distance between the two groups.
The authors reported a four times greater occurrence of
TMJ disorder in patient with PCOS compared to controls,
which may be attributed to an increase in matrix metallo-
proteinases or proinflammatory cytokines. Although this
study is interesting and gives credence to the systemic in-
fluence on joint pathology, the influence of joint degener-
ation and erosive changes may be minimal. The influence of
Critical overview of current myofascial pain literature
myofascial pain and muscle inhibition to the pterygoids and
other muscles of mastication as a result of elevated cyto-
kine levels could contribute to the pain, derangements,
clicking, and diminished lateral deviation. Although
tenderness was noted in these muscles, TrPs were not
assessed, which could warrant further evaluation in future
studies. It is not clear how the authors assessed pain and
tenderness in the lateral pterygoid muscles.
Soft tissue approaches
Niel-Asher, S, Hibberd, S, Bentley, S & Reynolds, J, 2014.
Adhesive capsulitis: Prospective observational multi-
center study on the Niel-Asher Technique (NAT). Inter-
national Journal of Osteopathic Medicine, 17, 232e242.
The main aim of this study from a group of osteopaths
from Israel, the UK and the USA was to evaluate the Niel-
Asher Technique (NAT) for treating adhesive capsulitis. One
hundred and fifty-four patients (113 from Israel, 25 from the
UK and 16 from the US) were recruited with pain, stiffness
and globally restricted gleno-humeral shoulder active range
of motion (AROM). The main outcome measures were a
change in active flexion and abduction of the gleno-humeral
joint and visual analogue scale (VAS) pain scores. Patients
from the three clinics demonstrated a significant improve-
ment in AROM for both flexion and abduction. VAS pain scores
were significantly reduced in patients from Israel, while VAS
were not systematically recorded at each visit in the UK and
US clinics. The reported increases in AROM and reduced VAS
for adhesive capsulitis after a mean course of seven treat-
ment sessions are encouraging. The study clearly described
the NAT protocol and illustrated this with clear photographs
of the treatment sequence. This is a strong point of the
paper, as it will assist clinicians to understand and replicate
the technique in their clinical practice.
There are, however, a few key limitations that may
reduce the overall validity of this study. The researchers
identified the following limitations; no control group or
blinding, lack of gold standard for adhesive capsulitis in-
clusion, no long term follow up, and a large variability in
response to treatments between the three treatment
clinics. The lack of blinding, control group and subsequent
randomization of patients into a control or intervention
group has introduced bias and reduced the internal validity
of the study. Although the design is reported as being a
prospective observational multi-center trial, it could be
argued that apart from the multiple treatment sites and use
of inferential statistical tests, it is more like a case series.
The authors also acknowledged the resultant possible
conflict of interest in the payment for treatment by the
patients and the subsequent possible placebo effect with
highly motivated patients and a large selection bias.
Importantly in relation to the methods, the authors did not
describe ethical approval or participants informed con-
sent. The main intervention protocol consisted of stroking
massage and myofascial TrP compression of the upper
trapezius, teres minor, long head of biceps, subscapularis,
and infraspinatus muscles. In relation to TrPs, the authors
did acknowledge Simons et al. (1999), but they could have
included more detail on how TrPs were identified, the
diagnostic criteria, and related pathophysiology.
339
Bakar, Y, Sertel, M, Ozturk, A, Yumin, ET, Tatarli, N &
Ankarali, H 2014 Short term effects of classic massage
compared to connective tissue massage on pressure pain
threshold and muscle relaxation response in women with
chronic neck pain: a preliminary study. Journal of Manip-
ulative and Physiological Therapeutics, 37, 415e421.
The purpose of this randomly controlled trial was to
evaluate the short-term effects of classic massage (CM) and
connective tissue massage (CTM) on pressure pain threshold
(PPT) and muscle relaxation response in women with
chronic neck pain. Forty-five female participants with neck
pain for 3e6 months were randomly assigned to either the
CM or CTM group. Each participant received one application
of CM or CTM to the thoracic spine and neck. Pre and post
intervention outcome measures were PPT algometry for TrP
sensitivity (pain) and electromyography biofeedback (EMG-
BF) for muscle relaxation in the sternocleidomastoid (SCM).
According to the researchers, an overall statistically sig-
nificant difference in pain reduction was found for the CM
group (PPT) and muscle relaxation for the CTM group (EMG-
BF). The overall conclusion was that one treatment of CM
may decrease pain and CTM may demonstrate a relaxation
response in woman with chronic neck pain. The overall
results of this study are of interest and may be clinically
significant. There are unfortunately quite a few limitations
in this research. Firstly as acknowledged by the researchers
there were no males in either group, which could affect the
external validity of the results specifically in relation to
known differences in the literature between males and
females for PPT. The method section was not clear on
whether the assessor for the outcome measures was blin-
ded to group allocation. The protocol for measuring pain by
assessing PPT of TrPs in the SCM was very unclear and
needed to be much more specific. There was no information
initially in the method section as to which muscle the TrPs
were to be assessed. Throughout the whole paper, no
definition on what a TrP is, how is it identified and how it
relates to fascia/connective tissue in CTM/CM.
REVIEW: LITERATURE REVIEW
Espi-Lopez, GV, Gomez-Conesa, A, Gomez, AA, Marti-
nez, JB, Pascual-Vaca, AO & Blanco, CR, 2014. Treatment
of tension-type headache with articulatory and sub-
occipital soft tissue therapy: A double-blind, random-
ized, placebo-controlled clinical trial. Journal of
Bodywork and Movement Therapies, 18, 576e585.
A group of Spanish researchers explored the effective-
ness of two different manual therapy treatments on pa-
tients with tension type headache (TTH). Eighty-four
subjects were randomly assigned to 1 of 4 groups: sub-
occipital inhibition (SI), occiput-atlas-axis global manipu-
lation (OAA), combination of SI and OAA (SI OAA), and
control. Treatments were performed once per week over a
4-week period. Eighty subjects completed the study. As-
sessments were performed prior to treatment, after the
last session, and 4 weeks after the final treatment.
Outcome measures included the Headache Impact test-6
(HIT-6), the Headache Disability Inventory (HDI), the
Headache Pain Intensity with the Visual Analog Scale (VAS),
cervical range of motion with the CROM device, and a
headache diary. Results showed that both the manual
 340
treatments were effective on different measures tested,
although the SI group did not have changes as significant as
either the OAA or SI OAA groups. Only the OAA group had
significant results on the HIT-6 at the end of the treatment
period. For the HDI, craniocervical flexion and extension
range, only the treatment groups had large effect sizes.
