J. Phys. Ther. Sci.

25: 341–344, 2013

A Comparison of the Effects of PNF, ESWT, and TPI

on Pain and Function of Patients with Myofascial
Pain Syndrome

Jung-Ho Lee, MSc1), Eun-Yeong Han, MSc2)

1) Departmentof Physical Therapy, Graduate School of Physical Therapy, Daegu University
2) Departmentof Psychology, Graduate School of Psychology, Daegu Catholic University: 330
Geumnak-ri, Hayang-eup, Gyeongsan-si, Kyeongsangbuk-do, Republic of Korea.
TEL: +82 010-8778-7233, E-mail: hdnchocho@hanmail.net

Abstract. [Purpose] The study aims to examines the effects of proprioceptive neuromuscular facilitation (PNF),
extracorporeal shockwave therapy (ESWT), and trigger point injection (TPI) on pain reduction and functional
improvement in patients with Myofascial pain syndrome (MPS) of the upper trapezius muscle and compares their
treatment effects, thereby presenting precise and efficient treatment methods. [Subjects] Thirty-three patients with
MPS in the upper trapezius muscle were divided into three groups: a PNF group (n=11), ESWT group (n=11), and a
TPI group (n=11). [Methods] The degree of pain was measured using the visual analog scale (VAS). Pressure pain
threshold (PPT) was measured at trigger points in the upper trapezius muscle by using a pressure algometer, and the
Constant-Murley scale (CMS) and neck disability index (NDI) was applied for functional evaluation. [Results] A
comparison of the effects of the different treatment methods revealed no significant differences among the groups
in terms of PPT, but CMS (pain, range, and activities of daily living) and NDI showed significant differences among
groups. [Conclusion] PNF treatment enhanced neck function, range of motion in the shoulder joint, and activities of
daily living relative to the other methods; ESWT reduced degree of pain and improved functioning. TPI treatment
reduced pain, but had limited effects in enhancing functional activities.
Key words: PNF, ESWT, TPI
(This article was submitted Oct. 11, 2012, and was accepted Nov. 7, 2012)