The SI group did not demonstrate any significant changes in
this area. Overall, the combined treatment of SI OAA was
more effective than SI or OAA individually. It was inter-
esting that the control group had some short-term signifi-
cant improvements in this study, but much of the
improvements were lost at the follow-up. The results of this
article highlight that a combined treatment is more effec-
tive than a single individual manual therapy treatment for
TTH. It is not entirely clear how this paper differs from a
very similar study by the same authors of 62 women with
TTH who were divided into the same four groups with
nearly that same conclusion that a combined treatment was
the preferred choice (Espi-Lopez et al., 2014).
Gulick, DT, 2014. Influence of instrument assisted soft
tissue treatment techniques on myofascial trigger points.
Journal of Bodywork and Movement Therapies, 18,
602e607.
From the United States comes the next randomized
controlled trial (RCT), which aimed to examine the influ-
ence of instrument assisted soft tissue techniques (IASTT)
on TrP sensitivity. In phase 1 (n Z 27), two TrPs (right &
left) in the upper back were identified. One was treated
with IASTT, while the other functioned as a control. In
phase 2 (n Z 22), one TrP was identified in a treatment and
a control group. In each phase, the treatment groups
received six treatments of IASTT. The outcome measures
were PPT of the TrP assessed with a dolorimeter. There was
a significant improvement in both groups over time, but
overall there were no significant differences between the
treatment and control groups. This study is needed, as
according to the researcher, no other evidence in relation
to the influence of IASTT on TrPs exists. The protocol in
REVIEW: LITERATURE REVIEW
relation to the TrP identification could be clarified in rela-
tion to the inclusion of latent or active TrPs. Also in phase 1
and 2, were participants excluded if one TrP was latent and
the other was active in the control or treatment condition/
group? The researcher acknowledged that the use of the
pressure dolorimeter may have served as a form of
compression treatment and therefore been a confounding
variable in overshadowing any potential influence of the
IASTT on the TrP. Range of motion and strength testing of
the affected muscles were suggested as alternative
outcome measures. These additional or replacement
outcome measures are recommended. The researcher
concludes that the effect of IASTT on TrPs is inconclusive.
Cashman, GE, Mortenson WB, Gilbart MK, 2014.
Myofascial treatment for patients with acetabular
labral tears: a single-subject research design study.
Journal of Orthopaedic & Sports Physical Therapy, 44 (8),
604e614.
Canadian researchers utilized a single-subject research
design on four patients with a diagnosis of an acetabular
J. Dommerholt et al.
labral tear to explore the use of Active Release Technique
(ART), stretching and strengthening of specific hip muscles
related to hip function and pain. The authors developed the
study based on their clinical observations of patients with
acetabular labral tears, who did not get relief of postero-
lateral hip pain with diagnostic injections. The lack of
response to injections suggests that the source of the
posterolateral hip pain may not be related to the labrum
and could possibly be extra-articular. During the treatment
period the patients were seen between 1 and 3 times per
week, for a minimum of eight sessions, with a maximum of
eights weeks of treatment. The total number of treatments
for the patients ranged from 9 to 16 visits. Treatments
consisted of ART to the posterior gluteus medius, gluteus
minimus, deep external rotators, tensor fascia latae, and
anterior gluteus medius muscles. Instruction on strength-
ening and stretching of the muscles was also performed.
Outcome measures included the activities of daily living
subscale of the Hip Outcome Score and a visual analog scale
to assess both anterior/medial and posterolateral hip pain.
Results showed that there were clinically meaningful and
statistically significant improvements in posterolateral hip
pain and functional mobility. There were also clinically
meaningful improvements in the anterior/medial hip pain
in three of the four patients.
Although this work was done on a very small sample of
female patients, the study does suggest that some of the
pain experienced with a labral tear is not related to the
labrum. Other considerations, such as myofascial involve-
ment should be considered and included in treatments. The
authors description of myofascial involvement, however, is
not completely clear. They did describe tender and tight
bands, but they did not mention how the muscles were
palpated and which specific criteria were used. Addition-
ally, the muscle tenderness may not even be due to
involvement at that local point, as it could be tender due to
referred hyperalgesia from a trigger point in a region
further away (Alonso-Blanco et al., 2011; Torres-Chica
et al., 2014; Rubin et al., 2009, 2010). A couple of other
drawbacks to the article include that there were no in-
structions as to how specific non-myofascial structures,
such as the anterior hip and capsule or lumbar facets, were
palpated. From a reproducibility standpoint, it will be
difficult to replicate this study. Additionally, there were
several physical examination procedures performed to
determine if a patient met the inclusion/exclusion criteria,
yet no details were provided as to the reliability or validity
of the techniques performed.
Dry needling and acupuncture
McDowell JM and Johnson GM, 2014. Acupuncture
needling styles and reports of associated adverse re-
actions to acupuncture. Medical Acupuncture 26,
271e278.
According to the Guidelines for Safe Acupuncture and
Dry Needling Practice published by the Physiotherapy
Acupuncture Association of New Zealand (PAANZ, 2014),
acupuncture by physiotherapists can be divided into three
categories:
Critical overview of current myofascial pain literature
 Traditional Acupuncture: Utilization of meridian or
extra points based on a Traditional Chinese Medicine
approach, which includes diagnosis and clinical
reasoning using various Chinese medicine assessment
methods and/or paradigms.
 Western Acupuncture: Western acupuncture utilizes
meridian points but applies it to Western scientific
reasoning with particular consideration to neurophysi-
ology and anatomy.
 Trigger Point/Dry Needling: Rapid, short term needling
to altered or dysfunctional tissues in order to improve or
restore function. This may include (but is not limited to)
needling of myofascial trigger points, periosteum and
connective tissues. It may be performed with an
acupuncture needle or any other injection needle
without the injection of a fluid.
Especially for readers in the United States, the PAANZ
definition makes so much more sense than the turf war
battles being fought throughout the US, where some
acupuncture organizations and individuals are claiming that
any use of an acupuncture needle by definition means that
it would be outside the scope of physiotherapy practice
(Dommerholt, 2011). McDowell and Johnson adopted the
definition of the PAANZ in their new article about adverse
reactions. They clearly differentiated the practice of
acupuncture and dry needling, which they referred to as
sustained needling and trigger pointing, respectively. In this
cross-sectional descriptive study, the authors evaluated 176
reports of adverse reactions to acupuncture and dry
needling from three different databases in New Zealand
during the period of 1998e2013. Unfortunately, there is no
record of the total number of treatments with acupuncture
and dry needling, which is a limiting factor of this study. As
the authors mentioned, data from one of the sources,
Physiotherapy New Zealand, is derived from a voluntary
reporting system, which may result in under-reporting
(McDowell et al., 2013). Nevertheless, 81% of the adverse
events were considered minor and 19% were major.
Acupuncture was much more commonly associated with
major adverse reactions than dry needling (76% vs. 18%
respectively), which could be an indicator that acupuncture
may be practiced by more physiotherapists than dry
needling. Data was collected from patients and practi-
tioners. Interestingly, patients report short-term reactions
approximately five times more frequently than practi-
tioners do (MacPherson and Thomas, 2005).
Records from the national no fault insurer the Acci-
dent Compensation Corporation from 2005 to 2010 included
279 physiotherapy-related claims of which 7 were consid-
ered minor and 3 major linked to physiotherapy acupunc-
ture. Minor was defined as reactions that resolved without
medical treatment, whereas major required treatment or
severely interfered with the patients wellbeing. Dry
needling was associated with a higher ratio (3% higher) of
major-to-minor adverse reactions compared to sustained
needling, but the proportion of minor adverse reactions was
greater with sustained needling. Overall, the symptoms
ranged from vasovagal prodromes (30%) to pneumothoraces
(2%). A recent study by Brady and colleagues showed that
the risk of major adverse reactions with dry needling by
physiotherapists was less than 0.04% (Brady et al., 2014).
341
Couto, C, de Souza, IC, Torres, IL, Fregni, F & Caumo,
W, 2014. Paraspinal stimulation combined with trigger
point needling and needle rotation for the treatment of
myofascial pain: a randomized sham-controlled clinical
trial. Clinical Journal of Pain, 30 (3), 214e323.
A Brazilian randomized controlled trial investigated
multiple deep intramuscular stimulation therapy (MDIMST)
dry needling (DN) compared to TrP lidocaine injection
(LTrP-I) for the treatment of myofascial pain syndrome
(MPS). Seventy-eight females, who were functionally
limited due to MPS, were recruited and randomly allocated
into either a placebo-sham, LTrP-I or MDIMST group. For the
LTrP-I group, lidocaine was injected into a TrP. For the
MDIMST group acupuncture needles were inserted into the
paraspinal muscle dermatomes and myotomes or direct DN
into the TrP. The placebo-sham group consisted of an
electro acupuncture device (with current turned off) and
electrodes placed over the paraspinal muscle dermatomes
and myotomes and directly over TrPs. The treatments were
provided twice weekly over 4 weeks using standardized
MDIMST and LTrP-I protocols. The main outcome measures
were the visual analogue scale (VAS), pressure pain
threshold (PPT), pain medication diary and recordings of
sleep quality and health related quality of life measured by
SF-12. Compared with the sham-treated group, MDIMST and
LTrP-I interventions significantly improved VAS pain scores,
PPT and analgesic use. Although both active treatments had
a clinical effect on pain, sleep diary and improved SF-12
physical and mental health scores, the MDIMST led to a
stronger effect overall. This was a rigorously designed study
using the CONSORT guidelines for standardization and
replication of method. The authors acknowledged, that the
acupuncturist/physician administering the intervention was
not blinded to group allocation. Overall this RCT is a valu-
able source of evidence to support the use and efficacy of
DN for patients with MPS and its associated symptoms.
Cummings, M, Ross-Mars, R & Gerwin, R, 2014. Pneu-
mothorax complication of deep dry needling demonstra-
REVIEW: LITERATURE REVIEW
tion. Acupuncture in Medicine, 32 (6), 517e519.
A case report of a pneumothorax complication due to
deep dry needling (DDN) over the thorax was reported by
two experienced UK and one US medical physicians. The
subject was a lean 55-year old male medical doctor, with a
BMI of 20 and well-controlled asthma. The practitioner in
question was highly experienced with 45 years of practice
and teaching DDN. The pneumothorax occurred during a
hands-on workshop, while demonstrating DDN of the ilio-
costalis muscle at the eight rib level. The lecturer/practi-
tioner clearly emphasised the danger of pneumothorax,
discussed and used the technique of blocking the rib by
placing a finger on either side of the intercostal space. A
day after the demonstration, the subject had a dry cough,
described being unable to take a deep breath and a sense
of breathlessness on the left side. A chest X-ray demon-
strated a 20% left sided pneumothorax. After conservative
management of the pneumothorax, a repeat x-ray 14
weeks after the incident demonstrated a fully inflated
lung. The authors fully recognize the risk of pneumothorax
with DDN especially over the thorax. This case report
 342
concludes with varying techniques to avoid puncturing the
lung and pleura when targeting a TrP in the ilocostalis
muscle. Of relevance to this case report and the subject
treated, is the depth of inserting a needle in the thoracic
region may be reduced with slim individuals. This is an
important case report clinically as it spells out that the
potential complications of DDN may affect even the most
experienced clinician.
bscher, M, Rothmay,
Wilke, J, Vogt, L, Niederer, D, Hu
J, Ivkovic, D, Rickert, M & Banzer, W, 2014. Short-term
effects of acupuncture and stretching on myofascial
trigger point pain of the neck: A blinded, placebo-
controlled RCT. Complementary Therapies in Medicine,
22, 835e841.
Researchers from Germany conducted a crossover RCT
to evaluate the short-term effectiveness of acupuncture
plus stretching in patients with cervical MPS. Nineteen pa-
tients (11 females, 8 males) with neck pain where randomly
allocated to receive acupuncture, acupuncture plus
stretching, and placebo laser acupuncture (one week
apart). The outcome measures were algometric mechanical
pain threshold (MPT), VAS and cervical range of motion
(ROM) recorded with an ultrasonic 3D movement analysis
system. Outcomes were assessed pre-treatment as well as
5, 15 and 30 min post-treatment. Both acupuncture and
acupuncture plus stretching increased the MPT by 5% and
11% respectively. Only acupuncture in combination with
stretching was superior to placebo (p < 0.05). The VAS did
not differ between treatments at any measurement. Cer-
vical ROM (frontal and transverse plane) in the acupuncture
plus stretching group was only significantly increased
compared to placebo for five minutes after the application.