INTRODUCTION A lot of research has been performed on treatment

Myofascial pain syndrome (MPS) is characterized by
localized tenderness, taut band structure, convulsive response,
and referred pain under compression and has been defined
as a localized pain syndrome caused by pain trigger points1).
The etiologies of MPS include improper muscle contraction
and relaxation resulting from inappropriate posture or
excessive utilization of the joints and repetitive microtrauma
of the muscles caused by muscle overuse. Stress, metabolic
disorders, hormonal disorders, and infections have also been
reported as stimulating factors for MPS2).
Treatment methods for MPS are divided into invasive and
non-invasive techniques. Representative invasive techniques
are trigger point injection (TPI) and dry needling, both of
which are effective in treating acute MPS3, 4). Non-invasive
treatment methods include electrical treatment and exercise
treatment. Electrical treatments include extracorporeal
shockwave therapy (ESWT), transcutaneous electrical
nerve stimulation, ultrasonic treatment, and magnetic field
treatment; exercise treatments include stretching, massages,
taping, stabilization exercises, and proprioceptive neuro-
muscular facilitation (PNF). Such non-invasive methods
are effective for pain reduction and functional ability
improvement5–7).
methods for MPS but research comparing the effects of
different treatment methods (exercise, electrical, and drug
therapies) has been lacking to date. The current study
examines the effects of PNF, ESWT, and TPI on pain
reduction and functional improvement in patients with MPS
of the upper trapezius muscle and compares their treatment
effects, thereby presenting precise and efficient treatment
methods.
SUBJECTS AND METHOD
Subjects
The subjects of this study were 33 patients who visited
the Department of Rehabilitation, were diagnosed with MPS
of the upper trapezius muscle, and who satisfied all intrinsic
diagnosis elements by Simons8). They had no neurological
symptoms and tested negative for subacromial impingement
syndrome. Subjects were randomly and equally assigned to
one of three groups: a PNF treatment group, a shock wave
treatment group, or a TPI treatment group. Treatment was
applied twice per week for 4 weeks for a total of 8 treatment
sessions. All the subjects participated in this experiment
after sufficiently listening to the purpose and experimental
procedure of this study (Table 1).
342 J. Phys. Ther. Sci. Vol. 25, No. 3, 2013
Table 1. General characteristics of subjects (Mean ± SD)
PNF group (n=11)
Age (yr) 51.92 ± 7.53
Height (cm) 163.48 ± 9.46
Weight (kg) 53.73 ± 8.22
* p<0.05, PNF = proprioceptive neuromuscular facilitation, ESWT = extracorporeal
shock wave therapy, TPI = trigger point injection.
Methods
All the groups received hot pack therapy for 20 minutes
and ultrasound therapy for 5 minutes. The PNF group,
the shock wave group, and the TPI group received upper
trapezius muscle relaxation therapy, ESWT, and injection
therapy, respectively.
Upper trapezius muscle relaxation therapy was conducted
using the PNF hold-relax technique. The subject sat with the
therapist holding the back of the head and pulling the head
in the opposite direction from the extended muscles and
stretched with the face toward the extended muscles. The
subject relaxed for 10 seconds after isometric contraction;
this was performed a total of 5 times.
Shock wave therapy was applied 1000 times to the pain
trigger point of the upper trapezius muscle at 5 Hz using
ESWT (JEST-2000, Joeun Medical) via an air cylinder
method using the head of a 17-mm gun and low power. For
TPI, the Travell method was applied by a specialist injecting
0.2 mL of 0.3% lidocaine in the pain trigger point8).
The subject’s pain was measured using a 100-mm visual
analog scale (VAS). The pain trigger point of the upper
trapezius muscle was measured using pressure in order
to determine the pressure pain threshold (PPT). The neck
disability index (NDI) was used to assess each subject’s
neck function. NDI consists of 10 items with zero to 5
points given to each item; the higher the score is, the more
severe the disability is in the cervical area. The Constant-
Murley Scale (CMS) was used to evaluate functioning of the
shoulder joint in each subject. The evaluation items consist
of pain, activities of daily living, range of motion, muscle
strength, and total scores. The higher the score of each item
and the total score are, the better the function is.
To describe the general characteristics of the treatment
groups, a statistical analysis was conducted. For inter-group
comparison, one-way ANOVA was used. For statistical
analysis, SPSS version 12.0 was used and significance was
accepted for values of α<0.05.
RESULTS
A comparison of pre-test on VAS, PPT, NDI, and
CMS among the groups showed no significant differences
(p>0.05) (Table 2). In terms of PPT, this was no significant
differences among the groups, but VAS showed statistically
significant differences among the groups (p<0.05) (Table 3).
Comparison of CMS among the groups showed significant
differences in pain, range, and activities of daily living
(p<0.05). Also, NDI showed significant differences among
groups (p<0.05) (Table 4).
ESWT group (n=11) TPI group (n=11)
51.61 ± 8.3 52.67 ± 7.58
164.14 ± 8.69 164.48 ± 9.61
54.7 ± 8.62 53.6 ± 8.08
DISCUSSION
In the past, a key element in treating MPS patients was
removal of pain. The importance of increased muscle tension
caused by pain and the resulting disability has been gradually
recognized. In particular, functional recovery in chronic pain
patients is an important issue as the reduction of pain.
Wrong muscle tension and functional restriction decrease
treatment effects and may trigger the recurrence of a
disorder, and management is necessary through appropriate
treatment interventions9, 10). There has been a lot of research
on PNF using proprioceptive senses, and this method has
been reported to have positive effects on muscle activity
adjustment, body balance, and functional improvement11, 12).
In a study that compared the treatment effects of functional
electrical stimulus (FES) and PNF, Moon et al.13) observed
improvement in the PNF group’s upper limb functioning.
In a study that examined the effects of massage and PNF
relaxation stretching on the myofascial trigger point (VAS)
and the PPT, Trampas et al.14) reported pain reductions in
the group receiving PNF relaxation treatment combined
with myofascial trigger point therapy. In the present study,
the PNF group’s neck function, shoulder range of motion,
and activities of daily living improved by a statistically
significant degree compared to the other groups (p<0.05).
Recent studies have reported that ESWT in muscu-
loskeletal disorder patients was good for pain reduction
and functional improvement15), and ESWT has drawn
attention as an alternative treatment method for such
patients. Accordingly, the application of ESWT has been
increasing16). Furia17), who examined the effects of ESWT
on pain and functional improvement in 34 subjects, and
Hsu18), who looked at the effects of ESWT in 36 subjects,
noted significant changes in VAS and CMS after treatment.
In the present study, the ESWT group’s pain as measured
by VAS and CMS and activities of daily living showed
statistically significant improvement compared to the PNF
group (p<0.05). These results are due to the effects of ESWT
which destroys damaged tissues and initiates recovery in the
damaged parts by facilitating the formation of new blood
vessels and stimulating local growth factors.
TPI has been presented as an effective method to treat
acute MPS. In TPI, injections are given in pain trigger
points, which are areas where pain is triggered due to muscle
tension or spasm. In a study that examined the effects of TPI,
Kim et al.3) observed that application of TPI was effective in
reducing pain and increasing range of motion. In the present
study, the TPI group’s pain as measured by VAS and CMS
showed statistically significant improvement compared to
 343