Overall this study is useful in that it identifies the benefits
of combining acupuncture and stretching as a treatment
option for MPS in the short term. This was a well-designed
and clearly reported trial, that will inform future
research and show the benefits of a combined dual mo-
dality focussed TrP treatment.
REVIEW: LITERATURE REVIEW
Skorupska, E, Rychlik, M, Pawelec, W, Bednarek, A &
Samborski, W, 2014. Trigger point-related sympathetic
nerve activity in chronic sciatic leg pain: a case study.
Acupuncture in Medicine 32, 418e422.
This is an interesting case report on the vasodilatation
following dry needling of active myofascial trigger points
(TrPs) in the anterior portion of the gluteus minimus. A 22-
year-old male had a 3-year history of sciatica-like pain that
started after moving furniture. The patient also developed
a fever and pain in the thoracic spine in addition to the leg
pain. When the symptoms did not improve, he had several
diagnostic tests including measurements of the erythrocyte
sedimentation rate and C-reactive protein, a thoracic spine
CT, and a lumbosacral spine MRI. No abnormalities were
shown except in the MRI, which showed L3-4 and L4-5 disc
bulging without dural sac compression and L5-S1 minor
herniation with insignificant dural sac compression.
Approximately a year later the patient had a laser decom-
pression of the L5-S1 disc, which only decreased his lumbar
pain but had no change on his leg pain. When rehabilitation
J. Dommerholt et al.
was attempted after surgery his symptoms worsened
despite an MRI 6 months after surgery showing no hernia at
the level that was treated surgically. Additional testing was
done including a three-phase scintigraphy of both hips and
electromyography, which resulted in normal findings. Prior
to, during, and after the authors performed dry needling,
thermographic images were taken, which showed that
vasodilatation occurred after the dry needling. Dry
needling of the anterior portion of the gluteus minimus
reproduced the referred pain area. Interestingly, the area
of vasodilatation, the referred pain pattern of the anterior
portion of the gluteus minimus, and the pain pattern drawn
by the patient matched. The patient received dry needling
1/week for 5 weeks. At the end of the 5 weeks the patient
had no pain except occasionally in the thigh with prolonged
periods of sitting. This case report highlights that the
symptoms experienced by a patient may not necessarily
correlate to imaging findings (Brinjikji et al., 2015). Addi-
tionally, since the patient had residual pain issues with
sitting, it would be interesting to explore if there were TrPs
in the medial hamstring or adductor magnus as involvement
of these muscles has been shown to contribute to difficulty
sitting (Gerwin, 2001). Finally, further studies on a larger
scale need to be performed to confirm if the vasodilatation
observed was caused by dry needling of the active TrPs or
some other confounding factor as the authors mentioned.
Salom-Moreno, J, Sanchez-Mila, Z, Ortega-Santiago, R,
Palacios-Cena, M, Truyol-Dominguez, S & Fernandez-De-
Las-Penas, C, 2014. Changes in spasticity, widespread
pressure pain sensitivity, and baropodometry after the
application of dry needling in patients who have had a
stroke: a randomized controlled trial. Journal of Manip-
ulative and Physiological Therapeutics 37, 569e579.
A group from Spain published an interesting randomized
controlled trial on the effects of dry needling in relation to
spasticity, plantar pressure and pressure sensitivity in sub-
jects who have had a stroke. Thirty-four patients were
randomly assigned into either a control group or a group
that received a single session of dry needling into the taut
band of the medial and lateral gastrocnemius and anterior
tibialis muscles. Outcome measures assessed prior to and
after treatment included spasticity with the Modified
Modified Ashworth Scale (MMAS), mechanical pain sensi-
tivity with a pressure algometer to the second metacarpals,
deltoid and anterior tibialis muscles bilaterally and several
baropodometric factors. The group that had the dry
needling showed significant improvements in spasticity via
a reduced grade with the MMAS, improvements in all pres-
sure pain threshold measurements, and increased plantar
pressures of the affected limb, which also resulted in an
improvement of the support surface. Although there are
several limiting factors to the study including a small
sample size, no long-term outcome follow-up, and the same
therapist performing all the dry needling treatments, this
study poses some interesting concepts to help those who
have had a stroke with residual spasticity issues. By being
able to reduce the spasticity in the affected limb,
improving plantar pressures of the foot and improving
widespread pain sensitivity there is the potential to
improve gait and other quality of life factors that otherwise
Critical overview of current myofascial pain literature
may not have been able to be addressed further. Further
research is needed in this area to explore these options, but
this work opens the door for many future research ideas
with this population.
Rock JM, Rainey CE, 2014. Treatment of nonspecific
thoracic spine pain with trigger point dry needling and
intramuscular electrical stimulation: a case series. In-
ternational Journal of Sports Physical Therapy, Oct; 9
(5):699e711.
The following case series described two active duty
military males with nonspecific thoracic spine pain (TSP).
The first subject presented with symptoms of spasm type
pain that was ongoing for 8 weeks with no known trauma.
Neurological screening and red flags were negative. The
second subject presented with TSP since 2006 where
deadlifting resulted in spasms. Initial radiographs were
negative, along with screening for neurological symptoms
and red flags when later evaluated. Outcome measures
utilized for both subjects included the visual analog scale
(VAS), the numeric pain rating scale (NPRS), and the Global
Rating of Change scale (GROC). For the evaluation, posture,
active range of motion, specific movement patterns utiliz-
ing the Selective Functional Movement Assessment (SFMA),
palpation of the thoracic paraspinals, and joint accessory
testing of the thoracic spine with posterior to anterior (P/A)
pressures were performed. The first subject presented with
a spinal flexion motor control dysfunction, pain with motion
testing, tissue hypertonicity and tenderness along the
bilateral thoracic paraspinals and pain with joint accessory
testing from T9-T12 without any hypo- or hypermobility.
The second subject presented with a rotational motor
control dysfunction, tenderness and hypertonicity along the
bilateral thoracic paraspinals, and pain with joint mobility
testing from T4-T9 without any hypo- or hypermobility.
Treatment consisted of dry needling with intramuscular
electrical stimulation for 20 min to the thoracic multifidi of
the spinal segments that were found to be painful for each
session. Afterward a specific exercise was given to address
the motor control dysfunction. Both subjects had two
treatments, but subject 1 returned 19 days later for the
second treatment and subject 2 returned 2 days later. Both
subjects demonstrated improvements in pain, range of
motion, and motor control. Although this is only a case
series, there are currently no documented studies of dry
needling for TSP. This article highlights that both subacute
and chronic TSP can be treated to improve pain and
movement patterns for return to high-level activities,
however, further research with a larger population is
needed to draw any firm conclusions. Additionally, a few
things need to be clarified for reproducibility. First, the
authors discussed palpating the thoracic paraspinal mus-
cles, without acknowledging that palpation of the multifidi
is different than palpation of the longissimus and iliocos-
talis muscles. The lack of a detailed description may affect
the treatment outcomes and the reproducibility. Addition-
ally, the authors described a TrP as a tender spot in muscle
often with a palpable taut band, which deviates from Si-
mons, Travell and Simons notion that a TrP is a hyperir-
ritable spot in skeletal muscle that is associated with a
hypersensitive palpable nodule in a taut band (Simons
343
et al., 1999). The results of this case series offer insight
into additional treatment options for nonspecific thoracic
spine pain and offer future research ideas for TSP.
Injection therapy
Huang, QM & Liu, L, 2014. Wet needling of myofascial
trigger points in abdominal muscles for treatment of
primary dysmenorrhoea. Acupuncture in Medicine, 32,
346e349.
Already in 1983, Travell and Simons had described
dysmenorrhea in association with TrPs in the abdominal
muscles (Travell and Simons, 1983). They stated that
inactivation of abdominal TrPs would relieve the symptoms
of dysmenorrhea, citing two older references from 1949
(Theobald, 1949a, 1949b). More recently, Giamberardino
and colleagues confirmed that dysmenorrhea lowered the
electrical thresholds in especially the left abdominal mus-
cle and sometimes in the subcutis, but never in the skin
(Giamberardino et al., 1997). The paper by Huang and Liu
from China is therefore a much-needed clinical contribu-
tion. Sixty-five patients with moderate and severe
dysmenorrhea (mean VAS score: 7.49  1.16) were treated
with lidocaine injections into abdominal TrPs combined
with abdominal stretching exercises. Treatments were
administered two weeks before the menstruation. Forty-
one subjects (63% of all subjects) experienced an immedi-
ate dramatic reduction of pain during their following
menstrual cycle (mean VAS score: 1.63  0.49). Twenty-
four subjects needed two treatments to bring down their
menstrual pain to 0.58  0.50. The authors assessed pain
levels up to one year following the treatments and found
that the mean VAS score was only 0.28  0.45 (p < 0.0001)
with a response rate of 100%. It would be interesting to
explore whether dry needling would have similar results.
This study should be shared with gynecologists to reduce
needless suffering of thousands of women because of
dysmenorrhea, even though the researchers did not use a
REVIEW: LITERATURE REVIEW
control group. It is unlikely that the dramatic results were
strictly due to a placebo response.
Karadas, O, Gul, HL & Inan, LE, 2013. Lidocaine in-
jection of pericranial myofascial trigger points in the
treatment of frequent episodic tension-type headache.
The Journal of Headache and Pain, 14, 44.
Researchers from Turkey investigated the efficacy of
lidocaine injections into myofascial trigger points (TrPs) of
several pericranial muscles in patients diagnosed with
episodic tension type headache (ETTH) according to the
criteria established by the International Headache Society.
The study was a double-blinded placebo controlled random-
ized study with 108 patients randomly placed into 1 of 4
groups. Subjects within group 1 received a single saline in-
jection, group 2 received a single 0.5% lidocaine injection,
group 3 received 5 saline injections, and group 4 received five
0.5% lidocaine injections. TrPs were assessed according to the
criteria established by Simons, Travell and Simons. Muscles
examined and treated bilaterally for TrPs included the fron-
tal, temporal, masseter, sternocleidomastoid, semispinalis
 344
capitis, splenius capitis, and trapezius muscles. It was not
specified in the study whether the TrPs were active, latent, or
both. Outcome measures used included the visual analog
scale (VAS) and the frequency of painful days per month (FPD)
prior to treatment and at 2, 4, and 6 months post treatment.
Results showed that compared to placebo, a series of 5 lido-
caine injections on alternating days to the pericranial muscles
significantly reduced both the frequency and severity of pain
at 2, 4 and 6 months post treatment. Although there were
significant changes in the FDP and VAS at the 2-month follow-
up in groups 2e4 and groups 2 and 4 respectively, only the
group with repeated lidocaine injections had significant
changes at the 6-month follow up. This article highlights that
addressing TrPs with multiple lidocaine injections is more
effective than a single injection. Myofascial TrPs are consid-
ered a source of peripheral nociceptive input (Fernandez-de-
Las-Penas and Dommerholt, 2014); therefore reducing this
input will lead to a decrease in symptoms if the muscles are a
contributing factor (Rubin et al., 2009).
Modalities
Manca, A, Limonta, E, Pilurzi, G, Ginatempo, F, De
Natale, ER, Mercante, B, Tolu, E & Deriu, F, 2014. Ul-
trasound and laser as stand-alone therapies for myofas-
cial trigger points: a randomized, double-blind, placebo-
controlled study. Physiotherapy Research International,
19, 166e175.
Sixty subjects (28 women and 32 men; mean age
24.5  1.44 years) participated in this well-executed Italian
double-blind, randomized, placebo-controlled study of the
effects of ultrasound (US) and low-level laser therapy
(LLLT) as stand-alone therapies for TrPs in the upper
trapezius muscle. Subjects with at least one active TrP in
the upper trapezius muscle were randomly assigned to 1 of
5 groups: active US (n Z 12), placebo US (n Z 12), active
LLLT (n Z 11), placebo LLLT (n Z 11) and no therapy
(control, n Z 14). Subjects in the intervention groups were
REVIEW: LITERATURE REVIEW
treated five times per week for two weeks. Outcome
measures (pressure pain threshold, subjective pain on a
numerical rating scale and muscle extensibility performing
cervical lateral flexion) were taken prior to intervention,
after 2 and after 12 weeks. Subjects and examiner were
blinded to group allocation and therapy. In conclusion, US
and LLLT as well as placebo significantly improved pain
levels and muscle extensibility compared to no therapy. A
concern with this study is that by assigning 60 subjects to 5
groups, each group is rather small with no more than 12
subjects. Of interest is that US was delivered in a 3 MHz
continuous mode (intensity 1.5 W cm2, duration 12 min. US
probe head size: 5 cm2), which is characterized by a more
limited penetration depth compared to 1 mHz. Whether the
choice of US parameters would impact the outcome of the
study is not known. Similar concerns can be raised about
the parameters of the LLLT. In this study, LLLT was deliv-
ered with a 904 nm wave length (pulse duration 200 ns;
pulse frequency 1953 Hz; peak power 90 mW; average
output 30 mW; power density 22.5 mW cm2; treatment time
600 s; energy dose 18 J per session; spot size 4 cm2). The
authors confirmed that several surveys showed that using
J. Dommerholt et al.
US and LLLT as mono-therapies is common practice in
Europe, which based on this study, raises significant con-
cerns especially when there is no difference between the
interventions and placebo.