Table 2. A comparison of pre-test on VAS, PPT, NDI, and CMS among groups (Mean ± SD)

PNF group (n=11) ESWT group (n=11) TPI group (n=11)

Visual analog scale 7.09 ± 1.04 7.18 ± 0.98 7.36 ± 0.67
Pressure pain threshold 33.56 ± 8.70 31.42 ± 7.98 37.00 ± 9.09
Neck disability index 24.45 ± 4.57 28.00 ± 4.96 26.73 ± 5.92
Constant-Murley scale 65.27 ± 10.33 62.09 ± 13.73 65.01 ± 10.76
* p<0.05, PNF = proprioceptive neuromuscular facilitation, ESWT = extracorporeal shock wave
therapy, TPI = trigger point injection

Table 3. A comparison of effects on VAS and PPT among groups (Mean ± SD)

PNF group (n=11) ESWT group (n=11) TPI group (n=11)

Visual analog scale* 2.26 ± 0.91 3.28 ± 1.03 3.22 ± 0.84
Pressure pain threshold –2.71 ± 2.11 –2.50 ± 1.99 –2.63 ± 1.43
* p<0.05, PNF = proprioceptive neuromuscular facilitation, ESWT = extracorporeal shock wave
therapy, TPI = trigger point injection

Table 4. A comparison of effects on NDI and CMS among groups (Mean ± SD)

PNF group (n=11) ESWT group (n=11) TPI group (n=11)

Neck disability index* 6.26 ± 1.53 5.26 ± 1.26 5.19 ± 1.15
Pain* –4.18 ± 2.34 –5.62 ± 3.45 –5.54 ± 2.67
Range* –5.78 ± 2.47 –4.48 ± 2.32 –3.74 ± 3.19
Constant-Murley
Activities of daily living* –6.45 ± 3.53 –5.34 ± 2.98 –2.67 ± 3.78
scale
Strength –2.63 ± 2.21 –2.82 ± 2.18 –2.77 ± 2.68
Total 13.15 ± 8.63 14.77 ± 6.64 11.73 ± 8.78
* p<0.05, PNF = proprioceptive neuromuscular facilitation, ESWT = extracorporeal shock wave therapy, TPI = trigger point
injection

of cervical strain in the emergency department. Kor Soc Traumatol, 2002,

only pain in the PNF group (p<0.05). These results are due
to the effects of local anesthetics by lidocaine injection.
The present study examined and compared the treatment
effects of PNF, ESWT, and TPI on patients with MPS of
the upper trapezius muscle. In this evaluation of different
treatment methods, pain, range of motion, and activities of
daily living as measured by VAS, NDI, and CMS signifi-
cantly differed among the groups (p<0.05). PNF treatment
enhanced neck function, range of motion in the shoulder
joint, and activities of daily living relative to the other
methods; ESWT reduced degree of pain and improved
functioning. TPI treatment reduced pain, but had limited
effects in enhancing functional activities.
The present study had the limitations of a short experi-
mental period; a small number of subjects; and the possibility
that administration of medication may have increased
effects of specific techniques. Future research should apply
the studied treatment methods of PNF, ESWT, and TPI in
patients with MPS in different areas of the body.
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