Other clinical studies
Sharan D, Manjula M, Urmi D, Ajeesh PS, 2014. Effect of
yoga on the myofascial pain syndrome of neck. Interna-
tional Journal of Yoga, 7 (1):54e59.
Neck pain, including myofascial pain syndrome (MPS),
among physiotherapists is reported to have a 15%e48%
prevalence rate as a result of repetitive movements, static
awkward postures, carrying, bending, etc. (Alrowayeh
et al., 2010; Cromie et al., 2001; Nordin et al., 2011). As
a result, therapists suffering from MPS may change their
way of working, which may adversely affect the quality of
treatment. Although yoga is commonly utilized in the
treatment of individuals with musculoskeletal disorders
(Pearson, 2008; Sherman et al., 2005; Williams et al.,
2005), the literature is limited on its effect on physical
and subjective outcomes in the treatment of cervical MPS.
Eight physiotherapists who were diagnosed with cervical
MPS participated in this study. Outcome measures were
used comparing cervical active and passive ROM, hand and
grip strength, pain threshold, Disability of Arm, Shoulder
and Hands (DASH) score, Neck Disability Index (NDI), and
Short Form 36 (SF 36). The subjects performed various
forms of yoga and meditation for one hour per day for four
weeks. The variables were compared before and after the
intervention and revealed that all parameters (DASH, NDI,
VAS, PPT, Grip strength, Key pinch, Palmar pinch, and Tip
pinch strength) improved significantly after intervention.
Kabat-Zinn reported 65% of patients with chronic pain who
had not improved with traditional medical care, had
diminished pain following meditation for ten weeks (Kabat-
Zinn, 1982). Similarly, the authors concluded that a planned
yoga program for physiotherapists suffering from cervical
MPS resulted in significant improvements in pain levels and
improved quality of life. The possible mechanisms under-
lying the effectiveness of yoga in relation to breathing,
circulation, increased range of movement and anxiety are
of clinical significance. The limitations of this study were
the small sample size (8), the lack of a control group, and
the no-discussion upon the subjects prior exercise activ-
ities. This study does, however, demonstrate the impor-
tance in strength, ROM, balance, flexibility, and muscle
tone in the treatment of MPS.
Bae Y, 2014. Change the myofascial pain and range of
motion of the temporomandibular joint following
kinesio-taping of latent myofascial trigger points in the
sternocleidomastoid muscle. Journal of Physical Therapy
Science, 26, 1321e1324.
A research group from Korea performed a study to
determine the effects of Kinesio taping on myofascial pain
and range of motion of the temporomandibular joint (TMJ)
in patients with latent TrPs of the sternocleidomastoid
(SCM) muscle. Forty-two patients were equally divided into
Critical overview of current myofascial pain literature
a control group that received no intervention and an
experimental group that received Kinesio taping on the SCM
muscle three times per week for two weeks. The subjects
were instructed to leave the tape attached until the next
treatment session. The pain intensity (VAS), pressure pain
threshold (PPT), and TMJ ROM were assessed at the
conclusion of the two weeks with the experimental group
having significant improvements in the VAS, PPT and TMJ
ROM, whereas no changes were noted in the control group.
Although this study only examined the immediate ef-
fects of treatment aimed at latent TrPs found within the
SCM, it does highlight the effect of TrPs and their rela-
tionship to altered muscle function. Altered activation of
the SCM can effect the position of the mandible and
therefore the tone of the masticatory muscles as a result of
altered head posture. Consequently, the assessment and
treatment of patients with TMJ disorder should consist of
possible TrPs found within the SCM as well as other muscles
involved in head posture.
Demirkol, N, Sari, F, Bulbul, M, Demirkol, M, Simsek, I
& Usumez, A, 2014. Effectiveness of occlusal splints and
low-level laser therapy on myofascial pain. Lasers in
Medical Science, Feb 7 Published online.
The authors evaluated the effectiveness of occlusal
splints and low-level laser therapy on myofascial pain in
thirty patients with temporomandibular disorders (TMD)
and TrPs with familiar pain upon provocation. The exam-
iners equally divided the subjects into three groups. Sub-
jects in the occlusal splint group wore splints 12 h a day for
3 weeks. Subjects in the low-level laser group (LLLLT)
received a neodymium-doped yttrium aluminum garnet
laser (Nd:YAG; 1064 nm) treatment at 8 J/cm2, while sub-
jects in the control group received a placebo laser treat-
ment. Prior to testing, there were no statistically significant
differences between test groups for pain. Three weeks
following the treatment, the subjects receiving splint and
LLLLT treatment reported significantly less pain on the VAS
as compared to the placebo group. There were, however,
no significant differences between these two treatment
groups following three weeks of treatment.
Myalgia as a result of masticatory muscle fatigue,
weakness, and pain can be a mechanism for TMD. Exam-
ining patients for the presence of TrPs is therefore essential
for patients presenting with TMD. Various forms of treat-
ment have been advocated in the literature including
posturing and laser therapy. The authors have demon-
strated the effective use of these treatment approaches
and demonstrated their effect on treatment of TMD.
Reviews
Wall, R, 2014. Introduction to myofascial trigger points in
dogs. Topics in Companion Animal Medicine, 29, 43e48.
In this interesting narrative review, the author shows a
clear knowledge and understanding of myofascial pain and
TrPs in relation to dogs. Areas covered relate to sensory and
motor abnormalities and an interesting discussion on the
evaluation of muscle weakness in dogs that may be
345
associated with TrPs. The etiology, pathophysiology and
perpetuating factors in the development of TrPs were dis-
cussed in detail. Perpetuating factors in relation to me-
chanical stresses, muscle overload and orthopedic injury in
dogs were also identified. The role of osteoarthritis and
compensatory postural changes in muscle TrP perpetuation
is developed. Flat and pincer palpation that is used in TrP
identification and manual therapy in humans are related to
dogs and supported by clear diagrams. The lack of evidence
in non-invasive TrP therapy and the use of dry needling and
TrP injections in dogs were outlined and discussed. This
paper recommends that for the veterinary clinician with an
interest in pain management, rehabilitation and/or sports
medicine, the assessment and treatment skills in TrPs is
essential. This review will be of interest to the manual
therapist and veterinarian alike.
Diercks, R, Bron, C, Dorrestijn, O, Meskers, C, Naber,
R, De Ruiter, T, Willems, J, Winters, J & Van Der Woude,
HJ, 2014. Guideline for diagnosis and treatment of sub-
acromial pain syndrome. A multidisciplinary review by
the Dutch Orthopaedic Association. Acta Orthopaedica,
85, 314e322.
The Dutch Orthopaedic Association recently published
guidelines for the diagnosis and treatment of subacromial
pain. Although the paper does not specifically pertain to
myofascial pain, there are several important conclusions
and recommendations that make it worthy of inclusion in
this overview article. First, the authors emphasized that
the term impingement of the rotator cuff as introduced
by Neer in 1983 (Neer, 1983) no longer describes what is
currently known about the pathology. The assumption that
with impingement there would be direct contact between
the acromion and the rotator cuff cannot be substantiated
with imaging or arthroscopic techniques (Papadonikolakis
et al., 2011). Therefore, the preferred term is now sub-
acromial pain syndrome abbreviated as SAPS. To quote
directly from the paper: SAPS is defined as all non-
traumatic, usually unilateral, shoulder problems that
REVIEW: LITERATURE REVIEW
cause pain, localized around the acromion, often worsening
during or subsequent to lifting of the arm. The different
clinical and/or radiological names, such as bursitis, tendi-
nosis calcarea, supraspinatus tendinopathy, partial tear of
the rotator cuff, biceps tendinitis, or tendon cuff degen-
eration are all part of SAPS. After a thorough review of the
best available evidence, the authors concluded among
others that (1) the diagnosis of SAPS can only be made using
a combination of clinical tests such as the HawkinseKen-
nedy test, the painful arc test, and the infraspinatus muscle
strength test; (2) SAPS should preferably be treated non-
operatively; (3) Diagnostic imaging is useful after 6 weeks
of symptoms with ultrasound examination being the rec-
ommended imaging approach; (4) Occupational in-
terventions are useful when complaints persist for longer
than 6 weeks; (5) Exercise therapy should be specific and
should be of low intensity and high frequency, combining
eccentric training with stabilization training, attention to
relaxation and posture; (6) Treatment of myofascial trigger
points (including stretching of the muscles) can support
exercise; (7) There is no convincing evidence that surgical
treatment for SAPS is more effective than conservative
 346
management; (8) There is no indication for the surgical
treatment of asymptomatic rotator cuff tears. The authors
provided much detail in support of their recommendations.
Noteworthy is that physical therapist Carel Bron, PT, PhD
was a member of the workgroup representing the physical
therapy profession in the Netherlands. Dr. Bron is also a
member of the International Advisory Board of this journal.
Borg-Stein, J & Iaccarino, MA, 2014. Myofascial pain
syndrome treatments. Physical Medicine and Rehabilita-
tion Clinics of North America, 25, 357e374.
Borg-Stein and Iaccarino provided a comprehensive re-
view of the current thinking about myofascial treatments.
The authors addressed the epidemiology and clinical pre-
sentation of myofascial pain and emphasized that a
comprehensive medical, neurologic, and musculoskeletal
examination is required to diagnose myofascial pain
syndrome (MPS) and to rule out other potential diagnoses.
The article includes a comprehensive list of other di-
agnoses to consider, such as joint, inflammatory, neuro-
logic and regional soft tissue disorders. The authors
suggested considering MPS in difficult-to-treat cases and
mentioned TrPs are commonly observed with many of the
included diagnoses. The treatment of patients with MPS
should correct structural and mechanical imbalances, and
address autonomic dysfunction and psychosocial factors
through a combination of education, pharmacotherapy,
local needle therapy, and exercise. The management
approach is summarized in an easy to follow algorithm
followed by a review of pharmacological and non-
pharmacological options. The authors valued the impor-
tance of muscle stretching as a fundamental part of the
treatment to reduce pain and achieve optimal muscle
length prior to strengthening exercises. Unfortunately,
there is little current research in support of an extensive
stretching program for MPS. The authors recommended the
use of ultrasound for the treatment of TrPs, yet, most
studies demonstrate only a temporary reduction in pain or
improvements similar to placebo (Srbely et al., 2008;
REVIEW: LITERATURE REVIEW
Manca et al., 2014; Vernon and Schneider, 2009). On the
other hand, high-intensity stationary ultrasound applica-
tions have shown some clinical applicability (Majlesi and
Unalan, 2004), although even that has been disputed
(Kim et al., 2014). Acupuncture is listed but was not
included in a section about needling therapy. Surprisingly,
the authors repeated the somewhat questionable claim
that there is a close relationship between TrPs and
acupuncture points citing an older paper by Melzack and
colleagues (Melzack et al., 1977). More recently, Dorsher
has made similar claims (Dorsher, 2006), but these were e
at least in our humble opinion - effectively refuted by Birch
(Birch, 2003, 2008). The authors recommended needling
therapies only for persistent cases of MPS, which is con-
trary to contemporary practice by many clinicians. The
article concluded with a thorough review of TrP injection
approaches. In spite of a few inaccuracies, the article
provides a solid review of the current state of affairs.
Sharan, D, Manjula, M, Urmi, D & Ajeesh, PS, 2014.
Myofascial pain syndrome: Diagnosis and management.
Indian Journal of Rheumatology, 9 (2), S22eS25.
J. Dommerholt et al.
This review article on myofascial pain syndrome (MPS)
diagnosis and management was published in the Indian
Journal of Rheumatology. This brief paper defines MPS,
discusses prevalence, etiology, clinical presentation
including symptoms and differential diagnosis, the differ-
entiation between MPS and Fibromyalgia syndrome (FMS)
and treatment. This is a basic review that shows breadth,
but unfortunately is lacking in depth. More key and current
evidence is needed to support many of the statements
made. One example of this was found in the paragraph on
the various methods to identify TrPs (EMG, Ultrasound, US
Elastography and Magnetic Resonance Elastography), which
included no supporting evidence or appraisal of the rele-
vant studies. Overall this review needed more depth and a
more critical stance of the available literature in relation to
MPS, however, this review does target a new audience in
India of clinicians who may not be too familiar with the
concepts of myofascial pain. The basic concepts in this
review may stimulate the reader to search for more in
depth evidence in relation to MPS and be more aware of
MPS assessment and treatment in musculoskeletal
dysfunction.
Bennett, RM, 2014. Guidelines for the successful
management of fibromyalgia patients. Indian Journal of
Rheumatology, 9 (2), S13eS21.
Guidelines for the management of fibromyalgia (FM)
were outlined in a paper by an experienced fibromyalgia
researcher and clinician from the US. This paper starts off
on the premise that successful management of FM patients
seldom results in a cure. The author then clearly defines FM
and the important fact that the clinical presenting symp-
toms are normally without obvious tissue pathology or
abnormal laboratory tests. This paper outlines the 2014
Alternative Fibromyalgia Criteria, which is a validation of
the modified 2010 ACR preliminary criteria (Bennett et al.,
2014). These diagnostic criteria are a one-page question-
naire, which confirm the diagnosis of FM related to pain
location and a 10-item symptom score for symptoms of at
least three months. Apart from establishing a firm diagnosis
in the successful management of FM, the author clearly
describes and develops a template for managing FM pa-
tients, based on the following themes; initial and ongoing
patient education, validation and assurance, patient can-
tered management, medications for FM, comorbid pain and
associated conditions, including myofascial pain, assess-
ment of mood and sleep disorders. This is a very clearly
written, holistic approach that is well supported by the
evidence and highly recommended as a resource in the
management of this challenging condition.
Brandenburg, JE, Eby, SF, Song, P, Zhao, H, Brault, JS,
Chen, S & An, KN, 2014. Ultrasound elastography: the
new frontier in direct measurement of muscle stiffness.
Archives of Physical Medicine and Rehabilitation, 95,
2207e2219.
The use of and development of ultrasound electrography
in evaluating the mechanical properties of tissue including
skeletal muscle was reviewed by a team of US-based cli-
nicians and researchers. The authors identified the
Critical overview of current myofascial pain literature
continuing evolution of ultrasound technology, which can
directly measure the mechanical properties of tissue,
including muscle stiffness. They described different ultra-
sound elastography techniques for studying muscle stiff-
ness, including strain elastography, acoustic radiation force
impulse imaging, and shear-wave elastography and covered
the basic principles of these techniques, including the
strengths and limitations of their measurement capabil-
ities. The authors cited the evidence in support of elas-
tography and how it appears to be able to detect changes in
muscle stiffness in persons with myofascial pain and TrPs.
They acknowledged that while the exact etiology of TrPs is
still unknown, histological changes in the muscle in
response to pain may be detected with elastography. In this
review the authors acknowledged the longstanding role of
palpation in the physical examination of patients and the
use of elastography to quantify subjective clinical exami-
nation measurements and diagnosis. This is particularly
pertinent in myofascial pain evidence, due to some of the
identified reliability issues confirmed in a review article on
manual palpation for MTrP identification and physical ex-
amination for MTrP diagnosis (Myburgh et al., 2008; Lucas
et al., 2009). This review adds to the accumulating body
of knowledge supporting and providing objective mea-
surement and diagnosis in muscle pain.
Abboud J, Marchand AA, Sorra K, and Descarreaux M.,
2013. Musculoskeletal physical outcome measures in in-
dividuals with tension-type headache: A scope review.
Cephalalgia, 33:1319e1336.
Tension-type headache (TTH) has the greatest socio-
economic impact of any primary headache as it is the most
prevalent headache with a 70% occurrence rate (Crystal
and Grosberg, 2009). In addition to headache pain, in-
dividuals with TTH typically suffer from pericranial muscle
tenderness and increased muscle tone. In clinical studies,
however, physical and physiological outcomes are not
commonly assessed and are not proposed as outcome
measures. Abboud and coworkers conducted a literature
review resulting in 26 studies (22 laboratory, and 3 clinical
studies) that meet inclusion criteria of reporting physical
and physiological outcome measures. Many of the papers
that were included originated with the research team led
by Ferna ndez-de-Las-Penas from the Rey Juan Carlos Uni-
versity in Alcorcon, Madrid, which has shown that there is a
43%e92% increase in the number of active and latent TrPs in
individuals with chronic TTH and a 59%e86% increase in
episodic TTH patients as compared to healthy subjects. A
lower pressure pain threshold (PPT) of 35%e52% in patients
with CTTH and 35%e43% in patients with ETTH was re-
ported for the trapezius, frontalis and temporalis muscles
(Fernandez-de-Las-Pen as et al., 2012; Fernandez-de-las-
Penas et al., 2010; Ferna ndez de las Penas et al., 2007b;
Fernandez de las Pen as et al., 2007a; Ferna ndez de las
Penas et al., 2006a; Fernandez de las Pen
as et al., 2006b;
Fernandez-Mayoralas et al., 2010; Sohn et al., 2010). Other
findings included increased muscular tenderness (de
Tommaso et al., 2006), decreased cervical muscular
strength, increased EMG activity, and decreased muscle
cross-sectional area (Bendtsen, 2000), decreased cervical
range of motion, and a positive correlation between the
347
number of active TrPs in the upper trapezius, sternoclei-
domastoids, suboccipital, and temporalis and forward head
posture (Sohn et al., 2010).
TrPs have been noted to contribute to muscular weak-
ness/inhibition, altered muscle function, restricted ROM,
local tenderness, and referred pain. These objective find-
ings were noted in the evaluation of CTTH and ETTH,
therefore a comprehensive evaluation should warrant the
assessment of TrPs as a causative factor in TTH. The
increased myofascial pain sensitivity in patients with TTH is
attributed to central sensitization. A thorough evaluation
and treatment of patients with TTH should therefore
include the assessment of peripheral nociceptive input via
TrPs and their contributions into TTH.
Conflict of interest
Jan Dommerholt, Rob Grieve Michelle Layton and Todd
Hooks have a financial relationship with organisations that
promote recognition and treatment of individuals with
myofascial pain, including Bethesda Physiocare, Bethesda,
MD, USA (Dommerholt and Layton), Myopain Seminars,
Bethesda, MD, USA (Dommerholt, Layton and Hooks),
PhysioFitness, Rockville, MD, USA (Dommerholt), Champion
Sports Medicine in Birmingham, Alabama, USA (Hooks), and
Physio First, Northampton, Northants NN4 9BA, UK (Grieve).
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